By Rick Relinger
While both China and India have experienced rapid urbanization and economic growth over the last half-century, China has achieved better public health outcomes for its citizens than India. This holds true for diarrheal mortality, which primarily impacts children younger than five years of age. Yet despite this, diarrhea remains the second-most deadly infectious and parasitic disease in China: it is responsible for one of every 100,000 deaths.  Such a statistic warrants an examination of both the biological and social factors that determine the outcome of diarrheal mortality. This paper is arranged to correspond with the order of the biological progression of the disease (which is represented in a linear fashion along the bottom of the conceptual map). Each step of the illness timeline will be accompanied by a discussion of the specific factors and broader social determinants that lead to diarrheal mortality. Thus, the paper is ordered in accordance with the model from left to right and down to up, beginning with social determinants of exposure to bacterial/parasitic agents, next the onset of diarrhea and finally dehydration, which leads to eventual mortality. Based on this analysis, three China-specific implications for policy intervention will be identified to minimize the outcome of diarrhea mortality.
Changes in food consumption habits and dietary behavior have facilitated the transmission of bacterial or parasitic causative agents for diarrheal disease. Indeed, the ingestion of contaminated food is a primary way in which young children are exposed to such bacteria or parasites. Since 1992 there has been a decline in cereal intake and a substantial growth in the consumption of animal products contributing to the 300 million cases of food-borne illness in China each year.  This change in diet has been facilitated by China’s growing standard of living, which is a consequence of the success of the country’s export-driven strategy in the global economy. Accordingly, the domestic food industry has grown to meet the demands of Chinese consumers. The growth has contributed to the prevalence of contaminated food primarily because the government currently lacks the resources to regulate China’s one million food companies – 70% of which are small family-owned businesses.  Thus due to insufficient regulation of food quality, Chinese consumers are exposed to food contaminated with causative agents for diarrheal disease. The Chinese government, recognizing this public health threat, adopted the Food Safety Law in 2004 to enhance the monitoring and enforcement of food safety standards.  This law is intended to minimize the ingestion of contaminated food by increasing the rigor of restaurant/ food production inspection and health examinations for food workers. The real success of this policy will be determined by its effectiveness in improving and eradicating poor sanitation practices in food production. By addressing the problem of unsanitary food preparation, the Chinese government can minimize the number of exposures to causative agents for diarrheal disease.
In the instance of an exposure to a causative agent, the lack of access to rotavirus vaccinations is a crucial determinant contributing to diarrheal mortality in China. Rotavirus, an RNA viral agent, is the leading cause of severe diarrhea among children younger than five.  Oral vaccines, which contain live disable virus, are available on the market and are effective in preventing the onset of diarrhea following exposure to rotavirus. However, access to rotavirus vaccination is constrained by the affordability and proximity to such care for families to provide for their infants.
Ultimately, the affordability of rotavirus vaccination and the onset of diarrhea symptoms are determined by the exclusive patent rights held by the producers of such vaccines. There are currently two rotavirus vaccines on the market – Rotateq and Rotarix produced by pharmaceutical giants Merck and GlaxoSmithKlien, respectively. Under the WTO agreement on Trade Related Aspects on Intellectual Property Rights (TRIPS), these companies have a monopoly on the production and sale of these vaccines and thus face no market competition over price setting. Predictably, both vaccines are more expensive than the average Chinese family can afford for their newborn children – Rotateq costs $63/dose while Rotarix is slightly cheaper at $25/dose.  Without affordable access to vaccines, children are more likely to develop rotavirus diarrhea and face potential mortality. There have however, been efforts to produce more affordable, and thus accessible, rotavirus in China. PATH (Program for Appropriate Technology in Health) recently partnered with the Wuhan Institute of Biological Products to develop a new low-price oral rotavirus vaccine.  The production of a new vaccine could reduce the development of diarrhea in young children and subsequently diarrheal mortality by addressing the determinant of affordability.
Since current rotavirus vaccinations are costly, insurance coverage is also an important determinant of access to necessary care and the onset of diarrhea. The Chinese government offers several different health insurance plans depending on one’s occupation and rural or urban residency. Current health insurance schemes cover 75% of the urban labor force, however these plans do not cover workers’ dependents.  Therefore, this insurance does not cover the medical needs of the infants of these workers (not to mention the 25% of the urban workforce that does not even have access to government insurance). Insurance coverage is no better for China’s rural residents: “nearly 80 percent of residents in rural areas had no insurance at all by 2003.”  With such poor insurance coverage, Chinese families are often forced to assume the medical costs for their children. Since the state insurance plans are unable to absorb the medical costs for infants depending on one’s occupation and residency, many families cannot afford rotavirus vaccinations for their children. Occupation and residency of parents are thus important social determinants for the onset of diarrhea because they dictate insurance coverage and thus the affordability of rotavirus vaccinations.
