The Diplomat author Mercy Kuo regularly engages subject-matter experts, policy practitioners, and strategic thinkers across the globe for their diverse insights into U.S. Asia policy. This conversation with Dr. Xun Zhou – reader in modern history at the University of Essex, expert on health intervention and delivery in China, and author of The People’s Health: Health Intervention and Delivery in Mao’s China, 1949-1983 (forthcoming) – discusses the origins of COVID-19 and the future of China’s health systems.
Explain the decision-making and authorization process behind health intervention and delivery in China.
After the SARS outbreak in 2003 exposed grave deficiencies in the Chinese health system and the increasing public complaints in China over unaffordability and low quality medical care, the Chinese authorities acknowledged that an efficient health system is pivotal to China’s overall social and economic development, the country’s stability, and the CCP’s political legitimacy as well as China’s image on the world stage. In 2009, the Central Committee of the Communist Party of China (CCCPC) and the State Council mandated major health reforms. The goal of this Healthy China Strategy is to establish an equitable and effective health system so that China would achieve Health for All by 2020. This entails strengthening healthcare delivery, health security, and provision of essential medicines.
At the top, the State Council set up a State Council Health System Reform Office to coordinate the relevant ministries to develop specific reform policies. The Office is also responsible for evaluating the reform work performed by different ministries as well as by provincial authorities. While this annual evaluation would have a direct impact on the allocation of the state health subsidy as well as promotion of individuals, neither the Office nor the relevant ministries such as the Ministry of Health responsible for formulating national policies have any real power over the implementation of the reform strategy.
To this day the health intervention, delivery, and financing systems remain fragmented. On the ground, each provincial authority is responsible for allocating resources to implement national-level health policies, which may be at odds with local interests. They often treat national policies as merely guidelines, and are not obliged to implement them, whether due to lack of funding, resources, or local interests. On the other hand, with their eyes fixed on more state subsidies and the next opportunity for promotion, local authorities and officials are always more interested in showing their superior in Beijing how well any specific locality is doing in terms of health, rather than being seen as a problem. Even at the national level, health resources in China are managed by different sectors. Coordination between them has always been problematic. In crisis situations, such as during the SARS outbreak in 2003 and the COVID-19 outbreak early this year, such fragmentation severely impeded crisis management.
Identify the factors behind growing international pressure to investigate China’s handling of COVID-19 domestically and with the World Health Organization (WHO).
The COVID-19 crisis that first took hold in Wuhan in central China exposed the Chinese authorities’ consistent lack of transparency in acknowledging any disease outbreaks threatening public health. Local and national authorities’ unwillingness to report the onset of the outbreak as well as their failure to acknowledge the resulting tragedy in Wuhan turned it into as much a man-made catastrophe as a biological one. More importantly China’s reluctance to share uncensored information with international communities has led some of its Western critics to condemn Beijing. In the United States, capitalizing on the growing public distrust of China that was fanned prior to the outbreak, several leading Republicans have waged a major anti-China campaign aimed at diverting voters’ attention away from the Trump administration’s local mismanagement of the pandemic.
In the U.S. war on COVID-19, China is portrayed as the “Patient Zero” that has contaminated the rest of the globe, and hence is responsible for costing nearly 30 million American jobs as well as the federal government trillions of dollars in emergency spending. China is blamed for the deepening economic recession not only in the United States but globally. Around the world, as a variety of interests intersected to replicate the horror of the pandemic in different contexts, China has become the ultimate scapegoat. Australian Prime Minster Scott Morrison, for instance, has accused China of having caused the huge loss of lives across the world as well as the global economic shutdown.
The WHO now serves as a political and diplomatic arena in the current health/diplomatic war between the U.S. and China. This is not new, however. From its onset, as pointed out by one of its founding fathers, Dr. Sze Szeming, the WHO has really had more to do with politics than medicine and health. As my book illustrates, throughout the Cold War, the United States, China, and the USSR regularly used the World Health Assembly (WHA) as a political and diplomatic arena to battle each other. China, for example, after rejoining of the WHO in 1973, began to use the WHA meetings to promote its new Third World policy and to combat the First World “superpowers” such as the USSR and the United States.
Explain the correlation between the CCP’s legitimacy and ability to control the COVID-19 narrative on domestic and global health policy as well as geopolitics.
Throughout Chinese history, epidemic, war, and natural disasters, including famine, had been seen as signs indicating the loss of the Mandate of Heaven that inexorably led to the downfall of many dynasties. In the People’s Republic of China (PRC) politics and health have always been inextricably linked. After the Chinese Communist Party (CCP) seized power in 1949, locally endemic diseases such as schistosomiasis were seen as threats to people’s livelihood, social stability, and national security. Public health campaigns aimed at eradicating such diseases linked allopathic medicine and public health work with the ongoing legitimization of the new order. Fighting the disease came to stand for fighting for socialism. As such the CCP leadership made eradicating diseases and improving the health of the entire population a central pillar of its policies. As the promise to improve the people’s health has been a central tool utilized by the CCP in establishing political legitimacy, its failure to deliver such promise could also cost the party its legitimacy. Hence, the CCP’s campaign to control COVID-19 is simultaneously political. At the same time, as public health work in the PRC has served as one of the central means of impacting and influencing the masses, the CCP has also turned the political campaign to combat COVID-19 into a moral crusade involving the entire Chinese nation. This way, the CCP has managed, with some success, to rally support from a large section of the population.
Nationalism is on the rise in China. In the meantime, with the spread of disease globally as well as the xenophobic anti-Chinese discourse in some Western countries, the official propaganda in China is turning COVID-19 into an external menace. This has allowed the CCP to further gain support from Chinese populations both within China and overseas in an alleged “united” effort or “common goal” to fight the disease. Such nationalistic rhetoric is also diverting people’s attention away from the earlier tragedy in Wuhan.
