North Korea continues to declare that it has not had a single case of COVID-19, but health experts find it inconceivable that the infectious disease would not be in the country given its proximity to China and South Korea, two early victims of the pandemic. A coronavirus outbreak in the North could be devastating, says Asian affairs and security expert Victor Cha, as it would act on an extremely vulnerable population with already-compromised immune systems and outdated health care infrastructure.

Cha, professor of government and holder of the D.S. Song-KF Chair in Government and International Affairs at Georgetown University, has joined Shorenstein APARC as the Koret Fellow in Korean Studies for the winter quarter of 2020. He spoke with APARC via videoconferencing about the threat of COVID-19 to North Korea, the deadlock in the diplomacy of denuclearization, and the North Korean human rights problem.

COVID-19 or not, the Kim regime has recently stepped up again its weapons testing. The North typically resorts to missile tests, notes Cha, in periods of non-dialogue with the United States, and the data also shows that North Korea will bolster weapons testing before and after U.S. presidential elections.

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What is to be done about engagement with the North? Cha believes that any new U.S. administration should prioritize three areas: first, focus not only on North Korea’s nuclear program but also on its ballistic missile delivery capability; second, enable the flow of humanitarian assistance into the country; and third, genuinely work with our allies and partners in the region, “who have tended to be neglected lately and seen in largely transactional terms.”

While at Stanford, Cha has been researching a project that he calls “Binary Choices” and that examines how U.S. allies and partners in Asia react when they are forced to choose between the United States and China over various issues. Regardless of how one feels about the U.S.-China trade war, Cha concludes, the question is if we are “calculating the other externalities, in terms of how our allies make choices, into our net assessment of whether a policy towards China is working or not.”

Watch the Q&A with Cha above or on our YouTube channel:

Organizational sociology may not be the first academic field people tend to look to for an explanation of the origins of a public health crisis such as the spreading Wuhan coronavirus, but from the perspective of Stanford sociologist and APARC faculty member Xueguang Zhou, who specializes in institutional change in contemporary Chinese society, the writing on the wall has long been there for all to see. Zhou, who is also Kwoh-Ting Li Professor in Economic Development and senior fellow at FSI, studies Chinese organizations, Chinese state building, and Chinese bureaucracy. His work sheds light on the characteristics of and tensions in governing China, and is pertinent to understanding the unfolding of the coronavirus crisis and the Chinese government’s response to it.

In the following interview, Zhou talks about these issues, his research into the institutional foundations of governance in China, and some of the challenges the country now faces. The conversation has been edited for length and clarity.

Q: The death toll from the coronavirus continues to rise in mainland China along with anger over the government’s response to the outbreak. What are the implications of this crisis for Chinese governance?

This is not only an outbreak of a novel virus, it's also a manifestation of the breakdown of China’s governance structures. The crisis has exposed the cracks in the system. Granted, any government might be underprepared to handle an outbreak of a new epidemic. However, based on what we now know, the new virus strain was detected in Wuhan some weeks before the beginning of the outbreak, yet the bureaucracies at several levels didn’t work and the authorities involved were not put into high alert.

I wouldn’t place the blame on the local officials, who have followed the same old pattern of crisis response. For both cultural and political reasons, their primary concern was to lie low and keep things stable just weeks before the Chinese New Year and in the lead-up to the annual gatherings of the Provincial People’s Congress. That pattern of response has been built into the Chinese bureaucracy for years. But in this case, the default behavior exposed the weaknesses of the central and local governments. We can imagine similar scenes of health crises and other problems happening in other Chinese provinces and cities, because the officials have similar mentalities. The problem is not with individual officials here or there, but rather that the general bureaucracy has been tamed to respond to such dissonant information in this manner.

I hope that this crisis becomes a turning point; that the gravity of the situation touches people's lives deeply enough to make them aware of the kind of conditions that need to be transformed. I hope it makes them realize that the government must improve its decision-making process, transparency, and openness to societal input. The present system of governance in China is designed for top-down decision implementation, not bottom-up information pooling and transmission. Therefore, even though information is abundant — as has been the case with the coronavirus — there is no efficient information transfer from localities to the upper levels. And the latter cannot deal with the load of information coming from the country’s vast territory and huge, heterogeneous population. In fact, top officials tried to shield themselves and filter information instead of open up to input the scale of which they cannot deal with.

