The SARS crisis and China's response to it highlighted both the modernization of China's health care system and the serious flaws that remain. Gail Henderson explores the rapid development of China's public health system over the past few decades and explores the lessons to be learned.

Gail E. Henderson, PhD is a medical sociologist, Professor of Social Medicine, and Adjunct Professor of Sociology at the University of North Carolina at Chapel Hill. Her teaching and research interests include health and inequality, health and health care in China, and research ethics. She is lead editor of Social Medicine Reader (Duke University Press, 1997). Her dissertation, a study of a teaching hospital in Wuhan, was published as  The Chinese Hospital: A Socialist Work Unit (Yale University Press 1984). She has been involved in numerous health studies in China. She is the co-editor, with Barbara Entwisle, of  Re-Drawing Boundaries: Work Households and Gender in China (University of California Press, 2000). She is also co-editor of a research ethics casebook, Beyond Regulations: Ethics in Human Subjects Research (with Nancy King and Jane Stein, University of North Carolina Press 1999).

In the early 20th century, America perceived China as the ‘sick man of Asia.’1 In 1948, a report by the UN Relief Organization stated, “China presents perhaps the greatest and most intractable public health problem of any nation in the world.” Two decades later, the dominant image of Mao’s China was one of healthy, red-cheeked babies born to a nation that provided health care for all.2 There is an appealing simplicity in using such images – no matter how incomplete – to characterize a regime.

More recently, the spread of HIV/AIDS in China in the 1990s and the SARS epidemic of 2003 have created a new set of health-related images for China, of a regime unequal to the challenges of potentially disastrous epidemics, with a dangerously inadequate health care system. Newspaper reports about government cover-ups, poor quality hospitals and farmers who could not pay for needed medical care proliferated. Unfortunately, such reports often overshadow a more balanced assessment of the forces that have shaped the health care system and its ability to prevent and control infectious diseases. This assessment requires an excursion into history to revisit China’s remarkable achievements in health care and explore the complex and sometimes contradictory economic incentives that determine how the system is able to respond to current challenges.

What does history tell us? First, Chinese government advocacy and investment in community infrastructure fostered a strong and effective public health system, which became a WHO model during the 1970s. Second, economic incentives in the post-Mao era that encouraged the development of hospital-based, high technology medical care have shaped China’s current curative health care system. In concert with the move away from collective welfare and central administration, inequalities in access to services have increased and the investment in public health infrastructure and services has declined, especially in remote rural regions. Lastly, while there may be some similarities between the Chinese HIV/AIDS epidemic and the recent experience with SARS, superficial media reports have focused too much attention on government neglect. HIV and SARS are very different pathogens, with different modes of transmission, degrees of infectiousness, and number and types of people affected, all of which limit the extent to which accurate comparisons can be drawn.

Public Health Under Mao

Public health – including disease surveillance, health education, environmental sanitation, nutrition and food hygiene, and maternal and child health, was probably Mao’s biggest triumph. Under his leadership, from 1949 to 1976, China experienced the most successful large-scale health transition in human history – a near doubling of life expectancy (from 35 to 68) and the eradication of many endemic and epidemic infectious diseases, including sexually transmitted diseases,3 that resulted in a gradual shift in the leading causes of death from infectious disease to chronic conditions.4 This transition was not accomplished through great gains in per capita income but rather by creating a closed socialist political economy that redistributed income and wealth, exercised control over industry, agriculture and migration, and had the ability to set national and local priorities in health care. By broadly distributing resources and relying on low-tech public health measures and “patriotic public health campaigns” that mobilized the population against environmental and behavioral risk factors, China achieved impressive improvements in sanitation, maternal and child health, infectious disease surveillance and vaccination. Its three-tiered primary health care system became the WHO model for developing countries.5 This system developed hospital-based services and public health departments at the county and township levels and united both curative and preventive services at the village level in the person of the “barefoot doctor.” Rural cooperative programs and urban workplace programs provided most citizens with medical insurance, although the level of coverage, quality of services and overall health status indicators were never equivalent between rural and urban locations.6 

