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SUPPLEMENT ARTICLE
China’s Heath Care System and Avian Influenza
Preparedness
Joan A. Kaufman
AIDS Public Policy Project, John F. Kennedy School of Government, Harvard University, Cambridge, and Heller School for Social Policy
and Management, Brandeis University, Waltham, Massachusetts
The severe acute respiratory syndrome crisis exposed serious deficiencies in China’s public health system and
willingness to report outbreaks of threats to public health. Consequently, China may be one of the weak links
in global preparedness for avian influenza. China’s rural health care system has been weakened by 20 years
of privatization and fiscal decentralization. China plays a huge role in the global poultry industry, with a
poultry population of 14 billion birds, 70%–80% of which are reared in backyard conditions. Although
surveillance has been strengthened, obstacles to the timely reporting of disease outbreaks still exist. The
weakened health care system prevents many sick people from seeking care at a health care facility, where
reporting would originate. Inadequate compensation to farmers for culled birds leads to nonreporting, and
local officials may be complicit if they suspect that reporting might lead to economic losses for their communities. At the local level, China’s crisis-management ability and multisectoral coordination are weak. The
poor quality of infection control in many rural facilities is a serious and well-documented problem. However,
traditions of community political mobilization suggest that the potential for providing rural citizens with
public health information is possible when mandated from the central government. Addressing these issues
now and working on capacity issues, authority structures, accountability, and local reporting and control
structures will benefit the control of a potential avian influenza outbreak, as well as inevitable outbreaks of
other emerging infectious diseases in China’s Pearl River Delta or in other densely populated locations of
animal husbandry in China.
The threat of an avian influenza pandemic is the next
chapter in a story that began with the severe acute
respiratory syndrome (SARS) epidemic. The common
thread of both epidemics would be their likely origin
in China. With SARS, the Chinese government went
from being a global pariah for its initial failure to alert
the world about the outbreak, which resulted in a
worldwide epidemic, to being a global hero for successful containment. However, China’s lack of trans-
Potential conflicts of interest: none reported.
Presented in part: Harvard University Asian Flus and Avian Influenza Workshop,
Cambridge, Massachusetts, 8–10 December 2006.
Financial support: supplement sponsorship is detailed in the Acknowledgments.
Reprints or correspondence: Dr. Joan A. Kaufman, AIDS Public Policy Project,
John F. Kennedy School of Government, Harvard University, 79 JFK St., Cambridge,
MA 02138 ([email protected] or [email protected]).
The Journal of Infectious Diseases 2008; 197:S7–13
2008 by the Infectious Diseases Society of America. All rights reserved.
0022-1899/2008/19704S1-0003$15.00
DOI: 10.1086/524990
parency at the outset of the SARS epidemic was troubling, and there is no guarantee that it would not
happen again.
Even before the global SARS epidemic in 2003, the
threat of emerging infectious diseases already had the
world’s attention. In 2003, the Institute of Medicine of
the US National Academy of Sciences issued a report,
Microbial Threats to Health, that noted that, “in the
highly interconnected and readily traversed ‘global village’ of our time, one nation’s problems soon become
every nation’s problems” [1, p. 1]. The rapid global
response to the SARS epidemic was impressive and,
fortunately, succeeded in averting a worse outcome.
This response was possible because post–September 11
investments in global health-information systems, surveillance, and rapid-response planning paid off. Strategies for infection control, as well as therapeutic information, were quickly shared worldwide. The good
news is that these already-effective global infrastruc-
Avian Influenza and China’s Health System • JID 2008:197 (Suppl 1) • S7
tures have been strengthened further since the SARS epidemic
and are being deployed to prepare for and control an outbreak
of avian influenza.
Opinions differ about the reality of the threat of an avian
influenza pandemic. Human deaths have been confirmed in 12
countries, including some countries outside Asia, but the number of cases of avian influenza in humans is still small, even
though the mortality rate is high, at 150%. No clusters of cases
in humans in any country have been documented conclusively
as being caused by human-to-human transmission. Past influenza pandemics, such as that caused by the influenza A(H1N1)
virus in 1918–1919, resulted in large numbers of deaths, which
were likely caused by a combination of virus virulence and
other factors not yet fully understood. One factor leading to
the high mortality rate was the unavailability of antibiotics at
that time [2], which resulted in deaths from secondary bacterial
infections after acute viral illness [3]. Some public health professionals suggest that the number of deaths during a similar
epidemic today would be unlikely to be so high, although the
widespread use of antibiotics in poultry in southern China and
other parts of Asia may contribute to antibiotic resistance.
