<DOC>
[108th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:88399.wais]
DANGEROUS SECRETS--SARS AND CHINA'S HEALTHCARE SYSTEM
=======================================================================
ROUNDTABLE
before the
CONGRESSIONAL-EXECUTIVE COMMISSION ON CHINA
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
MAY 12, 2003
__________
Printed for the use of the Congressional-Executive Commission on China
Available via the World Wide Web: http://www.cecc.gov
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CONGRESSIONAL-EXECUTIVE COMMISSION ON CHINA
LEGISLATIVE BRANCH COMMISSIONERS
House Senate
JIM LEACH, Iowa, Chairman CHUCK HAGEL, Nebraska, Co-Chairman
DOUG BEREUTER, Nebraska CRAIG THOMAS, Wyoming
DAVID DREIER, California SAM BROWNBACK, Kansas
FRANK WOLF, Virginia PAT ROBERTS, Kansas
JOE PITTS, Pennsylvania GORDON SMITH, Oregon
SANDER LEVIN, Michigan MAX BAUCUS, Montana
MARCY KAPTUR, Ohio CARL LEVIN, Michigan
SHERROD BROWN, Ohio DIANNE FEINSTEIN, California
BYRON DORGAN, North Dakota
EXECUTIVE BRANCH COMMISSIONERS
PAULA DOBRIANSKY, Department of State*
GRANT ALDONAS, Department of Commerce*
D. CAMERON FINDLAY, Department of Labor*
LORNE CRANER, Department of State*
JAMES KELLY, Department of State*
John Foarde, Staff Director
David Dorman, Deputy Staff Director
* Appointed in the 107th Congress; not yet formally appointed in
the 108th Congress.
(ii)
C O N T E N T S
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Page
STATEMENTS
Henderson, Gail E., professor of social medicine, University of
North Carolina School of Medicine, Chapel Hill, NC............. 2
Huang, Yanzhong, assistant professor of political science, Grand
Valley State University, Allendale, MI......................... 6
Gill, Bates, Freeman Chair in China studies, Center for Strategic
and International Studies, Washington, DC...................... 9
APPENDIX
Prepared Statements
Henderson, Gail E................................................ 28
Huang, Yanzhong.................................................. 33
Gill, Bates...................................................... 41
Submissions for the Record
Editorial by Bates Gill and Andrew Thompson from the South China
Morning Post, entitled ``Why China's Health Matters to the
World'' dated Apr. 16, 2003.................................... 45
Editorial by Bates Gill from the International Herald Tribune,
entitled ``China Will Pay Dearly for the SARS Debacle'' dated
Apr. 22, 2003.................................................. 46
Editorial by Bates Gill from the Far Eastern Economic Review,
entitled ``China: Richer, But Not Healthier'' dated May 1, 2003 47
DANGEROUS SECRETS--SARS AND CHINA'S HEALTHCARE SYSTEM
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MONDAY, MAY 12, 2003
Congressional-Executive
Commission on China,
Washington, DC.
The roundtable was convened, pursuant to notice, at 2:30
p.m., in room 2255, Rayburn House Office Building, John Foarde
[staff director] presiding.
Also present: David Dorman, deputy staff director; Tiffany
McCullen, office of Under Secretary of Commerce Grant Aldonas;
Susan O'Sullivan, office of Assistant Secretary of State Lorne
Craner; Andrea Yaffe, office of Senator Carl Levin; and Susan
Roosevelt Weld, general counsel.
Mr. Foarde. Good afternoon. I would like to welcome
everyone to this staff-led issues roundtable of the
Congressional-Executive Commission on China [CECC]. On behalf
of Senator Chuck Hagel, our Co-Chairman, and Congressman Jim
Leach, our Chairman, and the members of the CECC, welcome to
our panelists and to those of you who are here to listen to
their testimony.
The subject that we are going to tackle today is important
and timely. It has been in the news a lot over the last couple
of months. Specifically in the case of Severe Acute Respiratory
Syndrome [SARS], mainland China has reported more than 4,600
cases and over 219 deaths from the disease. Recent news
articles report that over 16,000 people are now under
quarantine in Beijing, and thousands more in Nanjing and
elsewhere. These massive quarantine measures are becoming
commonplace throughout China in the country's increasingly
stringent efforts to control the epidemic. While the number of
cases in the rest of the world seems to be stabilizing or
possibly even decreasing, China's caseload continues to
increase as the disease spreads into the country's interior.
A problem particular to China is that migrant workers,
alarmed by the rise of the disease in the cities, have shown a
tendency to head home to poverty-stricken inland provinces in
hopes of avoiding infection. In some cases, of course, they are
bringing the illness with them. In a recent statement, Premier
Wen Jiabao warned that the country's rural healthcare system is
weak and might prove incapable of handling a SARS epidemic in
the countryside. Some observers are now asking whether the
public health system, already stretched thin by the central
government attempts to shrink local government budgets, will
simply collapse under the weight of SARS and the oncoming tidal
wave of HIV/AIDS.
But beyond public health, the SARS outbreak has raised
broader social, political, and economic questions that demand
new policies from Chinese leaders. We wanted to explore those
policies, the existing system, specifically the SARS problem,
and look at the medium and longer term. So, we are delighted to
have with us this afternoon, three distinguished panelists. I
will introduce all of them individually before they speak, but
welcome to Dr. Gail Henderson from the University of North
Carolina at Chapel Hill; Huang Yanzhong, Ph.D. from Grand
Valley State University; and Bates Gill, Ph.D., from here in
Washington at the Center for Strategic and International
Studies [CSIS].
Without further ado, let me introduce Dr. Gail Henderson.
She is a medical sociologist, professor of social medicine, and
adjunct professor of sociology at the UNC-Chapel Hill. Her
teaching and research interests include health and inequality,
health and healthcare in China, and research ethics. She is the
lead editor of ``Social Medicine Reader,'' and she has
experience with qualitative and quantitative data collection
analyses, as well as conceptual and empirical cross-
disciplinary research and analysis.
Professor Henderson and our other panelists, as usual, will
be asked to speak for 10 minutes. I will keep track of the time
and alert you when you have 2 minutes remaining. And then, as
is usually the case, if we don't get to all of your points, we
will try to catch them up in the question and answer session
after all three panelists have spoken.
So with that, I would like to recognize Professor
Henderson. Thank you very much for coming.
STATEMENT OF GAIL E. HENDERSON, PROFESSOR OF SOCIAL MEDICINE,
UNIVERSITY OF NORTH CAROLINA SCHOOL OF MEDICINE, CHAPEL HILL,
NC
Ms. Henderson. Thank you very much for inviting me. I feel
very honored to be here, and I hope that we will all have a
really fruitful discussion of the important topic at hand.
America has had a lot of images of the health and the
public health of China and the Chinese during the last century.
It began thinking of China as the sick man of Asia. Two decades
later, after the establishment of the People's Republic, the
dominant image was healthy, red-cheeked babies born in a Nation
that somehow provided healthcare for all.
Of course, the real story about health in China is more
complex than either of those images. But in a country as vast
and varied as China still is, many realities are true. The
recent spread of HIV/AIDS and now the SARS epidemic have placed
enormous stress on the Chinese healthcare system, as you said
in your introduction. It is important to realize that any
healthcare system, in no matter how developed a country, would
be stressed by this kind of a unprecedented epidemic.
To assist China in dealing with SARS, I think we must have
a clear understanding of the forces that have shaped this
system and the current epidemics. So, in my written testimony--
which is longer than the 10 minutes--I really focus on what I
think the history can tell us about the Chinese healthcare
system and its strengths and weaknesses, and I think some of
the current myths that we have in our media, and our response
to SARS in China. I make four main points.
First, public health is not a money making operation.
Public health, differentiated from healthcare services, is
disease surveillance, environmental sanitation, maternal and
child health, health education, nutrition, and food hygiene.
Those do not make money.
China was able to revolutionize public health and its
health status indicators, and establish a multi-tiered
infrastructure of hospitals, public health departments, and
clinics under Mao Zedong, because of strong government support
and resources. This is easier to accomplish when market forces
are held at bay, as they were until Mao's death.
The second point, China's current healthcare system,
curative clinic hospital-based system, has been shaped by
economic incentives in the post-Mao era familiar to all
students of modern China. They have emphasized the development
of high technology hospital-based medical care, which had been
substantially neglected under Mao. The move away from a
centralized collective welfare system that had fostered a
strong public health orientation resulted in de-emphasis of
public health functions, especially at the lowest levels. This
has been well-documented by the Chinese and others.
Aggregate income, of course, as you all know, rose
substantially in China as has health status in general, and
continues until this day to improve. But, inequality has also
increased and with it health and economic disparities between
rich and poor. This is the characteristic of this system as we
know it now.
Third, infectious diseases often strike hardest at the most
vulnerable groups, those with the least access to government
safety nets. This is true for HIV in China and true in all
nations for HIV. The fear with SARS is that weaknesses in the
world health system, particularly in remote areas, will make
containing the disease much more difficult.
The public health infrastructure remains. I really want to
emphasize that. It can be supported and strengthened by forces
now at work in China and from outside. Long before the SARS
epidemic, in the 1990s, the Chinese Government was developing a
very ambitious plan to respond to the breakdown of public
health services in rural areas. That plan went through a lot of
pilot testing, was initiated in 2002, and it reinforces rural
health insurance and public health control, establishing public
health--not curative medicine--public health hospitals at the
lowest levels. I think those things are quite important to
recognize.
Fourth, if we are to effectively assist China's response to
SARS, we must understand the sensitivity for any government of
the double-threats to public health and the economy, and
reject--if you'll excuse me--the rhetoric of accusatory phrases
like, Dangerous Secrets, the title of our roundtable. Instead,
we must recognize and build on the work of responsible
dedicated professionals in China, and the United States, and
other countries, people who are best-positioned to develop
strategies to contain SARS and prevent the emergence of other
deadly pathogens.
Now it has been suggested that lessons from AIDS and how
China dealt with AIDS can be applied to SARS. So, I want to
reflect on this comparison a bit in the remainder of my
testimony. A number of recent media reports on the SARS
epidemic remind us that China's secrecy and failure to respond
characterizes its response to AIDS as well. These shortcomings
were especially featured in media reports at the end of 2001,
when it became known that possibly thousands of commercial
plasma blood donors in impoverished rural areas were becoming
infected with HIV in China. We excoriated the Chinese
Government for allowing the AIDS epidemic to spread through
hundreds of poor villages.
But, I would like to ask us all to reflect on a couple of
things. Thinking about that response, I think we have to ask
how other countries with far-greater resources have performed
in responding to the AIDS epidemic. We must also ask whether we
apply a double-standard to some developing countries when it
comes to their public health performance. In fact, few
governments, rich or poor, have been immediately forthcoming
about the spread of HIV within their boundaries, and few, if
any, have successfully stemmed the spread of AIDS.
In my view, the use of public health challenges as
shorthand political critiques is a real danger as we move
forward to combat this newest global threat, SARS. Just turning
the lens a little bit, if the Chinese applied the same
shorthand to characterize the U.S. healthcare system and its
capacity to respond to crisis--a system, I should remind you,
that spends twice as much as the next big spending country on
healthcare per capita--what would they look at? We might be
reading in the Chinese press about systematic discrimination
against African Americans who are ten times as likely to die
from HIV as whites in this country, reflecting the disgraceful
fact that disparities in morbidity and mortality rates between
blacks and whites are actually greater now than in 1950. We
might also be reminded of the CDC's rapid response to protect
U.S. senators from anthrax, while failing to extend the same
response to postal workers.
While I don't minimize the real gravity of the HIV epidemic
among former plasma donors, or the negative consequences of
delay, I think the media's focus on this aspect of the story
drowns out really important realities that I wanted to bring
before this Commission. They include evidence in the medical
literature as early as 1995 that the plasma donors in rural
areas were being infected. International AIDS conferences in
1996 and later also reported on the studies of the blood supply
and what people could do in China to improve the quality in the
testing, which was not very good also during this time period.
By 2002, the Chinese Ministry of Health had a publicly
outlined plan for dealing with these and other populations with
HIV. In fact, China's progress in developing HIV prevention and
treatment programs rarely makes the evening news. But, there
has been an extraordinary amount of assistance in the last few
years provided by the United States and other countries through
biomedical and scientific collaboration, and it is having a
very important impact.
The NIH awarded a Comprehensive International Program on
Research on AIDS [CIPRA] grant to China in the summer of 2002.
That grant provides funds for vaccine development, research on
risk factors, behavioral interventions, treatment trials, and
so on. This also has fostered a lot of interest in human
subjects protections, which I consider to be very important,
because any NIH money that goes to China has to have NIH human
subject protections attached.
Perhaps most important, clinical research also has the
potential to focus attention on unmet treatment needs, just as
in Africa when the AIDS researchers of the world descended on
Durban, and they saw the epidemic in Africa and then it became
unacceptable to have some people get treatment and others not.
In some ways the same things have happened in China, and the
government has established funds for treatment in 100 counties
in China identified as the hardest hit by AIDS. This is
extremely important. Again, although SARS is prompting a lot of
activity on the part of the government, these things didn't
happen overnight. They have been in the works for several
years.
Statistics on disease and death rates are often used like
Rorschach tests to measure the legitimacy of the government.
Infectious diseases, including emerging pathogens like HIV and
SARS, are particularly potent foci for such critiques, in part
because they tend to fall hardest on the most vulnerable and
the least well-served by society. It is not clear how large the
SARS epidemic in China will be or how long it will last. I
really want to emphasize how little we know about this
epidemic. There are still problems defining cases. So, I think
we have to be very careful, even with the statistics that we
have.
In order to assist China's response, we must understand the
strengths and weaknesses in the system, the real strengths and
the real weaknesses. Actually, SARS and AIDS are a direct if
unintended consequence of economic reform and integration into
the global community, which are reforms that the United States
has encouraged, and in which the business and scientific
communities play key roles. So, rather than focus on failures--
and again, I think everyone acknowledges that there have been
considerable failures--we must credit China's current efforts
to contain the
epidemic in its hospitals, cities, and borders, and openness to
international collaboration and information sharing for what
they are now, contributions to the global efforts to control
this deadly disease and prevent and epidemic from becoming a
pandemic. Thank you.
[The prepared statement of Ms. Henderson appears in the
appendix.]
Mr. Foarde. Thanks very much. We can pick up some of the
remaining points when we get to the Q and A, but very useful.
Next, I would like to recognize Professor Huang Yanzhong,
who is assistant professor of political science at Grand Valley
State University and beginning in September of this year, Dr.
Huang will take up duties as assistant professor at the John C.
Whitehead School of Diplomacy and International Relations at
Seton Hall University.
Dr. Huang received his Ph.D. in political science from the
University of Chicago in 2000. He also completed a master's
degree in international relations at the well-known Fudan
University in Shanghai, where he also received a bachelor's
degree in international politics. His research interests
include global health, security and development, and Chinese
politics. He has published numerous articles, and books, and
journals. We are delighted to have him with us this afternoon.
Dr. Huang, please.
STATEMENT OF YANZHONG HUANG, ASSISTANT PROFESSOR OF POLITICAL
SCIENCE, GRAND VALLEY STATE UNIVERSITY, ALLENDALE, MI
Mr. Huang. Thank you for the nice introduction. It is an
honor to be here to share with the Commission and the public my
knowledge about the politics of public health and SARS in
China.
As far as the impact of the SARS epidemic is concerned, it
is now clear that the Chinese leadership is facing the most
severe social-political crisis since the 1989 Tiananmen
crackdown. Given the political aspect of the crisis, this
testimony will focus on the problems in China's political
system. It will proceed in three sections. I will first discuss
how problems in the political system allowed SARS to transform
from a sporadic nuisance to an epidemic that now affects
hundreds of millions of people across the world. I will then
examine the recent government crusade against SARS, with
special attention on its implications for human rights and the
rule of law in China. I will conclude with some policy
recommendations for the Commission to consider. The complete
written statement, which is about 15 pages long, will be posted
on the CECC Web page. What I will present here is just a
summary of the main points.
First, the making of the crisis. The events that unfolded
during November 2002 and April 2003 revealed two major problems
inherent in China's political system: coverup and inaction. As
far as a coverup is concerned, existing political institutions
in China have not only obstructed the information flow within
the system but also distorted the information itself. It is
worth noting that while bureaucratic misinformation is not
something unique to China, the country's refusal to enfranchise
the general public in overseeing the activities of government
agencies makes it easy for upper-level government officials to
be fooled by their subordinates. But, paradoxically,
manipulation of data, even though it erodes the governing
capacity of the central Chinese state, also serves to shore up
the regime's legitimacy. Because of the dying communist
ideology and the official resistance to democracy, the
legitimacy of the current regime is rooted in its constant
ability to deliver socio-economic progress. As far as this
performance-based legitimacy is concerned, government officials
routinely inflate data that reflect well on the regime's
performance while underreporting or suppressing bad news such
as plagues and diseases.
In explaining the government's slow response to tackling
the original outbreak, we should keep in mind that the health
system is embedded in an authoritarian power structure. In the
absence of a robust civil society, China's policymaking does
not feature a salient ``bottom-up'' process to move a
``systemic'' agenda in the public to a ``formal'' or
governmental agenda as found in many liberal democracies.
Because of this top-down political structure, each level takes
its cue from the one above. If the leadership is not dynamic,
no action comes from the party-state apparatus. The same
political structure also encourages lower-level governments to
shift their policy overload to the upper levels. As a result, a
large number of agenda items are competing for the attention of
upper-level governments.
The problem here is that in the reform era the bias toward
economic development has made public health the least of the
concerns of Chinese leaders. Compared to economic issues, a
public health problem often needs an attention-focusing event,
such as a large-scale outbreak of a contagious disease, to be
finally recognized, defined, and formally addressed. Not
surprisingly, SARS did not raise the eyebrows of top
decisionmakers until it had already developed into a nationwide
epidemic.
Thanks to strong international pressure, the government
finally woke up and began to tackle the crisis seriously. In
terms of the policy implementation, the Chinese system is in
full mobilization mode now. Yet in doing so, a bias against
routine administration has been built into the implementation
structure. In fact, the increasing pressure from higher
authorities makes heavy-handed measures more appealing to local
officials, who find it safer to be overzealous than to be seen
as ``soft.'' There are indications that local governments
overkilled in combating SARS.
