Developing Countries: Egypt, China, India, and South Africa

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 3NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEDeveloping OR DISTRIBUTION Countries: EgyptNOT FOR, C SALEhin ORa, DISTRIBUTION India, and South Africa © Jones & Bartlett Learning,Carol LLC Holtz © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONIbrahim Elsawy NOT FOR SALE OR DISTRIBUTION

“It’s immoral that people in Africa die like ἀies of diseases © Jonesthat & no Bartlett one dies of Learning, in the United LLCStates. And the more disease © Jones & Bartlett Learning, LLC NOT FORthere SALE is, the moreOR DISTRIBUTION political unrest there will be, leading to NOT FOR SALE OR DISTRIBUTION more Darfurs.” Former President Bill Clinton

© Jones &Objectives Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORAἀer SALE completing OR this DISTRIBUTION chapter, the reader will be able to: NOT FOR SALE OR DISTRIBUTION 1. Discuss family planning, infertility, abortion, and sterilization practices in Egypt, China, India, and South Africa. 2. Explain how communism affects health and health care in China. © Jones & Bartlett Learning, 3. Discuss women’s LLC rights issues in South Africa.© Jones & Bartlett Learning, LLC 4. Compare the health and healthcare systems of Egypt, China, India, and South Africa. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Introduction This chapter addresses the health conditions of four developing countries: Egypt, China, India, and South Africa. These countries were selected for examination because they differ in culture, economics, politics, geographic© regions, Jones and & types Bartlett of health Learning, care and health LLC issues. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Egypt Background © JonesEgypt & Bartlett(the Arab Republic Learning, of Egypt) LLC is located in the far northeastern© partJones of the &African Bartlett continent, Learning, bor- LLC NOT FORdered SALE on the northOR byDISTRIBUTION the Mediterranean Sea, on the east by the RedNOT Sea, FORon the westSALE by Libya, OR onDISTRIBUTION the south by Sudan, and on the northeast by the Gaza Strip and Israel. Egypt is traversed by the Suez Canal,

53 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 0085 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

54  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

which is located© Jones between & itsBartlett Asian and Learning,African territories. LLC The country’s total land area is© 1,002,450 Jones square & Bartlett Learning, LLC kilometers.NOT Most FOR of Egypt SALE is located OR in Africa,DISTRIBUTION but part of its land, the Sinai Peninsula, isNOT located FOR in Asia. SALE OR DISTRIBUTION The majority of its population of approximately 83 million people lives on the banks of the Nile River or on the coasts of the Mediterranean Sea, the Red Sea, and the Suez Canal. The largest defined landmass within Egypt is the Sahara Desert, which is very sparsely populated. The largest cities include Cairo (the capital), Alexandria, and other cities in the Nile Delta. Ninety-eight percent of the Egyptian population © Joneslives & on Bartlett just 4% of theLearning, country’s land LLC (Arab Republic of Egypt, Ministry© Jones of Foreign & A ffBartlettairs, 2010). Learning, LLC Most of Egypt’s rainfall occurs during the winter months, with only 0.1 to 0.2 inches of precipitation NOT FORfalling SALE each year. OR Before DISTRIBUTION the construction of the Aswan Dam, the NileNOT River FOR flooded SALE annually, OR producing DISTRIBUTION good soils and good harvests in its floodplains. Arabic is the official language; English and French are the most commonly used foreign languages. The majority ethnic groups are Egyptian, Bedouin Arab, and Nubian. Education is compulsory for children aged 6–15 years, and the literacy rate is 58% (“About Egypt,” 2010). © Jones & Bartlett Learning,Egypt has LLC a distinguished cultural heritage,© accumulated Jones & over Bartlett the thousands Learning, of years of LLC its history. NOT FOR SALE OREach DISTRIBUTION of the Egyptian successive civilizations (Pharaonic,NOT FOR Greco-Roman, SALE OR Coptic, DISTRIBUTION and Islamic) contrib- uted to the areas of philosophy, literature, and the arts. Because of its long-held ties with Europe, Egypt has been a cultural pioneer in the modern Arab world. In 2002, with the support of the United Nations Educational, Scientific and Cultural Organization (UNESCO), the new Bibliotheca Alexandrina was inaugurated. This world-recognized special historical site is located in Alexandria. The goal of the recon- struction© of theJones ancient & Library Bartlett of Alexandria Learning, was to reviveLLC the legacy of this universal center© Jones for science & Bartlett Learning, LLC and knowledgeNOT (“About FOR Egypt,”SALE 2010). OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION In terms of religion, the Egyptian population consists of 94% Muslims and 6% Christians. The two main Islamic institutions in Egypt are the oldest and the most important Islamic institutions in the country: ■■ Al-Azhar, which was built by the Fatimids to spread the Shiite sect in North Africa. Later Salah El-Din converted it to Sunni University, which became one of the main pillars of Sunni Islam in the world. © Jones■■ &Dar Bartlett el Eἀaa, foundedLearning, in 1895 LLCand headed by the Grand Muἀi of© Egypt. Jones & Bartlett Learning, LLC NOT FORThe CopticSALE Orthodox OR DISTRIBUTION Church, one of the oldest Christian churchesNOT in FOR the world, SALE and OR the Roman DISTRIBUTION Orthodox Church of the Arab Republic of Egypt are located in Alexandria (Arab Republic of Egypt, Ministry of Foreign Affairs, 2010). Economy © Jones & Bartlett Learning,Table 3-1 presents LLC statistics on Egypt’s current economy.© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION TABLE 3-1 Egypt’s Economy GDP $218.91 billion GDP growth© Jones & Bartlett Learning, LLC 5.2%/year © Jones & Bartlett Learning, LLC Inflation, NOTGDP de FORflator SALE OR DISTRIBUTION 10.1%/year NOT FOR SALE OR DISTRIBUTION Agriculture, value added 10% of GDP Industry, value added 29% of GDP Services and other revenue sources, value added 61% of GDP Exports of goods and services 21% of GDP © JonesImports & Bartlett of goods andLearning, services LLC © Jones28% of GDP& Bartlett Learning, LLC Gross capital formation 19% of GDP NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Source: World Bank, 2010.

© Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 0085 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Egypt  55

Health © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Table 3-2NOT presents FOR population SALE health OR statistics DISTRIBUTION for Egypt. NOT FOR SALE OR DISTRIBUTION Healthcare Systems The majority of Egyptians have access to health care for basic health services, managed by the Ministry of Health and Population (MOHP), the Health Insurance Organization (HIO), private health practitioners, © Jonesand & nongovernmental Bartlett Learning, organizations LLC (NGOs). The HIO covers 45% of© the Jones population, & Bartlettand there is aLearning, grow- LLC NOT FORing and SALE unregulated OR DISTRIBUTIONprivate healthcare sector. Pharmaceuticals accountNOT for nearlyFOR one-third SALE of OR all health- DISTRIBUTION care costs (World Health Organization [WHO], 2011).

TABLE 3-2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Egypt’s Population Health Statistics, 2011 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Birth rate 28.9 per 1000 Underweight children 7.5% Population younger than age 15 years 31.7% Population 65 years or older 3.7% Total births© perJones woman & Bartlett Learning, LLC © 3Jones & Bartlett Learning, LLC Adult literacy rate (among persons 15 years or older) 71% PopulationNOT with sustainableFOR SALE access OR to improved DISTRIBUTION water sources NOT94% FOR SALE OR DISTRIBUTION Population with sustainable access to improved sanitation 94% Smoking rate of adults 19% Total government expenditure per capita on health $124 Total government expenditure on health as a percentage of GDP 6.4% © JonesOut-of-pocket & Bartlett expenditure Learning, on health LLC per capita © Jones & Bartlett58.7% Learning, LLC NOT FORHuman SALE Resources OR (perDISTRIBUTION 10,000) NOT FOR SALE OR DISTRIBUTION Physicians 28.3 Dentists 4.2 Pharmacists 16.7 Nurses and midwives 35.2 © Jones & Bartlett Learning,Hospital beds LLC © Jones & Bartlett Learning,17.3 LLC NOT FOR SALE ORPrimary DISTRIBUTION healthcare units and centers NOT FOR SALE OR DISTRIBUTION0.7 Primary Health Care (per 100) Population with access to healthcare services 88 Contraception prevalence 57.6 Prenatal care 52 Births attended© Jones by skilled & personnelBartlett Learning, LLC ©84 Jones & Bartlett Learning, LLC Health StatusNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Life expectancy 72.3 years Infant mortality rate (per 1000 live births) 17 Under-five mortality rate 21.8 per 1000 Maternal mortality rate 55 per 100,000 © JonesProbability & Bartlett of not reachingLearning, 40 years LLC of age © Jones & Bartlett10.3% Learning, LLC Smoking prevalence (among males 15 years or older) 40% NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Source: WHO, 2011.

56  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

Communicable© Jones Dise &ases Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Within theNOT last decadeFOR thereSALE has beenOR aDISTRIBUTION huge decline in deaths from communicable diseasesNOT FORin Egypt, SALE OR DISTRIBUTION largely due to the high rate of vaccinations for preventable diseases. Hepatitis B and C continue to be problems, however. Schistosomiasis (a parasitic disease caused by flatworms), hepatitis C (affecting 9.8% of the general population), and tuberculosis are the top three infectious diseases found in Egypt today (WHO, 2011). © Jones &A Bartlett study conducted Learning, in Egypt and LLC supported by USAID to prevent© typhoid Jones fever & in Bartlett rural communities Learning, LLC NOT FORused SALEthe intervention OR DISTRIBUTION of hand washing with soap. Studies indicate thatNOT 9000 FOR to 42,000 SALE cases OR of typhoid DISTRIBUTION are reported in this country each year. Typhoid fever is transmitted by the fecal–oral route, so it is appropriate to build prevention strategies against this infection—yet only 40% of all households in Egypt had soap and water available for hand washing at the time the intervention was undertaken. The scarcity of water and problems with waste disposal are related issues for hand washing. As part of the interven- © Jones & Bartlett Learning,tion, proper hand LLC washing techniques were taught© Jones and general & Bartletteducation of Learning, disease transmission LLC was performed. Results indicated improvement in hand washing rates in the rural Fayoum region of Egypt NOT FOR SALE OR(Lohinivak, DISTRIBUTION El-Sayeed, & Talaat, 2008). NOT FOR SALE OR DISTRIBUTION

Maternal and Infant Health Despite health clinics that are accessible to the general public, maternal and infant mortality rates in Egypt are© high, Jones with an & infant Bartlett mortality Learning, rate of 17 deaths LLC per 1000 live births and a maternal© Jones mortality & Bartlett Learning, LLC rate of 55 deaths per 1000 live births. In addition, the 21.8 per 1000 death rate for children younger than age five isNOT considered FOR high. SALE These ratesOR re DISTRIBUTIONflect exceptionally high mortality rates among NOTwomen FORand chil- SALE OR DISTRIBUTION dren in rural Upper Egypt. Child survival initiatives, such as cord care, delivery instrument antisepsis, and infant warming have reduced the rate of mortality of children younger than five years. As is true in most developing countries, most births in Egypt take place in the home. A major contributing factor to maternal and infant morbidity and mortality is unhygienic conditions, which increase © Jonesthe & likelihood Bartlett of infections Learning, within LLC both the mother and the newborn.© TetanusJones typhoid & Bartlett immunization Learning, is LLC NOT FORone methodSALE of OR reducing DISTRIBUTION deaths due to tetanus, but many other infectionsNOT can FOR occur SALE at the time OR of DISTRIBUTIONbirth. Infection ranks third among the causes of maternal mortalities in Egypt. A cohort study explored the use of a clean delivery kit as a means of reducing infant and maternal infections. Kits were distributed from primary health facilities, and birth attendants received training on how to use the kits. Results from the study of 334 women indicated that neonates of mothers who had the use of the kits were less likely to © Jones & Bartlett Learning,develop sepsis fromLLC cord infection and mothers had© Jonesfewer postpartum & Bartlett infections Learning, (Darmstadt etLLC al., 2009). NOT FOR SALE OR DISTRIBUTIONPregnancy outcomes in Egypt are poorer as NOTcompared FOR to those SALE in other OR developing DISTRIBUTION nations with similar per capita gross national products (GDPs). The national rate of low birth weight in Egypt is 12% of all live births, but for 30% of low-birth-weight infants in Egypt, the mortality rate is 2.5 times that of full-term infants. These increased risks of mortality for low-birth-weight children persist throughout the first year of life and beyond, with this risk factor also being associated with increased cognitive disabilities. A special antenatal ©nutrition Jones project & Bartlettin Al-Minia, Learning, in Upper Egypt, LLC demonstrated an ability to improve© Jones birth weight & Bartlett Learning, LLC in newborns.NOT Women FOR in thisSALE project OR received DISTRIBUTION food supplements and nutrition education asNOT well as FOR prenatal SALE OR DISTRIBUTION care and home visits. Results indicated that infant birth weights increased, which ultimately resulted in healthier babies who were less likely to contribute to the infant mortality rate (Ahrani et al., 2006).

Noncommunicable Diseases © JonesNeuropsychiatric & Bartlett (19.8%),Learning, digestive LLC diseases (11.5%), chronic respiratory© Jones diseases & (6.9%), Bartlett cardiovascular Learning, LLC NOT FORdiseases SALE (6.7%), OR and diabetesDISTRIBUTION are major noncommunicable diseases whoseNOT incidence FOR SALE continues OR to increase DISTRIBUTION in Egypt. Smoking, substance abuse, failure to use car seats and seat belts, lack of exercise, and consumption of fatty and salty foods are major contributors to the disease burden. Diabetes mellitus affects

Egypt  57

TABLE 3-3© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Top FiveNOT Cancers FOR in Egypt SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Males Females Both Sexes 1. Bladder 1. Breast 1. Breast 2. Liver 2. Non-Hodgkins lymphoma 2. Bladder © Jones3. Non-& BartlettHodgkins lymphomaLearning, LLC 3. Ovary ©3. Jones Non-Hodgkins & Bartlett lymphoma Learning, LLC NOT FOR4. Lung SALE OR DISTRIBUTION4. Colorectal NOT4. Live FORr SALE OR DISTRIBUTION 5. Leukemia 5. Leukemia 5. Leukemia Source: WHO, 2011.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE ORnearly DISTRIBUTION 3.9 million people in Egypt, and its prevalenceNOT is expectedFOR SALE to increase OR to 9DISTRIBUTION million by 2025. A study conducted in 2011 in Cairo indicated that type 1 diabetes mellitus care needs to be carefully monitored, as complication rates were nearly 50% among patients in the study. Regular exercise for patients in this study demonstrated a significant positive effect for children and adolescents (Ismail, 2011). Table 3-3 lists the top five most frequently occurring cancers in Egypt. Breast cancer accounts for 38% of all© new Jones cancer &cases Bartlett among women Learning, living in LLCthis country. The age-standardized© rateJones (ASR) &for Bartlett Learning, LLC breast cancer incidence in Egypt is 37.3 per 100,000, and the mortality rate is 20.1 per 100,000. Incidence of breast NOTcancer isFOR lower SALEin Egyptian OR women DISTRIBUTION than in U.S. women, possibly due to a lowerNOT rate FORof cancer SALE OR DISTRIBUTION screening, and mortality rates for Egyptian women are higher than those for U.S. women (International Agency for Research on Cancer, 2010).

Mortality and Burden of Disease © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORTable SALE 3-4 provides OR childDISTRIBUTION mortality data for Egypt in 2009 and 2010.NOT Table 3-5FOR lists SALEadult mortality OR DISTRIBUTIONrates, defined as the probability of dying between 15 and 60 years of age per 1000 population; a breakout is provided for the maternal mortality rate. Table 3-6 identifies age-standardized mortality rates by cause. Table 3-7 gives causes of death for Egyptian children younger than age five. Table 3-8 provides mortality data related to HIV/AIDS, tuberculosis, and malaria. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONTABLE 3-4 NOT FOR SALE OR DISTRIBUTION Child Mortality in Egypt, 2009 and 2010 Year Rates Under-five mortality rate (probability of dying by age 5 per 1000 2010 22 live births)© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Number ofNOT under- FORfive deaths SALE (thousands) OR DISTRIBUTION 2010 NOT 41FOR SALE OR DISTRIBUTION Infant mortality rate (probability of dying between birth and age 1 2010 19 per 1000 live births) Number of infant deaths (thousands) 2010 35 Neonatal mortality rate (per 1000 live births) 2010 9 © JonesNumber & Bartlett of neonatal Learning, deaths (thousands) LLC © Jones2010 & Bartlett18 Learning, LLC Stillbirth rate (per 1000 total births) 2009 13 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Source: WHO, 2011.