China may be one of the weak links in global preparedness
for 2 main reasons: it lacks transparency in acknowledging
outbreaks, and its health care system is not up to the task of
putting in place systems to ensure preparedness or the capability
to contain the epidemic if it begins in China’s rural areas. The
SARS crisis exposed serious deficiencies in China’s public health
system. Consequently, since then, strengthening China’s public
health system has topped China’s public policy agenda. The
central government and the Chinese Communist Party have
made equity and social investments in rural health and education top priorities in their agenda for a harmonious society
[4]. The SARS crisis also highlighted the importance of political
will and national financial resources in the mobilization of
public health action [5]. Are enough resources and political
accountability being mustered for avian influenza preparedness?
Is China’s government and China’s health system now prepared
for controlling avian influenza? What areas of the health system,
including transparency in reporting outbreaks, must be
strengthened further so that the system is up to the urgent task
of preparedness and rapid response? This article provides a
critical review of the major health-system and governance challenges facing China’s potential to respond to avian influenza
and highlights areas that may need strengthening.
BACKGROUND ON CHINA’S HEALTH SYSTEM
Over the past 50 years, China has achieved remarkable progress
in improving the health of its population. Life expectancy is
170 years, and the major causes of morbidity and mortality
are now noninfectious and chronic infectious diseases, rather
than acute infectious diseases. China’s basic health infrastrucS8 • JID 2008:197 (Suppl 1) • Kaufman
ture, put in place 30 years ago, consists of a 3-tiered medical
system in rural areas and corresponding structures in cities.
Competent, trained health care personnel staff this infrastructure, and many of them are trained vocationally in 3-year medical colleges or by county health institutions and are certified
to provide basic care at the local level.
China’s health care system, however, has been seriously weakened by 20 years of relaxed government support and inadequate
regulation in the health sector, along with overall fiscal decentralization. China’s primary health care system was held up as
a model at the time of the call for “health for all by the year
2000” at the World Health Organization (WHO) conference
in Alma-Ata, Kazakhstan, in 1978. However, in 2000, China
ranked 188 of 191 countries in terms of fairness in financial
contributions to health [6], and, in 2001, 21.6% of poor rural
households fell below the poverty line because of medical expenses. In China, the average cost of hospitalization at the
township or county level is approximately equal to the per
capita annual income of a rural farmer [7]. Health care is
provided mainly on a fee-for-service basis at rural health clinics,
and most provided health care is curative.
China’s problems are less related to infrastructure than to
equity and affordability. Huge disparities in health care investment and access exist between urban and rural areas and
between the developed eastern coastal part of the country and
the more-underdeveloped west. The health care system in rural
areas has become a mainly privatized fee-for-service system,
with facilities maintained by the government but services and
drugs provided for a fee and for profit. Although many urban
residents have some health care insurance to defray costs, there
was virtually no system of health care insurance in rural areas
until recently. Preventive health care services and health-education outreach have been seriously weakened by 20 years of
China’s market-oriented economic policies [8]. Health care access in China today is determined by wealth, with debt from
a major illness identified as one of the major reasons for poor
rural households to drop below the poverty line. In 2005,
China’s own State Council published a scathing report that
castigated the state of China’s health system, noting that 49%
of the population cannot afford to see a doctor when ill and
that 30% are not hospitalized when necessary [9]. This report
prompted increased funding and attention to deficiencies and
inequities in China’s rural health system. The central government and the Communist Party have made equity and social
investments in rural health care, as well as education, top priorities in their agenda for a harmonious society [4].
In rural areas, the government is piloting a new system of
health care insurance for major medical expenses, but investment in basic disease prevention has yet to follow. For China’s
150 million economic migrants, an increasingly large segment
of the population that comprises the urban poor, there is little
to no coverage for seeking health care services. These huge
numbers of the rural and urban poor who cannot afford to
seek care when ill represent a worrisome threat to controlling
avian influenza.
