How Robust is China’s Health Security?

Scientific and medical discoveries have greatly enhanced the ability of the global community to detect and respond to infectious diseases. Major threats like smallpox have been entirely eradicated, and diseases like HIV/AIDS have become far more treatable. Nevertheless, epidemics and pandemics continue to put millions of people around the world at risk. Successfully managing these challenges requires advanced capabilities and robust resources. This leaves the world’s wealthiest nations best positioned to lead global efforts to promote health security. 

Decades of rapid economic development have enhanced China’s ability to defend against infectious diseases, but the outbreak of a novel coronavirus disease (COVID-19) in late 2019 laid bare critical weaknesses.¹ Political leaders in China made costly mistakes that delayed the country’s response and allowed the virus to spread from its origin in Wuhan to other parts of the country, and eventually around the world. Within a few months, millions of people had been infected and hundreds of thousands of individuals had lost their lives.

The global impact of COVID-19 exposed shortcomings in other countries as well. Some of these obstacles were unforeseeable, but others are reflected in the findings of the Global Health Security (GHS) Index. Released in October 2019, the GHS index ranks 195 countries based on their performance across six categories of health security, which are visualized in the below interactive.  

Although the GHS Index concludes that “[n]o country is fully prepared for epidemics or pandemics,” it finds that high-income countries are best positioned to respond. Among the countries in the top 20, all but two are high-income economies. The US ranks first overall, followed closely by the UK, the Netherlands, Australia, and Canada.

At 51^st in the overall rankings, China lags behind not only advanced economies but also several countries in the middle-income band, including fellow BRICS countries Brazil and South Africa. China likewise trails many of its neighbors, including Thailand (6^th), South Korea (9^th), and 11 other Asian countries. Among the index’s six categories, China receives the best marks (30^th) for the ability of its health care system to treat the sick and protect health care workers. This relatively strong performance is overshadowed by a weak commitment to international norms, where China lands at 141^st globally, alongside countries like Yemen and Papua New Guinea.

Ranking of BRICS Countries in the GHS Index
Country	Income Level	Overall Rank	Rank within Income Group
Brazil	Upper middle	22	3
South Africa	Upper middle	34	5
China	Upper middle	51	12
India	Lower middle	57	8
Russia	Upper middle	63	16
Source: Global Health Security Index

The GHS Index is not necessarily indicative of how the Chinese government, or any government, will perform during an epidemic or pandemic, but it provides a useful baseline for comparing health security capabilities across different countries. Given China’s standing within the index and Beijing’s continued poor performance in managing infectious diseases, it is clear that serious health security deficiencies remain.

Shoring Up China’s Health Security

A robust public health infrastructure is needed to effectively combat infectious diseases. While China has achieved some success on this front, its public health infrastructure has historically failed to keep pace with the country’s economic development. Pronounced failures during the 2002-2003 severe acute respiratory syndrome (SARS) epidemic exposed a pressing need for widescale reforms.

Ambitious government-driven efforts aimed at specific diseases have helped to improve health outcomes in China. Smallpox was one of the government’s earliest targets. Between 1950 and 1952, more than 85 percent of China’s roughly 600 million people were vaccinated, leading to the full eradication of the disease by the early 1960s. Other far-reaching immunization efforts have brought about significant health improvements and contributed to a jump in average life expectancy from just 49.5 years in 1965 to 76.7 years in 2018.

While many of these initiatives proved successful, Chinese leaders failed to significantly upgrade national disease prevention and control mechanisms. Most major countries instituted modern systems for managing infectious diseases throughout the twentieth century, but China continued to rely on an outdated network of epidemic prevention stations modeled in part after the system used in the Soviet Union. China moved to update its public health infrastructure by establishing a national Center for Disease Control and Prevention (China CDC) in January 2002, but the country still lacked a modern system for monitoring and reporting disease outbreaks.