In some cities, those who were quarantined lost their jobs.
Until recently, Shanghai was quarantining people from some
regions hard hit by SARS, such as Beijing, for 10 days even if
they don't show any symptoms. While overall, Chinese people are
cooperating with the government measures, even official reports
suggest that many people were quarantined against their will.
The heavy reliance on quarantine raises a question--will anti-
SARS measures worsen the human rights situation in China?
Again, the question is not unique to China, even the United
States is debating whether it is necessary to apply a
dictatorial approach to confront health risks more effectively.
While China's law on prevention and treatment of the
infectious disease does not explicate that quarantines apply to
SARS epidemic, articles 24 and 25 in the law authorize local
governments to take emergency measures that may compromise
personal freedom or liberties. The problem is that, unlike
democracies, China in applying these measures tended to exclude
the input of civil associations or civil societies. Without
engaged civil society groups to serve as a source of discipline
and information for government agencies, the state's capability
is often used against the society's interest. Official reports
suggested that innocent people were arrested simply because
they relayed some SARS-related information to their friends or
colleagues. According to the Ministry of Public Security, since
April, public security departments have investigated 107 cases
in which people used Internet and cell phones to spread so-
called ``rumors.''
Another problem that may complicate the government's
efforts to combat SARS is policy difference and political
conflicts within the top leadership. The reliance on
performance for legitimacy places the government in a policy
dilemma. If it fails to place the disease under control and
allows it to run rampant, it could become the event that
destroys the Party's assertions that it improves the lives of
the people. But if the top priority is on health, economic
issues will be moved down a notch, which may lead to more
unemployment and more social and political instability. The
disagreement on how to deal with the relationship was evidenced
in the lack of consistency in central policy.
On April 17, the Politburo Standing Committee meeting
focused on SARS and gave priority to people's health and life
security. Eleven days later, the Politburo meeting emphasized
former President Jiang Zemin's ``Three Represents'' and called
for a balance between combating SARS and economic work,
reaffirming the central status of economic development. This
schizophrenic nature of central policy is going to cause at
least two problems that will not help the state to boost its
capacity to combat SARS.
First, the Party center's failure to signal its real
current priorities loud and clear may confuse local
authorities, which may take advantage of the policy
inconsistency to ``shirk'' or minimize their workload. Second,
the policy difference could aggravate China's faction-ridden
politics, which in turn may reduce central leaders' autonomy in
fighting against SARS.
In fact, former President Jiang's allies in the Politburo
Standing Committee were quite slow to respond to the anti-SARS
campaign embarked upon by President Hu Jintao and Premier Wen
Jiabao on April 20. The making of big news in the official
media--President Jiang's order on April 28 to mobilize military
health personnel suggests that Hu Jintao and Wen Jiabao do not
have authority over the military. Intra-party rivalry in
handling the crisis reminds people of the political upheavals
in 1989, when the leaders disagreed on how to handle the
protests and Deng Xiaoping, the paramount leader, played the
game between his top associates before finally siding with the
conservatives by launching a military crackdown.
Given the international implications of China's public
health, it is in the U.S. interest to expand cooperation with
China in areas of information exchange, research, personnel
training, and improvement of the country's public health
facilities. But it can do more. It can modify its human rights
policy so that it accords higher and clearer priority to health
status in China. Meanwhile, it should send a clearer signal to
the Chinese leadership that the United States supports reform-
minded leaders in the forefront of fighting SARS.
To the extent that regime change is something that the
United States would like to see happen in China, it is not in
the U.S. interest to see Hu Jintao and Wen Jiabao purged and
replaced by a less-open and less-human government, even though
that government may still have strong interests in maintaining
a healthy U.S.-China relationship. The United States simply
should not miss this unique opportunity to help create a
healthier China. By calling President Hu in April, praising
what Beijing was doing, and indicating his willingness to
provide any possible support and assistance, President Bush has
taken a very important step in the right direction.
[The prepared statement of Mr. Huang appears in the
appendix.]
Mr. Foarde. Dr. Huang, thank you very much.
We would now like to go on and welcome an old friend of
both the individual members of the Commission and all of us on
the Commission staff, Dr. Bates Gill.
Bates currently holds the Freeman Chair in China Studies at
the Center for Strategic and International Studies here in
Washington, DC. A specialist in east Asian foreign policy and
politics, Bates' research has focused primarily on northeast
Asian political security and military technical issues,
especially with regard to China. Among his current projects, he
is focusing on the domestic socioeconomic challenges in China,
including issues related to HIV/AIDS and SARS. Results from
this work have appeared in such publications as Foreign
Affairs, the New York Times, and the Far Eastern Economic
Review.
Bates, welcome. Thank you very much for spending some time
with us this afternoon.
STATEMENT OF BATES GILL, FREEMAN CHAIR IN CHINA STUDIES, CENTER
FOR STRATEGIC AND INTERNATIONAL STUDIES, WASHINGTON, DC
Mr. Gill. Thank you very much. And thanks to everyone here
at the Commission for the opportunity to appear before you
today on this very timely, and I think important, topic.
As we all know, the repercussions of China and the SARS
epidemic will resonate well beyond tragic, unfortunate, and
growing loss of life. There is a silver lining here in some
sense. I think the progression of the epidemic from Guangdong
to Beijing, into the Chinese countryside, and across the world,
clearly demonstrates the mainland's increasing economic and
social openness, its mobility internally, and interdependence
within the country itself, interdependence within the East Asia
region, and across the planet. We also see a coming out of this
a mobilization a concern for China's healthcare system, both
internally, and internationally. We can hope that this will
spark a greater degree of openness and accountability within
the Chinese leadership.
I agree with Dr. Henderson that there is still much we do
not know, and we are at a very early stage in our analysis. But
I think it is worth thinking about some of these questions and
trying to get a better grasp of where the SARS epidemic is
going to be taking us in terms of some of these questions of
openness and change in China. On the other hand, we see that
the SARS outbreak exposes a number of very troubling
developments as well: old-style misinformation, opaque
miscommunication, the ailing healthcare infrastructure, and a
continuing reticence, by and large, to work openly with foreign
partners. So these negative developments also raise serious
questions about the Chinese ability to cope with other
infectious diseases, such as hepatitis, tuberculosis, and HIV/
AIDS.
I would like to present my remarks today in three parts.
First, to talk a little bit about what I see as some of the
lessons. Second, what some of the implications are, in the near
term, of the SARS epidemic. And then recommend steps that we
might consider to combat future healthcare crises in China more
effectively. I will note at the outset that I am drawing these
remarks largely from my recent publications, such as in the
``International Herald Tribune'' and the ``Far Eastern Economic
Review.'' And if I may, I will submit these for the record as
well.
[The above-mentioned publications appear in the appendix.]
Lessons. Clearly, first of all, we unfortunately saw, yet
again, a rather sclerotic and reactive political and
bureaucratic process in China. In taking so long to reveal the
real dimensions of the SARS problem, the Chinese authorities
unfortunately underscored their reputation as secretive and
often out of step with international practice. Unfortunately,
it wasn't just a question of bad communication, but we saw that
there was deliberate misinformation, and even obstruction of
information in the case of U.N. assessment teams attempting to
understand the full extent of the epidemic.
Some have argued that this current openness though, more
recently, to SARS, indicates a new and more positive direction
for the Chinese leadership. That may be, and we can hope so.
But, I think it remains relatively early to know with any
certainty, and whether or not this can be broadened to
encompass a new, across-the-board approach that doesn't include
just healthcare issues, but broader issues of the Chinese
social and political development.
I think it is unfortunate and paradoxical that despite what
I see as a rather sclerotic and old-style official response to
SARS, China's society has become more open than ever. Indeed
SARS spread as rapidly as it did precisely because of China's
expansive interaction domestically and with its international
partners. So something, obviously, is going to have to change
in the way Beijing
approaches these questions. I think the next 90 days or so are
going to tell us a great deal, and I would urge the Commission
to keep an eye--as this outbreak subsides somewhat--on whether
or not we do see continued focused attention, resources, and
opening for China in dealing with other, not only social and
health issues, but its lengthening lists of socioeconomic
challenges.
Another lesson, obviously, that we take away from this is
something we've known, but I don't think has reached
international
attention, and that is the ailing healthcare capacity, which
Dr. Henderson has already informed us about. This is a very
serious problem, and one I think which does offer numerous
opportunities for both non-governmental organizations and
governments to work with China to help expand healthcare
capacity in China.
Third, another lesson to mention is somewhat disturbing to
me, as we have seen it in the HIV/AIDS case as well, and that
is the unwillingness of authorities in China, and particularly
outside of the healthcare set of ministries and especially at
the local levels, to work with foreign partners who are seeking
to assist in healthcare capacity building and other healthcare
issues in China. Again, I think this may be an opportunity for
us to help build the capacities of those local and grassroot
organizations that can help bridge the gap between foreign
providers of assistance and local
authorities.
Second, let me turn to some near-term implications, again,
understanding that we don't know the full extent of this
problem yet. I am somewhat disturbed that the official Chinese
response to SARS in the early stages does not bode well for how
the government is going to respond to other new, and, in my
view, even more serious public health challenges which the
country is facing. I cite particularly in this regard, the
problem of HIV/AIDS, where I think we see a good number of
similarities between the response to SARS and the response to
that disease, meaning denial, reluctant acknowledgment and
hesitant mobilization of resources, and reticence to deal with
the international community.
Other looming epidemics are out there, and--as we can see
as China globalizes--do pose problems for its partners, and we
should watch carefully how China responds and whether or not
there can be other forms of boosted assistance. Such as
problems of other types of atypical pneumonias, hepatitis, and
HIV/AIDS are spreading in China and do pose issues not only
inside China, but internationally.
Another obvious near-term implication is the economic
downturn for China. This is not directly a healthcare-related
issue, but it does have an impact on the international economy,
something that concerns us all, especially at a time that we
are teetering on the brink of an international recession. When
we hear figures of China's SARS related downturn of its GDP
perhaps going down as much as 2 percent, that is going to have
an enormous impact on the global economy. Even if China is able
to ride through some of the economic implications of the SARS
outbreak, many of its major partners are suffering as well,
economically, such as Singapore, Hong Kong, and Taiwan, and
that, in turn, will affect the viability of the Chinese economy
going forward as well.
Let me conclude, by just looking ahead. As I have said
already, we need to watch very carefully how China in the next
60 to 90 days chooses to deal with other public healthcare
challenges once the SARS issue seems to be diminished somewhat,
or at least off the day-to-day front-page headlines. We should
be watching for a continued denial and inaction short of
international outcry or senior-leadership intervention. We have
already been made aware of the weakening public-healthcare
capacity to monitor, diagnose, prevent, and treat emergent
disease outbreaks in China--the capacity problem is really
enormous--and continued reluctance to collaborate effectively
with foreign partners.
Our first priority must be to implement more transparent,
accurate, and coordinated public healthcare management and
communication. In this regard, I believe healthcare-related
quasi- and non-governmental organizations could be more
effectively utilized to monitor and improve methods for the
prevention, treatment, and care of disease. For these to
succeed, China's new leadership must commit to raising the
political priority of public health on their agenda of
socioeconomic challenges as Dr. Huang has already mentioned.
Second is the capacity problem. At a very fundamental and
basic level, far more will need to be done to develop more
well-trained professionals who can properly diagnose, treat,
and care for persons afflicted with emergent epidemics in
China. And again, I see a role for grassroots and community-
based organizations that could be
effective partners in this effort, if well coordinated and if
given adequate leeway and resources internally.
Last, much more can be done between China and the
international public health community. They have a shared
interest in scaling up cooperative programs. There are numerous
international healthcare related programs in China, but most of
them are run on a very small scale at a pilot level. And one of
the problems of scaling them up again on local levels is
precisely the political one, especially if they are operated by
NGOs or dominated by foreign donors. The central authorities or
even provincial authorities are more reluctant to see those
programs expanded to a larger scale for political reasons.
But obviously, major donor nations need to reconsider
channeling development aid to focus even more on public health
programs in China. In the end China needs to know that as one
of the worlds largest economies and as an inspiring great
power, it will need to show a far greater commitment to working
with international partners and taking its public health
challenges much more seriously. In this regard, I will just
note that I was very encouraged to learn that on a basis of a
telephone call between Vice Premier and Minister of Health Wu
Yi and Health and Human Services Secretary Tommy Thompson, we
have committed an additional one-half million dollars to help
China in the near-term on the SARS issue, but the types of
assistance that are being provided--to provide for training; to
provide for capacity building and laboratories--is going to
have a far larger impact. If anything, I would encourage as one
of our recommendations coming out of this that our government
devote even greater resources to China in this regard. Thank
you very much.
[The prepared statement of Mr. Gill appears in the
appendix.]
Mr. Foarde. Bates, thank you very much.
We are going to let our panelists catch their breath for a
minute while I make an administrative announcement or two. Our
next issues roundtable will be 3 weeks from today, on Monday,
June 2, here at 2:30 p.m. in this room, 2255. We will be
sending out an announcement a bit later in the week about the
topic and panelists. We hope that you will put it on your
calendar and will join us.
In addition, as one aspect of our topic today, we published
last week a staff paper on SARS and its relationship to the
free flow of information in China. Copies are available on the
distribution table outside. If they are all gone, you can find
a copy of the paper in both HTML and PDF format on the
Commission's Web site, www.cecc.gov.
We have now turned to our question and answer session. As
we have in the past, we will give everyone here on the panel
table
representing the commissioners of the CECC a chance to ask our
panelists questions for 5 minutes, and hear the answer. We will
do as many rounds as there is still interest and our panelists
are still holding up, or roughly 4 p.m., whichever comes first.
I would like to begin by asking Professor Henderson to
elaborate a little bit. At the end of your presentation you
were talking about the strengths and the weaknesses of China's
public health system. I wondered if you would take another
minute for the record to tell us what you think the real
strengths and weaknesses are and what the relationship might
be, or what the United States might do to help strengthen the
system?
Ms. Henderson. OK. Some of the strengths are derived from
the earlier system which did set up a public health
infrastructure. As many of you know, this system is a multi-
tiered system with high-level city hospitals developed and
public health departments that are under the national China CDC
control down to districts and counties, in the rural areas,
townships, and the villages. In the post-Mao era resources were
shifted away from the countryside where resources were mainly
devoted under Mao Zedong. And that is why it was one of the
biggest successes of Mao, that he did what almost no government
has ever been able to do--focus resources in rural areas, limit
the development of high-technology medicine, and limit contacts
with the outside world. So, you didn't see any fancy machines
imported into China during that whole time period.
Nevertheless, this policy resulted in really letting the urban
health infrastructure go.
So, the big shift after Mao was toward devoting resources
into catching up, modernizing medicine--science, technology,
and medicine--as part of the foreign modernization programs.
The strength, though, is the infrastructure. If you think about
it in comparison to Africa and trying to put treatment programs
into Africa, the contrast is still quite vivid. Being able to
put treatment programs, prevention programs, health education
programs into rural China is not as possible now because the
township level hospitals and public health functions became
quite weak in the post-Mao era. But, the infrastructure exists.
And what the Chinese have been working on is re-instituting the
strength of that rural township hospital and public health
department control over public health functions at the very,
very basic level. That wouldn't be possible if they hadn't had
the prior system. So that is a really big strength that can be
built on. I would say that everything that our government can
do to recognize that it is there, and that they have a program
in place, and to assist with that would be excellent.
The other strength is that there have been so many advances
in infectious disease control in China, many of which are
ignored. As people look at health statistics in, for example,
hepatitis, almost 10 percent of Chinese have hepatitis B.
Hepatitis C is also epidemic. This is transmitted through sex
and blood. The Chinese developed a vaccine for hepatitis B.
There is almost no vertical transmission now because they were
so successful in implementing that vaccination program. The
problem is the blood supply and hospitals. Dirty needles are a
big source of transmission, still, of hepatitis. So, the blood
supply which was also implicated, of course, in HIV
transmission is also something that has been a serious hazard
in terms of hepatitis. And that is the origin of most of the
increase in the epidemic.
So, if we say, ``the Chinese, their system is defunct. And
look, hepatitis is out of control.'' Well, yes and no. And I
think that kind of recognition of the strength of classic
infectious disease work, work on vaccinations and so on, is
something that our government should do and not accept more
general and sometimes superficial comments about the state of
health in China. Health in China is generally improving every
year. If you look at morbidity and mortality rates,
particularly mortality rates--if you look at infant mortality
rates, the disparities between urban and rural areas on the
aggregate, at least, are decreasing.
Mr. Foarde. I would recognize my partner in directing the
excellent staff of the Commission, David Dorman, who represents
Senator Chuck Hagel.
Mr. Dorman. First of all I would like to thank each of our
panelists today on behalf of all the commissioners for taking
the time to try to educate us on this very, very complex
subject. I know the commissioners themselves are extremely
interested in this subject and appreciate the time you have
taken today to help us understand it.
One thing I would like, perhaps, Dr. Gill and Dr. Huang to
address is helping us understand the issue of secrecy. What we
have seen written and heard discussed, on the one hand,
suggests that the Chinese reaction to the SARS crisis was
somewhat reflexive, in the sense that the initial reaction of
secrecy is the only answer the system could have given. There
are others who look at this a little bit differently and
suggest that perhaps part of the problem was a public health
system that was not functioning fully. In other words, if the
Chinese leadership had had more information, perhaps they would
have reacted differently. I am wondering if each of you will
comment on this. Do you feel the system itself, as it now
exists, could not have reacted differently, even if the public
health system was in some way more functional? I am recalling
Dr. Henderson's comments that even 20 years ago it may have
been better functioning than today? Could the current
leadership have reacted differently if they had better
information?
Mr. Gill. I think it is both of those problems that you
cited. It is not one or the other. So, in combination, you have
a synergy that makes things a lot worse than they should be.
Not only is the data collection and surveillance and
epidemiological capacity of the country poor, especially in
rural areas, but there is also the natural reaction of
bureaucrats everywhere that no news is good news, and bad news
you don't expose if you don't have to. And then you have the
overlay in China of potentially very serious consequences for
persons who reveal information that is considered secret or
somehow classified. So, you really have a synergy of both.