Although serious efforts are under way to revitalize health
care financing and equity in rural areas, the urgent and heavy
requirements of avian influenza preparedness cannot wait until
these efforts are completed. Any epidemic is likely to take hold
in China’s poorer areas, where there is only a limited amount
of local financing for health care, which will create shortages
of trained staff and quality services, including standard infection-control measures, as a result of chronic underfunding. In
addition to institutional constraints on the horizontal collaboration between different programs, especially between different government sectors (e.g., animal husbandry and infectious
diseases), there are a number of challenges facing the capacity
of China’s health system to respond to avian influenza.
DECENTRALIZED AUTHORITY AND
ACCOUNTABILITY FOR DISEASE REPORTING
China’s Law on Preventing and Treating Infectious Diseases,
enacted in September 1989, requires mandatory reporting of
many infectious diseases. Between October 2005 and February
2006, China’s Ministry of Agriculture, Ministry of Finance, and
State Council published 15 regulations, guidelines, and policies
related to avian influenza and disease prevention and control,
cost reimbursement during disease control, and financial assistance for poultry production [10]. However, this clear legislation regarding mandatory disease reporting for specified infectious diseases is hampered by a structure of decentralized
authority that impedes its realization. China’s ability to respond
to emergency disease outbreaks surely will be complicated by
decades of political decentralization and by its own governance
system, which will be compounded by weakness in the power
and authority of the national Ministry of Health.
In 1978, China began fiscal decentralization from the national level to the provinces and from the provinces to the
counties. The new approach of “every tub on its own bottom”
shifted major financing for province-level government operations and services to the provinces themselves and substantially
reduced centralized transfers. Unfunded mandates (directives
and policies) are set at the level of the central government, but
financing depends on local resources, allocation, and priority
setting. However, with privatization of the health care system
that began in the early 1980s and the focus on economic investment in infrastructure and industry, local governments, especially poor ones, have greatly reduced investment in social
sectors. Although the government owns health care facilities,
government contributions for health at the local level are scant,
and sometimes the only funds provided are for partial salary
support, with nothing allocated for public health programs. As
a result, the focus of the delivery of health care services in
China is almost exclusively on the provision of curative services.
User payment as a percentage of health care spending has been
rising steadily for 20 years, from 20% to 54% [11].
Moreover, the Ministry of Health is bureaucratically weak,
and it is hard for it to mobilize other ministries. This was a
major problem during the SARS epidemic, because the Ministry
of Health did not have the authority or ability to require direct
reporting from lower levels of government or even from military hospitals. Provincial governments have greater control
over provincial health bureaus than does the Ministry of Health.
The Ministry of Health has limited authority within any particular province outside the Bureau of Heath or its associated
Centers for Disease Control. The Ministry of Health may formulate national policies, but these policies serve merely as
guidelines or unfunded mandates for the lower levels of government, which must generate and allocate the funding needed
to support their implementation. This weakness limits the ability of the Ministry of Health to manage health crises. Moreover,
health resources in China are managed by many sectors, and
coordination is difficult if not impossible, further complicating
any urgent crisis-management situation. For example, in addition to the more-general functions of the Ministry of Health,
numerous other ministries and departments are involved in
health-related matters. The National Development Research
Center controls health infrastructure and financing, the Ministry of Finance controls routine budgets and national programs, the State Food and Drug Administration controls pharmaceuticals, the Ministry of Labor and Social Security deals
with basic medical insurance for urban employees, and the
Ministry of Civil Affairs handles medical financial assistance to
the poor. Provincial control over financing, personnel decision
making and allocation, and new initiatives within each province
complicate coordination and accountability even more. In
2005, the Minister of Health, Gao Qiang, identified key healthsystem challenges facing China, and the need for a health emergency–response network was at the top of the list.
CHINA AS THE INCUBATOR FOR A GLOBAL
EPIDEMIC OF AVIAN INFLUENZA
Recent events related to the global avian influenza threat included a massive dying off of 16000 wild migratory birds in
the Qinghai Lake nature reserve in northwestern China in April
2005. Following this, the number of countries reporting disease
outbreaks due to avian influenza A(H5N1) virus increased dramatically through the end of 2006, with 55 countries reporting
outbreaks of H5N1 virus infection in wild birds and/or poultry.
China has had several confirmed cases of infection in humans;
the first 2 were reported in November 2005.
It is not surprising that the current culprit in the global avian
influenza threat is likely to have originated in China. The H5N1
Avian Influenza and China’s Health System • JID 2008:197 (Suppl 1) • S9
virus was first isolated in China in 2003 from diseased pigs on
farms in southern China [12]. This was the first documented
infection of pigs by any H5 subtype of avian influenza virus.
