Chinese Medical Journal 2014;127(4):777-781:10.3760/cma.j.issn.0366-6999.20131054
Trends in the major causes of death in China, 1982–2010

Lian Zuping, Xie Youke, Lu Yunxin, Huang Dingping and Shi Huanzhong

Keywords
causes of death; mortality; cancer
Abstract
Since the introduction of a series of reform and open policies in its economic system in 1976, China has been in a boom period of social and economic fields. Rapid development in economy and the consequent improvement in living conditions, nutrition, and health care help to decrease infant mortality and deaths from infectious diseases, and notably effected the patterns of mortality. For example, respiratory diseases, acute infectious diseases, and tuberculosis were the leading causes of death in 1957, while diseases of heart, cerebrovascular disease, and malignant neoplasm were thefifth, sixth, and seventh leading causes of death.1Up to 1975, cerebrovascular diseases, diseases of heart, and malignant neoplasm were the top three death causes, followed by respiratory diseases, digestive diseases, and pulmonary tuberculosis.1A prospective cohort study involving a representative sample of the adult Chinese population was conducted in 2005, which revealed that the five leading causes of death were malignant neoplasm, diseases of heart, cerebrovascular disease, accidents, and infectious diseases among men and diseases of heart, cerebrovascular disease, malignant neoplasm, pneumonia and influenza, and infectious diseases among women.2
In this study, we analyzed the temporal trends in mortality in China during 1982–2010 based on the data from all 29 issues ofChina Health Statistics Yearbooks, published by the Ministry of Health annually since 1983. The data of major causes of death in the year 2010 appeared in the latest issue ofChina Health Statistics Yearbook 2011.3We also examined the leading causes of death in age-specific death rates and the spectrum of the topmost death cause, malignant neoplasm, in 2010.
Data collection
Resource of data
The Ministry of Health obtains nationwide estimated information about mortality through two systems, the Ministry of Health-Vital Registration system and the Disease Surveillance Points (DSP) system. The sample sites in the Ministry of Health-Vital Registration system are not representative because they are focused almost entirely on the eastern region and the numbers in these sites vary from year to year. In contrast, the sites in the DSP system remain constant over time and are representative of the national population (satisfactory). Therefore,statistics on causes of death from the DSP have been the principal data source for estimating theburden of disease in China. A detailed description of the DSP system has been provided elsewhere by Yang et al.4Several studies have verified that the ascertainment of cause of death is reasonably reliable by this system.5-7In each DSP site, there is at least one township hospital, and the “Department of Prevention and Health” in these hospitals is responsible for vital registration according to the guidelines for surveillance.8In urban areas, almost half of all deaths occur in hospitals, and there are standard protocols for death registration. For people who die at home, the attending physician issues a medical certificate of cause of death, in compliance with the registration protocol. In rural areas, for deaths occurring in the township hospital, DSP staff collects the death certificate from the hospital, completed by the physician who attended the death. For deaths occurring at home, a village health worker reports the death to the Department of Prevention and Health at the township hospital. A staff member from that department visits the household and completes a death certificate based on a description of symptoms from family members and available documents from recent contact with health services. Annual reports of deaths by causes, age, and sex that appear in theChina Health Statistics Yearbookshave been published by the Ministry of Health since 1983. The present study was performed based on the mortality data obtained from all 29 issues ofChina Health Statistics Yearbooks.
Statistical analysis
All data were obtained from the 29 issues ofChina Health Statistics Yearbooks. Authors did not make any modification or statistical analysis in this study.
Ethical review committee approval
No ethical review committee approval was obtained because the estimation was based on published or otherwise publicly available information.
Data analysis
Changeof main death cause in urban and rural
population
Causes of population deathhave changed in the past three decades. The main deaths during 1982–2010 included malignant neoplasm, cerebrovascular diseases, diseases of heart, respiratory diseases, injury and poisoning, endocrine and metabolic diseases, digestive diseases, genitourinary diseases, nervous diseases, mental disorders, perinatal diseases, tuberculosis, and non-tuberculosis infectious diseases. Endocrine and metabolic diseases became one of the top 10 deaths since 1987 in urban residents and then increased steadily. This also happened in rural population since 1997. Tuberculosis was excluded from the top 10 death causes in urban residents since 1992 and in rural residents since 2005. Death due to mental disorders became a problem since 1992 in urban residents and 13 years later in rural residents. A trend similar to mental disorders was found for nervous diseases. Between 1982 and 2010, malignant neoplasm, cerebrovascular diseases, diseases of heart, respiratory diseases, and injury and poisoning were the five leading causes of death in both urban and rural residents (Figure 1). These leading causes always accounted for >85% of all deaths each year during the past 29 years.
Change of main death cause in urban population
