读书笔记：大流行病在中国

关于中国政府如何回应和处理Covid-19的问题一直以来争议很大，有很多批判也有很多赞扬。最近在写论文的时候有本书讲了与之相关的内容，觉得有一定的参考价值。对比着来看今天我们所体验到的各种不同的现实，有很多神奇的事发生了，很多思考都不仅仅停留在是否或是非。为了省去大家再去看原书的时间，我把我的笔记公开在下面。这份笔记主要讲的是过去中国政府应对突发性紧急卫生事件的做法。除此之外这本书还谈到了其他的卫生健康问题，在这里我只截选了和传染病相关的内容。

Reference:

Huang, Y., 2013. Governing health in contemporary China. London ; New York: Routledge.

P2: 1. Infectious diseases: microbial& viral

(e.g. HIV/AIDS, tuberculosis(TB), viral hepatitis, rabies, endemic schistosomiasis...)

[增速快]* e.g. 740,000 with AIDS - 1.2 million 2005 (China Daily, April 24, 2010)

P6: Paul Pierson theory: the core of governance:

1. the incentive structures & behavioral patterns of government officials;

2. the state capacity to mobilize resources & enforce policies;

3. the role of social forces & international actors in the health policy process.

三个考察方向：incentives, capacities, effectiveness

Harnessing the fourth horseman: Capacity building in disease control and prevention

P82: state capacity in disease prevention and control;

core capacities to detect, assess, notify and report disease events effectively.

P82: 1. a nation’s disease surveillance network (e.g. sufficient resources to conduct the necessary tests, improve the study of infectious diseases, and engage government agencies at different levels in complementary activities. );

P82-83: ‘To the extent that strengthening core surveillance capacities aims at improving sensitivity (early recognition), information sharing and risk communication focus on horizontal and vertical connectivity. Horizontally, a nation’s capacity to respond to disease outbreak requires open and effective communication between multidisciplinary groups (such as clinicians, researchers, epidemiologists and public health and other government officials) in multiple sectors (for example, civilian vs. military, prevention vs. treatment, government vs. non-government, national vs. international) that involve various key operational areas (hospitals, clinics, airports, ports, ground crossings, laboratories and government ministries). Multi-sector coordination is particularly important because a disease outbreak could have an impact on almost every sector of the society. /Vertically, effective crisis management depends on the ability of healthcare workers and public health officials to utilize available technologies and information systems (such as phones, computers and databases) to formulate reports to local and higher-level health authorities and other relevant government agencies in a timely and accurate manner. However, vertical communication is not just a bottom-up process: it also entails the need to publicize the presence of a disease outbreak through media outlets (such as newspapers, television, radio, the Internet and social media) in a way that reduces potential panic and fear and minimizes disturbing effects.’ (失败案例: 1918 Spanish flu pandemic)

2. states are also expected to develop, strengthen, and maintain core capacities so that they can respond promptly and effectively to public health risks and emergencies. (e.g. such capacities include the capacity to rapidly determine the required control measures for specific events; provide support through specialized staff, laboratory analysis of samples and logistical assistance; provide on-site assistance as required to supplement local investigations; and to work closely with relevant actors to rapidly approve and implement containment and control measures.)

P83: difference from natural disasters:

1. an infectious disease outbreak can spread fast and far beyond the epicenter since disease agents may self-amplify and mutate;

2. correctly and rapidly pinpointing the etiology and transmissibility of a disease is often crucial for effective response;

3. the emergence of a novel pathogen is often associated with diagnostic delays or even misdiagnosis;

4. when dealing with an unknown disease, “[w]e respond to the likelihood of death in the event the disease is contracted, rather than the compound probability of contracting the disease and succumbing to its effects” (Stern 2002: 105).

