Healthcare Reform in China:

The future looks bright for China in terms of healthcare reforms according to this summer’s report from McKinsey & Company. The report outlines three themes in the reforms:

1) Continuation of economic and demographic trends in China
2) Further healthcare reforms to follow
3) Certain policies articulated in the government’s 12th Five Year Plans.

McKinsey also outlined 8 principles that are essential to long-term success for multinationals in China.

China’s reforms will continue to be fueled by current economic and demographic trends such as continued urbanization, increase burden from non-communicable disease, the expansion of the economy overall, income growth effects, and a new focus on health care as a strategic reform. Increase coverage in insurance will also provide leverage for individual access to healthcare, and people with under-diagnosed diseases (cancer, depression) will be more likely to seek treatment.

China’s healthcare reforms began in 2009 and has had unprecedentedly impressive progress. Of course, China is only at the beginning stages of its health care reform and has a long way to go in terms of public hospital reforms, rural healthcare access, and mismatched progress between provinces, rural/urban areas, and West-coast/Central China. Most policy and political experts agree, now that central government has a wide reach in terms of insurance coverage, the next step is for China to focus on the quality of provisions.


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Cornell China Conference

This weekend Cornell hosted its first annual Cornell China Conference. A hearty congratulations to the organizers! Two short highlights of today’s events:

– World Bank Chief Economist Kaushik Basu’s opening remarks, where he discussed China’s role as an emerging economy  in the global financial system.

– Panel discussion on US-China relations, where a heated debate ensued regarding critical rhetoric of both Chinese and US politicians and media.

Looking forward to tomorrow’s sessions on “Education and Talent Development” and “NGO’s and Civil Society”. I am also live-tweeting during the conference @Ljdubbz, #cornellchinaconference

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How to make our research in China relevant

With healthcare costs in China rising rapidly in the recent decade (and nutrition and dietary practices driving much of this cost), how researchers begin to put their findings into action is becoming especially salient. Researchers and policy-makers have done much to promote childhood vaccines in China, and have had successes reaching even the most rural households. In terms of nutrition, however, what are the major questions and problems facing the general public, and how can researchers collaborate with policy advocates to find workable solutions to these issues?

Unfortunately, vaccination dissemination and nutrition education may have little in common when it comes to how policy makers design health programs. Vaccination programs in China tend to be straightforward, with its applications black and white. There is a vaccine that has been proven to work, and medical personnel need to use this vaccine to immunize the public. Policy-makers then design a standardized vaccination schedule based on clinic visits. Children are inoculated with the vaccine, and specific illnesses no longer pose major public health threats.

Nutrition education and behavioral change does not work so easily. Factors such as context and economic status become overpoweringly important, and standardized procedures do not often result in behavioral change or better nutritional outcomes. Rural and urban divides make creating country-wide campaigns extremely challenging, and rapid economic and social development may make programs irrelevant soon after their inception.

There is also a gap between understanding and research facing China; there are simply too few people who know what questions to ask in the first place, much less design studies that will improve nutritional programs and policies. In my research with infant feeding, I realized fairly quickly just how little is known about behavior and opinions surrounding breastfeeding. It is very challenging for public health advocates to promote better infant feeding practices when they aren’t even clearly aware of what current practices are.

The U.S., of course, is notorious for research backlogs, with researchers and policy-makers facing completely different agendas. The gap between clinical research and evidence-based practice seems to grow wider with each academic year. Funding may be allocated to research projects that may not be particularly useful to improving pressing health issues because of a number of reasons; practitioners may be less inclined to follow evidence-based guidelines if they don’t fall in line with their experience; programs may not have the resources to implement the latest innovations.

Will China follow the U.S.’s example and turn into a back-logged bureaucracy? Or will they start to adopt a research system basing evidence on practice and practice on evidence?

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Worth the Read: Violence Against Physicians on the Rise in China’s Hospitals

An article by Bloomberg WorldView blogger Adam Minter (also writes for his own blog, Shanghai Scrap) came out a few days ago, Violent Crimes in China’s Hospitals Spread Happiness. A morbid look into the opinions of China’s netizens, Minter paints a picture of a healthcare system in disarray, where violence against physicians is on the rise, physicians are in the midst of an identity crises, and the Ministry of Health is desperately trying to hasten reforms to stave off more attacks.

