Disease Burden in China

Here is a rough analogy: As rich is to poor, so is non-communicable to communicable. That’s not an entirely accurate comparison across the board, but roughly speaking, it seems to hold true around the world. Where there is poverty, there are infectious diseases. And when the economic situation in a country changes, the major health problems shift to illnesses that are not contagious, like cancer and heart disease.

Obviously, exceptions about. The common cold might be the most common contagious illness in the world. But if we’re looking at what diseases kill people, this division is one way to look at the matter.

Changes in the disease burden in China between 1990 and 2010 are extremely illuminating in considering how rising income, urbanization, and living to an older age impact health. An article published in The Lancet (in an issue focused entirely on China) this past June charts this change, and makes for a gripping look at the leading causes of death and diminishment of productive years of life in this country.

The report is based on the results of the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) that was completed this past March. GBD 2010 is an absolutely amazing collection of information about what ails people around the world. The results of the study can be viewed in graphic form in a way that provides a view into global health that we have never had before. If you’ve got some time to spend, go to the website and fiddle with the graphs. It is totally worth it if you want to understand, say, changes in how many children around the world die from war, or the increasing recognition of mental disorders as a source of disability — or the rising rates of cancer in China.

Speaking of which … The Lancet study looks at the health transition from 1990 to 2010. There is so much to cover in just summarizing this article, and of course the best thing is to just get yourself a PDF of the study or look at the graphs online. But here’s some choice findings from the study, which was sponsored by The Bill & Melinda Gates Foundation (as was all of the GBD 2010 work).

The report begins by noting the strides made since the 1970s, with an increase in life expectancy and a plummeting rate of under-five mortality. (And because it’s nearly impossible to talk about China without talking about the one-child-only restriction, the study notes that the total fertility rate dropped from 4.77 to 1.64 children per woman between 1970 and 2010.)

When considering disease burden, several measures come into play, and it’s interesting to think about what each measure implies. There are years of life lost (YLLs); years lived with disability (YLDs); disability-adjusted life years (DALYs); and healthy life expectancy (HALE). In other words, the study gives equal billing to factors that are keeping people out of the workplace or unable to fulfill their family responsibilities and to what is killing them.

What is killing people: According to GBD 2010, the leading causes of death in China in 2010 were stroke, ischaemic heart disease, and chronic obstructive pulmonary disease. Among children, neonatal problems, infectious disease and injury were responsible for far fewer YLLs in 2010 as they were in 1990.

What is disabling people: The leading causes of DALYs in 2010 were cardiovascular diseases, cancers, low back pain, and depression. These conditions were the result of high blood pressure, poor diet, and tobacco exposure, with ambient and household air pollution rounding out the top five causes.

China’s Place Among the G20

As the authors define it, the G20 is “the set of developed and developing countries identified as global agenda setters.” These countries are Argentina, Australia, Brazil, Canada, China, Germany, France, UK, Indonesia, India, Italy, Japan, South Korea, Mexico, Russia, Saudi Arabia, Turkey, USA, South Africa. (Dingdingding to the readers who counted only 19 countries here … the EU is #20, and not ranked on its own in The Lancet paper or by any of the other GBD 2010 publications).

Some rank information: China is —

#13 in age-standardized death rate (#14 in 1990)
#11 in age-standardized YLLs (#13 in 1990)
#1 in age-standardized YLDs (#2 in 1990)
#12 in life expectancy at birth (#13 in 1990)
#10 in HALE at birth (#13 in 1990)

Infectious Diseases

I don’t want to provide so many numbers that the information becomes impossible to digest, so consider this an overview of the study, and not a journalistic report of it. The essential thing, I think, to convey about the change in infectious disease rates in China from 1990 to 2010 is that almost every single one declined. Diarrhea, diptheria, tetanus, measles, tuberculosis, malaria, leishmaniasis, schistosomiasis, STDs excluding HIV, hepatitis A, hepatitis C, and many others – all of these showed declining rates.

