In terms of projected growth and demography, China and India now confront very different scenarios. With a median age of 33, China's population is edging toward middle age, while India, with a median age of just 25, is still relatively youthful. The ratio of workers to dependents in China, Bloom and Canning observe, will likely peak at 2.6 in 2010, then decline, leaving ever smaller numbers of workers born of the country's one-child policy to support a vast aging population. In India, meanwhile, the demographic transformation will be less sharp but longer lived; the ratio of workers to dependents will peak at 2.2, but not until 2035, suggesting that the potential economic gains from India's demographic dividend are still to come (see chart, above). This suggests a tortoise and hare scenario: China, having sped ahead, will slow down, and India will enjoy some catch-up in terms of income per capita as its demographic transition matures.

But both countries must rise to meet monumental challenges. China is now confronting what has become known as the "one-two-four problem"--that is, one child caring for two parents as well as four grandparents. This harsh legacy of the country's one-child policy has profound implications for health and well-being in China as the population ages. It also promises to reweave China's social fabric and may place huge strains on the economy.

Particularly in rural areas, millions of elderly could saddle the country with what Nicholas Eberstadt, a political economist on the Visiting Committee at HSPH, calls a "slow-motion humanitarian tragedy, already under way." Eberstadt predicts a dire existence for this group, citing their lack of accumulated capital, their inadequate education, and the absence of a state-funded pension system to provide for them. "A third of Chinese women retiring in two decades will have no sons," he says, adding that most--despite being potentially ill and frail--will have to support themselves through farm labor.

India, despite recent progress, must grapple with staggering health issues. HIV infections alone are expected to quadruple in the next four years to 20 million cases, up from 5.7 million now, according to UNAIDS. Yet in 2005, the World Health Organization reports, India had less than one hospital bed, and one doctor, for every 1,000 residents. In the countryside, one doctor may be responsible for as many as 200,000 people.

A further problem is the emergence of chronic diseases, such as cancer, lung disease, heart disease, and diabetes, linked to rising rates of smoking and obesity and, ironically, longer lifespans and higher incomes. Both China and India face the problem of providing health care for people with these chronic diseases while still tackling a widespread infectious disease burden. In both countries, the public health system is failing to meet demand.

Although both countries now offer world-class health services to the minority who can pay, Canning is wary of this emerging trend in developing countries. "I don't have any problem with people paying for high-level care in developing countries through the private sector," Canning says. "But to really improve population health in the long run, you get more cost-effective results from inexpensive public health interventions directed towards the poor. By that I mean clean water, de-worming, oral rehydration for diarrheal diseases, vaccinations, and disease prevention. A major challenge in both countries is going to be how to treat chronic diseases in an aging population in what are still relatively poor countries."

Looking forward, China and India will have to address the fundamental demographic shifts occurring within each country, as well as swiftly widening socioeconomic disparities that could prove politically destabilizing. Bloom notes that while China has pursued a policy of mass education, India's educational focus has centered more on the middle class and elite. China is increasingly divided between affluence in the cities and poverty in the countryside; similarly, India's northern states are desperately poor, while the South claims the lion's share of educated, upwardly mobile people. Bloom and Canning have begun to investigate these regional differences with their colleagues.

"India and China are so big that the populations of some of their states and provinces, respectively, are larger than the population of many countries," Canning says. "And there are big differences between regions that potentially make treating each country as a single unit misleading."

Lessons learned from China and India have great value elsewhere, the HSPH researchers agree. China has made remarkable strides in alleviating poverty, Bloom says, adding that "aid agencies, donor countries, and developing countries will benefit from a greater understanding of China's experience." And India has nurtured an information technology sector with an increasingly global reach. The prospects for India look good for the next 30 years as its demographic dividend matures and it follows in China's footsteps. China's prospects are less clear. A rapidly aging population may lead to a reduced rate of economic growth and put new pressures on health and social security systems that are as yet unprepared for the task. Although India, too, will inevitably face similar pressures, its day of reckoning with population aging is less imminent.

Charlie Schmidt writes about health, science, and the environment for the Washington Post, Environmental Health Perspectives, and National Geographic Online.

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