Discussion

Despite limited mortality data, it is evident that China’s overall fatal injury rate has decreased during this reform period. Sufficient rigorous studies using combinations of data sources provide acceptable evidence of this downward trend. This trend is despite rapid motorisation and many other new hazards introduced by economic development such as work deaths in the construction industry and new technologies such as electric bicycle rider fatalities.31 32 Relatively few studies have provided evidence of targeted interventions contributing to these reductions.

During a period of rapid and complex change, including improved access to healthcare, epidemiological transition, reduced poverty, higher employment, increased life-expectancy and increased social welfare, injury has not declined as a proportion of all deaths in China in any age group, but has significantly increased proportionately in the 0–4 year age group and slightly in some other age groups.

The many social and developmental changes had different impacts on fatal injury rates and patterns for the specific major causes, with complex patterns of change including initial and possibly ongoing RTF rate increases and substantial decreases in suicide and drowning rates over the study period.

As in other countries, rapid motorisation in China led to a dramatic increase in RTFs.33 34 The shift from a centrally planned economy to a socialist market economy enabled rapid motorisation contributing to economic growth by improving market access and to social welfare by increasing flexibility and mobility.1

Motorisation proceeded rapidly in China from the 1990s with the main means of transportation changing from animal carts and bicycles to motor vehicles.35 Four-wheel motor vehicles increased from 60 000 in 1951 to almost a million in 1975 and 10 million in 1987. It then rose to 50 million in 1999, with an additional 30 million motorcycles.36

By 2012, China was the largest producer of vehicles and had the largest vehicle market growth world-wide.37 Ownership of motorised vehicles almost quadrupled in 10 years, from 42.2 million in 1997 to 159.7 million in 2007.38 These developments have resulted in China’s motor vehicle fleet being relatively new and potentially equipped with modern safety features.

An estimated 120 million electric bikes (E-bikes) were on the road in China in 2011, having become a dominant transportation means, with further increase expected.39 While many E-bikes resemble small motorcycles and often travel in motor-vehicle lanes, they are not regulated as motor vehicles. Increases in E-biker fatalities as high as fivefold were reported for the period 2004–2008.40

Described as of strategic importance to economic development, China completed nearly 45 000 km of high-grade toll expressways from 1990 to 2006 (from none in 1985) coinciding with rapid motorisation. Development of other road classes also continued during this period.41 Pedestrian safety measures including median barriers and overpasses and underpasses also proliferated.

In high-income countries, RTF rates peaked about 20 years after rapid motorisation commenced, post-World War II.33 Major reductions followed in high-income countries (HIC) as targeted road safety interventions such as seat belt use and traffic law-enforcement were progressively implemented.33 While there may be a recent downturn in RTF in China, the markedly different data from police and death registrations make confirmation difficult.

Although national seat-belt wearing legislation became effective in China in 2004 and associated provincial and city regulations followed, low wearing rates have been consistently reported.42–44 Since 2004, the Chinese government has adopted increasingly stricter drunk-driving policies and laws, with criminalisation from May 2011.45

Few evaluations of road safety interventions have been reported. A time series evaluation of the 2011 drunk-driving legislation (2009–2012) in Quangzhou found a corresponding significant reduction in road traffic injuries.45

Another study evaluated a 5-year drink-driving and speeding intervention in two Chinese cities (Suzhou and Dalian) from 2010 to 2014.46 The targeted interventions included social media campaigns, advocacy for legislative change and law enforcement training. Statistically significant reductions were found for both drink-driving and speeding in both cities. Although, there were no control cities and these interventions coincided with the 2011 drunk-driving legislation, the results suggest beneficial effects of the co-ordinated interventions.46

A 2010 study, citing Traffic Administration Bureau data, reported that widely installed speed radar and cameras in most cities and on express highways had proved to be effective in reducing speeding, evidenced by increases in law enforcement incidents for speeding from 12.8 million incidents in 2004 to 15.3 million in 2005 and total fines for speeding from $75.6 million (averaging $5.9 per incident) in 2004 to $155.2 million (averaging $10.1 per incident) in 2005.38

Favourable to road safety are new road networks, pedestrian treatments (barriers and over/underpasses), traffic management systems and the relatively new vehicle fleet, theoretically including modern safety features, though the extent of possible descheduling of safety features required by other markets is unknown.

