Eradication of Schistosomiasis in Guangxi, China. Part 1: Setting, Strategies, Operations, and Outcomes, 1953-92

Article excerpt

Introduction

This article analyses policies, strategies, activities and outcomes of the programme leading to schistosomiasis eradication in Guangxi, a large autonomous region in south-west China. In many areas of China schistosomiasis has been eradicated (1), and reviews of the general features and substantial success of schistosomiasis control in the country have appeared (1-8). However, a detailed analysis of a successful regional programme and its subsequent maintenance has not been reported outside of the country. This article, and two others (9, 10), close the gap in our knowledge of a public health success of great importance -- schistosomiasis eradication in a large and generally poor region of the country which had the heaviest burden of schistosomiasis in the world (see Fig. 1).

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This, the first article in the series, describes the setting and analyses activities and outcomes over a period of 40 years; the second analyses the political economy, management, and costs of the programme; and the third evaluates prospects, problems, and strategies for maintenance in the future, with a description of the three worst-affected counties. Our work led to community feedback in 1995 and 1996, resulting in several changes in current strategies, which are now kept under continuous review (10-12).

The experience accumulated during Guangxi's eradication programme, and the approach that led to its eventual success on such a large scale, despite limited resources and very low per capita income, are object lessons for other programmes attempting to control endemic schistosomiasis. This information will also benefit future public health workers in Guangxi: oncomelanid snail hosts for schistosomiasis persist in seven other Chinese provinces, and perhaps also (undetected) in isolated uninhabited areas of Guangxi itself.

Setting

Guangxi Zhuang Autonomous Region is the eleventh most populous (population, 44 million in 1994) and ninth largest (236 600[km.sup.2]) of the 22 provinces, five autonomous regions, and four national municipalities in China (13, 14). The region lies in China's subtropical south (lat. 20 [degrees] 54' N to 26 [degrees] 23' N) and borders four provinces: Hunan (north-east), Guizhou (north-west), Guangdong (east) and Yunan (west). The South China Sea and Viet Nam form the southern border (see Fig. 1).

Along with Guizhou and Yunan, Guangxi forms part of south-west China, an area of widespread poverty, numerous ethnic minorities, difficult transport, poor communication, mountains, and large rivers. The national government singled out this area for priority in current development efforts: many improvements are emerging, including a rail link opened in March 1997 between the capitals of Guangxi and Yunan, connecting the south-west to the rest of China and to the growing port at Beihai.

Of the population of Guangxi, 39% is made up of 12 minority ethnic groups, including the Zhuang (34%), the largest and best integrated minority in China, and the mountain-dwelling Hmong, Yao, Dong, Maonan, Mulao, Jing and Yi groups. The remaining 61% are Han, China's main ethnic group (15). Before 1949 the average birth rate in Guangxi was 50-60 per 1000 per year. Between 1949 and 1983 the population grew rapidly from 18.42 million to 37.33 million. Family planning then slowed the growth rate, which is now below 2.5% per year. In 1994 the population reached 44.38 million, a density of 188 persons per [km.sup.2].

Most of the land in Guangxi lies >800m above sea level (35%); tableland and terraced areas cover 8%, flatland 14%, and the rivers are so large and numerous that they cover 3%. The 69 rivers and tributaries stretch 34000km, with a catchment area [is greater than] 1000[km.sup.2]. The rivers divide into three systems: those forming the Pearl (Zhu Jiang) entering the sea near Hong Kong Special Administrative Region, 30 others that are tributaries of the Yangtze (Chang Jiang), and several that flow directly into the South China Sea. …