Public Health in the Post-Mao Reform Era

After Mao’s death, the market-oriented economic reforms of the 1980s and 90s transformed the nation once again. Incomes and productivity rose dramatically as agriculture and then industry were de-collectivized and administrative authority over lower level units loosened. Living conditions, diet, health and nutrition all improved steadily.7 These developments were in sharp contrast to Russia, where life expectancy actually declined, from 70 in 1986 to 64 in 1994, and continued to decline thereafter. Major investments were made in urban medical services, long stagnant under Mao, as China turned to the West to help modernize its hospitals, pharmaceuticals and medical research and training. These changes had a positive impact on health status as well.8 Better treatment for chronic conditions such as cancer and cardiovascular disease that require more hospital-intensive services was increasingly available. The incentives to develop new diagnostic and treatment services included not only the clear medical needs of the population but also increased profitability. Under the financing system of the reform period, hospitals were established as relatively independent economic units that received decreasing amounts of funding from government sources but were able to set prices for new technology and medicines at much higher levels than other services. As World Bank and Chinese public health researchers have clearly documented,9 these incentives promoted the use of new technologies at the expense of other, less profitable services. In some cases, the reforms forced inefficient and poor quality hospitals to offer better services; in others, especially for the lowest level township hospitals in poorer rural areas, they produced failing hospitals with little to replace them.

Public health programs that did not generate profits suffered under the transition to a market-oriented system as well, with implications for health outcomes. For example, during the mid-1980s, funding for childhood immunizations in rural areas declined, which resulted in an increase in childhood infectious diseases. With assistance from UNICEF, the government reversed this trend by providing more funds and personnel for immunization programs. As many have observed, increased financial and administrative independence of local health institutions also undercut the ability of the central government to mobilize public health activities.10 The national-provincial conflict over response to the HIV epidemic is one example of this breakdown, especially in areas with HIV-infected commercial plasma donors. Decentralization of authority and shifts in concentration of resources from rural to urban areas, and from public health to curative medicine, had direct consequences for China’s capacity to respond rapidly to the SARS epidemic, at least initially, by making it more difficult to access information from affected provinces and to mobilize public health personnel in rural areas.

On the other hand, it is dangerous to generalize; the quality of the public health system is far from uniform across rural China. Research in a Shandong county public health department in 199011 and surveys of rural health services in eight provinces during the 1990s12 document that collective benefits and funding for public health varied with the wealth of the region. In many regions, the medical and public health supervision continued to extend to clinics in villages and county towns. In these areas, village doctors continued to implement standard, low-cost protocols in response to outbreaks of infectious diseases. However, the public health system was less capable of responding to new or more complex challenges such as identifying hypertension, which was not routinely screened, or conditions requiring expensive new diagnostic technology.

Thus, during the reform era, China experienced an increase in both aggregate income levels and disparities in income distribution (income inequality in China now equals that of the US).13 In any economic system, both trends are related – in complex and sometimes contradictory ways – to health outcomes.14 On the positive side, increased income and wealth produce improved health outcomes. China’s impressive gains in per capita income in the post-Mao era, and especially in the last decade, are correlated with improvements in many health status indicators: during the 1990s, overall mortality rates declined in both urban and rural areas;15 between 1991 and 2000, infant mortality dropped, from 17.3 to 11.8 per 1,000 live births per year in urban areas, and from 58.0 to 37.7 in rural areas; and maternal mortality rates declined as well between 1991 and 2000, in rural areas from 100.0 to 69.6 per 100,000 women per year, and in urban areas, from 46.3 to 29.3.16 

On the negative side, inequality in income distribution is linked to unequal access to preventive and curative health care and consequently to disparities in health status. In some cases, health status indicators declined, while in others health status improved but disparities in aggregate health outcomes increased. Urban-rural health disparities are evident in the mortality figures cited above, although the gap is declining for infant mortality. However, highly aggregated health status measures often mask significant differences between geographic and sub-population income groups,17 and this is certainly true for China’s border and minority regions where mortality rates are much higher. In addition to income and geographic location, the strongest predictor of access to health care is having medical insurance. In urban areas the percent with employment-based coverage declined between 1993 and 1998, from 68.4% to 53.3%; but the rural insurance programs that depended on the collective economy for funding collapsed almost entirely in the 1980s and by 1998, only 8.8% of the rural population had coverage.18 Initially, because medical care charges had been kept below cost through price controls, loss of insurance did not create widespread hardships. However, as medical services improved and charges rose steeply during the 1990s, paying for medical care became increasingly burdensome to the poorest citizens.19 Data from surveys during the 1990s document a decline in rural inpatient admissions compared to urban,20 and anecdotal reports suggest that many do not seek care due to the financial burden.