58  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

TABLE 3-5© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Adult MortalityNOT FOR in Egypt, SALE 2008 OR and DISTRIBUTION 2009 NOT FOR SALE OR DISTRIBUTION Number of Deaths Among Persons Aged Year 15–60 Years per 1000 Population

Male 2009 215 © JonesFemale & Bartlett Learning, LLC 2009 © Jones130 & Bartlett Learning, LLC NOT FORBoth SALEsexes OR DISTRIBUTION 2009 NOT FOR174 SALE OR DISTRIBUTION Maternal mortality ratio (per 100,000 2008 82 (range: 51–130) live births; interagency estimates) Source: WHO, 2011. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE ORFemale DISTRIBUTION Circumcision NOT FOR SALE OR DISTRIBUTION Female circumcision has been a tradition in Egypt since the Pharaonic period. The prevalence of female circumcision is widespread in Egypt; 91% of all women age 15–49 have been circumcised. The female circumcision rate among women younger than age 25 is lower than the corresponding rate in the 25–49 age group, in which 94% to 96% of women have been circumcised. The rate also is lower among never-married than ever-married© Jones women & Bartlett (81% and 95%, Learning, respectively). LLC Urban women are less likely to© be Jones circumcised & Bartlett Learning, LLC than ruralNOT women FOR (85% andSALE 96%, respectively).OR DISTRIBUTION The likelihood that a woman is circumcisedNOT also FOR declines SALE OR DISTRIBUTION with the woman’s education level and is markedly lower among women in the highest wealth quintile than in other quintiles (78% versus 92% or higher). The majority of circumcised women (63%) report that (midwives) were responsible for performing the procedure. Trained medical personnel (primarily doctors) performed most of the remaining circumcisions (Egypt Demographic and Health Survey, 2008). © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORSpousal SALE Violence OR DISTRIBUTION in Egypt NOT FOR SALE OR DISTRIBUTION Nearly three-fourths of women visiting family health centers in Alexandria, Egypt, have experienced spousal violence in their lifetimes. Approximately half of the women experienced physical violence (“Spousal Violence in Egypt,” 2010).

© Jones & Bartlett Learning,Mental Health LLC © Jones & Bartlett Learning, LLC NOT FOR SALE ORA DISTRIBUTION national household survey of prevalence of disordersNOT iFORn five governorates, SALE OR using DISTRIBUTION the Mini International Neuropsychiatric Interview–Plus (MINI-Plus) instrument, indicated that almost 17% (range: 11% to 25.4%

TABLE 3-6© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Age-StandardizedNOT FOR Mortality SALE Rates OR byDISTRIBUTION Cause, 2008 (per 100,000 population) NOT FOR SALE OR DISTRIBUTION Mortality rate from communicable disease 76 Mortality rate from noncommunicable disease 749 Mortality rate from injuries 34 © JonesSource: & Bartlett WHO, 2011. Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Egypt  59

TABLE 3-7© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Causes ofNOT Death FOR Among SALE Children OR Younger DISTRIBUTION Than Age Five Years, 2008 (percentageNOT of all FOR deaths) SALE OR DISTRIBUTION Prematurity 30 Pneumonia 11 Diarrhea 6 Birth asphyxia 5 © JonesInjuries & Bartlett Learning, LLC 5 © Jones & Bartlett Learning, LLC NOT FORNeonatal SALE sepsis OR DISTRIBUTION 1 NOT FOR SALE OR DISTRIBUTION HIV/AIDS 0 Measles 0 Malaria 0 Other 23 © Jones & Bartlett Learning,Source: WHO, 2011. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

in different governorates) of adults in Egypt had mental disorders, with the common being mood disorders (6.4%), anxiety disorders (4.9%), and somatoform disorders (0.6%). Psychoses were seen in 0.3% of the population© Jones (WHO, & 2005). Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Environmental Problems Air pollution, especially in Cairo and Alexandria, is a major source of chronic respiratory diseases (WHO, 2006). According to the Country Cooperation Study, Egypt receives 98% of its fresh water from © Jonesthe & Nile Bartlett River; unfortunately, Learning, there LLC is excessive water pollution in the© Nile Jones due to large& Bartlett discharges Learning, of pes- LLC ticides, nutrients, and heavy metals from industry in Cairo, making obtaining clean water a major health NOT FORchallenge SALE for theOR country’s DISTRIBUTION population. Tap water assessments indicateNOT that FOR lead levels SALE are at OR a high DISTRIBUTION risk level as well. A recommendation by the WHO suggested that lead and other heavy metal residuals should be lowered for health safety of the population (Lasheen, El-Kholy, Sharaby, Elsherif, & El-Wakeel, 2008).

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC TABLE 3-8 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION HIV/AIDS, Malaria, and Tuberculosis in Egypt, 2008 and 2009 Year Data (Range) Deaths due to HIV/AIDS (per 100,000 population per year) 2009 0.6 (0.5–0.9) Deaths due© toJones malaria (per& Bartlett 100,000 population Learning, per year) LLC 2008© 0.2Jones (0.1–0.2) & Bartlett Learning, LLC Deaths dueNOT to tuberculosis FOR SALE among ORHIV-negative DISTRIBUTION people 2009NOT 1.10 (0.74–1.50) FOR SALE OR DISTRIBUTION (per 100,000 population per year) Prevalence of HIV among adults aged 15 to 49 (%) 2009 <0.1 Incidence of tuberculosis (per 100,000 population per year) 2009 19.0 (16.0–22.0) Prevalence of tuberculosis (per 100,000 population) 2009 30.0 (13.0–49.0) © JonesSource: & Bartlett WHO, 2011. Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

60  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

Egypt’s© R esponseJones &to theBartlett Millennium Learning, Development LLC Goals © Jones & Bartlett Learning, LLC The tablesNOT presented FOR in SALE this subsection OR DISTRIBUTION profile Egypt’s responses to WHO’s MillenniumNOT Development FOR SALE OR DISTRIBUTION Goals (WHO Global Health Observatory Data Repository, 2011):

■■ MDG 1: Poverty and hunger (Table 3-9)

Percentage of children younger than 5 years who are underweight 8.1 5.4 6.8 © Jones & Bartlett Learning,Percentage of children LLC younger than 5 years who© are Jones stunted & Bartlett33 Learning, 28.4 LLC 30.7 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Source: WHO, 2011.

■■ MDG 4: Child mortality (Table 3-10) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC TABLE 3-10 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Egypt: Child Mortality Indicators, 2009 and 2010 Year Data Under-five mortality rate (probability of dying by age 5 per 2010 22 © Jones 1000& Bartlett live births) Learning, LLC © Jones & Bartlett Learning, LLC NOT FORNumber SALE of under- ORfi veDISTRIBUTION deaths (thousands) NOT FOR2010 SALE OR 41 DISTRIBUTION Infant mortality rate (probability of dying between birth and age 1 2010 19 per 1000 live births) Number of infant deaths (thousands) 2010 35 Measles (MCV) immunization coverage among 1-year-olds (%) 2009 95 © Jones & Bartlett Learning,Source: WHO, 2011. LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ MDG 5: Maternal health ●● Maternal mortality (Table 3-11) ●● Births attended by skilled health personnel, 2008: 79% ●● Reproductive© Jones health& Bartlett (Table 3-12 Learning,) LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION TABLE 3-11 Egypt: Maternal Mortality Indicators, 2008 © JonesMaternal & Bartlett mortality Learning, ratio (per 100,000 LLC live births; interagency estimates)© Jones 82 & (range: Bartlett 51–130) Learning, LLC Births attended by skilled health personnel 79% NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Source: WHO, 2011.

Egypt  61

TABLE 3-12© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Egypt: ReproductiveNOT FOR HealthSALE Indicators, OR DISTRIBUTION 2006 and 2008 NOT FOR SALE OR DISTRIBUTION Year Data Contraceptive prevalence 2008 60.3% Contraceptive prevalence, among women aged 15–19 2008 23.4% © JonesAdolescent & Bartlett fertility Learning, rate (per 1000 girlsLLC aged 15–19 years) © Jones2006 & Bartlett 50 Learning, LLC NOT FORAntenatal SALE care ORcoverage: DISTRIBUTION at least one visit NOT FOR2008 SALE OR 74% DISTRIBUTION Antenatal care coverage: at least one visit, among women aged 15–19 2008 76.5% Antenatal care coverage: at least four visits 2008 66% Unmet need for family planning 2008 9.2% Unmet need for family planning: women aged 15–19 2008 7.9% © Jones & Bartlett Learning,Births attended LLC by skilled health personnel, among© Joneswomen aged & 15–19Bartlett Learning, 2008 LLC 78.8% NOT FOR SALE ORSource: DISTRIBUTION WHO, 2011. NOT FOR SALE OR DISTRIBUTION

■■ MDG 6: HIV/AIDS, malaria, and other diseases (Table 3-13) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC TABLE 3-13NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Egypt: HIV/AIDS, Malaria, and Tuberculosis Indicators, 2008 and 2009 Year Data Prevalence of HIV among adults aged 15–49 (%) 2009 <0.1 © JonesDeaths & Bartlett due to malaria Learning, (per 100,000 LLC population per year) © Jones2008 & Bartlett 0.2 (0.1–0.2) Learning, LLC NOT FORIncidence SALE of tuberculosis OR DISTRIBUTION (per 100,000 population per year) NOT FOR2009 SALE 19.0 OR (16.0–22.0) DISTRIBUTION Prevalence of tuberculosis (per 100,000 population) 2009 30.0 (13.0–49.0) Deaths due to tuberculosis among HIV-negative people (per 100,000 2009 1.10 (0.74–1.50) population per year) Case detection rate for all forms of tuberculosis 2009 63 (54–75) © Jones & Bartlett Learning,Smear-positive LLC tuberculosis treatment: success rate© Jones(%) & Bartlett Learning,2008 LLC 89 NOT FOR SALE OR Source:DISTRIBUTION WHO, 2011. NOT FOR SALE OR DISTRIBUTION

■■ MDG 7: Environment sustainability (Table 3-14) © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC TABLE 3-14NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Egypt: Water and Sanitation Indicators, 2008 Urban Rural Total © JonesPopulation & Bartlett using improvedLearning, drinking-water LLC sources ©100% Jones & 98%Bartlett 99%Learning, LLC Population using improved sanitation facilities 97% 92% 94% NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Source: WHO, 2011.

62  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

■■ Not ©a MDG Jones. The following& Bartlett is a table Learning, relating nutrition LLC in Egypt (Table 3-15). © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION TABLE 3-15 Egypt: Nutrition Indicators, 2008 Both © Jones & Bartlett Learning, LLC ©Male Jones Female& BartlettSexes Learning, LLC NOT FORChildren SALE younger OR than DISTRIBUTION 5 years: overweight NOT19.8% FOR 21.2% SALE OR 20.5% DISTRIBUTION Children younger than 5 years: stunted 33% 28.4% 30.7% Children younger than 5 years: underweight 8.1% 5.4% 6.8% Children younger than 5 years: wasted for age 8.8% 7.1% 7.9% Source: WHO, 2011. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Traditional Health In the Arab Republic of Egypt, a national policy on traditional medicine/complementary alternative medicine© (TM/CAM) Jones is& part Bartlett of the national Learning, drug policy LLC that was issued in 2001. Herbal ©medicine Jones regula- & Bartlett Learning, LLC tion in EgyptNOT began FOR in 1955, SALE and is OR achieved DISTRIBUTION through the same laws as are applied to conventionalNOT FOR phar- SALE OR DISTRIBUTION maceuticals. Herbal medicines are regulated in the forms of prescription medicines, over-the-counter medicines, self-medication, and dietary supplements. Control mechanisms exist for both manufacturing and safety assessment requirements. There are 600 registered herbal medicines, though no herbal medicines are included on the national essential drugs list. In Egypt, herbal medicines are sold in pharmacies © Jonesby licensed& Bartlett practitioners, Learning, as over-the-counter LLC products, and as prescription© Jones medicines & Bartlett (WHO, 2011). Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION China Description China is the world’s fourth largest country in area (aἀer the countries of Russia, Canada, and the © Jones & Bartlett Learning,United States), LLCand is located in east Asia, bordering© Jones numerous & countries, Bartlett including Learning, the Russian LLC Federal NOT FOR SALE ORRepublic, DISTRIBUTION India, Pakistan, Vietnam, and Mongolia.NOT China, FOR which SALE is slightly OR DISTRIBUTION smaller than the United States, has climates varying from tropical in the south to subarctic in the north. At present it has a great amount of air pollution—mostly greenhouse gases and sulfur dioxide particles from use of coal and other carbon-based fuels. It also has water pollution, hazardous waste, deforestation, and soil erosion problems (Central Intelligence Agency [CIA], 2011a). © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC PopulationNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION China currently has 1.3 billion people. A graph of China’s aging population and the forecast for the increased percentage of the total population represented by people 65 and older can be seen in Figure 3-1. Table 3-16 provides a breakdown of China’s health and vital statistics.

© JonesEthnic & Bartlett Groups inLearning, China LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The Han ethnic group makes up 91.9% of the population, with the remainder being Zhaung, Uygur, Hui, Yi, Tibetan, Miao, Manchu, Mongol, Buyi, Korean, and other nationalities. The official religion of China

China  63

FIGURE© 3-1 Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC China’s AgingNOT Population FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Percent 100% = 1.13 billion 1.27 billion 1.50 billion people people people Ages 65 and older 5 7 © Jones & Bartlett Learning, LLC © Jones16 & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Ages 15–64 67 70 67

1990 2000 20301

1Forecast © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Source: QuotedNOT from FOR the website SALE of the NationalOR DISTRIBUTION Bureau of Statistics of the People’s Republic of China,NOT www.stats.gov.cn FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORTA BSALELE 3-16 OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION China’s Population, 2010 Total population 1.330 billion people Birth to 14 years 17.9% 15–64 years 73.4% © Jones & Bartlett Learning,65+ years LLC © Jones8.6% & Bartlett Learning, LLC NOT FOR SALE ORPopulation DISTRIBUTION growth rate NOT0.494% FOR SALE OR DISTRIBUTION Birth rate 12.17 per 1000 people Death rate 6.89 per 1000 people Gender ratio 1.08 males per 1 female Infant mortality rate 16.51 deaths per 1000 live births © Jones & Bartlett Learning, Males:LLC 21.21 deaths per 1000 live births© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONFemales: 27.5 deaths per 1000 live birthsNOT FOR SALE OR DISTRIBUTION Life expectancy at birth (ranks 92nd in world) Males: 72.54 years Females: 76.77 years Fertility rate 1.54 children per woman HIV rate 0.1% (700,000 persons already have the disease) Education (average) 11 years © JonesLiteracy & Bartlett (can read Learning,and write) LLC 91.6% © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Source: CIA, 2011a.

