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Public Health In China: Bull’s Nose Ring Or Tail?

Public Health in China: Bull’s Nose Ring Or Tail?

Post Series: 2020: Volume 19, Number 2
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Like a bull in a china shop, COVID-19 has shattered lives and wrecked economies worldwide. With millions of people in lockdowns, quarantines, or other forms of restrictions on mobility because of the ongoing COVID-19 pandemic, questions abound. Was the pandemic preventable? Who should be held responsible for the outbreak? How are we going to prevent the next pandemic? What was the source of the virus? It would take several doctoral dissertations to respond to all these questions in a manner that is not too cursory. I will, therefore, focus this essay on China’s public health systems, including its evolution over time, its handling of the outbreak, and key lessons learned.

China’s Public Health Systems

Public Health in Ancient China

It is debatable whether ancient China and other early civilizations had a systematic way of dealing with public health issues. However, ancient Chinese did discover primitive forms of strategies used today for infectious disease containment, including vaccination, quarantine, and prevention (IOM, 2007). The origin of vaccination can be traced back to the practice of variolation (smearing of a skin tear of someone with smallpox to confer immunity) in 17th century China (The Immunisation Advisory Centre, 2016). Isolation and quarantine of leprosy patients had been conducted in China, with the first house for leprosy patients in China built in 1518 in Fujian. Early forms of community hygiene had been used in large populations centers in ancient China, including the clearing of sewage (Chinese Academy of Science, 2003).

Culture is also relevant to public health. It is widely known that traditional Chinese medicine has emphasized the importance of prevention. At times, China’s social norms had improved the balance of nutrition and reduced the likelihood of epidemic gastrointestinal infections. Anecdotes suggested that Chinese laborers building the transcontinental railways in the U.S. were less likely to suffer from malnutrition and diarrhea because their diet included a mix of vegetables and meats, and they consumed little alcohol (PBS, Not dated).

Dawn of Western Medicine and Public Health in China

The last century of the Qing Dynasty (1636–1912) witnessed the introduction of Western medicine. Peter Parker (伯驾1804–1888), a Yale-trained missionary and physician, founded the first-ever Western-style hospital in China, the Ophthalmic Hospital in Canton, on November 4, 1835 (Wikipedia, 2020a). The hospital later became the Second Affiliated Hospital of Sun Yat-sen University. In 1844, Dr. Divie Bethune McCartee (麦嘉缔) established the first successful Presbyterian Church (USA) mission station in mainland China in Ningbo, where he practiced medicine (Wikipedia, 2020b). The introduction of Western medicine accelerated in the last decade of the Qing Dynasty. In 1906, several religious groups banded together to establish Peking Union Medical College (PUMC) Hospital,1 which from 1916 was supported by the China Medical Board. In 1910, missionaries from the UK, Canada, and the U.S. founded the West China Union University Medical College, and in 1914, Xiangya Medical College was founded by the Hunan Yuqun Society and the Yale-China Association (雅礼学会).

With the growing acceptance of Western medicine, the idea of modern public health gradually gained a foothold. In 1905, the Qing court established a police department with its very own hygiene unit (Du, 2014), marking the start of modern public health practices. Supported by the China Medical Board, PUMC created China’s first academic department of public health, and actively promoted public health practice. PUMC collaborated with the Capital Police Department to create an Institute of Public Health on May 29, 1925. A major task of the institute was the training of public health nurses. In 1929, the Peking Municipal Government created possibly the first department of health by Chinese authorities. The pioneers of public health practices forged ahead while lamenting the lack of authority and funding. In 1934, health organizations in Peking started annual campaigns of vaccination against smallpox, cholera, diphtheria, scarlet fever, and typhus (Du, 2014). The war with Japan and the Chinese civil war ensued, hampering further development of public health. However, Chiang Kai Shek, leader of the Republic of China, promoted his signature New Life Movement during wartime. Hygiene was one of the pillars of the movement, sparking one of the earliest modern health education campaigns in China (Dirlik, 1975).

Public Health in the People’s Republic of China

With Chiang’s retreat to Taiwan and the establishment of the People’s Republic of China in 1949, the role of the private sector in providing health care in China has subdued. China’s then Ministry of Health, a responsible body for overseeing health care services and running of the country’s health care network, soon began transforming private hospitals into public ones, including the PUMC Hospital. By the late 1960s, government-funded and -run hospitals fully took over health care services in China. In rural areas, barefoot doctors (赤脚医生) took responsibility for public health. They were considered a new cadre of community-level health workers that brought basic curative care, health education, and a continuous public health approach to large swaths of the rural population in China. Barefoot doctors managed a village-level cooperative medical scheme, which some considered a successful model in improving primary care in rural settings (Blumenthal & Hsiao, 2015).