While the overall improvement in health status indicators is impressive evidence of the positive effects of the economic reforms, especially in contrast to the recent experience of Russia, it is the inequalities in income distribution that are more relevant to the challenges of recent infectious disease outbreaks. This is because most infectious diseases, such as HIV/AIDS, TB and malaria, tend to be most prevalent among those individuals and communities that are already economically and socially disadvantaged, thus exacerbating the burden imposed by the illness itself. As Paul Farmer, a physician and anthropologist who has written about AIDS in Haiti and the striking relationship between inequality and infections, observes, “inequality itself constitutes our modern plague.”21  

In response to the rising inequalities in health and access to health care, one of the most researched topics in China during the 1990s was health insurance reform, resulting in a number of pilot insurance programs in urban and rural areas.22 As a result, in 2002, a program to rebuild rural health infrastructure, based on multi-ministerial coordination, established the following policies: 1) reconstitute rural cooperative insurance to cover 900 million farmers through a joint funding mechanism, with direct investment from central, provincial and local governments and from the farmers themselves; and 2) re-establish rural township public health hospitals to implement and oversee public health activities at the township and village levels that had become “unfunded mandates” during the reform era. If implemented, these initiatives will have a positive impact on public health and disease prevention in the long term.23 The current dual challenges of dealing with HIV/AIDS and possible future outbreaks of SARS add impetus to ensuring that these programs are actually carried out.

Lessons from the AIDS Epidemic in China?

In assessing the Chinese response to SARS, the media has sought lessons from the recent experience with HIV/AIDS, highlighting China’s weaknesses in dealing with the epidemic.24 They criticize the lack of medical treatment available to AIDS patients in remote rural areas, most of whom have acquired the infection through intravenous drug use, and the government’s inaction in the face of an emerging HIV epidemic in commercial blood plasma donors during the 1990s, in a number of central provinces, as reported in the New York Times in late 2001. Failure to provide treatment and the negative consequences of obfuscation and delay should not be minimized. However, these media reports fail to acknowledge the complexity of both the challenges posed by an epidemic that may include as many as one million people, and the very limited resources available to meet those challenges.25  

In fact, few governments, rich or poor, have successfully stemmed the spread of AIDS. In the US, since the introduction of antiretroviral drug therapy in the 1990s, the rate of new cases has leveled off at around 40,000 new cases a year.26 In sub-Saharan Africa, where there are about 2 million new cases in young adults each year, only Uganda has demonstrated reduction in the prevalence of AIDS, achieved through international assistance, government advocacy and a strong condom promotion program.27 Comparisons between nations are complicated by the fact that in addition to social and economic disadvantages and government inaction, there are many biological factors that promote transmission (such as the presence of other infections, especially other sexually transmitted infections, and greater susceptibility to different strains of HIV virus).

Poverty and the rise of a private market for blood plasma fueled the plasma donor epidemic in China. In 1995, the international and Chinese medical literature reported that the epidemic was spreading to plasma donors,28 and in 1996, presentations at the International AIDS meeting in Vancouver also described this trend.29 By the first international AIDS conference in Beijing in 2001, detailed epidemiology was being conducted and reported.30 During this same time period, a number of publications documented the daunting difficulties involved in protecting China’s blood supply. These difficulties included cultural barriers to an all-volunteer blood donation system, shortage of clinical transfusion specialists and the high cost of technology required for accurate testing for transfusion-transmissible diseases such as hepatitis and HIV.31 Efforts to improve the safety of the blood supply have been ongoing and increasingly successful. In the fall of 2003, just prior to notification that funds totaling almost $100 million were awarded by the UN Global Fund for AIDS, Malaria and TB, the Chinese Ministry of Health began implementation of a plan to include AIDS comprehensive prevention and care programs for plasma donors and other risk groups in 100 counties identified as hardest hit by AIDS.32 These developments are extremely important and deserve media attention as well as international support.

