HSERV 534 # 13: HSERV 534 # 13 INDIA and CHINA


Review so far: Key ideas: 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: 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: 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: India China Health Comparisons


India China Health Comparisons: India China Health Comparisons


India: 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 (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


Indian History: 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: 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: 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+: Indian Reforms 1991+ Eased foreign exchange restrictions Devaluated rupee Lower import tariffs Resulted in growth of middle class Entrepreneurs (Forbes Billionaires 23 in 2006, 12 in 2005, ranking 6th in world) China has only 8 (+17 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: 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 : 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


Chinese Revolution : 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: 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


Slide17: 1960 India China 0 100 200 300 400 500 600 700 800 GDP/cap life Exp IMR India China 44 47


Slide19: Sen 1999


Slide20: Kerala has low rural/urban differences in LBW, IMR


Social Security Pre-Reform China: 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


PRE-REFORMAuthoritarianism, famines and vulnerability: PRE-REFORM Authoritarianism, famines and vulnerability


Famines of 1958-61 in China killed between 23 and 30 million people: 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: Crude Death, Birth Rates China 50-96


Famines of 1958-61 in China killed between 23 and 30 million people: 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: 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: 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: 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


Slide30: NYT 021124


China health improvement post reform : 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 1960-90 India, China, S. Korea Kerala had no economic growth


Chinese economic growth in 1980s: 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: Post-Reform Changes in China Village health services comprehensively privatized Economic growth at cost to social services became under-funded Huge increases in inequality between urban and rural, between coastal and inland, within regions IMR improvement overall flattened, rural worsened Stunting seen increasing in rural populations SUICIDE rates very high, and rural > urban, pesticide


Slide36: NYT Aug 1, 2004


Urban Social Security Post-Reform: 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?


Rural Social Security Post-Reform: 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: 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 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: 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 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


Kerala Model: 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: 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


Kerala's Health: 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 / India gender comparisons http://www.kerala.gov.in/


Slide47: Multi-level Individual mortality, 1998-99 Indian National Family Health Survey 529,321 people in 26 states Subramanian 2006


Slide48: Subramanian 2006


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


Curative Care Subsidy to Richest fifth vs poorest fifth in India: Curative Care Subsidy to Richest fifth vs poorest fifth in India World Bank 2001


India euphoria "Overtake China?": 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 6th 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


China Today: 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


Slide53: 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 Comparisons Today REASONS? Businesses like Totalitarian governments


Summary: 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