Public health was a high priority for the nascent government of the People’s Republic. Between 1950 and 1952, more than 512 million of China’s then roughly 600 million people were vaccinated against smallpox. When the last patient recovered in 1961, smallpox was eradicated in China, 16 years before global eradication (Wang, 2019). Of note is that China declared the elimination of sexually transmitted diseases (STDs) by 1964 with the efforts spearheaded by George Hatem (马海德), a Maronite American who was the first foreigner naturalized as a Chinese citizen in the People’s Republic. Dr. Hatem also served as a physician for Mao Zedong in Yan’an (Porter, 1997). Unfortunately, STDs reappeared in the 1980s with the liberalization of commerce and mobility and correspondent changes in social customs and sexual behaviors.

Indeed, as an unexpected consequence of China’s economic liberalization and the privatization of agriculture, the rural health system started to collapse in the late 1970s and early 1980s. Recent efforts have been made to re-establish a system of “village doctors,” who have again assumed responsibilities of public health.

China’s primary health agency had been reorganized several times. The Ministry of Health (1949-2013) merged with the Family Planning Commission to form the National Health and Family Planning Commission (2013-2018), a not-so-subtle hint of the change in the long-standing “one-child” policy. The Commission took the much-shortened name of the National Health Commission in 2018.

China’s health care reforms are relevant to public health as well. Several insurance and safety networks had been established for urban and rural residents, including a rural cooperative medical scheme and basic medical insurance for urban residents. These insurance schemes were merged (三保合一) and managed under the various levels of health care security agencies. One goal of the 2009 health care reform was to provide essential public health services to vulnerable populations.

China’s Lead Public Health Agency: The Chinese Center for Disease Control and Prevention

The Chinese Center for Disease Control and Prevention (China CDC) became the principal national-level public health agency, but disease prevention in the People’s Republic dates back to the Epidemic Prevention Stations (EPS) of the 1950s. In 1953, China modeled its health system on the Soviet Union’s and established EPSs to contain and eliminate infectious diseases. By 1957, more than two-thirds of China’s roughly 2,050 counties had an EPS. They vaccinated the population, with laudable achievements such as elimination of smallpox in 1960 and, to some extent, STDs by 1964 (Wang, 2019).

On December 23, 1983, then Ministry of Health created the China Center for Preventive Medicine, subsequently renamed the Chinese Academy of Preventive Medicine on January 19, 1986 (China CDC, 2018). In 2002, the Academy merged with several other institutes, including the Institute of Occupational Health and Institute for Health Education and formed the China CDC on January 23, 2002. (China CDC, 2012). As its name suggests, the China CDC considered the U.S. Centers for Disease Control and Prevention (U.S. CDC) a model for public health practice. The honor of the first provincial CDC in China earlier went to the Shanghai CDC, which was established in November 1998.

China CDC’s mission is “to create a safe and healthy environment, maintain social stability, ensure national security, and promote the health of people through prevention and control of disease, injury, and disability.” Under the auspices of China’s National Health Commission, China CDC takes leadership in disease prevention and control and provides technical guidance and support for China’s public health community. Shortly after China CDC’s creation, it took on the task of dealing with the 2002-2003 outbreak of the Severe Acute Respiratory Syndrome (SARS).

China ramped up investments in infectious disease control after the SARS outbreak. To address the need for enhanced disease surveillance systems identified after the SARS outbreak, China launched a nationwide system in 2004 that is capable of reporting infectious disease and emerging public health events via the internet. By 2013 the system had more than 70,000 reporting units, including CDCs at different levels and incorporating most of the medical providers in China.

During the 2009 round of health care reform in China, there were proposals to enable China’s CDC systems to take on the basic public health services. However, as the China CDC has been primarily a science and technical support agency, the plan did not materialize.

China CDC vs. U.S. CDC

COVID-19 has prompted numerous assessments of the public health systems across the world, including a comparison of the CDCs in China and the U.S. The following compares the two agencies in terms of workforce, budget, authority, and coordination with regional health authorities.

The China CDC is limited in terms of workforce with a total of 2,120 Full-time equivalents (FTEs) in 2016, compared with the 11,195 FTEs for its counterpart in the U.S., a figure that does not include several thousand of contractors (Frieden, 2020).2 The Public Health Foundation put the U.S. government public health workforce at 403,323 in 2011, with county/city and state-level public health workers totaling 287,267 (University of Michigan/Center of Excellence in Public Health Workforce Studies, 2012). Meanwhile, statistics from the 2017 China Health Statistics Yearbook reported national, provincial, prefectural, and county CDC employees in China at about 193,000 FTEs.