China was unprepared when the SARS outbreak occurred in the early 2000s. Virologists working at the China CDC incorrectly identified the cause of the disease as chlamydia, which is caused by bacteria rather than a virus. The mistake proved embarrassing for China and slowed attempts to control the disease. Poor coordination and political interference also delayed reporting of the disease to the World Health Organization (WHO) and to the Chinese public. The first case of SARS was documented in mid-November 2002, but Beijing failed to relay pertinent information to the WHO until the following February. Before the epidemic ended, over 5,300 people in mainland China, and more than 2,700 elsewhere, were infected.

The Global Impact of SARS
Location	Cases	Deaths
Mainland China	5,327	349
Hong Kong	1,755	299
Taiwan	346	37
Canada	251	43
Singapore	238	33
Vietnam	63	5
Rest of World	116	8
Total	8,096	774
Source: WHO

The global impact of SARS was limited in scale compared to more deadly diseases, such as the 1957 and 1968 influenza pandemics, which collectively killed more than 2.1 million people around the world. Nevertheless, SARS had a high case fatality rate of about 9.6 percent, and Chinese leaders faced protests at home and immense criticism from abroad for their handling of the outbreak. WHO director-general Gro Harlem Brundtland issued a rare rebuke, asking Chinese leaders to “let us come in as quickly as possible” when new diseases arise in the future.

Beijing subsequently adopted several measures aimed at shoring up the country’s health security, including the establishment of a national, internet-based case reporting system. The system was designed to speed up response times, especially in rural areas. The Chinese constitution was amended in March 2004 to allow central government authorities to declare martial law to manage public health crises and other national threats. The Law on the Prevention and Treatment of Infectious Diseases was likewise revamped to promote greater transparency and facilitate swifter action during future outbreaks.

Additional resources were spent on improving and expanding the broader health care system, which had been underfunded for decades as a result of local officials and hospitals prioritizing profit-driven treatments over more costly preventative measures. Between 2002 and 2018, government spending on health care jumped from just $11 billion to more than $247.9 billion. Overall spending on health care across the country likewise increased, from $70 billion to $893.5 billion over the same period.²

The Chinese government increased investments in combating infectious diseases, including malaria and HIV/AIDS. From 2002 to 2016, annual government spending on malaria increased from just $1.6 million to $17.7 million. Government expenditure on HIV/AIDS jumped from $111.9 million per year to more than $1.1 billion over the same period, propelling China into the ranks of top spenders behind Brazil (1^st) and South Africa (2^nd).

These efforts have produced mixed results. China has not recorded an indigenous case of malaria since August 2016, a remarkable achievement for a country of China’s size. The fight against HIV/AIDS has been less successful. Limited government support for sex education has contributed to rising incidents of HIV/AIDS transmission, and according to Chinese government figures, deaths from the disease have risen sharply from 0.02 per 100,000 persons in 2002 to more than 1.3 deaths per 100,000 in 2018.

Lingering Health Security Challenges

Grappling with the outbreak of a novel disease is a challenge for any country. The reforms undertaken by Chinese leaders in the aftermath of SARS upgraded their ability to manage public health crises, but Beijing’s mishandling of COVID-19 made clear that major shortcomings remain. Political interference played a critical role in furthering the spread of the disease.

COVID-19 likely originated in bats and was transmitted to humans through an unknown intermediary animal. According to the US CDC, roughly three quarters of new or emerging infectious diseases are zoonotic (transmitted from animals to humans). SARS and Middle East Respiratory Syndrome (MERS), which first appeared in 2012, are both coronaviruses that are believed to have originated in bats. The novel H1N1 influenza virus that first emerged in the US in 2009 is linked to avian and swine species.

The transmission of diseases from animals to humans poses a significant problem for China. The GHS index pegs China at 101^st out of 195 countries in preventing zoonotic diseases. After SARS, the Chinese government implemented restrictions on wildlife trade, but the laws were later relaxed. Amid the COVID-19 outbreak, Beijing again passed legislation restricting wildlife trade and the consumption of wild animals, but it remains to be seen if political leaders will enforce these measures.

