Hello, welcome to visit Shanghai Forum
This is a verygreat country, and you should learn the lesson from the west that we wentthrough, and keep your population from getting sick with non-communicablediseases.
Reporter:Fu Hua (Professor, School of Public Health, Fudan University )
Editor: Huang Xinyi
Reporter:In China, the prevalenceof smoking is very high, when we talk about NCD prevention this is the highpriorityfor prevention of NCD. What do you thinkwhen faced with this great challenge, what we should do in China?
Michael Merson:Certainly I agree with you that right nownon-communicable diseases are the highest priority. The media gives a lot ofattention to the viruses like avian flu, andTB.Of course these are problems, and we need to take them seriously. But by farthe greatest threat to the billions of people in Asia and the Chinesepopulation are the non-communicable diseases, particularly like stroke, diabetes,cancer, but also the mental health problems. These are great challenges.
It is interestingfor me that some of the countries in the west faced this problem a generationago, and learnt how to deal with the problems. Unfortunately, those lessons arenot being applied in Asia, or in China, to my great disappointment. It lookslike you are going to go through the same sad stories of many people dyingearly, many people getting sick early, and not having a long and happy life.
The main two riskfactors are smoking and diet. Withregardto diet, of course it is eating too much fat, andnot enough grains and fruit, and also far too much salt, which results inserious problems with blood pressure and stroke, which is a very big problem inChina.
About tobacco, Ithink there is no doubt that the greatest threat to the health of everyone inthe world is tobacco. Sometimes people ask me, what is the world’s greatest pandemic?And they think of AIDS, but for me, the world’s greatest pandemic is the use oftobacco. Look at 2030, there will almost 180 million deaths from tobacco, mostof them will be in middling income countries. Tobacco is a terrible veryserious risk factor for heart disease, and of course for respiratory disease,and for a lung cancer, which is the leading cause of cancer in men and women inChina. So I think that the risks are profound from tobacco, and theconsequences are great.
Now what to do?The experience in countries like Singapore or the United States is very muchthat you have to make some policy changes. There is a global framework, adoptedby WHO Convention on Tobacco Control. But it is very easy to sign a document,it is another thing to act on the document. In the United States, probably thebiggest effort has been on tax. To put the tax very high so the cigarettepacket will cost a lot of money. And if the cigarette cost a lot of money, fewerpeople will buy. And you know that we should focus our efforts on young people. Because tobacco is so addicting thatonce you are hooked, you are going to have a hard time unhooking. So we need tobe sure that we keep the price high, and educate our young people, from thetime they are five years old, right through the teenage years, about the risk ofsmoking particularly in China. Now I hear about other reasons that why peoplesmoke, like people have too much stress, women like to smoke so that they keeptheir weight down. I know the arguments, but the consequences are so greatlater in life that we need to make people realize that, and we need to givethem other ways to relieve their stress, for example, they can exercise, take abreak from work, and for women they can eat healthier, if they are worriedabout their weight.
But it is going torequire political will, it is going to require much more than a health system.We need the education system, the finance ministry, the trade industry, and aresponse not just in ministry but at all level, including the central level andthe provincial level. Because there are decisions made at all levels that havean important impact on smoking, everywhere, including in China.
Also in China ofcourse, we need to provide incentives for farmer who is growing tobacco to growsome other product. There has to be a decision made on provincial level toencourage them to grow something else that can make as much profit for them,because everybody wants to earn a good living, therefore you cannot just say tothe farmers stop growing tobacco. You need to give the farmers some otherincentives.
Reporter:And I also have another question. You talked aboutrisk factor, one is the tobacco, and another is the diet, and also physicalinactivity. And for tobacco, maybe you mentioned for policies and multi-sectorcooperations. For the diet, and also the physicalinactivity, what is the solution for this?
Michael Merson:: Again we need to make sound policies. With regard todiet, which is complicated because the food industry. They have done a lot ofresearch, they know what people like toeat. And that is of course they are expertise. But we need on our side toeducate particularly young people on the importance of eating healthy, to lookgood and also to have a long life. We maybe need to use popular celebrities topromote safe eating. We also need to put some policies in place that will helppeople eat. For example, what food do we use in the schools? We should only usehealthy food, no soda pop in the schools, not even near the schools. Becausein child they take many calories from eating carbonated soda and sugarbeverages.Also we can talk to the industry. We can ask the fast foodindustry to cook with healthy oil, to reduce their calories in their meals,particularly the meals for children. It will be better if they volunteer to dothis, if not, maybe we have to impulsecertain policies.
Also for salt, wecan think about how to make people to have less sodium chlorite.We can putspoons in the home, or we can replace the sodium chlorite partially with potassiumchlorite or magnesium chlorite. I know the taste is not quite the same, butmaybe if we give people at young age, they will start to develop that taste.
So it is going totake multi-sector approach, we need both to educate and make strong policy andmaybe we have to legislatetoget the success that we need. You know in New York city, you now have on themenu the calorie of every meal that you order in every restaurant in New Yorkcity. I don’t know, maybe that would work in Shanghai, maybe not. Butthe point is, it makes a lot of advocacyand make people more conscious of the problem.
