Modeling Health Outcomes Among East Asian Populations

The chronic progression to diabetes-related complications is apt for computer simulation modeling due to the long-term nature of health outcomes and the time lag for interventions to impact patient outcomes. It is problematic, however, to estimate the impacts of health interventions on East Asian populations with diabetes using existing models, which were developed and validated in European and North American populations with different epidemiology and outcomes.

To fill in this gap, Eggleston and her colleagues set out to develop and validate an outcomes model for the progression of diabetes and related complications in Chinese populations. They compared this new model, called the Chinese Hong Kong Integrated Modeling and Evaluation (CHIME), to two widely used existing models developed and validated in the United Kingdom (known as the United Kingdom Prospective Diabetes Study Outcomes Model 2, or UKPDS-OM2) and in the United States/Canada (called Risk Equations for Complications of type 2 Diabetes, or RECODe). Despite the continuum of risk across the spectrum of risk factor values, these two existing models ignore the progression from prediabetes to diabetes.

The CHIME integrates prediabetes and diabetes into a comprehensive model comprising 13 outcomes. These include mortality, micro- and macrovascular complications, and the development of diabetes. The researchers developed the CHIME simulation model using data from a population-based cohort of 97,628 participants in Hong Kong with type 2 diabetes (43.5%) or prediabetes (56.5%) from 2006 to 2017. Known as the Hong Kong Clinical Management System (CMS), this cohort makes one of the largest Chinese electronic health informatics systems with detailed clinical records. 

The next step was to externally validate the CHIME model against individual-level data from the China Health and Retirement Longitudinal Study (CHARLS) cohort (2011-2018), a nationally representative longitudinal cohort of middle-aged and elderly Chinese residents age 45 and older. The researchers validated the CHIME model against six outcomes measures recorded in the CHARLS data and an additional 80 endpoints from nine published trials of diabetes patients using simulated cohorts of 100,000 individuals.

Towards Reducing the Disease Burden of Diabetes

The researchers found that the CHIME model outperformed the widely used UKPDS-OM2 and RECODe models on the data used, meaning that the validation of the CHIME model was more accurate for trials with mainly Asian participants than trials with mostly non-Asian participants. The results indicate that the CHIME model is a validated tool for predicting the progression of diabetes and its outcomes, particularly among Chinese and East Asian populations, for which the existing models have been unsuitable.

With the new model, clinicians and health economists can evaluate population health status for prediabetes and diabetes using routinely recorded data and therapies related to the long-term management of diabetes. In particular, the CHIME outcomes model enables them to assess patients' quality of life and measure cost per quality-adjusted life-years over the long-time horizon of chronic disease conditions. The new model thus supports the economic evaluation of policy guidelines and clinical treatment pathways to tackle diabetes and prediabetes, address micro- and macrovascular complications associated with these conditions, and improve life expectancy.

To celebrate its May Release, the Stanford China Program hosted a virtual book launch event for Fateful Decisions: Choices That Will Shape China’s Future (Stanford University Press) on June 2^nd. Joining co-authors Thomas Fingar (Shorenstein APARC Fellow, Stanford University) and Jean C. Oi (Director, Stanford China Program; William Haas Professor of Chinese Politics, Stanford University) were contributors Karen Eggleston (Senior Fellow at FSI; Director of the Asia Health Policy Program, Shorenstein APARC, Stanford University), Barry Naughton (Sokwanlok Chair of Chinese International Affairs, School of Global Policy and Strategy, UC San Diego), and Andrew Walder (Senior Fellow at FSI; Denise O'Leary and Kent Thiry Professor, Stanford University). As Fingar and Oi point out in their volume, despite China’s extraordinary growth over the past 40 years, the country’s future is uncertain. China has enjoyed optimal conditions for development since the 1980s, but new hurdles including an aging populace, the loss of comparative economic advantage, a politically entrenched elite, and a population with rising expectations will test the country’s leaders. With each focusing on a different facet of China’s challenges, the panelists gathered to share their expertise and provide the audience with a glimpse into what the future might hold for this important country.