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Q: Since the coronavirus broke out, there has been a surge of interest in your research on Chinese governance. Tell us more about that.  

For more than ten years, I have been doing fieldwork in China and publishing my writings on that topic in Chinese. In 2017, I published a collection of essays in a volume whose English translation is The Institutional Logic of Governance in China: An Organizational Approach. The book’s theme is the relationship between China’s central government and different levels of local government with regards to various governance issues. That relationship is fraught with frictions in and challenges for governing China, which the coronavirus crisis has now exposed.

Within six months of publication, the book was “unshelved” in China and reprint was prohibited. The publisher returned the copyrights to me. So I made a digital version of it available for free download. Since the coronavirus broke out, within a few days, references to the book have been shared on Chinese social media platform Weibo nearly 4,000 times. This set of issues that I have been discussing for more than a decade has suddenly become highly relevant. On the one hand, I am sad about this turn of events: sometimes you don't want your predictions to come true. Yet I also feel vindicated. That is to say, for the longest time, I have been studying something that I thought was fundamental yet never fully understood, and now suddenly the lines of argument I developed over the years are circulating broadly and having impact. I am working on an English translation of the book.

Q: You describe a fundamental tension in governing China. What is this tension and how is it manifested?

Given the formidable scale of governance in China, the centralization of authority inevitably introduces a separation between policymaking at the center and policy implementation at local levels. This separation gives rise to a fundamental tension between the centralization of authority and effective, local governance. The source of the tension is this: the extent of the centralization of authority is achieved at the expense of the effectiveness in local governance. That is, the centralization of authority places decision rights and resources further away from those levels that have more accurate information and capacities in problem solving. Conversely, the strengthening of local governance capacities implies the expansion of local authority, which often leads to (or is interpreted as) deviation from the center, thereby becoming an acute threat to the central authority.

Over the last several years under the new leadership, China has undergone tremendous consolidation and centralization of political power. And that's what made local governments paralyzed. They lack autonomy and initiative and shun responsibility. One outcome is that information is filtered or being blocked from one level of governance to another. Problems arise every day and never make it into media or public attention: there are accidents, crimes, corruption, and people protest, but we never hear of that. The coronavirus outbreak is one extreme case that the authorities simply cannot hide, and, temporarily, we hear more voices and criticism via social media and other informal channels.

It is my hope that this crisis will be a turning point and make Chinese society realize that information, and efficient information sharing is critical for its well-being. From time to time, I post book reviews, commentary, and my thoughts on various topics via a personal page on Weibo. A while ago, I posted my reflections after watching the HBO miniseries Chernobyl, considering the failures that caused the Chernobyl disaster from the perspective of organizational sociology. And those are all information failures. There are many parallels to what has now happened in Wuhan. Since the virus outbreak, this post of mine has been shared many times in China, in social media and various other channels.

Q: What are the implications of this fundamental tension between the centralization of authority and effective governance for China’s future?

This tension creates cycles of centralization and decentralization over time. Decentralization gives rise to diverse interests and propels economic developments in different parts of the country. Indeed, China’s decades of economic rise and reforms were marked by tremendous decentralization. It’s what made China so successful. But decentralization poses a threat to the central authority, so it reverts back to power consolidation, such as we have observed over the last several years under the new leadership.

Then again, the more resources and decision rights are centralized upward, the lower is the effectiveness of governance at local levels. This is manifested in the form of lack of initiative by local governments, which, in turn, creates burden on the central government. China’s economic slowdown has already been putting tremendous pressure on the central government and now, with the scramble to contain the spread of the coronavirus, China’s economy is virtually grinding to a halt. Economic stagnation is almost inevitable, the questions are how severe it will be and how long it will take to recover from it.

I therefore believe it is only a matter of time until China goes through yet another phase of decentralization, but that will most likely be merely another part of a perpetual cycle. The cycle will continue unless China’s challenges are translated into political action and fundamental changes are made to the institutional foundations of governance. Such changes, however, will involve the Chinese bureaucracy and official ideology and are unlikely to happen in the foreseeable future.

Q: What are some of the findings from your research into the Chinese bureaucracy?

Over the last decade, I have been conducting fieldwork and studying the inner workings of the Chinese bureaucracy in action: observing how local officials behave in problem solving, crises management, policy implementation, and interact with both higher authorities and lower-ranking bureaucrats. I have developed theoretical models and arguments about how the Chinese state has been organized and how it operates both at the local levels (bottom-up perspective) and central level (top-down perspective).

