Causes of effective policy implementation: China's public health response to SARS

Journal of Contemporary China

Volumn 16, Issue 51, 2007, Pages 195-213

  Schwartz, Jonathan ^a   Evans, R Gregory ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

DISEASE CONTROL; EPIDEMIC; HEALTH POLICY; INFECTIOUS DISEASE; POLICY IMPLEMENTATION; PUBLIC HEALTH; SEVERE ACUTE RESPIRATORY SYNDROME;

ASIA; CHINA; EURASIA; FAR EAST; SHAANXI;

EID: 34247869861     PISSN: 10670564     EISSN: 14699400     Source Type: Journal    
DOI: 10.1080/10670560701194426     Document Type: Article

References (123)

1. See for example, Canadian Department of National Defense Policy Report, available at: http://www.forces.gc.ca/admpol/eng/doc/ strat_2003/sa03_09_e.htm (accessed 1 February 2006).
2. 'China's new leadership passes test presented by SARS', People's Daily, (25 June 2003).
3. Chi Fulin describes this as a delicate time in China - one of economic and social transformation. He argues that if poorly handled, a crisis like SARS can lead to a social crisis. See http://www.worldbank.org/ transitionnewsletter/aprmayjun03/pgs8-11.htm (accessed 19 February 2004).
4. Epidemic prevention stations have been renamed Centers for Disease Control, remaining subordinate to the MoH (Ministry of Health) bureaucracy. The epidemic prevention stations were responsible for surveillance and other public health services. The genesis of the SARS outbreak can be found in Joan Kaufman, 'SARS and China's healthcare response', in Arthur Kleinman and James L. Watson, eds, SARS in China: Prelude to Pandemic? (Stanford: Stanford University Press, 2006), pp. 55-57.
5. Although Hong Kong is part of China and had many SARS cases, it is administratively autonomous from the mainland and therefore not relevant to this study.
6. 'Quarterly chronicle and documentation', The China Quarterly 175, (September 2003), pp. 862-865. According to Kaufman, 'SARS and China's health-care response', China had 5,327 cases and 349 deaths.
7. 'Quarterly chronicle and documentation', p. 866.
8. Aspects of the Maoist public health system are discussed in Dean T. Jamison, China: The Health Sector (The World Bank, 1984)
9. Ruth Sidel and Victor Sidel, The Health of China (Boston: Beacon Press, 1982)
10. William C. L. Hsiao, 'The Chinese health care system: Lessons for other nations', Social Science and Medicine 41(8), (1995), pp. 1047-1055.
11. Yuanli Liu, Keqin Rao and Shanlian Hu, People's Republic of China: Toward Establishing A Rural Health Protection System (Asian Development Bank), p. 8, available at: http://www.adb.org/Documents/ Reports/PRC _Rural_Health_Protection _System/prc_rural_health.pdf (accessed 24 June 2004).
12. Numbers often vary by source; The World Bank gives 32 years as the life expectancy in 1950 (Jamison, China: The Health Sector, p. 113).
13. Hsiao, 'The Chinese health care system', p. 1048
14. and Jamison, China: The Health Sector, p. xiii.
15. Jamison, China: The Health Sector, pp. 18, 129, and 133. Notably, some of these diseases have once again begun to emerge.
16. H. A. Ronaghy and S. Solter, 'Is the Chinese "barefoot doctor" exportable to rural Iran?', The Lancet, (1974), pp. 1331-1333.
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18. Judith Banister, 'Population, public health and the environment in China', The China Quarterly 156, (1998), p. 987. Also, an interview with Henk Bekedam, M.D., M.Sc., WHO Country Representative to China (31 May 2005). According to Bekedam, in his own pre-SARS outbreak discussions with Hu Jintao and Wen Jiabao he found that, while the leaders recognized the existence of a funding shortage in public health, they remained unconcerned.
19. 'China's 8-7 national poverty reduction program' (The World Bank), available at: http://www.worldbank.org/wbi/reducingpoverty/docs/newpdfs/ case-summ-China-8-7PovertyReduction.pdf (accessed 1 August 2004).
20. From an interview with Bekedam. Bekedam based his assessments on his experiences in Cambodia and Africa.
21. Yanzhong Huang, Mortal Peril: Public Health in China and Its Security Implications (Chemical and Biological Arms Control Institute, 2003), p. 10, available at: http://www.cbaci.org (accessed 6 July 2004)
22. David Blumenthal and William Hsiao, 'Privatization and its discontents: the evolving Chinese health care system', New England Journal of Medicine, (15 September 2005), p. 2.
