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Chinas economic growth is closely integrated with 6 China Tuberculosis Control Collaboration. Results of directly observed
short-course chemotherapy in 112 842 Chinese patients with
its global role, and Chinas health development can be smear-positive tuberculosis. Lancet 1996; 347: 35862.
anticipated to continue to have global dimensions. The 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.
investment and scale of Chinas global health strategy 8 Ren M. China and global health. The 45th Asia-Pacic Academic
will expand both the interests of global health and Consortium for Public Health; Wuhan, China; Oct 2427, 2013.
9 Qian W, Haochao L. Study on the ratio of Chinese total health expenditure
Chinas diplomacy. 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
*Ren Minghui, Lu Guoping health cooperation. Beijing: World Aairs Press, 2013: 3691.
Department of International Cooperation, National Health and 11 Hoekman A, Hong L, de Bernis L. Strengthening the reproductive health
systems in African countries through ChinaAfrica health cooperation. The
Family Planning Commission, Beijing 100044, China
pathnder in new phase of ChinaAfrica health cooperation. Beijing: World Aairs Press, 2013: 92149.
RM is the Director-General for International Health in the National Health and 12 Bosman A, Ki-Zerbo G, Gaborone M, et al. ChinaAfrica collaboration on
Family Planning Commission and the Chinese Governments principal malaria, control and elimination. The pathnder in new phase of ChinaAfrica
health cooperation. Beijing: World Aairs Press, 2013: 20637.
representative on global health. We declare no competing interests.
13 Xiaofeng L, Feng C, Jiankang Z, et al. Analysis of potential areas for
1 Han Q, Chen L, Evans T, Horton R. China and global health. Lancet 2008; ChinaAfrica cooperation on immunization. The pathnder in new phase of
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2 Liu P, Guo Y, Qian X, Tang S, Li Z, Chen L. Chinas distinctive engagement in 14 Chen L, Stirling M, Zhao C, Schwartlander B. Chinas capacity in producing
global health. Lancet 2014; 384: 793804. quality ARVs for domestic and global needs. The 3rd Round of ChinaAfrica
3 Zhu C. Chinas health diplomacy: sharing experience and expertise. Global Health Cooperation; Beijing, China; June 1213, 2012.
Health 2012. Geneva: The Graduate Institute, 2012. 15 WHO. News release: newly accessible Japanese encephalitis vaccine will
gzdt/2012-05/25/content_2145204.htm (accessed June 16, 2014). make saving children easier in developing countries. 2013. http://www.who.
4 Liu E, Rou K, McGoogan JM, et al. Factors associated with mortality of int/mediacentre/news/releases/2013/japanese_encephalitis_20131009/en/
HIV-positive clients receiving methadone maintenance treatment in China. (accessed June 16, 2014).
J Infect Dis 2013; 208: 44253. 16 Hui L, Ming X. In-depth changes in pharmaceutical trade: situation review
5 Yin W, Hao Y, Sun X, et al. Scaling up the national methadone maintenance in 2012 and outlook in 2013. 2013.
treatment program in China: achievements and challenges. Pub/1757/82973.shtml (accessed June 16, 2014).
Int J Epidemiol 2010; 39 (suppl 2): ii2937.

Globalisation and environmental health in China

As one of the most rapidly growing countries and the neighbours to acid deposition and dust storms.5 Another
largest energy consumer in the world, environmental issue of importance is the development of atmospheric
pollution in China, including that of air, water, and brown clouds caused by air pollution from Asian
land, puts its people at risk of many acute and chronic countries, including China.6 More recently, the eect of
diseases.1,2 Recent reports that more than half of Chinas Chinese air pollutant emission on air quality in the western
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
Rolex Dela Pena/epa/Corbis

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 Vol 384 August 30, 2014 721