Funding from the US and other donors for biomedical and scientific research collaborations is also having an important impact on HIV prevention and treatment. Awarding a $15 million NIH Comprehensive International Program of Research on AIDS (CIPRA) grant to the China CDC in the summer of 2002 did not garner much media attention, but it provided funds for vaccine development, research on risk factors and behavioral interventions and treatment trials that are all moving forward. Other US and international organizations have contributed to research efforts as well. An additional consequence of these collaborations is increased attention to and training for researchers and communities on the ethics of protecting human subjects in clinical research.33 Equally important, clinical research also has the potential to focus attention on unmet treatment needs, as occurred after the first International AIDS meeting held in Africa in 2000, when the magnitude of HIV among Africans became suddenly so salient that the world could no longer ignore the double standard of access to drugs only in developed countries. While many factors influenced China’s decision to establish AIDS prevention and treatment services in the 100 highest prevalence counties, the initiative was spearheaded after a major Sino-US conference, in November 2002, on AIDS research and training in Beijing.

We should also remember that the Chinese public health system has proven that it can respond to potential threats with speed and decisiveness: in December 1997, fearing an outbreak of a deadly strain of avian flu, in one day 1.2 million chickens from 160 farms and from more than 1,000 retailers and stalls were slaughtered.34 In fact, public health and security personnel effectively halted the spread of the SARS epidemic, working across sectors and geographic regions and applying classic public health strategies (masks, hand washing, and isolation).35 The widespread perceived vulnerability to SARS, in contrast to the perceived low risk of HIV infection held by many in China, generated enormous support throughout the country for improvements in the public health system, and these improvements will ultimately also benefit work to combat the HIV/AIDS epidemic. 

The Challenge of Emerging Infectious Diseases in China

Statistics on disease and death rates are often used like Rorschach tests to measure the legitimacy of a government. Infectious diseases, including emerging pathogens like HIV/AIDS, are particularly potent foci for such critiques, in part because they tend to fall hardest on the most vulnerable and least well-served members of society. In contrast, in 2003, SARS had a different profile: with a high case fatality rate, its route of transmission, and degree and duration of infectiousness were not known. Furthermore, society’s most valued members – health care workers charged with controlling the epidemic – were initially the people at greatest risk of infection. In the face of such a threat to public health, China launched a campaign to eradicate SARS that few countries could have accomplished. It is not clear whether SARS will reappear or how large the epidemic in China might ultimately be. What is clear is that the outbreak of 2003 alerted China and the world to the importance of maintaining a strong public health system, and the special burden that may fall on society’s most disadvantaged groups if we do not.

The spread of these emerging pathogens in China and elsewhere is a direct, if unintended, consequence of economic reform and integration of China into the global community. These are reforms that the US has encouraged and in which the business and scientific communities have played key roles. Helping to enhance the strengths of China’s public health system instead of focusing on the failures brought about by the increasingly market-oriented features of health care will reinforce needed reforms that in some cases are already underway. We must credit China’s efforts to contain the SARS epidemic in its hospitals, cities and borders, and its openness to international collaboration and information sharing. These efforts were contributions to the global efforts to control this deadly disease, and prevented an epidemic from becoming a pandemic.

Endnotes

 1 J Horn, Away with All Pests: An English Surgeon in the People’s Republic of China (New York: Monthly Review Press, 1969); GE Henderson, “Public Health in China,” in WA Joseph (ed), China Briefing 1992 (Boulder: Westview Press, 1992).

 2 V Sidel, Serve the People: Observations on Medicine in the People’s Republic of China (Boston: Beacon Press, 1974).

 3 MS Cohen, GE Henderson, P Aiello, Zheng HY, “Successful Eradication of Sexually Transmitted Diseases in the People’s Republic of China: Implications for the 21st Century,” Journal of Infectious Disease 1996; 174 (Supplement 2): S223-230.

