China engages global health governance: Processes and dilemmas

Abstract

Using HIV/AIDS, Severe Acute Respiratory Syndrome (SARS), and avian influenza as case studies, this paper discusses the processes and dilemmas of China's participation in health governance, both at the domestic level and the global level. Globalization has eroded the boundary between public and private health and between domestic and global health governance. In addition, the SARS outbreak of 2002–2003 focused global attention on China's public health. As a rising power with the largest population on earth, China is expected by the international community to play a better and more active role in health management. Since the turn of this century, China has increasingly embraced multilateralism in health governance. This paper argues that China's multilateral cooperation is driven by both necessity and conscious design. International concerns about good governance and its aspiration to become a ‘responsible’ state have exerted a normative effect on China to change tack. Its interactions with United Nations agencies have triggered a learning process for China to securitize the spread of infectious diseases as a security threat. Conversely, China has utilized multilateralism to gain access to international resources and technical assistance. It is still a matter of debate whether China's cooperative engagement with global health governance can endure, because of the persistent problems of withholding information on disease outbreaks and because of its insistence on the Westphalian notion of sovereignty.

Keywords:

• China
• infectious diseases
• global health governance
• WHO
• sovereignty

Acknowledgements

We are grateful to the anonymous reviewers for their thoughtful comments and suggestions. Any errors or omissions remain our responsibility. We have also benefited from the logistical assistance of Spandy Lai.

Notes

1. The report is available at http://www.who.int/whr/2000/en/ Accessed 13 February 2007.

2. According to the International Health Regulations, states’ international legal obligations are to report outbreaks of cholera, plague, and yellow fever. SARS, a new pathogenic lethal disease, was not included in the regulations by that time. Therefore, strictly speaking, China owed no international legal obligation to involve WHO in addressing the SARS problem within its territory.

3. There is an extensive and growing literature, including Altman (2003), Brundtland (2003), Chen et al. (2003a, b), Heymann (2003), Lee (2003a, 2003b), Curley and Thomas (2004), Prins (2004), Doyle (2006), Elbe (2006), McInnes and Lee (2006). The March 2006 edition of International Affairs is devoted to the study of HIV/AIDS.

4. The origins of the 1918 Spanish influenza are under debate. Some scientists believe that it originated in Guangdong, China.

5. For a more detailed account on China's healthcare system, see L.H. Chan (2006).

6. For example, the proportion of spending on preventive care in the government's recurrent health budget dropped from 23% in 1978 to 18% in 1994.

7. A total of 842,525 people in nearly 3,900 townships and towns in China had schistosomiasis (also known as snail fever; xuexichong bing) in 2004 and an estimated 30 million are at risk. See 2005 nian Zhongguo weisheng tongji diyao [China's Public Health Statistical Digest 2005], Ministry of Health, People's Republic of China. Accessed 1 March 2006, available at www.moh.gov.cn; 2005 Zhongguo weisheng tongji nianjian [China's Public Health Statistical Yearbook 2005], p. 246; and Yardley (2005).

8. In 2003, the official figure of the estimated number of HIV/AIDS in China was 840,000. On 25 January 2005, the Chinese government and the UN agencies endorsed the new figure of 650,000, down by 22%. The Chinese government said the adjustment was mainly caused by its overestimate of the number of people who were infected by illicit blood trading in the 1990s. The government released the news after months of delay because officials feared that a significantly lower number of HIV infections might draw criticism and doubt over the data. Both the Chinese government and the UN agencies agreed that the new estimate was derived from better data collection and calculation models, although some HIV/AIDS activists and NGOs still questioned the reliability of the data. See UNAIDS and WHO (2006).

9. World AIDS Day takes place every year on 1 December.

10. The regulations were approved by the National People's Congress, China's legislature, in January 2006. They stipulate the principles, roles and responsibilities of government departments at national and local levels in the prevention and control of HIV/AIDS (Embassy of the PRC in the USA 2006).

11. Dr. Gao, a 78-year-old gynaecologist in Henan province, has been named an AIDS crusader and has fought the scourge of HIV/AIDS since 1996. After exposing the HIV/AIDS epidemic and the misconduct of health officials and private entrepreneurs in the collection and dissemination of blood in the province, Dr. Gao was accused of being ‘anti-government’. In the wake of a 3-hour private meeting between Wu Yi and her (with the exclusion of Henan officials) during Wu's visit to the province in December 2003, the central government began to be more tolerant of her activities in the country. The national China Central Television (CCTV) honoured her with the ‘Touching China’ award in February 2004. In addition, she recently got her new books, Yiwan fengxin [Ten Thousand Letters] (2004), and Zhongguo aizibing tiaocha [The Investigation of AIDS in China] (2005) published. The books reveal her encounters in AIDS villages in the province. Interestingly, the first book was published by the Chinese Academy of Social Sciences (CASS), a government think-tank in Beijing. See, among others, Agence France-Presse ( 2004 ).

