Pulmonary Perspectives® China’s Pulmonary Crisis

Over the past 2 years, we had the opportunity to participate in an annual cross-cultural exchange that has broadened our horizons. Xi’an, the ancient capital of China and home of the Terracotta warriors, is a sprawling megapolis similar to Los Angeles. In the southern suburb of Huxian, US trained pulmonary, neurosurgical, and critical care physicians from Cooper University Hospital and Morehouse School of Medicine partnered with physicians of Ji-Ren Teaching Hospital to deliver a Chinese Medical Association accredited continuing medical education conference. The conference agenda included a variety of pulmonary and critical care topics highlighting sepsis, neurovascular disease, and lung cancer screening and diagnosis. We also provided a hands-on workshop for point of care ultrasound, and, in return, received education about Chinese medicine.

We found our hosts appreciative and hospitable, and they treated us with the highest level of respect (the cornerstone of Chinese culture). The audience was receptive and very interested in learning. However, while we were impressed with their rapid growth and interest in incorporating western medicine into their daily practice, it was impossible to overlook the major pulmonary health-care concerns threatening their communities. Tobacco use was omnipresent, and the haze of air pollution made the sky a constant shade of grey. In both public and private spaces, powerful echoes of a once familiar America resonated, and they served to underscore the obstacles the Chinese medical community now faces in caring for their country’s pulmonary health.
 

An Old, Familiar Foe

The China National Tobacco Corporation (CNTC) is the largest tobacco company in the world, as well as China’s most profitable state-owned enterprise (Pratt, A, et al. WHO Report. 2017. ISBN 9789290617907 [https://www.wpro.who.int/china/publications/2017_china_tobacco_control_report_en_web_final.pdf?ua=1]). As such, the CNTC controls every aspect of its production and supply chain with the force of the federal government and also exerts heavy influence over regulatory policy. It controls about 98% of domestic crop production and manages to price cigarettes just short of one American dollar per pack, yet contributes about $170 billion annually to the government (Rich, et al. Nicotine Tob Res. 2012;14[3]:258). This accounted for nearly 7% of total governmental revenue in 2015 (Pratt, 2017).

To date, nearly 44% of the world’s cigarettes are manufactured and consumed in China (Pratt 2017, Rich 2012). In 2015, more than 315 million Chinese adults were daily smokers, or about 28% of the adult population and nearly half of all men (Pratt, 2017). This is about double the proportion of US smokers (about 15.1%) and more than eight times the 36.5 million daily smokers in the United States (CDC Online Tobacco Use Report, 2016 [https://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/]). However, to visit China is not only to know a love for tobacco, but also an overwhelming guest and gift culture. Gift giving and hospitality is central to the Chinese identity, from business meetings to afternoon tea. Given their economy and such rich supply, people gift cigarettes to one another at all times for nearly any occasion. Unfortunately, tobacco smoke in China is as inescapable as its health consequences.

The direct effects of smoking on China’s pulmonary health have been catastrophic. Cancers of the lung and bronchus constitute their most common malignancy across both sexes, accounting for the majority of the annual 4.3 million new cancer diagnoses (Chen et al. CA Cancer J Clin. 2016;66[2]:115). In Chinese men, lung cancer is the second most common cancer before the age of 60, and over the age of 75, it is the most common malignancy and also accounts for the majority of that group’s cancer mortality. Women fare only slightly better, with breast cancer being their most common malignancy, but with lung cancer remaining the most pervasive across all age groups, and, by far, the most deadly (Chen, 2016). All told, of the projected 2.8 million cancer deaths occurring in 2015 in China, 21% were directly a result of lung cancer.

Likewise, COPD also threatens China. The Global Burden of Disease study conducted in 2004 demonstrated that nearly 3 million people die of COPD each year. Chinese adults over the age of 40 had an overall prevalence of COPD of 9% for the last decade, though this may be higher given the high rate of underdiagnosis in rural China (Fang X, et al. Chest. 2011;139[4]:920). After 2004, the Chinese Ministry of Health affirmed that COPD was the fourth leading cause of mortality in urban areas, but third in rural ones (Fang, 2011). When investigators analyzed deaths secondary to cor pulmonale coexisting with COPD, they found COPD-related mortality increased to 179.9 for men and 141.3 for women per 100,000 persons, which is about double the COPD mortality for other countries in the Asian-Pacific region (Reilly K, et al. Am J Epidemiol. 2008;167[8]:998).

Both cancer and COPD in China disproportionately affect those in rural areas and with lower socioeconomic status, with smoking being the most potent causative exposure. On average, the annual direct and indirect per-patient cost of treating COPD amounted to about $2,000, comprising about 40% of a family’s total annual income (Fang, 2011). The cost of treating malignancy is even more expensive, but the higher likelihood of death results in an additional 10% to 20% reduction of family income when a working family member dies (Pratt, 2016). Taken together, and especially since rural Chinese citizens spend close to 20% of their income on tobacco products, the pulmonary health consequences of smoking are a significant driver of both health and economic inequality.