Historically, densely populated southern China has been a
breeding ground for new influenza viruses, because of the large
numbers of animals and people living in close proximity; the
ubiquity of backyard animal husbandry of pigs, chickens, and
ducks; and the presence of live-animal markets. All these factors
were implicated in the SARS outbreak of 2003. However, other
factors also are at play in the current avian influenza threat.
China plays a large role in the global poultry industry and,
according to the WHO, has a poultry population of 14 billion
at any one point in time, 70%–80% of which is reared in
backyard conditions [13]. Individual poultry farmers have little
incentive to report sick birds.
AVIAN INFLUENZA PREPAREDNESS
AND THE REQUIREMENTS FOR AN EFFECTIVE
RESPONSE
The WHO has taken a lead role in defining the steps that will
be required for the prevention of an avian influenza epidemic
and has been working with countries to put in place systems
to ensure early identification and containment. These steps
include (1) recognizing the possible event of an avian influenza
outbreak through detection of clusters of cases, investigation
of suspected clusters, and reporting of early signals to the scientific community for comparative studies of virus isolates and
in-depth investigation of sources of reservoirs of the virus; (2)
verifying an outbreak event and then making an assessment of
that event and putting in place immediate infection-control
measures; and (3) containing the outbreak event through a
rapid response that entails active case finding and contact tracing and the administration of antiviral drugs. If necessary, exceptional measures such as quarantine, the wider prophylactic
administration of drugs, and social distancing measures such
as staying home from work and home schooling should be
used.
Ideally, all countries should put in place systems to successfully implement these steps. To do this, however, countries must
invest in building the institutional and operational capacity to
reach rural areas, where an outbreak is likely to begin. In addition, there is a need to create multisectoral, integrated authority and control systems that can be activated if an outbreak
is detected or an epidemic begins.
Prior to an outbreak, however, there is a critical need for
the institutional and operational capacity to implement educational outreach aimed at prevention and containment,
through a focus on birds and poultry-industry practices, to
minimize the opportunity for the avian influenza virus to mutate into a type that can easily infect humans (T. Kane, personal
communication). The widespread mobilization of people (esS10 • JID 2008:197 (Suppl 1) • Kaufman
pecially rural farmers) is needed to reduce practices that increase the odds of an epidemic and to prepare the population
for what to do if an outbreak or epidemic occurs.
CHINA’S AVIAN INFLUENZA PREPAREDNESS:
KEY ISSUES
Full surveillance, timely reporting, and transparency in reporting avian influenza cases in birds and humans are very
important. Containment and effective quarantine and culling
after a reported outbreak also are essential. In addition, the
need for communication about basic hygiene practices for humans and for the poultry and animals in their care are key
prevention measures. Is China up to the task?
China’s surveillance system has been strengthened during
the post-SARS era, which is perhaps one of the biggest lessons
learned from that mishandled epidemic. Both the US Centers
for Disease Control and Prevention and the WHO’s Beijing
office have been working closely with the Chinese Ministry of
Health and Centers for Disease Control during the post-SARS
era to strengthen and computerize routine disease reporting of
many infectious diseases, in accordance with China’s newly
strengthened Law and Regulations on Infectious Disease Reporting. By mid-2005, all 2800 counties in China had direct
Internet connections to a Ministry of Agriculture monitoring
system, and 93% of county or higher-level hospitals and 43%
of township hospitals had direct connections to the diseasereporting system of China’s Centers for Disease Control [10].
The WHO is working with China to develop an integrated
surveillance system, to strengthen laboratory diagnostic capacity, and to create a reporting system that will allow epidemiological, clinical, and laboratory information from both human
and animal surveillance, the environment, and other sectors to
be analyzed and shared with decision makers in all sectors. The
WHO and China also are working on strengthening early response to an outbreak event and on fostering better collaboration between the animal sector and the health sector and are
working with health institutions on the surveillance and control
of facility-acquired infections. China’s capacity to accomplish
these goals with its current infrastructure is high. The communications infrastructure and the designated personnel exist
throughout the 3-tiered medical system, down to the county
level. China’s laboratory and science infrastructure, pharmaceutical research, and biotech sector are strong. Owing to the
political will that resulted from the acknowledgement of failures
in the timely reporting of SARS cases, there now exists a strong
mandate, as well as financial support, for a strong diseasesurveillance infrastructure for avian influenza.
