Public Health Crises In Comparison: China’s Epidemic Response Policies From SARS To COVID-19

ABSTRACT

The rate of infectious disease outbreaks has been accelerating over the past two decades, from the SARS epidemic in 2003 to COVID-19 in 2020. Termed by some as the twenty-first century’s first pandemic, SARS originated in China and alerted the country to the importance of public health and epidemic response. After SARS, China improved its health infrastructure and reformed its political and legal health governance system. The emergence of COVID-19 from Wuhan in late 2019 put those reforms to the test. This paper analyses China’s public health and epidemic response policies from a historical perspective, tracing the evolution of Chinese public health policies after the SARS outbreak in 2003. This paper assesses China’s response to COVID-19 and how post-SARS policy reforms, particularly in epidemic response, played out on the ground in Wuhan. What policies worked well? What were the challenges faced? Based on the policy analysis, this paper presents recommendations for how China can improve its epidemic response through strengthened infectious disease surveillance, more transparent political coordination, and expanded public health infrastructure.

KEYWORDS:

• Chinese public health
• infectious disease
• epidemic response
• COVID-19
• health infrastructure

Introduction

Severe acute respiratory syndrome (SARS) emerged in Guangdong province, China in November 2002, eventually infecting over 8,400 individuals worldwide and killing 916 (Cherry & Krogstad, 2004). In addition, the epidemic cost the global economy an estimated US$40-54 billion (Institute of Medicine Forum on Microbial Threats [IOM], 2004) and sparked discussions worldwide about public health and outbreak preparedness in the modern age.

The Chinese government was criticised for a lack of transparency and information cover-ups during the early days of SARS. A poorly functioning infectious disease surveillance system and fragmented government coordination delayed initial case reporting to China’s Ministry of Health (MOH). As SARS spread globally, the Chinese government downplayed the epidemic’s severity and suppressed news about its spread. Chinese health workers were under-informed about the epidemic, and many hospitals treated SARS patients without taking necessary protective measures.

SARS was contained in July 2003, but early missteps highlighted a need for greater transparency in case reporting, better disease surveillance, and improved central-local coordination of epidemic response. Many Chinese government officials realised the severe consequences that could result from a public health crisis, including international scrutiny and domestic instability. SARS marked a turning point in how the Chinese government viewed public health, elevating outbreak preparedness and health reform on the political agenda. After SARS, Chinese public health expenditure doubled from RMB 111.69–229.71 billion between 2003 and 2007 (Chan et al., 2010). China also created a new online disease surveillance system and pledged to improve epidemic information disclosure.

In 2019, the emergence of another novel coronavirus (COVID-19) in Wuhan, China put these policies to the test. COVID-19 hails from the same virus family as SARS but is much more infectious, quickly growing into a global pandemic. Against the backdrop of this new crisis, pressing questions arise: How does China’s epidemic response today compare to its SARS response in 2003? Have lessons from SARS been transformed into effective anti-epidemic policies? What can be learned from China’s COVID-19 response to inform its future public health governance?

COVID-19 cases continue to rise around the world, with ongoing outbreaks in the United States, Brazil, and more. Thus, it is essential to assess China’s early COVID-19 response, learn from its successes and challenges, and offer policy recommendations to improve pandemic preparedness. This paper aims to 1) Provide an overview of how Chinese public health and anti-epidemic policies evolved after the 2003 SARS epidemic, 2) Identify gaps between current policies and their implementation in the context of COVID-19, and 3) Based on the gap analysis, propose policy recommendations to improve epidemic response in China.

Methods

Primary and secondary source review

This article is based on primary and secondary source review. To better understand the evolution of China’s public health system over time, secondary sources including book chapters and peer-reviewed academic journal articles were reviewed. The goal was to conceptualise lessons learned from SARS and whether they were applied to China’s COVID-19 response. Primary sources included daily WHO situation assessments, government press releases, data from local health bureaus, Chinese legal code, academic pre-prints, and COVID-19 news coverage by Chinese and international media outlets.

Expert interviews

The written source review was supplemented with qualitative expert interviews, informing conclusions with evidence from the field. Interviews were conducted with international and Chinese health policy experts, physicians, and community health workers on the frontlines of the COVID-19 response. These interviews aimed to 1) Provide a first-hand perspective on Chinese public health policies from SARS to COVID-19, and 2) Test the feasibility of policy recommendations directly with stakeholders involved in their implementation. Interviewees included affiliates of Peking University, Tsinghua University, and Peking Union Medical College. (See Appendix 1 for a complete interviewee list.) A total of 9 interviews were conducted from February to March 2020 using English and Mandarin Chinese. Interviews were conversational, following a semi-structured interview guide. (See Appendix 2 for a complete questions list.) Interview transcripts were analysed to identify shared themes, quotes, and data used to support or clarify conclusions drawn from written sources.

