China surprised me in a number of ways during my Project HOPE meetings, interviews, and hospital visits in Shanghai, Beijing, and Hangzhou. What’s interesting is that the patient needs and priorities in China, as I’ve found, seem very different from a number of neighboring countries. This is a product of distinct cultural patterns, family lifestyles, eating habits and government healthcare policies – all of which are rapidly changing the healthcare needs of patients everywhere in China. In a number of countries so far, I’ve been able to walk down the street and pick out individuals who show clear signs as being high-risk for Type 2 diabetes and other chronic conditions. In China this wasn’t exactly the case.
Diabetes: China is #1
According to the latest research, a population-based study of 46,000 from the New England Journal of Medicine (NEJM), China has the highest prevalence of diabetes in the world with an estimated 92.4 million1. This is almost double the WHO’s estimations of 43.2 million in October of 20092. Either way, this is enormous. To put this in perspective, the diabetes prevalence in China is 1.5-3X greater than the GLOBAL prevalence of HIV/AIDS today (32.9 million)3.
The NEJM article has actually stirred some issues with the Ministry of Health (MOH) in China who has rejected the NEJM figures entirely. The MOH also produces reports detailing health metrics in China and their data is quite different. I had Pan Chengrui, Project HOPE’s Program Officer for their chronic disease programs, actually walk me through every chart in the MOH’s 28 page chronic disease report from 2006 (only available in Mandarin). The impressive document is extremely detailed and went through virtually every disease state we could have researched for Project HOPE (note China does not have electronic medical records so I’m guessing this is also population based). According to the report, an estimated 6.07% of urban, 3.74% of suburban, and 1.83% of rural people in the country have diabetes. In comparison, this is about half the prevalence rates in India.
All things considered, I have hope for China and diabetes prevention. In interviewing physicians, diabetes educators, and patients, I found that although the current resources (primary care training, patient education materials) are limited, patients are fairly open to lifestyle change in general. When physicians tell them to eat differently, most of the time they do. This sounds easy, but it is REALLY very difficult – this is a permanent change to habits that have been developed and reinforced over years and years. I also noticed that unlike Mexico or India, I had a difficult time identifying people who appeared to be high-risk, for example people who are overweight or obese. While these rates are high, 28.1% for overweight and 9.8% for obesity in urban areas; this is about half that of the US or Mexico where over 60% of the population is overweight or obese.
Still, the warning signs are there. China’s food is heavy on meats with an array of traditional foods that with increased consumption will undoubtedly drive obesity rates and diabetes. China’s infrastructure is also very car friendly and as the family income increases, it’s very likely that in a few years you will see more sedentary lifestyles and fewer bicycles on the road.
Hypertension: A National Crisis
Learning about hypertension in China has been one of the most interesting experiences in my research to date. Hypertension is a huge need and serious health concern for Chinese citizens. This is partially due to genetic propensity, but largely to do with the Chinese diet. In Shanghai, we interviewed Dr. Ji-Guang Wang, the Vice Director of the Shanghai Institute of Hypertension and Professor at the Shanghai Jiaotong University School of Medicine. He is considered one of the top 3 hypertension specialists in China and had some extremely interesting insights to share with us:
- About 200 million people with hypertension in China
- Only 30% of the general population is aware of the dangers of high hypertension (and the need to be screened)
- Stroke is the #1 killer in China and have doubled in the past 10 years
- Chinese citizens ingest 2-3X (12-18g) the recommended salt intake per day (6g)
- Potassium deficiencies make some effective treatments for hypertension unusable for a large percentage of the population (and can also lead to an early onset of diabetes)
What are the dangers of hypertension? Hypertension is a condition in which the blood pressure in the arteries is elevated. Over time, this basically wears our your blood vessels and is the leading risk factor for strokes, heart attacks, heart failure, and chronic kidney failure (kidneys are the highest in demand for transplants among that of any organ). Hypertension is usually asymptomatic, but if you read through the long list of potential symptoms – it’s basically anything you might experience with a cold or stressful work week: headache, drowsiness, confusion, vision disorders, nausea, and vomiting.
