China’s growing contribution to health at home and on the global stage, lecture at the Chinese Academy of Governance
Dr Margaret Chan
Director-General of the World Health Organization
Excellencies, honourable Minister Li Bin, provincial leaders, directors-general of provincial health and family planning, ladies and gentlemen,
In the eyes of the world, China is increasingly seen as a model for development at many levels.
The world’s second largest economy grew rapidly yet reliably. China opened its markets to liberalized trade only when its own economy was mature enough to compete internationally. Countries with fragile economies thinking about entering trade agreements should learn from this experience.
The world’s most populous country used its steady economic growth to lift millions of its people out of poverty. The fact that the Millennium Development Goal for poverty reduction was met depended greatly on China’s achievement.
In reducing threats to health, some of China’s past achievements have been spectacular.
Using medical doctors, barefoot doctors, practitioners of traditional Chinese medicine, health inspectors, and medical staff at factories, this vast and populous country eradicated smallpox two decades before the rest of the world. In the three years prior to its last case, China administered smallpox vaccine to more than 500 million people.
That achievement established an attitude at WHO that persists today: China can do anything whatsoever it decides to do.
Within a decade, China moved from a heavily criticized response at the start of the 2003 SARS outbreak to top performance, and international gratitude, as it managed the emergence of the H7N9 avian influenza virus.
Having built the world’s largest real-time electronic disease surveillance system, China provided a model of immediate, transparent, and complete reporting. Your scientists and epidemiologists quickly published reports in the world’s most prestigious medical journals, showcasing the country’s world-class research capacity.
The government’s response to the Shandong vaccine scandal was likewise rapid and sweeping. The scale of the scandal was large, involving 2 million doses of improperly stored vaccines administered to children and adults.
Within a month after news of the scandal broke, the vaccine circulation and immunization law was updated by the State Council to include reforms that addressed both the immediate and root causes of the scandal. Health authorities also took steps to restore public confidence in the safety of vaccines and appreciation for the life-saving protection they confer.
China values social stability and understands that inclusive social services, also for health, contribute to social cohesion and stability.
Over the last decade, China embarked on the biggest health system reform the world has ever seen, aiming to extend health services beyond the country’s prosperous urban centres.
At the start of the century, less than one-third of China’s population had access to health insurance. Now nearly 100% do. This equality in access to health services underpins social harmony.
In essence, China has given its huge population a safety net that protects people from being impoverished by the costs of health care. This makes a tremendous contribution to a fair and prosperous society.
Ladies and gentlemen,
China enjoys a special status in its engagement in international health development. What the country does well at home carries a distinctive prestige when exported elsewhere.
For most of the developing world, China is a fellow traveller that faced and overcame similar development challenges not so long ago. This shared experience creates a rapport not always enjoyed by wealthy development partners.
Centuries ago, the Silk Road carried knowledge about traditional Chinese medical cures along the trade routes from China to India, the Middle East, and Europe. Today, the One Belt, One Road Initiative continues this tradition as a modern instrument for economic diplomacy.
As a distinct strategy for development, the initiative promotes international cooperation in the Silk Road Spirit of "peace and cooperation, openness and inclusiveness, mutual learning and mutual benefit".
In matters of health, I see great potential for the Initiative to move beyond its present concern with issues of health security to promote wider cooperation, especially for diseases like heart disease, diabetes, and cancer that can be heavily influenced by trade and economic policies.
As early as 1963, Chinese medical teams in Africa became a signature programme for international health outreach work, which eventually included the construction and donation of hundreds of hospitals and clinics that now dot the landscape throughout sub-Saharan Africa.
While some critics argue that this assistance is largely aimed at securing natural resources needed to fuel the Chinese economy, independent studies have found no pattern linking assistance in individual countries to the flow of natural resources.
In 1978, the barefoot doctor approach for training locals in basic health care inspired the primary health care movement launched by the Declaration of Alma-Ata, which became the brand name for much of the work of WHO.
China's contribution to global health security attracted international attention during the Ebola outbreak in West Africa, when courageous Chinese medical teams were among the first to answer my call for hands-on clinical support under some very dangerous conditions.
In supplying well-trained and self-sufficient medical teams, China took lessons from its decades of experience in sub-Saharan Africa, where medical teams brought their own equipment, supplies, and medicines.
More recently, the skills of an emergency medical team from Shanghai East Hospital were evaluated by WHO and certified as meeting international standards for competency.
The Shanghai team is now classified by WHO for emergency deployment when the next regional or global outbreak strikes.