64  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

is atheist,© but Jones 1% to 2% &is Daoist,Bartlett Buddhist, Learning, or Muslim, LLC and 3% to 4% is Christian. The standard© Jones language & Bartlett Learning, LLC is Mandarin; other dialects spoken in the country include Cantonese, Shanghaiese, Fuzhou, Hokkien- Taiwanese,NOT Xiang, FOR Gan, andSALE Hakka. OR China DISTRIBUTION has a 91.6% literacy rate (CIA, 2011a). NOT FOR SALE OR DISTRIBUTION

Government The government of China (also called the People’s Republic of China [PRC]) is communist, and the capi- © Jonestal is& in Bartlett Beijing. China Learning, has 23 provinces LLC and 5 autonomous regions (CIA,© Jones 2011a). & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Economy Since 1978, the Chinese economy has moved from a centrally run and planned Soviet-style of government to a market economy. Business and agriculture are now more locally run, rather than being controlled by the central communist government. The overall economic system continues to function within strict © Jones & Bartlett Learning,communist political LLC control, however. The change© Jones in management & Bartlett style of businessLearning, has increased LLC the NOT FOR SALE ORGDP DISTRIBUTION four times and boosted per capita income toNOT $8288 FORin 2011 SALE(CIA, 2011a). OR DISTRIBUTION China has now moved beyond Japan to become the world’s second-largest economy, and it may over- take the United States in terms of national income within the next 10 years, though it remains far behind in per capita income. The country now has hundreds of millions of people who have moved out of poverty and has a large group of students and tourists who visit the West. In spite of China now having many bil- lionaires,© as Joneswell as numerous & Bartlett millionaires, Learning, the average LLC income for most of its residents ©is still Jones among &the Bartlett Learning, LLC world’s lowestNOT (“China FOR Surges SALE Past OR Japan,” DISTRIBUTION 2010). NOT FOR SALE OR DISTRIBUTION Healthcare System History © JonesChina & Bartletthas one of the Learning, longest historical LLC records of medicine of any existing© Jones civilization & Bartlett in the world. Learning, Both LLC NOT FORtraditional SALE medicine OR DISTRIBUTION and new technology are components of the ChineseNOT healthcare FOR SALE system. OR DISTRIBUTION In 1949, Chairman Mao Zedong established a rural preventive healthcare program, emphasizing disease prevention. At that time, the ministry of public health was made responsible for all health care. Large numbers of more sophisticated urban physicians were sent to the countryside to practice. In addition, less trained “barefoot doctors” were sent to small rural communities to help supply the needs for local rural health care. They worked out of village medical centers, providing preventive and primary © Jones & Bartlett Learning,medical care. InLLC addition, township health centers© thatJones had 10–30 & Bartlett bed hospitals Learning, were established LLC as part NOT FOR SALE ORof DISTRIBUTION the so-called rural collective health system. OnlyNOT seriously FOR ill SALEpatients wentOR to DISTRIBUTION county hospitals, which served a much larger population base. In large urban areas, health care was provided by paramedical personnel, who were assigned to factories and neighborhood health stations. Patients with serious illnesses went to the district or municipal hospitals. In the 1950s, China was isolated by the Western powers, and the Soviet Union was its only ally. During this© era,Jones medical & schoolsBartlett and hospitalsLearning, in China LLC were built with the help of Russians.© Jones There was& Bartlett Learning, LLC an emphasisNOT on publicFOR health SALE and ORprevention DISTRIBUTION of illness. The government mobilized theNOT people FORto begin SALE OR DISTRIBUTION massive patriot health campaigns aimed at environmental sanitation and preventing disease. An example was the assault on the “four pests” (rats, sparrows, flies, and mosquitoes), as well as the efforts directed toward eradicating snails that carried schistosomia disease. Other health campaigns were devoted to water quality and waste management (CIA, 2011a). Unfortunately, much of the country’s agricultural sec- © Jonestor & was Bartlett ignored or Learning, handled poorly LLC by overplanting and not harvesting© Jonesall the crops, & Bartlettleaving them Learning, to rot. LLC NOT FORThus SALE many of theOR agricultural DISTRIBUTION programs failed. As many as 20 to 30NOT million FOR people SALEstarved to OR death, DISTRIBUTION and infant mortality rose to 300 per 1000 (Hesketh & Zhu, 2002).

China  65

In the© 1960s,Jones campaigns & Bartlett to prevent Learning, sexually transmitted LLC diseases, such as syphilis,© Joneswere success- & Bartlett Learning, LLC ful. By the 1970s, China was able to set up affordable primary health care in the rural areas. During the 1980s, its NOThealth policyFOR was SALE restructured OR DISTRIBUTIONbased on market-driven reforms. The barefoot doctorsNOT wereFOR then SALE OR DISTRIBUTION less needed, as a more sophisticated system of health care was established. With a 1% growth rate and a population of 1.3 billion people, China became very concerned about population growth and began restricting family size by implementing the “one child per family” policy. Diseases such as tuberculosis, hepatitis, hookworm, and schistosomiasis still remained problems. Later, other, more chronic diseases © Jonessuch & as Bartlett HIV/AIDS, Learning, cancer, cardiovascular LLC disease, and heart diseases© became Jones frequent & Bartlett causes of mortal-Learning, LLC NOT FORity, similar SALE to the OR situation DISTRIBUTION in other developed societies (CIA, 2011a).NOT FOR SALE OR DISTRIBUTION According to Freedom House (an organization that judges how much freedom citizens of various countries have), China is near the bottom of the list of countries for limiting freedom. It is possible that these restrictions actually helped the healthcare system in China, however. From the 1950s to the 1970s, health care in China improved greatly under a very strict authoritarian rule. Brothels and opium dens © Jones & Bartlett Learning,were officially closed,LLC the four pests (flies, mosquitoes,© Jones rats, and & sparrows)Bartlett were Learning, greatly reduced, LLC and the NOT FOR SALE ORtraining DISTRIBUTION of a million barefoot (lay) doctors by NOT urban doctorsFOR wasSALE accomplished. OR DISTRIBUTION Health care through prevention was promoted. The communist government claimed that incidence of sexually transmitted diseases, schistosomiasis, and leprosy decreased, access to health care for all was promoted, and infant mortality decreased. It is almost impossible to verify all of these claims, however, because China was a closed system that allowed few outsiders to document facts. The irony today is that as China becomes freer and© turns Jones toward & a more Bartlett market-driven Learning, economy, LLC some advances in health care have© Jonesactually been & Bartlett Learning, LLC reversed. NOTFor example, FOR universal SALE accessOR DISTRIBUTIONto health care for all is gone, and poor rural ChineseNOT haveFOR great SALE OR DISTRIBUTION difficulty today getting prevention and treatment under the current partial out-of-pocket payment system (Hesketh & Zhu, 2002). China, through its market reforms, has experienced tremendous economic growth. One of the results of the economic upturn has been the establishment of a fee-for-service private medical prac- © Jonestice & with Bartlett few governmental Learning, restrictions. LLC Private medical practice was© Jonesnot allowed & duringBartlett the CulturalLearning, LLC Revolution, but it reemerged in the 1980s aἀer the dissolving of the Cooperative Medical System (CMS) NOT FORduring SALE the Maoist OR times, DISTRIBUTION when many people lived in communes. At NOTpresent, FOR rural families SALE must OR pay DISTRIBUTION out- of-pocket fees for medical services; these oἀen prohibitive costs render health care inaccessible for many (Lim, Yang, Zhang, Feng, & Zhou, 2004). The Chinese barefoot doctors today in the small remote villages of the far west are oἀen supported by a very small government salary each month and typically work out of their homes rather than a clinic, © Jones & Bartlett Learning,which enables LLCthem to maintain their farms when© Jonesthere are no& patients.Bartlett The Learning,doctors charge LLCa small fee NOT FOR SALE ORto DISTRIBUTION the patients for their services, and the remainderNOT of theirFOR salaries SALE comes OR from DISTRIBUTION drug sales. Oἀen doctors overprescribe medicines simply to increase their incomes. Village doctors have inadequate training and oἀen do not take patient histories or keep medical records as part of China’s economic reforms. The Chinese government has increasingly cut the funds made available for health care, so by 2000, 60% of all healthcare costs were paid for by the individual. The typical city doctor earns $600 to $1200 per month and sees 60© toJones 80 patients & Bartlettper day. Th eLearning, government has LLC recently budgeted $350 million ©dollars Jones to estab- & Bartlett Learning, LLC lish diseaseNOT control FOR and preventionSALE OR centers DISTRIBUTION in poor areas. Many poor areas had difficultyNOT treating FOR severe SALE OR DISTRIBUTION acute respiratory syndrome (SARS) cases when this disease emerged in China because of the inadequate resources (“Life as a Village Doctor,” 1997).

Access to Health Care and Costs © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORSince SALE the 1980s, OR the DISTRIBUTIONChinese government has had a laissez-faire policyNOT for healthFOR careSALE in rural OR areas. DISTRIBUTION As part of that policy, it reverted to a self-pay system for clinic visits and hospitalization, which are now

66  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

both very© expensive Jones relative & Bartlett to income. Learning, One average LLChospitalization costs 50% more ©than Jones the average & Bartlett Learning, LLC annual income. Access to health care in many areas is now priced on a sliding scale based on the ability to pay, yetNOT many FORpeople SALEare still unable OR DISTRIBUTIONto afford health care. In urban areas, medical NOTcare includes FOR the SALE OR DISTRIBUTION use of high technology. The government health insurance program has given more equal access to health care, but cost inflation is now a major governmental concern. Copayments were first started to make the users more aware of health costs when accessing medical care. Medications and high-tech tests are now charged to patients and not covered by the government insurance. © Jones &Th Bartlette majority ofLearning, China’s population LLC lives in rural areas. Those who© Jones live in urban & Bartlett areas are in Learning, many LLC NOT FORways SALEadvantaged. OR Th DISTRIBUTIONe distinction between rural and urban subpopulationsNOT FOR is reinforced SALE by aOR system DISTRIBUTION of population registration that limits migration from rural to urban areas (Zimmer & Kwong, 2004). In recent years, China has made great efforts to improve its public health system. Funds have been expended to modify and enlarge the disease prevention and control centers and to establish emergency centers and hospitals throughout the country. The major infrastructure has been improved. The ministry © Jones & Bartlett Learning,of health set up LLC 10 national medical teams for disaster© Jones relief and & diseaseBartlett prevention Learning, in some ofLLC the major NOT FOR SALE ORcities DISTRIBUTION. The SARS epidemic was controlled rapidlyNOT with through FOR thisSALE new infrastructure OR DISTRIBUTION (Zheng, 2005). China has the most hospitals (60,784) and the most doctors (1.97 million) of any country in the world. In 1949 when the Communists came to power there were only 2,600 hospitals in China. There are now 17 doctors per 10,000 people which compares to 25 doctors per 10,000 people in the United States. About 4.5 percent of the gross domestic product (GDP) is allocated to health care, half of which comes from the ©private Jones sector. & By Bartlett comparison Learning, the average healthcare LLC expenditure of countries© in Jonesthe European & Bartlett Learning, LLC Union is 9NOT percent FOR of GDP, SALE while in OR the UnitedDISTRIBUTION States, it is closer to 16 percent (Hays, 2011).NOT FOR SALE OR DISTRIBUTION Government insurance programs have been expanded in recent years to decrease the out-of-pocket payments and lack of equity in healthcare availability and quality. With China’s strong economic growth and huge financial reserves, it has the potential of decreasing the health disparities and improving access to and quality of healthcare nationwide (Hu, Tang, Liu, & Zhao, 2008). The Chinese government is hoping © Jonesto establish& Bartlett a universal Learning, healthcare LLCplan and plans to overhaul most of© its Jones inadequate & hospitalsBartlett by 2011;Learning, the LLC government also approved a plan to spend $124.3 billion by 2012 on healthcare improvements. The plan is NOT FORto provide SALE annual OR health DISTRIBUTION subsidies to citizens as well as to implementNOT a system FOR to provide SALE drugs OR and DISTRIBUTION vac- cines. In 2007, WHO ranked the healthcare system of China as number 144 out of 190 nations, well below the systems found in far poorer countries such as Haiti (Wang, 2009). The makeup of the current healthcare workforce in China differs from that in many other nations. China has more doctors than nurses. In 2005, there were 1.9 million licensed doctors and 1.4 million © Jones & Bartlett Learning,licensed nurses. LLC The density of healthcare providers© Jones is much & greaterBartlett in urban Learning, as compared LLC to rural NOT FOR SALE ORareas—speci DISTRIBUTIONfically, a 3:1 ratio. Most doctors and NOTnurses haveFOR only SALE a junior OR college DISTRIBUTION or high school level of education. Approximately one-third of physicians and nurses have been educated at the college level or higher. The majority of the higher-educated healthcare workers can be found in the urban areas, which creates a great disparity in the quantity and quality of healthcare providers in urban versus rural areas (Anand, Fan, & Zhang, 2008). © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Health PNOTriorities FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION China has experienced rapid growth in social and economic development that has created a demand for high-quality health care within the country. The life expectancy of the average person has increased, and this trend is expected to create an aging population with chronic health problems. The leading cause of death in those 1–44 years is injury. Approximately 750,000 deaths and 3.5 million hospitalizations occur © Joneseach & year.Bartlett More people Learning, are now using LLC motorcycles and cars, and fewer© Jonespeople are & walking Bartlett or using Learning, bicy- LLC NOT FORcles. SALEAs a result OR of changesDISTRIBUTION in diet and activity, cardiovascular diseaseNOT is increasingFOR SALE rapidly. OR Nearly DISTRIBUTION 2.6 million deaths occur annually from this problem, but by 2020 it is projected that 13 million people will die each year from cardiovascular disease (George Institute for International Health, 2003).

China  67

Environmental© Jones Health &Issues Bartlett and Respiratory Learning, Problems LLC © Jones & Bartlett Learning, LLC China’s movementNOT FOR toward SALE a market OR economy DISTRIBUTION has increased incomes and improved healthNOT indicators FOR for SALE OR DISTRIBUTION its population but created some difficult environmental problems. Biomass fuel and coal are burned in most of China for cooking and heating in most rural areas and a significant number of urban areas, which contributes to a major problem with indoor air pollution. In addition, the country has intense pollution from coal combustion for industry, which is damaging the air, water, and ultimately the agricul- © Jonesture, & which Bartlett in turn Learning, affects the residents’ LLC health. Of the 10 most polluted© Jonescities of the & world, Bartlett China isLearning, home LLC NOT FORto 7 ofSALE them. China OR isDISTRIBUTION also the world’s second highest emitter (aἀer NOTthe United FOR States) SALE of carbon OR dioxide DISTRIBUTION pollution, mainly from industry. With the help of the United Nations and the United States, China hopes to develop a multimillion-dollar energy strategy to combat pollution (Zhang & Cai, 2003). Respiratory diseases are now a widespread and serious issue. Driven by China’s tremendous industrial growth, the pollution that causes these diseases is taking a heavy toll on both the environment and © Jones & Bartlett Learning,public health. HighLLC rates of smog from industrial© and Jones traffic pollution & Bartlett are associated Learning, with very LLC high rates NOT FOR SALE ORof DISTRIBUTION respiratory infections and chronic illnesses. ChinaNOT relies FOR heavily SALE on coal OR that DISTRIBUTION contains high levels of sulfur; this fuel is used to satisfy 70% of the country’s domestic energy needs (Zhang & Cai, 2003). Water pollution is another major problem. Half of all of China’s water sources are considered too polluted for human consumption. Air and water pollution in China is estimated to cause 2.4 million premature deaths per year from cardiopulmonary and gastrointestinal diseases. Increases in the use of fossil fuels in industrial© Jones and &residential Bartlett use Learning,increases the country’s LLC production of greenhouse© gases, Jones which & in Bartlett Learning, LLC turn poses significant health risks to the population. Significant health disparities exist between poor and wealthyNOT populations, FOR SALE related to OR the exposureDISTRIBUTION to polluted air and water in poorer householdsNOT FOR (Zhang, SALE OR DISTRIBUTION Mauzerall, Zhu, Liang, Ezzati, & Remais, 2010). Lead poisoning is a concern among many residents. In 2009, approximately 2000 children living near zinc and manganese smelting plants in two provinces were found with unsafe levels of lead in their blood—a revelation that provoked riots (Watts, 2009). © Jones &A Bartlett major food Learning,safety incident LLCin China was made public in 2008.© AnJones estimated & Bartlett300,000 infants Learning, and LLC NOT FORyoung SALE children OR were DISTRIBUTION made ill and 6 died aἀer melamine was deliberatelyNOT addedFOR to SALE diluted rawOR milk DISTRIBUTION as well as other food and feed products. This additive led to formation of kidney stones and renal failure. Twenty-two manufacturers of infant formula sold this contaminated product, in what is considered one of the largest ever food contamination incidents—which also had implication for international food safety (Gossner et al., 2009). © Jones & Bartlett Learning,Tobacco smoking, LLC especially among adult males,© Jones is another & growing Bartlett environmental Learning, problem LLC in China NOT FOR SALE ORthat DISTRIBUTION has caused many respiratory diseases and deaths.NOT ChinaFOR makesSALE and OR sells DISTRIBUTION more cigarettes than any other country in the world and has more than 350 million smokers, which represents about one-third of the population. Rates are highest among adult men, who have a 67% smoking rate; in contrast, only 4% of all females smoke. Cigarette smoking is now the leading cause of preventable deaths in China (and the rest of the world). It seems inevitable that China will see a tremendous increase in mortality from smoking-related diseases such© Jones as chronic & obstructive Bartlett pulmonary Learning, disease LLC (COPD), lung cancer, and pulmonary© Jones tuberculosis. & Bartlett Learning, LLC The China National Tobacco Corporation is the largest tobacco manufacturer in the world. As part of an effort to stemNOT the FOR tide of smoking,SALE ORthe Minister DISTRIBUTION of Health publishes an annual tobacco controlNOT report FOR and SALE OR DISTRIBUTION campaigns have been launched to increase tobacco taxes and put health warnings on the tobacco products beginning in January 2009 (Gonghuan, 2010).