12. Wan Yanhai, head of the Beijing Aizhixing Institute of Health Education, was put in jail for 27 days in 2002, for posting on his website a Henan government document about the HIV/AIDS outbreak there, and detained for a month in the following year for receiving a classified document showing that the provincial officials were aware of the AIDS problem long before their formal acknowledgement of it. See Pomfret (2003) and Russell (2006).

13. Li Qianji was a clinic worker at the Xingtai Blood Centre in Hebei province in northern China. After appearing on a TV programme on 13 August 2004, about the problems with Xingtai's blood supply in which Li revealed dangerous practices of blood collection and the sale of tainted blood and plasma to Shanghai, Beijing, and Hebei in the 1990s, Li's monthly salary was cut from a normal 1,500 yuan to 2.75 yuan in February 2005. The Centre's director claimed that his salary cut was triggered by pressure from the provincial government. See S.S. Chan (2005).

14. The ‘Four Frees and One Care’ policy is a nationwide policy to provide: (a) Free ARV drugs to AIDS patients who are rural residents, or people with financial difficulties living in urban areas; (b) Free Voluntary Counselling and Testing (VCT); (c) Free drugs to HIV infected pregnant women to prevent mother-to-child transmission, and HIV testing of newborn babies; (d) Free schooling for children orphaned by AIDS; and (e) Care and economic assistance to the households of people living with HIV/AIDS. See MOH et al. (2006).

15. The former party secretary of Shangcai, Yang Songquan, and other local officials, were allegedly arrested in June 2006 for appropriating 10 million yuan in HIV/AIDS-prevention funds.

16. Accordingly, Wen Jiabao did not physically attend the conference, but his message was recorded on a videotape shown at the conference.

17. She was harassed by Henan officials in November 2003 when she went to Tsinghua University, Beijing, to attend an AIDS and SARS summit to which Bill Clinton delivered a speech (Spencer 2004).

18. Wu Yi is regarded as the ‘Chinese iron lady’, renowned for her toughness in negotiations with the USA and other nations on China's World Trade Organization membership drive while she was the Foreign Trade Minister.

19. Interestingly, the SARS outbreak has some positive impacts on China's engagement with regional and international institutions, particularly on non-traditional security issues. Its cooperation with ASEAN on non-traditional security issues has increased and the scope has been expanded to various non-traditional security issues, ranging from public health to finance and to natural resources (see Tang and Zhang 2003). Accordingly, discussions about non-traditional security among Chinese leaders and scholars have started to appear after the SARS outbreak in 2003. For instance, with the first research project on ‘China and non-traditional security issues’ undertaken in September 2003, the first national academic conference on the issue was held in Beijing in December 2003, under the auspices of the Institute of World Economics and Politics at the Chinese Academy of Social Sciences. In order to strengthen dialogues about how to address non-traditional security threats in the era of globalization, Shijie jingji yu zhengzhi [World Economics and Politics], a monthly academic journal, published by the Institute of World Economics and Politics, has run a special column on ‘non-traditional security studies’ since 2003 (see Wang 2004).

20. Jiang is a retired Chinese People's Liberation Army (PLA) doctor and Communist Party member. He disclosed the under-reporting of SARS cases in Beijing to Time magazine in early April 2003. He told the magazine that in order to ensure that the National People's Congress and the Chinese People's Political Consultative Conference could be convened smoothly by that time, medical staff in the Beijing's military hospitals were warned not to publicize any information about SARS. Countering the official figure of SARS infections at 19, with four dead in Beijing, Jiang alleged that in the No.309 PLA Hospital alone, there were 60 confirmed SARS patients, of whom seven had died. The exposure by him directly altered the government's response to the illness. On 20 April, Deputy Health Minister Gao Qiang said that Beijing had 346 patients with SARS, almost 10 times the number the ministry had previously acknowledged just a few days before.

21. For that reason, when China's Agriculture Ministry announced on 15 November 2005 that it would vaccinate all of the country's 5.2 billion chickens and other poultry in order to guard against bird flu, various scientists held that China's bird flu plan could trigger a backfire on China. The effect of prophylactic use of antiviral drugs in the absence of a human outbreak is still controversial. Substandard vaccines or an improper vaccinating procedure could spread the virus easily. See French (2005) and McNeil (2005).

22. During the conference in Beijing, US$1.9 billion was pledged by 33 countries and international institutions, of which $334 million was from the USA, $159 million from Japan, and $120 million from the EU. China committed $10 million in total. China's financial contribution was criticized for being relatively little, especially in comparison with the USA and Japan. Beijing officials have defended that as a developing country and home to one third of the world's population of birds, China needs to spend its money to combat the disease at home. See Bradsher (2006) and People's Daily Online ( 2006)

23. China blamed the US Centers for Disease Control and Prevention for causing a prolonged delay in the delivery of the virus samples. Julie Hall of WHO's Beijing Office, however, disputed the Chinese account (Dow Jones International News 2006, Zhao 2006). One day after Chan's election, China sent 20 samples to a WHO collaborating laboratory in the USA (Benitez et al. 2006).

