19 June 2010
In sultry heat, I join a continuous stream of people making their laborious way up the 392 steps to the mausoleum of Dr Sun Yat-sen. It’s beautifully situated on the slope of a wooded mountainside in a huge park in Nanjing, Eastern China.
Everyone is in holiday mood, stopping frequently to rest, drink and take snaps of each other against the backdrop of the splendid double-eaved sacrificial hall built a few years after Dr Sun’s death in 1925.
But as soon as they reach the sarcophagus, absolute silence descends in an atmosphere of deep awe and respect. Dr Sun is a much revered figure, considered to be the ‘Father of the Republic of China,’ honoured by Chinese people on both sides of the Taiwan Strait.
He qualified in medicine at the turn of the century, but soon gave up medicine for politics, plotting the overthrow of the Qing Emperor and helping to establish the fledgling republic. As its inaugural President he extolled three fundamental ‘Principles of the People’ inspired by Abraham Lincoln: One nation of the people – governed by the power of the people – for the welfare of the people.
Back at the conference I’m attending on public health in Asia and the Pacific Rim by the APRU World Institute, I think about the parallels between Dr Sun’s three principles and Michael Marmot’s basic tenets of a healthy society – one that upholds fairness, social justice and the pursuit of wellbeing.
Certainly, health inequalities is a recurring theme at the conference. There are huge disparities between the rich and the poor across the region – and between the cities and rural areas – and this is reflected in the disease patterns observed.
The conference theme is the epidemic of chronic, non-communicable diseases (NCDs) in the tiger economies of east Asia. This part of the world is now going through the escalation of cardiovascular disease we saw in the West about 40 years ago.
But it’s happening so fast here. Urbanisation is rampant – by 2020 China will have over 200 cities each boasting more than a million population. And this is coupled with globalisation, code for westernisation. Nearly every major city has its MacDonalds, KFC and Pizza Hut. Smoking is on a roll – mostly western brands – and in many Asia-Pacific countries, notably China, it’s still allowed in public places.
As to physical activity, whilst it’s true that cycling is still a common means of transport – here in Nanjing for example there are dozens of pushbikes bunched together at the front of the traffic at every stoplight – nevertheless people are increasingly switching to scooters or cars. Air pollution is a big problem in China – not good for the lungs, especially if you’re on a bike. All in all, there can be little surprise that obesity, diabetes, stroke, coronary heart disease, lung cancer and chronic obstructive pulmonary disease rates are rocketing right across the region.
What’s more, although these health problems were first seen most among the better-off – the early adopters of western lifestyles – in recent years the problems have begun to extend down the social gradient, particularly among the urban poor.
Effective prevention and early diagnosis are clearly crucial – yet many Asia-Pacific countries have health systems skewed to favour hospital and specialist services, with little or no investment in health promotion or primary care. Although China for example has well developed communicable disease prevention and control systems, its approach to non-communicable disease is much less robust and its primary care is largely based on private specialists and a vast unregulated army of traditional medicine practitioners.
This pattern is typical of the whole region, and poorer people thus face the double whammy of unhealthy lifestyles plus inadequate access to preventive, diagnostic or curative care. So, despite the best efforts of policymakers to reduce health inequalities in many of the emerging tiger economies of the Asia Pacific, the headlong rush to the cities has meant that the cards are truly stacked against the less well-off.
As in the West, it will take a multisectoral mix of interventions to halt the rising tide of NCDs in these countries – health education, social marketing, regulation of the food and tobacco industries and, above all, health systems change. Marmot argues that efforts should be applied across the social gradient. But from the workers’ high-rises of China’s cities to the slums of Mumbai and the favelas of Rio, there’s also a clear need to focus on the world’s urban poor.
As the conference closes I think again of Dr Sun Yat-sen. I’m sure that, as a medical man, democrat and visionary, he would wish to see public health of the people, by the people, for the people, applied fairly to all the people, not just those who can afford to pay.