© JonesMental & Bartlett Health Learning, LLC © Jones & Bartlett Learning, LLC NOT FORMental SALE health ORis a major DISTRIBUTION issue in China today because of the rapid socialNOT and FOR economic SALE changes. OR Changes DISTRIBUTION that some members of the population face today include financial losses from bad business deals and gambling; higher rates of extramarital affairs, family violence, and divorce; rising rates of substance use

68  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

and abuse;© weakeningJones &of Bartletttraditional familyLearning, values and LLC relationships; large numbers of© rural Jones migrants & Bartlett Learning, LLC seeking employment in larger urban environments; a widening gap between the rich and poor; work- related stress;NOT and FOR a faster SALE pace of life.OR Eighty DISTRIBUTION percent of the country’s healthcare budget NOTgoes to theFOR urban SALE OR DISTRIBUTION residents, even though they represent only 30% of the total population. Funds for mental health are very limited for the rural population, most of whom cannot afford the out-of-pocket costs for mental health care. Shanghai, the largest population in China, boasts having the most comprehensive mental healthcare system in the country (Chang & Kleinman, 2002). © Jones &According Bartlett to Learning,2003 WHO data, LLC 13% of the Chinese population© has Jones psychological & Bartlett problems, Learning, and 16 LLC NOT FORmillion SALE people ORin China DISTRIBUTION suffer from serious mental illness. Every yearNOT in FORChina, someSALE 280,000 OR people DISTRIBUTION commit suicide, accounting for 25% of the entire world’s suicide statistics. Another 20 to 50 million people attempt suicide each year. Suicide is the fiἀh leading cause of death for Chinese people 15–35 years of age. The suicide rate in China is three times higher in rural areas as compared to urban areas. This rate is 25% higher among women than men, a trend that is the opposite of that found in many other nations of © Jones & Bartlett Learning,the world. The LLChigher rates of female suicides in rural© Jones areas are & primarily Bartlett due toLearning, poverty, the low LLC status of NOT FOR SALE ORrural DISTRIBUTION women, forced marriages, family violence NOTand con FORflict, chronic SALE stress, OR and DISTRIBUTION no hope for the future. Men in rural areas are oἀen absent from the homes for long periods of time, leaving the women to work in the fields, take care of children, cook, and care for the house (Pochagina, n.d.).

Nutrition © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ThroughoutNOT China, FOR there SALE has been OR a change DISTRIBUTION in diet and physical activity and overall bodyNOT composition FOR SALE OR DISTRIBUTION patterns. During the past 10 years, the number of people living in China in absolute poverty has sig- nificantly declined. The proportion of those considered extremely poor decreased from 20% to 6% of the total population during the same period. As a result of this change in economic status, the prevalence of obesity and diet-related noncommunicable diseases has increased more rapidly in China than in © Jonesother & developedBartlett societies. Learning, Diets have LLC shiἀed from high-carbohydrate© to Jones high-fat and & Bartletthigh-density Learning, energy LLC NOT FORfoods, SALE leading ORto overweight DISTRIBUTION and obesity—and their associated diseases,NOT such FOR as diabetes, SALE stroke, OR cancer, DISTRIBUTION and cardiovascular diseases (Du, Mroz, Zhai, & Popkin, 2004).

Cardiovascular Disease Cardiovascular disease is the leading cause of mortality in the world, including in China and other devel- © Jones & Bartlett Learning,oping countries. LLC China and other developing nations© Jones have been & experiencingBartlett Learning, an epidemic in LLC cardiovas- NOT FOR SALE ORcular DISTRIBUTION disease during the last few decades mainly NOTbecause FOR of lifestyle SALE and diet OR changes. DISTRIBUTION Currently, there is a growing prevalence of metabolic syndrome and overweight individuals among adults in China. Metabolic syndrome is characterized by a cluster of problems that consists of abdominal obesity, increased blood pressure and glucose concentration, and elevated cholesterol levels. Obesity is a risk factor not only for cardiovascular disease but also type 2 diabetes, hypertension, and cancer. Excess weight is also a cause for osteoarthritis© Jones and gallbladder & Bartlett disease Learning, (Dang, Yan, Yamamoto,LLC Wang, & Zeng, 2004; ©Gu Joneset al., 2005). & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Infectious Diseases Major infectious diseases in China include the following (CIA, 2011a): © Jones■■ &Food- Bartlett and water-borne Learning, diseases LLC (bacterial diarrhea, hepatitis A,© and Jones typhoid & fever) Bartlett Learning, LLC ■■ Vector-borne diseases (Japanese encephalitis and dengue fever) NOT FOR■■ SALESoil-contact OR diseases DISTRIBUTION (hantaviral hemorrhagic fever and renal syndrome)NOT FOR SALE OR DISTRIBUTION ■■ Animal contact diseases (rabies)

China  69

HIV/AIDS© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC HIV/AIDSNOT entered FOR China SALE in 1985, OR and moreDISTRIBUTION than 20 years later the epidemic continuesNOT to spread FOR at anSALE OR DISTRIBUTION alarming rate. The CIA (2011a) has estimated that 0.1% of the total Chinese population is infected with HIV; this rate, compared to that found in other parts of the world, ranks 115th worldwide. It translates into 700,000 adults living with HIV/AIDS, which ranks as the 17th largest population with this disease in the world. The estimated number of deaths from this cause—39,000 per year—places China at 15th world- © Joneswide & in Bartlett AIDS deaths Learning, (Kanabus, 2005). LLC © Jones & Bartlett Learning, LLC NOT FOR ThSALEe general OR population DISTRIBUTION of China knows little about the sexual practicesNOT FOR that increase SALE the ORrisk of DISTRIBUTION con- tracting HIV infection. HIV/AIDS prevention in the general population has been rare. Those now living in China with HIV/AIDS face severe discrimination and have limited access to healthcare services, especially in the rural areas (Chen, Han, & Holzemer, 2004). The government has promised to provide free HIV tests to anyone who wants one and fully cover treatment costs for poorer patients (Kanabus, 2005). © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE ORTuberculosis DISTRIBUTION NOT FOR SALE OR DISTRIBUTION China reported the worldwide second-highest number of new tuberculosis (TB) cases (1.31 million) and the second-highest number of TB deaths (201,000 TB cases) in 2007, behind only India. China has 4.5 million TB cases currently, and each year 1.4 million people fall ill with the disease. TB killed 160,000 people in© China Jones in 2008, & Bartlettaccording to Learning, WHO. TB also LLC represents a big drain on China’s© healthJones budget & Bartlett Learning, LLC because of the high incidence of people with a drug-resistant strain of the disease, which is much more difficult andNOT expensive FOR to SALE treat; these OR patients DISTRIBUTION need to take drugs for up to two years. ThNOTis worst FOR type ofSALE OR DISTRIBUTION TB, for which there is no cure, kills one out of every two patients. Regular TB costs 1000 Yuan ($158.60) to treat in China, whereas drug-resistant TB costs range from 100,000 to 300,000 Yuan ($15,900 to $47,600) per person. China spent $225 million on tackling TB in 2008, up from $98 million in 2002, according to WHO. (These figures do not take into account the amounts that patients pay out of their pockets, which © Jonestypically & Bartlett amounts Learning,to between 47% LLC and 62% of their hospital bills.) ©Th eJones World Bank & Bartlettfunded the fiLearning,rst TB LLC NOT FORsurvey SALE in China, OR which DISTRIBUTION was followed by a new program that aimedNOT to treat FOR the cases SALE and preventOR DISTRIBUTION new ones (“China Fights Growing Problem of Tuberculosis,” 2010).

Population Control © Jones & Bartlett Learning,China has only LLC 7% of the world’s arable land, ©yet Jones22% of the & world’s Bartlett population. Learning, To feed, LLChouse, and NOT FOR SALE ORpromote DISTRIBUTION good health care for this country’s citizensNOT despite FOR the relativelySALE scarceOR DISTRIBUTION resources, the “one child per family” policy was established by Chinese leader Deng Xiaoping in 1979 to limit China’s population growth. The advantages of such a policy are that each child will have a healthier life, family costs will be lower, and the child will get a better education. Women will be able to focus on their careers as well as on care for their families. The government claims that this policy has prevented mass starvation. Fines,© pressures Jones to & abort Bartlett a pregnancy, Learning, and even forced LLC sterilization occur with subsequent© Jones pregnan- & Bartlett Learning, LLC cies aἀer NOTthe first. FOR The policy SALE includes OR ethnic DISTRIBUTION Han Chinese living in urban areas. CitizensNOT living FOR in rural SALE OR DISTRIBUTION areas and minorities living in China are not subject to the law. The “one child” policy has estimated to have reduced the population of the country by as much as 300 million people in the past 20 years. A new law in addition to the “one child” regulation states that if both parents have no siblings, they may have two children, thus preventing too dramatic a population decrease. © Jones &One Bartlett problem Learning,with this population LLC control policy is that Chinese© Jonesparents usually & Bartlett rely on their Learning, chil- LLC dren—especially their sons—for support in their old age. The result is that most couples want a male NOT FORchild SALE if they can OR have DISTRIBUTION only one child (Population—China, 2004). In NOTturn, sex FOR selection SALE during OR pregnancy DISTRIBUTION (e.g., through ultrasound and subsequent abortion of female fetuses) has resulted in a ratio of 114 males

70  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

to 100 females© Jones among children& Bartlett from birth Learning, to 4 years old. LLC Over time, the population control© Jones policies have & Bartlett Learning, LLC caused serious problems for female infants such as abortion, neglect, abandonment, and even infanticide (Rosenberg,NOT 2011). FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Internal Migration and Its Healthcare Implications China has a highly mobile population of 140 million rural-to-urban migrants representing 10% of the © Jonestotal & population. Bartlett Migrants Learning, move betweenLLC cities and provinces in search© Jones of improved & Bartlett living conditions. Learning, LLC NOT FORMost SALE are young, OR single DISTRIBUTION males, who have a socioeconomic status aboveNOT rural FOR groups SALE but below OR urbanDISTRIBUTION populations. Migrants are excluded from urban healthcare services, including access to public health facilities, and they do not qualify for public medical insurance and other assistance programs. They must pay out-of-pocket for medical services in the cities. Within this population are individuals who pose special concerns given their spread of communicable diseases such as sexually transmitted diseases (STDs), © Jones & Bartlett Learning,respiratory infections LLC such as TB, diarrheal infections,© Jones and & parasitic Bartlett infections. Learning, A second LLC concern is maternal and infant health for members of migrant groups; such care is also not covered by public insur- NOT FOR SALE ORance DISTRIBUTION to migrants. Lastly, occupational diseases NOTand injuries FOR have SALE become OR a signi DISTRIBUTIONficant problem among this group, given their lack of public insurance coverage (Hu, Cook, & Salazar, 2008).

Traditional Medicine The practice© Jones of traditional & Bartlett Chinese medicineLearning, was strongly LLC promoted by Chinese leaders,© Jones and it & has Bartlett Learning, LLC remainedNOT a major FOR part of SALE health care. OR Western DISTRIBUTION medicine gained acceptance in the 1970sNOT and 1980s. FOR Th SALEe OR DISTRIBUTION goal of China’s medical personnel is to synthesize the use of both Western and traditional Chinese medicine, yet this practice has not always worked seamlessly. Physicians trained in traditional medicine and those trained in Western medicine are very separate groups with different basic ideas. Traditional Chinese medicine uses herbal treatments, acupuncture, acupressure, moxibustion, and cupping of skin © Joneswith & heatedBartlett bamboo. Learning, These approaches LLC are very effective in treating© Jonesminor ailments & Bartlett and chronic Learning, dis- LLC eases, and they produce far fewer side effects. Some more serious and acute problems are also treated with NOT FORtraditional SALE medicine. OR DISTRIBUTION For more information regarding this topic seeNOT the chapter FOR entitled, SALE “Global OR UseDISTRIBUTION of Complementary and Alternative Medicine.”

India © Jones & Bartlett Learning,History LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The Indus Valley civilization, one of the world’s oldest, was a vibrant presence during the second and third millennia b.c.e. Aryan tribes from the northwest came to the Indian subcontinent in 1500 b.c.e., merging with the earlier Dravidian people and creating the classical Indian culture. Many years later in the nineteenth century, India came under British rule. Nonviolent resistance to British rule, led by Ghandi and© JonesNehru, brought & Bartlett India to independenceLearning, in LLC 1947. Violence in the new state eventually© Jones led to& a Bartlett Learning, LLC partition NOTof the nation,FOR creatingSALE two OR countries, DISTRIBUTION India and Pakistan. Later, a war in 1971NOT resulted FOR in East SALE OR DISTRIBUTION Pakistan becoming the country of Bangladesh (CIA, 2011b).

Geography The country of India is located in southern Asia, bordering the Arabian Sea and the Bay of Bengal, between © JonesBurma & Bartlett and Pakistan. Learning, It has a large LLC land area, ranking seventh in the© world.Jones The & climate Bartlett includes Learning, mon- LLC NOT FORsoons SALE in the south OR and DISTRIBUTION a more temperate climate in the north. The country’sNOT naturalFOR resourcesSALE ORinclude DISTRIBUTION coal (India has the fourth largest reserves in the world), iron ore, manganese, mica, titanium ore, natural gas, diamonds, and petroleum, among others. Within this country there is an abundance of deforestation, soil

India  71

erosion, overgrazing,© Jones air & pollution Bartlett from Learning, industry and vehicleLLC emission, and water pollution© fromJones raw sew-& Bartlett Learning, LLC age and agricultural pesticides, making water nonpotable throughout the country (CIA, 2011b). NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Population India is home to 1.173 billion people, ranking the country second in the world in terms of population size. The population is growing at a rate of 2% annually, which will create the world’s largest popula- © Jonestion—surpassing & Bartlett China—by Learning, 2030. LLCBy 2050, India’s population is expected© Jones to reach & 1.6 Bartlett billion people. Learning, The LLC NOT FORpopulation SALE increase OR isDISTRIBUTION due to increases in life expectancy, decreases NOTin infant FOR mortality, SALE and emphasis OR DISTRIBUTION on eradication of diseases such as hepatitis, tetanus, and polio among infants. The median age is 25.9 years, with approximately 30% of the population being younger than 14 years, 64.6% being between the ages of 14 and 64 years, and 5.3% being 65 years or older. The birth rate is 21.34 births per 1000 population; the death rate is 7.53 deaths per 1000 population. The infant mortality rate is 49.13 deaths per 1000 live births. © Jones & Bartlett Learning,Life expectancy LLC is 66.46 years, ranking 159th in the© Jonesworld. & Bartlett Learning, LLC The majority of India’s people live in a rural agrarian economy and have incomes of less than $1 per NOT FOR SALE ORday DISTRIBUTION (CIA, 2011b). Only 29% of the total populationNOT lives inFOR urban SALE areas. OR DISTRIBUTION

Infectious Diseases The HIV/AIDs rate in India is 0.3% (2007 estimate) of the total population, with 2.4 million (2007 estimate) people© Jones living with & HIV/AIDS, Bartlett and Learning, 310,000 deaths LLC occurring from this cause (2001© estimate). Jones Food- & Bartlett Learning, LLC and water-borneNOT FORdiseases SALE cause a ORhigh rateDISTRIBUTION of bacterial diarrhea, hepatitis A and E, andNOT typhoid FOR fever. SALE OR DISTRIBUTION Vector-borne diseases include chikugunya, dengue fever, Japanese encephalitis, and malaria. Rabies is caused from animal contact, and leptospirosis is caused from water contact. India’s malaria and TB rates are ranked third in the world (CIA, 2011b).