Results: challenges of China’s SARS response

China’s early SARS response faced considerable political and health infrastructure challenges, including delayed initial case reporting, distorted information flow, fragmented government coordination, and lack of health financing. (See Table 1 for a timeline of major events during this period.)

Table 1. SARS timeline.

Date	Major Events
16 Nov 2002	SARS index case diagnosed in Guangdong province, China.
02 Jan 2003	Guangdong doctors alert provincial health bureau about the disease; information is passed to provincial government and national MOH.
20 Jan	MOH expert team sent to Guangdong to investigate disease.
27 Jan	Expert team sends report to provincial health bureau and MOH.
08 Feb	Rumours of a ‘deadly flu’ circulate online in Guangdong.
10 Feb	Guangdong media acknowledge the disease and advise the public on preventative measures. WHO queries Chinese government on the potential outbreak.
11 Feb	Guangdong provincial health bureau publicly confirms outbreak, reporting 305 cases and 5 deaths.
19 Feb	WHO expert team dispatched to investigate but is barred from entering Guangdong.
12 Mar	WHO issues a global health alert and calls for worldwide disease surveillance.
25 Mar	Chinese government acknowledges spread of SARS outside of Guangdong.
02 April	State Council holds first meeting to discuss SARS. WHO team finally allowed to enter Guangdong.
16 April	WHO Beijing expresses ‘strong concern over inadequate reporting’ of SARS cases in China.
17 April	Meeting of Politburo standing committee to discuss SARS. Chinese state media begins daily case reporting.
20 April	China declares ‘nationwide war’ on SARS, beginning mass anti-epidemic mobilisation.
05 July	WHO declares SARS contained.

The MOH’s initial report on SARS was delivered to national and provincial health authorities on January 27, 2003. However, its dissemination to provincial hospitals was delayed due to the Chinese New Year holiday, which fell from February 1 to February 3. And because outbreak information was classified as a state secret (European Union & WHO, 2015), Guangdong health authorities couldn’t discuss the disease with other provinces until the Party authorised the MOH to announce information publicly. This left hospitals nationwide unprepared for the outbreak. The initial failure to inform the public about SARS also led to widespread anxiety, fear, and misinformation.

When the outbreak was finally publicised on February 11, the municipal government attempted to downplay its severity, announcing the virus was ‘comprehensively’ under ‘effective control’ (IOM, 2004). Most likely, this was to ease the negative effects an outbreak would have on economic activity. Economic development and social stability are the pillars by which Chinese governmental legitimacy is assessed, and many local bureaucrats feared the negative economic, social, and political repercussions of an outbreak. Perhaps in response to media outlets questioning the government’s handling of SARS, the provincial government stopped all case reporting on February 23 (IOM, 2004).

This lack of transparency existed outside of Guangdong too. When SARS first emerged, the Chinese government was preparing for the Two Sessions, important political meetings held at the national and local levels. Many leaders did not want to acknowledge the outbreak during such a critical time. In one story of the cover-up reported in TIME Magazine, Beijing military hospitals knew SARS was sweeping through the capital in early March but were instructed not to publicise the information in case it interfered with the national Two Sessions (Jakes, 2003).

Another political challenge was the slow, inaccurate flow of outbreak information through government channels. According to one expert, ‘The government’s ability to formulate a sound policy against SARS was hampered as lower-level government officials intercepted and distorted the upward information flow’ (Yanzhong Huang, IOM, 2004). Under pressure to report good news to their superiors (and thus secure future promotions), government officials ‘at all levels’ distorted information about the virus, highlighting only positive results and downplaying failures. Coupled with the lack of legitimate media or citizen watchdogs in China to monitor government actions, if local officials chose not to report upwards, the central government had little ability to identify or investigate information distortion at the local level.

Fragmented government coordination also hindered the response. China in the early 2000s experienced a dilution of clear, top-down political control. While national administrative agencies like the MOH were in charge of setting guidelines and making policy, provincial governments had full control over how to allocate local resources and budgets. This decentralisation of budgetary authority made it difficult for public health to make it onto local governments’ political agendas, especially when economic development was a higher national priority. Eventual mobilisation against SARS required political support from top party leadership, which was able to override those existing local agendas. Essentially, until authority from higher reaches of government was given, even the MOH had its hands tied in directing the nationwide SARS response.