To answer your question, though, that you asked in the
second portion, would things have been different if they had
had greater access to information? Yes, I think it would be. I
mean, I think we are looking at leaders in China today that
have over time recognized the need to be responsive to society
and to try and be more open and try and be more accountable. I
am not going to exaggerate any of this, but there is movement
in that direction, and that is all very positive. As the
leadership recognizes that its legitimacy relies upon retaining
an image for the people of being responsive and accountable to
a degree, they need to be more so. Thus, I suppose if there had
been more information available, we might have been able to
expect a little bit more rapid response. But there wasn't. And
on top of that, there is the secrecy and less-than-responsive
action. So, unfortunately, in China I think today still and
even after the SARS debacle, you have the worst of both worlds:
both a lack of information and a tendency toward secrecy.
Mr. Foarde. Dr. Huang, I will give you about 2 minutes to
say a little, if you would.
Mr. Huang. OK. I agree with Dr. Gill that the Chinese
Government could act differently provided that there were some
changes in the Law of Prevention and Treatment of Infectious
Disease, because that law, which was enacted in September 1988,
had some major loopholes. First, under the law, provincial
governments are allowed to publicize epidemics in a timely and
accurate manner only after being authorized by the Minister of
Health. Second, atypical pneumonia was not listed in the law as
an infectious disease under surveillance. Therefore, local
government officials legally were not accountable for the
disease. It is true that the law allows addition of new items
to the list, but it does not specify the procedures through
which the new diseases can be added.
That being said I still believe that there are some deep-
rooted systemic problems in the Chinese political system.
First, as I just presented, China lacks the decentralized
system of oversight that we have here. And second, it is about
the regime's legitimacy. The manipulation of data actually
helps shore up the regime's legitimacy. Third, this is about a
political system that is very secretive. In fact, according to
China's 1996 implementation on the State Secret Law of 1988,
which handles public health-related information and any such
diseases should be classified as a state secret before they are
announced by the Ministry of Health or authorized by the
Ministry. In other words, until such time that the Ministry
chooses to make public information about the disease, any
physicians or journalists who report on such a disease would
risk being prosecuted for leaking such secrets.
Mr. Foarde. Very interesting point. I would like to go on
now and recognize Andrea Yaffe, who represents Senator Carl
Levin, a member of our Commission. Andrea.
Ms. Yaffe. Hi. I think Dr. Gill touched upon this issue
regarding the recent appointment of Vice Premier Wu Yi. I am
wondering whether some news reports are accurate and if you
think she will be a catalyst for more openness? What can the
United States expect from her leadership? Do you agree with her
appointment, and how do you think she is going to handle that
position? Any of the speakers.
Mr. Gill. I take her appointment generally in a very
positive light. We've argued in other contexts that often for
real action to be undertaken in China, it requires a higher
level of senior leadership attention. Madame Wu is a vice
premier, and a woman of great resources, political and
otherwise, and who has a pretty strong reputation in China, and
importantly, internationally. So, I think another silver lining
in all of this is that we see appointed to this very important
post of Minister of Health a person who brings to her position
a great deal of clout, far greater politically than her
predecessor, Minister Zhang had. So, I think we can hope. The
pieces are being put in place for a more robust response from
China on its public health agenda, and I think Madame Wu will
be a very good partner to work with.
Mr. Foarde. Does another panelist want to address that
question?
Mr. Huang. I think I could comment on Professor Henderson's
remarks. I agree with Professor Henderson, actually. While
pointing out the weakness of the health system in China, we
should also recognize the strengths of that system, that is, as
Professor Henderson has said, the infrastructure, basically, is
still there. It's just that they need money. They need to
increase government financing to help boost the capacity of
China's health system to deal with all of these public health
problems.
And also, as Professor Henderson pointed out, in terms of
the public health status in China, we have indicators of health
status like mortality rate, life expectancy, under five
mortality rate, infant mortality rate. In fact, there is no
sign suggesting that there is a measurable decline in China's
public health status in that regard.
And also I wanted to add that the government has already
taken some positive steps to improve the health system in
China, including the rural health system. Actually, what I have
found is that they are trying to revitalize the Maoist health
system by endorsing officially the so-called, Cooperative
Medical System, to ask officially to put more emphasis on the
countryside. These are all positive signs that I think we
should recognize.
Mr. Foarde. Thank you. We've got about a minute. Andrea, do
you have another one?
Ms. Yaffe. I was also wondering--I think this was also
briefly touched on--with the clampdown on universities, with
the clampdown on all tourism, how long do you think it is going
to take for the economy to start getting revitalized? How long
do you think the quarantine can actually last?
Mr. Gill. I don't think anyone can make a prediction on
that. What I really wanted to touch on in testimony was that we
had a session over at CSIS this morning and some responses were
generated. So, maybe I can convey some of them. One is that
some experts believe that before the data and epidemiological
surveillance in the countryside begins to kick in, we are
seeing a little bit of a slowdown in the daily prevalence, or
at least of new cases. Some experts believe that once we are
able to pull data accurately from the countryside, we will see
an upswing.
There is even evidence that SARS does not affect children
in a strong way, but they can remain carriers, so that they can
infect others who would fall ill to it. So, there is a lot that
just isn't known. If we are going to go by the World Health
Organization's [WHO] standards of when we can go back to the
country or feel safe to go back to China, it will be a very,
very long time. They have very rigorous standards for when
these advisories can be pulled. And with 5,600 Chinese infected
and counting, it is going to be a lengthy period of time. I
mean I think we should certainly be thinking in terms of
several months, if not much longer. I don't think anyone is
really ready to make a very accurate prediction because we just
don't know.
Mr. Foarde. And you are out of time. So, we will go on and
try to find out something else. I now recognize our friend and
colleague, Tiffany McCullen, who represents Under Secretary of
Commerce Grant Aldonas, one of our Commission members.
Ms. McCullen. Thank you, John. And I would like to also
thank the panelists for their thoughtful remarks earlier. I
would like to go back to some of the comments that Dr. Gill
touched on as you were closing out your remarks. You were
talking about the economic downturn. I was wondering if you
would elaborate on that a little bit further and maybe if you
have any information on investment, how you feel SARS may
affect foreign investment in China, and please open it up to
the other panelists also? Thank you.
Mr. Gill. Well, obviously, the most hard hit sectors of the
Chinese economy are going to be some of those that generate a
good amount of foreign exchange. Certainly tourism and service
industries are going to be very heavily affected. To my
knowledge, at this point, however, the basic production base
that makes China the export platform to the world has not been
affected in any serious way. So, it would seem that on the
fundamentals China remains the same attractive place that an
investor would have found in China half a year ago. So, I don't
think that is affected.
Now, what is funny and what is not measurable, is the issue
of confidence. Whether or not you feel, as investors, beyond
the fundamentals that your gut instincts are right in investing
in a country like this for fear that you might lose some of
your investment owing to the spread of this epidemic. At this
stage of the SARS epidemic, again, without knowing the full
extent of whether we are going to see a resurgence in the
winter, the numbers, as a part of the overall Chinese
population and economy, are still relatively small. And I think
it is largely a perception in our gut understanding as
outsiders that has led to this downturn.
I would suppose that if things could be brought under
control and some of the higher numbers could be diminished, or
if the WHO advisory could be lifted before the end of this
year, potentially, or early next year, I would only see this as
a near term economic hit for China. But all of that is very
speculative, because we just don't know. I hope my other
panelists will be able to join me on this.
Mr. Foarde. With the understanding that none of you is an
economist, and not Alan Greenspan either, you can say what you
think, please.
Ms. Henderson. I want to reinforce the idea about how
little we know. There is no simple diagnostic test. We have
some numbers for probable cases out of China. We don't know if
those are true. We don't know if they are high. We don't know
if they are low. But, what I want to point to is the ability of
infectious disease to strike terror in the heart of every
human. The kinds of things that we want to worry about are the
stigma and the discrimination, and the unthinking application
of categories of diagnosis before they are ready, of actions--
not so much taken by the Chinese Government, as simply
perpetuated in the media and fear mongering. I think we need to
be really careful about that. And that is not just SARS. That
is emerging pathogens. And, of course, this is not our last
emerging pathogen. They have been increasing in the last few
decades, in the world. So, I think the whole global community
needs to take a look at how we present these things and try to
introduce more thoughtfulness. But, basically, we just don't
know right now.
Mr. Huang. I will just be very quick. There is no doubt
that the SARS epidemic is going to hurt China's economy. There
are concerns that the epidemic is going to wipe out economic
growth in the second quarter, and possibly reduce the growth
rate for the entire year to about 6 percent, which is well
below the level that the government says is required to serve
the millions of new workers who need jobs. In the meantime,
this is not necessarily a bad thing, considering that the
economy for the first quarter was about 9.9 percent, which some
economists believe is overheating. So, that is not necessarily
a bad thing, because the fundamentals are still there.
Mr. Foarde. I would recognize our colleague Susan
O'Sullivan, who represents Assistant Secretary of State for
Democracy, Human Rights, and Labor, Lorne Craner. Susan.
Ms. O'Sullivan. Thank you, John. I would like to return a
little bit to a question that was touched on earlier, and that
is the disparity in numbers of cases in major Chinese cities. I
am reading State Department reporting on--I think we are
reporting seven cases in Shanghai, for instance, and hundreds
in other cities, like Beijing. I am wondering if there is some
explanation in the way the disease spreads, or do we have to
assume because Shanghai is a major financial center, that there
is still some degree of suppressing the numbers? It strikes me
as odd every time I see these big differences in numbers.
Ms. Henderson. This seems a little bit of a broken record,
but I don't think we know why it has spread, because the risk
factors which predict the spread of this disease are still not
really clear. It has been reported in major cities throughout
the world. It has been reported less in rural areas, but
whether there is something about being in a city, as opposed to
being somewhere else, which is conducive to the spread is not
totally clear.
There must be something about the migration patterns of
particular people from Guangdong to Beijing. In my view it is
more luck that Shanghai doesn't have a lot of reported probable
cases.
Mr. Huang. I agree with Professor Henderson that it is pure
luck that largely accounts for the low incidence rate of SARS
in Shanghai. But, the Shanghai Government and the Chinese
Government as well, also provided another version of the
explanation. That is the Shanghai Government capacity is higher
than other local governments. The official media features a
story that when the Shanghai Government located a SARS patient,
within 6 hours they had found and quarantined 100 people with
whom the patient had direct and indirect contact. That is quite
efficient, if that is true.
Mr. Foarde. I would recognize our colleague, Susan Weld,
who is general counsel of the Commission.
Ms. Weld. Thank you, John. I am thinking about the problem
of information in a large healthcare system such as China has
to have. And the first thing you mentioned, Professor Huang, is
the law that makes communicable disease a state secret. I've
been wondering whether one way of rebuilding external and
internal confidence in the state will be to change that law. I
wonder if that would solve the problem. But, I am also thinking
about professional ethics and doctors and public health
practitioners in China. Is there any sense of professional
ethics that would require them to publish or to speak out on
issues like SARS? I know there has been really courageous
action by the doctor in the military hospital in Beijing, but
can you tell me more about that? Not just you, Professor Huang,
but also Gail and Bates.
Mr. Huang. Well, in terms of the changes in the law, so far
we haven't found any indication that the government is willing
to consider changing the State Secret Law, and also its
implementing regulation with regard to the handling of public
health-related information. Technically, they could do this
very swiftly. They acted very fast by adding SARS as a disease
under surveillance under the Law of Prevention and Treatment of
Infectious Disease. They could act in a similar manner. It's
just that we haven't seen any discussions in that regard.
Also, in terms of professional ethics, I think that many--
actually, in the Guangdong case, evidence suggests that many
physicians were informed about this disease before January 31,
the Chinese New Year. Apparently few people there spoke out.
This, again, is probably because of the State Secret Law, which
prohibits people from speaking out, because they will risk
being persecuted by the government. But fortunately, we have
Dr. Jiang who spoke out. In that regard, I don't have much
information to share with the Commission.
Ms. Henderson. I think a lot of the weaknesses of the
system don't need my reiterating, and I don't disagree with
them. But, I would say that there is probably some important
reasons that there needs to be central control for the
announcement of a major new epidemic. So, while I share the
concerns, perhaps, that this kind of control might lead to
suppressing information, at the same time, I don't think that
the U.S. local public health departments can willy nilly
announce a new epidemic without some kind of OK from the
Centers for Disease Control and Prevention [CDC] as well.
Epidemics introduce new kinds of issues that I think abrogate
some of our normal feelings about human rights.
Second, in terms of the professional ethics, sometimes it's
reported in the press and other places that physicians and
scientists in China never feel free to report any real
statistics. For example, sexually transmitted diseases, which
have been epidemic during the 1990s and into this era. The
initial reports on those were very hesitant in the medical
literature. People might participate in studies, but not want
their names on papers, because they were a little unsure that
it would be the right thing to do for them in their careers in
China. So that is real.
At the same time, I feel that--particularly with the advent
of a lot of international collaboration--there has been a real
change among professionals in China in both the medical and the
scientific communities. I've seen that myself, personally, over
the years with all my work in healthcare. Now I spend a lot of
time at the China CDC and the new AIDS Center. I just think it
is a different world now. It would be great if I could say to
you, ``Here are the structures and the avenues by which people
are able to do this.'' I'm not sure I can recount that. What I
can do is look back in history and say, ``You thought that
there was nothing going on about HIV, but there was. And here
it was in the biomedical literature. The transfusion medicine
literature was full of it way before the New York Times found
out.''
Mr. Foarde. Bates, did you want to take a crack at that?
Mr. Gill. I have one very quick comment. And that is that
laws on the books are great, but obviously, they don't make any
difference if they are not enforced or if the population
doesn't believe that they will get equal treatment under that
law. So, even if they change the law to allow for some sort of
more open reporting mechanism, will a lot of people feel
confident enough to operate under it in China? That's the whole
issue we are examining here: the extent of the scope of rule of
law in China.
Just one other comment I wanted to add to this so let me
stop there. I know we are short of time, but thank you.
Mr. Foarde. Let me go on and try to begin to tie all of
this together with an overall question. You have all sort of
alluded to the answer, but I would like you each to comment on
it more specifically. In the last couple of weeks, we have
heard some observers in the United States suggest that the SARS
crisis may be, or already is, or may become, China's Chernobyl.
The theory being that the Chernobyl disaster was the first in a
set of events that ended up with the collapse of the former
Soviet Union. What are your thoughts on the impact of this SARS
development on the possibilities for political change in China?
We can start with Dr. Huang if you would like to step up to
that question.
Mr. Huang. This analogy of China's Chernobyl is very
appealing, but I think it flies in the face of reality. First,
we should realize that, in terms of the economy, China's
economic situation is much better than Mr. Gorbachev had in the
former Soviet Union. China's economic growth is very strong and
it is probably the fastest growing economy in the world. It is
a bright spot in the global economy with all that global
recession going on. Second, we haven't seen any apparent split
in the Chinese leadership. There might be some policy
differences, power struggles, but as President Jiang used to
say, ``We are all in the same boat.'' So, they may eventually
compromise and still muddle through the crisis. I will leave it
to the other two panelists to comment.
Ms. Henderson. At that time, one of the things about Russia
was not only that its economy was nose-diving, but also its
actual health indicators. Life expectancy was declining. It was
hard to believe that the statistics were right. Life expectancy
had gone from 70 years or above down to, now, below 60 for men.
So much was wrong with that system then and also now, that I
think it is just not comparable. There is a lot of strength now
in the Chinese system.
The way I see this is that this event mobilizes a lot of
forces that have already been at play in China during the
1990s. Both panelists brought up correctly that the public
health system was the ``low person on the totem pole'' for many
years. And now they are going to be boosted up, and they are
going to be implementing things and getting assistance for
things that they have been working on but have been under-
funded. So, I see this as a wonderful transition opportunity as
opposed to a revolutionary event.
Mr. Gill. I would agree with both of my fellow panelists. I
think the Chernobyl analogy is overdrawn. It may be a kind of
Chernobyl-like transformation of the healthcare sector. That is
to say we will see some important changes there, probably a
real devotion of new resources, certainly in the near term. If
Madame Wu Yi stays there, I would assume that she will see to
it that she is able to bring her political clout to bear on
improving matters, but does this mean a political
transformation of the Chinese body politic? No. I don't think
it does.
Another important thing to consider, and it is similar to
lots of other socio-economic ills in China, is that there are
pockets of some unrest and unhappiness and disgruntlement here
and there, and sometimes it does rise up to localized violence
in places, but there is no indication that there is going to be
a systemic uprising of any kind as a result of SARS. The one
comment that I wanted to make before, that I recall now is that
maybe SARS will make a demonstrable case for those who argue
that greater openness is not a bad thing, and it is good to
have laws that make sense and are enforceable and are known to
the people, what their rights are and aren't, that gives people
a greater confidence to speak out when they think they can.
Those who want to advocate that sort of approach in China can
certainly look at the SARS case and say, ``Look at what happens
when we don't have this openness.'' Again, I don't see that as
becoming system-wide, taking on board of that kind of approach,
but rather in certain cases where it can be demonstratively
shown, like in epidemics, for example.
Ms. Henderson. Could I just add one thing real quick?
Mr. Foarde. You've got plenty of time.
Ms. Henderson. If we think about HIV versus SARS, one of
the things about HIV is that even when it moved into the
provinces because of the infection of commercial plasma donors,
even then, the Chinese are still able to think of it as a
disease that is not going to affect them in a major way. SARS
is different. This is really different. Healthcare workers are
affected first; people in cities; people who are near the
centers of power. I think for public health it is a disaster,
but it is also an opportunity to lobby.
Mr. Foarde. Very useful. Let me ask Dave Dorman if you have
another question for the panel?
Mr. Dorman. Thanks, John. We touched upon several times the
fact that the basic pieces of the preventative and curative
healthcare structure are in place. I think some of you
suggested that, perhaps, the SARS crisis may lead to some
change in political commitment, and through it, an increase in
the inflow of cash into that structure. What other factors for
improvement should we be looking for? For instance, in terms of
managing a very large health structure like this, are there
presently sufficient numbers of experts and technicians in
China to make it happen? And are there other factors that we
haven't talked about yet? Is political commitment from the
leadership and an influx of cash enough? Or are there other
pieces that we should be looking for as we review what happens
in the next 12 months or so?