© JonesChronic & Bartlett Diseases Learning, LLC © Jones & Bartlett Learning, LLC NOT FORIndia SALE is now facedOR DISTRIBUTION with a double burden of long-term chronic illnessesNOT FOR and serious SALE acute OR illnesses. DISTRIBUTION Cardiovascular diseases, cancer, degenerative diseases, and diabetes have become major health issues in addition to the acute communicable diseases mentioned previously.

Culture © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE ORIndians DISTRIBUTION practice a number of different religions:NOT Hindu FOR (80.5%), SALE Muslim OR(13.4%), DISTRIBUTION Christian (2.3%), Sikh (1.9%), other (1.8%), and unspecified (0.1%). English is the official language, yet Indians use many other languages as well. Hindi is the most widely used of these languages (used by 41% of the population), but 14 other languages are also spoken. Approximately 61% of the population is literate, being able to read and write, and the average education level is 10 years. Inequality of opportunity has caused the lower-caste Hindus, Muslims,© Jones tribal & people,Bartlett and otherLearning, minority LLC populations to be disproportionately© Jones represented & Bartlett Learning, LLC within the poor, the uneducated, and those with most health problems (CIA, 2011b). NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Government and Economy India is a federal republic with New Delhi as its capital city. The country contains 28 states and 7 union territories. The economy is developing into an open-market economy, which encompasses tra- © Jonesditional & Bartlett village farming, Learning, modern LLC agriculture, handicraἀs, and a© wide Jones range &of Bartlettservices, including Learning, LLC NOT FORinformation SALE technology OR DISTRIBUTION and soἀware workers. India’s annual perNOT capita FOR income SALE is $3100 OR (2009 DISTRIBUTION estimate). The country has a significant labor force of 467 million people (second largest in the world) and has 81 million people using the Internet (the fourth largest group of users in the world). The

72  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

unemployment© Jones rate is & 10.7%. Bartlett The Indian Learning, pharmaceutical LLC market has grown rapidly© in Jones the past &few Bartlett Learning, LLC years and the federal government uses price controls to ensure that vital drugs are available to the general populationNOT FOR (CIA, SALE 2011b). OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Health Care Health care is the responsibility of each state or territory of India. Each state is expected to pay for 80% of © Joneshealthcare & Bartlett facilities, Learning, and the federal LLC government pays 15%, mainly through© Jones national & healthcare Bartlett programs. Learning, LLC NOT FORHealth SALE care in ORIndia DISTRIBUTION can be traced back 3500 years to the inceptionNOT of Ayurvedic FOR traditionalSALE OR medicine, DISTRIBUTION which is still used today. India has historically suffered from great famines, which have been eradicated, yet continues to experience significant problems with malnutrition, starvation, and disease, especially in the rural areas. Undernutrition rates in children in India are higher than sub-Saharan Africa. Approximately 46% © Jones & Bartlett Learning,of children from LLC birth to 3 years are undernourished© Jones (Rao, 2009). & Bartlett A preference Learning, for male babies LLC has led to an imbalanced ratio of 93.5 girls per 100 boys, in contrast to the natural gender ratio at birth of 105 males NOT FOR SALE ORto DISTRIBUTION 100 females. Maternal and infant death rates remainNOT high.FOR Th SALEe vast majority OR DISTRIBUTIONof the Indian population suffers from waterborne and airborne infections. Most of the country lacks a basic infrastructure, as its development has not kept up with the growing economy. Almost 1 million people die each year due to inadequate health care, and 700 million people lack access to specialist care, which mainly exists in large urban areas. Forty percent of the healthcare facilities in India are understaffed (Rao, 2009). The ©number Jones of hospital & Bartlett beds is low—only Learning, 0.7 per LLC1000 population, compared to the© world Jones average & of Bartlett Learning, LLC 3.96 hospitalNOT beds FOR per 1000 SALE population. OR In DISTRIBUTION addition, India lacks an adequate number of trainedNOT healthcare FOR SALE OR DISTRIBUTION personnel for its growing healthcare industry. Rural healthcare services are mainly provided by smaller primary healthcare centers, which rely on trained paramedics for most of the care. Serious cases are sent to urban areas, where specialists and acute care facilities are available. Skilled birth attendants are needed, yet are still not provided in adequate numbers to decrease the high rates of maternal and infant © Jonesmortality & Bartlett (Rao, 2009). Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR IndigenousSALE OR traditional DISTRIBUTION medicine is practiced throughout the NOTcountry. FOR The main SALE forms OR are AyurDISTRIBUTION vedic medicine, which addresses mental and spiritual well-being as well as physical well-being. In addition, Unani herbal medicine is practiced. Today only 25% of the Indian population has access to Western medicine (Rao, 2009). The government has made a major commitment to telemedicine to reach the majority of the poor, rural, © Jones & Bartlett Learning,underserved population. LLC Health insurance is inaccessible© Jones to the & majority Bartlett of Indians, Learning, and 75% of LLC healthcare expenses are paid on an out-of-pocket basis, which is very challenging for the many people who live in NOT FOR SALE ORpoverty. DISTRIBUTION Emergency and specialty care is well beyondNOT the FOR reach ofSALE most of OR the poorDISTRIBUTION lower-class residents. Among those in the urban middle and upper classes, approximately 50% have private health insurance. The National Rural Health Mission was begun in 2005 to provide major improvements in health care for the rural population. Primary healthcare clinics, which have social activist leanings, help support public© healthJones priorities & Bartlett such as childhood Learning, immunizations LLC and compliance with TB© treatments. Jones Th&e Bartlett Learning, LLC National Rural Health Mission program was established to address issues of poverty and provide 100 days of work atNOT minimal FOR wage SALEto one family OR member DISTRIBUTION per household. In addition, an increase inNOT primary FOR school SALE OR DISTRIBUTION enrollment, particularly among girls, was established as a goal.

South Africa © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Geography NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION South Africa is located at the southern tip of the continent of Africa. It is bordered by Botswana, Lesotho, Mozambique, Namibia, Swaziland, and Zimbabwe, as well as the Atlantic and Indian Oceans. Its climate

South Africa  73

is mostly© arid, Jones with a subtropical& Bartlett region Learning, found along theLLC country’s east coast. Natural resources© Jones include & Bartlett Learning, LLC gold, chromium, antimony, coal, iron ore, manganese, nickel, phosphates, tin, uranium, gem diamonds, platinum,NOT copper, FOR vanadium, SALE salt, andOR natural DISTRIBUTION gas (CIA, 2012). NOT FOR SALE OR DISTRIBUTION

Population South Africa’s population as of 2010 was approximately 47 million. The country is currently experiencing © Jonesthe &world’s Bartlett highest Learning, rate of people withLLC HIV/AIDS, as well as the world’s© Jones highest mortality& Bartlett rate from Learning, this LLC NOT FORdisease SALE (see Table OR 3-17 DISTRIBUTION). NOT FOR SALE OR DISTRIBUTION Ethnic groups in South Africa include the following (CIA, 2012):

■■ Black African (79.6%) ■■ White (9.1%) ■■ Colored (8.9%) © Jones & Bartlett Learning,■■ Indian/Asian LLC (2.5%) © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Religions practiced include the following:

■■ Zion Christian (11.1%) ■■ Pentecostal/Charismatic (8.2%) ■■ Catholic (7.1%) ■■ Methodist© Jones (6.8%) & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ DutchNOT Reformed FOR (6.7%) SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Anglican (3.8%) ■■ Other Christian (36%) ■■ Islam (1.5%) ■■ Other (2.3%) © Jones■■ &Unspeci Bartlettfied (1.4%) Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR■■ NoneSALE (15.1%) OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Languages spoken in South Africa include the following:

■■ IsiZulu (23.8%) ■■ IsiXhosa (17.6%) © Jones & Bartlett Learning,■■ Afrikaans LLC (13.3%) © Jones & Bartlett Learning, LLC NOT FOR SALE OR■ DISTRIBUTION■ Sepedi (9.4%) NOT FOR SALE OR DISTRIBUTION ■■ English (8.2%) ■■ Setswana (8.2%) ■■ Sesotho (7.9%) ■■ Xitsonga (4.4%) ■■ Other© (7.2%) Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC The literacyNOT rate ofFOR the total SALE population OR isDISTRIBUTION 86.4%. NOT FOR SALE OR DISTRIBUTION South Africa has the largest population of people of European descent in Africa, the largest Indian population in Africa, and the largest colored (mixed European and African) group in Africa. It is one of the most ethnically diverse countries in Africa. The country has had a long history of racial problems between the black majority and the white minority. The country’s Apartheid policy, which was intro- © Jonesduced & Bartlettin 1948, ended Learning, in 1990. Crime LLC remains a major problem in South© Jones Africa, which& Bartlett ranks first Learning, in the LLC NOT FORworld SALE in terms OR of number DISTRIBUTION of murders by firearms, manslaughter, rape,NOT and FOR assault SALE cases. It OR also DISTRIBUTIONranks fourth in the world in terms of robbery incidence, according to a survey done by the United Nations during 1998–2000. Problems also persist with illegal drug transportation and sales (CIA, 2012).

74  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

TABLE 3-17© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC South Africa:NOT RatesFOR of SALE HIV/AIDS OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Population 47 million (2010 data) Birth–14 years 30.3% 15–64 years 64.5% © Jones65+ & years Bartlett Learning, LLC 5.2% © Jones & Bartlett Learning, LLC Population growth rate –0.31% NOT FORDeath SALE rate OR DISTRIBUTION21.32 per 1000 people NOT FOR SALE OR DISTRIBUTION Infant mortality 61.81 per 1000 live births Life expectancy 43.27 years HIV/AIDS adult prevalence rate 21.5 % (2003 estimate) Approximately 5 million people (20% of 15- to 49-year-old © Jones & Bartlett Learning, LLC population© Jones and 35% & of Bartlett all women Learning,of childbearing LLCage) NOT FOR SALE ORSource: DISTRIBUTION Adapted from U.S. Department of State, BureauNOT of African FOR Affairs, SALE 2005. OR DISTRIBUTION

The South African population is relatively young, with approximately one-third younger than age 15. Fertility© isJones declining, & and Bartlett there is an Learning, increase in persons LLC older than 60 years. The country’s© Jones healthcare & Bartlett Learning, LLC services includeNOT notFOR only SALE services forOR obstetrics, DISTRIBUTION pediatrics, and adolescents, but also thoseNOT for FORthe aging SALE OR DISTRIBUTION population. A large proportion of the population (18% in some areas) is illiterate. Half of all households use electricity for cooking (Bradshaw & Nannan, 2004). Since 1994, life expectancy in South Africa has declined by 20 years, mainly because of the increase in HIV/AIDS incidence. The average life expectancy at birth is now 50 years for men and 54 years for © Joneswomen. & Bartlett The global Learning, burden of disease LLC is quite high, and morbidity and© Jonesmortality &rates Bartlett are very high Learning, due LLC to HIV/AIDS, violence and injury, chronic diseases, mental health disorders, and maternal, neonatal, and NOT FORchild SALE mortality OR (Chopra DISTRIBUTION et al., 2009). NOT FOR SALE OR DISTRIBUTION

Government The government is a republic, formally named the Republic of South Africa (RSA), with a legal system © Jones & Bartlett Learning,based on Roman-Dutch LLC law and English common© law.Jones The system & Bartlett of government Learning, is also called LLC a parlia- mentary democracy. South Africa has three capital cities: Cape Town, the largest, is the legislative capital; NOT FOR SALE ORPretoria DISTRIBUTION is the administrative capital; and BloemfonteinNOT FOR is the SALE judicial capital.OR DISTRIBUTION The country comprises nine provinces (CIA, 2005; U.S. Department of State, Bureau of African Affairs, 2005).

Economy South Africa© Jones has a two-tiered & Bartlett economy. Learning, One segment LLCis similar to other economically strong© Jones developed & Bartlett Learning, LLC countries,NOT and the FOR other SALE is more OR like developingDISTRIBUTION countries with only the basic infrastructure.NOT FOR South SALE OR DISTRIBUTION Africa has well-developed financial, legal, communication, energy, and transportation systems. It has the world’s tenth largest stock exchange and a modern infrastructure. It has the best telecommunications system in Africa. At the same time, South Africa has a very high unemployment rate (25%) and most of the country’s citizens live on less than $1.25 per day. © Jones &Th Bartlette country’s Learning, wealth is unevenly LLC distributed, with the minority© whites Jones having & a Bartlettmuch larger Learning,portion LLC NOT FORof the SALE wealth andOR the DISTRIBUTION majority blacks having a very challenging existenceNOT FOR with di SALEfficulty fi ndingOR DISTRIBUTION well- paying jobs. The country has an overall per capita GDP of $11,100 (2004 estimate). Its industries include mining (South Africa is the world’s largest producer of platinum, gold, and chromium), auto assembly,

South Africa  75

metalworking,© Jones machinery, & Bartlett textile, iron Learning, and steel, chemicals, LLC fertilizers, ship repair, and foods© Jones (CIA, 2005; & Bartlett Learning, LLC U.S. Department of State, Department of African Affairs, 2005). The main agricultural products are corn, wheat, sugarcane,NOT FOR fruits, SALE vegetables, OR beef, DISTRIBUTION poultry, mutton, wool, and dairy products NOT (CIA, 2005;FOR U.S. SALE OR DISTRIBUTION Department of State, Department of African Affairs, 2005).