In urban population, cerebrovascular diseases, the first leading cause in 1982, were replaced by diseases of heart from 1983 to 1986 (Figure 1A). Death rates due to diseases of heart dropped more rapidly than that due to both malignant neoplasm and cerebrovascular diseases during 1987–2003; since 2004, death rate due to diseases of heart increased gradually, and the trend was similar to that due to cerebrovascular diseases – both were lower than death due to malignant neoplasm. For urban people, death rates due to malignancies became the top cause from 1987, increased to high level in 1999, and maintained the high level until 2010. Respiratory diseases were the fourth leading cause in the last 29 years, but mortality due to these has increased as highly as that of diseases of heart since 1987. Injury and poisoning were always the fifth leading cause of death for urban residents during the past 29 years. The overall trend increased for the main chronic diseases (malignant neoplasm, cerebrovascular diseases, diseases of heart, and respiratory diseases) from 405.8 per 100 000 in 1982 to 485.6 per 100 000 in urban population.
Change of main death cause in rural population
Similar to the situation in urban population, mortality due to diseases of heart was in the first place in rural population from 1982 to 1986, was reduced by half after 1987, and showed a slight increase during the past 8 years (Figure 1B). During the same period, death due to respiratory diseases was listed in the fourth place from 1982 to 1986 and increased by twofold in 1987. It became the topmost death cause and lasted for 15 years, but decreased dramatically in the recent 9 years, except for 2005. Mortality due to malignant neoplasm or cerebrovascular diseases was similar during the past 29 years, and both were much lower than those in urban residents before 2004. Following a small drop in 2002, they increased gradually since 2003 and became the first and second death causes with similar levels in 2010. The increased trend was observed for main chronic diseases from 443.1 per 100 000 in 1982 to 489.4 per 100 000 in 2010 in rural China.
Change of main death cause in male and female population
Data concerning comparisons of mortality trends between male and female population are available fromChina Health Statistics Yearbookssince 1988. The comparisons of proportional trends of the top five causes are illustrated in Figure 2. Mortality due to malignant neoplasm was listed in the first place in urban male population (Figure 2A) and was higher than that in urban female population during the past 23 years (Figure 2B). On the other hand, death rate due to cerebrovascular diseases was always in the first place in urban female population. Its pattern of mortality was similar in male urban residents. Death rate due to malignancies increased gradually during 1988–2010, exceeded that of respiratory diseases in 2001, and constantly became the top one in rural male population (Figure 2C). It was higher than that of malignancies in each year in rural female population (Figure 2D). The changed trend of mortality was also similar in male and female rural residents.
Analysis of the 10 major deaths of malignant neoplasm
in 2010
The relative proportion of the 10 major deaths in Chinese urban cities in 2010 is shown in Figure 3A. Malignant neoplasm became the topmost cause of population death in urban cities and accounted for almost one-third of the total deaths. As far as malignant neoplasm was concerned, the top 10 cancer types included lung cancer (28.2%), liver cancer (22.3%), gastric cancer (21.6%), colorectal cancer (11.8%), esophageal cancer (6.6%), breast cancer (3.1%), leukemia (2.9%), bladder cancer (1.2%), cervical cancer (1.1%), and nasopharyngeal cancer (1.0%) (Figure 3A). Malignant neoplasm also became an important death cause, but was the second main one (24.7%) in rural area in 2010. Among the mortality of malignant neoplasm, the top 10 cancer types were lung cancer (27.2%), liver cancer (22.3%), gastric cancer (18.7%), esophageal cancer (16.3%), colorectal cancer (6.7%), leukemia (2.8%), breast cancer (2.4%), nasopharyngeal cancer (1.7%), cervical cancer (1.0%), and bladder cancer (0.9%, Figure 3B). Lung cancer, which was the third cancer death in 1990–1992 and fourth one in 1973–1975, became the number one cancer death in 2004–2005. This change was accompanied by an increased development of China economy, suggesting some relation existed between them.
Analysis of mortality relative to age
The trend of mortality among different age groups in urban (Figure 4A) and rural (Figure 4B) population in 2010 was somehow similar. The leading deaths were injury and poisoning among persons aged <40 years, not including neonates with age <1 year. In 2010, more than 20% of the Chinese people aged 30–74 years died due to malignant tumors. Excluding mortality of neonates and postneonatal infants with age ≤4 years, death rates due to diseases of heart, cerebrovascular diseases, and respiratory diseases all increased when the age increased. On the contrary, death due to infectious diseases and nervous diseases decreasedas the age increased.
Discussion
We found that more than 85% deaths during the past 29 years in China were attributable to the following five diseases: malignant neoplasm, cerebrovascular diseases, diseases of heart, respiratory diseases, and injury and poisoning. The other main death included endocrine and metabolic diseases, digestive diseases, genitourinary diseases, nervous diseases, mental disorders, perinatal diseases, tuberculosis, non-tuberculosis infectious diseases, and so on. The data were consistent with a recent research from World Bank. The researchers believed that chronic, non-communicable diseases were the greatest health threat for Chinese and contribute to more than 80% of the country’s 10.3 million annual deaths and nearly 70% of its total disease burden.9
Some deaths due to malignant neoplasm, cerebrovascular diseases, diseases of heart, respiratory diseases, and so on were thought to be associated with tobacco. The most disappointing findings in this study might be the substantial increase in tobacco-related mortality during the past 29 years. In 2010, 28.1% of adults in China (52.9% of men and 2.4% of women) were estimated to be current smokers. In other words, 301 million people were supposed to be current smokers in China, making China the largest consumer of tobacco in the world.10Moreover, it is estimated that 72% of non-smokers, including 180 million children, are exposed to second-hand smoke.11Smoking cessation rates in China are very low – only 11% of smokers successfully stop smoking and 82% of smokers had never even thought to quit.11It was estimated that tobacco smoking was responsible for about 673 000 premature deaths in Chinese adults in 2005, and the number of deaths attributed to smoking was much greater in men than in women.12In addition, lung cancer was the leading death cause attributed to smoking in men. And chronic obstructive pulmonary disease was the leading death cause in women.12Lung cancer became the most common cancer during the past few years in China.
