Journal critique 1

Comparing the United States’ and China’s Shifting Health Challenges

The United States and China

both face the question of how

to prioritize programmatic re-

sources and policy interven-

tions to make the greatest

impact on the health of their

populations.

I discuss strengths and limi-

tations of the expert panel sur-

vey used byWu et al. in “The 20

Most Important and Most Pre-

ventable Health Problems of

China: Opinions From Chinese

ExpertsUsing aModifiedDelphi

Process,” in this issue of AJPH.

I juxtapose this method with

several US approaches to pri-

ority setting at the federal,

state, and county levels and

suggest steps for moving from

research to action. (Am J Public

Health. 2018;108:1603–1606.

doi:10.2105/AJPH.2018.304782)

Jonathan Fielding, MD, MPH, MBA

See also Yu, p. 1574; and also the AJPH Public Health in China section, pp. 1592–1603.

Setting national priorities toimprove health and prevent disease is vital. Ideally, priorities should be driven by scientific processes, but in reality, they tend tobedrivenbyperception, political realities, feasibility, and timing. Those of us in public health feel it is imperative to put science and data first so that there can be broad agreement and a common under- standing that underlies the discus- sion of priorities.

Difficulty in setting health pri- orities is magnified when there are rapid changes in economic, social, and political conditions. Such is the case in China. That nation’s ex- plosive economic growth over the past 40 years brought many ad- vantages to its people, including increased longevity and progress in controlling some occupational and communicable diseases.

China faces shifting health challenges, with noncommuni- cable diseases now accounting for the vast majority of all deaths, many attributable to environ- mental degradation, global warming, changes in health- affecting behaviors, and aging of the population. In addition, emerging diseases threaten the public’s health, and even infectious disease notifications for common infectious diseases have increased despite substantial investments in disease control and prevention.

Like many other countries, including the United States, China faces the question of how to prioritize programmatic

resources and policy interventions tomake the greatest impact on the health of its 1.3 billion inhabitants. “Prevention first” has been se- lected as the national priority. However, an operational plan specifying which diseases to pre- vent and which to control, as well as target objectives and what in- terventions are needed to effect the desired improvements, has yet to be published.

US APPROACHES TO SIMILAR PROBLEMS

The United States confronts issues of shifting health burdens similar to China’s. To address them, the United States has worked through public or private sponsors at three levels—federal, state, and county—although not always in a coordinated fashion.

Work on a major prevention- oriented, data-driven, federal government–coordinated de- cennial product, Healthy People, began in 1980. Healthy People 1990, the initial Healthy People, had two overarching goals, 15 topic areas, and 226 objectives. Since then, the scope and

number of objectives have in- creased in every succeeding it- eration, sometimes dramatically. The latest report, Healthy People 2020, included 42 topic areas and more than 1200 objectives.

One major addition in recent reports has been an increased focus on the social determinants of health, including economic sta- bility, education, neighborhood and built environment, and social and community context. In planning for Healthy People 2030, the issue of health equity has be- come more central. For each ob- jective or related group ofHealthy People objectives, the Department of Health and Human Services coordinated a group of experts charged with developing quanti- fiable targets and identifying the policies, programs, and systems that could be employed to achieve the objectives.

However, quantifiable targets alone are insufficient. They need to be coupled with interventions that move the needle. Fortu- nately, over the past 40 years, increased attention and in- vestment have accelerated de- velopment and application of scientific methods to assess the

ABOUT THE AUTHOR Jonathan Fielding is a Distinguished Professor of Health Policy and Management in the Fielding School of Public Health, University of California, Los Angeles.

Correspondence should be sent to Jonathan Fielding, MD, MPH, MBA, University of California, Los Angeles, Fielding School of Public Health, Center for Health Advancement, 650 Charles E. Young Dr. South, Room 61-253 CHS, Box 951772, Los Angeles, CA 90095 (e-mail: [email protected]; [email protected]). Reprints can be ordered at http://www. ajph.org by clicking the “Reprints” link.

This article was accepted September 15, 2018. doi: 10.2105/AJPH.2018.304782

December 2018, Vol 108, No. 12 AJPH Fielding Peer Reviewed Commentary 1603

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ability of different interventions to improve the health of populations. The US Preventive Services Task Force, a federal government–sup- ported independent volunteer panel of experts in disease pre- vention and evidence-based medicine, performs systematic re- views to develop clinical pre- ventive service recommendations for clinicians. A companion with a similarly composed expert panel, the Community Preventive Ser- vices Task Force, performs parallel analyses to select interventions to prevent disease and improvehealth for public and private sector or- ganizations. The task force staff also performs economic analyses on recommended interventions, adding a critical dimension to the information available for decision- makers. Both task forces are staffed by federal agencies. Other well- established nonprofit groups per- forming systematic reviews on potential population-oriented in- terventions include the Cochrane Collaboration and the Campbell Collaboration.

