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Epidemic control in Chinese public health: past and present

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Depending on who you ask, the Party-state of the People’s Republic of China has either saved the world, or damned it. In December 2019, medical professionals first notified the WHO of a novel respiratory infection—now familiar to us as SARS-CoV-2 or COVID-19—in the central Chinese city of Wuhan, in Hubei province. The early weeks and months of the virus’ infiltration of human bodies coincided with a period of high-traffic domestic travel for the Lunar New Year. Multiple factors have all been blamed for its apparently rapid spread within the PRC in the first months of 2020: efforts by local governments to suppress information about the spread of the virus; the insufficient capacity of Chinese primary health-care systems; and the ability of the virus to infect many via asymptomatic carriers, to name a few.

Domestic discontent caused by early reluctance to address the epidemic danger in Wuhan posed a serious threat to the Chinese Communist Party’s legitimacy, and as the story broke globally, China was faulted for failing to confine the disease within its borders. The identification of COVID-19 with China and Chinese people has fanned flames of xenophobia and racism around the world.

And then, the story changed. As stories criticising the incompetence of the Wuhan authorities’ initial response began to appear in Chinese state-sanctioned publications like the Global Times, the central government sent in the cavalry in the form of medical staff, shipments of personal protective equipment, and hospital construction crews. Orders to ‘lock down’ Hubei severely restricted travel across the province. Other cities and villages soon followed suit in implementing quarantines that reflected a ‘grid reaction,’ in which local authorities seek to control disease by strictly curbing the movements of people and goods and enacting thorough surveillance of residents ordered to stay confined to their homes. Observers from the WHO have praised these actions, describing them as unprecedented in their scope, extremity, and effectiveness.

Yet the rapid implementation of mandatory quarantine in China is far from new as a means of epidemic control. Likewise, the public promotion of Chinese achievements in public health is a well-worn strategy. Both these aspects of epidemic control pose a conundrum intrinsic to public health, one not at all unique to China: to what extent does protecting the common good justify state limitation of private freedoms?

Education, persuasion and coercion

Public health in China has long been characterized by the implementation of extensive quarantine mechanisms. One of the most important epidemic events in modern history was a 1911 outbreak of pneumonic plague in northeast China. Its remarkably high incidence and mortality rates threatened the sovereignty of the Qing dynasty in the northeastern region of Manchuria, vulnerable to encroachment by Russian and Japanese forces.

The Qing sent in Wu Liande (Wu Lien-teh 伍連德), a Malayan-born, Cambridge-trained medic, who undertook what has been remembered as the first effective public demonstration of Western medical expertise in China to stop epidemic mortality rates from rising. And yet in Neither Donkey Nor Horse: Medicine in the Struggle over China’s Modernity, Sean Hsiang-lin Lei reminds us that this victory of Western medicine did not actually employ any effective therapeutic measures against the disease. Its success depended simply upon the isolation of infected individuals in plague hospitals, to the dismay of local populations who feared and avoided removal to wards from which there was no return.

Most health measures in twentieth-century China weren’t restrictive or extreme to the degree that Wu Liande’s were, in those extraordinary circumstances. Before the 1949 establishment of the People’s Republic of China, the ruling Nationalist Party lacked the resources and political will to implement sweeping hygienic reforms across the country. After 1949, mass mobilization was one of the central public health strategies adopted by the Chinese Communist Party. Yet still, throughout the twentieth century, the restriction of personal freedoms for the public’s health did not automatically imply radical actions that punitively removed all individual autonomy.

‘Compliance’ with quarantines and other hygienic measures has long encompassed a broad spectrum of voluntary, self-interested, altruistic, and fearful behaviours. When the CCP expanded mandatory smallpox and typhoid fever vaccination across the nation in the early 1950s, for instance, its directives stressed education and persuasion as a tactic to get people to accept jabs—although the threat of coercive implementation was constantly present in, and would have tacitly shaped, interactions between vaccination teams and their targets. Xiaoping Fang has shown that in coastal Zhejiang, responses to the El Tor cholera pandemic of the early 1960s encompassed a range of immunisation and quarantine orders that met with uneven uptakes. The central government’s management of this episode ultimately combined pre-existing systems to require vaccination certificates for travel with strict quarantines to produce a lasting public health strategy for epidemic control, one which emphasised strict information control and mass mobilization.

“Medical diplomacy”

Although the SARS pandemic of 2003 occurred almost fifty years later, in a radically transformed national context of post-socialist economic growth and mobility, the Party-state’s response was consistent with precedents set long before. It featured tight information control, punishment of whistle-blowers, and stringent epidemic control measures that were imposed only after the disease aroused the attention of a broader public. In Infectious Change: Reinventing Chinese Public Health After an Epidemic, Katherine Mason argues that after SARS, Chinese public health was re-envisioned as a professional, biomedical, and highly technological discipline.

One goal of this reconceptualization was to stress global perceptions of China as a healthy nation where epidemics were successfully controlled. And this is the narrative that is currently winning out in media outlets today. As I write, numerous news reports from within and without China are stressing its victorious control of the COVID-19 epidemic, for instance repeating the statistic that the PRC reported no new domestic cases of the disease on 19 March. The PRC’s announcement of its successes in controlling the epidemic via new social control measures, like its announcement of diseases imported from western countries, plays well into emerging narratives—at home and abroad—that China’s actions 'bought the West time' to deal with the coronavirus, which European and North American nations then squandered. In other words, in this version of events, China has provided a model of public health interventions against which most other countries have fallen short.

This reversal of public-relations fortunes, too, is a familiar phenomenon. Medical diplomacy has been a part of the Party-state's international-relations toolkit almost since its establishment. Photographs of Chinese medical teams flying with planes full of face masks and other hygienic supplies to Italy, for example, are remarkably evocative of promotional materials for medical teams that the PRC sent to decolonised nations in Africa in the late 1950s and 1960s. Medical diplomacy not only provided a means of gaining political goodwill and recognition across the non-aligned world during the Cold War; it also offered avenues for promoting Chinese rural health systems to global health professionals in the west. Accounts of China’s successful control of infectious diseases provided supporting evidence for the efficacy of these systems, helping make the PRC a model for strategies that stressed ‘primary health care’ across the world in the 1970s.

Here, now, again, China is asserting a model for public health in a global context—one supported by systems of social control, surveillance, and intervention. These methods, and their promotion, reflect a variable tapestry of independent initiative and enforced rulings; they are also responsive to domestic and global media narratives. As the quarantines begin to lift across China, and people make their way outside once again, time will tell if they have been sufficient to protect the public’s health.

Please note: Views expressed are those of the author.

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