However, the challenges for surveillance are great, and a
number of factors might interfere with the verification of disease events in both birds and humans. Farmers and government
officials have economic reasons for not reporting suspected
avian influenza outbreaks in an area. If the government does
not properly compensate farmers for culled birds, farmers may
hide the birds. The weakened and privatized health care system
prevents many sick people from seeking care at a health care
facility, where reporting would originate (i.e., at the township
level). Moreover, local officials, who control the work of the
sectors under their jurisdiction, may hide cases of disease if
they suspect that reporting might result in economic losses for
their communities. Many suspect that unreported deaths of
fowl have occurred on a large scale in many places in China,
because similar events among poultry have occurred across
China’s borders, in Hong Kong, Vietnam, and other neighboring countries, with no plausible explanation other than an
origin in China [14].
Moreover, China is still poorly prepared for a rapid response
to an outbreak event. Its crisis-management capability and ability to coordinate different agencies, such as the Ministry of
Agriculture and the Ministry of Health, is weak, especially at
the local level. During the SARS epidemic, the Ministry of
Health was unable to put in place the needed interventions at
either the national or local level. To support the recently
strengthened response to AIDS, a new State Council Working
Committee on AIDS was created to manage the needed multisectoral collaborations [15], but no such similar agency exists
for a potential outbreak of a communicable disease. The weakness of the health sector in mobilizing other sectors must be
addressed and an emergency-response agency and plan formulated, to avoid the problems that occurred during the early
response to SARS. For example, an obvious failure in response
to SARS occurred when millions of migrants fled Beijing because they feared being unreasonably quarantined without concern for their personal rights. Fortunately, this mass exodus
did not result in a widespread rural epidemic, owing to a combination of luck and strong, albeit belated, local action [5].
Rural communities in China quickly built local infectious-disease hospitals modeled after the SARS hospital that was built
in Beijing. Staff was seconded from all health institutions in
the county, and training in infection-control measures, including quarantine and reporting procedures, was provided. These
hospitals still exist in rural communities in China and would
likely be mobilized during another infectious disease emergency. In the event of a much more contagious influenza epidemic, stronger measures to ensure quarantine and social distancing would be needed.
Other significant concerns are the limited potential for
proper case management and shortcomings in infection-control
practices in hospitals. By some estimates, 170% of the health
care visits in China that do occur (many individuals do not
seek care at all) occur at village-level clinics. These clinics are
staffed by village-level rural doctors and doctors of traditional
medicine. Although they are certified to practice and capable
of dealing with common illnesses and first aid, these doctors
may not be capable of recognizing and dealing with the early
symptoms of avian influenza during an epidemic. However, as
a step in the right direction, rural doctors now are required to
report, by telephone, to township health centers all cases of
suspicious pneumonia or serious influenza. Infection-control
measures in many rural facilities leave much to be desired, and
facility-acquired infection is a serious and well-documented
problem in China.
The capacity for outreach to and mobilization of the population threatens to be a major limitation of any effort at avian
influenza preparedness. China’s outreach system for public
health information has been seriously weakened by the privatization of the rural health care system, which has driven
service providers to focus on income-earning curative care. As
a result, the capacity for health education (in terms of human
resources and responsible institutions) has been seriously weakened. However, a tradition of community political mobilization
suggests that the potential for reaching rural citizens with public
health information exists when mandated from the central government. China’s ability to mobilize its population has been
an enduring feature of its single-party system of governance
for the past 50 years. Early patriotic health campaigns were
responsible for important public health achievements during
the “barefoot doctor” era (i.e., the 1960s and 1970s, until the
end of the Cultural Revolution). The patriotic health campaign
was resurrected during the SARS epidemic, and its success in
mobilizing and reaching the public with critical prevention information was impressive. In the event of an avian influenza
outbreak, it could be used to reach rural citizens with communications about behavior change and hygiene. An important
question is why it is not already being used to its fullest extent
to deal with the repeated outbreaks of epidemics among poultry, to reach out to the rural population to communicate the
necessary hygiene measures mentioned above and, thus, minimize the potential of infection in humans? In this area, China’s
preparedness for avian influenza could easily be strengthened.