Second, the U.S. CDC’s budget dwarfs that of the China CDC. In 2019, The U.S. CDC had a budget of $11 billion, while the total budget of the National Health Commission (which includes China CDC and many other units) in 2019 was just over $3 billion.3

Third, the U.S. CDC is a federal agency with a legal mandate to quarantine patients who may pose risks to public health across national or state borders. The China CDC serves as one of the supporting technical institutes but the legal mandate to quarantine patients resides in governments at the county level or higher. Successful efforts in epidemic detection and control require the strong leadership of the national public health institute.

Fourth, China CDC does not have authority over provincial, prefectural, and county-level CDCs, as many observers have assumed. Being a supporting agency of the central government, China CDC provides technical guidance to local CDCs. A local CDC, however, usually reports to the local health commission, which has the final say on operations, including financing and personnel. The China CDC merely works with local health commissions and local CDCs when outbreaks occur. As China CDC does not have strong influence in funding or personnel decisions, its recommendations may be brushed off, and it may not be provided with full information.

This comparison probably is made at an inconvenient time because the U.S. CDC faced sharp criticisms for its handling of the COVID-19 pandemic (Abutaleb, Dawsey, Nakashima, & Greg, 2020). CDC’s failure to produce an adequate test for COVID-19 was a black mark against the agency. An unintended implication is that more financial and human resources are not associated with better outcomes.  However, I argue that the mediocre performance of the U.S. CDC this time resulted from a combination of misfortunes, political interference, and possibly lack of political influence. As one of the most renowned public health agencies, the U.S. CDC remains a model for public health agencies worldwide. I relegate an in-depth examination of the performance of the U.S. DC in containing COVID-19 to future analysis.

COVID-19 and China’s Public Health System

As of May 26, 2020, there were 5,304,772 cases worldwide of COVID-19 and 342,029 deaths (WHO, 2020). Recent estimates put R0, the number of people a contagious COVID-19 patient might infect if no intervention is involved, at 5.7 (Li et al., 2020; Sanche et al., 2020; Xu et al., 2020). Note that the number is an estimate, and the true R0 is unknown, possibly not to be known. However, the estimated R0 does indicate that COVID-19 is highly contagious. Transmission by asymptomatic or presymptomatic people and an incubation period ranging from two to 14 days pose a serious challenge to public health communities (Bai et al., 2020).

China’s public health system faced initial vehement criticism for its presumed delay in detecting and communicating information about early cases of COVID-19. Early warning signs emerged in late December of 2019, but it took days for the China CDC to be informed. It was around this time that Dr. Wenliang Li, a doctor with the Central Hospital of Wuhan, posted an online message warning about the outbreak. A few days later, he was reprimanded by Wuhan authorities and forced to confess to making false statements. After Dr. Li died of COVID-19 he was hailed as a national hero.

It wasn’t until early January that central authorities disclosed information about the virus to the world, prompting more allegations, strongly denied by Beijing, that the central government had withheld vital information. In fact, it’s unclear what the central authorities knew about the coronavirus in late December and the first part of January.

But it is clear that other factors influenced the uproar over the reporting delay. First, after reading a paper published in the New England Journal of Medicine (Li et al., 2020) in late January, a popular blogger accused the authors, most of them China CDC scientists, of purposely delaying the reporting of their findings about the virus. It later turned out that the blogger had made a gross misinterpretation of the timeline that was retrospectively dated. Although the blogger retracted his post, the notion that China CDC delayed the reporting quickly spread. Second, many have been frustrated by the fact that the outbreak was not reported sooner via the direct report system. However, a delay in reporting early COVID-19 cases in the system indicates issues in enforcing reporting protocols. Dr. Sheng Hua, a prominent economist, later revealed that the director-general of China CDC learned of the outbreak through his social network instead of the reporting system, and a national-level investigation was quickly set up afterward.4 This incident points to an issue that has long pestered China (or any large country with powerful regional governments) – how the central government leads and coordinates with regional authorities.

The public also questioned China CDC’s management of risk communication during the epidemic, demanding timely reporting and transparency. To be fair, China CDC technically is not a government agency and does not have the authority to publish information related to outbreaks. Besides, China CDC may not be fully capable to function in health communication – the Center for Health Education was separated from China CDC after a short-lived marriage. An integrated approach emphasizing coordination between different agencies would better serve the public.

Nonetheless, China CDC has played a critical role in containing the COVID-19 outbreak in China. Along with other provincial and local CDCs, they have put field staff in Hubei province to conduct epidemiological investigations and contact tracing (The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team, 2020). They have contributed to the understanding of the epidemiological features of COVID-19 (Li et al., 2020) and promptly advocated for international collaboration to contain the pandemic (Abutaleb et al., 2020).