Weakened public health infrastructure posed another challenge. The infectious disease surveillance system was sorely underdeveloped. There was a lack of medical facilities and healthcare workers prepared for an outbreak, even in large cities. Meanwhile, rural health infrastructure was ‘weakly financed, and standard infection-control procedures [were] hardly standard practice outside urban hospitals’ (Kaufman, 2006).

SARS alerted Chinese leaders to the fragile state of the Chinese healthcare system. Former Minister of Health Chen Zhu declared SARS a turning point: ‘For some time, the medical care system was given more attention—big hospitals and medical centers … But in the meantime, the importance of public health was … weakened. The issue became very acute during the SARS outbreak’ (Watts, 2008). China’s experience with SARS revealed the country’s need for stronger anti-epidemic infrastructure as well as improved public health governance.

Results: post-SARS policies

Improved infectious disease reporting and surveillance

After 2003, the Chinese government invested US$850 million into building ‘a three-tiered network of disease control and prevention’ (IOM, 2004). The new online disease surveillance system, established in 2004, allowed local hospitals to report cases of infectious disease in real-time to the Chinese Center for Disease Control and Prevention (CDC) and MOH (Zhang et al., 2017). Village, township, and county hospitals would have a direct communication link with central health authorities, bypassing the bureaucracy of provincial health commissions.

As of 2014, this system mandated case reporting for 39 infectious diseases based on their outbreak potential, including SARS, AIDS, hepatitis, and cholera. This reporting network covers 100% of CDCs across the country, 97% of hospitals, and 89% of township-level clinics (Zhang et al., 2017). The system also provides real-time monitoring of public health emergencies, mandating reporting of such events to local and national CDCs within 2 h of discovery.

In addition to human reporting of public health emergencies, the national CDC developed an automated alert system to facilitate faster central-local communication of outbreak information (Zhang et al., 2017). Introduced in 2008, it conducts real-time, daily analyses of data entering the surveillance system from local hospitals and health bureaus. Any abnormalities indicating an emerging outbreak would be automatically detected and sent to the CDC via SMS. At the CDC level, staff monitoring the system can verify the alert and provide a timely response as needed. Previous studies show that this system is sensitive, specific, and has shortened response time for public health emergencies. For example, the automated alert system successfully generated abnormal signals for all 30 dengue fever outbreaks occurring in China between 2009 and 2012 (Zhang et al., 2014).

Political governance reform

Immediately following SARS, China revised its laws governing transparency and information-sharing during public health emergencies. In response to the distortion and concealment of SARS information by government officials, China implemented new Regulations on Public Health Emergencies in 2003. These regulations stated that officials should ‘make timely and truthful reports about … [public health] emergencies’ (IOM, 2004). The MOH also gave provincial and municipal health authorities the ‘right to regularly release general information on the epidemic situation of those infectious diseases that have to be reported by law … in their jurisdiction’ (Meng et al., 2015). This allowed provincial health authorities, supervised by the provincial government, to release epidemic information to the public without prior authorisation from officials at the MOH level, bypassing a major central-local bottleneck for information-sharing during SARS.

These regulations were positive steps towards encouraging government accountability and transparency during public health emergencies. Frost et al. (2019) found that in the decade between SARS and the 2013 H7N9 influenza epidemic, the Chinese public’s perception of the MOH’s transparency, speed, and coordination of information release all improved. However, it should be noted that these new regulations still did not allow nongovernmental actors, like individual citizens or journalists, to publicise epidemic information before the government. China’s 2007 Emergency Response Law streamlined the government’s emergency early warning system. But its only mention of nongovernmental reporting states: ‘Citizens … [with relevant] information … shall immediately report to the local people’s governments … or designated specialised institutions’ (National People’s Congress, 2007). Within this centralised emergency reporting structure, there are few avenues for citizens to independently share outbreak information or protections in place for those who draw attention to government reporting failures.

Expanded public health infrastructure

Post-SARS, China also implemented reforms to expand public health infrastructure and insurance coverage. Between 2008 and 2017, government spending on health increased from RMB 359 billion to 1.52 trillion, growing from 5.7% of total government expenditure to 7.5% (Yip et al., 2019). Nearly half of this spending went towards subsidising universal health insurance. In 2018, the Chinese government reported 1.34 billion people received ‘basic health insurance nationwide’ (Tao et al., 2020), although inequalities still exist between wealthy urban residents and migrant workers (Duckett, 2020). For example, because Chinese health insurance is tied to residency, rural-to-urban migrant workers labouring in urban areas outside of their place of insurance registration experience decreased health access (Chen et al., 2020).

