Only a few years ago, in 2002-2003, China dealt with outbreaks of Severe Acute Respiratory Syndrome (SARS) in a famously secretive manner that hampered international public health agencies as they tried to analyze and control the disease. Since then, China has made efforts to improve the swiftness and openness of its public health reporting. Yet outbreaks of the H5N1 avian flu strain occurred in China earlier this year and again the international public health community criticized China for not cooperating with international public health goals. They publicly suspected that China had wantonly authorized widespread use of the antiviral drug Amantine to innoculate chickens.
In the wake of SARS, China took pains to address its international public health image. The country invested millions of dollars to build an epidemic reporting system. The move to vaccinate its 14 billion domestic fowl against against H5N1 is somewhat controversial, nevertheless China is marching through the Herculean task. China itself is most self-congratulatory about these efforts, but it has also drawn recognition from public health organizations like the World Health Organization (WHO).
Despite progress, there are continual reports of information bottlenecks. There is persistent world-wide suspicion about the country's reported numbers because of China's historical lack of candor. Combined with increasing edginess on the part of health officials about an H5N1 pandemic, the atmosphere is ripe for rumors and panic. Last week Japanese virologist Masato Tashiro reportedly told a German newspaper that China had far more deaths from H5N1 than it led the world to believe. China defended its accounting vigorously and Tashiro has since denied his original accusation, insisting that he referred only to China's general issues with accurate reporting. At the heart of the unresolved questions, fears and suspicions, lie the real challenges to accurate reporting. Among these are geographic logistical challenges, disparate government agency agendas, and incorrect international perceptions of state power in China.
Real logistical barriers to collecting statistics are sometimes blithely ignored. New York Times wrote in, "Experts Doubt Bird Flu Tallies From China and Elsewhere", about discrepancies between Chinese officials' epidemic statistics, that seem far less then foreign expectations. It was an interesting article, but noted that "news on outbreaks has sometimes been slow to emerge from provinces and to the state media. Vietnam, in contrast, posts a daily 4 p.m. update on the Internet, detailing human and animal infections." It didn't weigh that China is about 9.5 million square miles, whereas Vietnam is 329,560 square miles, and that China's population is 1,306,313,812 people whereas Vietnam's is 85,535,576.
On top of very real logistical barriers to consistent reporting, observers see a striking lack of cooperation between government agencies. China Digital Times translated the October and November issues of Caijing Magazine recently, which reported that prior to 2003 veterinary epidemics were state secrets. China lifted this rule but there is uneven progress towards openness. The Public Health Ministry makes genuine efforts to appease foreign requests for information, however the Ministry or Agriculture is insistent that certain details of planning for an epidemic are "not public". Problematically, a subsidiary of the Ministry of Agriculture is reportedly the only organization that is authorized to research the avian flu virus. The lack of communication between agencies apparently figured in the obfuscation of pertinent information about the alarming number of human deaths in the outbreak of Streptoccocus suis in swine earlier this year according to Caijing. A WHO official investigating the S. suis epidemic shared this view -- that China's "human health side" was cooperative, whereas "veterinary" information was not forthcoming. (Science Vol. 309. pp 1308-9).
China's public health system is part of a maze of political and economic ambitions at the national and local levels. We often perceive China to be a centralized top-down authority, but the reality is that local politics and decentralized control often determine the outcomes of state policies. As economists and businessmen know, at different levels - provinces, districts, villages - officials have different approaches and capabilities for their duties. These individuals (as anywhere) are often motivated by personal ambitions that propel behavior that's not necessarily in national or international interests. Reporting is one certainly a critical aspect of public health; who's getting sick, where and how determine medical action. The AIDS epidemic is an example of devastation wrought when a disease gathers momentum because countries deny epidemics among their citizens. In China especially, infectious disease reporting depends both on the complicated and unpredictable social organization of individuals from the bottom up, and trust that key facts will survive the labyrinth of bureaucracy and political motivations.
Epidemics gain a foothold when public health is inadequate. China's health care was once centralized and rural health cooperatives and barefoot doctors provided insurance and care to people isolated in the country. This effective though sometimes idealized system was dismantled by the government in the 1980's. Health care was privatized, barefoot doctors abandoned their traditional practices to sell pills, and the cooperatives were disbanded. Medicine became expensive and decentralized, with resources concentrated in the cities and many individuals left without access to health care. Care facilities vary widely and different areas lack cohesive policies. Depending on where someone is located, if they are sick with flu, they may not be able to access a doctor who would recognize their symptoms.
China can try to rectify its public reporting system, but this on its own would be a superficial solution to problems within the current public health system. Nor does it address issues stemming from a political system habituated to secrecy, fiefdoms, and protecting local semblances of order. Its quite likely that the reports of an isolated case of a sick duck here or there covered up larger outbreaks of H5N1. While H5N1 was a "state secret" veterinary epidemic up to 2003, it had years to gain a foothold as a virus, and perhaps there are other diseases that are also threats. H5N1 is not the only infectious disease threat, in China or elsewhere.
The world's public health now relies in part, incongruously, on cohesive individual actions from the bottom up all over the globe. Today all eyes are on China. The world depends on a different type of China, but while the country seems to be moving towards transparency, change is slow. And its not only China, effective international public health care, which includes reporting, national and international cooperation, and sound politics (the position seems unfilled), all influence the outcomes of infectious diseases. Increasingly isolated country protocols affect global public health.