We need to note that the China CDC comprises only a part of China’s public health system. To achieve its objectives, China CDC coordinates with provincial and local CDCs, as well as public health functions embedded in the health care systems, including hospitals and community health centers. At the height of the outbreak in Hubei, more than 40,000 health care providers from other provinces converged on Hubei province to offer much-needed assistance to the local health care systems. The contribution of all the parties to containing the COVID-19 outbreak should not be forgotten.

It is worth recalling the earlier section on the history of China’s public health efforts. The major approaches that China’s public health system used to contain COVID-19 continue to include old methods such as social distancing, quarantine, and sanitation. Social distancing and other measures to reduce mobility are effective in the containment of COVID-19 (Prem et al., 2020). Meanwhile, although Chinese scientists are making progress in developing vaccines for COVID-19, the take-up rate of flu vaccine in China has been poor, which may have led to hospital-acquired infections during the flu season. The lack of coverage of flu vaccination is partially attributed to the separation between the health care systems and public health. In China, the payers – various levels of the health care security administrations – are not allowed to cover flu vaccination, which is budgeted in the basic public health services provided by community health centers.

Looking Forward

Dr. Jeffrey Koplan, former director of U.S. CDC, and Dr. Yu Wang, former director of China CDC, together published an analysis 10 years after the 2002-2003 SARS outbreak. They highlighted the need for enhanced disease and symptom surveillance systems, effective infection control, and a central focus of public health for coordination and leadership with delegated responsibility and authority, among other things (Koplan, Butler-Jones, Tsang, & Yu, 2013). Seven years later, the call still stands true for China, and probably for the U.S. and the rest of the world as well. The COVID-19 pandemic further highlights the need for concerted multi-sectoral efforts (Chen, Cao, & Yang, 2020). The following offer food for thought and possible topics for more in-depth discussions on China’s public health system.

  1. Strengthening the leadership of public health agencies deserves attention. Elevating the status of Chinese CDCs would help to facilitate timely communication and decision-making. Clarifying the legal authority of Chinese CDCs would be useful (Li et al., 2020).
  2. Provincial and local public health systems, as essential components of the national public health system, need to be sustained. In addition to the China CDC, China’s provincial and local CDCs have also suffered workforce shortages (Wang et al., 2019). Capacity building at the regional and local levels is critical for successful epidemic control.
  3. China’s public health system needs to coordinate between different levels of CDCs and collaborate with local hospitals. A world-class direct reporting system is fantastic, but it will function properly only with adequate training and a close working relationship with the staff members of health care providers.
  4. To prevent transmission of infectious diseases, early identification of cases and their close contacts are crucial. Because asymptomatic and presymptomatic COVID-19 patients are both contagious, it is vital to identify close contacts of COVID-19 patients and to implement effective self-isolation and quarantine guidelines. Massive efforts in contact tracing have paid off in containing the epidemic in the Chinese City of Ningbo (Chen et al., 2020).
  5. China’s public health system needs to recruit and retain talent. Current wage levels for the workers in China’s CDC systems are not comparable to those with equivalent qualifications in health care, fueling a recent exodus of people from the CDC system. It is not too late to examine the pay scale of the CDC workforce nationwide and assess alternative mechanisms of recruiting and retaining talent.
  6. Improving risk communication is critical. Health communication is a burgeoning field that involves multidisciplinary collaboration among behavioral science, communication, and public health. China’s public health system needs to build up its capacity in health communication, not just for the prevention and control of infectious diseases but also for chronic diseases.

Concluding Remarks

Policymakers have competing priorities. Resources and attention are often directed to projects that show quick and certain returns at the price of reduced investment in public health. COVID-19 proves such a tactic to be risky and provides an opportunity to reflect and revise our approaches. In times of uncertainty, prevention and preparedness is key to avoiding a future redux of the COVID-19 pandemic. We must strengthen public health institutions by providing sufficient financial and human resources and conferring them concrete and implementable authorities. We also need to improve collaboration between central and regional authorities, and most importantly, trust the expertise of public health workers.

If a bull is near a china shop, it is better to lead it by holding its nose ring. Failing to prevent or detect an epidemic is the same as grabbing the bull’s tail – imagine what might happen to the china shop.

Acknowledgments and Disclaimer

The author acknowledges Ms. Yeran (Cynthia) Deng for excellent research assistance. I learned about the enlightening metaphor of bull’s nose ring vs. tail from Professor Zuofeng Zhang, who attributed the metaphor to Professor Guangwen Cao. I thank Professors Penny Prime and Hanchao Lu for the invitation to present this material at the China Research Center seminar series and to submit it to this journal. The thorough editing of Drs. Betty Feng and James Schiffman is much appreciated. Any remaining errors are undoubtedly and totally my own.

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