Another area of concern is China’s veterinary surveillance
and its ability to control its widespread live-animal markets or
to apply restrictions and controls to its backyard poultry- and
duck-raising industries. A matter of some concern is the fact
that, in parts of Asia, mammals that were thought to not be
susceptible to H5N1 virus infection have developed disease
(WHO, unpublished data) [12]. Live-animal markets were implicated in the emergence of the SARS epidemic, when the civet
cat, which is sold in live-animal markets in southern China,
was identified as the likely source of the mutated human SARSassociated virus. Many of the live-animal markets were shut
down in the immediate aftermath of the SARS epidemic, but
many have reopened or operate behind closed doors, catering
to traditions for food preparation and to traditional health
Avian Influenza and China’s Health System • JID 2008:197 (Suppl 1) • S11
beliefs about the consumption of certain foods. How these
markets are monitored is far from clear, and the possibility of
animal-to-human transmission of infection remains high. A
recent analysis pointed to direct and indirect factors that facilitate the spread of avian influenza virus and discussed 8 highrisk farming practices related to poultry and farm animals, 5
unsafe poultry-transport practices, and 11 high-risk practices
at “wet” markets (i.e., live-animal markets) that are common
in China, Vietnam, and other Asian countries.
Complicating veterinary infection-control measures is the
fact that the Chinese government has chosen chicken immunization, rather than restrictions on backyard poultry- and
duck-raising that would minimize the possibility of wild fowl
infecting poultry and duck flocks. After confirmation of a human case of H5N1 virus infection in Anhui Province, the provincial government decreed that all backyard poultry must be
kept in cages, but this localized response was neither sufficient
to deal with the problem nor easy to enforce. It is difficult to
ensure the implementation and monitoring of restrictions to
prevent the intermingling of these 2 populations in China’s
backyard ponds. Moreover, there are questions about the effectiveness of the vaccination of poultry. China has vaccinated
120% of its chickens [13], and many suspect that infection
control through poultry vaccination is only mildly successful
and may be leading to the selection of more-virulent viruses.
A recent article in the Proceedings of the National Academy of
Sciences of the United States (PNAS) [16] suggested that a more
dangerous “Fujian-like” variant of the H5N1 virus had been
strengthened as a result of poultry vaccination (a response
noted that 95% of domestic birds had been vaccinated [17]).
The Chinese government vehemently denied this suggestion
[18], but doubt remains. The WHO noted that its ability to
assess the accuracy of the PNAS report had been hampered by
China’s refusal to share avian influenza virus samples with the
international scientific community, which uses such samples
for the development of human avian influenza vaccines [17].
China’s resistance to sharing information and virus samples
with Hong Kong and the United States impedes efforts to document the mutations occurring in the virus in cases of infection
in both birds and humans. China claimed that such virus samples had been misused previously but agreed to share 20 virus
samples from 2004 and 2005 with the WHO, to support its
claim that no new strain of H5N1 virus had emerged in southern China [17].
CONCLUSION
If an avian influenza pandemic among humans were to emerge,
its likely source would be China. The good news is that China
has a reasonably good health infrastructure and a demonstrated
ability to mobilize for action, given the political authority of
its single-party system of governance, as proved by its quick
S12 • JID 2008:197 (Suppl 1) • Kaufman
turnaround during the SARS epidemic. However, China’s crisis-management procedures for epidemic threats currently are
very weak, its authority structures are unclear and potentially
dysfunctional, and it is difficult, if not impossible, for the Ministry of Health to exercise local control, as a result of decentralized financing and authority. Moreover, China has a long
history of and an incentive system that leads to the concealment
of sensitive and negative information, by lower levels of government from higher levels, which does not bode well for the
timely reporting and containment of disease outbreaks among
poultry and humans. Many incentives exist for concealment,
but the main incentive is a supervision and promotion system
based on the achievement of targets and an expectation of
negative consequences for the reporting of bad news. The example of the response to SARS shows that these problems can
be overcome with an infusion of strong political will. However,
given the worldwide importance of preventing avian influenza
viruses from mutating to adapt to human hosts, this political
will should be mobilized now, not after an epidemic begins,
since preparedness can help prevent the virus reassortment that
happens in the type of backyard-farming conditions present in
rural China today. Moreover, it is essential that Chinese scientists and officials exhibit greater transparency in sharing virus
information, so that global efforts to develop influenza vaccines
are as efficient and effective as possible. Addressing these issues
now and working on issues related to institutional and operational capacity; authority structures; accountability; and more
local surveillance, reporting, and infection-control structures
will benefit the response to not only a potential avian influenza
outbreak but also the inevitable future outbreak of another
emerging infectious disease that will be likely to originate in
China’s Pearl River Delta or in other densely populated locations of animal husbandry in China.