Healthcare System © JonesSouth & BartlettAfrica’s healthcare Learning, system consistsLLC of a large public sector and© aJones smaller, yet& fast-growingBartlett Learning,private LLC NOT FORsector. SALE Basic primary OR DISTRIBUTION health care is offered free to all residents of theNOT country, FOR but SALEis highly specialized;OR DISTRIBUTION high-tech care is limited to only those who can afford private care. The dilemma is that the government contributes approximately 40% of healthcare costs for the public health, yet 80% of the population uses the services. The number of public hospitals continues to grow, and companies in the mining industry operate their own 60 hospitals and clinics in different locations within the country (U.S. Department of © Jones & Bartlett Learning,State, Department LLC of African Affairs, 2005; Coovadia,© Jones Jewkes, &Barron, Bartlett Sanders, Learning, & McIntyre, 2009).LLC Since 1978, the country has had a decentralized basic primary healthcare system, instead focusing on NOT FOR SALE ORa DISTRIBUTION district healthcare system run by local governments.NOT Disparities FOR SALE exist between OR DISTRIBUTION municipalities, depend- ing on the funding from the local area. Poor municipalities with little funding have little allocated for their healthcare budgets. Rural areas are poorly funded as compared to urban areas. Poor women, especially in rural areas, are oἀen seen by a nurse or nurse–midwife for prenatal care and delivery, whereas urban women more oἀen receive prenatal care and delivery from a physician (Harrison, 2004). The ©South Jones African & healthcare Bartlett system Learning, faces many challenges.LLC The country’s history of© veryJones high rates & Bartlett Learning, LLC of communicableNOT FOR and noncommunicable SALE OR DISTRIBUTION diseases, combined with the legacy of colonialism,NOT Apartheid, FOR SALE OR DISTRIBUTION and post-Apartheid turmoil, have led to major racial and gender discrimination, a migrant labor system, destruction of family life, great disparities in family incomes, and extreme violence, which have all affected the health and healthcare system of the nation. For many decades, black people were forced to work for the white minority for very low wages. Before 1994, politics restricted health and healthcare for © Jonesblacks. & Bartlett The public Learning,healthcare system LLC has now been transformed into© an Jones integrated & nationalBartlett service, Learning, but LLC NOT FORis plagued SALE by aOR lack ofDISTRIBUTION management and leadership. Some of the mainNOT problems FOR related SALE to health OR include DISTRIBUTION poverty-related illnesses such as infectious diseases (HIV/AIDS, TB, and malaria), maternal mortality, malnutrition, and high rates of noncommunicable diseases. HIV/AIDS accounts for 31% of the disability- adjusted life-years, and violence and injury continue to cause premature deaths (Coovadia et al., 2009). South Africa is considered a middle-income country because of its economy, yet its disease rates are © Jones & Bartlett Learning,higher than those LLC in many low-income countries.© ItJones is one of &only Bartlett 12 countries Learning, in the world whereLLC child mortality has increased, rather than decreased, since the 1990 Millennium Developmental Goals were NOT FOR SALE ORestablished DISTRIBUTION (Coovadia, Jewkes, Barron, Sanders,NOT & McIntyre, FOR 2009). SALE There OR are greatDISTRIBUTION disparities between the country’s public and private healthcare systems. Less than 15% of the population uses private health care, yet 46% of all healthcare expenditures are devoted to private healthcare services. There is also a disparity in funding among the provinces within South Africa’s healthcare system. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC State of Health in South Africa NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The general state of health in South Africa reflects the huge burden of disease, particularly the tremendous impact of HIV/AIDS. HIV rates have reached as high as 31% of all pregnant women being HIV positive, and 25% of the general population being HIV positive. Approximately 5 million people in South Africa are living with HIV/AIDS at present. The link between high risk sexual behaviors, IV drug use, and trans- © Jonesfer &of BartlettHIV virus fromLearning, mother to LLCchild (vertical transmission) which© Jonesresulted in & HIV Bartlett disease was Learning, long LLC NOT FORdenied SALE by both OR former DISTRIBUTION president Thabo Mbeki and former Prime MinisterNOT FORKgalema SALE Motlanthe. OR In DISTRIBUTION 2008, Mbeki resigned, and by 2009 a new government administration was committed to increasing the funding for HIV/AIDS treatment. Only 12% to 13% of patients who need antiretroviral drugs actually receive

76  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

them, however.© Jones Approximately & Bartlett 60% to Learning,70% of all hospital LLC admissions are HIV/AIDS related,© Jones which is cre-& Bartlett Learning, LLC ating a huge burden on the healthcare system, with concomitant challenges related to financing of health care and NOTavailability FOR of trainedSALE healthcare OR DISTRIBUTION personnel. At present there are 1.2 million orphansNOT FOR in South SALE OR DISTRIBUTION Africa, In addition, many elderly have lost their financial support due to the early deaths of their adult children from HIV/AIDS (Coovadia et al., 2009). Healthcare spending in South Africa averages $748 per capita. Solutions to the problems facing the healthcare system need to include the integration of services, including maternal and child health, at the © Jonesprimary & Bartlett care level. Learning,The average life LLCexpectancy at birth is low—53.4 years© Jones (2005)—in & South Bartlett Africa, Learning,mainly LLC NOT FORdue to SALE HIV rates, OR which DISTRIBUTION are exceptionally high among the 15- to 49-year-oldNOT FOR age group. SALE Maternal OR mortal- DISTRIBUTION ity is 150 deaths per 100,000 live births, and child mortality is 55 deaths per 1000 live births (Coovadia et al., 2009).

© Jones & Bartlett Learning,Violence and LLC Injury © Jones & Bartlett Learning, LLC NOT FOR SALE ORSouth DISTRIBUTION Africa also has many disturbing social issuesNOT that haveFOR proved SALE challenging OR DISTRIBUTIONto manage. It is estimated that 500,000 women are raped each year in the country. Approximately 28% of men state that they have committed rape. Gender-based violence is especially high, with South African female homicide rates being six times the global average; 50% of the female victims are killed by their spouses or partners. In addition, this country is ranked by the United Nations as second in the world for murder and first for assaults and rape. Violence© Jones and injury & are Bartlett the second Learning, leading cause of LLC death, and the injury rate is almost© twice Jones the global & Bartlett Learning, LLC average. ApproximatelyNOT FOR 16,000SALE road-related OR DISTRIBUTION (motor vehicle collision) deaths occur yearly. NOTChildren FOR also are SALE OR DISTRIBUTION subject to very high rates of sexual, physical, and emotional abuse and neglect (Coovadia et al., 2009).

Maternal and Infant Health South Africa has a major problem with maternal and infant health. The infant mortality rate is 42.5 per © Jones1000 & live Bartlett births. Each Learning, year approximately LLC 75,000 children die, and 23© die Jones within their& Bartlett first month Learning, of life. LLC NOT FORIn addition, SALE 23,000 OR babiesDISTRIBUTION are stillborn, a factor closely associatedNOT with the FOR 1660 SALE maternal ORdeaths DISTRIBUTION that occur annually. The major causes of maternal deaths are HIV/AIDS infections. Strengthening HIV/AIDS health care will require at least a 2.4% increase in funding for HIV prevention and treatment programs (Coovadia et al., 2009).

© Jones & Bartlett Learning,Major Health LLC Issues © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION As noted previously, South Africa is challenged by very high rates of injury, the problem of underdevelop- ment of the country as a whole, and numerous residents with chronic diseases. The largest rise in death rates for adults has occurred among the young adult group, who are dying in increasing numbers from HIV/AIDS. Deaths from tuberculosis, pneumonia, and diarrhea are also increasing rapidly. The leading cause of death© Jones in South & Africa Bartlett is HIV/AIDS Learning, (infants LLCand young adults), followed by homicide© Jones (young & Bartlett Learning, LLC adult men), tuberculosis, road traffic accidents, and diarrhea. Large numbers of deaths from noncommunicable diseasesNOT occurFOR in SALEthe 60 and OR older DISTRIBUTION group of the population. Causes of death for childrenNOT FOR younger SALE OR DISTRIBUTION than 5 years are ranked as follows (Bradshaw & Nannan, 2004): 1. HIV/AIDS 2. Low birth weight © Jones 3. & Diar Bartlettrhea Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR 4. SALELower respiratory OR DISTRIBUTION infections NOT FOR SALE OR DISTRIBUTION

South Africa  77

5. Protein-energy© Jones malnutrition & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 6. Neonatal infections 7. BirthNOT asphyxia FOR and birthSALE trauma OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 8. Congenital heart disease 9. Road traffic accidents 10. Bacterial meningitis © JonesTh ere& isBartlett a significant Learning, increase in the LLC use of tobacco in South Africa,© which Jones in turn & is Bartlett causing more Learning, lung LLC NOT FORdiseases, SALE especially OR lung DISTRIBUTION cancer. Campaigns to deter youth from smokingNOT and FOR encourage SALE smokers OR to DISTRIBUTION stop are being led by healthcare organizations in increasing numbers. Throughout South Africa, there is a major change in diet in terms of types and quantity of foods consumed, with movement away from traditional plant foods to high-fat and high-sugar foods with low fiber. As a result of this change, overweight and obesity are now chronic problems among South African © Jones & Bartlett Learning,people. Urban peopleLLC are more likely to be obese© than Jones rural people, & Bartlett and those Learning,older than 65 years LLC are less likely to be obese. South Africans are now more sedentary than they previously were as well. NOT FOR SALE OR DISTRIBUTIONAlcohol consumption is also increasing, especiallyNOT FORamong males.SALE It notOR only DISTRIBUTION is causing chronic diseases such as liver and esophageal cancer, but also is contributing to homicides, violence, and motor vehicle accidents (Bradshaw & Nannan, 2004).

Racial/E©thnic Jones Inequ &alities Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NumerousNOT racial FORinequalities SALE continue OR toDISTRIBUTION exist in the wake of Apartheid. Significant disparitiesNOT FOR in stan- SALE OR DISTRIBUTION dards of living persist, with most blacks continuing to lack adequate public health services, such as clean water, a proper sewage system, and access to health care, making them much more vulnerable to disease. Unemployment is much higher within the black or African populations compared to the other ethnic groups. Whites are the most employed group. Half of all Africans live in formal housing (solid structures © Joneswith & indoorBartlett plumbing Learning, and electricity), LLC compared with 95% of whites.© Jones Poverty-related & Bartlett health problems Learning, LLC such as infectious diseases, maternal and infant deaths, and malnutrition remain widespread (Kon & NOT FORLackan, SALE 2008). OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Healthcare Personnel There is a shortage of nursing and other healthcare personnel in South Africa, as well as a problem of © Jones & Bartlett Learning,maldistribution LLC of resources. The majority of trained© Jones nursing &and Bartlett allied health Learning, professionals LLCwork in the NOT FOR SALE ORprivate DISTRIBUTION sector, which serves much less of the generalNOT population FOR SALE than does OR the publicDISTRIBUTION sector. In addition, more trained health personnel work in urban areas than in rural areas. Doctors, especially those with more subspecialty training, are more likely to work in the private sector and in urban areas (79%) as well. Moreover, there has been a trend of skilled health personnel leaving South Africa for other countries, such as the United States, Canada, New Zealand, the United Kingdom, and Australia. South Africa is actively trying© Jones to recruit & nursesBartlett and doctors, Learning, especially LLC to work in the underserved areas.© InJones addition & to Bartlett Learning, LLC healthcare personnel trained in Western medicine, there are 200,000 traditional healers who practice in South AfricaNOT (Coovadia FOR etSALE al., 2009; OR Padarath, DISTRIBUTION Ntuli, & Berthiaume, 2004). NOT FOR SALE OR DISTRIBUTION

Chronic Diseases South Africa, a developing country, currently is experiencing a vast increase in the prevalence of chronic © Jonesdiseases, & Bartlett which historically Learning, were LLC more associated with developed © countries. Jones Health & Bartlett problems Learning, such as LLC NOT FORhypertension, SALE elevatedOR DISTRIBUTION cholesterol, alcohol and tobacco use, and obesityNOT are FORnow being SALE observed OR in DISTRIBUTIONSouth

78  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

Africa in ©greater Jones frequencies. & Bartlett Risks for Learning, chronic diseases LLC reflect individuals’ age, gender, tobacco© Jones and alco- & Bartlett Learning, LLC hol use, diet, and physical activity. Other risk factors include family history and genetic background. Most chronicNOT diseases FOR are SALE preventable OR withDISTRIBUTION modification of lifestyle behaviors, and changesNOT inFOR activity SALE OR DISTRIBUTION and diet can greatly influence the risk for numerous chronic diseases. The leading causes of deaths in South Africa include the following:

■■ HIV/AIDS © Jones■■ &Heart Bartlett disease Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR■■ HomicideSALE ORand violence DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Stroke ■■ Tuberculosis ■■ Lower respiratory infections ■■ Road traffic accidents © Jones & Bartlett Learning,■■ Diarrhea diseasesLLC © Jones & Bartlett Learning, LLC ■■ Hypertension NOT FOR SALE OR■ DISTRIBUTION■ Diabetes NOT FOR SALE OR DISTRIBUTION All of these conditions are chronic diseases, with the exception of homicide and violence and traffic accidents (Coovadia et al., 2009; Padarath, Ntuli, & Berthiaume, 2004).

Communicable© Jones Dise &ases Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Sexually transmitted infections (STIs) remain one of the most common problems in adolescents and young adults in South Africa. Approximately 10% of all adults who visit a health clinic have concerns about a STI. Nearly 4 million people develop these diseases each year. Healthcare workers are involved in treatments and prevention measures, such as counseling, condom promotion, and partner notification © Jones(Shabalala & Bartlett et al., 2002). Learning, LLC © Jones & Bartlett Learning, LLC Tuberculosis is a chronic pulmonary and extrapulmonary disease characterized by positive acid-fast NOT FORstains SALE or cultures OR of DISTRIBUTION Mycobacterium tuberculosis. A TB skin test providesNOT FOR evidence SALE of the infection,OR DISTRIBUTION if positive. A chest X-ray is taken to confirm shadowing, reflecting lung invasions from TB. Cervical lymph node swelling may also be present. Tuberculosis is a huge problem in South Africa. South Africa ranks fiἀh in the world in number of TB cases, with 948 cases per 100,000 population, and cure rates remain at 60%. Part of the reason for © Jones & Bartlett Learning,the high prevalence LLC in this country is improved© case Jones detection & broughtBartlett on by Learning, the HIV/AIDS LLC epidemic, NOT FOR SALE ORespecially DISTRIBUTION among young adults. The high rate alsoNOT reflects FOR South SALE Africa’s ORpoor standardDISTRIBUTION of living, which is characterized by poverty and overcrowding. Other factors include the increase and extent of drug resistance, particularly multidrug resistance (MDR) (Mwinga & Fourie, 2004). A recent study reported that 55% of the people with TB were also HIV positive. Those affected by HIV/AIDS are five times more likely to develop TB. One-third of the 40 million people in all of Africa with HIV/AIDS also have TB; in sub-Saharan© Jones Africa, & the Bartlett rate is even Learning, higher. The South LLC African Medical Research Council© Jones predicted & Bartlett Learning, LLC that thereNOT would FORbe 300,000 SALE cases ofOR TB andDISTRIBUTION 30,000 deaths from this cause in the country—aNOT fatality FOR rate SALE OR DISTRIBUTION of 10%, in a nation that once had one of the lowest TB death rates in Africa before the advent of HIV/ AIDS (Bamford, Loveday, & Verkuijl, 2004; Nullis-Kapp, 2005). The Eastern Cape, a very poor rural area with limited resources, has an extremely high incidence of TB, with 675 cases per 100,000 population (Bamford et al., 2004). © Jones &Cholera Bartlett is an Learning, intestinal illness LLC caused by the Vibrio cholerae ©organism. Jones Cholera & Bartlett results in Learning, loss of LLC NOT FORlarge SALE volumes ORof watery DISTRIBUTION stool (excrement), leading to rapid dehydrationNOT and FOR shock, SALE and oἀen OR resulting DISTRIBUTION