5. The uncertainty involved in handling a public health emergency of unknown causes or sources often generates fear and panic at a level that is disproportionate to the disease-caused morbidity and mortality, placing further constraints on state capacity to tackle a public health emergency;

6. a major communicable disease outbreak is often associated with widespread fear, social distancing, and restrictions on international trade and commerce. (e.g. SARS; …)

7. a dilemma between its “moral obligation to mankind” and potential negative socioeconomic repercussions incurred by publicizing the presence of such an outbreak (Hays 1998:58). [measures as well]

Public health in crisis

- The changing policy context

P84: ‘the Maoist “prevention first” policy and the mobilization-based public health system proved very effective in tackling some major public health challenges.’ ; e.g. Tangshan earthquake: ‘Because of the relatively strong surge-response capacity, the initial spike in reported cases of communicable diseases in the wake of the earthquake did not develop into a full blown epidemic (CNR 2006).’

1980s改革削弱了国家在疾病预防和控制方面的能力：‘Previously, preventive healthcare tasks were assigned with corresponding funds earmarked from upper level government institutions. Yet, according to the new policy of “pay-for-benefits” (shui shouyi shui fudan [*谁受益谁负担?]), the localities that would directly benefit from the policy were to set aside a fixed amount of funds for that purpose each year. The problem was that those localities that most needed preventive care services had very weak fiscal capacities…This resulted in rapidly declining financial support for public health activities…

[财政支持骤降的后果] As government financial support shrank, local health departments reversed the previous free-of-charge policy by combining exemptions with user charges (shou jian mian) in providing public health services…The slashing of subsidies also forced many anti- epidemic stations to place priority on clinical care and to select preventive services that were more lucrative (such as food hygiene and physical checkups) instead of basic childhood immunization and health education…many village doctors ceased to provide preventive health services for which they were not compensated…

P85: …the diseases that were officially declared under control reemerged and spread rapidly again.’ 

e.g. 80s的血吸虫病; 等等。

重振: 1990 the Law on the Prevention and Treatment of Infectious Diseases《传染病防治法》等。公共卫生工作政治化(89后的调整)：‘Li Tieying, the State Councilor whose policy portfolio included public health, echoed this by stressing the direct relevance of the health work to the “blood-and- flesh links between the party-state and the masses” (ZGWSNJ 1991: 4). The politicization of health work led to attempts to “institutionalize, routinize, and normalize” public health.’

Achievement: ‘Since the late 1980s, China has also intensified political and financial support for its Expanded Program on Immunization (EPI). As a result of stepped-up efforts in preventive care and childhood immunization, coverage for the four basic vaccines (diphtheria, pertussis and tetanus; polio; measles; BCG [白喉，百日咳和破伤风，小儿麻痹症，麻疹，卡介苗. 怎么有五种？]) reached more than 89 percent nationally throughout the 1990s (ZGWSNJ 2001: 488).’ ; In October 2000, the government declared the eradication of polio in China [顾方舟].

P86 However 再损害: 

The political window was soon closed, however, with the regime’s shift to performance-based legitimacy基于绩效的合法性. The 1989 Tiananmen crackdown signaled that, by the late 1980s, the Chinese state had become what was termed a “defensive regime” (Zhao Dingxin 1994). Since the regime was not based on legal–electoral legitimacy, and could no longer justify its rule by self-praised ideological superiority, it had to rely on the promotion of economic development to survive.3 Rooted in delivering economic growth, this performance-based legitimacy, in conjunction with fiscal and bureaucratic decentralization, compromised China’s ability to detect and respond to emerging and reemerging infectious diseases for three reasons. First, the performance-based legitimacy made it difficult for major public health challenges to move up onto the agenda of political leaders. Assuming that the decline in public services would be checked by the trickledown effect of economic growth, Chinese leaders adopted an ostrich policy toward critical public health problems. Second, at the local level, by making the ability to deliver short-term growth or similar tangible results the major criterion for promotion, the performance-based legitimacy created a perverse incentive structure that hurt public health financing. Among other things, it encouraged local leaders to spend large sums of money on vanity projects or programs that did little to improve public services such as disease surveillance and laboratory capacity building. Third, by making economic development the key to solving China’s problems and social stability the prerequisite to development (People’s Daily 2010), the performance-based legitimacy reinforced the incentive of the authoritarian state to cover up disease outbreaks. Government officials feared that public health problems, if revealed, would scare off potential investors or endanger social–political stability. /While bureaucratic agents in any political system tend to distort the information that they pass to their political superiors to place themselves in a good light, the problem is alleviated in democracies through “decentralized oversight” that enables citizen interest groups to check up on government actions. Since China still refused to enfranchise the general public in overseeing the activities of government agencies, lower-level officials could fool higher authorities more easily than their counterparts in liberal democracies.4 As we will see in the following case studies, the changing institutional landscape complicated China’s ability to mount an effective and coordinated response to emerging or reemerging disease outbreaks. 

