Measuring progress in health in China and its provinces

Abstract

In The Lancet, Maigeng Zhou and colleagues1Zhou M Wang H Zeng X et al.Mortality, morbidity, and risk factors in China and its provinces, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2019; (published online June 24.)http://dx.doi.org/10.1016/S0140-6736(19)30427-1Summary Full Text Full Text PDF Scopus (1645) Google Scholar present a systematic analysis for the Global Burden of Disease Study (GBD) 2017 on mortality, morbidity, and risk factors in China and its provinces, from 1990 to 2017. Their report is, to our knowledge, the first comprehensive subnational assessment of health in the Chinese population after previous GBD China 2010 on mortality, morbidity, combined health loss, and risks at the national level2Yang GH Wang Y Zeng YX et al.Rapid health transition in China, 1990–2010: findings from the Global Burden of Disease Study 2010.Lancet. 2013; 381: 1987-2015Summary Full Text Full Text PDF PubMed Scopus (1511) Google Scholar and GBD China 2013 on mortality at the national and province level.3Zhou M Wang H Zhu J et al.Cause-specific mortality for 240 causes in China during 1990–2013: a systematic subnational analysis for the Global Burden of Disease Study 2013.Lancet. 2016; 387: 251-272Summary Full Text Full Text PDF PubMed Scopus (955) Google Scholar This study is part of the methodological progress of GBD 2017.4GBD 2017 Causes of Death CollaboratorsGlobal, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 1736-1788Summary Full Text Full Text PDF PubMed Scopus (3582) Google Scholar The findings are more innovative than those of the previous studies because more data have been used, including from the expanded Disease Surveillance Point system, cause-of-death reporting system in hospital and community settings, and cancer registries. Zhou and colleagues’ study1Zhou M Wang H Zeng X et al.Mortality, morbidity, and risk factors in China and its provinces, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2019; (published online June 24.)http://dx.doi.org/10.1016/S0140-6736(19)30427-1Summary Full Text Full Text PDF Scopus (1645) Google Scholar readjusted mortality changes in ischaemic heart disease in GBD 2013 and further confirmed the upward trend in ischaemic heart disease, tracheal, bronchus, and lung cancer, pancreatic cancer, and several diseases and injuries with the age-standardised years of life lost (YLLs) and the age-standardised death rates since 1990 by using broader data. They report that in 2017 stroke and ischaemic heart disease were the leading causes of death and disability-adjusted life-years at the national level in China and that age-standardised stroke, ischaemic heart disease, lung cancer, chronic obstructive pulmonary disease, and liver cancer were the five leading causes of YLLs. An added value of the study is that it describes the situation for control of chronic non-communicable diseases (NCDs) more comprehensively and accurately in China. If assessed only by mortality indicators, the prospects of certain NCDs are encouraging in China. However, the reported age-standardised rates of years lived with disability (YLDs) show substantial increases for cardiovascular disease (20·9%) and neoplasm (87·3%). These rising YLDs are related to the socioeconomic environment and people's behaviour and lifestyle (eg, tobacco use, physical inactivity, unhealthy diet, and harmful alcohol use). With YLLs falling while YLDs rise for these diseases, the numbers of patients being treated evidently increases, which will also result in rising costs of health care and social assistance. Reducing unhealthy behaviours and improving the social environment to reduce the prevalence of NCDs will be important in China. These key findings indicate that various strategies for prevention and control of disease have not been implemented effectively in China. For tobacco control, although the WHO Framework Convention on Tobacco Control came into effect on Jan 8, 2006 in China, the relevant articles of this treaty have not been effectively implemented in the past 10 years or more, and the prevalence of smoking has not substantially dropped.5Yang GH Tobacco epidemic and health risk in the Chinese population.in: Yang GH Tobacco control in China. Springer, Singapore2018: 17-46Crossref Scopus (3) Google Scholar China needs to put into practice the call of the Chinese president for integrating health into all policies.6People's DailyXi Jinping's important speech at the National Health Conference has been received with undiluted enthusiasm.People's Daily. Aug 22, 2016; http://paper.people.com.cn/rmrbhwb/html/2016-08/22/content_1706098.htmDate accessed: June 18, 2019Google Scholar More importantly, disease control requires efforts at the province and local levels. Zhou and colleagues1Zhou M Wang H Zeng X et al.Mortality, morbidity, and risk factors in China and its provinces, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2019; (published online June 24.)http://dx.doi.org/10.1016/S0140-6736(19)30427-1Summary Full Text Full Text PDF Scopus (1645) Google Scholar describe the distribution of the age-standardised YLLs of 20 diseases at the province level. These findings are important for evaluation and promotion of local disease control strategies. However, at present, the geographical distribution pattern of some diseases by province level remains unstable; for example, the age-standardised YLLs for stroke in 2017 are not consistent with the province-level distribution of stroke in GBD 20133Zhou M Wang H Zhu J et al.Cause-specific mortality for 240 causes in China during 1990–2013: a systematic subnational analysis for the Global Burden of Disease Study 2013.Lancet. 