China has a glasses problem. You might not quite see it because many
people wear contacts or get LASIK. But many Chinese are nearsighted.
The People’s Republic of China has the most myopic people in
the world - with some 600-700 million afflicted.
That number is predicted to go to over 950 million in the near future.
Of course, China has a big population. But Chinese rates of nearsightedness
are also higher than that in the West - hovering at some 50% across the whole population.
This is a pan-Asia problem. But the Chinese people are getting hit particularly hard
and it is not because they are genetically predisposed to it.
So for this video, I want to take a look at what is
going on and what the country is doing about it.
## The Problem
Nearsightedness - or myopia, I will use the terms interchangeably - is a refractive error in
the eye. The eyeball gets too long and this shape keeps light from correctly focusing on the retina.
Higher myopia can lead to other issues like retinal detachment,
glaucoma and cataracts. You can fix the seeing part of your nearsightedness by wearing glasses,
but high myopia still raises the risks of the other bad stuff regardless.
The myopia trend is especially bad amongst the youths.
A study of refractive errors of schoolchildren in Tianjin
found that nearsightedness progression begins at age 6 or 7 - the time the child is in
first grade. Progression accelerates throughout elementary school and reaches 90% by 12 years old.
In certain urban areas, 80% or higher of children have some form of the disease.
10-20% have it in a more severe form. Rural areas are known to do better, with rates half that.
Researchers regularly refer to the nearsightedness issue as a growing epidemic. It is an especially
concerning development considering the fact that myopia is naturally irreversible.
## Causes
Myopia has a variety of genetic and environmental causes. Studies in China found that some of the
notable factors associated with myopia in Chinese youths include having parents with myopia,
spending time indoors, spending excessive time with electronics, and intensive studying time.
That last one presents some significant issues when it comes to early education policy making.
Chinese students deal with intense educational pressure,
lots of homework, remedial classes, and long class hours.
One 2-year study conducted in 2015 found that 50% of fourth grade children spend over 30
minutes on their math homework. About 44% of children attend after-school math and Chinese
classes. Over 60% of them sleep less than 8 hours, due to the homework burdens.
The more years a child spends in education, the more likely they are to become nearsighted.
By the time the youth are in college, nearsightedness is basically universal.
In Shanghai, 97% of postgraduate students are nearsighted.
I picked up an interesting paper that found academic performance to be positively correlated
with myopia - especially in math and the Chinese and English languages. This is
even when adjusting for BMI, outdoor activity, screen time, reading time, and parental myopia.
In other words, the more kids study and do better at their studies,
the more likely they will develop nearsightedness. Correlated to that, the richer the family or
location is, the more likely the child will be nearsighted. This presents issues with reform.
## A High Priority
The epidemic has some economic impacts. For instance, it is estimated that China's annual cost
of treating and preventing myopia is estimated to be about $10 billion or about $69 (nice) per
person. This is higher than the corresponding cost in the United States - roughly about $4-7 billion.
With that being said, China can probably afford the economic cost.
Regardless, the government has narrowed on the issue as a health and well-being policy point.
The Chinese government has been trying to decelerate this creeping myopia epidemic
ever since the 1960s - when it developed a program
of eye exercises based on traditional Chinese medicine. Clearly, that program hasn't worked.
In 2018, Chinese President Xi Jinping noted that the high nearsightedness
rates are blurring the health and wellbeing of the children. He said:
> Myopia among students in our country shows a trend of high incidence and younger age,
which seriously affects the physical and mental health of children.
This is a major problem related to the future of the country
and the nation. It must be attached great importance to and cannot be allowed to develop.
Thusly, the Ministry of Education in China led a consortium on trying to address the issue.
This includes participation from eight different central
government bodies - which gives the consortium wide-ranging policy reach.
## Prevention
I have heard my fair share of old wives' tales about preventing nearsightedness.
Do your Chinese eye exercises! Eat more carrots! Take these fish oil pills! Sleep more!
However to date, the only thing actually known to have a repeated
causal association with myopia *prevention* is time spent outdoors.
If you make your kids spend more time outdoors,
they are less likely to develop myopia. Five trials - randomized
and non-randomized - and various studies have also confirmed this information.
A famous study in 2008 found that children of Chinese ethnicity in Sydney are less often
nearsighted than their peers in Singapore. The most significant difference between the
two populations is that the kids in Sydney spend much more time outside
than the kids in Singapore - 13.75 hours a week to 3 hours.
The mechanism through which being outdoors performs this protective effect
is uncertain. Animal control studies have implied
that it might be due to the intensity of outdoors light releasing more retinal dopamine.
Furthermore, it is not certain whether or not sending your kids outdoors
will slow the progression of someone who is already myopic.
With this in mind, however, you can start building up some policy around it.
