Comment
Chinas economic growth is closely integrated with
its global role, and Chinas health development can be
anticipated to continue to have global dimensions. The
investment and scale of Chinas global health strategy
will expand both the interests of global health and
Chinas diplomacy.
*Ren Minghui, Lu Guoping
Department of International Cooperation, National Health and
Family Planning Commission, Beijing 100044, China
renmh@nhfpc.gov.cn
RM is the Director-General for International Health in the National Health and
Family Planning Commission and the Chinese Governments principal
representative on global health. We declare no competing interests.
1 Han Q, Chen L, Evans T, Horton R. China and global health. Lancet 2008;
372: 143941.
2 Liu P, Guo Y, Qian X, Tang S, Li Z, Chen L. Chinas distinctive engagement in
global health. Lancet 2014; 384: 793804.
3 Zhu C. Chinas health diplomacy: sharing experience and expertise. Global
Health 2012. Geneva: The Graduate Institute, 2012. http://www.gov.cn/
gzdt/2012-05/25/content_2145204.htm (accessed June 16, 2014).
4 Liu E, Rou K, McGoogan JM, et al. Factors associated with mortality of
HIV-positive clients receiving methadone maintenance treatment in China.
J Infect Dis 2013; 208: 44253.
5 Yin W, Hao Y, Sun X, et al. Scaling up the national methadone maintenance
treatment program in China: achievements and challenges.
Int J Epidemiol 2010; 39 (suppl 2): ii2937.
Globalisation and environmental health in China
As one of the most rapidly growing countries and the
largest energy consumer in the world, environmental
pollution in China, including that of air, water, and
land, puts its people at risk of many acute and chronic
diseases.1,2 Recent reports that more than half of Chinas
groundwater is polluted, and of so-called cancer villages
where increased incidence of cancer might be due to
industrially polluted water along the Huai river, have
sparked public outcries.3 In todays global economy,
products are manufactured and traded around the
world. In the context of this increasing globalisation,
measurable amounts of pollutants from China are
spreading overseas via both natural and human means,
resulting in substantial global health concerns.
Among the many environmental challenges in China,
ambient air pollution might pose the biggest risk to
population health. The Global Burden of Disease study
estimated that, in 2010 in China, ambient air pollution
alone cost more than 12 million lives and 24 million
healthy years of life.4 In the meantime, the strong increase
of air pollution in China has subjected its east Asian
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6 China Tuberculosis Control Collaboration. Results of directly observed
short-course chemotherapy in 112 842 Chinese patients with
smear-positive tuberculosis. Lancet 1996; 347: 35862.
7 Chen X, Zhao F, Duanmu H, et al. The DOTS strategy in China: results and
lessons after 10 years. Bull World Health Organ 2002; 80: 43036.
8 Ren M. China and global health. The 45th Asia-Pacic Academic
Consortium for Public Health; Wuhan, China; Oct 2427, 2013.
9 Qian W, Haochao L. Study on the ratio of Chinese total health expenditure
to global total health expenditure. Med Soc 2013; 26: 58.
10 Mengjie H, Kuo NT, Hong H, et al. ChinaAfrica cooperation on the
prevention and control of AIDS. The pathnder in new phase of ChinaAfrica
health cooperation. Beijing: World Aairs Press, 2013: 3691.
11 Hoekman A, Hong L, de Bernis L. Strengthening the reproductive health
systems in African countries through ChinaAfrica health cooperation. The
pathnder in new phase of ChinaAfrica health cooperation. Beijing: World
Aairs Press, 2013: 92149.
12 Bosman A, Ki-Zerbo G, Gaborone M, et al. ChinaAfrica collaboration on
malaria, control and elimination. The pathnder in new phase of ChinaAfrica
health cooperation. Beijing: World Aairs Press, 2013: 20637.
13 Xiaofeng L, Feng C, Jiankang Z, et al. Analysis of potential areas for
ChinaAfrica cooperation on immunization. The pathnder in new phase of
ChinaAfrica health cooperation. Beijing: World Aairs Press, 2013: 238311.
14 Chen L, Stirling M, Zhao C, Schwartlander B. Chinas capacity in producing
quality ARVs for domestic and global needs. The 3rd Round of ChinaAfrica
Health Cooperation; Beijing, China; June 1213, 2012.