Affordability and accessibility (more broadly) for rotavirus are also determined by the prevalent practice of bribery at healthcare facilities. These informal payments, often made in cash, are paid in addition to formal medical costs associated with the care or medication received. This practice is particularly pervasive in China’s healthcare system as “more than 70% of Chinese hospital patients have providers red packages [bribes].”  The occurrence of such practices is especially crucial in the outcome of diarrheal mortality since it exacerbates the financial burden that deters many families from seeking necessary care in the first place. Indeed, a China Health Ministry survey found that 36% of urban patients and 39% of rural patients avoided seeking medical care because of the high costs of treatment.  Without sufficient government oversight of healthcare facilities, corruption can increasingly discourage families from accessing care. Therefore, the practice of corruption is a determinant of the affordability of rotavirus vaccine, which is an important factor in preventing diarrheal mortality.
As previously mentioned, proximity to care is also a determinant of access to rotavirus vaccinations and the onset of diarrheal symptoms in infants. One’s residency, whether rural or urban, dictates proximal access to healthcare facilities. There is an oversupply of healthcare in urban areas as 80% of government health expenditures and resources are allocated to urban centers, which only account for 46% of the total population.  Due to the neglect of 54% of China’s population living in rural areas, many families are physically unable to access care for their children. Since the government is limited by a finite amount of resources for healthcare, urban care is prioritized due to the efficiency that accompanies health service provision in more densely populated areas (urban clinics geographically accessible to a greater population than rural clinics). Distance and associated transportation costs serve as a deterrent for rural families with young children to access rotavirus vaccines from healthcare facilities, thus residency is thus a determinant of the proximity and access to rotavirus vaccinations, which is as illustrated, a critical factor in minimizing the outcome of diarrheal mortality.
During the onset of diarrheal symptoms, excessive dehydration due to the inability to retain water leads to potential mortality. Proper access to educational information about therapies to prevent dehydration is a social determinant of diarrheal mortality. The education for applying traditional Chinese medicine (TCM) therapies plays a central role in the management of illness-related symptoms in China. Herbs employed in TCM treatments are widely available and affordable relative to biomedical therapies. If parents are educated in TCM they can effectively prevent their child from becoming dehydrated due to diarrhea. A regimen of Huang Lian Su Pian (Coptis extract), which kills bacterial pathogens and Mu Xiang Shan Qi Wan (Saussurea lappa herb), which restores digestive functioning should prevent potentially fatal dehydration and end diarrheal symptoms within a week.  Additionally, access to educational information regarding oral rehydration therapy (ORT) is equally as crucial in minimizing dehydration and preventing diarrheal mortality. Parents informed and educated in administering ORT can better prevent the dehydration and potential death of their child. This process exemplifies the life-course model as described by Ben-Schomo et. al.,  in which the education of an older generation minimizes the risk that a certain health outcome poses to the next generation. In fact, China has been relatively successful in educating parents and disseminating information about ORT – of approximately 360 million annual diarrhea episodes, 85% are treated with oral rehydration salts.  Part of this success is likely due to public health education campaigns, which began in China in the 1950’s. Using roadside billboard advertising and promoting easily- remembered slogans, the government has successfully disseminated public health knowledge to teach behaviors such as administering TCM and ORT treatments to citizens.  And parent’s adoption of such treatment practices has been crucial in preventing young children from becoming dehydrated. Therefore, access to educational information regarding rehydration therapies is a social determinant of diarrheal mortality.
Following the examination of the social determinants of diarrheal mortality in China, it is clear that government policy is instrumental in minimizing this adverse health outcome. From regulating food production quality to providing different health insurance schemes and conducting public health education campaigns, the Chinese government has attempted to address a variety of social determinants to improve public health. Accordingly, this paper proposes three implications for government policy interventions intended to reduce rates of diarrheal mortality. First, the Chinese government should bolster efforts to develop the capacity for domestic pharmaceutical production. If Chinese companies can manufacture a rotavirus vaccine domestically, the vaccination could be sold at a price affordable for most Chinese families. The affordability of the vaccine will enable parents to no longer depend on purchasing vaccinations from Merck or GlaxoSmithKlien at inflated (patent-protected) prices. Additionally, this increased accessibility will save the Chinese government millions of dollars in annual healthcare spending as the vaccination of infants will reduce the number of hospitalizations due to severe diarrhea. Indeed, rotavirus accounts for over 50% of hospitalizations for severe diarrhea in children.  Second, these savings from healthcare spending should be reinvested to address proximity to care. The Chinese government should allocate this revenue to construct healthcare facilities for primary care in particularly neglected rural areas. This expansion of primary care will not only reduce the distance rural residents must travel to receive care for their child but it will allow practitioners to customize care to meet local needs. Finally, the government needs to expand efforts for oversight and accountability of hospital and clinic staff. By demonstrating that solicitors of bribery and “red packages” will be punished, oversight measures will minimize reluctance among patients to seek needed primary care. This will similarly reduce hospitalizations due to neglected health problems and generate additional savings for future interventions.
Despite comparatively better health outcomes relative to India, China has substantial room for improvement to reduce the prevalence of diarrheal mortality. There are a variety of social factors that determine the onset of each stage of the biological process, beginning with exposure to a causative agent (specifically focusing on rotavirus) and ending with the outcome of mortality. Further policy interventions by the Chinese government can address regional disparities and facilitate behavioral change needed to minimize the diarrheal mortality in China.
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