Rankings have been incorpo- rated in several data-driven products. State health rankings, privately funded but with the participation of public and private sector experts, are used to annually rank the relative health of each state’s population on the basis of a wide range of then current and trend data on behaviors, com- munity and environment, policy, clinical care, and outcomes. The County Health Rankings and Roadmaps, funded by the Robert Wood Johnson Foundation and operated by the University of Wisconsin, are used to rate health using more than 30 measures that relate to two outcomemetrics and four major determinants (clinical care, social factors, the environ- ment, and individual behaviors) on a yearly basis. A major em- phasis of this product is its action orientation. Rankings are a

starting point for action by the adoption of health-promoting policies and programs. The County Health Rankings offer step-by-step guidance and tools to help users move from data to action. Other initiatives are oriented to helping cities, counties, or regions assess and improve health and health equity in their jurisdictions.

End products of these and other projects with similar aims sup- port the development of goals, objectives, and recommended evidence-based interventions. However, expert opinion is still required for the Healthy People process and others with similar goals because of the lack of baseline data for a growing percentage of the mushrooming objectives. For the Healthy People series, small groups of experts are convened by topic to develop reasonable targets to be achieved within the next decade. Because of data limitations and uncertainty regarding effec- tive interventions, many groups defaulted to a 10% improvement target for their area. Despite likely future improvements in surveil- lance data, methods, and inter- ventions, expert opinion will continue to be a necessary input when setting goals and objectives.

RANKING CHINA’S HEALTH PROBLEMS

In China, the Prevention First national priority, like the Healthy People initiative in the United States, needs to be translated into discrete activities. In support of Prevention First, a working group from China’s Center for Disease Control and Prevention developed an innovative ap- proach to add the broad-based opinions of health experts to the surveillance data on health and health care. As reported in this

issue ofAJPH,Wu et al. (p. 1592) asked experts in medicine, public health, and medical research to use a modified Delphi process to achieve consensus in the identi- fication and ranking of the most important health problems and the most preventable problems over the next 20 years in China. The panelists were given a list of 106 diseases and health-related conditions so they could identify and rank the top 20 in terms of importance and the top 20 for preventability. As part of the process, panelists could add up to five additional diseases or health-related conditions. This creative use of a modified Delphi technique yielded clear priorities for both importance and pre- ventability of diseases and health- related conditions for the 1.3 billion people living in the world’s most populous nation.

One strength of this survey is the ability to compare impor- tance and preventability scores. Another strength is the revealing of differences in perceptions among medical, public health, and medical research experts. Composite scores by professional field revealed broad agreement on some rankings (e.g., diabetes, hypertension, and air pollution) but strikingly different rankings on others, such as emerging in- fectious diseases, smoking, hep- atitis, depression, and unhealthy diet. Time engaged in practice alsomade a big difference in some composite rankings. Of particular note, those with 15 to 30 years of practice ranked liver cancer number one (vs 12th and 8th for older cohorts) and coronary heart disease 11th (vs 4th and 5th).

An additional strength, which, paradoxically, can also be con- sidered a limitation, is that lacking the receipt of objective infor- mation on burden, the judgments of the expert panelists were likely to be significantly influenced by

their own experience and criteria for importance. These might include how many people they believed to be affected; the problems they see in their pa- tients, population, or research; and their perception of trends.

It appears there was no in- formation provided to the pan- elists on disease burden, health behaviors, or the impact of past interventions on the overall population and sociodemo- graphic segments. Moreover, the article does not suggest that the panelists were given information on trends. This raises the ques- tion, for example, of whether air pollution would have received the same importance ranking if panelists were told that air pol- lution is trending downward and that the trend is expected to continue.

Information on the surveyed panel is limited (including only invitation response rate, basic demographic characteristics, current professional field, and time engaged in that field) and leaves open the question: What knowledge base did participants bring to the rankings? Their area of specialty or expertise is not specified—a crucial omission because it presumably informed their choices. How would an academic urologist or cell biology researcher decide how to rank road safety versus breast cancer or HIV?

The minimal number of changes in ranked items between rounds and quick achievement of consensus may reflect limited familiarity of most panelists with the wide range of disparate dis- eases and health-related condi- tions to be ranked. A possible source of bias is how the initial 106 diseases and health-related issues were presented to the panelists. Were they presented in roughly the rank order of disability-adjusted life years

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(DALYs) or mortality, even though these baseline measures were not included? If not, how did the working group under- taking the study determine the initial order? The limited scope of some panelists’ experience may predispose them to support the initial rankings if they come from an authoritative source, unless a panelist perceived that their area of expertise was being under- valued in the first of the two rounds of ranking.