## 13th Five Year Plan
The resulting 2018 national plan - the 13th 5-Year Plan - was very conservative. Its
goal is to reduce the rate of myopia by 0.5% each year from 2018 to 2023.
If all goes well, then by 2030 the myopia rate amongst primary school students will be below 38%,
junior high under 60%, and senior high under 70%.
The multi-faceted plan was in many ways is sensible. For instance,
a focus on increasing the number of eye doctors, having more specialists in rural
areas and educating parents about the importance of wearing glasses.
One notable step is that the Chinese government is setting clear targets on the factors known
to cause myopia. The targets that have gotten the most press were for video games.
China's video game industry is the biggest in the world,
driven by publicly traded companies like Tencent. These new policies curtail the amount of time
children can spend on their video games and in some cases held up video game sales altogether.
Western media reports mentioning this initiative often mention these sometimes
heavy-handed policies. But in doing so, they also often gloss over the other bits.
Which is unfortunate because I feel that the limits on schooling are just as interesting.
## Education Reform
As I mentioned earlier, myopia is correlated with academic performance.
The more the kid is studying, the more likely they are to become nearsighted.
Chinese education is known for its rather heavy workload - characterized by written
homework and exams in preschool and primary school. So for China,
myopia interventions and education reforms are pretty closely tied together.
The 13th Five Year Plan calls for two hours of daily time outdoors for children
and no written homework in the first two years of school.
The homework limits after that are 60 minutes for grades 3 to 6, and 90 minutes thereafter.
Key to making these homework reductions stick is whether
or not parents will attempt to compensate these reductions using private tutoring.
In July 2021, China introduced new regulations turning tutoring
companies into non-profit entities and limited their operating hours.
It wiped out a significant chunk of the $100 billion industry.
## 14th Five Year Plan
At the end of the 13th plan, the government managed to achieve some policy successes.
Their self-graded report card noted that the people's awareness of eye health
has increased. The number of eye doctors has risen by
47,000. And they have managed to do more cataract surgeries, which is nice.
In October 2021, the government announced that it managed to reduce its myopia rate
0.9 percentage points from 53.6%
in 2018 to 52.7% in 2020. This is in line with the 0.5 point goal laid out in the plan.
This is despite a 2.5 percentage point bump
from 2019 to 2020 due to the implementation of remote learning policies during the pandemic.
In some areas, the change was a bit more significant.
In Chongqing, it went up from 44.6% in 2019 to 55% in 2020.
The 14th 5-Year Plan covers the time period from 2021 to 2025. In terms of myopia prevention,
the plan emphasizes extending eye care coverage and monitoring to 90% of young children. For the
most part, this seems to be primarily focused on strengthening the country's eye doctor population.
I assume that the long term 2030 goals are still
the same - reducing nearsightedness prevalence by 0.5 points each year.
Assuming that these early self-reported results aren't being filtered through
rose-colored glasses, they are heartening.
So I am looking forward to whether or not they can make a bigger dent.
## Other Regions
I know that this is a pan-Asian issue. Taiwan,
South Korea, Singapore, and Hong Kong have all been straining to reduce the prevalence of myopia
within their populations as well. I can't cover them all but perhaps just a few small successes.
Taiwan is also sadly afflicted. I just asked a number of my friends and virtually all of them
have to wear glasses. Up to 84% of Taiwanese high school students have myopia in some form
or fashion. However, Taiwan has also been able to gaze upon some limited successes.
Before 2010, Taiwanese government policy centered on encouraging eye exercises and massages.
After reviewing data about the protective benefits of being outdoors, the Taiwanese
government instituted a national intervention policy called the Tian-Tian 120 program:
120 minutes outdoors a day. 10 minute breaks with every 30 minute work session.
It's worked. The prevalence of myopia in primary school children
after 2010 has declined from a peak of 50% in 2011 to 46% in 2015. Based on this success,
the government has brought out another initiative called Sports and Health 150,
which promotes an additional 150 minutes of exercise each week.
In South Korea, the myopia epidemic is especially bad. In 2012, a study found that 96%
of 19-year old males in Seoul had myopia - with 22% having a particularly bad case of it.
One difficult thing about the South Korean myopia problem is that it also requires the country
to corral its out-of-control private tutoring problem.
75% of school children receive an average of 7 hours of private tutoring each week.
China's 2021 private education reform has multiple reasons behind it,
but avoiding Korea's situation is probably one of them.
## Conclusion
I should note that myopia rates are also rising around the world. Likely for the same reasons,
kids spending more time indoors studying or with their electronics. Considering China's
limited experience, it will be interesting to see how COVID will affect global myopia rates.
For China, the private education reform is a good step forward. However,
the bigger challenge is reforming the attitudes and pathways of children education as a whole.
Success has long been defined as going to an elite college - determined by acing a
single exam that defines your entire life. Such an education system carries
a hard burden for the youth and parents, and it is making them literally go blind.