Mr. Huang. I think I can answer that question. I think that
such a commitment is important. More healthcare financing is
also important. But, it is equally important to strengthen the
bureaucratic capacity in managing China's health system. What
we have found here is actually two problems. First the lack of
coordination between different bureaucratic organizations. We
have evidence that suggests--in 1993, for example, the Minister
of Health wanted to strengthen rural healthcare by promoting a
primary healthcare and assigning targets that were to be
fulfilled by local government officials. But they had the
Ministry of Agriculture step in and say, ``No, we are going to
eliminate these items, because they are going to increase the
peasant burden.'' So, you can see this lack of coordination
between different bureaucratic organizations.
And so is the case in the recent SARS outbreak. What we
have found here is lack of coordination between the central
ministries and the local governments. A good example is the
Ministry of Health in Beijing actually learned about what was
happening in Beijing in March and they wanted to do something,
but Beijing city authorities basically didn't want to have
involvement from the Ministry of Health. They said, ``We can
handle it.'' So, this is another example of coordination
between different bureaucratic organizations.
The second problem is the lack of regulatory ability.
Unlike the United States, China doesn't have a very strong,
very capable Food and Drug Administration [FDA] that regulates
foods and pharmaceuticals. Officially they have this
pharmaceutical administrative bureau, but that is the one that
doesn't have the teeth. The State Council wants to expand the
functions of the State Pharmaceutical Bureau to make it China's
FDA, but they haven't specified what they are going to do to
make it really happen.
Ms. Henderson. I am not a political scientist, so I am not
going to talk about the lack of coordination between the
different ministries and the top and the bottom. I would
comment, however, on the scientific and technical personnel,
which are in short supply, but incredibly talented, and that is
the bottom line. There are not enough people, the people are
remarkably overburdened at the top. They are talented,
dedicated professionals but they are in short supply. But,
checking the blood supply, which is one of the major reasons
there is such big HIV epidemic they knew what to do, and they
have been working on it, but there are a certain number of
things that they couldn't do because the tests are too
expensive in Xinjiang Province. Because a cheap one isn't
sensitive, isn't specific, there are a lot of missed cases, but
they can't afford the expensive ones. And it is that level of
difficulty with resources that is very nuts and bolts. So more
trained people and devoting a lot of resources technically to
the capacity to do testing, surveillance, making the system
really work. It is expensive.
Mr. Gill. Let's not forget we are talking about 800 to 900
million people who live in remote, often very backward parts of
China. It strikes me that--especially on the HIV/AIDS side of
things--this is not going to get taken care of through a
formalistic, overarching, top-down, massive public healthcare
system. It is not going to happen. They are going to have to
come up with some ways of managing, especially in these very
far and remote areas through some sort of localized, even
family-based forms of treatment and care. Mostly care,
unfortunately, because you are not going to have qualified
persons. And then the talented ones get out and go to where the
money is in the system. So, to the degree that your question is
asking how are we going to manage this at this very low
grassroot levels, where the vast, vast majority of the Chinese
population lives, that is going to be very, very difficult. I
think it is going to have to require some more innovation and a
little bit more loosening of the strings, if you will, to come
up with more localized, community-based, even family-based
answers. As Dr. Henderson said, the problem is just enormous.
And the challenge is extremely expensive.
Just as another aside, how about delivery of drugs to the
patient? Let's say you did have all of the drugs you wanted.
How are you going to get it to the point of care in a place
like China? It's a huge problem, especially in the countryside.
Mr. Foarde. Susan Weld.
Ms. Weld. Yes. That just makes me think of the
possibilities that NGOs could undertake in different parts of
China, and maybe in some of the more remote parts. If the laws
were reformed to make NGOs easier to establish, then they could
provide some of this difficult work or treatment and care for
the people who are living with AIDS and the people living with
the after effects of SARS. Does anybody think that this will
happen? Is that something which is a hopeful way of dealing
with the after effects of this disease and other diseases like
it?
Ms. Henderson. Well, there are a lot of NGOs and
international aid organizations already working on these things
in different ways in China. I think there is a pretty good
coordination. Everybody knows what the others are doing. I
would like to say that in the last year the Chinese Government
has stepped up to this responsibility, and said that 100
counties that are hardest hit with HIV/AIDS will have treatment
programs there.
NIH and AIDS clinical trial groups--the units that have
been working on research and treatment in many medical centers
across the United States--have also been to China, mobilizing
to set up centers there to institute treatment programs. You
really do need to learn to treat. You need to follow people.
But at the same time, there is a demand from the local areas to
get the training; on how to carry out treatment. I've seen that
in meetings in China last year. So, there is a political will
in the local areas and some help from outside, and now
especially from the central government, to fund it.
I don't want to be too rosy. There is funding and then
somebody goes, ``Oh yeah, but we need to think about how much a
monitoring test will cost.'' So it is difficult to find the
money for every little incremental bit.
Ms. Weld. I guess I am thinking of the connection between
one problem or SARS and the possibility that civil society will
develop using NGOs if you want to call them that, or social
organizations, ``shehui tuanti,'' that level of development and
capacity-building. The hope would be that, instead of having to
find outside money to put in in the future these kinds of
organizations will be self-sustaining on the local or national
level.
Ms. Henderson. I have only seen a few NGOs that deal with
AIDS. Unfortunately, I think they find that they encounter a
lot of resistance. There is a lot of stigma. There is a lot of
difficulty in talking about some of the risk factors for AIDS,
until very recently, in highly stigmatized groups. So, I
haven't seen that as being an avenue. I'm sorry to say that I
haven't.
Mr. Gill. Anything that comes close to what we might call
an NGO in China is a relatively small operation and certainly
doesn't have the capacity to undertake nationwide programs. I
think in the near-term if we are going to look to quasi-
governmental groups to have a national impact, it would be the
so-called social organizations that are government organized
organizations. They are one or two steps removed from the line
ministries, but often have quite an extensive reach down into
the provincial, county, and even village levels. Maybe they
wouldn't be treatment and care providers, but they certainly
could be effective in terms of preventive messaging and
awareness; transmission belts; passing information. Maybe they
could be empowered to a greater degree in the Chinese system,
because they really are government organizations, even though
they do have authority connected to government ministries.
Maybe the way to go in the near term is to encourage a process
of empowering those sorts of organizations.
Mr. Foarde. We are just about out of time for this
afternoon. So, if you would, I would ask each of the panelists
to spend a couple of minutes making a final statement if you
have something to say. If you don't, that's fine.
Ms. Henderson. Thank you. Now, of course, I don't want to
repeat the earlier things I've said. There are a lot of
strengths and weaknesses. The strengths come from earlier era,
and also from most recent developments, partly as a result of
international collaborations, in China opening up in great ways
to the rest of the world. Weaknesses have to do with the
economic reforms and the destruction of a lot of public health
programs.
I think the main thing I want to say is that this is an
unprecedented event, certainly in our recent history. I think
it is short-sighted to come down too hard on the way the
Chinese have dealt with this crisis. I am not sure how our
country would have dealt with it had we actually had an
epidemic here. We don't know whether we did or not since we
don't know if we had cases.
I think this is an opportunity for the system to reform, to
learn important lessons, lessons that can't be ignored, that
they ignored, unfortunately, with AIDS. This was because they
could tuck it into Xinjiang, tuck it in Yunnan, blame the drug
users and so on, and not really confront the weaknesses in the
system to treat. Plus, the world changed with regard to
treatment for AIDS patients in the year 2000 with the Durban
Conference. So, now we think people with HIV have a right to
treatment. That was not part of the world view before 2000.
So, there is a lot that has changed dramatically. But, I
also think that in our media and in our response to China, we
have an opportunity now to be supportive and nonjudgmental. I
would advocate for that approach because this is an
extraordinary challenge to any system. Even a system that
functions perfectly and has all bureaucracies talking to each
other and so on. It's just unprecedented. I would advocate that
we be humble, because we have a lot of problems ourselves. We
haven't done so well with infectious epidemics. I know that
sounds a little like seeing it through rose-colored glasses.
But I think that this approach could get results from the
Chinese Government.
Mr. Huang. I would like to talk a little bit about the
importance of international actors in setting an agenda for the
Chinese Government. The recent agenda shift, to a large extent,
was caused by the strong international pressures exerted by the
international media, the international organizations like WHO,
and foreign governments. And there is an indication that the
Internet is increasingly used by the new leadership to solicit
policy feedback, collect public opinions, and mobilize
political support.
In fact, it is very likely that Hu Jintao and Wen Jiabao,
who are both Internet users made use of international
information in making decisions on SARS. In other words,
external pressures can be very influential, because Chinese
Government leaders are aware of the weakness of the existing
system, and have incentives to seek political resources beyond
the system.
Mr. Gill. Just two quick points here. I think we are at a
very interesting window of opportunity. It is too early yet to
quite determine just how far and fast we can move with China to
bring about and foster the kinds of changes we would like to
see there. Not only in terms of the public health system, but
also in terms of openness, transparency, and accountability.
Opportunities like this don't come along very often. This is a
huge issue inside China. It is something that is not going to
be quickly forgotten, and the leaders are upright and at
attention, and they are focusing on this like a laser beam.
This is an opportunity for us to speak with them frankly,
forthrightly, about the issue as a public health problem, but
also more broadly as how it ripples out into the questions of
socioeconomic change and transformation that the Commission is
trying to examine. I think this window is going to close before
long. So, I think it is a good opportunity to follow through
with that.
Second, in that regard, I would encourage all of the
Commission members, to the extent you can to speak to your
principals and make sure that even though they may not be
Secretary of Health and Human Services Tommy Thompson, you can
bring up public health issues and question the social safety
nets with your Chinese counterparts. That is going to foster
the kind of cross-bureaucratic attention to this issue in China
that is so badly needed. So, it is not just health issues. I
mean, if the Secretary of Commerce goes over and speaks to his
counterpart, and bullet point two--you know right after WTO
bullet point--is why the collapse in social safety net in China
is a threat to the world economy, that guy is going to listen.
He is going to find one of his people to start working on this
issue. Believe me.
So, we need to help the Chinese understand that this is not
just a healthcare issue, that we do need to help foster that
cross-bureaucratic interagency process. It will happen if our
principles are going over there and raising these issues as
something important to the United States.
Mr. Foarde. Thanks to all three of you for sharing these
views with us this afternoon. You are all extremely well-
disciplined and extremely articulate, and thanks very much for
that.
I would remind you that our next session will be on Monday,
June 2, 2:30 p.m. in this room. The topic and panelists to be
announced. I hope you will join us then.
With that, we will close this afternoon's roundtable with
thanks to all who attended, to the staff that helped us put it
on, and to our three panelists. Good afternoon to everyone.
A P P E N D I X
=======================================================================
Prepared Statements
----------
Prepared Statement of Gail E. Henderson
may 12, 2003
Myths and Reality: The Context of Emerging Pathogens in China
America's first images of China in the early 20th century were as
the ``sick man of Asia.'' \1\ In 1948, the U.N. Relief Organization
stated, ``China presents perhaps the greatest and most intractable
public health problem of any nation in the world.'' Two decades later,
the dominant image of Mao's China was one of healthy, red-cheeked
babies born to a nation that seemingly provided healthcare for all.\2\
The real story is more complex than either of these images, but in a
country as vast and varied as China, many realities are true. The
recent spread of HIV/AIDS and now the SARS epidemic have placed
enormous stress on the Chinese healthcare system, as would be the case
for any healthcare system. To effectively assist the Chinese response
to SARS, we must understand the forces that have shaped this system.
This requires a small excursion in history, past and recent, to revisit
remarkable achievements and the factors that have determined the
current system's strengths and weaknesses.
---------------------------------------------------------------------------
\1\ J Horn, Away with All Pests: An English Surgeon in the People's
Republic of China (New York: Monthly Review Press, 1969); GE Henderson,
``Public Health in China,'' in WA Joseph (ed), China Briefing 1992
(Boulder: Westview Press, 1992).
\2\ V Sidel, Serve the People: Observations on Medicine in the
People's Republic of China (Boston: Beacon Press, 1974).
---------------------------------------------------------------------------
What will the history tell us? (1) Public health, which includes
disease surveillance, health education, environmental sanitation,
nutrition and food hygiene, and maternal and child health, is not a
money-making operation. The trends in China's recent history
demonstrate that public health agendas require strong government
support and resources; it is easier to accomplish them when market
forces are held at bay--or at least not in direct competition. (2)
China's current curative healthcare system, of hospitals and clinics,
has been shaped by economic incentives in the post-Mao era that have
encouraged the development of hospital-based high technology medical
care. In concert with the move away from collective welfare and central
administration, inequalities in access to services have increased. But
the infrastructure remains and can be supported and strengthened by
forces within and outside of China. (3) Infectious diseases often
strike hardest at the most vulnerable groups, those with least access
to governmental safety nets. This was true for HIV in China--and in all
nations--and the fear with SARS is that weaknesses in the rural health
system, particularly in remote areas, will make containing the disease
much more difficult. Newspaper reports about poor quality hospitals or
farmers who cannot pay for needed medical care tell an important side
of the story, but focus attention away from other critical components.
(4) If we are to effectively assist China's response to SARS, we must
understand the sensitivity for any government of double threats to
public health and the economy, and reject the accusatory rhetoric that
has characterized much of the editorializing of recent reports.
Instead, we must recognize and build on the work of responsible,
dedicated professionals in China and the US, people who are best
positioned to develop strategies to contain SARS and prevent the
emergence of other deadly pathogens.
Public health was probably Mao's biggest triumph. Under his
leadership (1949-1976), China experienced the most successful large-
scale health transition in human history--a near doubling of life
expectancy (from 35 to 68), the eradication of many endemic and
epidemic infectious diseases, including illicit drug use, prostitution
and sexually transmitted diseases,\3\ that resulted in a gradual shift
in the leading causes of death from infectious disease to chronic
conditions.\4\ This was not accomplished through great gains in per
capita income, but rather by creating a closed socialist political
economy that exercised control over industry, agriculture, and
migration; redistributed income and wealth; and had the ability to set
national and local priorities in healthcare. By focusing on broad
distribution of resources and reliance on low-tech public health
measures and ``patriotic public health campaigns'' that mobilized the
population against environmental and behavioral risk factors,
achievements were made in sanitation, maternal and child health,
infectious disease
surveillance, and vaccination; and China's three-tiered primary
healthcare system became the WHO model for developing countries.\5\
Most citizens had medical insurance through rural cooperative programs
or urban workplace programs, although the level of coverage, quality of
services, and overall health status indicators were never equivalent
between rural and urban locations\6\
---------------------------------------------------------------------------
\3\ MS Cohen, GE Henderson, P Aiello, Zheng HY, ``Successful
Eradication of Sexually Transmitted Diseases in the People's Republic
of China: Implications for the 21st Century,'' Journal of Infectious
Disease 1996; 174 (Supplement 2): S223-230.
\4\ WC Hsiao, ``Transformation of Health Care in China,'' New
England Journal of Medicine 310:932-6, 1984; GE Henderson, ``Issues in
the Modernization of Medicine in China,'' in D Simon and M Goldman (ed)
Science and Technology in Post-Mao China (Cambridge: Harvard University
Press, 1989); see also World Bank reports on China's health sector
(1984 and 1989).
\5\ RJ Blendon, ``Can China's Health Care Be Transplanted Without
China's Economic Policies?'' New England Journal of Medicine 300: 1453-
58, 1979.
\6\ GE Henderson et al., ``Distribution of Medical Insurance in
China,'' Social Science and Medicine 41,8: 119-30.
---------------------------------------------------------------------------
After Mao's death, the market-oriented economic reforms of the
1980s and 1990s transformed the nation once again. Incomes and
productivity rose dramatically as agriculture and then industry were
de-collectivized, and there was a general loosening of administrative
authority over lower level units. Living conditions, diet, and health
and nutrition outcomes all improved steadily.\7\ This was in contrast
to the Soviet Union where life expectancy actually declined, from 70 in
1986 to 64 in 1994, and has continued to decline thereafter. Major
investments were made in urban medical services, long stagnant under
Mao, as China turned to the West to help modernize its hospitals,
technology, pharmaceuticals, and medical research and training; and
these changes had a positive impact on health status as well.\8\ In
part, these were responses to the increase in chronic diseases, for
which modern medicine had developed expensive, intensive
interventions--conditions like heart disease, stroke, and cancer--which
were all increasingly prevalent. In part, however, as World Bank and
Chinese public health researchers have clearly documented,\9\ the
economic reforms created irrational incentives for hospitals to
emphasize new technology and drugs because, as the government funded a
smaller and smaller proportion of hospital budgets, profits on their
use provided much needed revenue. In some cases, these reforms forced
inefficient and poor quality hospitals to offer better services; in
others, especially for the lowest level township hospitals in poorer
rural areas, they have produced failing hospitals with little to
replace them.
---------------------------------------------------------------------------
\7\ See appended tables from Zhongguo Weisheng Nianjian (China
Health Yearbook) 2001 (Beijing: People's Medical Publishing House,
2001) reporting 2000 mortality rates and leading causes of death. See
BM Popkin et al., ``Trends in diet, nutritional status and diet-related
non-communicable diseases in China and India: The economic costs of the
nutrition transition.'' Nutrition Reviews 59: 379-90, 2001,
demonstrating the decline in malnutrition across rural China during the
1990s and rise in non-communicable disease.
\8\ GE Henderson et al., ``High Technology Medicine in China: The
Case of Chronic Renal Failure and Hemodialysis,'' New England Journal
of Medicine 318,15:1000-4, 1988.
