Health as a Global Public Good: SARS in China and Global Health Governance

José Carlos Matias dos Santos
Instituto de Estudos Europeus de Macau
International Organizations and Multilateralism
May 2004


Table of Contents

Introduction

1. Global, Public, Private and Collective Goods

2. Health as a Global Public Good at the era of Globalization
3. Health Care in China: The (Counter) Revolution
Infectious diseases in China

4. SARS: from the outbreak to the crisis

5 SARS and Global Health Governance

Conclusion

Bibliography



Introduction

The year 2003 was marked by the Severe Acute Respiratory Syndrome (SARS). During Several months in the streets of Beijing, Shanghai or Toronto thousands of people wore the masks of the fear. In a world surrounded by real or imaginable fears for the existence of humanity, SARS appeared as the real threat, an infectious disease that was spreading worldwide with the forces of globalization. Ordinary people could feel from Beijing, to Toronto, from the United States to Europe the globality of a threat to public health. Hence, the aim of this paper is to envisage whether and how SARS showed Health as a Global Public Good.
In the first chapter we look for a definition of what is a global public good in dialogue with the concepts of private, pure and impure public goods and collective goods. Further on, we will comprehend health as a global public good at the era of globalization, noticing in what way can health be understood as what are the current trends on the public health policies, how globalization is changing the concept of health as a global public good. The third chapter regards the evolution of the Health Care in China, from Mao Zedong revolutionary to the reforms set up by Deng Xiao Peng. The objective is to figure out how health as a public good changed in China since the Communist Revolution until nowadays. Then we will focus on the core, the case-study, SARS in China, from the outbreak to the crisis. This chapter analyses under which circumstances did the outbreak occurred and how did it became a crisis for China, in first place and suddenly to the world. And as a global problem, how did SARS affect, on the one hand the Health policy in China, and on the other hand the Global Health Governance. In Sum, the paper endeavors to figure out the consequences of the SARS crisis, in the Health governance China, wherein the effects were more serious, and at a broader range, concerning the Global Health Governance.


Global, Public, Private and Collective Goods

In a narrow approach a good can be envisaged merely as assets. A broader definition given by Foldvary (Sageson 2002, p. 5) contemplates also “facilities, intangible institutions, services and systems involved in production and exchange”. But these characterizations cope solely with the neoclassical overview of the concept. A much wider definition, beyond economic utility, is brought up by Benjamin: “goods are whatever needs humans perceive as necessary or desirable to fulfill”.
Without aiming to catalogue thoroughly the vast realm of the various concepts of good, it is, nevertheless, relevant to our discussion to enquiry the scope of the public, private and collective goods. Before that, we underline the difference between intrinsic and final goods: the latter concept, encompasses the good as an end provided by the former (goods produced as means to achieve an end) In a general description a pure private good shall be excludable, rivalrous, produced and allocated in the market and legally owned, whilst a pure public good must meet opposite criteria, such as nonrivalry in consumption, shall not be excludable, without market mechanisms nor property rights in the production. Moreover the costs and benefits of the productions are externalized. Pure air, peace, law, order or good governance are examples of the latter concept. Indeed, to be accurate, a few baskets of goods can fulfill the criteria for being considered pure public or pure private, there is a wide grey area amid the black and white, there is an uncountable number of mixed and impure public and private goods.
Another clarification has to be made between global and nonglobal goods. The idea of global goes beyond any geographical criteria, “rather, it is multidimensional, including, besides the geographical dimension, a sociological and temporal dimension” (Kaul, Grunberg and Stern 1999. p. 12). Thus, a pure global good is characterized by universality, i.e. benefits all countries, people and generations. Other scholars identify the collective goods. What distinguishes these types from the other goods is the degree of joint supply: some collective goods are funded and maintained by public authorities, despite being financed by private banks and international financial institutions (Sargeson 2002, p.6). Other feature concerns the different levels of non-excludability. For instance trade regimes are collective goods, but only shared and available to the members of the group or club (that is why some scholars call it “club goods”). Furthermore collective goods may also have differentiated degrees of non-rivalry.