Building on these achievements and its domestic successes, China moved to centre stage of the global development agenda twice last year.
At the United Nations General Assembly in September 2015, President Xi Jinping announced the creation of a $2 billion fund, rising to $12 billion by 2030, to support least developed countries under the 2030 Agenda for Sustainable Development.
The President further announced that China will cancel the debts of very poor countries and launch 600 specific projects to cut poverty, improve education, and support better health care.
As many have noted, China’s leadership was decisive in reaching agreement during the Paris Conference on Climate Change held last December.
Air pollution in China is a major health threat. The country still depends on coal for more than 60% of its power, especially in the industrial heart of the country, and is the world’s largest emitter of carbon dioxide. China’s commitment to reduce these emissions eased negotiations considerably.
The government has taken a number of steps, including the establishment of automated real-time monitoring of air pollution, with a related alert and warning system, and heavy investments in the process of shifting to nuclear, solar, and wind power, in line with commitments under the Paris Agreement.
Provincial governors have a role to play in ensuring that coal-fired power plants and cement factories are moved outside city limits.
If every country took its obligations to mitigate climate change so seriously and vigorously, we really could save the planet and its climate.
This year marked another major milestone in the history of health reform. In August, health became an explicit national political priority with approval of the Healthy China 2030 plan by China’s Central Committee.
President Xi Jinping emphasized in his speech at the National Health Conference that without health for all people, there will be no all-around well-off society. President Xi Jinping put health at the centre of the country’s entire policy-making machinery, making the need to include health in all policies an official government policy.
In his speech, President Xi also stressed the need to establish an evaluation and assessment system for the health impact of all economic and social development plans and policies, as well as major projects.
This is an exceptional formal recognition of the political power of health, and bodes well for China’s leadership, at home and abroad.
But in China, as in all regions of the world, some formidable new threats have arrived. The challenges they pose, their costs to health and society, are big enough to stall or even reverse recent progress, here in this country as elsewhere in the world.
Ladies and gentlemen,
The world is undergoing some universal changes, with unprecedented speed, that threaten health in alarming ways. The world has 800 million chronically hungry people, but it also has countries where more than 70% of the adult population is obese or overweight.
Though adiposity is increasing everywhere, the epidemiology differs according to the age of the obesity epidemic. In North American and Europe, the prevalence of obesity is highest among lower-income groups, who often live in urban areas blighted by food deserts and littered with fast-food outlets.
In countries more recently affected by the obesity epidemic, as in the Asia-Pacific region, obesity is seen first in wealthy urban residents, and then later in impoverished rural areas and urban slums.
In China, as decades of food scarcity were replaced by abundance, the prevalence of obesity and overweight more than doubled during the last decades of the 20th century, moving from famine to feasting in less than a generation.
Population-wide increases in body weight are the warning signal that big trouble is on its way. It takes time, but trouble eventually arrives as a wave of lifestyle-related chronic diseases, including heart disease, diabetes, and some diet-related cancers.
Economic growth and modernization, historically associated with better health outcomes, are actually opening wide the entry point for the globalized marketing of unhealthy products, like tobacco, alcohol, highly processed foods, and sugar-sweetened beverages.
While the world’s rapid migration from rural to urban settings brings many benefits, it also hastens the transition from active to sedentary lifestyles.
For the first time in history, rapidly growing prosperity is making many previously poor people sick. This is happening in countries with few resources and health system capacities to respond. If current trends continue, a costly disease like diabetes, which accompanies the obesity epidemic, can devour the gains of economic development.
The Asia-Pacific region is generally considered the epicentre of the diabetes crisis. In these countries, people develop the disease earlier, get sicker, and die sooner than their counterparts in wealthier countries.
In some of Asia’s most populous countries, including China and India, a generation that grew up in rural poverty, with too little to eat and jobs involving hard manual labour, now lives in urban high-rise apartments, with sedentary jobs, low-cost cars, and food environments loaded with cheap and convenient calories.
Partly as a result of these changes, millions of people lifted out of poverty to join the booming middle class now find themselves trapped in the misery of chronic diseases and all their costly complications. With 12% of the adult population now affected, China has the world’s largest diabetes epidemic, and it continues to grow with terrifying speed.
WHO data show that the prevalence of diabetes, heart disease, and cancer in the Chinese population has risen more than nine-fold within a single generation, far faster than in the rest of the world.
This alarming situation is largely the result of a shift from traditional diets to a westernized diet, rich in fats, sugar, and salt, an ageing population, and the increased consumption of alcohol and tobacco.