Available Now: Fateful Decisions: Choices That Will Shape China’s Future

Following an introduction from Professor Jean Oi, the program kicked off with Professor Barry Naughton of University of California, San Diego, who discussed his chapter entitled “Grand Steerage.” Professor Naughton argued that, as it plans for the future, China’s policymaking is becoming increasingly technology-focused, particularly in the realm of economic policy. Naughton further notes that China’s economy is becoming simultaneously more state-guided and more centered around technology. This decision is a gamble, though: China is investing heavily in high-tech industries, advancing massive, centrally steered projects like the Greater Bay Area initiative and the Xiong’an New District. If they are successful, says Naughton, this will indeed be an incredible success. But, if they are not, China’s losses will be major: “There’s not really a middle ground.”

After Professor Naughton was Professor Karen Eggleston, an expert on health policy in Asia. Professor Eggleston’s chapter, “Demographic and Healthcare Challenges,” deals with emerging obstacles for China’s healthcare system, including population aging and the problems that come with it, like chronic diseases and elder care. Although China’s healthcare system has improved dramatically in recent decades, it has done so unevenly, notes Eggleston: life expectancy has greatly increased, but with disparities according to income, region, and urban vs. rural status; universal healthcare is available, but the benefit level is low, effectively limiting the standard of care many can receive. The ratio of health spending to GDP is also increasing, yet it is still modest compared to high-income countries. The COVID-19 crisis has, of course, introduced even more challenges: Will China be able to distribute future vaccines equitably? Will this crisis negatively affect young people’s decisions to choose healthcare as a career? Will telemedicine, which has seen a surge under the pandemic, improve or exacerbate existing disparities? China faces a multitude of constraints and choices going forward if it hopes to meet its population’s healthcare needs.

The audience then had a chance to hear from co-editor Thomas Fingar, speaking on his chapter, “Sources and Shapers of China’s Foreign Policy.” Fingar noted three key takeaways from both his chapter and his talk: Firstly, China’s foreign policy is a fundamental part of its national policy. Secondly, the global political environment plays an important role in shaping both foreign and domestic policy which, thirdly, plays an important role in shaping foreign policy. The conditions that allowed China to flourish over the past 40 years, emphasized Fingar, are very different from those of the present. In the 1970s and 80s, China was able to take advantage of Cold War bipolarity, globalization was in its infancy, and “China was the only significant developing country willing to embark, at that time, on the export-led path of development.” In recent years, though, China’s behavior internationally has alienated other countries; there are many competitors pursuing its style of development; and its needs and aspirations have changed, requiring more raw materials and depending upon multi-national economic agreements. Fingar suggests two potential foreign policy options: China could continue with its wolf warrior diplomacy, which has “alienated essentially all China’s neighbors to some degree,” or it could return to a style more similar to that of the 1980s and 90s Reform and Opening era. It remains to be seen which style will win out.

Finally, Professor Andrew Walder concluded the program with his discussion of China’s political future at large. His chapter, “China’s National Trajectory,” follows China’s remarkable advancement in recent years and “tr[ies] to divine what a lower growth era will mean for China’s political future.” The last 40 years of rapid growth have generated support for China’s political system, more patriotism, the near eradication of democracy movements, and an elite unity not seen in the 1970s and 80s. However, low growth rates could mean a reversal for many of these trends, says Walder. While the aforementioned support for and stability of the Chinese government was maintained by ever-improving living standards and upward mobility, a low growth period (coupled with an aging population) means the government will no longer be able to rely on these trends for popular support. Rather, it will need to improve its provision of public services to address present-day challenges. Regardless, argues Walder, the low growth era will undoubtedly lead to “dynamic changes underneath the façade of stability of Chinese politics….”

For more insights on the modern obstacles China faces and what they mean for the country’s future, check out Fateful Decisions: Choices That Will Shape China's Future, available for purchase now.

