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48 4 East Asia: China, Indonesia, Japan, and South Korea There are five blue marble health countries in Asia, and all of them except India are found in East Asia. The story of East Asia’s neglected diseases is a good representation of the tenets of blue marble health—namely, explosive economic growth in postwar Japan and Korea, as well as in eastern China following economic reforms that began during the 1980s, with each economic jump associated with dramatic reductions in the prevalence of NTDs and malaria. Nevertheless, significantly large areas have been left behind and are not benefiting from such successes, including southwestern China, Indonesia , and North Korea. These regions remain plagued by widespread NTDs. China The People’s Republic of China is the world’s second-­ largest and fastest-­ growing economy today. China’s economic and market reforms began in the 1980s with the ascendancy and leadership of Deng Xiaoping. According to the World Bank, China’s recent GDP economic growth has averaged 10% annually, and in so doing has lifted half a billion people out of poverty, while attaining most if not all its Millennium Development Goals [1]. Despite such gains, a crushing level of poverty persists. Data from 2011 show that 6.3% of China’s population lives below the 2005–14 World Bank poverty level of $1.25 per day [2], while 18.6% live on less than $2 per day [3]. With a population greater than 1.3 billion, there are more than 200 million people who live on virtually nothing in China. Hotez.indb 48 6/22/16 11:02 AM East Asia 49 China’s poverty is unevenly distributed. Not many of those 200 million destitute Chinese live in the amazing cities in the eastern part of the country with populations of more than five million people each—Beijing, Shanghai, Tianjin, Taipei, Nanjing, Wuhan, Shenyang, and Hangzhou; nor in a new megalopolis being created around Beijing and known as Jing-­ Jin-­ Ji, which comprises a population six times larger than the New York City metro area [4]; nor in the southeast in or near Guangdong Province (Pearl River Delta)— Dongguan, Guangzhou, Hong Kong, and Shenzhen. Instead, as shown in figure 4.1 [5], the economy of China exhibits a distinct east-­ to-­ west gradient of poverty. Let’s look at some of China’s poorest provinces, particularly those in the southwest corner—Sichuan, Yunnan, Guizhou, Guangxi, and Hainan Provinces . Here, where many of China’s “bottom 200 million” live, NTDs remain widespread, led by the intestinal helminth infections. Between 2001 and Guangdong Yunnan Tianjin Sichuan Shaanxi Shandong Shanxi Shanghai Beijing Ningxia Inner Mongolia Liaoning Guizhou Guangxi Gansu Tibet Xinjiang Hubei Hunan Hebei Henan Heilongjiang Fujian Qinghai Jilin Jiangsu Jiangxi Zhejiang Anhui Hainan PER CAPITA INCOME IMPOVERISHED POOR BETTER OFF Figure 4.1. China’s east-­ to-­ west poverty gradient. From [5]. Hotez.indb 49 6/22/16 11:02 AM 50 Blue Marble Health 2004, the Chinese Center for Disease Control and Prevention, including its Institute of Parasitic Diseases based in Shanghai, conducted fecal examinations on more than 350,000 individuals in 687 study sites across China to reveal that almost 13% of its population (more than 150 million cases) is infected with Ascaris worms [6, 7]. However, like China’s poverty, the distribution of ascariasis (as well as other intestinal helminth infections) in China is uneven. According to a study led by the Chinese CDC in collaboration with Swiss Tropical and Public Health Institute and the University of Basel, China’s human ascariasis cases are concentrated in some of the same southwestern provinces where extreme poverty is still rampant, namely, Sichuan, Yunnan, and Guizhou Provinces, as well as in Hubei (north [bei] of the lake [hu]) and Hunan (south [nan] of the lake), two of the Yangtze River provinces where there is also a serious level of poverty [6, 7]. These studies were led in part by Xiao-­Nong Zhou, who heads the Shanghai Institute, and Juerg Utzinger, who recently became director of the Swiss Institute. The reason that poverty is such an important social determinant for intestinal helminth infections is still not entirely known. The life cycle of ascariasis is propagated when parasite eggs in the feces are shed in the environment. Included among the potential social and environmental determinants that arise from poverty are inadequate disposal of feces in poor areas, in some cases from open and indiscriminate defecation, as well as China’s dependence on human feces as...


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