To be sure, the survey yielded at least a few surprises. Mental disorders are ranked lower than one might expect, considering that the 2016 Global Burden of Disease report from the Institute for Health Metrics and Evalua- tion ranks mental disorders third among causes or risks of disease burden in China (2200.73 DALYs per 100 000).1 Most surprisingly, substance abuse and addiction were not among the top 20, despite alcohol and drug use being fifth among risk factors driving the most death and dis- ability combined for China in 2016, after having a 10.5% in- crease in DALYs since 2005.2

China’s assistant minister of public security estimates that there are more than 14 million drug users, and the 2014 Drug ReviewAnnualReport estimates at least 49 000 deaths from drug abuse in that year.3

Although the population drinking level inChina used to be much lower than in many high- income and middle-income countries, per capita alcohol consumption rose from 2.5 liters in 1978 to 6.7 liters in 2010. It is important to note that more than half of the Chinese population aged 15 years and older abstain from alcohol: 42% of men and 71% of women. This means the alcohol consumption level of those who actually drink was 15.1 liters in 2010, higher than the

equivalent figure in the United Kingdom, the United States, Sweden, Germany, Australia, New Zealand, and many other countries. Further, great dispar- ities exist in alcohol consumption and rates of dependence.The rates of alcohol use disorder are 9.3% among men and 0.2% among women, amale–female ratio of 47 to 1, which is substantially higher than inmost other countries in the world. Alcohol use contributes to more than 310 000 deaths and 13.8 million DALYs per year in China.4

Also surprising is that mus- culoskeletal disorders were not ranked among the top 20 by any of the three groups of partici- pants, despite being ranked fifth among disease and injury in China for disease burden in 2016.1 Musculoskeletal disorders caused 26.98 million lost DALYs among the Chinese in 2016, accounting for 7.72% of the country’s total disease burden.1

Low back and neck pain tops the list of health problems that cause the most disability, and the In- stitute for Health Metrics and Evaluation also ranks osteoar- thritis and other musculoskeletal disorders among the top 10.2

Tracking demographic trends is important, particularly for ranking the importance of Alz- heimer’s disease and other de- mentias. The rapid decline in fertility in China since the 1970s combined with dramatically in- creased life expectancy has caused rapid population aging. Accord- ing to the US Census Bureau estimate, it will take China just two decades for the proportion of the elderly population to double (from 7% to 14%), compared with 45 years for the United Kingdom and almost 70 years for the United States.5 China’s de- pendency ratio for the elderly (the number of people aged 65 years or older for every 100

people aged 20–64 years) was 15% in 2015 and is expected to rise to 49% in 2050,with the num- ber of elderly people rising from approximately 140 million to 350 million in this same period. In other words, by 2050 China will be supporting an elderly population that exceeds the current population of the United States and that is more than twice the population of Russia.5

With the rapid aging of China’s population, health and macroeconomic models predict an unfolding Alzheimer’s disease epidemic. Simulated Chinese Alzheimer’s disease prevalence quadrupled during 2011 to 2050 from six million to 28 million,6

and annual costs associated with the illness are projected to be US $1.89 trillion by 2050.7 Yet de- spite the huge elderly population and growing demand for care, very little is known about the economic costs of dementia care in China. Responsibility to care for those with dementia mostly falls on the shoulders of unpaid caretakers, as the formal care sector is still in its infancy. For perspective, the United States has one quarter of China’s population but about half the number of Alzheimer’s disease patients and 73 000 beds in spe- cialist treatment centers, whereas China has fewer than 200 beds.8

In a country with an older population, disease incidence and prevalence will swell not only for dementia but also stroke, cancer, fractured hips, osteopo- rosis, Parkinson’s disease, lower back pain, sleep problems, and urinary incontinence. China’s low fertility rate over the past two decades (currently 1.6 births per woman compared with the world average of 2.49) means that there will be fewer family members to care for infirm elders suffering from dementia and other diseases that are associated

with significant disabilities. The looming challenges of meeting the needs of China’s older pop- ulation will surely need to be at the forefront of the nation’s 20-year health strategy and ap- pear to deserve a higher ranking.