23. Kaufman, 'SARS and China's health-care response', p. 60.
24. From an interview with Craig Shapiro, US Department of Health and Human Services, HHS Health Attaché, US Embassy, Beijing (26 May 2005); Tony Saich, 'Is SARS China's Chernobyl or much ado about nothing?', in Kleinman and Watson, eds, SARS in China, p. 93.
25. For a discussion of Fragmented Authoritarianism refer to: Kenneth Lieberthal, 'Introduction: The Fragmented Authoritarianism model and its limitations', in Kenneth Lieberthal and David Lampton, eds, Bureaucracy, Politics and Decision Making in Post-Mao China (Berkeley: University of California Press, 1992).
26. Also, Kenneth Lieberthal and Michel Oksenberg, Policy Making in China: Leaders, Structures and Processes (Princeton: Princeton University Press, 1988).
27. Michel Oksenberg, 'China's political system: Challenges of the 21st century', in Jonathan Unger, ed., The Nature of Chinese Politics: From Mao to Jiang (Armonk, NY: ME Sharpe, 2002), pp. 193-195.
28. 'Macro control proved to be timely and effective', People's Daily Online, (4 August 2004), available at: http://english.peopledaily.com.cn/ (accessed 4 August 2004).
29. Based on a joint World-Bank/IMF study of 100 countries; Conference on Mobilizing Urban Infrastructure in a Responsible Fiscal Framework, Urbanization and Sub-national Financing Background Notes, (6-8 January 2005), p. 3, available at: http://worldbank.org/urban/mun_fin/ uifpapers/bhattasali.pdf (accessed 3 February 2006).
30. Unfunded mandates are a key problem identified by public health officials across the country. From interviews with Shapiro, physician, Shaanxi Provincial People's Hospital (2 June 2005), and Staff, Nanjing Infectious Disease Hospital (7 June 2005).
31. Laurie Garrett, 'A Chinese lab's race to ID and halt SARS', Newsday (6 May 2003), available at: www.phucla.edu/epi/bioter/ chineselabsrace.html (accessed 11 July 2003).
32. Blumenthal and Hsiao, 'Privatization and its discontents', pp. 1-6.
33. Interview with Dr Lu Yan, Nanjing City Chinese Medicine Hospital (7 June 2005). Bekedam notes that pre- SARS, Chinese President Hu Jintao and Premier Wen Jiabao recognized the problems plaguing the public health system but gave the impression of being 'not overly concerned'. According to Bekedam, this attitude underwent a significant change following SARS.
34. Following SARS, training to identify potential infectious diseases increased dramatically. For example, interviews with Dr Lu yan, Dr Bekedam and with the Physician of the Shaanxi Provincial Hospital.
35. According to Bekedam, approximately 90% of funding is obtained locally. Furthermore, the MoH is bureaucratically weaker than the provinces and can therefore be relatively easily ignored. Decentralization has also resulted in the central government being unable to trace funds allocated to public health.
36. The PLA Department of Health is responsible to the Central Military Commission, not the Ministry of Health. Tony Saich, 'Is SARS China's Chernobyl?', pp. 92-93.
37. This is confirmed by Bekedam and Shapiro.
38. For example, the interview with Cheng Jun. Also, from interviews with Dr Hong Bing Shen, Associate Dean, Nanjing Medical University School of Public Health (7 June 2005)
39. Dr Li Jiequan, Director of the Nanjing Municipal CDC (7 June 2005)
40. Dr Yin Qilin, Associate Director of the Nanjing Municipal CDC, responsible for infectious diseases (7 June 2005)
41. and Physician, Shaanxi Provincial People's Hospital.
42. Richard Madsen, 'The public sphere, civil society and moral community: A research agenda for contemporary China studies', Modern China 9(2), (April 1993), p. 183
43. Lowell Dittmer and William Hurst, 'Analysis in limbo: Contemporary Chinese politics amid the maturation of reform', Issues and Studies 38(4)/39(1), (December 2002/March 2003), p. 39
44. Erica Strecker-Downs and Phillip C. Saunders, 'Legitimacy and the limits of nationalism: China and the Diaoyu Islands', International Security 23(3), (Winter 1998-1999), pp. 5-8
45. 'SARS to lead to tax drop of US$2.5 billion', People's Daily, (17 June 2003)
46. '14 million people to be out of jobs, SARS is one main reason', People's Daily, (18 June 2003).