24. Jiang Zuojun, Vice Health Minister, attributed the delay in identifying and confirming the bird flu case to a lack of communication between researchers and health officials rather than any deliberate cover-up. Until December 2004, China's research institutes were not required by law to report infectious diseases. Although this retrospective diagnosis has caused concerns as to whether there might have been other unidentified human bird-flu infections in China, the Chinese government refuses to re-examine other samples. Health experts have suspected that the virus was present in China in 2003. Several members of a Hong Kong family succumbed to the virus in Fujian in January–February 2003. An 8-year-old girl died and was buried there before local doctors could identify the cause of her death, and her 9-year-old brother and her father were diagnosed with bird flu on their return to Hong Kong. Later her father died in Hong Kong. But Fujian officials insisted that the family did not contract the virus in the province and that the girl died of pneumonia. See Lee and Benitez (2003), Zheng and Hu (2003), China Daily ( 2006b ), Kwok (2006), Wall Street Journal Asia ( 2006 ).

25. Compliance studies have shown that an actor's compliant behaviour could be motivated by both utilitarian and non-utilitarian reasons. See Chayes and Chayes (1995) and Young (1979).

26. The first application that China lodged to the Global fund was rejected in early 2002, due to its unreliable statistics and closed attitude towards its HIV/AIDS problem. The government submitted its application again later that year. See Rosenthal (2002).

27. In 2004 and 2005, China was granted by the Global Fund a total of US$56 million to tackle HIV/AIDS. In July 2006, the Global Fund signed an agreement on grant of US$12.5 million for HIV/AIDS work with China. The Global Fund to Fight AIDS, Tuberculosis and Malaria, available at http://www.theglobalfund.org/programs/Portfolio.aspx?countryID=CHN&lang=en (accessed on 12 July 2006) and Dickie (2006a).

28. The ‘Beijing Declaration and Platform for Action’ was adopted at the 4^th World Conference on Women in Beijing in 1995.

29. The key advocate was Richard Holbrooke, the then US ambassador to the UN. He pushed the Security Council to recognize the global HIV/AIDS threat after visiting Zambia in December 1999. Having overcome the opposition from Russia and China, which ultimately relented and did not take part in the debate, the USA followed through the deliberation and led to the passage of the resolution. See UN Security Council, Resolution 1308 (2000), Sternberg (2002), and Prins (2004).

30. Wang Yizhou of the Institute of World Economics and Politics at the Chinese Academy of Social Sciences argues that ‘low politics’ should enjoy the same degree of importance as ‘high politics’ in order for China to be able to handle non-traditional security issues successfully (Wang 2006).

31. In terms of threat to security, SARS was equated with the September 11 terrorist attacks on the USA (Zhang 2003).

32. Owing to China's increased participation in global governance, and its growing self-identity as a responsible great state after decades of rapid economic development, China's understanding of sovereignty has undergone a gradual evolution, shifting from a traditional concept that proclaims the centrality of the principle of non-intervention in internal affairs to one that embraces international cooperation and multilateralism in treating non-traditional security issues. In this paper, we deal with the spread of infectious diseases, which is regarded as one of non-traditional security threats. Despite the fact that it is still wary about external interventions and the fact that its conceptualization of non-traditional security threats is in large measure a state-centric concept, China has become more flexible and willing to cooperate with various actors both inside and outside the country. For a detailed account on the changing Chinese stances on sovereignty, see Carlson (2005). Wang Yizhou has also suggested that it would be sensible to adopt a flexible approach to understand sovereignty in the age of globalization, besides studying it purely from the perspective of international law. Sovereignty, according to him, is more than ever before bound to the obligation to protect human rights of the local populace. Failure to respect, defend, and promote human rights within one's territory would call into question the very legitimacy of the state. See his (2000) Zhuquan fanwei zai sikao [rethinking the scope of sovereignty], Ouzhou (Europe), 6, 4–11; and SARS yu fei chuantong anquen [SARS and non-traditional security] at http://test.aiwep.org.cn/info/content.asp? infold=1981 Accessed 30 September 2007.

33. More than 60 Chinese NGOs accused the Chinese government of excluding them from participation in the April 2006 election of representatives to the Chinese coordinating board of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The board is responsible for distributing and overseeing grants worth more than US$300 million. See Blanchard (2006b), Reuters News ( 2006 ), and Dickie (2006b).

34. Obviously, the younger generation of International Relations scholars in China show a stronger interest in using Western theories to study global governance than their predecessors. Su Changhe of Shanghai's Fudan University, born in 1971, examines global governance and international co-operation from the perspectives of global public issues, global public goods, and international regimes. As far as the authors are concerned, however, the discussion remains largely an introduction to the theories. See Su Changhe (2000).