\9\ China 2020 series: Financing the Health Sector (Washington DC:
World Bank, 1997)
---------------------------------------------------------------------------
Public heath programs that did not generate profits suffered under
the transition to a market-oriented system as well, with implications
for health outcomes. For example, during the mid-1980s, funding for
childhood immunizations in rural areas declined, which produced an
increase in childhood infectious diseases. The government response,
with assistance from the UNICEF, reversed this trend. My own research
in a Shandong county public health department in 1990,\10\ and surveys
of rural health services in eight provinces during the 1990s,\11\
document that collective benefits and funding for public health varied
with the wealth of the region, but the hierarchy of medical and public
health supervision continued to extend to clinics in villages and
county towns. The top-down mobilization style of health education and
prevention work was still effective against outbreaks of infectious
diseases for which standard protocols existed (such as epidemic
hemorrhagic fever, or Hanta virus); however, it was less capable of
responding to new and more complex challenges such as risk factors for
chronic conditions like hypertension which were not routinely screened.
As many have observed, increased financial and administrative
independence of local health institutions also undercut the ability of
the central government to mobilize public health activities. This was
demonstrated by the national-provincial conflict over response to the
HIV epidemic, especially in areas with HIV-infected commercial plasma
donors. This decentralization of authority and shift in concentration
of resources from rural to urban areas, and from public health to
curative medicine, has direct consequences for China's response to the
SARS epidemic.
---------------------------------------------------------------------------
\10\ GE Henderson and TS Stroup, ``Preventive Health Care in
Zouping: Privatization and the Public Good,'' In A Walder (ed), Zouping
in Transition: The Political Economy of Growth in a North China County.
(Cambridge: Harvard University, 1998)
\11\ China Health and Nutrition Survey (funded by NIH, NSF,
Foundation, UNC, and Chinese Academy of Preventive Medicine), conducted
in 1989, 1991, 1993, 1997, and 2000.
---------------------------------------------------------------------------
Two economic trends thus characterize China during the reform
period: (1) increase in aggregate income levels, and (2) increase in
disparities in income distribution (income inequality in China now
equals that of the United States).\12\ In any economic system, both
trends are related--and in complex and sometimes contradictory ways--to
health outcomes.\13\ On the one hand, increased income and wealth
produce improved health outcomes. China's impressive gains in per
capita income in the post-Mao era, and especially in the last decade,
are correlated with improvements in many health status indicators:
during the 1990s, overall mortality rates declined in both urban and
rural areas;\14\ between 1991 and 2000, infant morality dropped
significantly, from 17.3 to 11.8 per 1000 live births per year in urban
areas, and from 58.0 to 37.7 in rural areas; and maternal mortality
rates declined as well, in rural areas between 1991 and 2000 from 100.0
to 69.6 per 100,000 women per year, and in urban areas, from 46.3 to
29.3.
---------------------------------------------------------------------------
\12\ The World Bank reports the inequality index (Gini coefficient)
for both countries in 1997 at about 40. Gini measures income
distribution on a scale of 1-100. A rating of ``1'' would mean that
that income is perfectly equally distributed, with all people receiving
exactly the same income; ``100'' would mean that one person receives
all the income. European countries' Gini coefficients ranged in the 20s
and 30s; the highest were Brazil, South Africa, and Guatemala, at
around 60.
\13\ Moreover, extent of inequality itself seems to be related to
poorer healthcare access and outcomes.
\14\ Jun Gao et al., 2002, p. 22.
---------------------------------------------------------------------------
On the other hand, inequality in income distribution is linked to
unequal access to care and consequently to disparities in health
status. Urban-rural health disparities are evident in the mortality
figures cited above, although the gap is declining for infant
mortality.\15\ Such highly aggregated health status measures often mask
significant differences between geographic and sub-population income
groups,\16\ however, and this is certainly true for China's border and
minority regions where mortality rates are much higher. In addition to
income and geographic location, the strongest predictor of access to
healthcare is having medical insurance. In urban areas the percent with
employment-based coverage declined between 1993 and 1998, from 68.4
percent to 53.3 percent; but the rural insurance programs that depended
on the collective economy for funding collapsed almost entirely in the
1980s, and by 1998, only 8.8 percent of the rural population had
coverage.\17\ Initially, because medical care charges had been kept
below cost through price controls, loss of insurance did not create
widespread hardships. However, as medical services improved and charges
rose steeply during the 1990s, paying for medical care became
increasingly burdensome to the poorest citizens.\18\ Data from surveys
during the 1990s document a decline in rural, compared to urban,
inpatient admissions.\19\ and anecdotal reports suggest that many do
not seek care due to the financial burden. During the 1990s, one of the
most researched topics in healthcare in China was reform of health
insurance, and pilot insurance programs were initiated in a number of
urban and rural areas.\20\
---------------------------------------------------------------------------
\15\ Zhongguo Weisheng Nianjian (China Health Yearbook) 2001.
(Beijing: People's Medical Publishing House, 2001) The comparable US
figures are not too dissimilar: in 1997, IMR for whites was 6.0; for
blacks it was 13.7, a greater than twofold difference (CDC NCHS
website).
\16\ Liu YL WC Hsiao, and K Eggleston., 1999, p 1350.
\17\ Jun Gao et al., 2002 p. 26.
\18\ Liu Yuanli, WC Hsiao, and K Eggleston, ``Equity in Health and
Health Care: The Chinese Experience,'' Social Science and Medicine
49,10:1349-56, 1999; GE Henderson et al., ``Trends in Health Services
Utilization in Eight Provinces of China, 1989-1993,'' Social Science
and Medicine 47,12:1957-71; Jun Gao et al., ``Health Equity in
Transition from Planned to Market Economy in China,'' Health Policy and
Planning 17 (Suppl 1):20-29, 2002.
\19\ Jun Gao et al., 2002, p. 26.
\20\ GG Liu et al., ``Equity in Health Care Access: Assessing the
Urban Health Insurance Reform in China,'' Social Science and Medicine
55,10:1779-94; G Bloom and Tang SL, ``Rural Health Prepayment Schemes
in China: Toward a More Active Role for Government,'' Social Science
and Medicine 48,7:951-60; G Carrin et al., ``The Reform of the Rural
Cooperative Medical System in the People's Republic of China: Interim
Experience in 14 Pilot Counties,'' Social Science and Medicine
48,7:961-72.
---------------------------------------------------------------------------
In a developing country with 1.3 billion people, it is not
surprising that remote rural areas in China lack resources to respond
to HIV or SARS. Yet, one positive development appeared in 2002, prior
to the SARS outbreak, to address these well-recognized inequalities. A
program to rebuild rural health infrastructure, based on multi-
ministerial coordination, was initiated. It includes: (1)
reconstituting rural
cooperative insurance to cover 900 million farmers through a joint
funding mechanism, with direct investment from central, provincial and
local governments and from the farmers themselves; and (2) re-
establishing rural township public health hospitals to implement and
oversee public health activities at the township and village levels
that had become ``unfunded mandates'' during the reform era. If
implemented, these initiatives will have a positive impact on public
health and disease prevention in the long term,\21\ and the current
dual challenges of HIV/AIDS and SARS add impetus to seeing that these
programs are actually carried out. In the meantime, the government has
established a special fund for those without insurance who seek
treatment for symptoms of SARS.
---------------------------------------------------------------------------
\21\ Personal communication with Dr. Yiming Shao, Chinese Center
for Disease Control and Prevention
---------------------------------------------------------------------------
Despite these measures, public health experts believe that China
urgently needs international assistance in such areas as health
surveillance, prevention, and control of communicable diseases. This is
a role that the United States is well positioned to fill. The CDC and
NIH have added personnel and funded projects in China, but, compared to
other nations, the United States could be contributing much more.
In assessing the Chinese response to SARS, we are advised to turn
to the lessons of AIDS for guidance.\22\ Not surprisingly, the media
has tended to highlight China's weaknesses in dealing with AIDS,
particularly inaction in the face of HIV infection of commercial blood
plasma donors during the 1990s in a number of provinces, as reported in
the New York Times in late 2001. While I do not minimize the gravity of
this part of the epidemic or the negative consequences of delay, these
images distort appreciation of the strengths of the Chinese response,
strengths that must be recognized and reinforced for the current system
to respond effectively to SARS. For example, evidence that the epidemic
was spreading to plasma donors was actually reported in the
international and Chinese medical literature as early as 1995,\23\ and
in 1996, at the International AIDS meeting in Vancouver.\24\ By the
time of the first international AIDS conference in Beijing, in 2001,
detailed epidemiology was being conducted and reported.\25\ During this
same time period, the daunting difficulties involved in protecting
China's blood supply were documented in a number of publications. These
included cultural barriers to an all-volunteer blood donation system,
shortage of clinical transfusion specialists, and the high cost of
technology required for accurate testing for transfusion-transmissible
diseases such as hepatitis and HIV.\26\ Efforts to improve the safety
of the blood supply have been ongoing and
increasingly successful; and in 2002, the Chinese Ministry of Health
had publicly outlined a plan to include AIDS comprehensive prevention
and care programs for plasma donors and other risk groups in 100
counties identified as hardest hit by AIDS.\27\ These are extremely
important developments, and deserve media attention as well as
international support.
---------------------------------------------------------------------------
\22\ LK Altman, ``Lessons of AIDS, Applied to SARS,'' New York
Times May 6, 2003 D1
\23\ Ji Y, Qu D, Jia G, et al. ``Study of HIV Antibody Screening
for Blood Donors by a Pooling Serum Method,'' Vox Sang 1995, 9:255-6.
Wu Zunyou et al., ``HIV-1 infection in commercial plasma donors in
China,'' The Lancet 1995 Jul 1;346(8966):61-2. Lancet is the premier
British Medical journal. This first report featured a mother and her
two daughters who tested positive, in the absence of any other risk
factors except commercial blood donation, in rural Anhui Province,
between February and March 1995. The authors state, ``Notification of
HIV-1 infection to infected persons or their family members is not
routinely done in China. Neither these infected women nor their family
members were informed of the infection because it was feared that they
would commit suicide if they discovered they were infected with HIV-
1.'' The authors recommended screening plasma products and donors,
disclosing HIV status to infected individuals, and introducing
surveillance of plasma donors. Other articles about HIV in plasma
donors include: Ji Y et al., ``An Antibody Positive Plasma Donor
Detected at the Early Stage of HIV Infection in China,'' Transfusion
Medicine 6,3:291-2, 1996; VR Nerurkar et al., ``Complete Nef Gene
Sequence of HIV Type 1 Subtype B'' from Professional Plasma Donors in
the People's Republic of China,'' AIDS Res Hum Retroviruses 14,5:461-4,
1998; and Zheng X et al. (China CDC), ``The Epidemiological Study of
HIV Infection Among Paid Blood Donors in One County of China,''
Zhonghua Liu Xing Bing Xue Za Zhi (China Journal of Epidemiology)
21,4:253-55, 2000.
\24\ Dr. Yiming Shao, a virologist from the Chinese CDC, presented
data at this conference.
\25\ Before 2000, epidemiology was published in Chinese journals,
e.g., Ye DQ, et al., ``Serological epidemiology of blood donors in
Hefei, Anhui Province,'' Chinese Journal of Public Health 17:367-8,
1998; and in 2001, in the West, e.g., Wu ZY, Rou KM, and R Detels,
``Prevalence of HIV Infection Among Former Commercial Plasma Donors in
Rural Eastern China,'' Health Policy and Planning 16,1:41-46, 2001
\26\ Hua Shan, Wang J, Ren F, et al., ``Blood Banking in China,''
The Lancet 360:1770-5, 2002.
\27\ ``AIDS Comprehensive Prevention and Treatment Demonstration
Sites,'' China MOPH, 2003.
---------------------------------------------------------------------------
We excoriate the Chinese government for allowing the epidemic to
spread through hundreds of poor villages. But we should ask how well
other countries with far greater resources have performed? And we must
also ask whether we apply a double standard to developing countries
when it comes to public health performance.\28\ In fact, few
governments, rich or poor, have successfully stemmed the spread of
AIDS. In my view, the use of public health challenges as shorthand
political critiques is a real danger as we move forward to combat a
global threat. If China applied the same shorthand to characterize the
U.S. healthcare system--a system that spends more than any other nation
on medical care--and its capacity to respond to crises, what would we
be reading? That African Americans are ten times as likely to die from
HIV as whites, a statistic that reflects the disgraceful fact that
disparities in morbidity and mortality between blacks and whites are
actually greater now than in 1950? That the CDC responded rapidly to
protect U.S. senators from anthrax, while failing to extend that same
response to U.S. postal workers? In the rush to judgment on SARS we
should also remember that the Chinese public health system has proven
that it can respond to potential threats with speed and decisiveness:
in December 1997, fearing an outbreak of a deadly strain of avian flu,
the Chinese decided in 1 day to slaughter 1.2 million chickens from 160
farms and from more than 1,000 retailers and stalls.\29\ How many other
governments would have had the political will to take such action?
---------------------------------------------------------------------------
\28\ For example, what was our response when Nelson Mandela failed
to arrest the spread of HIV in South Africa, when under his watch, the
prevalence of HIV in antenatal clinics rose from under 1 percent to
near 30 percent?
\29\ G Kolata, Flu: The Story of the Great Influenza Pandemic of
1918 and the Search for the Virus that Caused It (NY: Simon and
Schuster, 1999) p. 239. In fact, it was suspicion that SARS was
actually avian flu that delayed response in some locations.
---------------------------------------------------------------------------
If response to SARS is compared to response to AIDS, we must
examine all components of the response. We need to recognize that
funding from the United States and other donors for biomedical and
scientific collaborations is having an important impact on HIV
prevention and treatment. Awarding a $15 million NIH Comprehensive
International Program of Research on AIDS (CIPRA) grant to the China
CDC in summer 2002 did not garner much media attention, but it provided
funds for vaccine development, research on risk factors and behavioral
interventions, and treatment trials that are all moving forward. Other
U.S. and international organizations have contributed to research
efforts, including the CDC, World Bank, DFID, UNAIDS, UNICEF, AUSAID,
WHO, Ford Foundation, USAID, and the Gates Foundation. An additional
consequence of these collaborations is increased attention to and
training for researchers and communities on the ethics of humans
subjects protections in clinical research.\30\ Perhaps most important,
clinical research also has the potential to focus attention on unmet
treatment needs, as occurred after the first International AIDS meeting
held in Africa, in 2000, when the magnitude of HIV among Africans
became suddenly so salient that the world could no longer ignore the
double standard of access to drugs only in developed countries. While
many factors influenced China's decision to establish AIDS prevention
and treatment services in the 100 highest prevalence counties, it was
initiated after a major Sino-U.S. conference, in November 2002, on AIDS
research and training in Beijing.
---------------------------------------------------------------------------
\30\ Research ethics training programs have been carried out at the
China CDC AIDS Center during 2002 and 2003, sponsored by NIH Fogarty
International Center AIDS International Training in Research and
Prevention Program, at both UCLA and UNC, and the NIH Office of AIDS
Research.
---------------------------------------------------------------------------
Statistics on disease and death rates are often used like Rorschach
tests to measure the legitimacy of a government. Infectious diseases,
including emerging pathogens like HIV and SARS, are particularly potent
foci for such critiques, in part
because they tend to fall hardest on the most vulnerable and least well
served by society. In fact, as Paul Farmer, a Harvard physician and
anthropologist who has written extensively about AIDS in Haiti, argues,
``inequality itself constitutes our modern plague.'' \31\ It is not
clear how large the SARS epidemic in China will be or how long it will
last. What is clear is that the outbreak has alerted China and the
world to the relationship between infections and inequalities, and the
peril to all of us if we ignore that relationship.
---------------------------------------------------------------------------
\31\ P Farmer, Infections and Inequalities: The Modern Plague.
(Berkeley: UC Press, 1999).
---------------------------------------------------------------------------
The spread of these emerging pathogens in China and elsewhere is a
direct, if unintended, consequence of economic reform and integration
of China into the global community. These are reforms that the United
States has encouraged and in which the business and scientific
communities have played key roles. Helping to enhance the strengths of
China's public heath system instead of focusing on its failures will
reinforce needed reforms that in some cases are already underway. We
must credit China's current efforts to contain the epidemic in its
hospitals, cities and borders, and openness to international
collaboration and information sharing for what they are--contributions
to the global efforts to control this deadly disease, and prevent an
epidemic from becoming a pandemic.
______
Prepared Statement of Yanzhong Huang
may 12, 2003
Implications of SARS Epidemic for China's Public Health Infrastructure
and Political System
the return of the god of plagues
Since November 2002, a form of atypical pneumonia called SARS
(Severe Acute Respiratory Syndrome) has spread rapidly from China to
Southeast Asia, Europe, and North America, prompting World Health
Organization (WHO) to declare the ailment ``a worldwide health
threat.'' According to the organization, as of May 10, 2003, a
cumulative total of 7,296 cases and 526 deaths have been reported from
33 countries or regions. The country that is particularly hit by the
disease is China, where the outbreak of SARS has infected more than
4,800 people and killed at least 235 nationwide (excluding Hong Kong
and Macao). The worst-hit city is China's capital Beijing, which has
more than 2,200 cases--nearly half China's total--and 116 deaths.
History is full of ironies: the epidemic caught China completely off
guard 45 years after Mao Zedong bade ``Farewell to the God of
Plagues.''
The SARS epidemic is not simply a public health problem. Indeed, it
has caused the most severe social-political crisis to the Chinese
leadership since the 1989 Tiananmen crackdown. Outbreak of the disease
is fueling fears among some economists that China's economy might be
headed for a serious downturn. It already seems likely to wipe out
economic growth in the second quarter and possibly reduce the growth
rate for the entire year to about 6 percent, well below the level the
government says it required to absorb millions of new workers who need
jobs. The disease has also spawned anxiety, panic and rumour-mongering,
which has already triggered a series of protests and riots in China.\1\
Meanwhile, the crisis has underscored the tensions and conflicts among
the top leadership, and undermined the
government's efforts to create a milder new image in the international
arena. As Premier Wen Jiabao pointed out in a recent cabinet meeting on
the epidemic, at stake were ``the health and security of the people,
overall State of reform, development, and stability, and China's
national interest and international image.'' How to manage the crisis
has become the litmus test of the political will and ability of the
fourth generation of Chinese leadership.
---------------------------------------------------------------------------
\1\ Anthony Kuhn, ``China's Fight Against SARS Spawns Backlash,''
Los Angeles Times, My 6, 2003.
---------------------------------------------------------------------------
Given the political aspect of the crisis, this testimony will
consider not only problems in China's public health infrastructure but
also dynamics of its political system. It proceeds in three sections.
