By December of last year, warning signs of the current COVID-19 pandemic had already begun flashing in the central city of Wuhan.
In the months since, as the outbreak evolved first into an epidemic, and then a global pandemic, the Chinese Center for Disease Control and Prevention (China CDC) has been vehemently criticized for not detecting COVID-19 and communicating the risks it posed to the public in a timely manner. In particular, many observers have expressed frustration at the apparent failure of the center’s electronic infectious disease reporting system, which was established in 2004 to rectify the reporting issues revealed by the severe acute respiratory syndrome, or SARS, outbreak in 2003.
There’s no doubt that the current pandemic has uncovered some of the defects in China’s epidemic reporting. Yet we shouldn’t rush to pin all the blame on the China CDC, which is beset by challenges both internal and external. Unlike the U.S. Centers for Disease Control which inspired it, the China CDC is not a government agency per se. Rather, it is more akin to a government-affiliated technical consulting organization. As such, it does not have the authority to publish information on infectious diseases and — in a redux of one of the longest-running conundrums in Chinese governance — it must rely on local health officials that it cannot necessarily control.
China first established a national network of epidemic prevention stations modeled along Soviet lines in 1953. By 1957, these covered more than two-thirds of the nation’s counties, and together they ran vaccination campaigns like the one that eradicated smallpox in the country by 1960.
But this system, with its emphasis on infectious diseases, gradually fell out of step with Chinese society. As citizens’ habits changed, noncommunicable diseases like cancer and heart disease became the leading causes of death in the country. Taking the U.S. Centers for Disease Control and Prevention as a model, China developed the China CDC out of a research center under its then-Ministry of Health in 2002. Now operated under the auspices of the National Health Commission, the China CDC is tasked with helping meet these new threats by leading and coordinating disease prevention and control efforts and providing technical guidance and support for China’s public health community.
Almost immediately after the China CDC’s creation, it was confronted with the deadly outbreak of SARS. The epidemic killed 813 people worldwide between November 2002 and July 2003. Although the China CDC played a critical role in containing the disease, its early missteps in pinpointing the pathogen contributed to the steep toll.
China responded by ramping up investment in infectious disease control. To address the need for enhanced disease surveillance systems, China launched a nationwide online system for reporting infectious disease cases and emerging public health events in 2004. By 2013, the system consisted of over 70,000 reporting units, including local CDCs and most of the country’s medical providers.
But unlike the U.S. CDC, which is part of the federal government and has both the legal authority to quarantine patients who may pose risks to the population’s health across national or state borders and the ability to disburse federal funding to local health authorities, the China CDC is more of an auxiliary organization. It does not have the authority to publish information about outbreaks or take legal action to control them. Instead, these powers lie with the National Health Commission.
Rather than direct the response, the China CDC can only collaborate with the local health authorities, who are the main actors during an outbreak. For example, the China CDC will provide technical guidance to provincial, prefectural, or county-level CDCs. But these usually report to their local health commissions, which fund and staff them, and which are subject to the control of local governments, who may have differing priorities in a crisis.
Without leverage or legal powers, the China CDC’s recommendations can be brushed off — or its requests for information ignored, as seems to have been the case during the early stages of the COVID-19 outbreak.
Even before the current pandemic, however, the China CDC was already in crisis. The center had just 2,120 full-time employees in 2016, the last year for which numbers have been reported. That’s far fewer than the 11,195 full-time employees at its American counterpart, which also has access to several thousand contractors. A 2005 regulation blocking the China CDC and its local counterparts from charging service fees for administering vaccines also cost the organization an important source of revenue. Poor funding in non-epidemic circumstances, low salaries, and a lack of access to the stipends given to civil servants at full government agencies have pushed many experienced and capable staff to look for work elsewhere, including the private sector.
The current situation jeopardizes China’s public health system. To address it, there needs to be more training and collaboration between local CDCs and hospitals, especially in the protocols for infectious disease reporting and the prevention and control of health care-associated infections. A world-class direct reporting system is fantastic, but it can only function properly if frontline health care providers have been trained in how to use it and maintain a close working relationship with their counterparts in local and national CDCs.
National and local CDCs also need to be able to recruit and retain qualified professionals. The current pay for CDC system employees does not match the qualifications required, fueling a recent exodus of talented workers. It is past time to examine the CDC system pay scale and assess alternative mechanisms of recruiting and retaining talented staff, including merit pay.
The China CDC should also strengthen its leadership of China’s public health sector. Upgrading the bureaucratic status of the China CDC and its local analogues would help facilitate timely communication and decision-making by shortening the chain of command. It would also be useful to clarify the legal powers of the China CDC when it comes to disease surveillance, data collection and transparency, and quarantine.
Last but not least, the China CDC should improve its risk communication capabilities. Health communication is a burgeoning, multidisciplinary field that involves everything from behavioral science, communications, and public health. Health communication capacity is critical, not just for the prevention and control of infectious diseases, but also for chronic conditions as well.
China has reaped the benefits of industrialization and globalization that come with its increasingly interconnected position in the world. But a more mobile population brings with it a higher risk of emerging infectious diseases, while also increasing the human and economic costs of outbreaks. Whatever the next threat is, a strong public health institute — one with support from society, business, and government — will be vital to its prevention and control.
Editors: Cai Yiwen and Kilian O’Donnell; portrait artist: Zhang Zeqin.
(Header image: A medical worker gets dressed for work at a local CDC in Enshi, Hubei province, March 21, 2020. Yang Shunpi via Xinhua)