SARS (severe acute respiratory syndrome), the first pandemic of the 21st century, was a much-needed wake up call for China’s health system. The disease first appeared in Guangdong Province in the autumn of 2002, before eventually spreading by the end of the following July to 29 countries, with a total of 8,422 cases and 916 fatalities, according to the World Health Organization.
China’s response at the time was roundly criticized, with its alleged secrecy (it was accused of hiding patients from inspectors and it initially refused entry to WHO assessment teams) hampering efforts to contain the disease.
According to Jonathan Schwartz, Associate Professor of Political Science at the State University of New York State, SARS was a call to action for a Chinese leadership that had been increasingly neglecting public health.
‘The initial Chinese response was to try to contain the outbreak without informing the public or the international community,’ he told me. ‘Once this approach proved impossible, with SARS reaching Hong Kong, China’s leadership rapidly shifted gears.’
The first case was reported in Guangdong in mid-November 2002, but the disease spread to Hong Kong on February 22.
Schwartz said the spread of the disease prompted the Chinese leadership, after years of decentralizing decision-making, ‘to recentralize decision-making powers in terms of pandemic response’ and to ‘activate a wide array of government agencies from the central down to the local levels. Tremendous resources were allocated and the population was mobilized.’
‘China learned from the SARS episode that it must be prepared to rapidly ramp-up its crisis response capabilities,’ he said.
In addition, China appears to have realized that it needed to invest significantly in upgrading funding on public health generally. According to a paper by the UTS China Research Centre, in 2003 central and local government increased funding on public health by 23 percent on a year earlier, while between 2002 and 2006 spending increased almost 100 percent.
Roberto Bruzzone, Chief Executive Officer of Hong Kong University’s Pasteur Research Centre, told me that, overall, he felt the legacy of the crisis has been ‘the strengthening of basic and public health research on infectious diseases and a clear jump in the competitiveness and recognition of the labs involved,’ and he noted that many labs in China have contributed essential scientific information of the SARS-coronavirus, including at the University of Hong Kong.
Bruzzone also suggested that there has since been a greater openness and willingness to engage in collaboration, and openness and collaboration, noting that the Institut Pasteur-Shanghai (an institute of the Chinese Academy of Sciences) is now also involved in local surveillance network for respiratory infection (especially SOI-H1N1).
So, what about the next outbreak? Schwartz said the key for China will be to not over-react to any outbreak, a danger he said was underscored by the country’s response to H1N1, where it introduced extensive quarantines, flight cancellations, road-blocks and other limits on movement of people that far exceeded any recommendations by the WHO and ‘likely had little impact on the spread of H1N1’.
He noted that China faces a number of challenges, not least an immense population that lacks sufficient access to regular preventive care. He also noted that the task of producing sufficient vaccines for a novel disease to meet the needs of just first responders is a major challenge. ‘There can be no expectation that the population as a whole can be immunized. This is clear from the vaccine response to H1N1,’ he said.
Bruzzone agreed that China faces some quite specific challenges, including : ‘training and motivation of personnel in public health structures (especially local); quality of the hospitals; access to health systems, impact of the transformation of the territory (such as projects like the three gorges dam) and also the mobility of people, which may bring unexpected consequences.’
It’s a daunting list, but China does genuinely seem to have learned some lessons from SARS that will hold it in good stead. For example, last April, Premier Wen Jiabao convened a cabinet meeting as soon as the WHO raised its pandemic alert phase from 3 to 4, despite there not having been any reports of swine flu in China at that point. Two days later, President Hu Jintao convened a meeting of the Standing Committee of the Politburo.
Schwartz told me he thought such centralized responses actually give China an advantage, with the clear hierarchy able to establish lines of control from the central government down to the lowest levels of the bureaucracy.
And he added: ‘At least in terms of ramp ups for rapid pandemic response, this centralized system contrasts well with the more decentralized, collaborative and democratic models found in most western countries.’
The China health series concludes Friday with a look at the government’s proposals for health reform.