Government response to the HIV/AIDS epidemic, 1985-2002

[讲得很简短；只讲到2011；现在2020了] 

P86: The spread of HIV/AIDS in China can be divided into three stages (Zhang and Ma 2002; Xinjing bao [New Beijing Daily], April 30, 2004[以下信息很多来源于官方新闻，信息是否可靠？]). 

1. 1985-1988: emergence of a very small number of imported cases in coastal cities, mostly of foreigners and overseas Chinese. 1988年底报道22例感染3例确诊(SCAIDSCO 2004) 。

P86-87: ‘The initial statistics reinforced the myth that HIV/AIDS was not so much a public health problem as a social ill confined to Western countries. Like their US counterparts, Chinese scientists and public health officials were initially convinced that HIV/AIDS spread mainly through homo- sexuality and promiscuity (Xinhua July 22, 1987). Believing that both behaviors were “illegal and contrary to Chinese morality” and therefore limited in China, senior health officials were confident that the AIDS epidemic was unlikely to occur within their borders (Toronto Star, August 10, 1987; Xinhua, July 22, 1987).’

最初的数据让人们认为艾滋病不是一份公共卫生问题，只限于西方。认为其主要通过同性恋和滥交传播，这不符合中国人的道德而且还违法。所以官员们认为这不会在国内流行。

P87: 2. 1989-1994: the steady spread of the disease, with an annual increase of several hundred cases (SCAIDSCO 2004)

1989.11.1 本地第一例确诊艾滋病例；随后在云南省静脉吸毒者中发现146例病例。——被迫重新评估。

1990.10: 卫生部宣布艾滋病传播已经“相对严重”。但是报告病例较少，没能引起国家级的广泛关注。卫生部长陈敏向国务院提案在此问题上建立中央组织被驳回，因为只报告了260例感染者—— 缺乏核心检测能力，缺乏核心检测系统。‘ In part, the low number of reported cases was a reflection of the lack of core surveillance capacities. China did not start to establish a national surveil- lance system for HIV/AIDS until 1992. Still, by 1996 only half of China’s 30 provincial units had the technological capabilities to test for HIV (United Press International, September 4, 1996). As a matter of fact, not until 2002 did China embark on the kind of comprehensive nationwide survey that would allow a more precise tally of HIV/AIDS cases.’ 直到2002年才开始进行全国性调查统计数据。[反应了12－17年之久。原因是？]。

3. 1995往后：

1995. 9: 卫生部发布政策文件正式认可对此疾病进行干预。“大力促进性教育，艾滋病意识和预防，去除污名化。” 花了五年，在全球层面上太慢。

‘By 1995, even these incomplete surveillance data suggested a rapid increase in the annual incidence of HIV, from several hundred in previous years to 1,567 cases (SCAIDSCO 2004). In September, the MOH issued a policy document formally endorsing behavioral intervention in HIV infected people and high-risk groups (Xinjing bao [New Beijing Daily], March 20, 2004). By comparison, some 37 percent of the countries that identified their first AIDS case between 1985 and 1986 began to formally implement preventive measures 18 months later (Hao Hong 2000). In other words, China was nearly ten years behind many other countries in effectively responding to this disease.’

