Friday, 18 January 2013

SARS was a watershed for China public health domestically but not globally

by Chan Lai-Ha
In 2002, SARS not only exposed a fundamental shortcoming of China's public health surveillance system as well as its single-minded pursuit of economic growth since the late 1970s, but also forced China to realise that, in the era of globalisation, public health is no longer a domestic, social issue that can be isolated from foreign-policy concern.
Its ailing health care system, its aspiration to be seen as a “responsible state,” and international demands for health cooperation have compelled China to be more proactive in the global health domain. There are signs that China is now using public health as a means to strengthen its diplomatic relations with the developing world, in particular the African continent. While China has embraced multilateral cooperation in a wide array of global health issues, its engagement remains “state centric” and therefore leaders attach primary significance to intergovernmental organisations, particularly the UN agencies.
Following the Chinese government's acknowledgement of a SARS outbreak in the country, it began to acknowledge the importance of public health to national development and to accordingly strengthen its multilateral cooperation in combating contagious diseases inside and beyond its borders. For example, in the midst of the recent global economic downturn, the Chinese government announced in 2009 an injection of 850 billion yuan (US$125 billion) into its health care system to improve its operation. Since the SARS outbreak, it has not only deepened its engagement with other nations and international organisations, and cooperated with a variety of actors in dealing with its own fledgling health care system including the problem of HIV/AIDS, but China has also developed a vision for global health diplomacy. A ground-breaking implication of the SARS outbreak for China is that it was struck to realise that public health is not simply a domestic, social issue that can be isolated from foreign-policy and security concerns. In a globalising world, the Chinese government appears to have learned that its health policy will be scrutinised by the world, and hence, it has become more open to and actively participates in global health governance. The government is now learning from such European countries as the UK, France, and Switzerland in the provision of the global public goods for health. Its substantial health assistance to sub-Saharan Africa in building hospitals and training health practitioners forms part of its health diplomacy and contribution to global health governance. It has also been proactively engaging with both regional and global health institutions since 2003 and set up different health surveillance networks with its ASEAN partners as well as other intergovernmental organisations, such as the Asia-Pacific Economic Cooperation (APEC) forum .
Despite its increasing engagement with global health governance since the SARS outbreak, China's approach remains, however, fundamentally state-centric, contrary to the essence of global health diplomacy and governance. With grave concern about the loss of national sovereignty to external or nongovernmental actors, Chinese senior leaders have therefore attached primary significance to intergovernmental organisations, particularly the UN agencies. In evaluating the impact of SARS, Andrew Price-Smith has put the same point succinctly: “while the SARS epidemic may have generated moderate institutional change at the domestic level …, it resulted in only ephemeral change at the level of global governance”. In other words, national sovereignty is still of paramount importance for the Chinese leadership. Because of its sensitivity to foreign interference into its internal affairs, the Chinese government has not yet formally or officially endorsed the notion of “human security.” Under the umbrella concept of national security, “human safety,” instead of “human security,” is discussed throughout all of China's five white papers on national defence since 2000 (i.e., 2000, 2002, 2004, 2006, and 2008). Taiwan's participation in the World Health Assembly is predicated on the condition that it is considered part of China, not an independent entity. Having no tolerance in ceding its supreme authority, the central government has adopted a multi-faceted attitude towards its civil society organisations. While Beijing shows its willingness to cooperate with a wide array of actors inside China, it refuses to let its domestic NGOs and activists establish direct links with their counterparts overseas.
It is still uncertain whether this sovereign concern will trump the provision of global public good for health. Nevertheless, in a highly globalizing world, infectious diseases know no border. While China is seeking to adhere as much as possible to the underlying norms and rules of global health governance (and sometimes even applies them to their extremes), as evidenced by its handling of the recent swine flu outbreak, the major step forward is perhaps to reframe health as a global public good that is available to each and every individual of the world, rather than merely as an issue of concern to nation-states.
Source: PLOS Medicine

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