China's Response to Avian Flu:
Steps Taken, Challenges Remaining, and Transparency

Testimony before the Congressional-Executive Commission on China
February 24, 2006, 2:00 to 3:30 p.m.
Room 2200, Rayburn House Office Building

Dr. Bates Gill
Freeman Chair in China Studies, Center for Strategic and International Studies
Washington, D.C.

Introduction

Let me begin by thanking the Commission Chairman and Staff Director for inviting me to provide my views this afternoon.  I commend the Commission for taking up issues related to China’s response to avian flu. 

This is clearly an important and timely hearing.  To date, the disease has spread from Asia to the Middle East, Europe and Africa with the prospect that it might also spread to the Americas and elsewhere.  Without prompt and effective detection and containment, the spread of avian influenza could potentially cause severe human casualties and catastrophic socioeconomic consequences, and threatens regional and global prosperity and security.  The World Bank has predicted that that the first year of an avian flu pandemic could cost the world economy up to USD 800 billion.[1]

With this in mind, and in response to the Commission’s request, I have divided the remainder of this testimony into three parts, covering:

• A brief overview of the current situation concerning avian flu in China
• Steps that have been taken by the Chinese government in response
• Challenges that are remaining in China’s approach to avian flu

A Brief Overview of the Current Situation

China is not only the world’s most populous nation, but also the world’s biggest poultry producer.  According the Food and Agriculture Organization of the United Nations (FAO), China has one-fourth of the world’s chicken, two-thirds of the world’s domesticated ducks, and almost nine-tenths of the world’s domesticated geese.  The sheer size of China’s human and poultry populations make the country a pivotal point in the global efforts to prevent and prepare for a possible human influenza pandemic. 

According to the World Health Organization (WHO), as of February 13, 2006, China has reported the country’s 12^th laboratory confirmed case of human infection with the H5N1 avian influenza virus, eight of which have been fatal.[2]  The most recent death was a 20-year-old female farmer from the county of Suining in the south-central province of Hunan.  China announced its first confirmed human case of infection in mid-November last year, and since then sporadic human cases have occurred in seven provinces and regions – Anhui, Fujian, Guangxi, Jiangxi, Hunan, Liaoning, and Sichuan.[3]

China has recently experienced an intensified recurrence of highly pathogenic avian influenza (HPAI) in poultry.  According to WHO, since May 2005 Chinese agricultural authorities have reported over 32 poultry outbreaks across the country, the majority of which were reported in October and November 2005.  However, about one-third of China’s reported human cases of avian flu occurred in areas where no recent poultry outbreaks have been officially reported.[4]  This has become a growing cause for concern.  Some health experts suspect that environmental pollution by sick or dead birds might be to blame for such human cases.  

Steps Taken

China’s health and agriculture authorities have become increasingly vigorous to contain HPAI among poultry and prevent its spread from birds to humans.  The government has conducted large-scale poultry culling in known avian flu-infected regions.  China has also launched tightened quarantine measures, extensive vaccination, and preventive measures against human infection.  Meanwhile, Beijing has called for enhanced cooperation among all countries, between governments and international organizations, among governments, business and non-governmental organizations (NGOs) to curb the epidemic.  Compared to the period of Severe Acute Respiratory Syndrome (SARS) outbreaks in 2003, Beijing this time has been praised for its efforts to control the avian flu.  A senior WHO official for communicable diseases has recently commented that “the Chinese government has taken very effective measures, and they are making improvements every month, even every day.”[5]  Another WHO regional director for the western Pacific said Beijing’s response to avian flu so far had been “aggressive and thorough once the outbreak was recognized.”[6]

Domestic Efforts

China’s central government leadership exhibits a strong political commitment to tackling the avian flu outbreaks.  The Chinese Ministry of Health (MOH) launched the national contingency plan for preparedness against a possible outbreak of pandemic influenza in September 2005.  MOH also urged all localities to draft their own contingency plans in accordance with local conditions and make good preparations for a possible flu pandemic.  According to the plan, the MOH is held accountable for organizing and coordinating epidemic contingency work, health authorities above the county level should ensure the collection, registry and delivery of flu virus samples for testing, and the national Center for Disease Control and Prevention (CDC) should establish a national system to manage the surveillance information.[7]

More recently, the State Council published national response plans for nine types of emergencies, one of which is public health incidents.  The emergency plans are believed to be the first comprehensive and detailed crisis management plans in China.  The new plans, which were released in January this year, listed preparedness, co-ordination of related parties and information transparency among the key elements of emergency management.[8]  With new and strengthened emergency planning, China is demonstrating a greater awareness of the need for a prompt and effective response to such crises as the SARS epidemic in 2003 and potential future avian flu outbreaks.

Changes in official structures have been an encouraging part of the government’s anti-flu efforts.  The MOH has set up a special department to deal with avian flu.  The Ministry has also established 192 monitoring spots throughout the country for flu outbreaks.  Following the State Council’s emergency response plans, the MOH announced the formation of a national expert team in response to emergent public health incidents, consisting of 105 experts in the field including communicable diseases, poisoning treatment and early warning networks.[9]  In early November 2005, the central government set up a general directorial office for avian flu prevention, bringing together six agencies in charge of food security, animal health and prevention science under a unified system, in order to coordinate the internal bureaucratic response.[10]

International Cooperation

Beijing has demonstrated greater openness and commitment on the international front as well.  On January 17 and 18, 2006, the international pledging conference on avian and human influenza was co-hosted in Beijing by the Chinese government, the European Commission and the World Bank.  The meeting of the delegates from more than 100 countries, regions and international organizations has led to USD 1.9 billion to fight avian flu worldwide, a higher figure than expected.[11]  Chinese Premier Wen Jiabao pledged that China would donate USD 10 million to help the global fight against the avian flu.[12] 

The conference endorsed the “Beijing Declaration”, which promised to enhance sharing of information and relevant biological materials, increase cooperation on global research and development of safe and effective animal and human vaccines and antiviral medicines for humans, and to periodically evaluate the impact of national pandemic influenza preparedness and action plans.[13]  This meeting was another positive example of China’s effort to become a more responsible global player on international health issues.

