China's Bird Flu Blues
How will Beijing respond to its latest public health crisis? Part of an ongoing series of discussions with ChinaFile.
A new strain of avian flu called H7N9 has infected at least seven humans and killed three in provinces near the Chinese metropolis of Shanghai, with the first death occurring on March 4 . Meanwhile, in the last month, about 16,000 pigs, 1,000 ducks, and a few swans have been pulled dead from Chinese rivers. An April 2nd World Health Organization (WHO) statement that scientists could find "no evidence of any connection" between the dead pigs and the human victims can no longer be found on its website.
Predicting whether infection will spread to the extremes required of the term "pandemic" is a fool's errand. But there's no question the H7N9 outbreak will test whether the administration of new president Xi Jinping is serious about its calls for greater transparency. The early evidence is encouraging; censors have allowed social media discussion of the disease to proceed, and state media is providing frequent updates. In fact, state-run CCTV's report of nine infections is ahead of the WHO's own recent estimates. On social network Sina Weibo -- which YaleGlobal rightly calls China's "virtual public square"-- the top trending post is a list of common-sense tips for preventing the disease.
President Xi is surely using the outbreak of Severe Acute Respiratory Syndrome, or SARS, as a case study. Precisely ten years ago today, teams of scientists from the WHO were traveling through mainland China to investigate early infections from SARS. Days later, I and the dozens of other Peace Corps Volunteers serving in China were told to vacate within 24 hours, taking the last available commercial flight from Chengdu to Washington, DC. Before I left my teaching post in Fuling, school leaders called the resident Volunteers to a quick meeting. They politely told us they disagreed with the Peace Corps' decision to pull out; SARS, the dean said, had "been cured." Ultimately, under then-President Hu Jintao, the government's tight-lipped approach to the disease only fed panic and sowed long-term mistrust.
With the unprecedented openness that social media provides for China civil society, Xi can --and perhaps must -- take a different path. But as Rachel Lu of Tea Leaf Nation recently wrote, the Chinese Web may yet prove "a double-edged sword." Thus far, it has provided government with an interactive platform to both assuage and gauge citizen fears. But it also allows fear to spread along with information. And if watchful Web users perceive anything less than full transparency, they will pounce, and the blow back could undermine public safety and Xi's early credibility at the same time.
David, I am also encouraged by the government's relative transparency when it comes to recent reports of H7N9 infections. By contrast, as you point out, the Chinese government response to the initial SARS outbreak was characterized by cover-up and inaction. As a result of the news blackout about the disease in the government-controlled press, SARS carriers traveled across the country without realizing that they were shedding a dangerous virus. According to Dr. Margaret Chan, then Director of Health in Hong Kong, China repeatedly declined her requests for information on the grounds of official secrecy. Consequently, SARS also developed into a full-blown epidemic in Hong Kong, from where it spread further to other parts of the world.
In the post-SARS era, the government has taken steps to promote the image of a more open and transparent government in its dealing with public health emergencies. As part of the government's transparency campaign, information on the current veterinary epidemics, including avian influenza, was no longer classified as state secrets. According to the Regulation on Infectious Disease Information Reporting Management (2006), cases of SARS and Highly Pathogenic Avian Influenza (HPAI) should be reported within two hours of a confirmed incident. The Emergency Response Law further requires governments at or above county level to "issue public-related forecast information and analytical assessment results about emergency events." This is reaffirmed by the Regulation on Government's Information Disclosure (2008), which asks the disclosure of "contingency plan, surveillance information and responses to public emergencies." Thanks to the revved-up state commitment, China now boasts the largest (if not the most efficient) infectious disease surveillance and reporting system in the world.
The government response to the ongoing H7N9 outbreak suggests that it is generally following the aforementioned regulations and becoming more transparent than 10 years ago. While questions were raised on why it took more than three weeks for the health authorities to publicize the first cases, it appears that this had more to do with the lack of laboratory and epidemiological capacities than deliberate cover-up. Nevertheless, as I have argued in my new book Governing Health in Contemporary China, the post-Mao policy process has witnessed a shift from "band-wagon" to "buck-passing," which encourages strategic disobedience and policy shirking. For this reason, China's response to public health emergencies may continue to be bedeviled by lingering problems of under-reporting, misinformation, and inaction.