Comparison of Major Epidemics and Pandemics
Name	Year(s)	Cases	Deaths	Case Fatality Rate (%)
COVID-19	2019-Present	+4.3 million*	+300,000*	–
West Africa Ebola Outbreak	2014-2016	28,652	11,325	39.5
MERS	2012-Present	2,519	866	34.4
2009 H1N1 Pandemic	2009-2010	700 million-1.4 billion	151,700-575,400	0.01-0.03
SARS	2002-2003	8,098	774	9.6
HIV/AIDS	1981-Present	74.9 million	32.0 million	–
1957-1958 Flu Pandemic	1957-1958	–	1.1 million	–
1968 Flu Pandemic	1968	–	1-4 million	–
1918 Flu Pandemic	1918-1919	>500 million	17-50 million	>2.5
Sources: US CDC; WHO
*As of mid-May 2020

In contrast to SARS, which was not reported to the WHO until three months after the first known case, Beijing was far more effective at identifying COVID-19 and notifying the WHO. Medical professionals in Wuhan began seeing patients with symptoms of the disease in early December, and by the end of the month officials had alerted the WHO.³ It was initially described as a “pneumonia of unknown etiology,” but Chinese experts soon found it to be a novel coronavirus.

The early response to COVID-19 was, however, marred by mistakes and bureaucratic inefficiencies. Hospital administrators and local officials in Wuhan were slow to utilize the online reporting system that was established after SARS, which handicapped efforts to contain the virus. Health authorities also did not pay sufficient attention to early warning signs of human-to-human transmission of the new disease.

Chinese authorities went so far as to punish medical professionals who attempted to publicly warn others about the virus. One of them, Dr. Li Wenliang, was thrust into the international spotlight when it was revealed that he was detained by public security officials and forced to confess to disturbing public order. When he later died from COVID-19, the Chinese public praised him as a whistleblower and widely criticized the Communist Party for his mistreatment. Before his death, Dr. Li was critical of China’s response to the outbreak, stating that if “officials had disclosed information about the epidemic earlier, I think it would have been a lot better.”

Beijing eventually took steps to control the spread of the virus by locking down Wuhan and other cities in Hubei province on January 23, 2020. These measures included closing all non-essential public venues, banning funerals and weddings, and strictly limiting the number of people from each household allowed outside. Local officials in Zhejiang province later implemented similar restrictions.

A WHO official called these moves “unprecedented in public health history,” but other countries soon instituted their own lockdowns. Officials in Italy initially resisted putting in place restrictions, but eventually instituted regional and then national lockdown measures in early March as the COVID-19 death toll mounted. In the US, the federal government did not enforce a national lockdown, but state governments put in place various social distancing and stay-at-home orders, beginning with California on March 19. Many European countries did the same.

Based on values at 60 days from first reported death.

Some governments were able to limit the spread of COVID-19 without instituting draconian lockdowns. South Korea, Japan, and Taiwan, in particular, were able to largely contain the virus through widescale testing and strict quarantining of infected individuals. In all three instances, the number of deaths per 1 million persons was a fraction of the per capita deaths in the US and several European countries.

According to official figures, China was able to cap the total number of COVID-19 cases and deaths at relatively low levels. It is nonetheless difficult to estimate the full extent of the disease in China, as the actual number of cases is believed to be significantly understated.

Bringing the COVID-19 pandemic to an end may only be possible through the development of a vaccine that provides immunity against the virus. Beijing may mandate vaccination against the coronavirus across China, but it is worth noting that the country has been racked by a number of scandals that have severely eroded public confidence in the safety and quality of Chinese vaccines. A 2016 survey found that only 11 percent of parents in China trusted Chinese vaccines. A major incident in 2018, in which 360,000 substandard vaccines were administered to children, heightened public concern over vaccines and likely encouraged many parents to seek more expensive vaccines produced outside of China.