47. 'China and SARS: China's Chernobyl?', The Economist, (26 April 2003), pp. 9-10
48. Eric Eckholm, 'Rude awakening', The New York Times, (13 May 2003).
49. Leiyu Shi, 'Health care in China: A rural-urban comparison after the socioeconomic reforms', Bulletin of the World Health Organization 71(6), (1993), p. 726.
50. The US Centers for Disease Control conduct epidemic investigations, research, training and public education. However, they do not have institutions that spread from the center to the local level, nor do they provide medical care services as is the case in China. Local Chinese CDCs fulfill many of the functions of US local health departments, offices of epidemiology and infectious disease.
51. According to Hu Yonghua, Dean and Professor, Beijing School of Public Health, the sub-national CDC network failed to satisfactorily fulfill its responsibilities during the SARS outbreak, with the result that its powers were reduced (interview, 31 May 2005). This view is shared by Henk Bekedam.
52. WHO Representative in Beijing, available at: www.cbc.ca/disclosure/ archives/031118_SARS/ docs/whobeijing (accessed 18 July 2003).
53. Presentation by Ms Wu Yi to the 56th World Health Assembly, (20 May 2003), available at: www.fmprc.gov.cn/eng/topics/sars/23097.htm# (accessed 11 April 2004 and 25 January 2006). Wu Yi became Health Minister on 20 May 2003.
54. According to Finance Minister Jen Renqing, 'the imbalance of revenue and expenditure remain an acute problem', with only a minimal rise in central government revenue while demands on the revenue continue to grow. Indeed, central government revenue in 2002 was 1.103 trillion RMB, whereas expenditures were 1.412 trillion RMB (Xinhua, 25 June 2003).
55. 'Chronology of China's fight against SARS since April 20', People's Daily, (13 October 2003), (accessed 20 February 2004).
56. According to 'The physician will not heal himself', China Development Brief, (July 2003), the greatest successes at this stage of the trial are in regions where foreign funding cover the costs for county governments.
57. People's Daily (25 June 2003).
58. Xinhua, 31 May 2003. $1US = 8.28 RMB.
59. For example, isolation rooms and monitoring equipment. From an interview with Cheng Jun, Director Infectious Diseases, Di Tan hospital, Beijing (30 May 2005).
60. Interviews with Cheng Jun (30 May 2005)
61. Hong Bing Shen, Li Jiequan, Yin Qilin (7 June 2005)
62. Shen Huiguo, Zheng Yingjie (7 June 2005)
63. and Director Xi'an Township CDC (3 June 2005).
64. Conference Summary, 'WHO Global Conference on SARS', Emerging Infectious Diseases 9(9), (September 2003), p. 1191.
65. Zhang Wenkang was replaced on 20 April 2003. Joseph Fewsmith, 'China's response to SARS', China Leadership Monitor 7, p. 2, available at: http://www.chinaleadershipmonitor.org.
66. 'China wakes up', The Economist, (24 April 2003), pp. 18-19
67. Yulin Ruan, 'Can China's public health system cope with SARS?', Zhong Guo Xinwen She, (8 June 2003), (accessed 23 January 2004).
68. Yulin Ruan, 'Can China's public health system cope with SARS?'. The important role played by the media in supporting the state initiatives and informing the population is discussed in Kaufman, 'SARS and China's health-care response', p. 67.
69. 'Quarterly chronicle and documentation', p. 866.
70. Tony Saich, 'Is SARS China's Chernobyl?', pp. 94-95. The Bureau was modeled on the US FEMA.
71. 'Plan put forward by Ministry of Health for Prevention of SARS', People's Daily, (29 August 2003), (accessed 5 January 2006).
72. Three levels of epidemic severity are identified: Ordinary - reflecting a single SARS case within a reporting period; serious - reflecting either a recurrent single case in one area or two or more cases within one prefecture or municipality; severe - reflecting two or more cases in one province, which will be seen as indicating that the disease is spreading.
73. The ministry designated SARS a contagious disease to be listed on the People's Republic of China Contagious Disease Prevention and Treatment Code ['PRC Health Ministry incorporates SARS into contagious disease code listing', Xinhua Domestic Service, (14 April 2003)].
74. Those suspected of, or confirmed as having SARS can be quarantined. Public security departments were made available to public health authorities where necessary to enforce quarantines. Public health departments across China have been required by the state Public Health Ministry to organize rapid reaction drills in preparation for possible epidemics ['China to organize nationwide SARS response drills in public health sector', Xinhua, (28 August 2003)].