All steps towards openness and transparency are to be applauded, perhaps we should hold off the standing ovation for a little while yet. The first avian flu death occurred on February 27th, the second on March 4th. The authorities waited 20 days to release this information.
There is a huge deficit of trust between the public and the government that can best be addressed by speedier and fuller disclosure. The failure to meet this challenge is one of the many things that feeds rumors which are generally, though not always, even darker than the truth.
The coincidence of the pig scandal and the bird flu deaths has led to a neat fusion of public worries. But if the government wants to avoid this kind of thing, it needs to be much more transparent itself and to stop preventing investigation by others.
Can you imagine 15,000 dead pigs floating down the Mississippi River without hundreds of reporters beating every inch of the river until they found the source and named the guilty party? Have you wondered why we only have vague indications of the source of the Huangpu pigs?
China Digital Times gives us a clue: below is the relevant directive, dated March 19, from China's censors to China's media, as the government tried to damp down this grotesque story:
The Shanghai Huangpu River dead pig incident is already being dealt with effectively. Related follow-up coverage should follow Xinhua wire copy and information issued by authoritative local departments. The media are not to send journalists to Jiaxing or similar locations to investigate, nor to sensationalize or comment on the issue.
So no reporting allowed from Jiaxing. Transparency is not just a matter of officials releasing data to the public at their convenience. It is also about facilitating effective scrutiny and oversight by press and public.. Incidentally, it might even make the official jobs of inspection and regulation easier to do, if the government seriously wants them done better.
To follow up on Isabel's point, the problem is not just whether the government is sincerely interested in transparency. It's whether it has the credibility that's needed to make certain policies effective. For example, the State Commission on Health and Family Planning yesterdayissued a notice stating that it was forbidden to delay treatment or turns patients away because of inability to pay fees. Nobody could quarrel with the wisdom of this policy; there's a significant public benefit in treating victims of a highly infectious disease. But how are hospitals to get reimbursed? "The matter of fees for treatment should be resolved through stipulated channels." I suspect that hospitals, probably on the basis of past experience, will be less than reassured by this vague language, and will with some justification fear that they will simply have to eat the cost despite whatever promises were made. Unfortunately, many necessary measures simply cannot be paid for immediately in cash; the only available coin is the state's promise. If that coin is devalued, any measures that must be funded by it won't be effective.
It is encouraging that the high-level reporting mechanisms seem to be working. This is progress. There was a period during one of the post-SARS avian flu outbreaks when, because the virus affected animals, the Ministry of Agriculture was in charge of reporting on the disease's spread and rigid protocol only allowed it communicate directly only with the U.N.'s Food and Agriculture Organization (FAO), not the World Health Organization (WHO).
Still, I'm with Isabel. It's worth remembering that in 2003 not only did health authorities in Beijing fail to release information to Hong Kong on the spread of SARS, they also lied to the WHO, the press and the Chinese public about the number of SARS cases in Beijing and elsewhere on the mainland. And they were so bent on trying to maintain that lie--even after the military doctor Jiang Yanyong loudly blew the whistle-- that they even hid very sick SARS patients from WHO inspectors by shuttling them around Beijng in ambulances in one case and sending them to a hospital basement in another.
Among the most fatal decisions of the SARS debacle were the orders to doctors, nurses and other health providers at multiple hospitals not to speak about what was happening inside their hospitals. Hundreds of people were infected as a direct result of those orders and some of them died.
The directive to journalists that Isabel posted is boilerplate for this kind of thing, but reading it gave me extra chills, because it echoes the orders issued to doctors at Beijing hospitals during SARS. I remember the quake in one senior doctor's voice as she explained that, at her hospital (which had handled Beijing's first SARS case), the orders to tell no one about the SARS patients had been issued verbally and hospital staff were forbidden to bring pens or notebooks into the room where the orders were issued.