As part of that project, I have been studying patterns of career mobility among bureaucrats in the Jiangsu Province, which has the second largest economy in China, just behind Shanghai. I now have a dataset encompassing half a million records on more than 40,000 officials, detailing their career flows from 1990 to 2013. This project sheds light on many important issues related to the Chinese bureaucracy and governance in China. For example, the dual authority between the party and government lines is a defining feature of the party-state in China. We can examine the key characteristics of this phenomenon through the lens of personnel management, that is, how officials are moving through different positions between the party and government. We have a paper forthcoming on this topic.

Another line of research in this project is what I call “stratified spatial mobility,” meaning a pattern whereby just a handful of officials are able to move beyond the administrative jurisdiction along the bureaucratic ladder into the immediate next higher-level administrative jurisdiction, whereas most officials stay within their own jurisdiction for life. It’s polarized mobility, in stark contrast between spatial mobility and local mobility. That’s why in each locality there are dense social networks and strong boundaries. This type of stratified mobility in the Chinese bureaucracy has huge consequences for understanding how China is governed. For example, local networks fiercely protect each other and have strong ties with those officials at an immediate authority, resulting in collusion among local governments when they respond to crises or interact with higher authorities. The failure to keep the Wuhan coronavirus outbreak from becoming an epidemic is a case in point. So we opened this conversation with the coronavirus and end it with the same topic.

Updated January 24
Millions of residents in China are under lockdown measures as the number of reported deaths from the coronavirus outbreak rises to 26. In the United States, dozens of people are being monitored for the virus. The World Health Organization on January 23 said at a press conference the outbreak did not yet constitute a global public health emergency.

The outbreak of a novel coronavirus that began in December 2019 in Wuhan, China “is evolving and complex,” said the head of the World Health Organization (WHO) after its emergency committee convened on Wednesday, January 22, and decided that more information was needed before the WHO declares whether or not the outbreak is a public health emergency of international concern. The new virus, known as 2019-nCoV, causes respiratory illness and continues to spread across China. Chinese health authorities, reports the Washington Post, announced that at least 17 people have now died as a result of infection and confirmed cases have been reported in Japan, Thailand, South Korea, Hong Kong, and Macao, with one travel-related case detected in the United States, in the State of Washington. The WHO decision was made as the city of Wuhan shut down all air and train traffic to try to contain the spread of the virus.

With concern over and coverage of the situation rapidly developing, Karen Eggleston, APARC Deputy Director and the Asia Health Policy Program Director at the Shorenstein Asia-Pacific Research Center, offered her insights on the outbreak and its impact on both Asian and international healthcare systems.

Q: Why has this outbreak raised so much concern in China and internationally, and how worried should people be about it?

Infectious disease outbreaks can challenge any health system. Events such as SARS, Ebola, and MERS outbreaks, and even the devastating flu pandemic a century ago, remind us of the frightening power that infectious diseases with high-case fatality can have. The global burden of mortality and morbidity is mostly from non-communicable chronic diseases, but no country or society is immune to old, newly emerging, and re-emerging infectious diseases. And although health systems are generally stronger now and have more technologies to trace and contain outbreaks, there are also deep and complicated challenges that make swift, coordinated disease response difficult even in the modern era.

Any government leadership or healthcare responders who have tried to manage an outbreak situation before are hyper-aware of the need to prepare for and manage future incidents, but we are living in a moment of very complicated social dynamics surrounding public health and healthcare. Distrust in drug companies and government agencies, controversies over vaccines, and increasing skepticism in science, even if only from vocal minorities, all make it more difficult to manage a cohesive international response to an outbreak situation and protect vulnerable people.

Q: As you’ve mentioned, many people looking at this situation with the memory of outbreaks such as SARS or H1N1 in mind. How is the Chinese government addressing this crisis and how does its reaction compare with China’s history of emergency health responses?