The first section focuses on the making of the crisis, and discusses
how problems in the health and political systems allowed SARS to
transform from a sporadic nuisance to an epidemic that now affects
hundreds of millions of people across the country. The next section
considers the government crusade against SARS, and examines how the
State capacity in controlling the
disease is complicated and compromised by the health infrastructure and
political system. The last section concludes with some policy
recommendations for the Commission to consider.
the making of a crisis (november 2002-april 2003)
Information blackout in Guangdong
With hindsight, China's health system seemed to respond relatively
well to the emergence of the illness. The earliest case of SARS is
thought to occur in Foshan, a city southwest of Guangzhou in Guangdong
province, in mid-November 2002. It was later also found in Heyuan and
Zhongshan in Guangdong. This ``strange disease'' alerted Chinese health
personnel as early as mid-December. On January 2, a team of health
experts were sent to Heyuan and diagnosed the disease as an infection
caused by certain virus.\2\ A Chinese physician, who was in charge of
treating a patient from Heyuan in a hospital of Guangzhou, quickly
reported the disease to local anti-epidemic station.\3\ We have reason
to believe that the local anti-epidemic station alerted the provincial
health bureau about the disease, and the bureau in turn reported to the
provincial government and the Ministry of Health (MoH) shortly
afterwards, since the first team of experts sent by the Ministry
arrived at Guangzhou on January 20 and the new provincial government
(who took over on January 20) ordered an investigation of the disease
almost at the same time.\4\ A combined team of health experts from the
Ministry and the province was dispatched to Zhongshan and completed an
investigation report on the unknown disease. On January 27, the report
was sent to the provincial health bureau and, presumably, Ministry of
Health in Beijing. The report was marked ``top secret,'' which means
that only top provincial health officials could open it.
---------------------------------------------------------------------------
\2\ ``Guangzhou is fighting an unknown virus,'' Southern Weekly,
February 13, 2003.
\3\ Renmin ribao, overseas edition, 22 April 2003.
\4\ http://www.people.com.cn/GB/shehui/47/20030211/921420.html.
---------------------------------------------------------------------------
Further government reaction to the emerging disease, however, was
delayed by the problems of information flow within the Chinese
hierarchy. For three days, there were no authorized provincial health
officials available to open the document. After the document was
finally read, the provincial bureau distributed a bulletin to hospitals
across the province. Yet few health workers were alerted by the
bulletin, because most were on vocation for the Chinese New Year.\5\
Meanwhile, the public was kept uninformed about the disease. According
to the 1996 Implementing Regulations on the State Secrets Law (1988),
any such diseases should be classified as a state secret before they
are ``announced by the Ministry of Health or organs authorized by the
Ministry.'' In other words, until such time the Ministry chose to make
public about the disease, any physician or journalist who reported on
the disease would risk being persecuted for leaking State secrets.\6\
---------------------------------------------------------------------------
\5\ John Pomfret, ``China's slow reaction to fast-moving illness,''
Washington Post, 3 April 2003, p. A18.
\6\Li Zhidong, et al, Zhonghua renmin gonghe guo baomifa quanshu
(Encyclopedia on the PRC State Secrets Law) (Changchun: Jilin renmin
chubanshe, 1999), pp. 372-374. I thank Professor Richard Baum for
bringing this to my attention.
---------------------------------------------------------------------------
In fact, until February 11, not only news blackout continued, but
the government failed to take any further actions on the looming
catastrophe. Evidence indicated that the provincial government in
deciding whether to publicize the event considered more about local
economic development than about people's life and health. The Law on
Prevention and Treatment of Infectious Diseases enacted in September
1989 contains some major loopholes. First, provincial governments only
after being authorized by MoH are obliged to publicize epidemics in a
timely and accurate manner (Article 23). Second, atypical pneumonia was
not listed in the law as an infectious disease under surveillance, thus
local government officials legally were not
accountable for the disease. The law allows addition of new items to
the list, but it does not specify the procedures through which new
diseases can be added. All this provided disincentives for the
government to effectively respond to the crisis.
To be sure, the media blackout and the government's slow response
are not only the sole factors leading to the crisis. Scientists until
today are still not entirely clear about the pathogen, spread pattern
and mortality rate of SARS.\7\ Due to the lack of knowledge about the
disease, the top-secret document submitted to the provincial health
bureau did not even mention that the disease was highly contagious,
neither did it call for rigorous preventive measures, which may explain
why by the end of February, nearly half of Guangzhou's 900 cases were
healthcare workers.\8\ Indeed, even rich countries, like Canada, were
having difficulty controlling SARS. In this sense, SARS is a natural
disaster, not a man-made one.
---------------------------------------------------------------------------
\7\ On February 18, the Chinese CDC identified chlamydia bacteria
as the cause of the disease. At the end of the month, WHO experts
believed the disease was an outbreak of bird flue. They did not
identify it as a new infectious disease until early March.
\8\ Pomfret, ``China's slow reaction to fast-moving illness.''
---------------------------------------------------------------------------
Yet there is no doubt that government inaction resulted in the
crisis. To begin with, the security designation of the document means
that health authorities of the neighboring Hong Kong SAR was not
informed about the disease and, consequently, denied the knowledge they
needed to prepare for outbreaks.\9\ Very soon, the illness developed
into an epidemic in Hong Kong, which has proved to be a major transit
route for the disease. Moreover, the failure to inform the public
heightened anxieties, fear, and widespread speculation. On February 8,
reports about a ``deadly flu'' began to be sent via short messages on
mobile phones in Guangzhou. In the evening, words like bird flu and
anthrax started to appear on some local Internet sites.\10\ On February
10, a circular appeared in the local media acknowledged the presence of
the disease and listed some preventive measures, including improving
ventilation, using vinegar fumes to disinfect the air, and washing
hands frequently. Responding to the advice, residents in Guangzhou and
other cities cleared pharmacy shelves of antibiotics and flu
medication. In some cities, even the vinegar was sold out. The panic
spread quickly in Guangdong, and had it felt even in other provinces.
---------------------------------------------------------------------------
\9\ Ibid.
\10\ South China Morning Post, February 11, 2003.
---------------------------------------------------------------------------
On February 11, Guangdong health officials finally broke the
silence by holding press conferences about the disease. The provincial
health officials reported a total of 305 atypical pneumonia cases in
the province. The officials also admitted that there were no effective
drugs to treat the disease, and the outbreak was only tentatively
contained.\11\ From then on until February 24, the disease was allowed
to report extensively. Yet in the meantime, the government played down
the risk of the illness. Guangzhou city government on February 11 went
as far as to announce the illness was ``comprehensively'' under
effective control.\12\ As a result, while the panic was temporally
allayed, the public also lost vigilance about the disease. During the
run-up to the National People's Congress, the government halted most
reporting. The news blackout would remain until April 2.
---------------------------------------------------------------------------
\11\ Southern Weekly, February 13, 2003.
\12\ http://www.people.com.cn/GB/shehui/47/20030211/921422.html.
---------------------------------------------------------------------------
Beyond Guangdong: Ministry of Health and Beijing
Under the Law on Prevention and Treatment of Infectious Diseases,
MoH is obliged to accurately report and publicize epidemics in time.
The Ministry learned about SARS in January and informed WHO and
provincial health bureaus about the outbreak in Guangdong around
February 7. Yet no further action was taken. It is safe to assume that
Zhang Wenkang, the health minister, brought the disease to the
attention of Wang Zhongyu (Secretary General of the State Council) and
Li Lanqing (the vice premier in charge of public health and education).
We do not know what happened during this period of time; it is very
likely that the leaders were so preoccupied preparing for the National
People's Congress in March that no explicit directive was issued from
the top until April 2.
As a result of the inaction from the central government and the
continuous information blackout, the epidemic in Guangdong quickly
spread to other parts of China. Since March 1, the epidemic has raged
in Beijing. Yet for fear of disturbance during the NPC meeting, city
authorities kept information about its scope not only from the public
but also from the Party Center. MoH was reportedly aware of what was
happening in the capital. The fragmentation of bureaucratic power,
however, delayed any concerted efforts to address the problem. As one
senior health official
admitted, before anything could be done, the ministry had to negotiate
with other ministries and government departments.\13\ On the one hand,
Beijing municipal government apparently believed that it could handle
the situation well by itself and thus refused involvement of MoH. On
the other hand, the Ministry did not have control of all health
institutions. Of Beijing's 175 hospitals, 16 are under the control of
the army, which maintains a relatively independent health system.
Having
admitted a large number of SARS patients, military hospitals in Beijing
until mid-April refused to hand in SARS statistics to the Ministry.
According to Dr. Jiang Yanyong, medical staff in Beijing's military
hospitals were briefed about the dangers of SARS in early March, but
told not to publicize what they had learned lest it interfere with the
NPC meeting.\14\ This might in part explain why on April 3, the health
minister announced that Beijing had seen only 12 cases of SARS, despite
the fact that in the city's No. 309 PLA hospital alone there were 60
SARS patients. The bureaucratic fragmentation also created
communication problems between China and World Health Organization. WHO
experts were invited by the Ministry to China but were not allowed to
have access to Guangdong until April 2, 8 days after their arrival.
They were not allowed to inspect military hospitals in Beijing until
April 9. By that time, the disease had already engulfed China and
spread to the world.
---------------------------------------------------------------------------
\13\ John Pomfret, ``China's Crisis Has a Political Edge,''
Washington Post, April 27, 2003.
\14\ Susan Jakes, ``Beijing's SARS Attack,'' Time, April 8, 2003.
---------------------------------------------------------------------------
What is to blame?
The crisis revealed two major problems inherent in China's
political system: coverup and inaction. Existing political institutions
have not only obstructed the information flow within the system but
also distorted the information itself, making misinformation endemic in
China's bureaucracy. Because government officials in China are all
politically appointed rather than elected by the general populace at
each level of
administration, they are held accountable only to their superiors, not
the general public. This upward accountability generates perverse
incentives for government officials in policy process. For fear that
any mishap reported in their jurisdiction may be used as an excuse to
pass them over for promotion, government officials at all levels tend
to distort the information they pass up to their political masters in
order to place themselves in a good light. While this is not something
unique to China, the problem is alleviated in democracies through
``decentralized oversight,'' which enables citizen interest groups to
check up on administrative actions. Since China still refuses to
enfranchise the general public in overseeing the activities of
government agencies, the upper-level governments are easier to be
fooled by their subordinates. This exacerbates the information
asymmetry problems inherent in a hierarchical structure and weakens
effective governance of the central state.
Nevertheless, a functionalist argument can be made to explain the
rampant underreporting and misreporting in China's officialdom. In view
of the dying communist ideology and the official resistance to
democracy, the legitimacy of the
current regime in China is rooted in its constant ability to promote
social-economic progress. As a result of this performance-based
legitimacy, ``government officials routinely inflate data that reflect
well on the regime's performance, such as growth rates, while under
reporting or suppressing bad news such as crime rates, social
unrest and plagues.'' \15\ In this sense, manipulation of data serves
to shore up the regime's legitimacy.
---------------------------------------------------------------------------
\15\ Minxin Pei, ``A Country that does not take care of its
people,'' Financial Times, April 7, 2003.
---------------------------------------------------------------------------
In explaining the government's slow response to tackling the
original outbreak, we should keep in mind that the health system is
embedded in an authoritarian power structure in which policies are
expected to come from the political leadership. In the absence of a
robust civil society, China's policymaking does not feature a salient
``bottom-up'' process to move a ``systemic'' agenda in the public to a
``formal'' or governmental agenda as found in many liberal democracies.
To be sure, the process is not entirely exclusionary, for the party's
``mass line'' would require leading cadres at various levels to obtain
information from the people and integrate it with government policy
during the policy formation stage. Yet this upward flow of information
is turned on or off like a faucet by the State from above, not by the
strivings of people from below.\16\ Under this top-down political
structure, each level takes its cue from the one above. If the
leadership is not dynamic, no action comes from the party-state
apparatus. The same structure also encourages lower-level governments
to shift their policy overload to the upper levels in order to avoid
taking responsibilities. As a result, a large number of agenda items
are competing for the upper level government's attention. The bias
toward economic development in the reform era nevertheless marginalized
the public health issues in the top leaders' agenda. As a matter of
fact, prior to the SARS outbreak, public health had become the least of
the concerns of Chinese leaders. Compared to an economic issue a public
health problem often needs an attention-focusing event (e.g., a large-
scale outbreak of a contagious disease) to be finally recognized,
defined, and formally addressed. Not surprisingly, SARS did not raise
the eyebrows of top decisionmakers until it had
already developed into a nationwide epidemic.
---------------------------------------------------------------------------
\16\ Jean Oi, State and Peasant in Contemporary China (Berkeley:
University of California Press, 1989), p. 228.
---------------------------------------------------------------------------
Another problem that bogged down government response is
bureaucratic fragmentation. Because Chinese decisionmaking emphasizes
consensus, the bureaucratic proliferation and elaboration in the post-
Mao era requires more time and effort for coordination. With the
involvement of multiple actors in multiple sectors, the policy outcome
is generally the result of the conflicts and coordination of multiple
sub-goals. Since units (and officials) of the same bureaucratic rank
cannot issue binding orders to each other, it is relatively easy for
one actor to frustrate the adoption or successful implementation of
important policies. This fragmentation of authority is also worsened by
the relationship between functional bureaucratic agency (tiao) and the
territorial governments (kuai). In public health domain, territorial
governments like Beijing and Guangdong maintain primary leadership over
the provincial health bureau, with the former determining the size,
personnel, and funding of the latter. This constitutes a major problem
for the Ministry of Health, which is bureaucratically weak, not to
mention that its minister is just an ordinary member of CCP Central
Committee and not represented in the powerful Politburo. A major policy
initiative from the Ministry of Health, even issued in the form of a
central document, is mainly a guidance document (zhidao xin wenjian)
that has less binding power than one that is issued by territorial
governments. Whether they will be honored hinges on the
``acquiescence'' (liangjie) of the territorial governments. This helps
explain the continuous lack of effective response in Beijing city
authorities until April 17 (when the anti-SARS joint team was
established).
china's crusade against sars (april 2003-present)
Reverse course
Thanks to strong international pressure, the government finally
woke up and began to tackle the crisis seriously. On April 2, the State
Council held its first meeting to discuss the SARS problem. Within 1
month, the State Council held three meetings on SARS. An order from the
MoH in mid-April formally listed SARS as a disease to be monitored
under the Law of Prevention and Treatment of Infectious Diseases and
made it clear that every provincial unit should report the number of
SARS on a given day by 12 noon on the following date. The party and
government leaders around the country is now held accountable for the
overall SARS situation in their jurisdictions. On April 17, an urgent
meeting held by the Standing Committee of the Politburo explicitly
warned against the covering up of SARS cases and demanded the accurate,
timely and honest reporting of the disease. Meanwhile, the government
also showed a new level of candor. Premier Wen Jiabao on April 13 said
that although progress had been made, ``the overall situation remains
grave.'' \17\ On April 20 the government inaugurated a nationwide
campaign to begin truthful
reporting about SARS.
---------------------------------------------------------------------------
\17\ Business Week, April 28, 2003.
---------------------------------------------------------------------------
The government also took steps to remove incompetent officials in
fighting against SARS. Health minister Zhang Wenkang and Beijing mayor
Meng Xuenong were discharged on April 20 to take responsibilities for
their mismanagement of the crisis. While they were not the first
ministerial level officials since 1949 who were sacked mid-crisis on a
policy matter, the case did mark the first sign of political innovation
from China's new leadership. According to an article in Economist,
unfolding of the event (minister presides over policy bungle; bungle is
exposed, to public outcry; minister resigns to take the rap) ``almost
looks like the way that politics works in a democratic, accountable
country.'' \18\ The State Council also sent out inspection teams to the
provinces to scour government records for unreported cases and fire
officials for lax prevention efforts. It was reported that since April,
120 government officials have lost their jobs.
---------------------------------------------------------------------------
\18\ ``China's Chernobyl,'' Economist, April 26, 2003, p. 9.
---------------------------------------------------------------------------
The crisis also speeded up the process of institutionalizing
China's emergency
response system so that it can handle public health contingencies and
improve interdepartmental coordination. On April 2, the government
established a leading small group led by the health minister and an
inter-ministerial roundtable led by a vice secretary general to address
SARS prevention and treatment . This was replaced on April 23 by a task
force known as the SARS Control and Prevention Headquarters of the
State Council, to coordinate national efforts to combat the disease.
Vice Premier Wu Yi was appointed as command-in-chief of the task force.
On May 12, China issued Regulations on Public Health Emergencies
(PHEs). According to the regulations, the State Council shall set up an
emergency headquarters to deal with any PHEs, which refer to serious
epidemics, widespread unidentified diseases, mass food and industrial
poisoning, and other serious public health threats.\19\
---------------------------------------------------------------------------
\19\ Xinhua News, http://news.xinhuanet.com/newscenter/2003-05/12/
content--866362.htm.
---------------------------------------------------------------------------
Meanwhile, the government increased its funding for public health.
On April 23, a national fund of two billion yuan was created for SARS
prevention and control. The fund will be used to finance the treatment
of farmers and poor urban residents infected with SARS and to upgrade
county-level hospitals and purchase SARS-related medical facilities in
central and western China. The central government also committed 3.5
billion yuan for the completion of a three-tier (provincial, city, and
county) disease control and prevention network by the end of this year.
This includes 600 million for the initial phase of constructing China's
Center for Disease Control and Prevention (CDC).\20\ The government has
also offered free treatment for poor SARS patients.
---------------------------------------------------------------------------
\20\ Renmin ribao (People's daily), overseas edition, May 9, 2003.
---------------------------------------------------------------------------
The government also showed more interest in international
cooperation in fighting against SARS. In addition to its cooperation
with WHO, China showed flexibility in cooperating with neighboring
countries in combating SARS. At the special summit called by ASEAN and
China in late April, Chinese premier Wen Jiabao pledged 10 million yuan
to launch a special SARS fund and joined the regionwide confidence-
building moves to take coordinated action against the disease.
Problems and Concerns
These measures are worth applauding, but are they going to work?