 4 WC Hsiao, “Transformation of Health Care in China,” New England Journal of Medicine 310:932-6, 1984; GE Henderson, “Issues in the Modernization of Medicine in China,” in D Simon and M Goldman (ed) Science and Technology in Post-Mao China (Cambridge: Harvard University Press, 1989); see also World Bank reports on China’s health sector (1984 and 1989).

 5 RJ Blendon, “Can China’s Health Care Be Transplanted Without China’s Economic Policies?” New England Journal of Medicine 300: 1453-58, 1979.

 6 GE Henderson et al., “Distribution of Medical Insurance in China,” Social Science and Medicine 41,8: 119-30.

 7 Zhongguo Weisheng Nianjian, “China Health Yearbook 2001” (Beijing: People’s Medical Publishing House, 2001) reporting 2000 mortality rates and leading causes of death. See BM Popkin et al., “Trends in diet, nutritional status and diet-related non-communicable diseases in China and India: The economic costs of the nutrition transition.” Nutrition Reviews 59: 379-90, 2001, demonstrating the decline in malnutrition across rural China during the 1990s and rise in non-communicable disease.

 8 GE Henderson et al., “High Technology Medicine in China: The Case of Chronic Renal Failure and Hemodialysis,” New England Journal of Medicine 318,15:1000-4, 1988.

 9 China 2020 series: Financing the Health Sector (Washington DC: World Bank, 1997)

 10 e.g., China 2020 series; also, Liu Yuanli, WC Hsiao, and K Eggleston, “Equity in Health and Health Care: The Chinese Experience,” Social Science and Medicine 49,10:1349-56, 1999.

 11 GE Henderson and TS Stroup, “Preventive Health Care in Zouping: Privatization and the Public Good,” In A Walder (ed), Zouping in Transition: The Political Economy of Growth in a North China County. (Cambridge: Harvard University, 1998)

 12 China Health and Nutrition Survey (funded by NIH, NSF, Foundation, UNC, and Chinese Academy of Preventive Medicine), conducted in 1989, 1991, 1993, 1997, and 2000.

 13 The World Bank reports the inequality index (Gini coefficient) for both countries in 1997 at about 40. Gini measures income distribution on a scale of 1-100. A rating of “1” would mean that that income is perfectly equally distributed, with all people receiving exactly the same income; “100” would mean that one person receives all the income. European countries’ Gini coefficients ranged in the 20s and 30s; the highest were Brazil, South Africa, and Guatemala, at around 60.

 14 Moreover, extent of inequality itself seems to be related to poorer health care access and outcomes.

 15 Jun Gao et al., “Health Equity in Transition from Planned to Market Economy in China,” Health Policy and Planning 17 (Suppl 1):20-29, 2002, p. 22.

 16 Zhongguo Weisheng Nianjian (China Health Yearbook) 2001. (Beijing: People’s Medical Publishing House, 2001) The comparable US figures are not too dissimilar: in 1997, IMR for whites was 6.0; for blacks it was 13.7, a greater than two-fold difference (CDC NCHS website).

 17 Liu YL WC Hsiao, and K Eggleston., 1999, p 1350.

 18 Jun Gao et al., 2002 p. 26.

 19 Liu Yuanli, WC Hsiao, and K Eggleston, “Equity in Health and Health Care: The Chinese Experience,” Social Science and Medicine 49,10:1349-56, 1999; GE Henderson et al., “Trends in Health Services Utilization in Eight Provinces of China, 1989-1993,” Social Science and Medicine 47,12:1957-71; Jun Gao et al., “Health Equity in Transition from Planned to Market Economy in China,” Health Policy and Planning 17 (Suppl 1):20-29, 2002

 20 Jun Gao et al., 2002, p. 26.

 21 P Farmer, Infections and Inequalities: The Modern Plague. (Berkeley: UC Press, 1999).

 22 GG Liu et al., “Equity in Health Care Access: Assessing the Urban Health Insurance Reform in China,” Social Science and Medicine 55,10:1779-94; G Bloom and Tang SL, “Rural Health Prepayment Schemes in China: Towards a More Active Role for Government,” Social Science and Medicine 48,7:951-60; G Carrin et al., “The Reform of the Rural Cooperative Medical System in the People’s Republic of China: Interim Experience in 14 Pilot Counties,” Social Science and Medicine 48,7:961-72.