1990s卖血潮，不检测，河南，中国中部东部，二次大规模爆发

P87-88: ‘Beginning in the early 1990s, health authorities and local governments, driven by the high profit margin for plasma-derived products, encouraged farmers to supplement their meager incomes by selling blood plasma. The number of blood and plasma collection stations expanded quickly, and a large number of poor peasants traveled to these stations to donate blood and plasma for cash (Gill et al. 2007). Many such stations were poorly regulated and administered. In 1993 several stations in southern Henan province began the practice of pooling blood to remove the plasma before reinfusing the blood to commercial plasma donors (so that they could give blood again quickly). Without testing for HIV, this practice almost guaranteed the spread of the virus among plasma donors. Not surprisingly, blood collection activities became the focal point of a second major outbreak of HIV/AIDS in China, this time among commercial plasma donors in central and eastern China. By early 2000, the cohort of former plasma donors began showing symptoms of AIDS and dying in large numbers. In 2003, officials estimated the total number of former plasma donors infected with HIV to be 199,000, which accounted for 31.1 percent of the confirmed HIV cases in China (Gill et al. 2007: 29). One of China’s most outspoken AIDS activists, Dr Gao Yaojie, implied in 2007 that the total number of infections could be as high as 300,000[这个数据没有明确证据].’

对政策和制度的批判：P88: ‘An ineffective response to HIV/AIDS was compounded by policy implementation problems. Decentralized governance and local policy autonomy generated “a mixed response and inconsistent enforcement of HIV/AIDS policy” (Wu et al. 2007: 687). The effectiveness of government intervention was also compromised by serious interdepartmental coordination problems.’

从提案到决策非常缓慢：P88 ‘(98年最后一个无艾滋省青海爷报告了病例)...The rapid spread of HIV/AIDS alarmed MOH officials. In early May, Minister Zhang Wenkang presented an update on the HIV/AIDS situation to the State Council executive meeting in an effort to increase awareness of the problem (Xinhua May 6, 1998). HIV/AIDS began to raise the eyebrows of national leaders. Still, the MOH failed in 1998 to move HIV/AIDS from the government agenda to the deci- sion agenda.6 Central leaders did not seek to mobilize the state apparatus until after April 2000, when Vice-Premier Li Lanqing convened a State Council meeting on HIV/AIDS and sexually transmitted diseases, urging all government officials to pay attention to HIV/AIDS control (Xinhua, April 4, 2000).’

作者观点：P89: ‘In the interim years, political leaders still had only a vague idea of how and where the disease was spreading. The national government’s ability to gauge the prevalence of HIV/AIDS was further crippled by the problem of information asymmetry inherent in a hierarchical structure. Local officials concerned about their political careers and/or local economic development were loath to admit to an HIV/AIDS problem in their jurisdiction. ’ 批判政策和制度层面：政府的无作为。官员认识模糊，心态缺乏变化，掩盖事实，未能有效实施政策。

1. 政策实施问题：P88 ‘In September 1995, the State Council approved a policy report that formally incorporated the MOH’s idea of behavioral intervention for HIV-infected people and high-risk groups (Xinjing bao [New Beijing Daily], March 20, 2004). Doing so would entail efforts to seriously promote sex education, AIDS awareness and prevention, destigmatization and harm-reduction. The MOH’s efforts in this area were nevertheless hamstrung by a lack of change in the mentality of other bureaucratic actors. ’； e.g. ‘The Ministry of Public Security, for example, failed to officially revoke the regulation that the mere possession of a condom by a female worker in a night club constitute evidence of prostitution (thereby serving as grounds for prosecution). Implementation of needle exchange programs was discouraged because it was thought to promote drug use rather than to serve as an effective HIV control method. Government crackdowns on these groups drove high-risk groups and activities underground, promoting a further spread of the disease while complicating efforts to target high-risk groups such as drug users or commercial sex workers for effective behavioral intervention (Huang 2006: 110).’ 性工作者的进一步传播。

2. 掩盖问题：P89: the Deputy Governor of Yunnan province said that ‘the AIDS problem was exceptionally serious in the province, the mayor of the provincial capital city maintained that AIDS was only a “foreigner problem” and there were no AIDS cases in the city.’; 河南省，拘留驱逐记者；封锁敏感话题。

2007: AIDS became the most deadly infectious disease in China (Moore 2009).