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USA has received public attention.7 Overall, airborne Chinas manufacturing economy to a high-added value
pollutants from China are estimated to have caused and low-emission economy.
around 30 000 additional deaths outside the country.8 In addition to traditional environmental policy through
Interestingly, although the western USA has experienced administrative ats, Chinas nance and environmental
reduced air quality due to transpacic pollutants from authorities need to use market-based mechanisms (eg,
China, air pollution in the eastern USA decreased as the environmental tax) to achieve the countrys pollution-
USA outsourced manufacturing to China.7 abating goal. Also, Chinas environmental authorities
Climate change is increasingly recognised as a major need to consider air quality issues and climate change
threat to global health. In 2007, China surpassed the together because, to a large extent, major air pollutants
USA as the number one emitter of carbon dioxide and CO2 stem from the same sources. This link might be
(CO2). Chinas CO2 emissions continue to grow faster of special importance in Chinese cities with high urban
than those of other major countries, with a projected population densities and high emissions of air pollutants
increase of 55% from 2011 to 2020;9 this is about three and CO2. Scientic studies on the eect of environmental
times the total amount of reduction that the European pollution on public health should also be encouraged in
Union and USA combined have committed to achieving China. For example, new studies are needed in the country
over the same period.9 Climate change has both to investigate whether widely used air puriers and
directly and indirectly aected human health globally, facemasks have protective eects on air pollution-related
including mortality due to extreme weather events and health hazards, especially during heavy smog days.
natural disasters, polluted air and water, and emerging In addition to domestic eorts, China also needs
infectious diseases. Notably, most of these adverse international collaboration to tackle environmental
health eects are expected to be greatest in low-income pollution eectively, particularly on cross-border air
populations.10 In this sense, China could play a crucial pollution, climate change, and electronic waste treatment.
part in resolving global climate change and related Because developed countries contribute to Chinas
health eects. pollution through trade, and per-head CO2 emission is still
Another issue resulting from globalisation of the lower in China than in developed countries, China still has
world economy is that China, as a world factory the moral right to develop. Developed countries can help
exporting products to developed countries, consumes China to protect its environment via training and capacity
its own natural resources and leaves pollutants behind building, transfer of environmental knowledge, and
in China.11 For example, in 2006, 36% of sulphur dioxide, environmentally benign technologies. One example is the
27% of nitrogen oxides, 22% of carbon monoxide, AirNOW international monitoring system launched by
and 33% of CO2 emitted in China were associated the US Environmental Protection Agency and Shanghai
with production of goods for overseas markets.7 Also, Municipality. China provides unique internationally
largely driven by illegal exportation of electronic waste collaborative opportunities for environmental health
by developed countries, China processes 70% of the research in view of its enormous population and relatively
electronic waste generated worldwide.12 high concentrations of environmental pollutants. Also,
China aims to double its 2010 gross domestic China should learn from developed countries lessons
product (GDP) by 2020, in the face of ever more serious about the dangers of putting economic gains ahead of
environmental pollution. In a continually globalising human welfare and environmental conservation.
world economy, both domestic measures and Chinas environmental problem is an important
international cooperation are needed for China to tackle issue for global health. Chinas success in tackling
these challenges. environmental challenges will not only improve the
The Chinese Government has decisively embarked health of the Chinese population, but also health globally.
on a strategic transformation, from GDP-driven Serious and appropriate actions on environmental
development to a balance between environmental and pollution in China will undoubtedly lead the Chinese
economic development and building an energy-saving Government to its goal of building a sustainable
and environment-friendly society. Consequently, it economy and a harmonious society. A good example
has become a national economic priority to transform is the recent amendment to Chinas Environmental

722 Vol 384 August 30, 2014

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Protection Law, which will take eect on Jan 1, 2015, 3 Yang G, Zhuang D. Atlas of the Huai river basin water environment:
digestive cancer mortality. Dordrecht: Springer Science and Business, 2014.
and provide powerful weapons in the war on pollution. 4 Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden
Meanwhile, the Chinese Government needs to overcome 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
policy and institutional barriers, such as the lack of Disease Study 2010. Lancet 2012; 380: 222460.
mechanisms for interdepartmental coordination and 5 Carmichael GR, Streets DG, Calori G, et al. Changing trends in sulfur
emissions in Asia: implications for acid deposition, air pollution, and
involvement of health authorities in environmental climate. Environ Sci Technol 2002; 36: 470713.
6 Gustafsson , Krus M, Zencak Z, et al. Brown clouds over South Asia:
management, and inadequate stang at both national biomass or fossil fuel combustion? Science 2009; 323: 49598.
and local levels. 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
Haidong Kan future contributions of sulfate, black and organic carbon aerosols from
China to global air quality, premature mortality and radiative forcing.
School of Public Health, Fudan University, Shanghai 200032, China; Atmos Environ 2009; 43: 281422.
and Global Health Institute, Fudan University, Shanghai, China 9 Yang Y, Zhang J, Wang C. Is China on track to comply with its 2020 Copenhagen Carbon Intensity Commitment? 2014.
abstract=2346516 (accessed July 14, 2014).
I declare no competing interests. I thank X Yang for his comments.
10 Patz JA, Campbell-Lendrum D, Holloway T, Foley JA. Impact of regional
1 Chen Z, Wang JN, Ma GX, Zhang YS. China tackles the health eects of air climate change on human health. Nature 2005; 438: 31017.
pollution. Lancet 2013; 382: 195960. 11 Liu J, Diamond J. Chinas environment in a globalizing world. Nature 2005;
2 Zhang J, Mauzerall DL, Zhu T, Liang S, Ezzati M, Remais JV. Environmental 435: 117986.
health in China: progress towards clean air and safe water. Lancet 2010; 12 Ni HG, Zeng EY. Law enforcement and global collaboration are the keys to
375: 111019. containing e-waste tsunami in China. Environ Sci Technol 2009; 43: 399194.

Can China age healthily?

China has more older people (65 years and older) than they begin to need support and care. Finally, China is
any other country. According to the 2010 census,1 undergoing rapid urbanisation characterised by a massive
the number of people aged 65 years and older was migration of younger workers from rural regions. The
119 million, 89% of the population. Moreover, Chinas disruption of family structures across generations might
population is one of the fastest ageing in the world. further weaken the ability of families to care for older
Although developed countries took around half a parents, many left behind in rural areas.
century to double the number of people aged 65 years Ultimately, however, the health of the older
and older (from 7% to 14%), China will do so in half that population determines its need for care. Non-
time.2 By 2050, Chinas ageing population will match communicable diseases have emerged to replace
that of many of todays developed countriesand infectious diseases as the leading causes of death in
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
Vince Streano/Corbis

rst cohort of parents aected are now in their 50s, and

the eects will be noticed in the next two decades as Vol 384 August 30, 2014 723

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