Now about physicalactivity, when I first came to China thirty-five years ago, I went out on thestreet, I didn’t see any car, everybody in the riding a bicycle,everybody taking Tai- Chi. In the morning, the streets were full of peopledoing Tai- Chi. Now I go to street, I see BMW, I see Toyota, I see KIA,I don’t see bicycles verymuch, and I don’t see too much Tai- Chi. And I look on streets for fitnessfacility, I don’t see fitness facility. When you go to the United States, youcan find a fitness facility everywher, even in the work place. Many work placeshave fitness facilities. All businesses and schools should have adequatefacilities for people to take a break, to exercise and shower afterwards. Wealso need in our schools to have physical education programs, during school, orafter school, and we should make them compulsory, so that all young people are exercising.Every adult should exercise thirty minute every day, even just walking is fine.We say everybody, every adult should take eight thousand steps a day. It is awonderful goal to have. So I think it is possible. We need the public to demandthese changes, and maybe then a policy maker will take the need more seriously.
Again we have to getthe private sector to work with us, not to fight us. Because they have moremoney, they can do more advertising, and so they need to be our partner and seethat they don’t have to lose their profit, if they are also making peoplehealthy.
Reporter:I think when we talk about NCD prevention and control, weknow the upstream and population approach are very important. AndNCD is often chronic diseases. What can the healthy system to do about it?
Michael Merson:Unfortunately, most people reach the health systemafter they are sick, with non-communicable diseases. But I think that thehealth system first can play a role in prevention. When they are seeing a youngperson for vaccination, they can talk about healthy diet, healthy living, nosmoking, talk to the mother and father. When a mother comes and check up forpregnancy, look up for all opportunities to educate people about prevention ofchronic disease. The difficulty of course is that most of these diseases havelong incubation period, so people are not seeing the benefit quickly. But weknow that the health care worker is trusted. And that health care worker shouldsee as their routine responsibility to educate people.
In China, we know thatmost people with high blood pressure, but they don’t know they have it. And ifthey knew, they could reduce their salt, maybe take a diuretic and somethingstronger to treat their high blood pressure. So the first and foremost thehealth sector can help on prevention. And we know if you have a high risk andyou are a mid-aged adult, if your family have heart disease, you can takeAspirin once a day. Aspirin is very effective to prevent the heart attack inpeople with high risk disease. So for me not only the doctors, but healthsector needs to think more about prevention, it can be the nurse, or anyoneworking in the health care system. Now, if people become sick, with high bloodpressure, or stroke, or heart attack, or angina, or cancer, we should make surewe need to provide them with the best care, and to learn to help them managetheir disease, most people are successfully managed with chronic disease.People need education on how to live healthier, and how to keep their chronicdisease from getting worse.
Reporter:Our Forum will focus on Asia, for it is the hottesteconomic developing area in the world. And mental problem has become a highrisk for people in China and other places of Asia. It is the one of the highrisk factor that WHO is focus on. How do you see the mental health and NCDprevention?
Michael Merson:You make an important point that the Asia veryquickly grew economic and China the second biggest economy, maybe quickly thebiggest. And I think maybe this happened so quickly that people forgot thesocial dimension, and they are now feeling economic invincibility, thatanything can be changed by having a strong economy.
Well, one of theprices China and Asia is paying for the rapid economy change is the rapidsocial change, more urbanization, more industrialization, more globalization,aging population, all of these things have come about as result of economicdevelopment, and they have come about very quickly, and it’s because they comeabout very quickly, I think that the policy makers have been too slow to act,but they cannot wait any longer. The longer they wait, the greater theconsequence will be.
Now alcohol is a risk.A little bit of alcohol probably is protective for heart disease, but we shouldnot exaggerate that. People who are drinking too much of course can have aliver disease, fatty liver in particular. But also they can have a drivingaccident. Alcohol is in moderation acceptable, but in access can be harmful. Sowe also care need to educate the public, and also have very strict rules. Forexample, I know in China, you have strong rules on driving, it is very good,and it must be enforced. I have noticed that my last few visits to China, there’sless Mao-tai, less wild drinking in dinner. I think it is the healthy goodthing to do, I think the government is doing the right thingto enforce the drinking in moderation.
The problem aboutalcohol reflects the stress people have. So how else to relieve their stress?So I think we need to have policies into the work place. For example, peoplecan take break in the day, people can exercise more, be sure to use theirvacation. If we create a norm where some break to release the stress is doneeverywhere, that hopefully everybody will feel comfortable have such break.
China has acompetition culture. The competition starts at a very young age. I see thestudents who come to the U.S. that they have tried so hard compete the exam andit’s something that they start very early in life. I think the Chinesegovernment needs to think about that. Are there other ways for young people todemonstrate their excellence? Are there other ways for young people to achievetheir goals without so much stress in the youth? Because I think that earlyyouth stress doesn’t go away. It is something grows into adulthood and affectstheir well-being.
Reporter:I think your comment and the point you made is veryhelpful. Thank you very much.
Michael Merson:Thank you. This is a very great country, and youshould learn the lesson from the west that we went through, and keep yourpopulation from getting sick with non-communicable diseases.
Michael Merson Introduction:
Director, DukeGlobal Health Institute; Vice Chancellor, Duke-National University of SingaporeVice Provost and Vice President, Office of Global Strategy and Programs;Wolfgang Joklik Professor of Global Health, Duke University.