The 2002-03 SARS crisis

P89: ‘Similar to its response to HIV/AIDS epidemic, China lacked sensitivity and connectivity in its initial handling of the severe acute respiratory syndrome (SARS) outbreak. To be fair, China was not the only country that sought to suppress the flow of information regarding infectious disease outbreaks. Few countries, however, were as unwilling as China to admit to the presence of an epidemic within their territory. According to the Implementing Regulations on the State Secrets Law Regarding the Handling of Public-Health Related Information, any occurrence of infectious diseases should be classified as a state secret before being announced by the MOH or other organs authorized by the Ministry (Li et al. 1999: 372–4)….’

‘…an information blackout characterized the initial government response to the SARS outbreak.’

传染病被标记为政治化的“机密”

保密－信息中断－传播迅速－应对不及。

1. P90-91：SARS最早2002.11－2003.1.20.MOH意识到危险，但政府持续否认态度－2003.4月中旬正式承认，采取行动

2.P90: 'behind the city’s lack of surveillance capacities and underreporting of SARS cases was a fragmented disease-reporting system in which many hospitals were not under the municipal government’s jurisdiction (Blog Weekly 2009). ’

3. P90: ‘Organizational barriers also delayed the process of correctly identify- ing the cause of the disease. According to government regulations, only the CCDC is the legal holder of virus samples’获取病毒样本&正确认识疾病之艰难.

4. 政治结构导致公共卫生问题危机：上下级信息流不畅通1. 高层重视之难: P91: ‘The presence of such a fragmented and disjointed bureaucracy in an authoritarian political structure means that policy immobility can only be overcome with the intervention of upper-level governments that have the authority to aggregate conflicting interests. Nevertheless, the drive toward economic growth in the post- Mao era marginalized public health issues on leaders’ policy agenda. Compared with an economic issue, a public health problem often needs a focusing event (such as a large-scale disease outbreak) to be finally recognized, defined, and formally addressed. Indeed, SARS did not raise the eyebrows of top decision makers until it had developed into a nationwide epidemic.’

4. 上下级信息流不畅通2. 下级瞒报, 高层误判局势: P91: 'The upward information flow problem posed additional challenges to top-level decision making. By early April, it was evident that SARS was already being taken very seriously at the top levels of government. Yet the government’s ability to formulate a sound policy toward SARS was hampered as lower-level government officials intercepted and distorted the upward information flow. Initial deception by lower-level officials led central leaders to misjudge the situation. On April 2, Premier Wen Jiabao chaired an executive meeting of the State Council to discuss SARS prevention and control. Based on the briefing given by the MOH, the meeting declared that SARS had “already been brought under effective control.” ’

5. 资源调动能力强且迅速：P91: ‘Despite these problems, once the Party leaders decided to intervene on society’s behalf, they seemed to be quite efficient in mobilizing resources for autonomous action. With the intensive and direct involvement of the Party Center, the potential for interagency and intergovernmental cooperation was maximized.’

(尽管存在这些问题，但一旦党的领导人决定代表社会进行干预，他们在调动资源以采取自主行动方面似乎非常有效。在党中心的直接参与下，机构间和政府间合作的潜力得以最大化。 4月23日，成立了一个名为“国务院非典控制和预防总部”的工作队，以协调全国抗击该疾病的努力。吴仪副总理被任命为工作队总司令。在省，市和县各级也进行了类似的安排。政治领导层的直接参与增加了计划资源，有助于确保将其用于计划目的，并从其他系统中调动了资源。 4月23日，国家设立了20亿元人民币（2.42亿美元）的国家基金，用于防治SARS。在该国任何地方都为SARS病人提供了免费治疗。在一周之内，建造了可容纳1200名患者的先进SARS医院，并于5月1日开始运营。SARS的崩溃也使中央领导人有理由加强对政策实施的控制。处理。 4月20日，北京市市长孟学农和卫生部长张文康被迫下台。据估计，到5月底，将有近1,000名政府官员因不遵守中央政策指示而受到纪律处分（2003年6月25日，新加坡，《联合早报在线》）。这些行动震惊了当地政府官员的自满情绪，迫使他们放弃最初的犹豫，转而加入反SARS潮流。在政治热情的驱使下，他们封锁了村庄，公寓大楼和大学校园，隔离了数十人，并设立了温度检查站。毛主义的“爱国卫生运动”也得到了振兴。在广东，动员了8000万人打扫房屋和街道（人民日报，2003年4月9日）。[还是讲得过于简洁]