 23 Personal communication with Dr. Yiming Shao, Chinese Center for Disease Control and Prevention.

 24 LK Altman, “Lessons of AIDS, Applied to SARS,” New York Times May 6, 2003 D1

 25 Joan Kaufman and Jing Jun, “China and AIDS—the time to act is now,” Science. 2002 Jun 28; 296(5577): 2339-40.

 26 http://www.cdc.gov/hiv/pubs/facts.htm

 27 “Uganda, whose HIV rates peaked at a staggering 14% in the early 1990s, was the first country in sub-Saharan Africa to reverse its own epidemic. Now, it has nearly halved its HIV prevalence to around 8% by strong prevention measures. Even rural areas, which are frequently among the last to evidence signs of both the advent and the reversal of an HIV/AIDS epidemic, have shown a reduction in HIV rates. In some areas of rural Uganda, for example, HIV infection rates among teenage girls dropped to 1.4% in 1996-97, from 4.4% in 1989-90. This was matched by a fall in teen pregnancies.” (UNAIDS “Country Successes” Fact Sheet, July 2000)

 28 Ji Y, Qu D, Jia G, et al. “Study of HIV Antibody Screening for Blood Donors by a Pooling Serum Method,” Vox Sang 1995, 9:255-6. Wu Zunyou et al., “HIV-1 infection in commercial plasma donors in China,” The Lancet 1995 Jul 1;346(8966):61-2. Lancet is the premier British Medical journal. This first report featured a mother and her two daughters who tested positive, in the absence of any other risk factors except commercial blood donation, in rural Anhui Province, between February and March 1995. The authors state, “Notification of HIV-1 infection to infected persons or their family members is not routinely done in China. Neither these infected women nor their family members were informed of the infection because it was feared that they would commit suicide if they discovered they were infected with HIV-1.” The authors recommended screening plasma products and donors, disclosing HIV status to infected individuals, and introducing surveillance of plasma donors. Other articles about HIV in plasma donors include: Ji Y et al., “An Antibody Positive Plasma Donor Detected at the Early Stage of HIV Infection in China,” Transfusion Medicine 6,3:291-2, 1996; VR Nerurkar et al., “Complete Nef Gene Sequence of HIV Type 1 Subtype B’ from Professional Plasma Donors in the People’s Republic of China,” AIDS Res Hum Retroviruses 14,5:461-4, 1998; and Zheng X et al. (China CDC), “The Epidemiological Study of HIV Infection Among Paid Blood Donors in One County of China,” Zhonghua Liu Xing Bing Xue Za Zhi (China Journal of Epidemiology) 21,4:253-55, 2000.

 29 Dr. Yiming Shao, a virologist from the Chinese CDC, presented data at this conference.

 30 Before 2000, epidemiology was published in Chinese journals, e.g., Ye DQ, et al., “Serological epidemiology of blood donors in Hefei, Anhui Province,” Chinese Journal of Public Health 17:367-8, 1998; and in 2001, in the West, e.g., Wu ZY, Rou KM, and R Detels, “Prevalence of HIV Infection Among Former Commercial Plasma Donors in Rural Eastern China,” Health Policy and Planning 16,1:41-46, 2001

 31 Hua Shan, Wang J, Ren F, et al., “Blood Banking in China,” The Lancet 360:1770-5, 2002.

 32 “AIDS Comprehensive Prevention and Treatment Demonstration Sites,” China MOPH, 2003.

 33 Research ethics training programs have been carried out at the China CDC AIDS Center during 2002 and 2003, sponsored by NIH Fogarty International Center AIDS International Training in Research and Prevention Program, at both UCLA and UNC, and the NIH Office of AIDS Research.

 34 G Kolata, Flu: The Story of the Great Influenza Pandemic of 1918 and the Search for the Virus that Caused It (NY: Simon and Schuster, 1999) p. 239. In fact, it was suspicion that SARS was actually avian flu that delayed response in some locations.

 35 Martin Enserink, “China’s Missed Chance: SARS in China,” Science 301:294-296, July 18, 2003.