Resuscitating public health
Feng Jianhua

IT HAS been an extraordinary summer for China with extreme weather that has tortured the country causing floods in the south and drought in the north. Under these conditions diseases can spread quickly and thoughts of how to prevent an epidemic have been on the minds of everyone working in China’s public health emergency response system.
“Public health is as indispensable to the country as the highways are, and to have a world-class public health emergency management system is a priority for the well-being of the people,” said Huang Jianshi, a professor of epidemiology, and Assistant President of Peking Union Medical College.
China did once have an efficient public health system even though the country’s economy was fragile. It was not until the early 1980s when market-oriented reforms swept across the land that the public health system began to become marginalized, and in some rural areas vanished altogether.
The 2003 severe acute respiratory syndrome (SARS) crisis caused panic across China and alarm spread to the international community, but the Chinese Government was able to control the crisis. “We came to an awareness that the reason the SARS epidemic was not controlled sooner was because of flaws and imperfections in the public health system,” said then the Vice Health Minister, Gao Qiang.
This was a catalyst for the country to rebuild its broken public health emergency response system. According to the Ministry of Health, with a large injection of state finance, China is expected to have a command and decision-making system to deal with health crises ready for action at the end of 2007, five years after the SARS outbreak.
“China didn’t pay real attention to having a public health crisis management system until the SARS epidemic. Though the motivation for building a system seems rather passive, the outcome is beneficial,” said Wang Ke’an, a Chinese epidemiology expert.
Past glory
Civil war, epidemics, endemic diseases and lack of medicine had left the country in a miserable state in the 1930s and 1940s. After 1949 when the People’s Republic of China was formally established, the government began to develop a system to care for the nation’s health while fostering the economy. In June 1965, Mao Zedong called on the nation to shift its key health mission to the rural areas.
As a result, medical resources were balanced between urban and rural areas in China. Take the number of hospital beds for instance. In 1965, 40 percent of hospital bed places were in rural areas and ten years later in 1975 that percentage had climbed to 60 percent. At the same time, a large number of urban medical manpower was shifted to rural regions to help improve people’s health in those areas.
At the end of 1968, a cooperative medical system was promoted across the country’s rural areas. In 1980, a medical network including 510,000 regular doctors, 1.46 million part-time paramedical workers and 2.36 million medical assistants, covering disease prevention, medical services and healthcare for the vast rural population was in place.
Medical work back then was focused on basic medical services such as the prevention and stamping out of epidemic diseases. Although China was behind much of the world in economic terms its public health system was considered quite successful: it made use of low-cost medical services to guarantee a basic medical and heath shield for the enormous Chinese population.
In 1949 China ranked among the worlds lowest in terms of health. But by the end of the 1970s it had joined the list of countries whose citizens enjoyed all-round healthcare with 80-85 percent of the Chinese people covered by basic medical services, and average life expectancy had jumped to 70 from the 40 before 1949. Though China didn’t rank high in the world GDP chart, its health record was something to be proud of.
The country’s public healthcare system at that time was still at a primary stage but the “Chinese mode” won great recognition from the international community for its “lowest cost but largest health benefit” approach, and the country’s achievements were even praised by the World Health Organization and the World Bank.
Smallpox was prevalent in many parts of the world in the late 1960s, infecting 10-15 million and killing around 2 million every year. “China stamped out smallpox in early 1980s. In eliminating snail fever and poliomyelitis China also took the lead, and that owed much to its public health system at that time,” said Wang.
Market crash
China said goodbye to the planned economy era and embraced market-oriented reform in the 1980s, and two decades of booming economic growth followed. While economically the country made leaps and bounds, in healthcare there was little advance. Instead, the nation’s healthcare system was overlooked by government at all levels as it pursued economic goals. Statistics show that China’s medical expenditure at present make up 5 percent of its GDP, of which 12 percent is devoted
into the public medical field, while in other developed countries, public medical expense makes up 50 percent of their total medical expenditure. In 2000, WHO evaluated the healthcare systems of 191 countries and regions. China ranked 144th, even below Sudan and Haiti, two countries which have GDP far behind China.