但是，应该指出的是，这些重大措施仅在病毒的繁殖数量（Rt）降至1以下（无法持续传播的临界值）之后才实施。换句话说，严格的控制措施可能在加速SARS的消失或防止疫情蔓延到未受影响的地区方面发挥了作用，但它们“对遏制SARS流行的事实遏制作用很小”（de Vlas等（2009：103）。该流行病在5月下旬开始趋于平稳并失去了发展势头。 6月24日，世界卫生组织（WHO）取消了前往北京的旅行咨询。 2003年8月16日，最后两名SARS患者从北京地坛医院出院。) 

Post-SARS capacity building and its effectiveness

P92-93: 修改和增添突发卫生事件法律框架；增加财政资金；四级网络疾病报告系统，覆盖地方；

(非典危机凸显了建立应对突发公共卫生事件的法律框架的必要性。 2003年5月，国务院发布了《中国突发公共卫生事件处理条例》。该法规要求卫生主管部门和省级政府制定突发公共卫生事件应急预案，并责成国务院和省级政府建立应急预案总部，以协调所有相关部门的工作。 2004年，全国人民代表大会（NPC）修改了《传染病预防和控制法》。在要求政府为预防传染病提供资金保障的同时，新修订的法律规定了公共卫生机构应对突发公共卫生事件时需要采取的措施。该法还规定卫生当局在疾病监测和报告方面应承担更多法律责任。 2007年，全国人大通过了《紧急事件应对法》，规定使用四种颜色的紧急情况声明（蓝色，黄色，橙色和红色）来表示危险程度，红色表示最严重的情况（第十届全国人大常委会2007年） 。根据法律，当发生紧急情况时，全国人大常委会或国务院可以宣布紧急状态。这三份法律文件（《突发公共卫生事件处理条例》，修订的《传染病预防和控制法》和《应急法》）共同构成了中国突发卫生事件的法律框架。

SARS危机还凸显了追求平衡社会和经济发展的国家议程的重要性。用于公共卫生的资金大大增加。从2002年到2006年，公共卫生支出增长了107％。 2007年，仅中央政府就安排了312亿元人民币用于公共卫生，比2006年增长了85.8％（新华社2007）。 2009年4月发布的《深化医疗体系改革指南》标志着1980年代的不干预做法的逆转，明确表明政府将为所有公共卫生机构提供全部资金。国家增加的承诺有助于完成从县级到国家级的四级疾病预防和控制框架（见图4.1）。 2004年初，中国启动了基于Internet的疾病报告系统，使医院（包括乡镇卫生中心）可以直接向CCDC和MOH报告可疑疾病病例。到2007年9月，该系统已覆盖95％的县级以上卫生机构和71％的乡镇卫生院（中国共产党，2007年）。此外，到2008年，在省和地（市）级建立了独立出资的卫生应急响应办公室（三联生活周刊，2009年5月15日，北京）。中国现在拥有世界上最大，甚至不是最快的传染病监测和报告系统。)

关于AIDS政策的推动：

P93-94: ‘The growing emphasis on social justice and harmony in the post-SARS era also accounted for a new, more proactive attitude toward HIV/AIDS. In summer 2003, the government launched the “four frees, one care” (simian yi guanhuai) program, which featured free voluntary HIV testing and counseling; free antiretroviral drugs for the poor; free medication for all pregnant HIV carriers; and free school- ing for AIDS orphans, with care provided for AIDS patients and their families. Along with screenings intended to prevent blood-borne infections and needle- exchange programs to reduce the infection rate among injecting drug users, China kicked off nationwide awareness and “safe sex” campaigns to address transmission through sexual contact. The government allocated 11.4 billion yuan for the strengthening of the AIDS medical assistance system and the training of more health personnel for AIDS prevention and treatment (Jian Kangbao [Health News], Beijing, November 7, 2003). On December 1, 2003, Premier Wen Jiabao appeared on state television shaking hands with AIDS patients and called on the nation to treat them with “care and love.” Until then, no senior Chinese leader had even addressed the issue in public. Since then, China has rapidly scaled up its AIDS response. Between 2002 and 2009, China, through the National Free Antiretroviral Treatment Program, increased drug coverage from almost zero to 63 percent of all patients who needed treatment. This, according to a review of the program, accounted for the reduction in China’s AIDS mortality by two-thirds, from 39.3 deaths per 100 person-years in 2002 to 14.2 deaths per 100 person-years by 2009 (Zhang et al. 2011). When the Global Fund to Fight AIDS, Tuberculosis and Malaria decided to cancel its next call for country proposals (round 11) in 2011, the Chinese government announced that it would fill the resource gap and continue funding its AIDS programs (UNAIDS 2011).’