Beijing has also worked with the United States to bolster avian flu prevention.  On October 31, 2005, Chinese Health Minister Gao Qiang visited Washington and signed with U.S. Health and Human Services (HHS) Secretary Michael Leavitt a Memorandum of Understanding (MOU) on collaboration on emerging and remerging infectious diseases between the United States and China.  As an important step for further cooperation, the MOU set up the mechanism for a biennial health ministerial meeting, and aimed to strengthen bilateral collaboration on emerging infectious disease including avian flu, HIV/AIDS, and West Nile virus.  In particular, the United States pledged to help enhance the capacity of Chinese public health laboratories, train biomedical research, prevention and control personnel, conduct emerging infectious disease surveillance, and cooperate on research and development of vaccines and drugs. 

Remaining Challenges

During the SARS outbreak two years ago, China encountered intense criticism from the international community for its delayed response and cover-up at the initial stages of the epidemic.  Facing a potential influenza pandemic, the Chinese government has made noticeable progress in terms of transparency of information and international cooperation.  However, there are still a range of lingering problems, particularly at the local level, which may limit the success of Beijing’s efforts to bring the disease under control.

Transparency

The growing political determination within the central leadership needs to be translated into local action.  Fearful of censure, Chinese provincial and county officials sometimes might choose to conceal infection cases from the central government. This was at least the case during the early stages of the SARS outbreak.  Additionally, to some predominantly poor Chinese farmers, economic damage brought by anti HPAI-measures is often a more pressing concern than potential health risks, giving them an incentive to hide an outbreak.  Transparency and accountability mechanisms need to be introduced and strengthened to avoid potential underreporting at all levels.  Involving community groups in disease monitoring and reporting can be an effective approach to enhance transparency.

Technical Capacity and Financial Resources

Lack of capacity and resources at local levels remains a large question mark in China’s handling of avian flu.  Health Minister Gao Qiang identified his largest concern in a press conference in November 2005 as “the inability of our medical and quarantine personnel at the local level to diagnose and discover epidemics in a timely fashion due to lack of skills and relatively backward equipment.”[14]  The country still faces a shortage of experienced and qualified professionals, resulting in misdiagnosed patients as having pneumonia instead of avian flu.  There is also a great need for qualified and experienced veterinarians.  Meanwhile, many villages and towns do not have effective surveillance systems, leading to delayed reporting of outbreaks.  Only after patients admitted into hospitals are identified as having the H5N1 virus do local officials begin investigations in patients’ villages.

The reality is that much of the country’s poultry is raised in backyard farms in close proximity to humans in rural China, where 70 percent of the nation’s population lives.  Close contacts between people and birds are so frequent that the risk of human infection is high.  However, according to a report released by the Development Research Center of the State Council, a think-tank directly under the cabinet, 90 percent of China’s rural population is not covered by any form of medical insurance.  The same report also notes that “China’s medical reform has been unsuccessful because it has become unbearably expensive to patients and many dare not go to hospital when they fall ill.”[15]  Lack of medical insurance, together with ill-equipped countryside clinics and hospitals, makes rural China an extremely vulnerable spot in the face of infectious disease outbreaks.

China’s animal epidemic prevention statue requires that local authorities cull all domesticated birds within a 3-kilometer, or 1.8 mile, radius and vaccinate the remaining birds in a 5-kilometer radius vicinity.  To date, over 24 million birds have been culled.[16]  Farmers face a significant loss in business and livelihood without appropriate compensation or reimbursement, which represents a substantial financial commitment for local governments.  As a matter of fact, the Ministry of Finance and the Ministry of Agriculture jointly issued a regulation that compensation for each bird destroyed for avian flu prevention would be approximately RMB 10 (about USD 1.25), with local governments allowed to set the exact standard in accordance with local conditions.[17]  Even at that seemingly low cost, the mass culling of birds would surely strain local governments’ finances.

Public Awareness

As a result of poor education conditions and lack of available resources, public awareness and knowledge of a possible pandemic is limited in many parts of China, especially in rural areas.  This adds a great barrier to overcome in terms of avian flu education and prevention.  Basic information about the symptoms, how it is contracted, and where the breeding grounds for H5N1 virus are and other general information should be distributed to the public, particularly the rural population, in order to instill preventative measures to combat this deadly virus.  As the “Beijing Declaration” called for mobilization of all social sectors including nongovernmental civil society to effect a coordinated response,[18] community-based grassroots NGOs should be encouraged to partner with the government to promote public education and enhance public awareness, in particular in hard-to-reach populations and areas.  China’s HIV/AIDS NGOs have tentatively begun to assist the government to reach out to socially marginalized groups and provide training, care and support.  The role of NGOs in the fight against avian flu should be expanded as well.