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\u2019s public health systems, including its evolution over time, its handling of the outbreak, and key lessons learned.<\/p>\n
China<\/strong>\u2019s Public Health Systems<\/strong><\/p>\n Public Health in Ancient China<\/em><\/p>\n 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).<\/p>\n Culture is also relevant to public health. It is widely known that traditional Chinese medicine has emphasized the importance of prevention. At times, China\u2019s 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).<\/p>\n Dawn of Western Medicine and Public Health in China<\/em><\/p>\n The last century of the Qing Dynasty (1636\u20131912) witnessed the introduction of Western medicine. Peter Parker (\u4f2f\u9a7e1804\u20131888), 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 (\u9ea6\u5609\u7f14) 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<\/a><\/sup> 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\u00a0Yale-China Association (\u96c5\u793c\u5b66\u4f1a).<\/p>\n 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\u2019s 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).<\/p>\n Public Health in the People\u2019s Republic of China<\/em><\/p>\n With Chiang\u2019s retreat to Taiwan and the establishment of the People\u2019s Republic of China in 1949, the role of the private sector in providing health care in China has subdued. China\u2019s then Ministry of Health, a responsible body for overseeing health care services and running of the country\u2019s 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 (\u8d64\u811a\u533b\u751f) 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).<\/p>\n Public health was a high priority for the nascent government of the People\u2019s Republic. Between 1950 and 1952, more than 512 million of China\u2019s\u2009then 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 (\u9a6c\u6d77\u5fb7), a Maronite American who was the first foreigner naturalized as a Chinese citizen in the People\u2019s Republic. Dr. Hatem also served as a physician for Mao Zedong in Yan’an (Porter, 1997). Unfortunately, STDs reappeared in the 1980s\u00a0with the liberalization of commerce and mobility and correspondent changes in social customs and sexual behaviors.<\/p>\n 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 \u201cvillage doctors,\u201d who have again assumed responsibilities of public health.<\/p>\n China\u2019s 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 \u201cone-child\u201d policy. The Commission took the much-shortened name of the National Health Commission in 2018.<\/p>\n China\u2019s 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 (\u4e09\u4fdd\u5408\u4e00) 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.<\/p>\n China<\/strong>\u2019s Lead Public Health Agency: The Chinese Center for Disease Control and Prevention<\/strong><\/p>\n The Chinese Center for Disease Control and Prevention (China CDC) became the principal national-level public health agency, but disease prevention in the People\u2019s Republic dates back to the Epidemic Prevention Stations (EPS) of the 1950s. In 1953, China modeled its health system on the Soviet Union\u2019s and established EPSs to contain and eliminate infectious diseases. By 1957, more than two-thirds of China\u2019s 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).<\/p>\n 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.<\/p>\n China CDC\u2019s mission is \u201cto 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.\u201d Under the auspices of China\u2019s National Health Commission, China CDC takes leadership in disease prevention and control and provides technical guidance and support for China\u2019s public health community. Shortly after China CDC\u2019s creation, it took on the task of dealing with the 2002-2003 outbreak of the Severe Acute Respiratory Syndrome (SARS).<\/p>\n 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.<\/p>\n During the 2009 round of health care reform in China, there were proposals to enable China\u2019s 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.<\/p>\n China CDC vs. U.S. CDC<\/em><\/p>\n 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.<\/p>\n 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<\/a><\/sup> 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.<\/p>\n Second, the U.S. CDC\u2019s 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<\/a><\/sup><\/p>\n 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.<\/p>\n 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.<\/p>\n 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\u2019s 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.\u00a0 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.<\/p>\n