Case study 1: hand, foot and mouth disease (2008)

Case study 2: The response to the H1N1 pandemic (2009)

［这两个案例也很有趣，时间问题不赘述了。］

P111: 削弱 ‘In the 1980s, agricultural liberalization, fiscal decentralization, and market- oriented health reform undermined China’s capacity to effectively address disease prevention and control. The shift to a performance-based legitimacy provided further incentives for cover-up and inaction.’

加强 ‘Drawing lessons from the SARS crisis, China has made considerable progress in strengthening its surveillance and responsive capacities in dealing with major public health challenges. ’

不足 1. the central–local capacity gap, health authorities & institutions at or below the provincial level: ‘…lack of epidemiological, laboratory, and medical-care capacities. This is made worse by lingering problems of cover-up, misinformation, and inaction at both central and local levels of government.’;

2. the unstable politics–science dynamics;

3. the absence of a genuinely engaged civil society;

4. incentive structure problems in the bureaucracy

作者的批判总结其一：P138: 'A study of contemporary health governance in China sheds some critical light on the country’s health system, evolving Chinese politics, and global health governance. The Chinese state has failed the governance test in the health sector in terms of incentives, capacity, and effectiveness. Despite the sea change in the Chinese society, government officials are still accountable only to their superiors, not to the general public. With the legitimacy of the government, both national and local, hinging on the delivery of steady economic growth, Chinese officials, especially local officials, have little interest in improving people’s health standards. Their lack of interest is reinforced by the rise of a buck-passing polity, under which responsibilities for promoting health and blame for inaction in this area can be easily passed onto other bureaucratic actors and departments. This is exacerbated by the changing state–society relations and the rise of special interest groups: while healthcare providers and government health officials collude to hijack public hospital reform, local government officials tend to provide protection for unscrupulous business interests to evade regulation on food and drug safety.

Another problem is the lack of bureaucratic capacity when it comes to health policy implementation. In addition to an ill-defined fiscal system, which has crippled the government’s ability to fund public services, policymakers in China cannot effectively monitor the behavior of policy implementers. In democracies, there are citizen groups to keep misbehavior by officials in check. However, as long as China does not empower the general public to monitor administrative measures, upper-level bureaucratic actors will continue to have their efforts thwarted by the action of their subordinates. This problem is of particular concern in the healthcare sector because the MOH is one of the weakest bureaucratic actors in China. The MOH nominally occupies the same rank as provincial governments, but the power to manage provincial health departments lies squarely with those governments. As a result, the horizontal coordinating bodies at various administrative levels – province, city, and county – have the final say in designing and implementing local health policies.

That said, as shown in the 2003 SARS epidemic, central government’s capacity can be strengthened when needed, especially in times of crisis. But because the state has not seriously taken into account the people’s needs, wants, and interests, strong state capacity has not yet translated into greater effectiveness. The government was quick to mobilize resources during the 2009 H1N1 pandemic, but instead of developing a new range of political tactics and instruments to manage the mild virus efficiently and keep the response within socially and economically acceptable limits, its recourse to vertically imposed prohibition and coercion – such as large-scale quarantine and other strict containment measures – not only failed to stop the rapid spread of the H1N1 virus but also squandered funds and manpower that could have been spent on fighting more serious diseases. In short, China’s health crisis is essentially a governance crisis (see Huang 2011).'