The proportion of China’s medical budget spent on public health has been decreasing over the past two decades. In the early years of reform and opening up 36 percent of the budget was spent on public health, but that number had dropped to 25 percent in 1990 and 14.9 percent in 2000.
In order to make up for its medical budget shortfall China’s public healthcare system moved to a market forces model. Some of the direct results of this were that healthcare shifted from rural to urban areas, from prevention to treatment and from low-cost to higher. Hospitals began to buy more expensive medical facilities and the cost of medical treatment began to eat away at the income of ordinary Chinese citizens. In 1980 the average person spent 23 percent of their income on medical treatment; in 2000 it had risen to 60.6 percent. In developed countries the proportion is around 27 percent. The high cost of medical treatment has for a long time been a major complaint in China.
China’s healthcare system also became distorted due to lack of guidance and regulation, with widening gaps developing between different regions, between urban and rural areas and between social classes. The urban-rural gap is particularly stark.
In 2000, China’s overall medical costs reached 476 billion yuan, of which rural costs were 107 billion, or 23 percent. That is to say, two thirds of the country’s population used less than one quarter of its medical resources and the other third (urban citizens) enjoyed the other three quarters. This imbalance of medical resource distribution finally pushed China to 188th place in a 191-country evaluation on health services in terms of fairness by the WHO in 2000.
For a long time many local public health institutions have been left starving for capital, with government money making up only one third of their funds. Many medical entities were unable buy new medical equipment and some could not pay their staff due to the lack of financial support. According to an anonymous source from the Ministry of Health, one third of the health clinics at the county-level and below are under normal operation so far, and the other two thirds are either breaking down or just one step from collapsing.
Scarce funds also forced many health clinics to search for profits and as a result their disease prevention and control functions have been diminished.
“The grassroots public health institutions, compared to the market-dominated medical ones, are poorer in medical facilities and lower in staff payment level. The talent drainage is considerable,” said Wang.
According to Gao, China doesn’t have any major disease prevention and control organs at the township and village level. It’s fortunate that the 2003 SARS epidemic didn’t spread to rural areas otherwise the situation would have been catastrophic.
Rebuilding
The SARS crisis propelled the Chinese Government to step up its efforts to build a public health emergency response system and also raised public awareness of the importance of such a system.
On May 9, 2003, one month after the SARS breakout, China stipulated and issued a regulation on public health incidents, according to which anyone who makes a false report or covers-up a real epidemic situation should be held responsible and punished. It also said that provincial governments should report to the State Council if there is any epidemic situation.
On May 12 that year, the Ministry of Health issued a SARS related prevention and management regulation, detailing everything including a SARS situation report, publicity, prevention and control, and supervision.
Two days later, the Supreme People’s Court and Supreme People’s Procuratorate stated that anyone who deliberately disseminates an epidemic pathogenic species and endangers public security should be sentenced.
In July the same year the Chinese Government also endeavored to form up a work team dealing with public emergency incidents.
On January 8, 2006, a national public incidents response plan was enacted, and a public emergency response system was established. The plan makes clear the principles and operation of the State Council in dealing with an emergency and has borrowed much from international experience. For example, the government should let the public know what’s going on immediately when there is any emergency situation.
In February 2006, the State Council issued emergency response plans covering public health, medical rescue, animal epidemics and food safety. The Ministry of Health also created a national training scheme between 2006 and 2010 to deal with health emergency responses.
By the end of 2006, 70.3 percent of the nation’s township-level health clinics, 95 percent of county-level medical institutions and above, and all disease control and prevention centers had been included in an online direct report network created to monitor infectious diseases and public health incidents.
China is becoming mature in managing public incidents and its citizens are growing calmer in the face of them. There was a bird flu breakout in 2006, which affected 16 provinces and autonomous regions and resulted in a direct loss of 10 billion yuan. The State Council immediately issued a response plan and launched a daily report mechanism to ensure information transparency and let the public know how the situation was progressing. Six months later, the situation was under well control.

