China's SARS epidemic was a watershed moment in the story of China's public health system. Before 1949, with rampant infectious diseases and private doctors who only served the urban rich, China was known as the “sick man of Asia,” so the reform of the health care system was one of the first orders of business for the triumphant Communists. Syphilis was eradicated and a primary health care system constructed, increasing access to care through barefoot doctors, a basic health insurance system and a “three-tiered” network of clinics and hospitals at county level and below. Greatly improved health status (infant survival, longer life expectancy through control of infectious diseases) resulted in a demographic dividend that was a major factor in China's spectacular economic growth. However, three decades of dismantling a publicly funded system and re-privatizing the medical payment system weakened the rural health system, creating inequity by restricting access to those who could afford the bribes and high fees for drugs and care. With little or no communal funds devoted to “patriotic health campaigns” and the fundamentals of community health efforts, a weakened epidemic control system was unable to address threats like SARS. China had the greatest number of SARS cases and deaths.
SARS was the wake-up call for China's leaders about the risks of a failed rural health system. After their mismanagement of the initial epidemic and its spread to the world, they instituted a mandatory quarantine in big cities to prevent migrants from returning home and spreading the disease to their rural towns. The government was rightly concerned that the broken health system might not be able to contain further spread. Once the crisis was averted, with luck and a big dose of political organization and funding, the government took a long overdue hand to fixing the system, through a new universal health insurance program and a revamping of early warning systems. China's current public health response to emerging infectious diseases threats has surpassed that of most countries, with an enviable level of real time surveillance and an accountability system more easily implemented in an authoritarian system. From a public health perspective this about face is reassuring to a global health community that has witnessed the dire consequences of recent failures in early containment of the Ebola and Zika epidemics. China is using its new found expertise to advance its soft power. During the recent Ebola crisis, China provided aid to West Africa, sending personnel, equipment, epidemiologists, and setting up a bio hazard lab in Monrovia. It has also contributed, along with the US CDC, to the building of an Africa CDC based at the Africa Union headquarters in Addis Ababa.
The professionalization of the CDC system which Mason so deftly recounts in the book, however, puts all of this in perspective. She reminds us that the image China is portraying nationally and internationally of a professional body has some serious flaws. Mason undertook 13 months of ethnographic research between 2008 and 2010 at a Centre for Disease Control and Prevention (jibing yufang kongzhi zhongxin) and her book documents the post-SARS reforms and strengthening of China's CDC system (previously the Epidemic Control Stations). She provides a bird's eye view of how the new CDCs work, for better or for worse, in a thinly disguised city (Tianmai) in the Pearl River Delta, the epicentre of not only the SARS epidemic but of outbreaks of avian and swine flus (a result of intermingling of backyard animal husbandry, live animal markets and high population density). It is a fascinating picture of how tensions play out for public health workers who are pressured from above to be accountable to the world (“the redesigned professionalized, biomedicalized and globalized technological machine”) and their self-defined and historic socialist roles as agents of the people. New professional demands and career trajectories defined by the need for research publications and accountability to organizations like the WHO and US CDC “bifurcate” the motivations of this new class of public health workers and result in ethical lapses (fabricated research results, lack of informed consent for research, taking specimens without consent, or falsely filling in questionnaires) in pursuit of publications by both Chinese researchers and their international collaborators. These workers must mediate directives from above and their own ambitions with ethical and compassionate accountability to the supposed beneficiaries – the people. As such, Mason partly describes the age old problem of how public health practitioners focus on population health, sometimes at the expense of the individual patient. But in the context of China's top down authoritarian regime, these tensions are magnified and exacerbated by a governance system that systematically justifies abrogating individual rights in the interest of the public good.
In China, government workers must adhere to national policy directives from the central government, in the “tiao-kuai” system that posits the financing, supervisory and management systems with provincial authorities and little horizontal authority over other technical aspects necessary for an enabling environment such as the veterinary sector. In the case of SARS and other emerging infectious diseases, the limited authorities and competition among different sectoral actors (e.g. failing to report outbreaks because they do not want to cull animals) impede the CDC from carrying out WHO's three steps for EID preparedness: recognizing the event, verifying the event and containing the event.
Katherine Mason's book is an important contribution to the fields of Chinese studies and anthropology, joining a recent spate of excellent studies using the methods of anthropology to look at the intersections of public health, cultural practices and politics in China (such as Uretsky, Occupational Hazards, Stanford University Press, 2016). Many are by former students of Arthur Kleinman at Harvard, who helped define the field of medical anthropology in Patients and Healers in the Context of Culture (University of California Press, 1980) and trained a generation of academics and practitioners who stress the importance of examining the bio-social angles of public health. In the insular China context, this plays out in the distinctions between “insiders” (Chinese citizens) and “outsiders” (foreigners), strong prejudices about rural citizens' and migrants' lower quality (suzhi di) – which reduces their entitlement to rights and agency and reinforces paternalistic views that they require protection – and the way in which guanxi, renqing and deep rooted reciprocity arrangements ultimately override everything else. For those of us who work on China, we see this every day and it helps us maintain a more realistic eye towards China's real integration into the global economy and shared value system.
Mason's book reminds us that implementing public health policy is never only about what is technically correct. It is about the cultural values and practices that govern relationships. It is also about understanding the power dynamics of the political system and generating the political will to construct an enabling environment and accountability mechanism to achieve it. In China, the tensions between centre and local are rarely resolved in favour of local and when new criteria for professional advancement are introduced, it results in the type of dysfunction so masterfully described by Mason.