China’s health system is much more prepared now, compared to the SARS crisis 17 years ago. More training and investment in primary health care, disease surveillance and technology systems for tracking and monitoring outbreaks, and the achievement of universal health coverage with improving catastrophic coverage even for the rural population, all suggest a health system that is much better prepared to handle a situation like this. Top-level leadership in China had already begun to publicly address the situation within days of the outbreak to assure the public that strict prevention measures will be taken and to urge local officials to take responsibility and share full information. Until more information is gained and more is understood about the nature of this virus, it’s been categorized as a “Grade B infectious disease” but will be managed as if it is a "Grade A infectious disease," which requires the strictest prevention and control measures, including mandatory quarantine of patients and medical observation for those who have had close contact with patients, according to the commission. China currently only classifies two other diseases as Grade A infection diseases—bubonic plague and cholera—and so that tells you something about how seriously this is being treated by those in leadership positions.

Q: And what about the response from the international health communities?

As with any major healthcare crisis, health systems around the globe must also respond with alacrity and integrity, including effective surveillance, monitoring, and infection control. Individuals also play a crucial role in supporting the instructions and recommendations made by established healthcare professionals. For example, the individual with the confirmed case in Washington State proactively told medical personnel about his recent visit to the Wuhan area. His medical providers then exercised appropriate levels of caution, given the unknown nature of the virus, and isolated him while his symptoms developed. He is currently combatting an infection similar in severity to that of mild pneumonia, and so far no other cases have been reported in the United States, though some may arise in the coming days and weeks.

There is always a fine balance between safeguarding public health while still respecting individual rights, civil liberties, and undertaking a prudent, scientific response. The aim is to remain clear and transparent in communications and actions without reverting to disproportionate or overly aggressive responses which lead to panic, distortion, and misinformation about the situation. Some countries, like the Democratic People’s Republic of Korea, may choose to seal their international borders until more is understood about the nature of this virus, but most nations will use tried-and-tested methods of monitoring travelers and alerting population health systems so that information about cases is widely available to health authorities and medical researchers trying to understand the cause and develop a potential cure.

Q: As this situation continues to develop, and with inevitable future disease outbreaks around the globe, what would you hope people keep in mind about the role we all play in healthcare crises and in public health?

One issue this outbreak reminds us of in a visceral and intimate way is how closely people are linked together across the world. Globalization and air travel almost instantaneously link continents, countries, and regions. The timing of this outbreak is particularly fraught, because it’s the beginning of the Lunar New Year, when there is a vast migration of people both within China, throughout greater Asia, and across the globe as massive populations go home to celebrate the holidays with family. The potential for a contagious disease to spread easily through crowds and across borders in circumstances like this is very high, and highlights the need for the international communities to share information, scientific expertise, and understanding.

We need to remember that this is not just a problem in a remote part of the world that has no impact on those of us who live in relative comfort in high-income countries. Rather, this is something that could easily impact anyone. Perhaps this latest outbreak and response will showcase how vital additional, ongoing investments in both domestic and international healthcare systems, technologies, and people are.

In the summer of 2018, the Asia Health Policy Program (AHPP) at the Shorenstein Asia-Pacific Research Center (co)hosted two conferences in Beijing. From June 25-26, AHPP hosted “Healthy Aging and Chronic Disease Management in China and India in International Comparison” at the Stanford Center at Peking University in Beijing. Immediately following the event, June 26-27 AHPP cohosted, along with Professor Fang Hai, Peking University China Center for Health Development Studies, the “Fourth Annual Conference on Primary Care and China’s Health System Reform”, focused this year on China’s family doctor system.

Healthy Aging and Chronic Disease

Day one of the Healthy Aging and Chronic Disease Management conference combined discussions of chronic disease control in India and China (part of an ongoing SCPKU Team Innovation faculty fellowship) with a workshop focused on assessing net value of diabetes management across Asia.

Research teams from Hong Kong, South Korea, India, Taiwan, and the United States convened to discuss research on net value analysis of diabetes in their respective countries. The Net Value in Diabetes Management project seeks to develop a method for measuring net value of diabetes internationally­–based on previous methods discussed in an 2009 study by Karen Eggleston and Joseph Newhouse with data from the Mayo Clinic for Type 2 Diabetes.

The research teams provided updates to their calculations from the gathering last year and explained the strengths and weaknesses of their data sets, the risk prediction model they employed or created for their specific population, and the cost effectiveness analyses conducted with their data.

Participants included Kavita Singh from the Public Health Foundation of India, Janet Lam from Hong Kong University, Hongsoo Kim and Wankyo Chung from Seoul National University, Rachel Lu and Ying Isabel Chen of Chang Gung University Taiwan, and Kyueun Lee and Karen Eggleston of Stanford University.