(The Daily Mail-Beijing Review Articles Exchange Item)


Bridge-people to the future
Tom Plate

A FUNNY thing happened to Tokyo’s Masahiro Kohara after he arrived in Los Angeles almost two and one half years ago. He felt right at home.
The intellectually elegant Japanese diplomat had been expecting to feel like a fish out of water. But, taking over as the deputy consul general in Los Angeles, Kohara quickly found his footing as he more or less found himself every other day — and night — at some community get-together or cultural event or whatever. And he was never really bored: Southern California didn’t seem half as superficial as had been advertised.
Another odd thing hit him. Though well briefed at the ministry of foreign affairs in Tokyo about the well-known diversity on the West Coast of America, he was astonished by the panoramic panoply of demographic cosmopolitanism that was spread out all before him. Asians were everywhere, Japanese-Americans were everywhere, and so Masa (as his friends call him) felt as if he were swimming in warm and friendly waters.
There were particular reasons for this.
One had a lot to do with his boss: the everywhere Kazuo Kodama. This peripatetic consul general, a career diplomat who’d served in Washington and India, and who’d handled international press relations for Japanese prime ministers, was not one of those stay-at-home ambassadors who shunned outsiders. Well-schooled in US politics, Kodama understood (better than some Americans, in fact) the political importance of the West Coast, the real brave new world of America. And so he pushed himself out to every event to which he was invited — often pushing his very witty wife, Keiko, along with him.
And so when Masa arrived, he found a boss who was not about to let his number-two be a stay-at-home, watching Japanese TV, even if that had been his inclination. Which it certainly was not. On the contrary, Masa soon recognised that the demographics of the West Coast (and increasingly of America in general) were becoming more Asian by the month: But not just Asian in the superficial sense, but in the sense that every Asian in the states not only had a well-developed network of business or religious friends here, but also over there, across the ocean.
This is to say that Asians (at least as much if not more than other ethnic and geographical groups) are prodigious trans-Pacific networkers: They network at night and they network during the day —- not just at the church around the block or the office where they work but back to business, religious, political and family networks in their home country in Asia.
This is not generally known, and it is significant. Depicting these Asian-Americans as key players in the Asia-Pacific future, the crack author and celebrated futurist John Naisbitt wrote this in his bestselling book “Megatrends Asia”:
“The pivotal players in the new global configuration of East and West will be Asians living in America and Asians born in America. Many Asian-Americans are as comfortable in the western world as they are in the Eastern. In the global village, Asian-Americans, as well as Asians who are educated and have worked in America, will be a bridge between the east and the west.”
And so Masa Kohara, in his new assignment, unexpectedly found himself a key bridge-person. It was not exactly a traditional role for the traditional diplomat. Kohara, the author of an incisive book touting the evolution of a revolutionary East Asia community, would not even seem aptly cast for the role. Precise, well-schooled and cautious, he nonetheless found himself caught up in the West Coast swirl of Asia-Pacific cosmopolitanism.
Another friend of mine — Stephen Christopher Liu, a well-known Southern Californian entrepreneur — uses an obvious truth (that Asian-Americans are the country’s fastest-growing minority) to tease out a related one. It is that, assuming trans-Pacific globalisation proceeds apace, the need for bilingual Asian-Americans in the job market will mushroom dramatically. This means Asians here in America are becoming very hot professional commodities. They will intensify the salience of those Naisbittian networks that are at the core of the growing and deepening West Coast/Asia-Pacific community.
What this then comes down to is that Kohara and his boss Kodama have been, in their own ways, futurists in the Naisbitt and Lui spirit. Instead of playing the traditional boring diplomatic sherry-and-tea game with the usual closed-in elites, they have pushed themselves out onto the public arena of California and the West. They have revised traditional diplomacy to make it more public and less private.
This is to make it more open and more transparent, more tangible and more personal and more future-oriented. In the process, they have done their country and all Asian-Americans a considerable service. It must be said, therefore, that Masa Kohara, who is returning to Tokyo for a new assignment, will be missed here. But for the true bridge-person, going back can also mean going forward — and never really ever leaving home.—Khaleej Times

In Darfur, from genocide to anarchy
Alex de Waal

IMAGINE you are a US Special Forces officer and you get a call: You are being posted to Darfur. Your job is to protect African villagers from marauding Arab horsemen and to show the Sudanese security chiefs that their bluff has been called — at last, the international community is standing up to their evil schemes.
What can you expect? According to news reports, a sort of slow-motion Rwanda in the desert. What will you find on arrival? A reality that’s complicated and messy. A Darfur that has more in common with Chad, southern Sudan and — dare we say it? — Somalia.
In Darfur today, knowing who is on which side is not straightforward. The savage counterinsurgency offensives, with their massacres and scorched earth, that Colin Powell called “genocide” in September 2004 had in fact largely concluded by the time Powell made that historic determination. This isn’t a moral exculpation; it’s simply a fact. It’s also been a regular sequence in Sudan’s recurrent wars over the past 25 years. Episodes of intense brutality and mass displacement are followed by longer periods of anarchic internecine fighting, ably exploited by the government.
Because the vanguard of government offensives is tribal paramilitaries — well known to prefer soft civilian targets to hardened rebels — the result of each offensive is a fractured and demoralized society in which every group is armed and most leaders cut opportunistic alliances to preserve their power bases.
The warlords who prosper in this environment deal only in the currency of power, switching alliances as their calculus shifts.
For the past three years, Darfur has been descending into this murky world of tribes-in-arms and warlords who serve the highest bidder, with some community leaders of integrity trying to carve out localities of tranquility. Many Arab militias are talking to the rebels; many erstwhile rebel leaders have struck bargains with the regime, receiving high-sounding positions and nice villas in return for providing an adornment to the government’s attempts to show a pluralistic facade.
While the script of many rights campaigners and activists has remained stuck in the groove of “genocide,” Darfur faces something that can be just as deadly in the long term: Anarchy. The government is a dictatorship, but its writ doesn’t run beyond the first checkpoints outside the towns. The army has a fearsome arsenal, but two much-heralded offensives last year were smartly and bloodily annihilated by rebels. The air force is rarely used, except when targets of opportunity arise — or the rebels have the army on the run. There have been no large-scale offensives by the government in 2007.
The Sudanese government relies on its Arab militias for a semblance of control, but increasingly these militias pursue their own agendas. The other big ongoing crisis, and the major cause of more than 100,000 people being displaced this year, is a multisided conflict in Southern Darfur involving warring Arab militias; rebel commanders from the Sudan Liberation Army who are now allied with the government, though other commanders are fighting it; a militia drawn from West African immigrants; and a rebel commander from the Justice and Equality Movement who answers to no one but himself. Simple, it isn’t.—Arab News