In addition to insurance expansion, the government funded more rural health infrastructure and committed to training a new generation of doctors and public health officials well-versed in disease prevention. By 2015, over 2,000 county hospitals and 300,000 community health clinics were built or upgraded, and the government’s targets for health worker training were largely met (IOM, 2004). Yet this professionalisation of public health had drawbacks. Mason (2016) writes that SARS ‘transformed a Chinese public health apparatus – once famous for its grassroots, low-technology approach … into a professionalized … technological machine.’ Newly-trained health workers operating within this machine often drew boundaries between themselves and those they served, for instance viewing migrant workers as dangerous intruders who threatened collective health rather than vulnerable citizens to be protected (Mason, 2016). This increased willingness to control populations seen as ‘contagious’ is reflected in examples such as strict quarantines during the 2009 H1N1 pandemic and widespread lockdowns during COVID-19.

Results: analysis of China’s COVID-19 response

Overall, China made positive strides towards improving disease surveillance, health infrastructure, and public health governance post-SARS. According to Yanzhong Huang:

‘In 2014, China completed a self-study on its compliance with the WHO’s International Health Regulations, which govern epidemic response and surveillance capacity. China claimed that it had fulfilled more than 91% of its capacity-building efforts. That was probably one of the highest among the developing countries’ (personal interview, March 28, 2020).

In 2019, the Global Health Security Index independently assessed and ranked countries based on pandemic preparedness. China ranked as 12th most prepared out of 56 upper-middle-income countries (Johns Hopkins Center for Health Security et al., n.d.). Given such progress, how did China’s public health reforms perform when put to the test during COVID-19? What were the successes and challenges of China’s improved epidemic response policies during this new outbreak? (See Table 2 for a timeline of China’s early COVID-19 response from December 2019 to February 2020.)

Table 2. Early COVID-19 timeline.

Date	Major Events
26 Dec 2019	Wuhan doctors report first COVID-19 cluster to municipal and provincial health authorities.
30 Dec 2019	Dr. Li Wenliang and 7 others share in private WeChat groups about an emerging, SARS-like outbreak. These messages and internal MHC reports are leaked and go viral online.
31 Dec 2019	Disease outbreak announcement by Wuhan MHC to the public and WHO. 27 cases confirmed with exposure to local wet market. Reportedly no evidence of human-to-human transmission and no medical staff infected.
01 Jan 2020	Wuhan police detain 8 whistleblowers, including Li Wenliang, who are accused of spreading false rumours about the outbreak.
11 Jan	Wuhan MHC reports 41 cases and 1 death. Public case reporting halts until Jan 18, coinciding with ‘Two Sessions’ political meeting in Wuhan.
15 Jan	Wuhan MHC states there is possibility of human-to-human transmission. Cases have begun appearing with no traceable link to the wet market.
18 Jan	Wuhan MHC resumes reporting about the outbreak, confirming 62 cases. However, local public gatherings to celebrate Chinese New Year go on as planned.
20 Jan	Dr. Zhong Nanshan publicly confirms human-to-human transmission. Xi Jinping and the State Council mobilises nationwide anti-epidemic response.
21 Jan	Wuhan MHC confirms human-to-human transmission and infection of medical staff.
23 Jan	Wuhan locks down, barring all travel into and out of the city and halting public transportation. Similar lockdowns ensue across Hubei province and the rest of China.

Success and failures of initial disease surveillance

The new national disease surveillance system expanded China’s ability to monitor infectious diseases post-SARS. In March 2019, Gao Fu, China’s CDC director, said he was ‘very confident that the SARS incident will not recur. This is due to our country’s well-built infectious disease surveillance network; we can block the virus when it appears’ (Yang, 2020). Multiple news outlets and experts agree that some signal about COVID-19’s emergence was indeed generated at the hospital level in Wuhan on December 26, 2019, transmitted to provincial health authorities, and picked up nationally by December 31.

However, the online reporting system was built to share information instantaneously. A signal indicating an atypical pneumonia cluster should have been automatically generated when Wuhan doctors first reported it on December 26 and sent immediately to the national CDC. Instead, there was a lag time of several days between local reporting and when national health authorities finally learned of the outbreak. What went wrong?

After local doctors identified the cluster, Wuhan and Hubei health authorities generated internal notices about the situation. On December 30, Gao Fu happened to see these notices being discussed informally within his professional WeChat groups. Alarmed that the situation was not picked up by the surveillance system, he contacted the Wuhan CDC to confirm the information (Yang, 2020). Upon confirmation, Fu alerted the National Health Commission, which sent their expert investigative team to Wuhan on December 31.