75. Illustrating the seriousness with which SARS was handled, the state even tightened China's building codes in an effort to prevent SARS from spreading due to substandard construction ['China to tighten building codes in wake of SARS', Xinhua, (28 May 2003)].
76. Wang Dan, 'Chinese leadership signals change', Taipei Times, (2 January 2003), p. 8.
77. See for example: B. Michael Frolic, 'State led civil society', in Timothy Brook and B. Michael Frolic, eds, Civil Society in China (Armonk, NY: ME Sharpe, 1997)
78. Jennifer L. Turner and Fengshi Wu, 'Development of environmental NGOs in mainland China, Taiwan and Hong Kong', Green NGO and Environmental Journalist Forum (Woodrow Wilson International Center for Scholars, 2001)
79. Elizabeth Knup, 'Environmental NGOs in China: An overview', China Environment Series (Woodrow Wilson Center, the Environmental Change and Security Project, 1998)
80. Kenji Otsuka, 'China: Social restructuring and the emergence of NGOs', in Shinichi Shigetomi, ed., The State and NGOs: Perspective from Asia (Singapore: Institute of Southeast Asian Studies, 2002). Notably, there is wide debate over the nature and extent of civil society in the context of China. Here we construe civil society broadly- including organizations that have no, limited or extensive ties to the state while remaining outside of the state.
81. See for example, Nick Young, 'Searching for civil society', China Development Brief (2003), available at: http://www.chinadevelopmentbrief.com/page.asp?sec=2&sub=3&pg= 0&mp=1 (accessed 7 May 2005).
82. Elizabeth L. Croll, 'Social welfare reform: Trends and tensions', The China Quarterly 159, (September 1999), p. 695.
83. Caroline Cooper, 'Quietly sowing the seeds of activism', South China Morning Post, (10 April 2003).
84. Communication with Shannon Ellis, Civil Society Program Coordinator, Chinese Civil Society Program of the Canadian International Development Agency (January 2004). The FPA is not a traditional NGO. See http://www.chinadaily.com.cn/en/doc/2003-05/30/content_167217.htm (accessed 13 October 2004).
85. 'Split appears among first generation Chinese NGOs', China Development Brief, available at: http://www.chinadevelopmentbrief.com (accessed 13 February 2004).
86. See http://www.westwoman.org (accessed 11 October 2004).
87. See http://www.cango.org/ (accessed 11 October 2004).
88. 'Migrant workers: Working against SARS in urban and rural China', available at: http://www.oxfam.org/hk/english (accessed 11 October 2004).
89. Shannon Ellis, ongoing communications through June 2004.
90. Since their relationship to the state is the same, while we refer to one or the other, the same holds true for the counterpart.
91. Melanie Manion, 'The electoral connection in the Chinese countryside', American Political Science Review 90(4), (December 1996), p. 737
92. Robert L. Worden et al. discuss the nature and activities of neighborhood committees in Robert L. Worden, Andrea Matles Savada and Ronald E. Dolan, eds, Country Study China (Federal Research Division of the Library of Congress, 1987), available at: www.country-data.com/frd/cs/cntoc.html#cn0356.
93. According to Kevin J. O'Brien, 'Villagers, elections and citizenship in contemporary China', Modern China 27(4), (October 2001), p. 422, local Party secretaries retain much of the power with the Party branch playing the role of the village's 'leadership core'.
94. The Party has a cell in every Shi Qu: China Ministry of Civil Affairs, Document #23: MOCA's Ideas on Improving Shequ Construction, available at: http://www.isanet.org/noarchive/derleth.html (accessed 5 February 2006) or available at: http://www.sqjs.org.cn.
95. See also, O'Brien, 'Villagers, elections and citizenship in contemporary China', p. 416.
96. Especially in terms of services for the village such as welfare, culture, education and public health. The extent of autonomy varies from village to village. See Jean C. Oi and Scott Rozelle, 'Elections and power: The locus of decision-making in Chinese villages', The China Quarterly 162, (June 2000), pp. 522-523.
97. O'Brien and Li analyse the roles of 'rightful resisters' - villagers who draw on existing laws and regulations to press government officials and cadres. One arena of activity is free and fair villagers' committee elections. Such 'rightful resistance' may be viewed as expressions of civil society activism. See Kevin J. O'Brien and Lianjiang Li, Rightful Resistance in Rural China (Cambridge: Cambridge University Press, 2006), especially chs 3 and 6.
