To use any word weaker than explosive when describing China's rapid process of urbanization is to risk an understatement. Since 1980 the number of people in Chinese cities has surged from 191 million to 622 million. The number continues to climb rapidly — especially as certain areas once considered countryside are converted into urban regions to accommodate growth:
Much of this urban influx is the result of the migration of rural workers into cities. That's a particular problem in China because, as our Nate Berg recently pointed out, the country has a "two-tiered population structure of rural and urban citizens" called hukou. While urban hukou get a number of social benefits, including access to good health care, simply moving from a farm to a city doesn't necessarily change your classification.
As a result, a great many of these rural-to-urban migrants reach the city uninsured and unlikely to visit a doctor. These conflicting realities present China with a potential health-care crisis, according to a recent review in the British medical journal The Lancet. An international group of authors, led by Peng Gong of Tsinghua University in Beijing, outline a number of public health consequences that may arise from China's rapid urbanization, many of them related to the influx of migrant workers:
The growing disease burden in urban areas attributable to nutrition and lifestyle choices is a major public health challenge, as are troubling disparities in health-care access, vaccination coverage, and accidents and injuries in China’s rural-to-urban migrant population. … To address the health challenges and maximise the benefits that accompany this rapid urbanisation, innovative health policies focused on the needs of migrants and research that could close knowledge gaps on urban population exposures are needed.
Urbanization typically results in a number of public health risks. The city environment can lead to injury (say, through increased motorization or new occupations) or illness. When the process connects places that were typically isolated, as is the case with rural-urban migration in China, the chances of spreading communicable diseases increase. Moving to a city also carries risks of non-communicable illnesses, including psychiatric disorders.
In China, these problems are complicated by the hukou system and its ties to strong urban health care. Policies have developed to meet these challenges in the capital city of Beijing, with basic services being offered to rural migrants at community health centers, but elsewhere throughout the country "progress has been slow," the review authors report.
In 2006, for instance, only about 28 percent of the entire urban population were covered by the country's primary basic urban health-care insurance — with migrant workers the bulk of those without coverage. The government announced a broader program to expand access to care in 2010, modeled on Beijing's success, but a lot of problems remain, particularly related to child immunization. Even in Beijing migrant workers are at greater risk for tuberculosis, based on living conditions.
Non-communicable diseases are a problem as well. Some research has found that rural-urban migrants have worse blood pressure than those who remained in rural areas. The dietary changes that come with leaving the farm, and the corresponding drop in physical activity, have contributed to urban rates of adult hypertension and child obesity double those of rural areas.
The psychological stressors of the city could also create a mental strain on migrants — a particular concern in a country where an estimated 17 percent of the population meet criteria for neuropsychiatric disorder. Water quality and abundance, air pollution following a rapid rise in motor vehicle use, and the occupational hazards of working in construction and heavy industry are also potential areas of concern.
The researchers recommend a number of steps to mitigate the health impact of Chinese urbanization as much as possible. First above all is improved research — particularly work that acknowledges a rural-urban population overlap. Health data must be updated very frequently, to keep pace with the move to the city.
Of course the right policies must be implemented to handle the problems at their source. That means an increased awareness of urban-rural disease risks, the authors conclude, as well as the urgent provision "of affordable health care to rural-to-urban migrants in urban areas irrespective of hukou status."
Figure from Urbanisation and Health in China, Gong et al., Lancet, 2012 Mar 3, 379(9818), pp. 843-52, doi:10.1016/S0140-6736(11)61878-3.
Top image: David Gray/Reuters.