The rise of noncommunicable diseases has profound consequences. This is a seismic shift that calls for sweeping changes in the very mindset of public health.
Most health systems in the developing world were built for the management of brief events, like childbirth or acute infections. They were not built for the long-term management of chronic conditions with their demanding complications that require costly medications and hospital-based interventions.
Public health must shift its focus from cure to prevention, from short-term to long-term management, from delivering babies, vaccines, and antibiotics to changing human behaviours, from acting alone to acting in concert with multiple sectors and partners.
Having a cadre of well-trained and motivated general practitioners is one of the smartest ways to respond to this shift. General practitioners offer preventive as well as curative services. They are also best-placed to catch a disease early, before complications requiring costly treatments and long hospital stays develop.
General practitioners are gatekeepers, who can keep patients with comparatively minor complaints from flooding emergency wards. They recognize that illness and disease have social as well as medical causes, and this gives them a great advantage when it comes to primary prevention and patient satisfaction. They are best positioned to provide truly patient-centred care.
Many outside observers of China’s ambitious reforms have noted that a lack of well-trained general practitioners is the main barrier to reducing the overuse of hospital care.
Provincial health leaders have a critical role to play in the allocation of resources. Investments in primary health care will go much further, with much broader cost-effective benefits, than investments in new hospitals and clinics.
The costs of these lifestyle-related diseases are staggering. Prevention is by far the better option, but is a major challenge for at least two reasons.
First, the root causes of chronic diseases lie in non-health sectors. Health bears the brunt of these diseases but has little control over the risk factors. Second, powerful economic operators, like the tobacco, alcohol, food, and soda industries, drive the globalization of unhealthy lifestyles. Economic power readily translates into political power.
Using the WHO Framework Convention on Tobacco Control as a legal instrument, government leaders, also at the provincial level, can introduce legislation that significantly reduces tobacco use. We know this from abundant evidence.
Beijing’s tobacco control policies are among the toughest in the world. Shanghai has just banned smoking inside airport terminal buildings and in the city’s railroad stations. The city’s legislative body is evaluating stricter rules which will extend the smoking ban to all indoor public venues.
If Beijing and Shanghai can do this, with broad public support, every provincial health leader can do the same.
Unfortunately, the tobacco industry is trying its utmost to undermine these most welcome laws. Industry’s aim is to weaken the language in China’s national tobacco control law currently being drafted.
Do not let an industry, known for its devious practices, set back these wins for China’s health. The protection of public health must take precedence over the protection of industry profits. Every death linked to tobacco use is an entirely avoidable tragedy.
Ladies and gentlemen,
In a world full of so many uncertainties, economic, trade, and industry considerations can dominate national and international agendas and override the best interests of public health.
Yet another trend needs careful scrutiny. Economic growth and rising prosperity are nearly always accompanied by an increased demand for meat and dairy products.
The world’s food system, which became industrialized during the last decades of the previous century, developed the model of factory farms, in which large numbers of pigs, cattle, and chickens are crowded together under unsanitary conditions.
For example, China now has individual mega-factory farms capable of raising more than a million pigs each year. The system of confined animal feeding operations meets the demand for abundant cheap meat, but at a huge cost.
The system is not environmentally sustainable. These farms heavily pollute the environment with animal and chemical wastes, and methane gas which contributes to climate change.
Raising large numbers of animals under crowded conditions requires the use of massive quantities of antibiotics. In several countries, more antibiotics are used in food production than in human medicine.
Research conducted in China provides the best evidence yet of the direct links between the use of antibiotics in food production and the detection of drug-resistant pathogens in animals, food, and humans.
Worldwide, more and more first- and second-line antibiotics, critically important for humans, have been rendered useless by the development of resistance, which is strongly linked to overuse of these fragile medicines.
With few replacement products in the pipeline, the world is moving towards a post-antibiotic era in which common infections will once again kill.
As host of the G20 summit in September, China was able to include antimicrobial resistance on the agenda and in the outcome communique.
China is extremely fortunate to have a President who has made health the centre of all government policies. All policies made in all government sectors need to include a health impact assessment.
In this way, China can ensure that the consequences of its rapid modernization and economic progress make people healthier, not sicker.
As China develops its One Belt, One Road Initiative further, I ask that you keep in mind the many economic and trade-related factors that can so quickly undo decades of steady progress in improving health.
Acknowledging and addressing these factors is another way to promote peace and cooperation, openness and inclusiveness, mutual learning and mutual benefit.
A world that is greatly out of balance in income levels, opportunities, access to health care, and health outcomes is neither stable nor secure.