Limited Contributions to Global Public Health

Chinese leaders are increasingly looking to global health initiatives as means of promoting a positive image of the country abroad. Although China’s overall contributions to global health remain relatively modest given its economic size, Beijing has succeeded in expanding its influence, especially through organizations like the WHO.

In the wake of several major epidemics like H1N1 and SARS, China joined dozens of countries and organizations in participating in the Global Health Security Agenda (GHSA), a multilateral partnership established in 2014 to enhance the capacity of countries to prevent and manage infectious diseases. Most GHSA member countries – including major regional players like the US, Japan, and Australia – have voluntarily completed a Joint External Evaluation (JEE), a process aimed at monitoring commitments to international health security targets. China has not completed a JEE, which is a major reason that it received such poor marks from the GHS Index (141^st globally) for compliance with international norms.

Total Contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria
Country	Value (US$ billions)	Share of Total (%)	Contributor Rank
US	16.1	30.5	1
France	6.3	11.9	2
UK	5.0	9.4	3
Germany	3.9	7.4	4
China	0.06	0.12	20
Source: The Global Fund to Fight AIDS, Tuberculosis and Malaria

Despite enjoying decades of unprecedented economic growth, China has only recently emerged as a major contributor to global health. Between 2003 and 2014, China received more than $802 million in grants from The Global Fund to Fight AIDS, Tuberculosis and Malaria. It was not until 2014 that China became a net contributor to the Global Fund. As of early 2020, China was the organization’s 20^th largest donor, with cumulative contributions totaling $63 million. The top three donors – the US, France, and the UK – have provided a combined $27.3 billion, more than half of the total amount raised since the Global Fund was founded in 2002.

Beijing has recently begun supporting the Gavi Alliance, which was founded in 2000 by the Bill and Melinda Gates Foundation to expand access to vaccines among the world’s poorest countries. For years, China was on the receiving end of support from the Gavi Alliance in its fight against hepatitis B. China became a donor in 2016, but its current overall contribution of $5 million amounts to just 0.1 percent of the organization’s total receipts from 2016-2020.

Chinese contributions to the WHO are similarly small given the country’s economic size. The WHO is funded through a combination of assessed dues and voluntary funding from member governments, as well as donations from philanthropies and other international organizations. The Chinese government contributed just under $86 million to the WHO in 2018-2019, which amounted to around 1.5 percent of the organization’s total biennial budget. China is the seventh largest financial backer of the WHO among countries, but only the 15^th largest donor when factoring in non-governmental contributors like the Bill and Melinda Gates Foundation.⁴

In response to the global backlash that Beijing has received for its initial handling of the COVID-19 outbreak, China ramped up its funding for the WHO, starting with a $20 million donation in March 2020. China pledged an additional $30 million in April after the Trump administration announced its intention to freeze US funding to the organization. Chinese officials sought to cast the move as “defending the ideals and principle of multilateralism.” At the annual meeting of the World Health Assembly (the decision-making body of the WHO) in May, Chinese President Xi Jinping announced that China would donate a total of $2 billion over two years to support the WHO’s COVID-19 response efforts.

China’s impact on the WHO has been considerable. The election of Margaret Chan as director-general of the WHO in March 2006 marked the first time that a Chinese candidate held the position. When Chan’s term ended in 2017, Chinese leaders supported the candidacy of her successor, Tedros Adhanom Ghebreyesus, who has led the WHO during the COVID-19 pandemic.

Beijing has also succeeded in pressing the organization to exclude Taiwan, leaving the island’s nearly 24 million people without direct access to the world’s preeminent public health organization. China permitted Taiwan to participate as an observer in the World Health Assembly from 2009 to 2016, but it was instrumental in stripping Taiwan of its observer status in the years that followed. Despite Taiwan’s exceptional success in handling COVID-19 and widespread international support for its inclusion in the WHO, Beijing has persisted in shutting out Taiwan.