Health as a Global Public Good at the era of Globalization

It is consensual among scholars that infectious disease surveillance is a global public good, since it fulfills the two criteria required: nondivisibility and nonexcludability. This is especially valid for epidemiological surveillance since the knowledge of foreign outbreaks allows countries to take measures to protect their people and prepare the medical institutions (Zacher 1999, p. 269). Historians report the dimension and threat of infectious diseases since the Athenian plague of 430 BC (the first transnational epidemic recorded) until the famous Black Plague in 1347, which was the first infectious disease related with international trade. If it is accepted that epidemics are a clear case of global public good, when it comes to non transmissible diseases or non communicable diseases, the debate is not peaceful. Before some could argue that the latter type of diseases is encompassed into a more private than public basket of goods. However with the process of globalization there have been some shifts on this division: ”by compressing time and distance, globalization is profoundly affecting the world economy, politics and ideas - virtually aspects of human life, including health” (Chen, Evans and Cash 1999, p. 285). Hence, recently, new infections and new environmental threats or behavioral pathologies are emerging worldwide, affecting all countries, developed, developing or poor. The prevention and fight against this “third wave” of diseases and health problems shapes the features of global public goods is beyond the control of a nation-state and, therefore, requires global response only possible through global cooperation (1999: pp. 286-287). Diseases in humans and animals, which can be transmitted to humans by the food chain burst since the late seventies in several parts of the world. Some became global, other remained as a global threats, i. e. potentially are global problems. AIDS, the Ebola hemorragic fever, Bovine spongiform ecephalopathy, Asian bird flu and SARS, the core of our analysis, are examples of what is referred above.
With the globalization process the scope of health as a global public good is widening. On the one hand, is enhancing cross-border migration, information and trade flows[1] and, on the other hand, is provoking world wide threats due to the pressure putted on the common-pool resources of air and water.
Another dimension of the effects of globalization concerns a more economic range of the ongoing course of transnationalization and deregulation. Thus, here we refer to globalization in a narrower point of view: the emergence of the neo-liberalism as the quasi-hegemonic economic, social and political model in the world. Hence, what are the main features of this neoliberal consensus[2] concerning the public an collective goods? Hence, what are the main features of this neoliberal consensus concerning the public an collective goods? The main goal of a country is to pursue national competitiveness, reducing government expenditure and making the tax system more attractive to Foreign Direct Investment. In order to achieve those endeavors key sectors that were kept in the hands of the State such as education, Transport or Health swung away to the hands of the privates, following the classic assumption “less state better state”. In East Asia the trend was felt tremendously in different countries, taking different shapes. China has began, in the early 1980s the movement towards the opening of the market set up by the watershed leadership of Deng Xiao Peng.


Health Care in China: The (Counter) Revolution

Since the opening movement drew by Deng Xiao Peng influenced the whole society, changing dramatically the role of the state as a provider of public goods to the society. Health has not been an exception. The collective goods in the pre reform era (before the early 1980's) were under the system of public ownership, aiming to remove the basis for human exploitation and unfair distribution, according to the theories of marxism-lenisism. Looking into the early years of People's Republic of China, right after 1949, the outbreak of the Korean War (1950-1953) led the President Mao Zedong to organize the first “Patriotic Hygiene Campaign” in 1952, in order to fight the alleged American germ attacks against the North Communist forces. In theory the health care system in China was characterized by equality and universalism. However, since the beginning of the Communist Regime,

Social security in China was biased towards groups that were economically and politically powerful, ideological privileged, and functionally important, such as military and categories of employees in strategically important sectors of trade, industry and service industry.” (Huang 2003, p. 2)[3]

Moreover there was a divide between the heath system in the urban areas and in the rural parts of China. In the latter the core of the social organization was the commune, created to held and handle local investment , production, food supply and medical care. In 1968 Government promoted a national policy called the “barefoot doctor”, a peasant with mission of providing elements of preventive medicine, primarily care or health education. At the same time the government launched the “Co-operative Medical” Care Yang (2003, p. 4) notes that

the objective of the Maoist health-care delivery policy was to consolidate a three-tiered jurisdiction-based referral chain, with a comprehensive hospital in every country, a health center in every commune and Bare Foot Doctors in every production brigade.