2016; 387: 251-272Summary Full Text Full Text PDF PubMed Scopus (955) Google Scholar and data from earlier local studies.7Wei XM Li ZS Yang QD et al.The geographic distribution of stroke in China.Chin J Neurosurg. 1989; S1: 11-15Google Scholar, 8Wu ZS Yao CH Zhao D An epidemiological study on the incidence and mortality of stroke in Chinese population.Chin J Epidemiol. 2003; 24: 236-239Google Scholar The early studies showed a decline in geographical distribution of stroke mortality and morbidity from north to south.7Wei XM Li ZS Yang QD et al.The geographic distribution of stroke in China.Chin J Neurosurg. 1989; S1: 11-15Google Scholar, 8Wu ZS Yao CH Zhao D An epidemiological study on the incidence and mortality of stroke in Chinese population.Chin J Epidemiol. 2003; 24: 236-239Google Scholar The GBD 2013 report indicated high stroke mortality in nine provinces located in the central and western areas of China.3Zhou M Wang H Zhu J et al.Cause-specific mortality for 240 causes in China during 1990–2013: a systematic subnational analysis for the Global Burden of Disease Study 2013.Lancet. 2016; 387: 251-272Summary Full Text Full Text PDF PubMed Scopus (955) Google Scholar By contrast, in the current GBD 2017 study,1Zhou M Wang H Zeng X et al.Mortality, morbidity, and risk factors in China and its provinces, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2019; (published online June 24.)http://dx.doi.org/10.1016/S0140-6736(19)30427-1Summary Full Text Full Text PDF Scopus (1645) Google Scholar stroke mortality was high in 16 provinces in the central part of the country and across the northeast, northwest, and southwest regions. These inconsistencies are understandable owing to some changes in data and methods since the publication of GBD 2010. For example, mortality from ischaemic heart disease in China was on the rise in GBD 2010 and then steady in GBD 2013.9Wan X Yang GH Is the mortality trend of ischemic heart disease by the GBD 2013 study in China real?.Biomed Environ Sci. 2017; 30: 204-209PubMed Google Scholar This issue caused debate among experts in cardiovascular disease and public health in China.10Yang GH Senior health policy seminar on burden of diseases for cardiovascular disease in China.Chin J Prevent Med. 2015; 49: 391Google Scholar After correcting garbage coding allocation, mortality from ischaemic heart disease was shown to be on the rise in later GBD studies including this study by Zhou and colleagues. How, therefore, should the China health and policy communities respond to these new findings? Discussion about the results would seem useful. For example, the estimated proportion of deaths attributable to tobacco use in GBD 2010 was 16·4% (95% uncertainty interval 12·8–19·9)2Yang GH Wang Y Zeng YX et al.Rapid health transition in China, 1990–2010: findings from the Global Burden of Disease Study 2010.Lancet. 2013; 381: 1987-2015Summary Full Text Full Text PDF PubMed Scopus (1511) Google Scholar but the value for the same year in GBD 2017 was 23·5% (22·4–24·6).1Zhou M Wang H Zeng X et al.Mortality, morbidity, and risk factors in China and its provinces, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2019; (published online June 24.)http://dx.doi.org/10.1016/S0140-6736(19)30427-1Summary Full Text Full Text PDF Scopus (1645) Google Scholar Furthermore, the GBD 2017 estimates differed from results in other empirical surveys.11Chen ZM Peto R Zhou M et al.Contrasting male and female trends in tobacco-attributed mortality in China: evidence from successive nationwide prospective cohort studies.Lancet. 2015; 386: 1447-1456Summary Full Text Full Text PDF PubMed Scopus (274) Google Scholar These differences in estimates of deaths attributable to tobacco smoking are worthy of further study and discussion. We appreciate that the GBD study provides a systematic approach to estimating population mortality, morbidity, and related risk factors and provides a comprehensive description of population health. Mastering the relevant methods of GBD and understanding and discussing the results of GBD are helpful to understand the distribution and changing trends of population health problems more deeply and comprehensively, and, at the same time, can also promote the further improvement of GBD methods. The process will contribute to further validation of data, optimisation of analysis strategies, obtaining optimal estimates, and facilitating policy advocacy to promote the implementation of disease control policies at the national and province levels. We declare no competing interests. Mortality, morbidity, and risk factors in China and its provinces, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017China has made substantial progress in reducing the burden of many diseases and disabilities. Strategies targeting chronic diseases, particularly in the elderly, should be prioritised in the expanding Chinese health-care system. Full-Text PDF Open Access

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