Diabetes-Related Mortality

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A product of Chinas rapid economic development is the transition in public health issues from infectious diseases to non-communicable diseases. Not only has urbanization changed Chinas economy, but it has also led to changes on the individual level. Personal lifestyle, diet, and social norms are a few of the main aspects that have led to diabetes taking priority over other non-communicable diseases that currently need serious attention (Yang, et al., 2012). In fact, China is experiencing the worst epidemic in the world, with 10% of its population (over 110 million individuals) in 2016 being diagnosed with full-blown diabetes. The CDC reported that the rate in rural areas is increasing faster than in urban areas.

This epidemic has placed enormous stress onto rural health care facilities through a high utilization of hospitals, as well as rising insurance costs (Wang F. , 2016). Living with diabetes is a huge financial burden, especially those covered by the rural health insurance plan, where 24% of household income will go to treatment (Liu, Vortherms, & Hong, 2017). There is also a huge economic burden that is placed on the country itself, with medical expenses for diabetes being one of the main leaders of poverty. Therefore, this issue is important because not only does it directly affect public health in rural areas, but its consequences also reach other key systems of society. There seems to be a harmful reinforcement between poor health and low socioeconomic status in rural provinces that is crippling Chinas health care system (Le, Jun, Zhankun, Yichun, & Jie, 2011).

A nationwide study conducted by the Epidemiological studies unit of the University of Oxford in 2017 found that despite prevalence rates being higher in urban areas, mortality rates were actually higher in rural areas. Looking into cause-specific deaths related to diabetes, the authors found a drastic difference in the risk ratio for chronic kidney disease, which was 18.69 and 6.83 for rural and urban areas respectively (Monaco, 2017). Currently, the demographics show that adults over 35 years of age with low income make up the majority of individuals that are diagnosed (Wang, et al., 2017).

However, the age bracket for acquiring diabetes has been continually decreasing. The American Diabetes Association reported that there has been an increasing rate in young individuals in rural areas. This is significant because they have a higher risk for chronic complications which lead to mortality (Hu & Jia, 2017). This also speaks to a lack of proper health education and schooling in rural provinces.

Currently, there is a large focus on treating the symptoms and outcomes of diabetes. The government spends the equivalent of $50 billion annually on diabetes alone. That is 13% of the total national health care expenditures. However, this has had minimal effect so far in rural areas. 84% of it goes to treating the disease through hospitalization, thus inpatient treatment (Wang F. , 2016). This is the main way rural individuals receive health care. Despite the large monetary investment into treatments, only 13% of the diagnosed population have their blood glucose under control. This is because the biggest issue is that 60% to 65% of the rural population are unaware of their disease (Wang, et al., 2017). Those with lower income, whose insurance translates into high medical bills, wait until they have their first heart attack to go to the hospital and get diagnosed.

This delay has a huge impact on mortality rates (Wang F. , 2016). Moreover, it is clear that prevention and awareness are lacking from the current strategy that is in place by the key players who are working on this issue.
The key players involved in the diabetes epidemic in rural areas are all in the direct circle of public health influence. They include provincial hospitals, pharmaceutical companies, big universities, key ministries and the Chinese Insurance Regulatory Commission. In terms of key ministries, there are two that play a crucial role in drug accessibility for the low SES population. These are the National Health Family Planning Commission (NHFPC) and the National Development and Reform Commission (NDRC).

The former is responsible for determining which drugs get included into an Essential Drug List that is covered by the rural insurance plan (Liu, Vortherms, & Hong, 2017). The latter has direct control over prices of both drugs and medical services. Both coordinate with the Chinese Insurance Regulatory Commission, who are responsible for the lack of coverage and high treatment cost of diabetes in the rural insurance plan (Mossialos, Ge, Hu, & Wang, 2016).

The pharmaceutical industry along with top universities (Peking university and Shanghai Jiao Tong University) are important for the research and development of treatment (Mossialos, Ge, Hu, & Wang, 2016). Overall, there is a clear mirroring of who the key players are to what is currently being done about the issue. Reiterating what has been previously established, the main focus is on treating the outcomes and not on prevention.

Actors who should be involved are those in the public health sphere as well as outside of it who can effectively work on prevention and awareness. This includes village doctors, smaller town clinics, local teachers, and the Ministry of Agriculture. Village doctors are fundamental players because of their relationship with the rural community. As a result of practicing Traditional Chinese Medicine, they are the most trusted actors in health care and can directly provide healthcare services in a way that far-away hospitals are unable to do (Li, et al., 2015). Moreover, smaller town clinics need to be strengthened to replace hospitals as the primary gatekeeper (Mossialos, Ge, Hu, & Wang, 2016). Increasing health education in a school environment is unfortunately not as feasible in rural areas compared to urban settings because 60% of students drop out before high school (Partner, 2018).

However, because of the increasing mortality-rate among young rural individuals, elementary school teachers are nonetheless important in educating children on prevention, as well as providing useful teaching skills in other settings. Due to farming being the most common type of work in rural provinces, the Ministry of Agriculture will also be important for raising awareness as well as implementing new policies (Westmore, 2015).

The intervention that I propose is an education initiative. This is arguably the most effective type of intervention because the fundamental problem lies in a lack of awareness and education in the rural community, which leads to later diagnosis and an earlier generational onset of diabetes that results in mortality. The education initiative is comprised of two steps: firstly, establish accessible health education classes as primary prevention, and secondly, promote open discussions through the utilization of Chinese Traditional Medicine culture for screenings on a secondary prevention level. This initiative will be funded by expenses already being invested by the government on this epidemic.
Most rural families use agriculture as their primary source of income, acquiring a large plot of land and often using the help of their young children for labor (Westmore, 2015).

Therefore, The Ministry of Agriculture should implement a new policy that as part of acquiring or renewing an agricultural land license, all households must take a free information class on diabetes. Moreover, it should be stated that all members who participate in agricultural activities must take it. This ensures that children who drop out of school to work will still receive the proper health education they need. The class will be a collaborative effort between key players, led by the local physicians and teachers. The information would focus on prevention, including proper nutrition and dieting, healthy lifestyle and behavioral activities.

The goal is to stimulate awareness about the main causes of diabetes and how these can be addressed through proper self-management. The information can be put into action with simple, take-home tools for the participants, including weekly food charts to track eating habits, simple local recipes, and setting exercise goals. This first step can be seen as addressing the socioeconomic factors which contribute to high mortality, which according to Friedens health impact pyramid has the biggest impact (Frieden, 2010).

Part of educating the rural population on diabetes surrounds changing the social stigma which hinders individuals to get diagnosed early on. This can be addressed through offering free screenings at local traditional medicine facilities operated by village doctors. This is important because the second step in this education initiative would be to promote open discussions through its integration into traditional Chinese medicine culture, which is highly prevalent in rural provinces (Li, et al., 2015). These traditional facilities are already highly utilized by the community for other purposes.

Diabetes screening does not require high levels of training, thus it would be more effective to train traditional practitioners who are readily available instead of providing inpatient treatment in distant hospitals. Village doctors can talk about the condition during screenings through a lens of culture that is already widely accepted. The second step is arguably changing the context of rural life to make individuals default decisions healthy since they would have to expend significant energy not to benefit from the free screening (Frieden, 2010). Its purpose would thus be to balance the issue of distrust in modern medicine and techniques that the first step might experience.

In conclusion, the two steps reflect the yin and yang of health education, balancing opposing cultures of public health to reach an effective solution. Building a holistic understanding of diabetes can improve the information that is currently available to rural populations. Increased knowledge will have a large impact on reducing diabetes-related mortality by preventing it from occurring at all. 

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