While the history of legislation and enforcement for road safety is poorly documented, this has been slow, not keeping pace with motorisation and the lack of ‘proper enforcement’ has been long-recognised.47 Gaps persist in China’s road safety laws compared with world best practice.48 For example, motorcycle helmet laws are not comprehensive and there is no national child restraint law. A gap in the implementation of associated best practice interventions follows the legislative limitations.49

Dramatic reductions in China’s suicide rate with improved economic and social welfare conditions followed the high rates associated with economic reform and related social change and increase in social stressors in the 1980s.

After the Chinese government first released national suicide data in 1989, very high rates were found for the period 1990–1994 (28.72/100 000) particularly for young rural women (30% of rural female deaths aged 15–29 years) and the elderly, especially men.9 Although there are no earlier data for comparison, it has been postulated that high rates were due to social stresses occurring as the economic reforms took effect, including: economic losses for individuals and families; increasing rates of marital infidelity and divorce; rapidly increasing healthcare costs; weakening of family ties; large rural migration to urban areas for work; dissatisfaction at the increasing economic and social gap between the rich and poor and some of these changes accelerated during the 1990s.9

Different characteristics of suicide rates in China (very high rates and higher rates in females than males) compared with other countries in the 1990-1994 period may indicate unique characteristics of the Chinese environment. The rural suicide rate in this period revealed a three-fold difference between rural and urban populations.9 In addition to social factors, convenient access to lethal means of suicide was clearly important. In a largely rural sample of suicides, 62% resulted from agricultural chemicals or rat poison in 1998–2000.29

The Chinese Government ordered production of some highly lethal pesticides to stop in 2002.50 In 2005, the WHO launched a global initiative to address pesticide suicides.51 By 2008, China, Japan and Sri Lanka had introduced legislation to regulate the production, importation, transportation, storage and sale of pesticides.52 However, some of these targeted interventions appear to have been introduced after the dramatic decrease in the overall suicide rate from 1987/1988 to 2005/2006 (table 1).

The proportion of all suicides due to pesticide poisoning continued to decline from 2006 to 2013 from 55% to 49%.53 Following the progressive control of access to pesticides, improvements in medical services and transport may also have contributed to these reductions in recent years.

By 2002–2006, China’s suicide rate was significantly lower,16 particularly among young rural women and the elderly, and based on 2013 and 2015 estimates,21 26 the downward trend continued, except for rural women in the older age groups.27 The availability of greater access to affordable healthcare may have contributed to the overall suicide reduction among the elderly with healthcare costs no longer burdening the family to the extent following the initial period of economic reform. However, other social changes may have become risk factors particularly for rural groups such as social isolation, insufficient family support, loss of spouse, or debilitating or terminal illness.27

It is argued by Phillips et al that changes in suicide rates are capable of being explained by ‘the historical and dominant view in China of suicide as a social problem, related to social stressors and not primarily a mental health problem’.9

Increased life choices (agency) for younger rural women escaping extreme poverty or unbearable family environments may have affected the suicide rate, with many women gaining greater life experience, independent income and potentially less harsh conditions as migrant workers, with less direct child care responsibility due to grandparents’ increased child-rearing role, and fewer children under the one-child policy (though less restrictive in rural populations). This policy was applied most strictly to urban residents and government employees. A second child was generally allowed in rural areas and a third in some ethnic minorities and remote underdeveloped areas.13 While selective abortion or neglect and abandonment of female foetuses or infants appears to have occurred in China resulting in excess young men,54 the one-child policy effects may also have enhanced the perceived value of girls and women in the family and society.55

Improvements in healthcare, enhanced education levels, increasing public awareness of suicide and specifically urbanisation and effective control of pesticides and rodenticides13 likely contributed to the overall suicide rate reduction.