In late December, Wuhan doctors discovered a disease cluster significant enough to prompt circulation of internal notices within the Wuhan and Hubei health commissions. However, this information did not immediately make it to national health authorities, suggesting the online disease surveillance system was not utilised for these initial reports. Instead of reporting through the system, it is likely that Wuhan doctors directly reported their findings to local health officials. Then, according to Dali Yang, local health authorities ‘clearly made a choice not to use the reporting system … They were trying to resolve the problem within the province.’ The national CDC’s deputy director later admitted the online disease surveillance system was ‘not activated that expeditiously’ for COVID-19 (Yang, 2020).

When comparing China’s initial detection of COVID-19 to its detection of SARS, there was indeed some improvement in transparency. The first SARS cluster appeared in November 2002, but national health experts and the WHO were not alerted until January-February 2003, indicating a months-long cover-up at the local level. For COVID-19, the lag time between local detection of cases and national and international alert was only a few days. While not necessarily indicative of a change in government attitude on public health transparency, this suggests that the communications infrastructure of the national disease surveillance system, which includes the official online reporting channels but also informal channels such as Gao Fu’s WeChat networks, helped disseminate outbreak information quickly. However, it remains that China’s much-lauded online disease reporting system did not work the way it was meant to.

Regardless of how technologically advanced a disease reporting system is, its effectiveness ultimately relies on human factors. In China’s bureaucratic public hospitals, which prioritise maintaining good relationships with local health authorities, doctors may be reluctant to directly report to the national CDC, perhaps viewing it as a circumvention of local officials’ authority. Local doctors may also lack training on how to use the complex online reporting system or lack confidence in their ability to diagnose a novel infectious disease, leading to hesitancy to report. They might be uncertain about their public health responsibilities, choosing to defer to local authorities rather than directly report cases. These human capital and political complexities impeded the efficient utilisation of China’s new online disease surveillance system to capture initial signs of COVID-19.

Lapses in political coordination and transparency

There was a four-month lag time between initial case detection and top-down national mobilisation against SARS in 2003. The lag time between case detection and national mobilisation against COVID-19 was much shorter—less than one month between December 26, 2019, and January 20, 2020. Compared to the mass information blocking by government officials during SARS, it appears local officials were faster to share information about COVID-19, aided by the new disease surveillance infrastructure, and the national government mobilised against the disease sooner.

However, lack of COVID-19 information transparency still existed at the municipal and provincial levels. There was a 7-day stretch between January 11 and January 18 when no new COVID-19 cases were reported by the Wuhan MHC. Chinese public health experts interviewed for this project agree that this was intended to prevent instability during the Two Sessions in Wuhan. Lack of public case reporting during this period diminished public perceptions of the outbreak’s urgency.

In addition, there appeared to be a cover-up by local health officials on whether COVID-19 caused human-to-human transmission. Dr. Zhong Nanshan’s public announcement of human-to-human transmission on January 20 spurred national, top-down mobilisation against COVID-19. Clearly, this information was crucial for national leaders’ decision on how strongly to respond. However, evidence suggests Wuhan hospitals and health officials knew about early cases of human-to-human transmission but delayed sharing that information with central authorities.

Li Yunhua, a Wuhan radiologist, said he read multiple CT scans between January 6 and January 20 that showed likely COVID-19 infection in medical staff. These patients did not have contact with the local wet market most initial cases were linked to, a clear sign of human-to-human transmission. However, Li said that his hospital was barred from reporting medical worker infections. He and his colleagues were hesitant to speak up independently about the situation, fearing police punishment after the detainment of 8 whistleblowers earlier in the month (Yu et al., 2020).

Multiple experts interviewed for this research agreed that local health officials concealed information about human-to-human transmission from national expert teams. One Chinese public policy professor interviewed said:

‘We see from various reports that three groups were sent [to Wuhan] from January 1st to January 19th. Only the third team actually determined there was human-to-human transmission … It seems to me there were indeed cover-ups during the first and second expert investigations’ (personal interview, April 1, 2020).

Professor Yanzhong Huang (personal interview, March 28, 2020) was more adamant, saying, ‘It was clear that the Wuhan Health Commission knew healthcare workers were being infected, which is smoking-gun evidence of human-to-human transmission. But they didn't share that with … central health authorities.’

Why did local officials conceal this information? Provincial officials may have felt pressure to manage and suppress COVID-19 locally, preventing it from becoming a national crisis that would destroy their political careers. One public health professor interviewed for this project told me, ‘Most politicians, including top-level health ministers, would prefer a situation that got managed at the lower levels, went away, and didn't interfere with anything’ (personal interview, March 20, 2020).