Improving hypertension rates involves significant awareness efforts and lifestyle changes: reduced salt consumption, reduced alcohol consumption, no smoking, increase physical activity, increase water intake. Dr. Wang has struggled with lifestyle changes with his patients with respect to salt in particular. Adjusting sugar or carbohydrates for diabetes is one thing, but no soy sauce? Dr. Wang has even proposed an innovative approach to helping with this problem: change the amount or type of available salts in the grocery store. Introducing potassium chloride (KCl) with sodium chloride (NaCl), for example, which would also eliminate the potassium deficiencies and help improve treatment options.
I spoke with a patient whose father died of stroke a few years prior. She was tall, thin, and seemed fairly physically active. I asked her about her hypertension experiences. She says that no matter how well she eats and how much she exercises, she cannot control her hypertension. She’s eliminated a number of salt sources but believes that her genetic propensity makes it “a lost battle” for her. The NIH currently has a sponsored study in progress to examine the impact of reduced salt intake on hypertension levels in China. Let’s hope this battle is not lost!
COPD, and Sleep Disorders: High Prevalence, Low Awareness
Smoking with obesity are the leading causes of Chronic Obstructive Pulmonary Disease, commonly referred to as COPD, in addition to a number of deadly sleep disorders (did you know sleeping can be deadly?)4. Smoking is a major concern in China. While only 3% of females smoke, 66% of all men smoke in the country. Although this is decreasing (both in prevalence and the quantity smoked per person), this is very “cultural” and reinforced in both work and personal settings, primarily for men. So why is smoking such an issue here? An estimated 8% of the population over 40 years old has COPD. In addition, lung cancer is the leading cause of cancer deaths in China (about 3.0 M) followed by prostate cancer (2.8 M) and stomach cancer (2.7 M).
Awareness is very low for COPD and sleep disorders among patients globally. COPD is a long-lasting obstruction of the airways that occurs with chronic bronchitis, emphysema, or both. The primary cause is smoking and the airway blockages over time can have serious and sometimes deadly implications while sleeping. When the airway is blocked, the personal sleeping actually stops breathing for a period of time (sometimes several minutes!) and is subconsciously aroused, enough to disturb the REM cycles but not enough to fully wake the sleeper. Over time, the duration of breathlessness is extended and a person can actually suffocate in their sleep by the blocked airway.
A major challenge is that the symptoms are often hard to identify– mostly tiredness or insomnia because patients are inhibited from getting a good night’s rest. A person has to go to a “sleep lab” to get diagnosed with a PSG test where their breathing is monitored overnight. In China the risk factors are very high and require more attention to encourage patients to seek help.
Treatment for COPD is another challenge – the CPAP. CPAPs are masks worn to bed that control the person’s breathing and prevent blockages form occurring. Often described as “Darth Vader masks,” patients have challenges with compliance because they can be cumbersome to wear and unattractive if you have a spouse or partner – but remind you, these are life saving devices. They are also fairly expensive in markets like China where personal devices are not covered and all paid out of pocket.
CAD and Osteoporosis: High Priorities
There are number of other high-priority chronic diseases in China that I would see as a focus with hypertension, COPD, and diabetes. Coronary artery disease (CAD) is caused my plaque blockages in the coronary arteries composed of fat, cholesterol, calcium, among other substances. This prevents oxygen-rich blood from getting to the heart, leadng to heart failure or heart attacks, and is the leading cause of death in the US. Coupled with stroke – CAD is a substantial cause of global deaths annually. China’s diet of heavy and fatty meats (a.k.a. bad cholesterol) contributes to the growth of high-risk populations and makes it a vital priority for the country to focus on prevention.
Another priority that surprised me during my interviews was osteoporosis. I honestly had never thought of this because it’s perceived in the US as a condition that mostly women encounter after menopause (and it’s not on the MOH priority list or radar in other developing countries). However, an orthopedic and rehabilitation specialist in Beijing urged me to think about the impact that osteoporosis has on the growing aging population. After doing some research, I found that in addition to post-menopausal women, people with high protein diets, vitamin D deficiencies, excess alcohol, or smoking habits are also at risk for osteoporosis. An estimated 1.2 million fractures per year are associated with osteoporosis in the US (700k vertebral, 250k wrist, and 250k hip fractures). In a society where multiple risk factors are hit by a large percentage of the population – this can have a huge impact on the aging health and lifestyle (especially with costs associated with orthopedic surgeries and rehabilitation).
China: A Nation in Flux
China has gone through a whirlwind of changes economically, culturally, structurally in the past 10 years. These changes all have dramatic effects on the lifestyle and choices each person makes – and subsequently personal health. Where do I live? What do I feed my family? How do I get to work?