98. Bjorn Aplermann, 'The post-election administration of Chinese villages', The China Journal46, (July 2001), pp. 46, 49-50, 67.
99. In the 1990s the Party began renaming and changing the responsibilities of neighborhood committees. Instead of JuminWeiyuanhui, they are now called She Qu. Their responsibilities have increased as have their geographical reach and the population they support: Organic Law of the Urban Neighborhood Committees (Beijing, 1990), available at: www.mca.gov.cn.
100. Benjamin Lelan Read, State, Social Networks and Citizens in China's Urban Neighborhoods (Ph.D. dissertation, Harvard University, 2003, unpublished), pp. 66-77.
101. Worden et al., eds, China: Country Studies.
102. Interview with Bekedam (31 May 2005).
103. Interview with Lu Yan (7 June 2005).
104. Interview with the director of a township hospital (3 June 2005). 'SARS lessons: How to address a crisis', People's Daily, (20 January 2004), available at: http://english.people.com.cn (accessed 21 January 2004).
105. Cases of roadblocks were described by officials in each province visited during our fieldwork. From interviews with Physician, Shaanxi Provincial People's Hospital (2 June 2005)
106. Hu Yonghua (31 May 2005)
107. and Rupert Wingfield-Hayes, BBC reporter, China (2 June 2005).
108. This relationship is further elaborated in the thesis by Read, State, Social Networks and Citizens in China's Urban Neighborhoods, especially chs 1 and 3.
109. On 2 June 2005 and June 2003.
110. On 3 June 2005.
111. On 2 June 2005. Where relevant, we supplement the analysis with interviews conducted in Beijing, Shanghai and Nanjing. In MinHang district of Shanghai, the local street committees provided 6,800 volunteers who were trained by the community doctors who were themselves trained by the CDC in disease detection. From interviews with Dr Shen Hui Guo and Dr Zheng Yigjie (7 June 2005).
112. The 1989 law can be found in Chinese Law and Government 36(4), (2003), p. 6.
113. Notably, in the case of the Xi'an International Studies University Clinic, notification also arrived via the Ministry of Education.
114. BSL-3 is suitable for work with infectious agents which may cause serious or potentially lethal diseases as a result of exposure by the inhalation route. Examples of agents that should be manipulated at BSL-3 include M. tuberculosis and Coxiella burnetii. See J. Y. Richmond and R. W. McKinney, Biosafety in Microbiological and Biomedical Laboratories, 3rd edn (US Department of Health and Human Services, CDC/NIH: US Government Printing Office, 1993).
115. The length of quarantines changed as understanding of the SARS incubation period increased. Thus, while in the early stages quarantines lasted between 10 and 21 days, they were eventually set at 14 days.
116. The hotline existed before the SARS epidemic but was upgraded in response to SARS with additional training for hotline workers. According to one township hospital official, during the epidemic the line was staffed with well trained individuals who provided information, consultations, and took information regarding potential SARS cases. The official noted that during the epidemic the phone rang almost constantly, 24-hours a day. To illustrate its accessibility, the official successfully called the hotline during our interview.
117. This procedure was the same at the provincial level hospital in Xi'an as well as in the Shaanxi township hospital and the hospitals visited in Beijing (Beijing United Family Hospital and Di Tan Hospital).
118. According to interviewees, hospitals were compensated by the state for patient care if the patient lacked insurance or the means to pay. Dr Cheng Jun claimed that state funding was sufficient. Shapiro notes that the state invested an immense amount of money in SARS control.
119. Infectious diseases are categorized as A, B, or C, with A being the most severe and requiring reporting within six hours. B types must be reported within 12 hours and C types within 24 hours. Although SARS was originally categorized as a B type infectious disease, reports of SARS were required within six hours.
120. In more advanced regions the computerized notification system reached to the township level. In less developed regions, these systems were to be installed at the township level in 2006. Interviews with the hospital director of Chang-an country hospital, and regional director of the township medical and administrative affairs office (3 June 2005).
121. National Institute of Occupational Safety and Health (CDC) approved N95 masks remove at least 95% of solid and liquid aerosols.
122. Village and neighborhood committees are discussed earlier in the paper. 114 This may include visits to homes to assess the health of guests. 115 Physician, Shaanxi Provincial People's Hospital (2 June 2005); Hu Yonghua (31 May 2005).
123. In total, 50-60 persons were quarantined on the campus.