Globally, capitalizing on the growing crisis in the United States and Europe, the official media in China has been trumpeting China’s purported success in controlling the disease. China has also sent medical missions to countries such as Italy. Sending medical missions abroad had been a strategy the PRC used during the Cold War to promote a new international order: a “people’s revolutionary movement” against colonialism, imperialism, and hegemonism. In the 1970s, the PRC’s increasing medical “humanitarian” activities, and the bonds of friendship created through such undertakings, helped the PRC win its battle against the Republic of China (Taiwan) for the permanent “Chinese” seat at the UN’s Security Council and membership in the General Assembly. This time, the PRC’s medical “humanitarian” efforts have once again won praise from the WHO as well as those who wish to criticize the Trump administration or their own government’s failures in tackling the crisis. On the other hand, it’s also ironic that while health and humanitarianism played pivotal roles in the political and diplomatic negotiations within the White House that eventually led to the opening to China in the early 1970s, currently both the White House and Beijing are using health as a weapon to engage in a new Cold War.
Assess the CCP’s strategy to counter global calls for China to be held accountable.
With mounting pressure from some Western countries threatening to bring China to international courts, China has become the global pariah for failing to alert the world about the outbreak. Faced with such a challenge, the CCP, assisted by its official media and the scientific community in China, has been working hard to try turn the tide by propagating itself as a global hero for its successful containment. At the same time, Beijing has launched a major propaganda campaign, backed up by purported scientific evidence, blaming the U.S. military for bringing the disease to Wuhan in the first place. Such strategy is nothing new, however. It resonates with the CCP’s campaign against the alleged American “germ warfare” during the Korean War in the 1950s. On the other hand, China has launched a diplomatic as well as propaganda campaign to attack Western “imperialists” by evoking the memory of the “Hundred Year National Humiliation.” In it, the COVID-19 is the new “opium plague” that the West, in particularly the United States, is using to hobble China’s rise. But this time, China is determined to not be defeated.
Similar to what happened in the aftermath of the Tiananmen Incident in 1989, the CCP leadership took to the decision that China would remain open to the outside world, and perhaps open wider than before. While last time, Deng Xiaoping sought the help of his “old friend” President George H. W. Bush of the United States to get China out of the crisis of international isolation, this time President Xi Jinping of China telephoned President Putin of Russia to agree on building stronger ties. Stating that “the attempt by some to smear China on the question of the origin of the virus is unacceptable,” Putin assured Xi that “Russia is ready to continue to strengthen exchanges and cooperation with China in fighting COVID-19 and in other areas.”
The day after Xi and Putin’s communication, on April 17 at the CCCPC Politburo meeting, it was announced that China would “facilitate the smooth flow of international logistics, strictly control the quality of epidemic prevention and control supplies for export and jointly advance high-quality development under the Belt and Road Initiative.” On the same day, the Wuhan authority published a revised mortality and morbidity figure that increased the city’s total COVID-19 death toll by 50 percent. That took the national total in China to more than 4,600. The official statement states that this revision was a result of efforts by authorities to “ensure that information on the city’s COVID-19 epidemic is open, transparent and the data [is] accurate.” At the exact moment, the Ministry of Foreign Affairs spokesman attacked the United States’ accusations of a cover-up by China as false: “We’ll never allow any concealment,” he said. Clearly China has crafted this new statistical campaign to deter external criticism. At the same time, by ceremoniously increasing the mortality figure, authorities hope to win back people’s trust, hence to ensure the stability of the country.
With U.S. and European policymakers questioning China’s credibility on health policy and data transparency, why does cooperation between Chinese and Western scientists and health experts remain crucial to containing COVID-19?
In the past 40 years, the West had made much effort to integrate China into the neoliberal world order. This Western enthusiasm to draw China in had been matched by China’s willingness to participate in it. China’s ascendance to the world’s second biggest economy, however, has had unintended and catastrophic consequences. Rapid modernization accompanied by unrestricted deforestation and unprecedented scale urbanization have threatened the capacity and resilience of the country’s ecosystems. The ever-increasing human efforts to exploit land, from agricultural expansion and intensification – including the animal husbandry industry to produce high protein food for human consumption due to the rise in living standards – to the construction of roads, railways, mining, and other large scale modernization projects such as the Three Gorges Dam drove much wildlife into populated areas due to the loss of habitats and led to closer integration between livestock and wildlife. This has increased human exposure to new pathogens threatened public health.
South of the Yangtze River, including the regions around Wuhan, as well as China’s southwest have become the “golden triangle,” the ideal environment for the emergence and transmission of a number of infectious diseases (EID), from SARS to the highly pathogenic avian influenza (HPAI) and COVID-19. All are zoonotic in origin. Yet China is not alone in this nor is China the sole culprit for the pandemic the world is now experiencing. Throughout history, the link between modernity, globalization, and epidemics is obvious. The expansion of global trade and travel have set us free but also left us exposed, ever more vulnerable. Geographical distance, the barrier that used to separate us but also slowed the transmission of infectious diseases, has been mitigated with our improved transportation network.
Today, in China as in much of the world, to catch an airplane is likened to catching a bus. The improved and increased aviation has also accelerated the spread of diseases and the rapidity of occurrence of a pandemic such as the COVID-19. The connectedness of everything in this universe, not only in geographic proximity, also meant science can no longer just rely on isolating particular causes and their effects. There is more than ever before a greater urgency and need for a better understanding of the drivers and causes of the emergence and spread of infectious diseases as well as for closer collaboration between international agencies and national governments together with scientists and health experts across the world and disciplines to strengthen animal and public health surveillance, response, prevention, and preparedness systems at the national, regional, and international levels.