At the core of this pressure is China’s government accountability structure, which tends to prioritise economic, political, and social stability over public health. This led to the widespread, prolonged concealment of SARS cases in 2003. Absent significant changes to the political accountability structure, Hubei officials likely faced that same pressure at the beginning of the COVID-19 epidemic, leading them to punish whistleblowers and withhold information in favour of preserving stability. When interviewed for this project, one Chinese health expert stated, ‘[In China], government officials are only accountable to their superiors, not to the people. So that affects the incentive to share information’ (personal interview, March, 2020).

Another reason for this lack of transparency is the tension between centralisation and decentralisation of government authority. Yanzhong Huang illustrated the tension as such:

‘Decentralisation gives the local government more autonomy in the decision-making process. So, in Wuhan, health authorities and government officials could withhold information from central health authorities. But centralised political power can also be problematic. In a centralised system, local governments are just waiting for instructions from the upper-level government. They have no incentive to take initiative when facing disease outbreaks. For example, there was a period of time when [COVID-19] cases were only reported in Wuhan, even though there were cases already emerging in other provinces. But these other provinces simply had no interest or incentive to contain the spread of the virus without explicit directions from the central government’ (personal interview, March 28, 2020).

China’s highly centralised political system can be a double-edged sword. On one hand, the central government has the authority to direct a concerted, nationwide epidemic response. It initiated restrictive lockdowns and deployed tens of thousands of health personnel to epidemic-stricken Wuhan at a scale impossible in the West. These actions are reminiscent of Mao-era patriotic health campaigns, models of mass mobilisation and propaganda to encourage the Chinese people’s participation in meeting public health goals. Under these campaigns, disease prevention efforts became the responsibility of every citizen, not just the government. This Mao-era spirit of mass mobilisation and commitment to group behaviour under a central government authority still contributes to the success of China’s epidemic response today.

However, excessive centralisation also impedes epidemic response. Politically, it makes local officials complacent, with no authority or desire to mount a serious response without central government direction. Because local governments have little power to mobilise citizenry without the central government’s blessing, epidemic response is viewed as the central government’s purview. Thus, public health remains low on local governments’ political agendas.

Local governments are not the only ones to blame. The central government, having to bear all responsibility for a nationally disruptive epidemic response, is more cautious about when and how it sounds the alarm to mobilise. Gordon Liu, a professor of health economics at Peking University, put it this way:

‘When authority is highly centralised, it takes longer to release disease information or mobilise because all information needs to be confirmed before final decisions are made by top leaders. In contrast, when authority and responsibility are shared with local entities, information can be released earlier’ (personal interview, March 23, 2020).

In conclusion, the Chinese government was indeed more transparent about COVID-19 compared to SARS, allowing for quicker mobilisation of the national epidemic response. However, as evidenced by delayed case reporting in Wuhan and the cover-up of human-to-human transmission, tensions around central-local coordination, transparency, and communication during the early epidemic response persist.

Public health infrastructure during COVID-19

After SARS, China invested significantly in improving its public health infrastructure. According to physicians involved in both the SARS and COVID-19 responses, this translated to ‘remarkable’ improvements in physical infrastructure, physician training on infection control, and quality and quantity of medical supplies across urban and rural health facilities (Zhao, personal interview, March 18, 2020).

However, many health infrastructure challenges remained, especially in Wuhan. Wuhan only had 5,000 infectious disease hospital beds available to take COVID-19 patients in late January (Xinhua, 2020a), while researchers estimate there were up to 15,000 infections in the city at the time (Kucharski et al., 2020). After the city-wide lockdown, public anxiety led to a surge in patients seeking care, overwhelming initial hospital capacity.

Frontline reports also reveal that failures in quarantine possibly increased rates of hospital and home cross-infection. Wuhan-based Professor Chen Bo asserts that ‘Between January 22 and February 1, the government focused … on adding fever clinics and hospital beds but failed to properly quarantine and care for suspected patients’ (Hui et al., 2020). Because of capacity issues, suspected COVID-19 patients were turned away from hospitals and told to quarantine at home. The home-quarantine policy produced three problems: first, a lack of medical care made patients deteriorate fast at home, spiking death rates; second, home-quarantine caused more family cluster infections; third, patients in critical condition continued to seek care at crowded hospitals, increasing the risk of hospital cross-infection (Hui et al., 2020).

Public health experts ultimately concluded that the strict Wuhan and Hubei lockdowns were effective in decreasing infection rates outside of the province (Leung et al., 2020). Less than 20% of China’s publicly reported COVID-19 cases, as of April 2020, occurred outside of Hubei (Johns Hopkins University, 2020; Xinhua, 2020b). However, lockdowns produced unintended consequences. Travel restrictions made it more difficult for people to access essential medicines, exacerbating the conditions of people suffering from chronic illness. There have been reports of overwhelmed Wuhan hospitals turning away cancer patients seeking chemotherapy and other life-saving treatments. According to Xinhua, over 400,000 non-COVID-19 patients in Wuhan were cut off from essential medicines and treatments due to travel restrictions (Qin & Wee, 2020).