The most prevalent increase, as you may have guessed from the STD mention just above, was with HIV. In 1990, there were 0.2 thousand deaths from HIV/AIDS (0.0-0.6 Uncertainty Interval [UI]). In 2010, there were 36,200 deaths from HIV/AIDS (with a UI of 25,100 – 49,200).

“Communicable, maternal, neonatal and nutritional disorders have declined by 59.5% (95% UI 54.5-63.8),” the authors write. “Among these disorders, however, the large increase in HIV deaths is notable.”

Increasingly Common Causes of Death and Suffering in China

According to the study, the death rate due to the following causes increased between 1990 and 2010:

• Lung cancer
• Breast cancer
• Uterine cancer
• Prostate cancer
• Mouth cancer
• Melanoma
• Kidney and other urinary organ cancers
• Multiple myeloma
• Pancreatic cancer
• Ischaemic heart disease
• Atrial fibrillation and flutter
• Peripheral vascular disease
• Respiratory disease
• Opioid use disorders
• Cocaine use disorders
• Road injury (with a dramatic increase in pedestrian injury by road vehicle)

Interestingly, drowning as a cause of death decreased substantially between 1990 and 2010.

The top 25 causes of YLLs in China for both sexes, all ages, in 2010 were (in numerical order): stroke, ischaemic heart disease, chronic obstructive pulmonary disease, road injury, lung cancer, liver cancer, stomach cancer, self-harm, lower respiratory infections, esophageal cancer, drowning, congenital anomalies, colorectal cancer, diabetes, falls, cirrhosis, hypertensive heart disease, leukemia, preterm birth complications, neonatal encephelopathy, other cardiovascular and circulatory, chronic kidney disease, HIV/AIDS, breast cancer, and poisonings.

In considering not death but disability, major depression was the second leading cause of YLDs. The top cause was low back pain. Taken together, major depression, musculoskeletal disorders and substance abuse disorders were responsible for nearly half of all years lost to disability in China in 2010.

Finally, the leading risk factors contributing to DALYs for both sexes in 2010 were dietary risks, high blood pressure, tobacco smoking, and pollution (both ambient particulate matter and household air pollution from solid fuels). In terms of diet, the problem is that many people are not consuming enough fruit and whole grains, and have a high sodium intake.

In conclusion, a few excerpts from the study’s Discussion section:

“The burden of disease is now dominated by cardiovascular diseases, lung cancer, chronic obstructive pulmonary disease, road injuries, and key causes of chronic disabilities such as mental and musculoskeletal disorders. Although the burden of suicide, drowning, and many injuries declined, the burden of road injuries and falls is increasing. The rise of non-communicable diseases and chronic disability is fueled by a shift away from risks for communicable diseases in children toward those for non-communicable diseases in adults. The one child policy in China implies the demographic shifts contributing to this rapid transition in health problems will intensify in the coming decades.”

And

“The burden of diseases attributable to individual behaviors and practices is steadily rising.”

That last line really says it, doesn’t it? Would it be fair to say that rising income and urbanization are associated with individual behaviors that lead to disease, whereas the diseases that are most common in poorer countries are less individualistic? Among the poor, the kinds of behaviors that lead to non-communicable diseases are not as accessible — though nor is the life span that enables certain non-communicable diseases (like prostate cancer) to arise.

One question: With regard to the increased prevalence of major depression, is this due to an increased recognition of this mental state (there all along but undiagnosed until now), or is there more depression – and if so, why?

Reference:
Gonghuan Yang, Yu Wang, Yixin Zeng, George F Gao, Yiaofeng Liang, Maigeng Zhou, Xia Wan, Shicheng Yu, Yuhong Jiang, Mohsen Naghavi, Theo Vos, Haidong Wang, Alan D Lopez, Christopher J L Murray. Rapid health transition in China, 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet 2013; 381:1987-2015.

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