Comparing the health care between 1949 and 1975, the so-called Maoist Era, China achieved remarkable goals in terms of mortality rate, infant mortality rate or life expectancy.
This system was only possible in the framework of a socialist planned economy and society, wherein the means of production and the collective goods were in the hands of the state, therefore, with the changes introduced by Deng Xiao Peng, the health care in China suffered tremendous shifts. The reformers opened the Chinese economy to private and foreign direct investment reducing the role of the state and prompting a new (counter) revolution in China. The aim of the changes projected and carried out by the leadership of Deng was to embolden the economy, through the openness to the world, "diversifying ownership to tap new sources of capital and jobs" (Wong 2002, p. 167), in a mixed system, combining features of the socialism and capitalism, i. e. the Chinese way to socialism, or market-socialist economy. Within this development of the economy, there was a marketisation of several sectors, including the health care, in an expanding movement of privatization. The end of the communes provoked the ruin of the rural health cooperative schemes, which were replaced by privatization arrangements. As a consequence, most of the rural population had to start to pay the health costs, and what is more serious, more than one third do not have financial means to afford the costs: "often contracting a major disease not only proved to be fatal to a farmer, it also ensured that their family remained poor for a few generations"(2002, p. 172)[4]. In the urban areas the situation of inequalily was also deepened, specially between the civil servants and the non state employess and migrant workers[5]. To tackle this problem, the government is developing a new health insurance system contributed by employers and employees, aiming to cover the whole urban working population. Nonetheless, even with some recent efforts, we have to consider with Yang that the "market-oriented health care reforms have been detrimental in China's public health care and have exacerbated the quality cost, access and equality problems[6]”(Huang 2003, p. 10). Besides theses problems noted above, there are two other endemic structural problems that have affected the lagging response to the SARS in China: State capacity to tackle public health and (lack of) transparence of the Chinese authorities.

Infectious diseases in China

Before analyzing SARS in China, it is important, in brief to draw the framework of the infectious diseases profusion. Official statistics show that hepatitis, tuberculosis, dysentery and Sexual Transmitted Diseases are the most serious infectious diseases in China. Despite the improvement on the incidence of this communicable diseases, since 1978, very worrying data have been revealed concerning hepatite B and tuberculosis. Concerning the former, the WHO estimates that 12 percent of China's population is thought to be carriers of the hepatite B Virus, which is a figure higher than sub-Saharan Africa. For example respiratory diseases accounts for 23 percent of causes of death in the rural areas, and 13 percent in the urban centers, which illustrates the great divide in China between the urban and rural areas.(Huang, p. 25-26). The spreading of Sexual Transmitted diseases is preoccupying the Chinese authorities. With the shift from a conservative, family-based society towards a more liberal and pleasure seeking oriented one, sexual behavior has change as well. This phenomenon combined with the diffusion of prostitution[7], the sharing of needles, the uncontrolled blood transfusions and the general lack of information about Sexual Transmitted diseases is leafing to an extremely worrying situation. The government estimates that up to one million Chinese may be infected with HIV, but, since authorities are not able to carry a thoroughly the surveillance in the rural ares, experts agreed that this is not an accurate figure. Some researchers estimate that the correct number may be between 1.5 and two million. In 2010, the United Nations Program on AIDS projects that in 2010 China can have between 10 and 15 million people infected with AIDS virus[8].