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This is the third installment in our series, “Stories in a Time of Pandemic,” in which APARC alumni across Asia share their perspectives on the responses to and implications of COVID-19 in their communities. In part 1 and part 2 of the series, we feature observations from our alumni in China, Mongolia, Myanmar, and Singapore.

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The first case of COVID-19 in the Philippines was reported on January 30, 2020, and local transmission was confirmed on March 7, 2020. As of May 21, the number of cases of COVID-19 has risen to 13,434 and the number of deaths attributed to the virus increased to 846, according to the Philippine Department of Health COVID-19 Case Tracker. It is quite alarming that among the ASEAN countries, the Philippines had the second-highest mortality due to COVID-19, next to Indonesia (as per May 5 date by the WHO COVID-19 Dashboard). This could be attributed to several factors, including whether the country’s health system can handle the overwhelming demand for health care due to the COVID-19 crisis and how effective the government’s response is in stemming the spread of this new pathogen. Inherent in the death statistics is the capacity of a country to conduct COVID-19 tests, which means that there should be a sufficient number of test kits available and that the health workers are properly trained to conduct the tests, trace the contacts, and isolate identified individuals.

The President of the Philippines imposed a total lockdown called enhanced community quarantine (ECQ) for the entire island of Luzon, which encompasses eight administrative regions, including the national capital region, from March 15 to April 30. Other parts of the country have also been under some degree of quarantine at different periods since the appearance of local transmission. Executive Order 112, signed on April 30, 2020, was issued to further extend the ECQ in identified high-risk areas and a general community quarantine (GCQ) in the rest of the country. The inter-agency task force for the management of emerging infectious diseases defines ECQ as the implementation of temporary restrictions on the mobility of people, strict regulations of industries, and a heightened presence of uniformed personnel. GCQ is, in a nutshell, a less strict version of ECQ.

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Image captured from the Center for Strategic and International Studies, Southeast Asia COVID-19 Tracker, May 21, 2020.

The Philippines has faced a lot of challenges during this crisis. First, the health system lacks adequate surge capacity to safely handle a nationwide outbreak of COVID-19 due to shortages of personal protective equipment (PPE), mechanical ventilators, and hospitals with ICUs and isolation beds (see this World Bank report and this Rappler article). More importantly, the insufficient number of health workers, especially in areas outside the metropolitan, is a major concern. Nonetheless, the Department of Health has worked hard to meet the surge in demand due to COVID-19, including partnering with the private sector to repurpose structures and providing data to the public to ensure transparency and accountability. As in other countries, the health workers and those with frontline responsibilities have truly been the new heroes or “bayani” with their tireless efforts and sacrifices. 

Another challenge pertains to the adverse economic impact of COVID-19. The Philippines has a relatively large informal sector and the income of many families depends on daily transactions with no formal job or social security. This has prompted the government to extend cash or in-kind support to vulnerable populations – a response that has posed several challenges, particularly related to the who/what/how framework. First, the Philippine government had to properly identify those in need (who). Second, it had to ensure that sufficient resources can be allocated to the identified groups (what). And third, it had to distribute aid in an efficient, timely, and equitable way (how). The government's social welfare efforts to provide for the vulnerable groups have mixed results: at times, the distribution of aid is organized and efficient, at other times insufficient and disorderly (see these CNN Philippines reports of April 7 and April 30).

COVID-19 in the Philippines – How Filipinos Have Coped

There has been a strong spirit of “bayanihan” or collectivism in the country amidst the COVID-19 crisis. People are volunteering, distributing goods to vulnerable groups, or donating PPE to those with frontline duties. Some enterprises also rose to the occasion by repurposing their businesses to meet the local demand for medical products and PPE.

Different individuals have coped differently: some have welcomed the work hiatus that the quarantine has afforded them, some connected more with friends and family, others become more productive working from home. Staying healthy and being mindful are also factors that contribute to remaining calm and rational in this time of national distress.