15 WHO. News release: newly accessible Japanese encephalitis vaccine will
make saving children easier in developing countries. 2013. http://www.who.
int/mediacentre/news/releases/2013/japanese_encephalitis_20131009/en/
(accessed June 16, 2014).
16 Hui L, Ming X. In-depth changes in pharmaceutical trade: situation review
in 2012 and outlook in 2013. 2013. http://www.cccmhpie.org.cn/
Pub/1757/82973.shtml (accessed June 16, 2014).
neighbours to acid deposition and dust storms.5 Another
issue of importance is the development of atmospheric
brown clouds caused by air pollution from Asian
countries, including China.6 More recently, the eect of
Chinese air pollutant emission on air quality in the western
Rolex Dela Pena/epa/Corbis
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 Comment
USA has received public attention.7 Overall, airborne
pollutants from China are estimated to have caused
around 30 000 additional deaths outside the country.8
Interestingly, although the western USA has experienced
reduced air quality due to transpacic pollutants from
China, air pollution in the eastern USA decreased as the
USA outsourced manufacturing to China.7
Climate change is increasingly recognised as a major
threat to global health. In 2007, China surpassed the
USA as the number one emitter of carbon dioxide
(CO2). Chinas CO2 emissions continue to grow faster
than those of other major countries, with a projected
increase of 55% from 2011 to 2020;9 this is about three
times the total amount of reduction that the European
Union and USA combined have committed to achieving
over the same period.9 Climate change has both
directly and indirectly aected human health globally,
including mortality due to extreme weather events and
natural disasters, polluted air and water, and emerging
infectious diseases. Notably, most of these adverse
health eects are expected to be greatest in low-income
populations.10 In this sense, China could play a crucial
part in resolving global climate change and related
health eects.
Another issue resulting from globalisation of the
world economy is that China, as a world factory
exporting products to developed countries, consumes
its own natural resources and leaves pollutants behind
in China.11 For example, in 2006, 36% of sulphur dioxide,
27% of nitrogen oxides, 22% of carbon monoxide,
and 33% of CO2 emitted in China were associated
with production of goods for overseas markets.7 Also,
largely driven by illegal exportation of electronic waste
by developed countries, China processes 70% of the
electronic waste generated worldwide.12
China aims to double its 2010 gross domestic
product (GDP) by 2020, in the face of ever more serious
environmental pollution. In a continually globalising
world economy, both domestic measures and
international cooperation are needed for China to tackle
these challenges.
The Chinese Government has decisively embarked
on a strategic transformation, from GDP-driven
development to a balance between environmental and
economic development and building an energy-saving
and environment-friendly society. Consequently, it
has become a national economic priority to transform
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Chinas manufacturing economy to a high-added value
and low-emission economy.
In addition to traditional environmental policy through
administrative ats, Chinas nance and environmental
authorities need to use market-based mechanisms (eg,
environmental tax) to achieve the countrys pollution-
abating goal. Also, Chinas environmental authorities
need to consider air quality issues and climate change
together because, to a large extent, major air pollutants
and CO2 stem from the same sources. This link might be
of special importance in Chinese cities with high urban
population densities and high emissions of air pollutants
and CO2. Scientic studies on the eect of environmental
pollution on public health should also be encouraged in
China. For example, new studies are needed in the country
to investigate whether widely used air puriers and
facemasks have protective eects on air pollution-related
health hazards, especially during heavy smog days.
In addition to domestic eorts, China also needs
international collaboration to tackle environmental
pollution eectively, particularly on cross-border air
pollution, climate change, and electronic waste treatment.
Because developed countries contribute to Chinas
pollution through trade, and per-head CO2 emission is still
lower in China than in developed countries, China still has
the moral right to develop. Developed countries can help
China to protect its environment via training and capacity
building, transfer of environmental knowledge, and
environmentally benign technologies. One example is the
AirNOW international monitoring system launched by
the US Environmental Protection Agency and Shanghai
Municipality. China provides unique internationally
collaborative opportunities for environmental health
research in view of its enormous population and relatively
high concentrations of environmental pollutants. Also,
China should learn from developed countries lessons
about the dangers of putting economic gains ahead of
human welfare and environmental conservation.
Chinas environmental problem is an important
issue for global health. Chinas success in tackling
environmental challenges will not only improve the
health of the Chinese population, but also health globally.