Cerebrovascular diseases were the second top death cause in China. While 153 million adults suffered from hypertension, only 24% of them were aware of their conditionand 19% of them were receiving antihypertensive drugs.13What is more, only 24% of the treated patients of blood hypertension attained adequate control of blood pressure. The low control rate made it a high risk for diseases of heart and cerebrovascular disease mortality associated with hypertension.13It was estimated that 2.11 million cardiovascular deaths were attributable to hypertension in China, and 1.15 million of them were premature deaths.14Among deaths due to cardiovascular diseases, 0.22 million were due to prehypertension, and 0.12 million of them were premature deaths.14Of all hypertension-related deaths, more than 80% were due to cerebrovascular diseases.14In addition, the aging era is coming in China, and the aged population exceeds 12%. Aging facilitates the occurrence of cerebrovascular diseases and increases mortality in these kinds of patients.
Changes in transport modes, housing, and lifestyles have contributed to new patterns of accidents and injuries in the past three decades. Rapid urbanization particularly drove these trends in many forms, such as traffic-related and occupational accidents and injuries.15Traffic-related injuries, suicide, drowning, and falls account for 79% of all injury deaths. Among these deaths, rural injury mortality was double that in urban cities, and injury mortality in male was double that in female.16Our results showed that injury and poisoning were always the fifth leading cause of death for both urban and rural residents during the past 29 years, accounting for 5%–10% of all deaths in China.
In the past 30 years, the largest human rural-to-urban migration emerged in China. During this process, urban population increased from 191 million in 1980 to 622 million in 2009.17Another 200 million rural-to-urban migrants are anticipated during the next 10 years.18In 2011, the proportion of China’s urban population reached 51% for the first time, and basic urbanization in China was seen.19Urbanization has led to changesin patterns of human activity, diet, and social structures, which implicated non-communicable chronic diseases, for example, endocrine and metabolic diseases, cardiovascular disease, cancer, and neuropsychiatry disorders.20In view of the change in diet and physical activity, population with adult hypertension and childhood overweight and obesity in urban areas was roughly twofold than in rural areas.13,20Previous studies reported that Chinese urbanization-associated changes in diet and physical activity were accompanied by a rise in cancer, and cancer mortality between rural and urban areas was quite different.21Urbanization also contributes mental disorders, which are a leading cause of disease burden in China, with about 17% of the Chinese adults estimated to be with one or more mental disorders.22It was said that 173 million adults had a mental disorder in China and 158 million of these patients have never received any kind of professional help for their condition.22In this study, we found that death due to mental disorders had emerged in the list of leading 10 death causes since 1992 in urban and since 2005 in rural residents.
Environmental health fear is overwhelming in most of the Chinese. Although economic development from industrialization improved health and quality of life indicators, it has resulted in environmental disasters and pollution in many districts. All of these problems are having severe effects on physical health as well as mental health. Environmental risk factors, especially air and water pollution, are a major source of morbidity and mortality in the country.23
The most spectacular advances in survival have been in childhood. The notable decline in mortality happenedat the ages of 1–10, with annual decline for both males and females and for both time periods ranging from 4 to 9%.24In addition, tuberculosis and non-tuberculosis infectious diseases represent a small proportion of deaths, but can not be ignored.
Although death rates due to communicable diseases and maternal as well as perinatal conditions dropped rapidly, mortality due to non-communicable chronic diseases, including malignancies, cerebrovascular diseases, diseases of heart, respiratory diseases, and endocrine and metabolic diseases, increased during 1982–2010. Most of these diseases are caused by heavy smoking and aging population, escalating urbanization, worried mental health, and increased environmental risks. The Chinese government needs to take urgent action to solve these factors that threaten the health of the population, not only in health care and public health systems, but also in economic policy and legal execution.
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(Received April 18, 2013)
Edited by Sun Jing

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Figure 1. Trends in mortality of the five leading causes of death (per 100 000) from 1982 to 2010 in urban (A) and rural population (B).

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Figure 2. Comparisons of trends in proportional contribution of the five leading causes of deaths in urban male (A), urban female (B), rural male (C), and rural female (D) population in China during 1982–2010.

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Figure 3. The 10 leading causes of death (per 100 000) and the cancer spectrums (per 100 000) in Chinese urban (A) and rural population (B) in 2010.

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Figure 4. Proportional contribution of the 10 leading causes of death in different age groups in Chinese urban (A) and rural population (B) in 2010.