Chinese officialdom may have been chastened, to some extent, by the disastrous consequences of that cover-up. And there's no question that technology has made guarding "sensitive" information more difficult. But that doesn't mean Beijing has embraced transparency in the ensuing years. Think of the official response to more recent calamities: the melamine milk powder scandal, the Sichuan earthquake, the high-speed rail crash. They tried to bury the train cars.
The scary thing, as Don suggests, is that when people don't trust official pronouncements and something frightening is going on (and connection or no, 15,000 dead pigs in a river = frightening), they latch onto other kinds of information, sound or unsound, and use it make --often -- really bad decisions. Beijing knows this and rightly recognizes that mass panic during disease outbreaks is dangerous. But the Party's reflexive method for preventing panic is to suppress information and control the press, which, among its other consequences, only makes people whose trust has been abused for years panic more.
Another side of Don's devalued coin is what happens when health fears are infected by economic fears. This was at play in the SARS cover-up. Remember Wen Jiabao on national television inviting tourists and business people to come and invest in Beijing just as the disease was spreading through the city?
But unlike SARS, avian flu and other animal diseases directly affect the livelihoods of farmers. For this kind of disease to be controlled, farmers have to trust that they won't be wiped out by complying with prevention measures. During the 2004 avian flu outbreak I interviewed duck farmers near the epicenter of the outbreak in Guangxi. They had learned of the outbreak when government officials had showed up at their farms to warn them that if any of their animals got sick, their entire flocks would be culled. These warnings came without any reassurance that the state would compensate them. Some responded by taking ducks they feared had been exposed to the virus to neighboring towns and selling them cheap at wholesale markets. One told me if his birds got sick he'd nurse them, he'd give them shots, and if all else failed, he'd hide them.
I am thinking about what it must feel like to be in China right now. You can't trust that the food you buy is safe, or that the medicines you buy will be effective. You can't trust that the air you are breathing is safe (it's not.) You can't be sure the government is telling you what you need to know about the possible spread of disease. Anxiety levels among people these days must be absolutely skyrocketing. What does that mean, and what will it lead to?
There is the contest involving the environment, which is a race between how fast conditions are deteriorating and creating public outcry, and how hard the government is trying to clean them up.
There is the race to "rebalance" the economy -- with whatever different meanings different people might have for that term -- and to do so quickly enough to allow a smooth(er) transition rather than any kind of crash.
Or the "soft power" race, between China's inevitably growing impact on the rest of the world and the often tin-eared, ham-handed instincts of its political leadership in dealing with non-Chinese sensibilities. One proxy for how this race turns out: we'll see when the central authorities realize that the best name for their propaganda department should probably not be the "Propaganda Department."
Or the Internet race, being carried out on two tracks. On one, the government forces trying to screen and censor online contact will -- I bet -- inevitably lose ground to the increasing power and ability of Chinese citizens to communicate. On the other, there's a race between how much freedom of communication Chinese institutions need if they are to become the true peers of their counterparts in the outside world -- for instance, Chinese universities, which will never attract their share of world-leading researchers, teachers, or students if those people know they'll live with a hobbled Internet -- and how quickly the authorities will be persuaded to relax control.
This may seem far afield from bird flu, but it's the way I view this latest news -- and the very good discussion so far on how much the government has increased, or squandered, the reserves of public trust in its ability and willingness to (1) guard against threats to the average person's well being and (2) to tell the truth about where those threats lie.
The most encouraging news on this score came during the generally very discouraging air-pollution crisis earlier this year. Five years ago, the press would have talked about "smog" or "mist." Now they were unleashed to say more about what was really going on. Compared with the initial cover-up of the SARS news ten years ago, it seems as if the government has -- so far -- been somewhat more forthcoming this time. But none of us has any idea how much of the truth it's telling, how much it is holding back, and how much it even knows. If that is worrisome to me, from the other side of the globe, I can only imagine how much more corrosive these fears are to people who (as Dinda points out) are breathing (obviously) dangerous air, drinking suspect water, worrying about tainted food, and now alert to one more danger.
As I say, it's a series of races. For reasons obvious to all of us, it will be a relief if the outcome of this episode, when people look back on it ten years from now, is that it demonstrated not only the government's ability to control threats to public well-being but also its trustworthiness in handling information on issues with these life-and-death stakes.