Despite the challenges, we will continue to face, especially once the quarantine has eased and the new normal is in effect, we can say that Filipinos have also learned some valuable lessons amid this crisis. For one, Filipinos have become more mindful of the importance of good sanitation and non-pharmaceutical public health measures in mitigating the transmission of the virus. Most Filipinos have also become more proactive in their approach, keeping social distance, wearing masks, and practicing proper handwashing, among others. Furthermore, this crisis has redefined and created new heroes who rose to the challenge – from those staying at home to avoid the further spread of the virus to those on the frontline who have dedicated their time and effort to combat the pandemic, to government and business leaders who have served the country sincerely during this crisis.

Perhaps there really is a silver lining in every cloud.

Mongolia, a nation bordered by China and Russia, does not usually attract much public attention. Its success so far in containing COVID-19, however, is well worth considering.

Any of several factors could make Mongolia highly vulnerable to COVID-19: its weak healthcare system, its proximity to China, the first epicenter of the coronavirus, and its close ties to South Korea, which experienced one of the largest initial outbreaks of COVID-19 outside China and which is home to a relatively large population of Mongolian migrant workers. Yet Mongolia’s strategy in fighting the pandemic seems to have worked well thus far for its 3.2 million people.

In the following post, Dr. Gendengarjaa Baigalimaa, a gynecological oncologist at the Mungun Guur Hospital in Ulaanbaatar, Mongolia’s capital, discusses the country’s response to the pandemic and its implications. Baigalimaa was a 2013-14 postdoctoral fellow on developing Asia health policy with APARC’s Asia Health Policy Program.

This is the second installment in our series, “Stories in a Time of Pandemic,” in which APARC alumni across Asia share their perspectives on the responses to and implications of COVID-19 in their communities. You can read the first part in the series, featuring reflections by several former Global Affiliates Program Fellows.

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Dr. Gendengarjaa Baigalimaa

As of May 17, 2020, the number of new coronavirus infections in Mongolia has reached 136. All of them are imported cases, including four foreigners and 132 Mongolians who came from abroad. They have been treated by the National Center for Communicable Diseases and some have been discharged as totally recovered. Most notably, there have been no reports of community transmission.

Following the World Health Organization's recommendation of January 22 that countries begin considering containment measures, Mongolia immediately activated its inter-agency State Emergency Commission in support of the Ministry of Health as a lead agency in the response against the coronavirus outbreak. The Mongolian government made an unprecedented decision to close all schools and kindergartens starting January 25. All classes are now being conducting via TV and the internet.

Already in mid-February, with the pandemic's spreading in China, the Mongolian government’s strategy was to adopt decisive preventative measures, including the cancelation of the national holiday Tsagaan Sar, the Mongolian lunar new year, and closure of all travel between Ulaanbaatar and provinces outside the capital. Mongolia also closed its borders with China and Russia, stopping the inflow and outflow of people, and banned international flights from all airlines. The government has been mobilizing its citizens to return home from countries like South Korea, Japan, Turkey, and Russia. Those arriving are quarantined for an extended 21-day period, with multiple coronavirus screenings.

The use of masks, especially from early November, when flu season starts and air pollution worsens, is already familiar to Mongolians. This season, the government has enforced mask-wearing in public places. In the capital city of Ulaanbaatar, the requirement that all employees at government offices, banks, shops, and markets wear masks was imposed as early as January 25. The State Emergency Commission would issue fines of 150,000₮ (54 USD) for violating the order. At the same time, health professionals and community leaders conveyed the importance of mask-wearing and handwashing and worked to increase sanitation at all public places.    

These steps have helped immensely to contain the spread of COVID-19. They have also had the added benefit of sharply reducing the number of flu infections. At the start of the flu season last year, almost 12.7 percent of all hospital visits were flu-related, compared to 1.8 percent this year. Another unexpected benefit was the drop in gastrointestinal infections among children. Children were staying home and washing their hands properly. As a result, there have been no cases of gastrointestinal infections registered this year so far.