While it may be easy to vilify physicians given the current healthcare climate in China, Minter notes that there is growing support for physicians, stuck in a profession where the main way to make ends meet is to accept bribes and prescribe unneeded prescriptions. In my own interviews and experiences working with physicians all over China, I can attest that Chinese MD’s themselves see the whole system as flawed. One young intern I spoke with reported that the way to improve the profession was to “improve the incomes of the doctors. In China, poor doctor-patient relationship and distrust of doctors all resulted (si from the low doctor’s income. The patient think that the aim of doctors is making money instead of helping them. This is a very serious problem. Many doctors resigned because of the poor doctor-patient relationship.”

With major problems in healthcare provider shortages in China, what impact will this have on people going into medicine in China?

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School Nutrition Programs Gaining Momentum

School nutrition programs are garnering more support in China this week, this time with the health of the Global Child Nutrition Foundation, the Chinese Ministry of Health, and Chinese basketball legend Yao Ming.

By-Health, a nutritional supplement company, has agreed to pay over 1.5 million dollars over the next three years in order to help improve the nutritional status among school children in China. The plan includes free nutritional tests, a national health report, funding for college, and voluntary teaching at schools in poor regions.

The Global Child Nutrition Foundation, who is collaborating with By-Health on the project, also has research projects underway in rural Sichuan (see the needs assessment here). Another foundation, the China Development Research Foundation recently released a survey of 1,400 students showing the surveyed rural students with higher rates of stunting and lower weights than their urban counterparts.

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New app on eating well in China

Received this news this morning, and am happy to pass it along to all who may be interested:

The Eat Well China app is perfect for anyone traveling and/or living in China.  
On a business trip to Guangzhou and you want to find a good vegetarian restaurant, tap on the listings and several will pop up before your eyes.  You have a visitor coming that is allergic to gluten ? Tap on the special diets tab and find restaurants, support groups and Mandarin phrases to help you along.  How about you just want to take a cooking class in Shanghai or Beijing ?  Eat Well China has that information ready to download at the tap of your finger.

Eat Well China App Available in iTunes Store 
GetAttachment-6.aspxWritten by registered dietitians Margaret Keefe, RD and Julie Meyer, RD, Eat Well China apps provide YOU with exclusive information on:

  • How to Eat Well:  Take a tour of a local fruit and vegetable market, decode food labels and organic regulations, discover nutrition insights from Chinese families and how to NOT spend your whole trip in the bathroom!
  • Where to Eat Well:  You will not go hungry when nutritionist-approved restaurants, markets, cooking schools and delivery services are easy to find with location-based technology.
  • Eating Well with Special Dietary Needs:  Vegan?  Gluten-free?  Kosher?  Wanna ask the nice waiter to NOT put pork in your veggie fried rice?  Audio files to the rescue!  One click and your special diet needs are effectively communicated in native tongue.
  • Eat Well At Home:  Healthy, authentic recipes written by amazing local chefs Ignatius Lau and Anthony Zhao available in English and Mandarin.

For any questions on using the app, email to  and for more tips on on eating well in Shanghai.     

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The Nutrition Transition

Due to shifts in food prices, urbanization, and the global food supply, the co-existance of undernutrition and obesity is becoming more prevalent. High calorie foods such as vegetable oil and sugar sweeteners are now cheaper than they’ve ever been. Because of this, dietary shifts are accelerating, and non-communicable disease stemming from overconsumption of high fat, high sugar foods are increasing. The “nutriton transition” refers to this trend; one from where causes of morbidity and mortality are transitioning away from infectious disease and undernourishment to non-communicable disease such as cancer and coronary heart disease.

This is especially so in low- to middle-income countries including (and perhaps especially) China. Dietary shifts to higher calorie foods (high fat, sugar) have economic causes and consequences, affecting individuals in China across the board. Urban Chinese remain at higher risk for obesity than rural, but seeing overweight rural resident’s is not unheard of.  Body composition (risk for obesity) is of course affected by physical activity, genetics, and energy expenditure as well as calorie consumption, so urban residents are typically at higher risk for obesity as they are more sedentary and have lower energy expenditure.

Community healthcare worker in rural China

But not all rural resident’s are farmers or expend high amounts of energy doing manual labor. Burden’s of disease are shifting world-over, and it’s important for those designing and implementing healthcare research studies, shaping policies, or working toward healthcare reform. Working in rural schools can be especially challenging, as teachers are dealing with high rates of undernutrition, but need to face the omnipresent threat of overweight an obesity as well. This can be done by physical activity programs, school garden programs, or culturally appropriate and geographically contextual healthy eating programs.

Time and again in China I heard people remarking that in the U.S., poor people are at risk for obesity whereas in China, it is the rich. Unfortunately, this is not the case. Obesity is a worldwide presence, and it makes no difference any more whether you are rich, poor, from China or Nigeria. Burdens of disease have shifted, or “transitioned”, world-over.