South Africa  79

in death ©without Jones treatment. & Bartlett The fatality Learning, rate for untreated LLC cholera is 50%. Persons with© cholera Jones develop & Bartlett Learning, LLC rapid breathing, vomiting, and painless diarrhea, and they go into metabolic acidosis. Appropriate oral or intravenousNOT rehydration FOR SALEtherapy is OR needed DISTRIBUTION to replace lost fluids and electrolytes. NOT FOR SALE OR DISTRIBUTION Cholera is one of the diseases requiring notification of the WHO. Nevertheless, cholera epidemics remain common in Asia, Africa, India, and South America (Sack, Sack, Nair, & Siddique, 2005). In South Africa, cholera represents a significant burden. In 2000–2001, a cholera epidemic occurred, with 106,389 reported cases. Cholera deaths result from poor sanitation and poor-quality water supplies—and an esti- © Jonesmated & Bartlett18 million South Learning, Africans have LLC no basic sanitation. Of this group,© Jones 75.8% live & in Bartlettrural areas. Learning,Almost LLC NOT FOR50% ofSALE those children OR DISTRIBUTION go to schools where there is only a pit for toiletNOT use. ByFOR 2002, SALE aἀer initiatives OR DISTRIBUTION were undertaken to help those persons without water and sanitation, the number of persons in South Africa with cholera infection was reduced to 7 million (Duse, da Silva, & Zeitsman, 2003; Mudzanani, Ratsaka- Mathokoa, Mahlasela, Netshidzivhani, & Mugero, 2004). Across the continent of Africa, more than 38% of all people have no access to safe water—a percent- © Jones & Bartlett Learning,age higher than LLC that found in any other place in© the Jones world. In & South Bartlett Africa, someLearning, 12 million LLCpeople lack NOT FOR SALE ORsafe DISTRIBUTION water and 20 million lack sanitation facilities.NOT By the FOR year 2020,SALE South OR Africa’s DISTRIBUTION population demands will exceed its water supply by 6%. Health maintenance is dependent on an adequate water supply and adequate sanitation facilities (toilets). It is vital in hospitals and healthcare clinics to have adequate clean water and sanitation for prevention and treatment of diseases and illnesses. A clean and adequate supply is necessary for simple hand washing in patient care. In short supply areas, it is necessary for healthcare workers© Jones to disinfect & waterBartlett if unclean Learning, and teach similar LLC techniques to patients. Example© Jones techniques & Bartlett Learning, LLC include boiling,NOT useFOR of chlorine SALE tablets OR, fi DISTRIBUTIONltration, and clean storage (Duse et al., 2003). NOT FOR SALE OR DISTRIBUTION Malaria is a serious disease transmitted to humans by the bite of the Anopheles mosquito. Symptoms include fever and a flulike illness characterized by chills, headache, muscle aches, and fatigue. Malaria can also cause anemia and jaundice. If not treated promptly, this infection can lead to kidney failure, coma, and death. Malaria can be prevented by antimalarial drugs, such as atova- © Jonesquone/proguanil, & Bartlett doxycycline,Learning, and LLC mefloquine. Chloroquine is not© e ffJonesective for & malaria Bartlett prevention Learning, in LLC South Africa. Protection from mosquito bites is also very important (Centers for Disease Control and NOT FORPrevention SALE [CDC], OR 2004).DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Malaria is a major health problem in sub-Saharan Africa and affects great numbers of young children and pregnant women. It is the main cause of 20% of all deaths of young children in Africa. Approximately 95% of the infections in South Africa are due to Plasmodium falciparum, a microbe that lives in the gut of the Anopheles mosquito. Transmission is seasonal, with October to February seeing the © Jones & Bartlett Learning,emergence of theLLC largest number of cases. Use of© drugs Jones for treatment & Bartlett and vector Learning, control by spraying LLC has NOT FOR SALE ORproved DISTRIBUTION effective in deterring infection. South Africa,NOT along FOR with SALE five other OR countries, DISTRIBUTION was given permis- sion by the United Nations Environmental Programme to use DDT for public health use only. The appli- cation of DDT in 2000 led to significant improvements in the mortality and morbidity associated with this disease. It should be noted, however, that DDT is a banned pesticide in the United States and most developed and developing countries (Moonasar et al., 2004). South© Africa Jones has an& estimatedBartlett 4–6 Learning, million people LLC living with HIV/AIDS. The national© Jones prevalence & Bartlett Learning, LLC of HIV inNOT pregnant FOR women SALE is 26.2%. OR ADISTRIBUTION study by the South African Medical ResearchNOT Council FOR con- SALE OR DISTRIBUTION cluded that for 2000–2001, the prevalence of HIV/AIDS was almost three times as high in reality as that listed in a government statistical report. In 80% of AIDS-related deaths in men, and 70% in women, the cause of death listed on the death certificate as TB or lower respiratory tract infection. In children, three times as many AIDS-related deaths were identified as due to lower respiratory tract infections, © Jonesdiarrheal & Bartlett disease, Learning,and protein-energy LLC malnutrition, rather than AIDS© Jones (“South Africa & Bartlett Needs to FaceLearning, the LLC NOT FORTruth,” SALE 2005). OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

80  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

The ©highest Jones rates &of diseaseBartlett transmission Learning, occur LLCamong newborns and breastfed children.© Jones Poverty & Bartlett Learning, LLC increases the vulnerability to HIV infection somewhat, because poor people usually have less education and less accessNOT to FOR information SALE about OR safe DISTRIBUTION sex practices. High unemployment rates andNOT lack of FOR support SALE OR DISTRIBUTION may deny mothers access to care in clinics. Access to antiretroviral therapy (ART) drugs for HIV/AIDS patients in South Africa is very limited. In 2002, of the 500,000 who could immediately benefit from such medications, only 20,000 to 40,000 were receiving treatment; of those who were receiving treatment, most were receiving care in the private sector. In 2003, the government made ART more widely available © Jonesto the& publicBartlett sector. Learning, One problem inLLC providing these drugs is the very© high Jones costs for& theBartlett medications Learning, and LLC NOT FORtests (DohertySALE &OR Colvin, DISTRIBUTION 2004). NOT FOR SALE OR DISTRIBUTION In 2005 in South Africa, where less than 3% of people who need ART actually receive it, private companies began supplying drugs directly to employees who are HIV positive. The corporate sector is presently taking more responsibility for care of workers with this disease than ever before (Venter, 2005). Some of the social factors that make South African women vulnerable to HIV/AIDS relate to the © Jones & Bartlett Learning,position of women LLC in society and practice of safe© sex. Jones Women & are Bartlett oἀen born Learning, into a low social LLC status in NOT FOR SALE ORSouth DISTRIBUTION Africa. Physiologically men are able to passNOT the virus FOR to womenSALE more OR easily DISTRIBUTION than women pass the virus to men, making a woman twice as likely to become infected. Women are also vulnerable to con- tracting the HIV virus and many other STIs because of the greater mucosal surface exposed to pathogens in females during sexual activity, particularly in young girls, who are not fully mature. Another HIV/AIDS risk factor is the very high rate of violence against women in South Africa. The incidence© of Jonesrape in South & Bartlett Africa is considered Learning, to be among LLC the highest in the world, yet© these Jones crimes &are Bartlett Learning, LLC seldom reported.NOT FOR Rates of SALE rapes of ORfemale DISTRIBUTION children are exceptionally high. A myth that NOT“having FOR sex with SALE OR DISTRIBUTION a virgin will cure AIDS” remains to blame for part of the increase in child rape. In addition, a very high incidence of husband/boyfriend violence occurs. Women can be beaten if they refuse to have sex with their partners. Women oἀen remain in abusive relationships for financial dependency reasons. No matter why it occurs, violence against women increases the risk of HIV and STI infections. © Jones &In Bartlett South Africa, Learning, 30% of women LLC are heads of households; these© individuals Jones are& Bartlettoἀen poor, haveLearning, no LLC financial aid from men, and consequently have a very unfavorable economic position and little power. NOT FORSelling SALE sex can OR oἀen DISTRIBUTION be a survival strategy for these women, albeit oneNOT that FOR makes SALEthem even OR more DISTRIBUTION vulnerable to HIV. Young girls may trade sex for money, clothes, or food (Ackerman & de Klerk, 2001). Another problem in South Africa is the increasing number of orphans who are leἀ behind when both of their parents die of AIDS. Some grandparents are trying to provide care for as many as 10 to 20 grandchildren aἀer they have lost their children. Other AIDS orphans are leἀ alone to care for themselves. © Jones & Bartlett Learning,There is a lost LLCgeneration of street children who© have Jones no education & Bartlett and have Learning, few economic LLC resources. NOT FOR SALE ORSome DISTRIBUTION sell themselves for sex to keep themselvesNOT and siblings FOR fed. SALE Some areOR HIV DISTRIBUTION infected and some are not, but many will die regardless of their situation (Sowell, 2000).

Aging The South© African Jones population & Bartlett is aging Learning,because of declining LLC fertility rates and decreases in© life Jones expectancy & Bartlett Learning, LLC among those persons infected with HIV. In 2001 those in their 70s represented 3.2% of the population, and those in theirNOT 80s FORrepresented SALE 1%. Elderly OR DISTRIBUTIONadults are expected to account for 30 people per NOT100 population FOR inSALE OR DISTRIBUTION 2015. Even with the AIDS epidemic there will be a large number of adults 65 and older, as compared to the number of children—AIDS affects the older adult population to the least extent (Joubert & Bradshaw, 2004). The older black adults of South Africa are among the poorest people in the country and oἀen lack credit or employment. Most have lived through the Apartheid years and have been poor all their © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Conclusion  81

lives. Fiἀy-eight© Jones percent & ofBartlett older adult Learning, Africans have LLCno education; in Limpopa the rate© isJones 74%, and & in Bartlett Learning, LLC Mpurmalanga the rate is 66%. Many older adults, especially the Africans who live in poverty and have little or noNOT formal FOR education, SALE are now OR taking DISTRIBUTION care of their children and/or grandchildren,NOT which FOR is a very SALE OR DISTRIBUTION difficult burden. Their main source of income is Social Protection (Old Age Pension), which is provided for men 65 and older and for women 60 and older (Joubert & Bradshaw, 2004).

© JonesTraditional & Bartlett Medicine Learning, LLC © Jones & Bartlett Learning, LLC NOT FORThe Alma-AtaSALE ORDeclaration DISTRIBUTION on primary health care, in conjunction NOTwith WHO FOR and SALE the United OR Nations DISTRIBUTION International Children’s Emergency Fund (UNICEF), gave international recognition to the positive role of traditional indigenous healthcare providers. Traditional practitioners and birth attendants are recognized as important people in the primary healthcare team, but not as part of the public health service. Historically Western-style health practitioners, such as Dr. David Livingston, consulted with indigenous © Jones & Bartlett Learning,healers on drug LLC treatment for fevers. Within South© Jones Africa, many & Bartlett traditional Learning,healers believe LLCthat illness NOT FOR SALE ORcannot DISTRIBUTION be directly explained in physical terms, andNOT some FOR believe SALE in supernatural OR DISTRIBUTION entities, such as spirits, that bring about illness. Some also believe in direct causal connections comparable to Western medicine. Different healthcare ideologies and systems have stood side by side together in South Africa for many years. Patients may want to use both types of medicine “just to play it safe.” As many as 80% of the indigenous African people are accustomed to using traditional medicine as a first means for treatment of illness. Th©eir Jones faith in this & Bartlettsystem may Learning,not necessarily LLCbe misplaced: Noristan Laboratories,© Jones a large phar- & Bartlett Learning, LLC maceuticalNOT company, FOR tested SALE 350 herbs OR used DISTRIBUTION by indigenous healers and found that 80% hadNOT some FOR medici- SALE OR DISTRIBUTION nal properties. In any event, patients are faced with two healthcare system perspectives and will most likely continue to seek care from either as they see fit. At present, there is limited cooperation between the two systems (Muller & Steyn, 1999). The indigenous flora of South Africa include 23,404 higher plant species, and the use of many of © Jonesthese & speciesBartlett for medicinal Learning, use dates LLC back to the San people in the© region Jones more &than Bartlett 20,000 years Learning, ago. LLC NOT FORTraditional SALE medicine OR DISTRIBUTION use in South Africa is oἀen unacknowledgedNOT by theFOR Western-style SALE OR healthcare DISTRIBUTION system, yet pharmacists are oἀen well equipped to bridge the gap between indigenous medicines and Western ones (Scott, Springfield, & Coldrey, 2004).

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONConclusion NOT FOR SALE OR DISTRIBUTION Table 3-18 compares and contrasts a variety of health statistics for the developing countries covered in this chapter—Egypt, China, India, and South Africa. It identifies the health indicator or type of health issue, the date of data collection, data type, and then the various data collected from each country. This ©chapter Jones has addressed & Bartlett the health Learning, and health careLLC of four developing countries. ©Although Jones Egypt, & Bartlett Learning, LLC China, India, and South Africa are located in different regions of the world, and they have a variety of languages,NOT customs, FOR values, SALE health ORpractices, DISTRIBUTION types of government, and health care per capitaNOT allocations, FOR SALE OR DISTRIBUTION they also share some commonalities and similar health challenges. Although the data presented here can be used for cross-country comparisons, the definitions of health problems and data collection methodol- ogy may greatly differ, so that these comparisons, at best, may be only a good estimate for a certain time and geographical location. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

82  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

TABLE 3-18© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC HealthcareNOT Statistics FOR forSALE Egypt, OR China, DISTRIBUTION India, and South Africa NOT FOR SALE OR DISTRIBUTION

Data Date/ Data South Indicator Date Range Type China Egypt India Africa © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC HIV/AIDS NOT FORPeople SALE living with OR DISTRIBUTIONData from most recent Number 740,000NOT 11,000 FOR 2,400,000SALE OR 5,600,000 DISTRIBUTION HIV/AIDS year available Adults living with 2009 Number 730,000 10,000 2,300,000 5,300,000 HIV/AIDS Adult HIV/AIDS 2009 % 0.1% <0.1% 0.3% 17.8% © Jones & Bartlett Learning,prevalence rate LLC © Jones & Bartlett Learning, LLC NOT FOR SALE ORWomen DISTRIBUTION living with Number of women living NOT% FOR 32%SALE OR 24% DISTRIBUTION 38% 62% HIV/AIDS with HIV/AIDS and women as a percentage of adults living with HIV/ AIDS, 2009 Men living© with Jones Number & Bartlett of men livingLearning, % LLC NA 81% 61%© Jones 38% & Bartlett Learning, LLC HIV/AIDS with HIV/AIDS and NOT FORmen SALE as a percentage OR DISTRIBUTION of NOT FOR SALE OR DISTRIBUTION adults living with HIV/ AIDS, 2009 Children living 2009 Number NA NA NA 330,000 with HIV/AIDS © JonesAIDS & deathsBartlett Learning,2009 LLC Number 26,000© Jones <500 & 170,000Bartlett 310,000 Learning, LLC NOT FORAIDS SALE orphans OR DISTRIBUTION2009 Number NANOT NAFOR SALE NA OR 1,900,000 DISTRIBUTION

ARV need 2009 Number NA 3,300 NA 2,600,000 ARV treatment 2009 Number 65,481 359 320,074 971,556 ARV coverage Rate 2009 % NA 11% NA 37% © Jones & Bartlett Learning,Tuberculosis LLC © Jones & Bartlett Learning, LLC NOT FOR SALE ORTuberculosis DISTRIBUTION HBCs 2010 NOTText FOR YesSALE OR No DISTRIBUTION Yes Yes New TB cases 2009 Number 1,300,000 15,000 2,000,000 490,000 New TB smear- 2008 Number 640,000 6500 890,000 200,000 positive cases New TB case rate 2009 Rate per 96 19 168 971 100,000 People living© Jones & Bartlett2009 Learning,Number LLC 1,900,000 25,000 3,000,000© Jones 400,000 & Bartlett Learning, LLC with TBNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION TB prevalence rate 2009 Rate per 138 30 249 808 100,000 TB death rate 2009 Rate per 12 1 23 52 100,000 © JonesTB & prevalence Bartlett in Learning,2007 LLC Rate per 1© Jones 0 & Bartlett 4 Learning, 345 LLC NOT FORHIV-positive SALE OR DISTRIBUTION 100,000 NOT FOR SALE OR DISTRIBUTION people per 100,000 population

Conclusion  83

TABLE 3-18© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC HealthcareNOT Statistics FOR forSALE Egypt, OR China, DISTRIBUTION India, and South Africa (continued) NOT FOR SALE OR DISTRIBUTION