Serious and appropriate actions on environmental
pollution in China will undoubtedly lead the Chinese
Government to its goal of building a sustainable
economy and a harmonious society. A good example
is the recent amendment to Chinas Environmental
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Protection Law, which will take eect on Jan 1, 2015,
and provide powerful weapons in the war on pollution.
Meanwhile, the Chinese Government needs to overcome
policy and institutional barriers, such as the lack of
mechanisms for interdepartmental coordination and
involvement of health authorities in environmental
management, and inadequate stang at both national
and local levels.
Haidong Kan
School of Public Health, Fudan University, Shanghai 200032, China;
and Global Health Institute, Fudan University, Shanghai, China
haidongkan@gmail.com
I declare no competing interests. I thank X Yang for his comments.
1 Chen Z, Wang JN, Ma GX, Zhang YS. China tackles the health eects of air
pollution. Lancet 2013; 382: 195960.
2 Zhang J, Mauzerall DL, Zhu T, Liang S, Ezzati M, Remais JV. Environmental
health in China: progress towards clean air and safe water. Lancet 2010;
375: 111019.
Can China age healthily?
China has more older people (65 years and older) than
any other country. According to the 2010 census,1
the number of people aged 65 years and older was
119 million, 89% of the population. Moreover, Chinas
population is one of the fastest ageing in the world.
Although developed countries took around half a
century to double the number of people aged 65 years
and older (from 7% to 14%), China will do so in half that
time.2 By 2050, Chinas ageing population will match
that of many of todays developed countriesand
exceed that of countries such as Denmark, New Zealand,
Australia, and the USA.3
Ageing in China has three distinctive features. First,
Chinese people by tradition rely on their family for old-
age support. Unlike high-income countries where the
net nancial transfers of family resources ow from
older generations to children, the reverse is the case in
China. Because family resources are the main protection
against poverty in old age, the nancial and care demands
on families will be severely stretched in years to come.
Second, Chinas population has also had a large decrease
in its proportion of children, partly as a result of the
One Child policy implemented in the late 1970s. The
rst cohort of parents aected are now in their 50s, and
the eects will be noticed in the next two decades as
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For personal use only. No other uses without permission. Copyright 2017. Elsevier Inc. All rights reserved.
Comment
3 Yang G, Zhuang D. Atlas of the Huai river basin water environment:
digestive cancer mortality. Dordrecht: Springer Science and Business, 2014.
4 Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden
of disease and injury attributable to 67 risk factors and risk factor clusters
in 21 regions, 19902010: a systematic analysis for the Global Burden of
Disease Study 2010. Lancet 2012; 380: 222460.
5 Carmichael GR, Streets DG, Calori G, et al. Changing trends in sulfur
emissions in Asia: implications for acid deposition, air pollution, and
climate. Environ Sci Technol 2002; 36: 470713.
6 Gustafsson , Krus M, Zencak Z, et al. Brown clouds over South Asia:
biomass or fossil fuel combustion? Science 2009; 323: 49598.
7 Lin J, Pan D, Davis SJ, et al. Chinas international trade and air pollution in
the United States. Proc Natl Acad Sci USA 2014; 111: 173641.
8 Saikawa E, Naik V, Horowitz LW, Liu J, Mauzerall DL. Present and potential
future contributions of sulfate, black and organic carbon aerosols from
China to global air quality, premature mortality and radiative forcing.
Atmos Environ 2009; 43: 281422.
9 Yang Y, Zhang J, Wang C. Is China on track to comply with its 2020
Copenhagen Carbon Intensity Commitment? 2014. http://ssrn.com/
abstract=2346516 (accessed July 14, 2014).
10 Patz JA, Campbell-Lendrum D, Holloway T, Foley JA. Impact of regional
climate change on human health. Nature 2005; 438: 31017.
11 Liu J, Diamond J. Chinas environment in a globalizing world. Nature 2005;
435: 117986.
12 Ni HG, Zeng EY. Law enforcement and global collaboration are the keys to
containing e-waste tsunami in China. Environ Sci Technol 2009; 43: 399194.
they begin to need support and care. Finally, China is
undergoing rapid urbanisation characterised by a massive
migration of younger workers from rural regions. The
disruption of family structures across generations might
further weaken the ability of families to care for older
parents, many left behind in rural areas.
Ultimately, however, the health of the older
population determines its need for care. Non-
communicable diseases have emerged to replace
infectious diseases as the leading causes of death in
Vince Streano/Corbis
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