Discussion: policy recommendations

Build holistic disease surveillance

While China has a comprehensive online infectious disease surveillance system, measures should be implemented to ensure its effective use. This begins with a national audit of all medical facilities linked to the surveillance network, confirming systems are installed and running as intended. National health authorities must also issue training modules teaching doctors how to use the system, raising clinicians’ awareness of their public health role. By integrating the surveillance system with China’s electronic medical record infrastructure, infectious disease reporting can become a natural part of clinical workflows, easing the burden on doctors. Finally, measures should be taken at the hospital level to better integrate doctors and public health authorities, streamlining their communication. One option could be to install a public health officer into each hospital or designate one doctor per facility as a public health liaison, responsible for coordinating with local and national health authorities as needed.

Because the online surveillance system relies on voluntary reporting, the biggest challenge will be ensuring doctors won’t bypass the system in favour of offline reporting to local health authorities. There needs to be a whole-health-system culture of openness and transparency around outbreak reporting. The existing political climate pressures Chinese doctors to circumvent national guidelines in favour of following orders from local superiors and health officials. This led to whistleblower doctors being detained and punished by Wuhan police when they discussed early signs of COVID-19 in private messages. China’s Supreme People’s Court later criticised these harsh actions, saying ‘If society had at the time believed those ‘rumours’ … perhaps we could better control the coronavirus today … Rumours end when there is openness’ (Shih et al., 2020).

Political reform to improve transparency

However, criticism from top leaders won’t be enough to change a culture of opaque communication about disease outbreaks. These are habits engrained in local governments by years of incentives prioritising economic development over public health. Despite China’s best efforts to increase disease surveillance after SARS, the political structure still impedes effective central-local coordination and communication about epidemics.

For local governments to prioritise swift epidemic response, there needs to be more decentralisation of authority, tolerance of risk at the local level, and dispersal of responsibility within the Chinese political structure. Local governments and health bureaus must be given the autonomy to report and act on epidemics without fearing political repercussions. Local leaders should be allowed to transmit bad news and take potentially disruptive public health measures without having to risk their political careers. At the same time, the central government should implement strong monitoring and disciplinary procedures to ensure this extra authority is not being misused to cover-up outbreaks.

In addition to more government transparency, China must consider modifying the rules and punishments for nongovernmental actors who share outbreak information. While China’s post-SARS public health regulations stress government transparency, they still do not allow individual citizens to publicly release epidemic information before the government does. SARS and COVID-19 both demonstrated the huge costs of delayed government communication. Concerned citizens, especially health professionals, can help raise the alarm early if governments are unwilling or unable to do so. Currently, this is not possible in China because the government fears the spread of false information. While false rumours can indeed incite panic, whistleblowers play an important role in drawing attention to issues overlooked by the government.

Broadly, there is a need for more diverse channels of information-sharing in China—through journalism and grassroots, citizen-led reporting efforts. An increase in societal tolerance for uncertainty must accompany that diversity. Currently, the Chinese government is the sole gatekeeper for epidemic information, meaning it takes sole responsibility for information accuracy. Thus, it must perform multiple checks before publicising any information, delaying the epidemic response. However, more tolerance for uncertainty and involvement of nongovernmental actors in disclosure can broaden the amount of information available to the public, speeding up epidemic response.

Expand public health infrastructure

Stockpile medical supplies and increase production capacity

To improve pandemic preparedness, Chinese hospitals and local health bureaus must increase stockpiles of face masks, protective gowns, ventilators, and other necessary supplies. The government should subsidise facilities unable to afford large purchases of medical equipment. But stockpiling can only go so far, as hospitals are limited by space and funding. The government must also work with medical supply companies to build manufacturing capacity, enabling fast production ramp-up to match pandemic-level demand. Existing medical supply companies can build capacity through equipment upgrades and increasing their workforce. Non-medical-supply manufacturers can draft plans to convert their assembly lines to produce medical equipment during a pandemic. This ensures all excess capacity in the manufacturing sector is utilised when an outbreak occurs.

Increase hospital capacity and utilise community health clinics

One of the biggest problems Wuhan faced during COVID-19 was a shortage of hospital beds. Temporary medical facilities were built to plug this gap, but existing hospitals were still overwhelmed during the several weeks between announcement of lockdown and when construction was completed. In the future, health officials should open up extra hospital capacity before announcing strict lockdown measures that will incite panic and drive people to seek care.