SARS: from the outbreak to the crisis

The Severe Acute Respiratory Syndrome (SARS) drew the attention of the world by the end of February, but only in the beginning of March it was identified as a new type of infectious disease. From then on until July SARS was the major threat to the World Health. However, the SARS story had began before, in November 2002 the first cases occurred in Foshan, a city in the South China province of Guangdong . Soon the mysterious diseases appeared also in other places in the province such as Hayuan and Zhongshan. Named priorly as atypical pneumonia, the infectious disease was classified later as SARS, infectious respiratory malady developed symptoms in the people infected such as fever higher than 38 Celsius degrees, cough, shortness of breath, difficulty breathing, chills, aches, sore throat and diarrhea. There is no guaranteed cure for this respiratory illness caused by a previously unknown type of corona virus, and it can be fatal.
The SARS story in China from November 2002 until April 2003 is a "sad" story that disclosed the shortcomings and failures not only of the Health System, but as well of the decision-making and communication and political structure of the People's Republic of China. To an extend that it was considered the most severe social-political crisis to the Chinese government since the Tianamen student oppression in 1989. Coming back to the beginning of the the first cases several deadlocks emerged in the Chinese Health System. On January 2003 a team of experts from the Ministry of Health went to Zhongshan to draw a report on the features of that unknown outbreak. But according to the Regulations on the State Secret Laws, the report was coined as top secret. As a result, for three days it was not permitted to any province health official to open the document before the Ministry of Health or someone authorized - the blackout continued until February 11, 2003. Huang (2003, p. 66) adds that local government officials were not legally accountable for the disease because atypical pneumonia was not listed in the law as an infectious diseases under surveillance. It is also noteworthy to underline that at that time scientists were not aware neither of the virus behind the disease nor the spread pattern and mortality rate of the disease. These three factors combined, inaction of the central government, information blackout and mystery about the characteristics of SARS, led to the sudden profusion of the atypical pneumonia from Guangdong to Hong Kong, Beijing, the rest of China e later to several countries in the world. In Beijing the problem became even more serious, specially because on the one hand Beijing Municipality Government was convinced that it would be able to cope with situation by itself, and on the other hand the Ministry of Health does not have the control over all the Hospitals in Beijing, as 16 of the 175 hospitals are ruled by the army, and until mid-April those health institutions refused to provide statistics about the SARS situation.
The crisis led to an emergency meeting of the Standing Committee of the Politburo, in which the cover-up of SARS was toughly condemned. Three days after, on April 20, surprisingly, Health Minister Zhang Wenkang and Beijing Mayor Meng Xuenong were dismissed for mismanagement of the SARS crisis. What was seen by some as accurate political accountability, was regarded by others as a way to find scapegoats. Later more than 200 government officials we fired, demoted or reprimanded. Anyway it was the turning point on the attitude of Chinese authorities in face of the crisis, when the international prestige of China was at stake. The SARS had relevant political, social and economic impact. Here it is important to highlight the effects felt at the level of the Chinese Health System. We can focus on four main achievements in the response to the SARS crisis: transparency, betterment of the emergency system, increasing on the funds for public health and civic conscience. First, the leaders of China realized that it was necessary to tell the truth to the people regarding issues like infectious diseases. Second, the process of institutionalization of China's emergency response system to health crisis was fostered, through the model of interdepartmental cooperation and coordination. Third, on April 2003 the government created a special fund of two billion yuan to prevent and control SARS. Fourth, the civic conscience on public hygiene awoke amid the Chinese, resembling the Maoist "Patriotic Hygiene Campaign - In Guangdong about 80 million people were mobilized to clean houses and streets (2003, 70).