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China Raising the Poverty Line

As you have probably heard, China has raised their poverty line to 2,300RMB a year, meaning there are about 100 million new poor people accounted for in China, bringing the total to 128 million (2,300RMB stacks up to a little less than $1.00 a day). More than China’s recent poverty line of $229 a year, China’s new standards better reflect international norms of $1.25 a day.

For those of you who are wondering, The Economist recently ran a story “China’s poverty line: Life at the bottom of the middle kingdom” and breaks down exactly just how far 2,300RMB goes in China in terms of current purchasing power. While I appreciate the breakdown of how poor is poor really, I’m unconvinced that 2,300RMB is an appropriate metric of poverty in China.

I remember during my first visit to rural Yunnan in the Spring of 2011, leafing through booklet’s of self-reported incomes, and noting over and over the box next to “less than 1,000RMB” checked ($150 a year). I asked the medical students I was working with if they thought this was enough to live off. “Of course not!” they laughed. “Why do you think so many young people are going to the cities to work?!”

The houses where the “young people” had left to work were obvious. Money had brought concrete and tile exteriors, larger rooms, and insulation to the migrant’s house. Those whose relatives weren’t able to leave for the city still lived in broken down brick houses that were usually in need of repair. The picture to the left illustrates this quite well, with the left houses being houses of migrants, and the house on the right not. As overviewed in the article in The Economist, average incomes aren’t a good metric for the entire country in China as prices in the cities are much higher than those in the countryside. While I can’t speak for the “average” price to redecorate or upgrade your house, I think it’s obvious what benefit having someone in the family bringing in capital from the cities (migrants can make ~1,200RMB a month).

However, housing and daily necessities aside, these rural people were still without good access to healthcare, education for their children, or social services. Electricity was on and off, and internet would be available only sporadically. Farmers were making less and less, but costs of living were going up and up. The topic of conversations strayed little from inflation, housing prices, and the lack of young people living in the community.

While I understand why these metrics for “poverty” are necessary to bring awareness to the international community, they tend to be overstated and oversimplified. Success and poverty should not be measured by monetary capital. A human development index is something that can bring more awareness to the problems that everyday people in these countries face, including access to proper nutrition information, safe food, and healthcare.

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For All the “Early Origins” Peeps Out There…

The 63 page supplement “Early origins of health: The role of maternal health on current and future burden of chronic noncommunicable diseases” is now available from the International Journal of Gynecology and Obstetrics (available here under special issue). It includes about 15 articles on many facets of the early origins theory, including implications for policy.

I recommend you leaf through this if you are at all interested in maternal and child nutrition research and/or policy, specifically if you’re interested in the development of type two diabetes, gestational diabetes, or anemia during pregnancy.

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Anemia in China’s Rural Schools

Written apparently by a nutritionist, this article quotes an economist who I haven’t worked with directly, but have done work with his rural educational project in China:

“For 5,000 years it was OK to be anemic if you’re never going to leave the farm,” said Rozelle… who is still experimenting with ways to improve children’s health in rural China and get the government to adopt the most effective methods.

“But we’re looking 20 years into the future where there are much fewer farms and you need at least a high school education to make a living in the city,” Rozelle said. “If you are sick with anemia, it is going to affect your cognitive ability, educational performance and ultimately your chances of going on in school.” (see this story for more information).

So it’s okay to be stupid…if you’re a farmer? Having known a number of farmers in my day, I can dutifully say that farmers are not stupid, and need every ounce of brain power they can muster. Grain and vegetable prices, calculating seed time to harvest, weather patterns…I could go on and on.

And this isn’t to even mention that anemia affects much more than cognitive ability. Iron deficiency anemia is a condition where the body doesn’t make enough red blood cells, so can affect any body system that requires red blood cells to function. Symptoms of anemia include fatigue, weakness, dizziness, irritability…all symptoms that do not particularly bode well for farmers. If left untreated, anemic individuals may have lasting organ damage, even die.

So no, being anemic for 5,000 years was never okay simply because you were a farmer. The problems of anemia and undernutrition in China’s rural schools do not have to do solely with traditional foodways or the ignorance of farmers. Undernutrition in China’s rural areas is multifactorial, and has to do with poverty, limited access to healthcare, limited education resources, the breakdown of social networks, and yes, nutrition education. Because of this, it takes economists, educators, nutrition professionals and public health workers to tackle the problem of rural undernutrition in China. And I continue to think of the above educational project as a model that should be celebrated, emulated, and otherwise mimicked as a global model for promoting school meal programs. But without a nutrition specialist or expert on their research staff, these programs remain limited in scope.

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