Data Date/ Data South Indicator Date Range Type China Egypt India Africa © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Malaria NOT FORMalaria SALE cases OR DISTRIBUTION2009 Number 14,491NOT FOR 94 SALE 1,563,344 OR 6072DISTRIBUTION Malaria deaths 2009 Number 12 2 1133 45 Other Diseases, Conditions, and Risk Indicators Yellow fever cases 2009 Number NA NA NA 0 © Jones & Bartlett Learning,Yellow fever deaths LLC 2004© Jones Number & Bartlett 0 Learning, 0 0 LLC 0 Diphtheria cases 2009 Number 0 0 NA 1 NOT FOR SALE ORMeasles DISTRIBUTION cases 2009NOT Number FOR SALE 52,461 OR 608 DISTRIBUTION NA 5857 Polio cases 2009 Number 0 0 752 0 DTP3 immunization coverage rate 2009 % 97% 97% 66% 69% Vitamin A supplementation 2009 % NA NA 66% NA coverage rate Percentage© with Jones water & Bartlett Learning,2008 LLC % 89% 99%© 88% Jones 91% & Bartlett Learning, LLC Access toNOT sanitation FOR SALE OR DISTRIBUTION2008 % 55% 94%NOT 31% FOR 77% SALE OR DISTRIBUTION Population undernourished 2005–2007 % 10% NA 21% NA Low-birth-weight babies 2000–2009 % 3% 13% 28% NA Child malnutrition 2000–2009 % 6.8% 6.8% 43.5% NA Female prevalence of obesity 2005 % 2% 46% 1% 35% © JonesMale & prevalenceBartlett of Learning, obesity LLC2005 %© 2% Jones 22% & Bartlett 1% Learning, 7% LLC Female prevalence of smoking 2006 % 4% 1% 4% 9% NOT FORMale SALE prevalence OR of smoking DISTRIBUTION2006 % 59.5%NOT FOR 27.6% SALE 33.2% OR 29.5%DISTRIBUTION Programs, Funding, and Financing Financial development assistance 2007 U.S. dollars $0.18 $1.23 $0.50 $6.60 for health per capita USAID NTD program countries Fiscal year 2010 Text No No Yes No © Jones & Bartlett Learning,USAID maternal LLC assistance Fiscal year 2010© Jones Text & Bartlett No Learning, Yes Yes LLC No NOT FOR SALE ORU.S. DISTRIBUTION food assistance Fiscal year NOT TextFOR SALE No OR No DISTRIBUTION Non- No program countries 2008 emergency USAID nutrition Fiscal year Text No Yes Yes No program countries 2010 Health expenditure per capita 2008 U.S. dollars $265 $261 $122 $843 Total expenditure© Jones on health & Bartlett Learning,2008 LLC % 4.3% 4.8% 4.2%© Jones 8.2% & Bartlett Learning, LLC Government health expenditures 2008 % 10.3% 5.9% 4.4% 10.4% as a percentageNOT FOR of total SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION government expenditures Government health expenditures 2008 % 47.3% 42.2% 32.4% 39.7% as a percentage of total health expenditures © JonesSocial & Bartlettsecurity expenditures Learning, LLC2008 % 66.3%© Jones 21.6% & Bartlett 17.2% Learning, 3.0% LLC NOT FORon SALE health OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Out-of-pocket expenditures 2008 % 82.6% 97.7% 74.4% 29.7% on health (continues) © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 0085 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

84  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

Data Date/ Indicator Date Range Data Type China Egypt India South Africa © JonesHealth & Bartlett Workforce Learning,and Capacity LLC © Jones & Bartlett Learning, LLC NOT FORPhysicians SALE OR DISTRIBUTION2000–2010 Rate per 14NOT 28 FOR SALE 6 OR 8DISTRIBUTION 10,000 Nurses and midwives 2000–2010 Rate per 14 35 13 41 10,000 Community health 2000–2010 Rate per 8 NA 1 NA © Jones & Bartlett Learning,workers LLC 10,000© Jones & Bartlett Learning, LLC Births attended by skilled 2000–2010 % 96% 79% 47% 91% NOT FOR SALE OR DISTRIBUTIONhealth personnel NOT FOR SALE OR DISTRIBUTION Hospital beds 2000–2009 Rate per 30 21 9 28 10,000 Demography and Population Population© Jones & Bartlett2011 Learning, Number 1,336,718,015LLC 82,079,636 1,189,172,906© Jones 49,004,031 & Bartlett Learning, LLC Adult sex ratio 2011 Number 1.17 1.03 1.07 1.02 Median ageNOT FOR SALE2011 OR DISTRIBUTION Number 35.5 24.3 26.2NOT FOR 25.0 SALE OR DISTRIBUTION Population younger than 2010 % 18% 33% 32% 31% age 15 Urban population 2010 % 47% 43% 29% 52% Land area 2009 Number 9,560,981 1,001,449 3,287,263 1,221,037 © JonesPopulation & Bartlett density Learning, 2010 LLC Number 140© Jones 80 & 362Bartlett Learning, 41 LLC NOT FORBirth SALE rate OR DISTRIBUTION2011 Rate per 1000 12.29NOT 24.63 FOR 20.97SALE OR 19.48 DISTRIBUTION Total fertility rate 2011 Number 1.54 2.97 2.62 2.30 Adolescent fertility rate 2000–2008 Rate per 1000 5 50 45 54 Contraceptive 2000–2010 % 84.6% 60.3% 56.3% 59.9% prevalence rate Death rate 2011 Rate per 1000 7.03 4.82 7.48 17.09 © Jones & Bartlett Learning,Infant mortality LLC rate 2011 Rate per 1000© Jones 16.06 & Bartlett 25.20 Learning, 47.57 LLC 43.20 NOT FOR SALE ORFemale DISTRIBUTION infant 2011 Rate per 1000NOT FOR 16.57 SALE 23.52 OR DISTRIBUTION 49.14 39.14 mortality rate Male infant mortality rate 2011 Rate per 1000 15.61 26.80 46.18 47.19 Under-five mortality rate 2009 Rate per 1000 19 21 66 62 Maternal mortality ratio 2008 Rate per 38 82 230 410 © Jones & Bartlett Learning,100,000 LLC © Jones & Bartlett Learning, LLC Life expectancy: female 2009 Number 76 73 66 55 Life expectancy:NOT maleFOR SALE 2009 OR DISTRIBUTION Number 72 69 63NOT FOR 54 SALE OR DISTRIBUTION Population growth rate 2011 % 0.49% 1.96% 1.34% -0.38%

Study Questions  85

Data Date/ Data Indicator Date Range Type China Egypt India South Africa © JonesIncome & Bartlett and the Economy Learning, LLC © Jones & Bartlett Learning, LLC NOT FORGDP SALEper capita OR DISTRIBUTION2009 $ $6828NOT $5673 FOR $3296 SALE OR $10,278 DISTRIBUTION GNI per capita 2009 $ $6890 $5680 $3280 $10,050 Population living Data from most % 4.0% 0.4% 10.5% 3.3% on less than recent year (2005) (2005) (2005) (2006) $1.25 per day available © Jones & Bartlett Learning,Unemployment LLC rate Data from most %© Jones 4.3% & Bartlett9.7% Learning,10.8% LLC23.3% recent year (2005) (2010) (2010) (2010) NOT FOR SALE OR DISTRIBUTIONavailable NOT FOR SALE OR DISTRIBUTION Country income As of July 2011 Text Upper Lower Lower Upper classification middle middle middle middle income income income income External country 2009 U.S. dollars $428,442 $33,257 $237,692 $42,101 debt © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ARV: antiretroviral therapy. Source: Kaiser Family Foundation, n.d.

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Study Questions 1. How are the health issues of infant mortality and nutrition similar for the countries of Egypt, China, India, and South Africa? © Jones & Bartlett Learning, 2. Compare LLCand contrast the health beliefs and© practicesJones of & traditional Bartlett medicine Learning, in China LLC with those NOT FOR SALE OR DISTRIBUTIONin India. How do cultural influences affect NOThealth andFOR health SALE care di ORfferently? DISTRIBUTION What are some basic commonalities? 3. What are some contributory factors leading to the exceptionally high rate of HIV/AIDS in South Africa?

86  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

Case© JonesStudy & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Smoking and health concerns vs. tobacco production in China “As the health impact of smoking, including rising heart disease and lung cancer, gradu- ally emerges, unless there is effective government intervention, it will affect China’s overall economic growth due to lost productivity,” said Yang Gonghuan, deputy director of © Jones &the Bartlett Chinese Center Learning, for Disease LLC Control and Prevention. Lost© Jones productivity & Bartlett from smoking- Learning, LLC NOT FORrelated SALE health OR problems DISTRIBUTION will hamper China’s economic growth,NOT and FOR related SALE costs incurredOR DISTRIBUTION by smoking far exceed the tobacco industry’s contribution in terms of profits and jobs it generates. China’s addiction to huge revenues from the state-owned tobacco monopoly is hindering anti-smoking measures, potentially costing millions of lives in the country with the world’s largest number of smokers. The warnings, issued in a report prepared © Jones & Bartlett Learning,by a group LLC of prominent public health experts© Jones and economists, & Bartlett came Learning, amid growing LLC calls NOT FOR SALE OR DISTRIBUTIONfor the government to give stronger supportNOT to FOR tobacco-control SALE OR measures. DISTRIBUTION China is the world’s largest tobacco producing and consuming country, with more than 300 million smokers on the mainland. Each year, about 1.2 million people die from smoking-related diseases on the mainland and the figure will increase to 3.5 million by 2030, according to estimates from the World Health Organization (WHO). The report underscores increasing concern© Jones that the& Bartlett country’s economicLearning, potential LLC will be jeopardized due to© escalatingJones & Bartlett Learning, LLC medicalNOT costs FOR and lostSALE productivity OR DISTRIBUTION if the government fails to take serious actionNOT to FOR com- SALE OR DISTRIBUTION bat smoking.

Reference Shan, J. (2012). Report: Smoking industry harming economic health. China Daily. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Case Study Questions NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1. What are some major health risks related to smoking and what is the impact on health for the Chinese people? 2. Why do you think that government owned tobacco production in China continues in spite of knowledge about health risks? 3. How would you suggest that smoking in China be decreased? © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

References About Egypt:© Jones General information& Bartlett (2010). Learning, Retrieved from LLC http://cabinet.gov.eg/AboutEgypt/GeneralInfo© Jones & Bartlett Learning, LLC .aspxNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Ackerman, L., & de Klerk, G. (2002). Social factors that make South African women vulnerable to HIV infection. Health Care for Women International, 23, 163–172. Ahrani, M., Houser, R., Yassin, S., Mogheez, M., Hussaini, Y., Crump, P. . . . Levinson, F. J. (2006). A positive deviance-based antenatal nutrition project improves birth-weight in Upper Egypt. Journal of © Jones &Health, Bartlett Population, Learning, and Nutrition, LLC 24(4), 498–509. © Jones & Bartlett Learning, LLC Anand, S., Fan, V., & Zhang, J. (2008). Health care reform in China 5. China’s human resources for health: NOT FOR SALEQuantity, OR quality, DISTRIBUTION and distribution. Lancet, 372(9651), 1774–1782.NOT FOR SALE OR DISTRIBUTION

References  87

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88  Chapter 3: Developing Countries: Egypt, China, India, and South Africa

Harrison,© S. (2004).Jones Medical & Bartlett schemes. In Learning, P. Ijumba & C. DayLLC (Eds.), South African Health Review© Jones (pp. 291–293). & Bartlett Learning, LLC Durban, South Africa: Health Systems Trust. Hays, J. (2011).NOT Health FOR Care SALE in China: OR Doctors, DISTRIBUTION insurance and costs. Retrieved from http://factsanddetailsNOT FOR SALE OR DISTRIBUTION .com/china.php?itemid=335&catid=13&subcatid=83 Hesketh, T., & Zhu, W. (2002). Health in China: From Mao to market reform. China: United Nations Development Programme. Hu, S., Tang, S., Liu, Y., & Zhao, Y. (2008). Reform of which health care is paid for in China: Challenges © Jones &and Bartlett opportunities. Learning, Lancet, 372 LLC(9652), 1846–1854. © Jones & Bartlett Learning, LLC NOT FORHu, X.,SALE Cook, S.,OR & Salazar, DISTRIBUTION M. (2008). Internal migration in China. Lancet,NOT 372,FOR 117–120. SALE OR DISTRIBUTION International Agency for Research on Cancer. (2010). Cancer in Egypt. Retrieved from http://www.iarc.fr /en/publications/scientific-papers/2010/index.php Ismail, H. (2011). Self-related health and factors influencing responses among young Egyptian type 1 diabetes patients. BioMedCentral, 11, 216–223. © Jones & Bartlett Learning,Joubert, J., & Bradshaw, LLC D. (2004). Health of older© persons.Jones In & P. BartlettIjumba & C. Learning, Day (Eds.), South LLC African Health Review (pp. 147–162). Durban, South Africa: Health Systems Trust. NOT FOR SALE ORKaiser DISTRIBUTION Family Foundation. (n.d.). Customized dataNOT sheet. FOR Retrieved SALE from OR http://www.globalhealthfacts DISTRIBUTION .org/data/factsheet.aspx?loc=59, 76,105, 195&ind=1,2 Kanabus, A. (2005). HIV and AIDS in China. Retrieved from http://www.avert.org/aidschina.htm Kon, Z. R., & Lackan, N. (2008). Ethnic disparities in access to care in post-Apartheid South Africa. American Journal of Public Health, 98(12), 2272–2277. Lasheen, © M. Jones R., El-Kholy, & Bartlett G., Sharaby, Learning, C. M., Elsherif, LLC I. Y., & El-Wakeel, S. T. (2008).© AssessmentJones & of Bartlett Learning, LLC selectedNOT heavy FOR metals SALE in some OR water DISTRIBUTION treatment plants and household tap water NOT in greater FOR Cairo, SALE OR DISTRIBUTION Egypt. Management of Environmental Quality, 19(3), 367. Life as a village doctor in southwest China. (1997). Newsweek/Healthweek. Retrieved from http://www .nurseweek.com/features/dispatches/China/971023.html Lim, M., Yang, H., Zhang, T., Feng, W., & Zhou, Z. (2004, November/December). Public perceptions of private health care in socialist China. Data Watch, 222–234. © JonesLohinivak, & Bartlett A., El-Sayeed, Learning, N., & Talaat, LLC M. (2008). Clean hands: Prevention© Jones of typhoid & Bartlett fever in rural Learning, com- LLC NOT FOR munitiesSALE inOR Egypt DISTRIBUTION. International Quarterly of Community HealthNOT Education, FOR 28 SALE(3), 215–227. OR DISTRIBUTION Moonasar, D., Johnson, C., Maloba, B., Kruger, P., le Grange, K., Mthembu, J., & van den Ende, J. (2004). Malaria. In P. Ijumba & C. Day (Eds.), South African Health Review (pp. 243–256). Durban, South Africa: Health Systems Trust. Mudzanani, L., Ratsaka-Mathokoa, M., Mahlasela, L., Netshidzivhani, P., & Mugero, C. (2004). Cholera. © Jones & Bartlett Learning,In P. Ijumba LLC & C. Day (Eds.), South African© HealthJones Review & Bartlett (pp. 257–264) Learning,. Durban, South LLC Africa: Health Systems Trust. NOT FOR SALE ORMuller, DISTRIBUTION A., & Steyn, M. (1999). Culture and the feasibilityNOT FOR of a partnership SALE OR between DISTRIBUTION Westernized medical practitioners and traditional healers. Society in Transition, 30(2), 142–156. Mwinga, A., & Fourie, B. (2004). Prospects for new tuberculosis treatment in Africa. Tropical Medicine and International Health, 9(7), 827–832. Nullis-Kapp, C. (2005). Africa is worst hit by dual epidemic. Bulletin of the World Health Organization, 83(3),© 165–166. Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Padarath,NOT A., Ntuli, FOR A., & SALE Berthiaume, OR L.DISTRIBUTION (2004). Human resources. In P. Ijumba & C. DayNOT (Eds.), FOR South SALE OR DISTRIBUTION African Health Review (pp. 299–318). Durban, South Africa: Health Systems Trust. Pochagina, O. (n.d.). Suicide in present day China. Far Eastern Affairs. Population—China. (2004, December). Putting on the brakes on reproduction. Canada and the World, 18–21. © JonesRao, & M. Bartlett (2009). Tackling Learning, health inequalities LLC in India. Perspectives in© Public Jones Health, & 129 Bartlett(5). Learning, LLC Rosenberg, M. (2011). China’s one child policy. Retrieved from http://geography.about.com NOT FORSack, SALE D., Sack, ORR. B., DISTRIBUTION Nair, G. B., & Siddique, A. K. (2005). Cholera. Lancet,NOT 363,FOR 223–33. SALE OR DISTRIBUTION

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