From what I’ve witnessed over the past two weeks, the Ministry of Health in China has actually worked hard to change with the times and stay in touch with the needs of patients. Over the past three years, China’s government spend on healthcare has more than doubled and total expenditures have increased with a 15% CAGR5 since 2002. This is an astounding financial dedication to improving access and quality of care. For any health initiative in China, understanding the MOH’s priorities is an imperative, both for financial and relationship-management reasons.
In Shanghai I spoke with one of the leads for China’s Center for Disease Control and Prevention (referred to as the China CDC) who discussed their focus on improving capacity at the primary care levels and restructuring the referral system across China’s healthcare system (Tier 1, Tier 2, and Tier 3 hospitals). The government seems very transparent about its focuses in healthcare and strategic plans to help patients in both urban and rural areas. For example, the Town and Village Doctors in the rural areas (previously known as “barefoot doctors”) are a large focus for improving care and referral systems to patients with minimal resources compared to cities like Shanghai and Beijing.
Either way, working with the government and local champions in China is a must. It is nearly impossible to be successful going against the grain of the government, but that’s not to say there’s no place for advocacy here – it’s just much trickier. As China becomes a more and more developed (even first world) country, it will be interesting to see how this changes international development initiatives in the region and especially the urban areas. Shanghai and Beijing were in some ways much nicer than many cities in the US. Although China’s used to being a recipient country for these funds, my sense is that the funding will change (and should change) in quantity or program focus over the coming years. As the government steps in to do more vaccination programs, for example, non-profits have to re-think their role in helping patients in these communities. What gaps are left to fill?
For Project HOPE, I think supporting patient education efforts could be a huge impact. Having worked with the government leads over the past 12 years to train diabetes educators (physicians and nurses in Tier 3 and Tier 2 hospitals), they can better support them with tools and programs that work to effectively deliver messages to patients in addition to medically treating diseases. New programs focused on obesity/nutrition education (not a specific government focus) would help prevent hypertension, “diabetesity”, coronary artery disease, osteoporosis, and many COPD cases. Smoking cessation is already a large government focus – but what else can be done?
Health Information is Power
It is becoming more universally apparent to me that health information is power. China has been working on electronic medical record (EMR) and medical informatics solutions to track patients and deliver better care and corresponding outcomes. I spoke with Jianbo Lei, Director for Medical Informatics at Peking University Medical Center Hospital (PUMCH) who showed me some of the EMR solutions they are working on (so cool!). Technology in many ways has opportunities to improve access and quality of care, but the data that is developed also helps the MOH validate national priorities and stay in tune with the changes in the population. I watched as one of the physicians entered in several pages of hand-written notes into the EMR system (note – the physicians do this themselves, not nurses/administrators to avoid errors). This is an extremely time consuming process and will likely have to be streamlined before being rolled-out nationally.
Physician entering in patient data for the EMR system - look at all those files on the right!I noticed during my time in China that many restaurants use PDA’s as a way for the waiters to electronically order food by table. As I request steamed bok choy, she is simultaneously penning the stylus on the PDA screen. Could this same technology be used for medical records in China? During the initial examination, could the physician record the patient’s height, weight, blood pressure, etc. into the PDA and upload it wirelessly to an integrated system? I found that in China the average cell phone user receives about 10 spam text messages per day, making it a less effective way to deliver health information to the masses. Mobile EMR platforms could be an interesting extension of China’s current health information efforts. But what other applications or technologies could be used to reach the masses? The answers could easily be found in Indonesia or Egypt... or solutions developed by completely unrelated industries (e.g. the restaurant industry). My eyes and ears will be open over the coming weeks!
For more information you can access the China Photo Album and all interview notes in the China Country Profile page.
Sources:
1. Prevalence of Diabetes among Men and Women in China (NEJM March 2010) http://content.nejm.org/cgi/content/short/362/12/1090
2. China overtakes India as diabetes capital http://timesofindia.indiatimes.com/india/China-overtakes-India-as-diabetes-capital/articleshow/5724579.cms
3. Kaiser Family Foundation http://www.globalhealthfacts.org/
4. China Chronic Disease Report 2006 (link does not work outside of China)
5. Ministry of Health, China; Ministry of Labor and Social Security, China
No comments:
Post a Comment