Forty-four years ago, China's respected defense
minister, Peng Dehuai, tried to bring to the attention of other
senior leaders the fact that millions of people around the country
were starving to death as a result of misguided economic policies.
But Chinese Communist Party Chairman Mao Zedong did not want to
hear that his policies were a failure. So he and his followers branded
Peng an "anti-Party element," and the blunt, able Peng
was put under house arrest in a village outside Beijing. During
the Cultural Revolution he was jailed, tortured and killed.
At first glance, it may appear that little has changed in China.
Like word of the famine, honest reporting of data about severe acute
respiratory syndrome (SARS), the latest threat to China's economic
plans, got lost somewhere among the doctors in Guangdong province,
local and provincial leaders, Beijing officials and the public.
None of the doctors or officials possessed the stature of the revolutionary
war veteran Peng, and they must have feared the consequences of
raising an alarm on the eve of a key National People's Congress
and change in leadership. When an honest and outraged military physician
in Beijing earlier this month broke ranks and exposed the severity
of Beijing's SARS epidemic, he was placed under surveillance by
the public security bureau. China has rarely rewarded individuals
who have sounded discordant notes or uncovered unpleasant facts.
While the SARS crisis shows that, in many ways, the China of 2003
resembles the China of 1959, it also shows how much China has changed.
Its system of governance still has no mechanisms to ensure the accountability
of officials or to bring problems to light. It possesses no system
of checks and balances, no independent watchdog agencies, no truly
free press. It lacks transparency and treats information as secret
that would, in a society like ours, be considered the stuff of newspaper
reports, regulatory disclosure and congressional hearings. Yet whereas
Mao's misguided Great Leap Forward lasted three years and resulted
in the death of at least 30 million people before it was abandoned,
the silence on SARS cases lasted just six months with a death toll
that numbered only in the low hundreds before the Chinese leadership
took steps to change the way it was dealing with the problem.
What has changed? The Chinese government is
finally recognizing that local events, even in China, can have global
impact and that global information can have local impact. In the
23 years since I first went to China, economic reforms have revolutionized
the country. China today is part of the modern, globalized world.
Large numbers of its people, once cut off, have contact with foreigners
on a regular basis, either in person or via the Internet. Chinese
people now travel within their country or abroad and in the process
carry new ideas and uncensored information, as well as diseases
such as AIDS and SARS, back and forth. That exposure has created
a new sort of pressure on China's leaders to be responsive both
to their own people's expectations and to the broader world community.
Yet even as China's new leaders begin to do the right things to
contain the spread of SARS, they will be hampered by a dysfunctional
health system and people's lack of trust. These are the same problems
I have seen in my work in China on HIV/AIDS, another area where
the medical and political system has failed to respond effectively.
The past 20 years have witnessed the dismantling of China's system
of socialized medicine. The central government has handed more and
more of the fiscal responsibility for health care to local and provincial
governments, and much of the system, like the rest of the economy,
has been privatized.
While China's urban residents have reasonable access to good-quality
health care, more than 100 million rural migrants living in the
cities are not covered by health insurance and cannot afford to
seek such care. In rural areas, the breakup of the commune system
in the late 1970s hurt funding for clinics. Economic development
goals have trumped investment in health care in most places. Communities
have chosen to invest in roads rather than disease surveillance,
the training of health workers or the building of better health
centers. The World Health Organization (WHO) recommends that at
least 4 percent or 5 percent of national GDP should be spent on
health care; in China, meeting that goal is difficult. In some places
it's a question of priorities; some places just don't have enough
Last August, I visited one part of the Chinese medical patchwork:
a typical clinic in a rural area of Guizhou province, a four-hour
drive from the provincial capital on a new highway. It was a two-room
brick and mud structure, decorated with a couple of health ministry
charts that explained drug interactions and essential medicines
for specific diseases. The clinic's autoclave for sterilizing medical
equipment was broken.
The doctor lived in the back room and
saw patients in the front room. A former "barefoot doctor"
who later received only three months of additional training, he
stood behind a counter dispensing medicine, his main source of income.