The battle against the disease can be compromised by China's inadequate
public health system. One of the major problems here is the lack of
state funding. Already, the portion of total health spending financed
by the government has fallen from 34 percent in 1978 to less than 20
percent now.\21\ Cash-strapped local governments whose health-care
system is under financed would be extremely hard pressed in the process
of SARS prevention and treatment. It is reported that some hospitals
have refused to accept patients who have affordability problems.\22\
The offer of free treatment for poor SARS patients is little
consolation to the large numbers with no health insurance, particularly
the unemployed and the millions of ill-paid migrant workers, who are
too poor to consider hospital treatment which getting sick. According
to a 1998 national survey, about 25.6 percent of the rural patients
cited ``economic difficulties'' as the main reason that they did not
seek outpatient care.\23\
---------------------------------------------------------------------------
\21\ Yanzhong Huang, Mortal Peril: Public Health in China and Its
Security Implications. CBACI Health and Security Series, Special Report
6, May 2003.
\22\ Washington Post, April 14, 2003.
\23\ Ministry of Health, National Health Service Research. Beijing,
1999.
---------------------------------------------------------------------------
The lack of facilities and qualified medical staff to deal with the
SARS outbreak also compromises government efforts to contain the
disease. Among the 66,000 healthcare workers in Beijing, less than
3000, or 4.3 percent of them are familiar with respiratory
diseases.\24\ Similarly, hospitals in Guangdong are reported to face
shortage in hospital beds and ambulances in treating SARS. This problem
is actually worsened by the absence of referral system and the
increasing competition between health institutions, which often leads
to little coordination but large degrees of overlap. As SARS cases
increases, some hospitals are facing the tough choice of losing money
or not admitting further SARS patients. In Beijing, the government had
to ask for help from the military.
---------------------------------------------------------------------------
\24\ Renmin ribao, overseas edition, May 1, 2003.
---------------------------------------------------------------------------
Tremendous inequalities in health resource distribution posed
another challenge to the Chinese leadership. To the extent that health
infrastructure are strained in Beijing, the situation would be much
worse in China's hinterland or rural areas. Compared with Beijing,
Shanhai, and Jiangsu and Zhejiang provinces, which receives a full
quarter of health-care spending, the seven provinces and autonomous
regions in the far west only get 5 percent.\25\ The rural-urban gap in
health resource distribution is equally glaring. Representing only 20
percent of China's population, urban residents claim more than 50
percent of the country's hospital beds and health professionals. So
far, a large-scale epidemic has not yet appeared in the countryside.
The percentage of peasants who are infected, however, is high in Hebei,
Inner Mongolia, and Shanxi, which points to the relatively high
possibility of spread to the rural areas.\26\
---------------------------------------------------------------------------
\25\ BusinessWeek, April 28, 2003.
\26\ Xinhua News, May 10, 2003.
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Some other concerns also complicate the war on SARS. In terms of
the mode of policy implementation, the Chinese system is in full
mobilization mode now. All major cities are on 24-hour alert,
apparently in response to emergency directions from the central
leadership. So far, all indications point to decisive action for
quarantine. By May 7, 18,000 people had been quarantined in Beijing.
Meanwhile, the Maoist ``Patriotic Hygiene Campaign'' has been
revitalized. In Guangdong, 80 million people were mobilized to clean
houses and streets and remove hygienically dead corners.\27\ By placing
great political pressure on local cadres in policy implementation,
mobilization is a convenient bureaucratic tool for overriding fiscal
constraints and bureaucratic inertia whilst promoting grassroots cadres
to behave in ways that reflect the priorities of their superiors.
Direct involvement of the local political leadership increases program
resources, helps ensure they are used for program
purposes, and mobilizes resources from other systems, including free
manpower transferred to program tasks. Yet in doing so a bias against
routine administration was built into the implementation structure. In
fact, the increasing pressure from higher authorities, as indicated by
the system that holds government heads personally responsible for SARS
spread under their jurisdiction, makes strong measures more appealing
to local officials, who find it safer to be overzealous than to be seen
as ``soft.'' There are indications that local governments overkill in
dealing with SARS. In some cities, those who were quarantined lost
their jobs. Until recently, Shanghai was quarantining people from some
regions hard hit by SARS (such as Beijing) for 10 days even if they had
no symptoms.\28\ While many people are cooperating with the government
measures, there is clear evidence suggesting that some people were
quarantined against their will.\29\
---------------------------------------------------------------------------
\27\ Renmin ribao, April 9, 2003.
\28\ Pomfret, ``China Feels Side Effects from SARS,'' Washington
Post, May 2, 2003.
\29\ Beijing Youth Daily, May 2, 2003; http://www.people.com.cn/GB/
shehui/45/20030510/988713.html.
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The heavy reliance on quarantine raises a question that should be
of interest to the committee: will anti-SARS measures worsen human
rights situations in China? This question of course is not unique to
China: even countries like the U.S. are debating whether it is
necessary to apply dictatorial approach to confront health risks more
effectively. The Model Emergency Health Powers pushed by the Bush
administration would permit state Governors in a health crisis to
impose quarantines, limit people's movements and ration medicine, and
seize anything from dead bodies to private hospitals.\30\ While China's
Law on Prevention and Treatment of Infectious Disease does not
explicate that quarantines apply to SARS epidemic, Articles 24 and 25
authorize local governments to take emergency measures that may
compromise personal freedom. The problem is that unlike democracies,
China in applying these measures excludes the input of civil
associations. Without engaged civil society groups to act as a source
of discipline and information for government agencies, the sate
capability is often used not in the society's interest. Official
reports suggested that innocent people were dubbed rumor spreaders and
arrested simply because they relayed some SARS-related information to
their friends or colleagues.\31\ According to the Ministry of Public
Security, since April public security departments have investigated 107
cases in which people used Internet and cell phones to spread SARS-
related ``rumors.'' \32\ Some Chinese legal scholars have already
expressed concerns that the government in order to block information
about the epidemic may turn to more human rights violations.\33\
---------------------------------------------------------------------------
\30\ Nicholas D. Kristof, ``Lock 'Em Up,'' New York Times, May 2,
2003.
\31\ http://www.people.com.cn/GB/shehui/47/20030426/980282.html.
\32\ http://www.people.com.cn/GB/shehui/44/20030508/987610.html.
May 8, 2003.
\33\ http://www.duoweinews.com Accessed on May 10, 2003.
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The lack of engagement of civil society in policy process could
deplete social capital so important for government anti-SARS efforts.
As the government is increasingly perceived to be incapable of
adequately providing the required health and other social services, it
has alienated members of society, producing a heightened sense of
marginalization and deprivation among affected populations. These
alienated and marginalized people have even less incentive than they
would ordinarily have to contribute to government-sponsored programs.
The problem can be mitigated if workers and peasants are allowed to
form independent organizations to fight for their interests.
Unfortunately, China's closed political system offers few institutional
channels for the disadvantaged groups to express their private
grievances. The government failure to publicize the outbreak in a
timely and accurate manner and the ensuing quick policy switch caused
further credibility problems for the government. Washington Post
reported a SARS patient who fled quarantine in Beijing because he did
not believe that the government would treat his disease free of charge.
This lack of trust toward the government contributed to the spread of
rumors even after the government adopted a more open stance on SARS
crisis. In late April, thousands of residents of a rural town of
Tianjin ransacked a building, believing it would be used to house ill
patients with confirmed or suspected SARS, even though officials
insisted that it would be used only as a medical observation facility
to accommodate people who had close contacts with SARS patients and for
travelers returning from SARS hot spots. Again, here the lack of active
civilian participation exacerbated the trust problems. In initiating
the project the government had done nothing to consult or inform the
local people.\34\ Opposition to official efforts to contain SARS was
also found in a coastal Zhejiang province, where several thousand
people took part in a violent protest against six people who were
quarantined after returning from Beijing.\35\
---------------------------------------------------------------------------
\34\ Erik Eckholm, ``Thousands Riot in Rural Chinese Town over
SARS,'' New York Times, April 28, 2003.
\35\ ``China's fight against SARS spawns backlash,'' Los Angeles
Times, May 6, 2003.
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Last but not least, policy difference and political conflicts
within the top leadership can cause serious problems in polity
implementation. The reliance on performance legitimacy put the
government in a policy dilemma in coping with the crisis. If it fails
to place the disease under control and allows it to run rampant, it
could become the event that destroys the Party's assertions that it
improves the lives of the people. But if the top priority is on health,
economic issues will be moved down a notch, which may lead to more
unemployment, more economic loss and more social and political
instability. The disagreement over the relationship between the two was
evidenced in the lack of consistence in official policy. On April 17,
the CCP Politburo Standing Committee meeting focused on SARS. In a
circular issued after the meeting, the Party Center made it clear that
``despite the daunting task of reform and development, the top priority
should be given to people's health and life security. We should
correctly deal with the temporary loss in tourism and foreign trade
caused by atypical pneumonia, have long-range perspective in thinking
or planning, and do not concern too much about temporary loss.'' \36\
Eleven days later, the Politburo meeting emphasized Jiang Zemin's
``Three Represents'' and, by calling for a balance between combating
SARS and economic work, reaffirmed the central status of economic
development.\37\ This schizophrenic nature of central policy is going
to cause at least two problems that will not help the State to boost
its capacity in combating SARS. First, because the Party Center failed
to signal its real current priorities loud and clear, local authorities
may get confused and face a highly uncertain incentive structure of
rewards and punishments. Given the central government's inability to
perfectly differentiate between simple incompetence and willful
disobedience, local policy enforcers may take advantage of the policy
inconsistency to ``shirk'' or minimize their workload, making strict
compliance highly unlikely. Second, the policy difference will
aggravate China's faction-ridden politics, which in turn can reduce
central leaders' policy autonomy so important for effectively fighting
against SARS. A perceived crisis can precipitate State elites to fully
mobilize the potential for autonomous action. Yet power at the apex in
China inheres in individual idiosyncrasies rather than institutions.
This lack of institutionalization at the top level, coupled with the
pretensions of a centralized bureaucracy, sets the stage for a very
constrained from of politics, limiting what passed as national politics
to relations among the top elite. A general rule in Chinese elite
politics is that policy conflicts will be interwoven with factionalism.
Former President Jiang's allies in the Politburo Standing Committee
seemed to be quite slow to respond to the anti-SARS campaign embarked
on by Hu Jintao and Wen Jiabao on April 20. Wu Bangguo, Jia Qinglin,
and Li Changchun did not show up on the front stage of SARS campaign
until April 24. The absence of esprit de corps among key elites would
certainly reduce state autonomy needed in handling the crisis. It is
speculated that the fall of Meng Xuenong, a protege of Hu, was to
balance the removal of Zhang Wenkang, a Jiang follower. Given that a
health minister, unlike a mayor of Beijing, is not a major power
player, this seems to send a message that the former president is still
very much in control. The making of big news Jiang's order on April 28
to mobilize military health personnel only suggests the lack of
authority of Hu Jintao and Wen Jiabao over the military. Intraparty
rivalry in handling the crisis reminded people political upheavals in
1989, when the leaders disagreed on how to handle the
protests and Deng Xiaoping the paramount leader played the game between
his top associates before finally siding with the conservatives by
launching a military crackdown.
---------------------------------------------------------------------------
\36\ http://www.people.com.cn/GB/shizheng/3586/20030422/
977907.html, April 22, 2003.
\37\ Renmin ribao, April 29, 2003.
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policy recommendations
The above analysis clearly points to the need for the Chinese
government to beef up its capacity in combating SARS. Given that a
public health crisis reduces State capacity when ever-increasing
capacity is needed to tackle the challenges, purely endogenous
solutions to build capacity are unlikely to be successful, and capacity
will have to be imported from exogenous sources such as massive foreign
aid.\38\ In this sense, building state capability also means building
more effective partnerships and institutions internationally. As I
summarized somewhere else, international actors can play an important
role in creating a more responsible and responsive government in
China.\39\ First, aid from international organizations opens an
alternative source of financing healthcare, increasing the government's
financial capacity in the health sector. Second, international aid can
strengthen the bureaucratic capacity through technical assistance,
policy counseling, and personnel training. Third, while international
organizations and foreign governments provide additional health
resources in policy implementation, the government increasingly has to
subject its agenda-setting regime to the donors' organizational goals,
which can make the government more responsive to its people. The recent
agenda shift to a large extent was caused by the strong international
pressures exerted by the international media, international
organizations, and foreign governments. There is indication that
Internet is increasingly used by the new leadership to solicit policy
feedback, collect public opinions and mobilize political support.
Starting February 11, Western news media were aggressively reporting on
SARS and on government cover-up of the number of cases in China. It is
very likely that Hu Jintao and Wen Jiaobao, both Internet users, made
use of international information in making decisions on SARS. In other
words, external pressures can be very influential because Chinese
governmental leaders are aware of the weakness of the existing system
in effectively responding to the crisis, and have incentives to seek
political resources exogenous to the system.
---------------------------------------------------------------------------
\38\ Andrew T. Price-Smith, ``Pretoria's Shadow: The HIV/AIDS
Pandemic and National Security in South Africa,'' Special Report No. 4,
CBACI Health and Security Series, September 2002, p. 27.
\39\ Mortal Peril: Public Health in China and Its Security
Implications.
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From the perspective of international actors, helping China
fighting SARS is also helping themselves. Against the background of a
global economy, diseases originating in China can be spread and
transported globally through trade, travel, and population movements.
Moreover, an unsustainable economy or State collapse spawned by poor
health will deal a serious blow to the global economy. As foreign
companies shift manufacturing to China, the country is becoming a
workshop to the world. A world economy that is so dependent on China as
an industrial lifeline can become increasingly vulnerable to a major
supply disruption caused by SARS epidemic. Perhaps equally important,
if the SARS epidemic in China runs out of control and triggers a global
health crisis, it will result in some unwanted social and political
changes in other countries including the United States. As every
immigrant or visit from China or Asia is viewed as a Typhoid Mary,
minorities and immigration could become a sensitive domestic political
issue. The recent incident in New Jersey, in which artists with Chinese
background were denied access to a middle school, suggests that when
SARS becomes part of a national lexicon, fear, rumor, suspicion, and
misinformation can jeopardize racial problems in this country.\40\
---------------------------------------------------------------------------
\40\ ``Fear, not SARS, rattles South Jersey School,'' New York
Times, May 10, 2003.
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Given the international implications of China's public health, it
is in the U.S. interest to expand cooperation with China in areas of
information exchange, research, personnel training, and improvement of
public health facilities. But it can do more. It can modify its human
rights policy so that it accords higher and clearer priority to health
status in China. Meanwhile, it could send a clearer signal to the
Chinese leadership that the United States supports reform-minded
leaders in the forefront of fighting SARS. To the extent that regime
change is something the U.S. would like to see happening in China, it
is not in the U.S. interest to see Hu Jingtao and Wen Jiaobao purged
and replaced by a less open and less humane government, even though
that government may still have strong interest in maintaining a healthy
U.S.-China relationship. The United States simply should not miss this
unique
opportunity to help create a healthier China.
______
Prepared Statement of Bates Gill
may 12, 2003
Lessons, Implications, and Future Steps
introduction
Allow me to begin by expressing my appreciation to the Commission
for this opportunity to appear before you today.
The repercussions for China of the SARS epidemic will resonate well
beyond the tragic and growing loss of life.\1\ On the brighter side,
the progression of the epidemic from Guangdong to Beijing, into the
Chinese countryside, and across the world demonstrates the mainland's
increasing economic and social openness, mobility and interdependence
within the country itself, within the East Asia region and across the
planet, mobilizes concern for China's health-care system, and may spark
greater openness and accountability within the Chinese leadership.
---------------------------------------------------------------------------
\1\This testimony draws from recent articles published by the
witness. See: Bates Gill, ``China: Richer, But Not Healthier,'' Far
Eastern Economic Review, May 1, 2003; Bates Gill, ``China will pay
dearly for the SARS debacle,'' International Herald Tribune, April 22,
2003; Bates Gill and Andrew Thompson, ``Why China's health matters to
the world,'' South China Morning Post, April 16, 2003.
---------------------------------------------------------------------------
On the other hand, the outbreak of SARS also exposes a number of
troubling developments and uncertainties in China: old-style
misinformation, opaque communication, an ailing public health-care
infrastructure, continued reticence in dealing with foreign partners,
and a likely slowdown in economic growth in China and the region. All
of these negative developments also raise serious questions about
China's ability to cope with other infectious diseases such as
hepatitis, tuberculosis, and HIV/AIDS.
To examine these issues, the following pages will analyze some of
the early lessons and implications of the SARS epidemic, and recommend
steps that can be taken to combat future health-care crisis in China
more effectively.
lessons
Sclerotic and reactive process
To begin, by taking so long to reveal the real dimensions of the
SARS problem, Chinese authorities underscored their reputation as
secretive and out of step with international practice. News of
falsified communications, deliberate misinformation, obstruction of
U.N. assessment teams and reluctance to reveal the full extent of the
epidemic to the World Health Organization all raise some troubling
questions about real change in China.
Some argue that Beijing's current openness and responsiveness to
SARS indicates a new and more positive direction for the leadership.
This may be, though it
remains relatively early to know with certainty whether this new
direction will be limited to SARS-related responses, or can be
broadened to encompass a new across-the-board approach by the Chinese
leadership. For the time being, it appears the mainland's initial
denial and slow response to the SARS outbreak characterizes a political
environment where individual initiative is discouraged and social
stability is protected above other interests, to the detriment of
social safety.
Additionally, the initial slow reaction by medical authorities can
be explained by outdated laws that prevent effective communication
about emerging epidemics. The State Secrets Law prevents local
authorities from discussing an emerging outbreak until the Ministry of
Health in Beijing has announced the existence of an epidemic. In the
case of SARS, the silence of the bureaucracy, coupled with an
increasingly mobile population, virtually guaranteed that an infectious
disease would quickly spread well beyond Guangdong to the rest of the
world.
Paradoxically, despite the sclerotic and old-style official
response to SARS, China's society has become more open than ever.
Indeed, SARS spread as rapidly as it did precisely because of China's
expansive interaction domestically and with its neighbors. But
Beijing's old way of doing things now faces a serious challenge: to
prevent infectious diseases from becoming major social, political and
economic problems will demand greater openness, transparency and
candor, both at home and with partners abroad.