Acknowledgments
The Harvard University Asian Flus and Avian Influenza Workshop was
hosted by the Harvard University Department of Anthropology, Harvard
School of Public Health, and Harvard Asia Center and was supported by
the National Science Foundation, Harvard Asia Center, and the Michael
Crichton Fund.
Supplement sponsorship. This article was published as part of a supplement entitled “Avian and Pandemic Influenza: A Biosocial Approach,”
sponsored by the National Science Foundation, Harvard Asia Center, and
the Michael Crichton Fund.
References
1. Institute of Medicine, National Academy of Sciences. Microbial threats
to health: emergence, detection, response. Washington, DC: National
Academy of Sciences, 2003.
2. Kelley LM. Is H5N1 the one? Avian flu facts and fiction. Washington,
DC: American Enterprise Institute for Public Policy Research, 2005.
Available at: http://cpass.georgetown.edu/articles/avian%20flu%20
facts%20and%20fiction.pdf. Accessed 12 January 2008.
3. Morens DM, Fauci AS. The 1918 influenza pandemic: insights for the
21st century. J Infect Dis 2007; 195:1018–28.
4. China Development Research Foundation and United Nations Development Programme (UNDP). China human development report. Beijing: UNDP China, 2005.
5. Kaufman JA. SARS and China’s health care response: better to be both
red and expert! In: Kleinman A, Watson JL, eds. SARS in China: prelude
to pandemic? Palo Alto, CA: Stanford University Press, 2006:53–68.
6. World Health Organization (WHO). World health report. Geneva:
WHO, 2000.
7. Saich T, Kaufman JA. Financial reform, poverty, and the impact on
reproductive health provision: evidence from three rural townships.
In: Huang YS, Saich A, Steinfeld E, eds. Financial sector reform in
China. Cambridge, MA: Harvard Asia Center Publications, 2005:
178–203.
8. Kaufman JA, Jing F. Privatisation of health services and the reproductive health of rural Chinese women. Reprod Health Matters
2002; 10:108–16.
9. State Council of China. Report on China’s health care system. Beijing:
China State Council Development Research Center, 2005.
10. Yu W, Wu M, Garber A. Control of infectious disease: challenges to
China’s public health system. Presented at Conference on Economic
Challenges in Asia (Palo Alto, CA). Stanford, CA: Stanford Center for
International Development and Stanford Institute for Economic Policy
Research, 2006. Available at: http://scid.stanford.edu/events/panasia/
papers/garber.pdf. Accessed 12 January 2008.
11. Liu Y. Gender and health equity network: China case study, China’s
health system and reproductive health status. Presented at Gender and
Health Equity Meeting (Stockholm). Stockholm: Swedish International
Development Agency, 2006.
12. Stohr K. Avian influenza and pandemics: research needs and opportunities. N Engl J Med 2005; 352:405–7.
13. Murphy C. Why Asia’s bird flu plans are grounded. Far East Econ Rev
2005; 168:22–5.
14. Rosenthal E. Experts doubt bird flu tallies from China and elsewhere.
New York Times. 2 December 2005; sec A. Available at: http://query
.nytimes.com/gst/fullpage.html?resp9D03EFD71531F931A35751C1
A9639C8B63. Accessed 12 January 2008.
15. Kaufman JA, Kleinman A, Saich T. Introduction: social policy and
HIV/AIDS in China. In: Kaufman JA, Kleinman A, Saich T, eds. AIDS
and social policy in China. Cambridge, MA: Harvard Asia Center
Publications, 2006:3–14.
16. Smith GJD, Fan XH, Wang J, et al. Emergence and predominance of
an H5N1 influenza variant in China. Proc Natl Acad Sci USA 2006;
103:16936–41.
17. Beck L. China shares bird flu samples, denies new strain report. Reuters
10 November 2006. Available at: http://www.alertnet.org/thenews/
newsdesk/PEK2663.htm. Accessed 12 January 2008.
18. Xinhua News Agency. Chinese minister refutes reports on new H5N1
strain. 13 November 2006. Available at: http://www.chinacdc.net.cn/
n272562/n276003/14956.html. Accessed 4 December 2006.
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