SARS and Global Health Governance

The dense bureaucratic Chinese system caused serious communication problems in the relationship with the World Health Organization. For example, the first WHO experts could only be in Guangdong eight days after their arrival and in Beijing they were not immediately allowed to visit military hospitals. This attitude was fiercely criticized by the WHO. After mid-April, the Chinese health authorities changed completely this behavior, opening the doors of the hospitals, providing information and following the instructions of the WHO. But the initial inaction, blackout and lack of cooperation of the government at the beginning of the crisis had a tremendous effect on the spread of the diseases to the rest of China and to many countries in the worlds. By August 27, 2003, twenty nine countries had reported 8.422 probable cases of SARS, among which more than 5000 were identified in China. In this case unlike cholera, Ebola or malaria, SARS was not just another disease of the poor, it hi the epicenters of the world commerce, such North America and Europe.[9]
Besides the internal factors inside China and the absence of cure, there are external reasons for the quick development of SARS: the rationale of globalization. It is clear for Michael Merson that "the forces of Globalization both drove the spread of SARS and are the key for its successful control". This happens because on the one hand, modern travel and labor migration patterns helped spread the disease, and global links amplified its political and economic impact and, on the other hand, modern communication[10] and science alerted the world to the disease and eased a strong public health response.
Indeed the SARS crisis functioned as a wake-up call to face Health as a Global Public Good. Ilona Kickbusch (2003) draws the direct relation:
SARS may finally have given a concrete example of how to understand the term and apply health policies based on a global public goods approach. This new realization might prove to be the wake up call that we need to move towards a strengthening of international institutions to ensure health security of all.
More than a threat to the global health, SARS started to be understood as a menace to the world economy due to the consequences on trade and commerce, tourism, banking, the airline industries, the restaurant and service industries or educational institutions. Just a few weeks after the identification of SARS, on April 24, The World Health Organization calculated that the global cost of the disease was close to US$30 billion. Under this point of view to spend money on the fight these type of infectious diseases is, at the end of the day, profitable, in other words, disease prevention saves money. Moreover with SARS, ordinary people regarded human beings as an interdependent single species, and human security anywhere depends on unified global action everywhere (Chen, Evans and Cash 1999, p. 299).
Thus, the SARS crisis implies also a serious reflection on the Global Health Governance. Kickbusch proposes five measures that shall be taken in order to avoid what happened with SARS. First the International Health Regulations should be revised, according to a global public goods model. In practice, the competence of the WHO shall be enforced. The experts should have the right to collect information, ensure transparency, establish protocols in case of outbreaks that can ease the inspections. The idea is to avoid situations like the days that the WHO had to wait until they had the information from the military hospitals or before going to Guangdong. In other words, in case of outbreak the sovereignty on health must be shared by the countries with WHO. Beyond the WHO, Kickbusch calls for a role of the United Nations and International Monetary Fund on sanctions for countries that do not adhere to global health transparency. Third, at the World Trade Organization level, countries shall not be penalized by having excessive measures on the restriction of trade from countries infected with this type of diseases. In addition , in cases of global health emergencies, the rules on intellectual property rights must be accomplished. Fourth, increase on the budget of WHO and special financing to the creation of an efficient global surveillance and rapid response network. Finally, "establish local surveillance and laboratory capacity in developing countries as a joint priority program among WHO and the World Bank.".”[11] The optimization and strengthening of surveillance – a global public good - at a global level involving different international actors and national governments is crucial because as we could observe in China with SARS, becaus as Zacher (1999, p. 281) notices “perhaps the greatest the greatest gap in the surveillance system is at national level, where local surveillance and laboratory capacities are weak”,