Some of the same changes, particularly economic reform, urbanisation, universal education and the one-child policy (affording responsible child care) may have influenced reductions in the drowning rate since child drowning is strongly associated with poverty, particularly with regard to parents’ educational level and number of children in the family.56

The reduction in drowning frequency, particularly in the 5–14 age group (table 5), and rate reductions (table 1) are difficult to explain by any targeted intervention since little evidence of interventions is available. A 2015 review of legislative coverage for child injury prevention in China reported that no law covered interventions to prevent child drowning deaths. There is no national programme to teach children to swim.57 Anecdotally few Chinese people can swim, though no published reports of swimming ability were identified. Hyder et al reported: a dearth of data on incidence rates and risk factors; absence of public health interventions; lack of research on intervention effectiveness and cost-effectiveness; and paucity of national drowning prevention programmes in low-income and middle-income countries including China.58

Much of the fatal drowning rate reduction may be due to economic and structural development. Urbanisation and the provision of reticulated water reduce exposure to the risk of drowning both during daily activities, such as collecting household water, bathing and washing clothes, and where child supervision is poor. Indicative China National Health Services Survey data for 1993 and 2003 show consistently high urban household access to safe drinking water (97.15% of households in 1993; 99.19% in 2003) and rural access improving from 52.49% in 1993 to 80.24% in 2003.3 Reduced family size due to the implementation of the one-child policy may have resulted in better child supervision by parents and caregivers.

A historical study of fatal drowning reductions in Victoria Australia over more than a century found that development including urbanisation and built-environment changes encompassing reticulated water, bridge construction and filling-in quarries and water holes were associated with dramatic reductions in the drowning rate. It also found that these changes preceded targeted drowning interventions.59

There are multiple limitations to this study. Mortality data for China are limited by incomplete population coverage and potentially non-representative sampling estimates both for vital registration and data surveillance points, under-reporting and misclassification, uncertain population data, including urban/rural population distribution and representation (eg, migrant workers), different methods used for scaling data to national estimates and changes over time, including improvements in coverage and quality.

Additional limitations apply to injury data by specific cause, including large discrepancies between vital registration and police estimates for RTF. There is no specific category for deaths involving electric bicycles despite their increasing numbers and crash risk. Apart from isolated studies, there is little information available on where and how drowning occurs in China, including body of water and activity, such as recreation, domestic, occupational or water transport.

It is possible that the search methods employed overlooked large scale targeted interventions or effective legislative changes which could explain reductions or stabilisation of injury rates or patterns.

Many of the large-scale or macro reforms and social changes in China have increased opportunities for individual agency or microlevel social change. Life choices have become possible due to decreased poverty, smaller families, health insurance, social mobility, migrant worker opportunities, affordable transport and mobility choices. In terms of the duality of structure, our findings suggest an increase in the roles of agency and microlevel social change over the study period. Nevertheless, macrolevel development and social change potentially explain much of China’s improvement in overall fatal injury rates, including drowning and suicide reductions, and RTF and fatal fall increases. Few large-scale targeted interventions were found to explain rate reductions and changing patterns. As supported by other authors, injury prevention efforts in China are fragmented and lack adequate research funding and many effective interventions are yet to be implemented.60 61

While data limitations persist, potentially retarding progress, sufficient information now likely exists, or could be developed with greater specificity in existing data, to inform research and further targeted interventions, based on proven countermeasures. To this end, China should invest in enhanced data and research to fill information gaps and implementation and evaluation research to drive further injury reductions. External drivers such as the Sustainable Development Goals may support action.62 These conditions now provide realistic opportunities for accelerated progress in reducing China’s injury burden.