The local government provides about two-thirds of his salary and
he earns the rest through fees and selling medicine, much of which
could only be obtained by prescription in this country. For local
residents who lack the money to go to a more advanced clinic in
the market town nearby, this is their main health care facility.
What will that doctor do for them if they start turning up with
SARS, for which no medication has yet proven effective?
The devolution of financial responsibility, making every tub rest
on its own bottom, has not only weakened access to quality medical
care, it has weakened the authority of the central government. Defiance
of central government guidelines carries no financial consequences.
The health ministry, already a weak player on the national stage,
sets guidelines but exerts little real control over the decision-making
that now rests with provincial and local governments.One side effect
of this is the lack of accountability of health officials. In Henan
province, as a result of a failure to follow sterile procedures,
the AIDS virus was given to hundreds of thousands of unsuspecting
blood donors, many of them poor people trying to make money by selling
their blood. Even after the problem became clear to local and provincial
officials, they concealed the scandal for years and blocked others
from engaging in reporting, research or prevention. The health minister
and the mayor of Beijing have already lost their jobs for concealing
cases of SARS from a WHO team, but the powerful Henan officials
who hid the AIDS epidemic remain in office.
Secrecy is an obstacle to dealing with health problems, and China's
government hides all sorts of information. In Henan, thousands of
citizens began to die of AIDS without knowing what illness they
had. In their ignorance, many infected friends and family members.
When a prominent AIDS activist, Wan Yanhai, revealed a government
report that proved Henan officials had long known about the extent
of HIV infections, he was jailed for revealing state secrets.
Similar secrecy has afflicted the SARS response. The Chinese media
were instructed to play down the issue, ostensibly to prevent public
panic, maintain "social stability," and avoid scaring
away business and tourism. Yet in an information age, it has become
more difficult to keep such things quiet, even in China. In Beijing,
an incensed doctor spilled the beans on China's hidden SARS cases.
In the Henan AIDS epidemic, an Internet newsletter posted the story
of an elderly retired doctor, Gao Yaojie, who was treating AIDS
These whistleblowers should be treated as heroes, latter-day versions
of the old model workers once extolled for their socialist spirit.
Instead, the brave whistleblowers are rewarded with suspicion and
often surveillance. In China's ailing governance system, these heroes
remain the only mechanism for forcing accountability because the
system lacks routine channels -- such as a free press -- for bringing
problems into the open.
Even today, in most of rural China, there is little way to get accurate
information on diseases such as AIDS. But the public increasingly
believes it has the right to know about health risks and other topics.
Even as it tries to come clean about the number of SARS cases, China's
ruling party, which has long regarded information as propaganda,
cannot convince people it is telling the whole truth. It has asked
people in big cities to stay put to reduce the risk of further infection
in remote provinces, but thousands and thousands of panicked residents
have disregarded that advice and jammed Beijing's West Railway Station
to flee town, even as appropriate infection control measures are
being put in place in the capital.
What began as a localized epidemic of atypical pneumonia late last
year in one of China's 30 provinces has now spread around the world
thanks to China's outdated system of governance. Diseases, especially
infectious ones, do not respect national borders. A country that
sends hundreds of thousands of students abroad, lures tens of billions
of dollars in foreign investment and ships hundreds of billions
of dollars' worth of products abroad must meet a higher standard
of international cooperation and transparency. China's new leaders
appear to recognize this. No one will invest in a place that covers
up real threats to health, growth and profits.
A country like China also owes more to its own citizens, not only
the SARS victims but the 1 million mostly poor, mostly rural people
infected with AIDS and the 1.3 billion other Chinese who deserve
to know about issues that affect their welfare. As China's rulers
mobilize their resources to fight SARS, they should also take steps
to improve the health of their entire system.
Joan Kaufman is a lecturer in social medicine at Harvard Medical
School and director of the AIDS Public Policy Project at Harvard's
John F. Kennedy School of Government. She was based in China for
10 of the past 23 years and frequently travels there.