China’s ‘hidden epidemics’: the preventable diseases that could reshape a nation

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China faces a health emergency from “hidden epidemics” of diseases such as cancer, heart trouble and diabetes that could have far-reaching social, economic and demographic consequences for the world’s most populous nation, experts have warned.

Although China imposed the world’s strictest lockdowns to protect its people from Covid-19, the deadly impact from non-communicable diseases is much less well understood and threatens to kill tens of millions of Chinese in the coming decades without tougher public health policies.

China has been transformed in recent decades by an economic miracle that has seen rapid industrialisation and the transfer of hundreds of millions of people from the countryside to towns and cities.

This enormous change has lifted multitudes out of poverty and given them a better standard of living than they enjoyed in rural areas. But along with higher wages and urban living have come “western” diseases such as cancer linked to very high rates of smoking, and diabetes and heart disease thanks to a richer diet, lack of exercise and high blood pressure.

Wang Feng, professor of sociology at University of California, Irvine, says the pace of change seen in China during the 1980s and 1990s is unlike anything seen anywhere else in history, and that the social and health problems stored up for decades are coming home to roost.

“These are hidden epidemics and they are enduring epidemics,” he says. “You have an explosion in a new diet and nutritional intake in a short time period. Combined with unforeseen, unprecedented ageing, it’s going to be one of the greatest challenges China faces – not just for individual families but it poses a political challenge to leadership.

“This issue could really explode out of control,” he says. “This is not something that is going to go away.”

Smoking ‘disaster areas’

More than a third of the world’s 1.1 billion smokers live in China, where around half the male population is addicted to tobacco. Smoking-related disease – which includes lung cancer, respiratory and heart disease – will kill a staggering one in three young Chinese men by 2050 according to current projections.

This is a grim statistic in a country that is already facing a demographic crisis due to a plummeting birthrate and a rapidly ageing population. The UN forecasts the population could fall from its current level of about 1.4 billion to about 1 billion by 2100. Chinese officials said in July that the population is already beginning to shrink as birthrates fall to their lowest for decades. But some predictions are far more drastic, with separate research in the US and China suggesting the population will almost halve by the end of the century to about 730 million. Populations in the UK and the United States, by contrast, are forecast to remain constant or grow slightly in the same timeframe.

Bernard Stewart, an internationally renowned expert on cancer causation and professor at the University of New South Wales in Sydney, says the evidence is categorical and China needs to take action to prevent what he calls an unfolding “disaster”.

“There is no sense in which you can qualify the disaster facing China in regard to deaths from smoking,” he says. “There is a vast difference in rates between provinces, but the highly industrialised cities are disaster areas.”

The biggest cause of death in China is strokes, followed by heart disease, chronic pulmonary disease and then lung cancer, according to the global burden of disease study produced by the US Institute for Health Metrics and Evaluation. Smoking is a contributing factor in many of those cases.

Cardiovascular disease is a major killer in China, especially in the heavily industrialised and urbanised north. People in that region are more likely to suffer from hypertension, obesity and a poor diet low on fruit and vegetables but high on red meat, a Lancet study has found.

China has more people with diabetes than any other country – more than 110 million – in what the World Health Organization (WHO) has described as an “explosive” problem. This number will climb to 150 million by the middle of the century.

Diabetes and complications from diabetes already contribute to almost a million deaths in China each year, according to the WHO. More than 40% of these fatalities are classed as premature – occurring before the age of 70 – which is another cause for alarm.

China is the second-biggest economy in the world and has become home to hundreds of billionaires in the last few decades.

But its health outcomes are still those of a much poorer nation. People in China have a 14.1% chance of premature death from a non-communicable disease which places the country 76th in the health world rankings. South Korea is top on 4.7%, while the UK is 27th on 9% and the US is 44th on 11.8%. The outcomes are worse for Chinese men, with a 19.8% chance of dying prematurely.

The ruling Communist party’s attempts to deal with the health crisis include the Healthy China 2030 campaign launched in 2019 to reduce premature deaths, control risk factors, and boost healthcare capacity. There are now more smoking bans in public places such as high-speed trains, shops and restaurants. Even last year’s crackdown on children’s screen time can be seen as part of the effort to reduce incipient obesity and improve health outcomes.

However, there remain obstacles such as the government’s dependency on cigarette tax, which provides about 10% of the tax base via the state-controlled tobacco monopolies.

‘Western-style’ problems

The health crisis can in many ways be traced back to China’s stratospheric economic growth since the late 1970s, when people started being able to consume a more western-style diet and acquire western-style habits.

In 1978, most Chinese people were on a subsistence-level diet. By 1988 they were consuming 60% more pork and 150% more vegetable oil, Wang says, which helped improve nutrition enormously. However, at the same time, alcohol consumption increased 3.5 times, and the number of packets of cigarettes being smoked doubled.

Wang says: “This was almost 30 years ago. But it is coming back as a problem for people in later life now. People were consuming liquor, sugar, and tobacco faster than food … There was no awareness of new malnutrition, people being overweight, and about how fast this has happened.”

The high cost of caring for a sick and ageing population is also a serious obstacle to Beijing’s hopes to revive a flagging economy. One reason is that a greater share of the expense falls on individual households than might be expected in the Communist-controlled nation – around a third of health spending per head. The need to save for healthcare is a huge drain on the budgets of families – often with just one child to do the saving and caring. This is in turn exacerbates the demographic problem because China’s current child-rearing generation of 18- to 40-year-olds have less money and inclination to start their own families.

These mounting problems are recognised by the Communist party leadership and are among the reasons the government has stuck so rigidly to its zero-Covid strategy while the rest of the world has returned to normal life. Beijing knows that the population – especially elderly people living in rural areas – do not have access to good healthcare, and with underlying health problems such as heart disease and breathing trouble already so common, would be at high risk from the spread of Covid. It is estimated that zero-Covid has saved a million Chinese lives.

‘A health problem means an economic problem’

About 95% of people in China have some form of health insurance, but that does not mean that healthcare is affordable. Attempts to reform the public health system have seen the number of private hospitals explode and the total now exceeds public facilities. Provision of care varies greatly from province to province and especially from urban to rural areas, but it is still seen as very inefficient and out-of-pocket expenses for people with insurance are still very high.

“Chronic conditions are a major contributor to health burden, inequalities in health outcomes, and economic burden in China,” a group of academics wrote in the Lancet in 2021.

One of the authors, Prof Barbara McPake, a health economist at the University of Melbourne, says households face dire consequences from the growing problem of China’s hidden epidemics.

“The health system is seeing big out-of-pocket expenses for people with non-communicable diseases,” she says. “A health problem means you have an economic problem. 95% of people have health insurance but there’s a high cost for medicine and care. The insurance doesn’t go far, so in some cases it’s insurance that’s not worth having.”