Ailing health-care capacity
Even if old-style political and bureaucratic bottlenecks could be
overcome, it is unlikely that the mainland's health-care system would
have been able to prevent the spread of SARS. The rapid spread of other
emerging infectious diseases throughout the mainland demonstrates the
inability of the public health system to deal adequately with the
complex nature of infectious diseases in a modern, globalized China. In
urban areas, public health is adequate for those who can afford it or
are still employed in the State sector, where insurance and company
clinics can provide primary care. However, in rural areas, where the
majority of the population resides, social services are inadequate to
non-existent. The ability to diagnose and treat emerging diseases
competently does not exist throughout most of China.
Blood-borne and sexually transmitted infections have posed a
particular challenge to health authorities in China. For example, HIV/
AIDS infects over one million Chinese, while similarly transmitted
diseases including hepatitis B and C infect over a hundred million
more. The capacity of China's health-care system is so stretched that
hepatitis B, a disease for which there is a vaccine, still affects an
estimated 170 million Chinese, accounting for two-thirds of the world's
cases. The inability to prevent the spread of infectious diseases
within China will have serious long-term economic impacts globally.
Reluctance to work with foreign partners
From the onset of SARS, Beijing and the provinces seem reluctant to
fully accept assistance from the international community to deal with
their burgeoning public health quandary. Only after a 2-week wait were
inspectors from the World Health Organization permitted to travel to
the SARS outbreak's epicenter in Guangdong. This same reticence
characterizes China's earlier response to its HIV/AIDS crisis;
political leaders in Beijing and particularly throughout local
jurisdictions remain overly cautious in their willingness to accept
international intervention and assistance.
implications
Future epidemics
The official Chinese response to SARS did not bode well for how the
government might respond to other new, perhaps even more serious
infectious disease threats. Beijing's initial reaction to SARS
parallels its response to HIV/AIDS: denial, followed by reluctant
acknowledgment and hesitant mobilization of resources to combat the
epidemic. At present, in spite of some recent positive steps by
Beijing, the political and socioeconomic conditions are ripe in for the
further spread of infectious disease, including atypical pneumonia,
hepatitis and HIV/AIDS.
True, Chinese leaders recently have taken greater interest in
dealing with SARS. But admitting to problems is only half the battle.
There is still a long way to go, not just in dealing with SARS, but
with other health-care-related challenges. Probably the biggest issues
to tackle have to do with improved monitoring and communication to
accurately gauge the nature and extent of disease outbreaks, and
developing a more effective health-care infrastructure to meet these
emergent challenges. Local health-care capacity varies wildly across
the country as central government spending in this sector flattens and
localities are expected to pick up the difference. As a result, the
expertise and capacity to diagnose, prevent and treat the spread of
disease--especially new viruses--is limited to nonexistent throughout
much of China.
Economic downturn
The ability of China to devote greater resources to its health-care
system will be constrained in the near term by SARS' near-term economic
impact, though the true effect over the next year or more is still hard
to measure. Rough estimates made by international economists indicate
that China's GDP growth for 2003 could be reduced by anywhere from 0.5
to 2 percent. Beijing is unlikely to issue figures on the economic
impact of SARS. But the decline in tourism, airline travel, trade and
international confidence will certainly be felt in China, particularly
in hard-hit Guangdong Province, one of China's main engines of direct
foreign investment and export-led growth. The government is trying to
counter the effects of the downturn with massive increases in funding
for SARS prevention and control. Billions of RMB have been allocated
for projects throughout the country, ranging from construction of
infrastructure, to purchasing of supplies, to expanded research and
development of tests and medicines to combat SARS.
On the other hand, the short-term damage from SARS to the economy
is perhaps minimal compared to the shaken confidence of foreign
investors in the Chinese government's ability to effectively manage the
health of the Chinese population--at a minimum, the Chinese
government's reaction to the SARS outbreak has reminded foreign
investors and the world at large of the uncertainties and
contradictions in dealing with China.
Partly because it did not take steps promptly to address the public
health crisis, the Chinese government will also have to cope with a
downturn in the economic health of greater China--consisting of the
mainland, Hong Kong and Taiwan--as well as the wider East Asian region.
Singapore, Hong Kong, and Taiwan have
already trimmed official forecasts for economic growth as a result of
the SARS outbreak. In one early analysis, Morgan Stanley lowered its
estimate of East Asian
economic growth, excluding Japan, from 5.1 percent to 4.5 percent for
2003.
looking ahead
China's approach to SARS exposes troubling weaknesses that are
reflected in Beijing's overall reaction to deadly disease outbreaks.
These are: opaque communication channels--and even deliberate
disinformation--from provincial to central authorities; denial and
inaction short of international outcry and senior-leadership
intervention; weakening public health-care capacity to monitor,
diagnose, prevent and treat emergent disease outbreaks; and early and
persistent reticence to collaborate effectively with foreign partners.
Chinese authorities, working with the United States and others, must
try to change this pattern.
A first priority must be to implement more transparent, accurate
and coordinated public health-care management and communication. As a
start, the country should invest even more heavily in its
epidemiological and surveillance capacity to accurately detect, monitor
and quickly report on disease outbreaks and their progress. Beijing
should impose improved cooperation both between the central and local
authorities and across the bureaucracy in a more effective interagency
mechanism.
More transparent and enforced regulatory structures will also guide
public health and other officials to react in a more professional and
socially conscious way. Health-care related quasi- and non-governmental
organizations could be more effectively utilized to monitor and improve
methods for the prevention, treatment and care of disease. But for
these kinds of steps to succeed, China's new leadership must commit to
raising the political priority of public health on their agenda of
socioeconomic challenges.
Second, resources for public health will need to be expanded
considerably, both as a part of central and provincial government
expenditures. At a basic level, more well-trained professionals will be
needed to properly diagnose, treat and care for persons afflicted with
emergent epidemics in China. Even more could be gained by promoting
greater awareness and preventive messaging, not to alarm people, but to
help them take the necessary precautions to protect against infectious
diseases prevalent in China. Again, grass-roots and community-based
organizations can be effective partners in this effort, if well-
coordinated and given adequate leeway and
resources.
Finally, China and the international public health community have a
shared
interest in scaling up cooperation and assistance programs. There are
numerous international health related assistance programs in China, but
most operate at a relatively modest scale. Expanding successful
programs will require significant new funding. Major donor nations
should also consider re-channeling development aid to focus more on
public health programs. In the end, however, China--as one of the
world's largest economies and an aspiring great power--will need to
show a greater commitment to working with international partners and to
taking its public health challenges more seriously.
Minister Wu Yi in her new role as the Minister of Health has
already taken steps to endorse increased cooperation with the United
States on many of these fronts. Speaking on the telephone last week,
Vice Premier Wu and Secretary of Health and Human Services (HHS) Tommy
Thompson agreed to proceed with planning for
expanded collaborative efforts in epidemiological training and the
development of greater laboratory capacity in China. These new efforts
will increase the number of HHS personnel working in China beyond the
two CDC employees currently
stationed in Beijing. This expanded collaboration, while certainly
spurred by the current SARS epidemic, will be very important in helping
China combat other infectious diseases, especially newly emerging
infectious diseases such as tuberculosis, HIV/AIDS and other STDs.
Submissions for the Record
----------
[From the South China Morning Post, April 16, 2003]
Why China's Health Matters to the World
(By Bates Gill and Andrew Thompson)
The unstoppable march of severe acute respiratory syndrome (SARS)
from Guangdong to Hong Kong and beyond demonstrates the mainland's
increasing economic and social interdependence with the region and the
entire planet. Since the mainland has globalised and become East Asia's
engine of growth, maintaining the health of its economy and society is
in the world's best interests and will present a significant challenge
to China's partners in the region and around the world.
The notion of the mainland as a closed society needs to be
seriously reconsidered. Domestically, more Chinese enjoy freedom of
movement then ever before. Internationally, millions of travellers from
all over the world visit the mainland while millions of Chinese travel
abroad in increasing numbers every year. As the most important transit
point for commerce throughout East Asia, Hong Kong has reaped great
benefits from its strategic position. Now Hong Kong, and to a lesser
degree the rest of East Asia and the world in general, are paying a
price for the mainland's underdeveloped and opaque public health
system.
The mainland's formerly admirable public health system has not
fared well in the years of gaige kaifang (reform and opening up), with
government spending unable to keep pace with a changing society and
integration with the rest of the world. The public health system has
proven itself ill-prepared to cope with rapidly emerging diseases such
as SARS, hepatitis and HIV/AIDS.
The mainland's initial denial and slow response to the SARS
outbreak characterises a political environment where individual
initiative is discouraged and social stability is protected above other
interests. Additionally, the initial slow reaction by medical
authorities can be explained by outdated laws that prevent effective
communication about emerging epidemics. The State Secrets Law prevents
local authorities from discussing an emerging outbreak until the
Ministry of Health in Beijing has announced the existence of an
epidemic. In the case of SARS, the silence of the bureaucracy, coupled
with an increasingly mobile population, virtually guaranteed that an
infectious disease would quickly spread well beyond Guangdong to the
rest of the world.
Even if the bureaucratic delay did not occur, it is unlikely that
the mainland's health-care system would have been able to prevent the
spread of SARS. The rapid spread of other emerging infectious diseases
throughout the mainland demonstrates the inability of the public health
system to deal adequately with the complex nature of infectious
diseases in a modern, globalised China. In urban areas, public health
is adequate for those who can afford it or are still employed in the
State sector, where insurance and company clinics can provide primary
care. However, in rural areas, where the majority of the population
resides, social services are inadequate to non-existent. The ability to
diagnose and treat emerging diseases competently does not exist
throughout most of China.
While SARS has had an immense, immediate economic impact on the
economy of the region, there will be a much greater impact in the long
term, as other infectious diseases emerge and spread. Blood-borne and
sexually transmitted infections have posed a particular challenge to
health authorities in China.
HIV/AIDS infects over one million Chinese, while similarly
transmitted diseases including hepatitis B and C infect over a hundred
million more. The capacity of China's health-care system is so
stretched that hepatitis B, a disease for which there is a vaccine,
still affects an estimated 170 million Chinese, accounting for two-
thirds of the world's cases. The inability to prevent the spread of
infectious diseases within China will have serious long-term economic
impacts globally.
The mainland will have to bolster its medical capacity if it is to
maintain steep economic growth rates and continue to play the role of
``factory to the world.'' The central government must create a more
effective, transparent and capable public health management system that
is able to communicate quickly both nationally and internationally.
Vice-Premier Wu Yi toured the Chinese Centres for Disease Control and
Prevention this month and insisted they establish an emergency response
mechanism that includes an early warning and reporting function. The
outcry over SARS might motivate the central government to improve the
country's health system, but that remains to be seen.
As the SARS outbreak demonstrates, the mainland's health matters to
the world. Global co-operation to quickly identify, treat and prevent
the spread of new, emerging diseases will help the mainland and the
world maintain its economic and medical health.
* Bates Gill holds the Freeman Chair in China Studies and Andrew
Thompson is a research associate, at the Centre for Strategic and
International Studies in Washington.
______
[From the International Herald Tribune, April 22, 2003]
China Will Pay Dearly for the SARS Debacle
contagious confusion
(By Bates Gill)
WASHINGTON: The repercussions for China of the outbreak of severe
acute respiratory syndrome will resonate well beyond the tragic--and
growing--loss of life. Beijing's evasive and tardy response to the
challenge of the SARS virus reflects very poorly on China's
international standing, undermines its economic prospects and bodes ill
for combating other infectious diseases.
The government's embarrassment was evident Sunday when it admitted
that cases of SARS were many times higher than previously reported. At
the same time, China's health minister and the mayor of Beijing were
sacked. This was not the hoped-for auspicious beginning for the newly
installed fourth generation of Chinese leadership and its widely touted
goal of ``building a well-off society.''
By taking so long to reveal the real dimensions of the SARS
problem, Communist Party authorities underscored their reputation as
secretive and out of step with international practice. They have
reminded foreign investors and the world at large of the uncertainties
and contradictions in dealing with China.
News of falsified communications, deliberate misinformation,
obstruction of U.N. assessment teams and reluctance to reveal the full
extent of the epidemic to the World Health Organization must give pause
to even the headiest optimist about real change in China. Beijing's
aspirations to regional leadership have been stalled and will take time
to put back on track.
The official Chinese response to SARS does not bode well for how
the government might respond to other new, perhaps even more serious
infectious disease threats. Beijing's reaction to SARS parallels its
response to AIDS: denial, followed by reluctant acknowledgment and
hesitant mobilization of resources to combat the epidemic.
And the steady spread of SARS, AIDS and other infectious diseases
shows that even when authorities openly recognize a public health
problem, they lack the infrastructure to fight back effectively.
Paradoxically, despite the sclerotic and old-style official
response to SARS, China's society has become open. SARS spread as
rapidly as it did precisely because of China's expansive interaction
domestically and with its neighbors. The international community
supports this trend and wants to see China succeed in its social,
political and economic transformation and its integration into the
global mainstream.
Official Chinese tactics of suppression and concealment seem to
work well in preventing what Beijing calls the ``poisonous weeds'' and
``spiritual pollution'' of serious political and social reform. But
Beijing's way of doing things now faces a serious challenge: to prevent
infectious diseases from becoming major social, political and economic
problems will demand greater openness, transparency and candor, both at
home and with partners abroad.
The political system in China appears to be becoming more
responsive. Yet the SARS debacle reveals a dangerous fragility beneath
the surface of the country's rapidly transforming society. Partly
because it did not take steps promptly to address the public health
crisis, the Chinese government will have to cope with a downturn in the
economic health of greater China--consisting of the mainland, Hong Kong
and Taiwan--as well as the wider East Asian region.
Singapore and Hong Kong have already trimmed official forecasts for
economic growth as a result of the SARS outbreak, and private
researchers see a similar SARS-related downturn in Taiwan. Beijing is
unlikely to issue figures on the economic impact of SARS. But the
decline in tourism, airline travel, trade and international
confidence--in addition to the poor prospects of key economic partners
in the region--will certainly be felt in China, particularly in hard-
hit Guangdong Province, one of China's main engines of direct foreign
investment and export-led growth.
Moreover, in an already skittish international economy teetering on
the edge of recession, loss of confidence in greater China, the one
area where there was some optimism, will have adverse implications for
the global growth. Morgan Stanley, for example, has lowered its
estimate of East Asian economic growth, excluding Japan, from 5.1
percent to 4.5 percent for 2003. And the SARS contagion may get worse
before it gets better.
* The writer holds the Freeman Chair in China Studies at the Center
for Strategic and International Studies.
______
[From the Far Eastern Economic Review, May 1, 2003]
China: Richer, But Not Healthier
(By Bates Gill)
The news about Severe Acute Respiratory Syndrome (SARS) out of
China seems to get worse with each passing week. For, in spite of some
recent positive steps by Beijing, the political and socioeconomic
conditions are ripe in China for the further spread of infectious
disease, including atypical pneumonia, hepatitis and HIV/AIDS.
True, Chinese leaders recently have taken greater interest in
dealing with SARS. But admitting to problems is only half the battle.
There is still a long way to go, not just in dealing with SARS, but
with other health-care-related challenges. To begin, even if political
and bureaucratic impediments can be overcome, the Chinese health-care
system is incapable of adequately addressing the complexities of
emergent epidemiological and prevention challenges. Local health-care
capacity varies wildly across the country as central government
spending in this sector flattens and localities are expected to pick up
the difference. As a result, the expertise and capacity to diagnose,
prevent and treat the spread of disease--especially new viruses--is
limited to nonexistent throughout much of China.
In addition, Beijing and the provinces seem reluctant to fully
accept assistance from the international community to deal with their
burgeoning public-health quandary. Only after a 2-week wait were
inspectors from the World Health Organization permitted to travel to
the SARS outbreak's epicentre in Guangdong. This same reticence
characterizes China's earlier response to its HIV/AIDS crisis;
political leaders in Beijing and throughout local jurisdictions remain
overly cautious in their willingness to accept international
intervention and assistance.
China's approach to SARS exposes troubling weaknesses that are
reflected in Beijing's overall reaction to deadly disease outbreaks.
These are: opaque communication channels--and even deliberate
disinformation--from provincial to central authorities; denial and
inaction short of international outcry and senior-leadership
intervention; weakening public-health-care capacity to monitor,
diagnose, prevent and treat emergent disease outbreaks; and early and
persistent reticence to collaborate effectively with foreign partners.
This must change.
A first priority must be to implement more transparent, accurate
and coordinated public-health-care management and communication. As a
start, the country should invest even more heavily in its
epidemiological and surveillance capacity to accurately detect, monitor
and quickly report on disease outbreaks and their progress. Beijing
will also need to oversee improved cooperation both between the central
and local authorities and across the bureaucracy in a more effective
interagency mechanism. But for these kinds of steps to succeed, China's
new leadership must commit to raising the political priority of public
health on their agenda of socioeconomic challenges.
Second, resources for public health will need to be expanded
considerably, both as a part of central and provincial government
expenditures. At a basic level, more well-trained professionals will be
needed to properly diagnose, treat and care for persons afflicted with
emergent epidemics in China. Even more could be gained by promoting
greater awareness and preventive messaging, not to alarm people, but to
help them take the necessary precautions to protect against infectious
diseases prevalent in China.
Finally, China and the international public-health community have a
shared interest in scaling up cooperation and assistance programmes.
There are numerous international health-related assistance programmes
in China, but most operate at a relatively modest scale. Expanding
successful programmes will require significant new funding. The World
Bank may be one resource that could expand its support for health-
related programmes in China, but major donor nations should also
consider re-channelling development aid to focus more on public-health
programmes. In the end, however, China--as one of the world's largest
economies and an aspiring great power--will need to show a greater
commitment to working with international partners and to taking its
public-health challenges more seriously.
The silver lining to the tragic SARS outbreak may be the attention
brought to China's health-care system, and how China's health is a
concern to the world. Given China's intensifying interaction with
partners around the world, more concerted action will be needed to stem
the spread of debilitating and even fatal infections from China, and
ameliorate their effects on the economic wellbeing of China, the region
and the planet.
* The writer holds the Freeman Chair in China Studies at the Centre
for Strategic and International Studies in Washington.