With respect to preventabil- ity, there are also some surprises. As an example, oral diseases are not ranked among the top 20. As demonstrated by the results from the fourth national oral health epidemiology survey (2017), oral diseases are still highly prevalent in China, and they are getting worse. The reported caries prevalence rates of children aged five years and 12 years were 70.1% and 34.5%, respectively. These problems are almost en- tirely preventable through public health and behavioral interven- tions. If dental care deserves a high priority, the dentist– population ratio of one to 10 000 reported in 2009 needs a sub- stantial increase.10

EXPERT OPINION: A PIECE OF THE PUZZLE

Interpretation of survey results would be facilitated by under- standing whether the panelists interpreted preventability to in- clude treatment (sometimes re- ferred to as tertiary prevention). The broader the definition of preventability, the greater the importance of medical insurance coverage and access to care. Should coverage be considered an underlying determinant for many identified priority diseases and health-relevant conditions?

A noteworthy feature of the survey is the inclusion of both upstream and downstream health problems, although this approach complicates the interpretation of the rankings. For example, how should we interpret the fact that

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smoking is ranked first in pre- ventability, whereas lung cancer, for which smoking is the major cause, is ranked 11th? Diabetes mellitus is ranked first in impor- tance and second in prevent- ability, but unhealthy diet, the primary determinant of type 2 diabetes, is ranked only 14th in importance and 5th in preventability.

It would have been helpful to start with an overarching model with outcomes and determinants separated to avoid having both of these on the same list. Consid- ering the burdens and prevention opportunities by age group, knowing urban versus rural res- idence and gender would also be helpful for determining priority opportunities for prevention.

China is far from homoge- neous with respect to health and medical care. Instead of one na- tional pattern, studies have illu- minated a number of distinct, geographically defined patterns. Although many wealthy prov- inces have mortality rates on par with those of the United States, populations in most rural prov- inces are characterized by poorer health outcomes and high levels of adverse health determinants and disease burden.

This survey did not directly address the social determinants of health and health inequity, such as income, education, occupa- tion, transportation, and housing. Inclusion of these underlying health and disease determinants is critical for identifying health- promoting policies and programs with the greatest potential impact.

In a research to action para- digm, this survey addresses the question of priorities on the basis of expert opinion. To oper- ationalize the results also requires an understanding of what works to reduce population burden. An essential step is to compile the

best evidence on impact from studies of intervention effective- ness and develop quantifiable targets on the basis of the most impactful interventions.

Despite their limitations, sur- veys of “experts” can be helpful in several ways. They contribute an important perspective worth considering in the prioritization process, especially when data are incomplete with respect to bur- den and intervention effective- ness. Survey results can also identify misconceptions that are widely held, even among experts. These can be addressed through continuing education. Consid- ering that experts are often queried by the media, they can help align public perceptions with the best scientific knowl- edge. In addition, the results can promote interaction among re- searchers and other medical and public health thought leaders, help establish research priorities, and invite collaboration among nations faced with similar challenges.

ACKNOWLEDGMENTS I would like to thank Ellie Faustino for research and editorial assistance and Steven Teutsch for helpful comments on the commentary.

REFERENCES 1. Institute for Health Metrics and Eval- uation. GBD compare. 2016. Available at: https://vizhub.healthdata.org/gbd- compare. Accessed August 28, 2018.

2. Institute for Health Metrics and Eval- uation. China. Available at: http://www. healthdata.org/china. Accessed August 28, 2018.

3. Wee S. Drug abuse cost China $80 billion last year as it clocked 49,000 drug related deaths. 2015. Available at: https:// www.businessinsider.com/r-china-says- economic-losses-from-drug-abuse-hit- 81-billion-a-year-2015-6. Accessed August 29, 2018.

4. JiangH,RoomR,HaoW.Alcohol and related health issues in China: action needed. Lancet Glob Health. 2015;3(4): e190–e191.

5. He W, Goodkind D, Kowal PUS. An Aging World: 2015. Washington, DC: USGovernment Publishing Office; 2016.

6. Keogh-Brown MR, Jensen HT, Arrighi HM, Smith RD. The impact of Alzheimer’s disease on the Chinese economy.EBioMedicine. 2015;4:184–190.

7. Jia J, Wei C, Li F, et al. The cost of Alzheimer’s disease in China and re-estimation of costs worldwide. Alz- heimers Dement. 2018;14(4):483–491.

8. Fuhrman P, Yansong W. China’s millions of Alzheimer’s patients cannot wait for specialized care. 2017. Available at: https://www.scmp.com/comment/ insight-opinion/article/2098539/chinas- millions-alzheimers-patients-cannot- wait-any-longer. Accessed August 29, 2018.

9. World Bank. Fertility rate, total (births per woman). Available at: https://data. worldbank.org/indicator/SP.DYN. TFRT.IN. Accessed August 29, 2018.

10. Liu J, Zhang SS, Zheng SG, Xu T, Si Y. Oral health status and oral health care model in China. Chin J Dent Res. 2016; 19(4):207–215.

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