Non-communicable/Chronic Disease Control

The afternoon of day one featured presentations by various representatives from provincial and national-level Centers for Disease Control and Prevention (CDC) in China regarding non-communicable disease (NCD) control initiatives.

Dong Jianqun from the People’s Republic of China CDC presented the “Effect of Community-Based 5+1 staged diabetes management.” This research project–fielded in sites in three different provinces–involved staged diabetes targeting management. Results showed that examination rates for complications management increased. Fang Le from the Zhejiang Provincial CDC presented updates on community management of NCDs in Zhejiang, including the intensive follow-up system for high risk diabetes patients. Representatives from Shandong University and the Shandong CDC, including Dr. WANG Yan, presented “The Status, Problems, and Determinants of community management and control of diabetes in Shandong Province” while also discussing current policy and implementation.

The afternoon ended in a session comparing health care systems and ongoing initiatives for chronic disease control in China and India. Kavita Singh discussed issues in India’s health system, including high out of pocket expenditure, over-privatization, and large health inequities across states and between urban and rural areas. Singh introduced existing innovations being used, including smartphone-based decision support software in heart disease monitoring. Dong Jianqun and colleagues discussed NCD control in China, including the demonstration areas that have integrated initiatives including better surveillance and management of diabetes and hypertension, and prevention education.

The first conference closed the next morning by bringing together representatives from various Chinese organizations to discuss the current state of primary care, family doctor system, and health care reform within the country. During a highly immersive classroom session for the Diabetes Net Value Teams, Dr. Sanjay Basu shared insights regarding best practices in predictive risk modeling.

China’s Family Doctor System

Beginning the afternoon of June 26, the second conference was devoted to China’s family doctor system, primary care, and health care reforms.  The event opened with remarks from Zhuang Ning, Deputy Director of the State Department of Health, System Reform Department, about the importance of community health and greater recognition of primary health providers in China.

The director’s remarks were followed by an opening keynote address by Professor MENG Qingyue, Dean of the Peking University School of Public Health and Director of the China Center for Health Development Studies at Peking University. Professor Meng reflected on the role of primary care in the development of China’s health system. Qin Jiangmei, Director of the Community Health Research Center, National Health and Family Planning Commission Health Development Research Center, next introduced the necessity of comprehensive health reform in China as well as funding challenges.

Afterwards, representatives from the Beijing Dongcheng district, Shanghai Changning district,  Xiamen City, and Shenzhen Luohu Hospital Group shared their experiences constructing family doctor systems within their respective regions. Important points stressed by the presenters included consolidation, maintaining a good evaluation system, and establishing trust with their patients.

The day ended with a Primary Medical Care Roundtable Discussion featuring four directors of district-level community health centers. The panelists answered questions concerning the future model of primary care in China, as well as changes they would like to see at the community and policy levels. The district directors advocated that more funds be allocated to general practitioners, believing that they will be the dominant form of primary care in China. Participants also spoke of the additional need for clearer targets to ensure that primary care providers are better funded (so that, with enough time, patients will begin to recognize the importance of the family physician).

The second conference concluded on June 27 by way of a highly engaging classroom session on the continuing collaboration between the Zhejiang Provincial CDC and Stanford University Asia Health Policy Program.

Rural areas of China have made remarkable progress in reducing adult mortality within the past 15 years yet broadened health insurance was not a casual factor in that decline, according to a new study by an international research team that includes Asia Health Policy Program Director Karen Eggleston.

The New Cooperative Medical Scheme (NCMS), a government-subsidized insurance program that began in 2002-03, expanded to cover all of rural China within a decade. Examining NCMS and cause-specific mortality data for a sample of 72 counties between 2004 and 2012, the researchers found that there were no significant effects of health insurance expansion on increased life expectancy.

The study, published in the September issue of Health Affairs, showed results consistent with previous studies that also did not find a correlation between insurance and survival, although much research confirms NCMS increased access to healthcare, including preventive services, and shielded families from high health expenditures.

Commenting on the study, Eggleston said population health policies remain central to China’s efforts to increase life expectancy and to bridge the gap between rural and urban areas.

Eggleston also noted that multiple factors beyond the availability of health care determine how long people live, and anticipates the research team will continue to explore the impacts of NCMS by extending the study to look at infants and youth.

Read the study (may require subscription) and view a related article on the Stanford Scope blog.