Conclusion

It is possible to state that SARS had a deep impact in the way China regards Health as a public good, and in addition, how the rest of the world could feel SARS as a global public threat. Hence, to some extend we can conclude with Michael Merson that SARS Proved Health is Global Public Good and function as Kickbush notes, that it functioned as a Wake-Up Call for a Strong Global Health Policy.
To China, the crisis opened the door of an inefficient and carelessness Health Care System, that is being putted aside from the priorities of the authorities since the beginning of the reforms of the 1980s and demonstrated how remarkably fragile is PRC to outbreaks of communicable diseases such as SARS. It does not mean that the pre-reform era, during Maoism was a Golden Era, it demonstrated that the process of privatization and deregulation token by the state during the last twenty years was not followed by the implement of regulatory entities and public control over the standarts and the level of Health Care given by the privates. Moreover, in the public sector with the end of the communes, the Government did not provide a substitute an acceptable health system for the rural population that has become growlingly the negative other side of coin of the development, along with the migrant workers in the urban centers. But the main shortcoming regards the dense bureaucratic health governance in China, which led to inaction and lack of transparency. There was a clear inability of the Chinese health care system to cope with this type of unanticipated health crisis. However, as happens in most of the crisis, there is a positive side: the lessons learned and the improvements already putted in practice. The fostering of the institutionalization of China's emergency response system to health crisis, the creation of a special fund of two billion yuan to prevent and control SARS, the improvement on transparency in what concerns to public health, the growth of civic conscience on public hygiene and the betterment on the articulation of the authorities with the WHO are examples of the positive effects of the SARS crisis. Despite having achieved good results after mid-April 2003 on the control of SARS, one question remains: Is China's current health system adequate to cope with infectious diseases as SARS? In other words, aren't we in front of a more structural rather than conjuncture problem?
As we said above, SARS in China was a global threat. Therefore, as Huang observes, "from the perspective of international actors, helping China fighting SARS is also helping themselves". When time and space are increasingly compressed by the process of globalization, in a world growlingly interdependent at several levels, the struggle against infectious diseases and the concept of health as a global public good shall be shared only attributed to the governments or intergovernmental agencies, but as well, by Non Governmental Organizations, pharmaceutical enterprises, the Academia, civic associations and individuals because "no individual or nation state can fully guarantee its own health. International cooperation within the health field and between the health sector and other development sector will become mandatory." (Chen, Evans and Cash 199, p. 297)


Bibliography


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Huang, Yanzhong, Implications of SARS Epidemic for China’s Public Health Infrestrucure and Political System. Retrieved May 20, 2004, from John C. Whitehead School of Diplomacy and iNternation Relations of Seton HallUniversity Web Site: http://diplomacy.shu.edu/5_12_2003_Huang.htm

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Kickbusch, Ilona, SARS: Wake-Up Call for a Strong Global Health Policy. Retrieved May 17, 2004, from Yale Global Online Magazine web site: http://yaleglobal.yale.edu/display.article?id=1476

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Sargeson, Sally, “Introduction: the contested nature of collective goods in East and Southeast Asia”, In: Sally Sargeson, ed. Collective Goods, Collective Futures in Asia, London: Rouledge 2002.

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[1] The Black Plague that infected Erope in 1347 was the first infectious disease related with international trade.
[2] Many scholars have been working on the buzzword during the last decade and thus, the debate is still a hot issue among politicians, social scientists and scholars in general. Here we assume that the landmark for this process was the so-called Washington consensus, the guidelines for the New World Order agreed before the fall of the Communist Regimes in Central and Eastern Europe.

[3] Huang adds that in the early 1950s the Communist Government established Insurance Schemes to guarantee free medical care for bureaucrats and state crucial sector urban workers. (2003, 3). This inequality practice quite common in socialist regimes reminds the famous George Orwell's novel Animal Farm: "all animals are equal but some animals are more equal than others".

[4]Even the World Bank stated, in the late 1990s, in a report, that if the current trend continues, China will begin the 21st century with a poor performing, but costly health system.

[5] The situation of migrant workers in urban centers is one of the major challenges for the Chinese leadership. Those laborers are a kind of "sub-class", earning very low salaries, without adequate social protection. Around 100 people, mostly peasants, migrated to the cities, carrying health problems to the urban population.

[6] According to the Ministry of Health the average medical fees per outpatiet increased from 1.31 US$ in 1990, to 10.46 US$in 2000.
[7] According to the Chinese authorities there are about 6 million prostitues in China (2003, 28)
[8] http://www.casy.org/chron/AIDSchron_111603.pdf
[9] http://yaleglobal.yale.edu/display.article?id=1476
[10] The media coverage of the SARS crisis is a very intersting topic to analyse. We can regard it at two different levels. First, being SARS at the top of the agenda of the media, it disclosed information that was kept in blackout by the Chinese authorities and inspired the international cooperation on the research of the new corona virus. Second, the media exaggerated the public’s fear, emboldening the stigma against Asians.
[11] http://yaleglobal.yale.edu/display.article?id=1476