Community health facilities should also play a larger role in testing and isolating suspected patients to prevent overflow in bigger hospitals. For this to happen, clinics must receive additional infectious disease control training and retain larger medical supply stockpiles sufficient for performing small-scale testing and mild case isolation. This frees capacity in large hospitals to treat the most severe patients.

Use telehealth to provide care for non-epidemic patients

Telehealth can also help plug the gaps of an overwhelmed healthcare system during an outbreak, alleviating negative effects of lockdown on non-epidemic patients. Telehealth expansion in response to COVID-19 has already occurred in several U.S. health systems. Yale professor and clinician Dr. Michael Cappello stated:

‘There’s been an aggressive move in the hospital where I work to ramp up telemedicine, in particular for patients with cancer and other chronic diseases. By limiting their exposure in a healthcare setting, you'll be able to reduce their risk of acquiring the coronavirus and maintain some degree of continuity of care’ (personal interview, March 24, 2020).

China should consider building similar telehealth infrastructure nationwide and revising medical insurance reimbursement policies to cover virtual doctor’s visits. China’s telecommunications system is strong enough to support such an infrastructure, with 60% of the population connected to the internet in 2018, surpassing the global average of 48.6% (China Power Team, 2019). With rapid growth in 5G technology and large rural populations still struggling to access healthcare, China’s potential telehealth market is vast.

Conclusion

As of September 6, 2020, there have been 85,134 confirmed cases of COVID-19 in China and over 4,600 deaths (Johns Hopkins University, 2020). Yet China learned from its previous experience with SARS to improve its COVID-19 response, possibly averting an even greater tragedy. Thus, the lessons China takes away from this pandemic are crucial for informing domestic and international responses to future infectious disease outbreaks.

There is no one-size-fits-all strategy for epidemic response. What works in one country may not be perfectly replicable in another. However, the basic recommendations for improving China’s epidemic response—streamlining disease surveillance, ensuring political transparency, and building up health infrastructure—are relevant to all countries. If policymakers around the world take and share these lessons from COVID-19, we move one step closer to preventing another major public health disaster.

Limitations

Potential limitations to this article arise from the scope of the written sources reviewed, which mainly includes English-language articles from international journals. This may lend the study a Western bias. Since the COVID-19 pandemic is a politically charged issue, news reports included in the review may also hold political bias. Finally, due to the emergent nature of the pandemic, the written source review included academic pre-prints that were not fully peer-reviewed and possibly subject to inaccuracy.

Acknowledgements

The author would like to thank Schwarzman Scholars and Tsinghua University for supporting this research. Thank you as well to Joan Kaufman for her continuous guidance and advice. Finally, the author acknowledges the professors, experts, frontline physicians, and public health workers who agreed to be interviewed for this project.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Appendices

Appendix 1. List of interviewees

Table

Name	Title and Affiliation
Michael Cappello	Professor of Pediatrics, Microbial Pathogenesis, and Public Health at the Yale School of Medicine
Douglas Corley	Founder & CEO at Beijing Health Forum
Yanzhong Huang	Senior Fellow for Global Health at the Council on Foreign Relations, Associate Professor at the John C. Whitehead School of Diplomacy and International Relations, Seton Hall University
Yong Li	Employee at Longxian County People’s Government, Shaanxi, China
Gordon Liu	Director at China Center for Health Economics Research, National School of Development, Peking University
Chunyao Wang	Physician at Peking Union Medical College Hospital
Anna Zhao	Executive Director at United Foundation for China's Health
Anonymous	Executive Associate Dean, LKS Faculty of Medicine at the University of Hong Kong
Anonymous	Professor of Public Health Policy at Tsinghua University

Appendix 2. Interview questions

Table

Category	Question
Surveillance	Did China’s centralised, online infectious disease reporting system work the way it should have when COVID-19 first appeared in Wuhan?
	What are your thoughts on the delayed reporting of initial COVID-19 cases?
Quarantine	How effective were Chinese quarantines?
	How can the government deal with unintended consequences of quarantine, such as limited access to medical care?
Health Infrastructure	How have healthcare worker protection, training, and mobilisation improved from SARS to COVID-19?
Government Coordination	How can China improve government accountability during public health crises and solve the central-local coordination issue?
	Is more or less decentralisation needed? Should local governments be given more or less autonomy during public health emergencies?
	How to ensure the urgency and motivation to design sustainable epidemic response systems will persist beyond COVID-19?
Nongovernmental Actors	What is the role of charities and NGOs in Chinese epidemic response?
	What is the role of the private sector in Chinese epidemic response?