Red flags in China’s disease control

Author: Yanzhong Huang, CFR

The H7N9 bird flu is back in China. Since last October, more than 165 new human H7N9 cases have been reported, compared with 136 last spring. At least 115 cases (with 25 fatalities) have been confirmed this year. While the mortality rate of H7N9 is not as high as that of H5N1, the total number of H7N9 cases identified in the past month equals the number of H5N1 cases reported in 2006 (the most active calendar year for H5N1).

In contrast to the systematic cover-up and inaction during the initial stage of the 2002–03 SARS outbreak, the Chinese government has handled the outbreak in a more transparent and decisive manner. It updates bird flu data on a regular basis. Live poultry trading was halted in many cities of Eastern China. Central health authorities have dispatched expert teams to affected provinces to supervise local hospitals in diagnosing and treating H7N9 patients. Most confirmed human cases of H7N9 have been isolated. In so doing, China has benefited from an enhanced disease surveillance and reporting system and improved surge response capacity.

Does that mean China has successfully bridged the normative gap with the international society in disease prevention and control? A closer look at China’s response to the H7N9 outbreak raises alarming questions on its ability to effectively manage a public health emergency of international concern.

First, while the government has become more transparent in sharing disease-related information, the cover up mentality dies hard, especially at the local level. As Zeng Guang, chief epidemiologist at the China CDC noted, local governments with a large tourism or poultry industry are still reluctant to report disease outbreaks in their jurisdiction. Moreover, political factors continue to interfere in China’s disease reporting process. Not only do local governments continue to arbitrarily assign disease control targets for health authorities to fulfill but the political leaders still have the final say in deciding whether to publicise a new disease outbreak or not. By 1 March 2013, for example, scientists in Shanghai had already identified a novel influenza A virus (which was later confirmed to be H7N9), yet the local media at the request of health authorities were busy refuting the ‘rumor’ of anything unusual by attributing the increase of respiratory infections to ‘seasonal changes’.

Second, despite a decade of capacity building in the public health sector, China’s surge response capacity continues to be hampered by interdepartmental coordination problems and lack of capacity to identify, diagnose and treat patients in a timely and effective manner.

The capacity gap was observed even in Shanghai, China’s largest and most cosmopolitan city that is supposed to have the most robust surge response capacity. In early March 2013, even though a group of Chinese scientists confirmed that a patient admitted by Shanghai No. 5 Hospital died of an unknown virus, doctors in the hospital failed to take any extra measures in treating patients with similar symptoms. In a manner reminiscent of the risk communication failure during the SARS outbreak, the Shanghai health authorities for nearly two weeks did not share with China CDC in Beijing the news of a confirmed H7N9 virus. Worse, China’s existing flu vaccine manufacturing capacity can only meet the needs of one tenth of its population. This might explain why during a disease outbreak in China indigo woad root (a Chinese herbal medicine) is more popular than vaccines or antiviral drugs.

Last but not least, during an outbreak the government reactive mobilisation efforts often run counter to a risk management strategy essential for effective disaster response. A primary objective of risk management is to maximise protection and minimise disruption to the society and the economy. But even today the government is still heavily reliant on state-centric, vertically imposed prohibition and coercion — such as mass culling and other draconian containment measures — to address disease outbreaks without differentiating the risk posed by different viruses.

Indeed, the SARS crisis reinforced the notion that aggressive containment measures are the silver bullet to all infectious disease outbreaks. As shown in the 2009 H1N1 pandemic, such measures potentially can do more harm than good. In coping with the H7N9 outbreak, drastic public health interventions have already resulted in consumer panic and increased the financial burden of poultry farmers, costing the poultry industry over US$16.4 billion in 2013 alone.

In the post-SARS era, China has managed to withstand crises associated with major infections, including H5N1 and H1N1. Since the viruses have either been relatively mild (in the case of H1N1) or failed to transmit among human beings (in the case of H5N1), none of them can rival SARS in terms of its devastating effect. Yes, China has made great strides in improving its ability to handle a public health emergency, but lingering problems in disease reporting and response raise red flags on its ability and effectiveness at addressing a SARS-type disease outbreak. Given the enduring gaps in China’s crisis management system, one can only hope that H7N9 does not evolve into a more virulent form or achieve efficient human-to-human transmission.

Dr Yanzhong Huang is a Senior Fellow for Global Health at the Council on Foreign Relations and an associate professor at Seton Hall University’s School of Diplomacy. He is also the founding editor of Global Health Governance journal.