“Not only did Mongolia close its borders early and move promptly, but also did a great job at quarantining evacuees from overseas immediately upon arrival and taking safety measures,” said Mr. Sergey Diorditsa, the WHO representative to Mongolia. He praised the country’s economic stimulus measures and noted that prolonged restrictions may adversely affect its social and economic sectors and that WHO Mongolia is conducting a study on the in-country impacts of COVID-19. Indeed, data provided by the National Statistical Office shows that the country’s economy is expected to decline sharply due to the adverse effects of the pandemic.

Mongolia’s urgent response to COVID-19 offers lessons for vulnerable communities on containment of the coronavirus and prevention of its spread. The country is also a relevant case study for the economic repercussions of the pandemic.

While Wuhan, China was the first epicenter of the COVID-19 pandemic, every nation in Asia has been deeply affected by the spread of the virus. In a virtual seminar convened by the Freeman Spogli Institute, APARC experts discuss the social and economic impacts of COVID-19 and the various policy responses to the pandemic across Asian nations.

Senior Fellow Xueguang Zhou focuses on the phases of crisis response taken by the PRC in the early stages of the unfolding coronavirus outbreak. Center Fellow and Korea Program Deputy Director Yong Suk Lee discusses the policy responses of the South Korean government. Southeast Asia Program Director Don Emmerson offers a comparison of different governance strategies and actions implemented across Southeast Asian countries, while Karen Eggelston, APARC's deputy director and director of the Asia Health Policy Program, addresses the response of health systems in Japan and South Asia.

Watch the full discussion and Q&A below. You can also read the Stanford Daily's coverage of the event.

WATARU FUKUDA
Chief Representative of the Shizuoka Prefectural Government in Singapore
Global Affiliates Program Fellow, 2014-16

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TSUYOSHI KOSHIKAWA
Chief Advisor, Japan International Cooperation Agency Expert for the Ministry of Planning, Finance, and Industry in Myanmar
Global Affiliates Program Fellow, 2014-15

I currently live in Naypyitaw, Myanmar, though I am originally from Japan. Naypyitaw is currently not under shelter-in-place, though the city of Yangon is. In Naypyitaw, restaurants are serving only take-out meals, and most amusement facilities like movie theaters, karaoke boxes, bars, and beauty salons have been closed. There are still a few big department stores open, as well as the public golf course and tennis courts.

At the time of this writing, the number of known COVID-19 cases in Myanmar is nearly 150, and I am worried about the potential risks because the healthcare and medical information systems here are not as organized as in countries like Japan, the UK, or the United States.

Anyone with a fever of 37.5 degrees C (99.5 F) or higher is being kept from entering Yangon. The Ministry of Health is taking all traveler’s temperatures at the airport, railways stations, and the exits of all highway interchanges throughout Yangon. Foreigners with a fever of 38 degrees C (100.4 F) have been told that they will not be permitted into private hospitals anywhere in Myanmar at present. Isolation wards in general hospitals will accommodate foreigners. The situation is frightening, but with frequent handwashing and hygiene, we are trying to take care of each other.

XIAOYUAN SHI
Deputy General Manager in the Internal Audit Bureau at the Industrial and Commercial Bank of China
Global Affiliates Program Fellow, 2012-13

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Thankfully, our efforts have worked. The new confirmed cases are mostly coming in from foreign travel. Big cities like Beijing and Shanghai have low infection rates, and people feel much less stressed. Social life, work, and production are recovering, and the lockdown of Wuhan City has been lifted. Most schools will continue to use online classes for the time being and restaurants are still not fully open, but I think the most difficult time is behind us.

It’s impossible to spot all of the potential virus carriers, and therefore precautionary measures like avoiding going out unnecessarily, wearing masks in public, and handwashing are still recommended. I’ve not heard of COVID-19 cases or deaths among my acquaintances, thankfully, but the conditions here have proven that this virus is highly infectious and death is possible. I hope our practices here can provide some references for other places where it is spreading.

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.