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.

In 2008, the U.S. National Intelligence Council (NIC) published the fourth installment in its effort to identify “megatrends” likely to shape world events a decade or more into the future. Shorenstein APARC Fellow and China expert Thomas Fingar, the then chairman of the NIC, oversaw that report, Global Trends 2025. The unclassified report uses scenarios to illustrate some of the ways in which the factors driving world events – from climate change to demographic decline to changing geopolitical powers – may interact to generate challenges and opportunities for future decisionmakers. One of these scenarios is the emergence of a global pandemic that bears a chilling resemblance to COVID-19.

We sat down with Fingar for an online conversation about the NIC report and its pandemic scenario, the government action it spurred, the United States’ failed initial response to the COVID-19 outbreak, and the implications of the current crisis for U.S.-China relations. Watch:

Twelve years after its publication, the NIC’s "Potential Emergence of a Global Pandemic" scenario (p. 75) has proven to be woefully accurate:

“The emergence of a novel, highly transmissible, and virulent human respiratory illness for which there are no adequate countermeasures could initiate a global pandemic. If a pandemic disease emerges by 2025, […] it probably will first occur in an area marked by high population density and close association between humans and animals, such as many areas of China and Southeast Asia […] Slow public health response would delay the realization that a highly transmissible pathogen had emerged […] Despite limits imposed on international travel, travelers with mild symptoms or who were asymptomatic could carry the disease to other continents. Waves of new cases would occur every few months. The absence of an effective vaccine and near-universal lack of immunity would render populations vulnerable to infection.”

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It was not a prediction, recalls Fingar, but rather an attempt to urge policymakers to think “beyond tomorrow,” past the end of their administration, and to stimulate strategic thinking about how to reinforce positive trends and change or ameliorate negative ones. If the report and its global pandemic scenario are precise, he notes, it is because the NIC’s effort involved the best specialists within the U.S. intelligence community and engaged numerous and varied groups of non-U.S. Government experts.

Yet the United States has been unprepared for the COVID-19 pandemic and the crisis is now worsening U.S.-China tensions. To address the crisis, however, argues Fingar, both countries must cooperate in the international fora. “Let that be the way that builds towards a better bilateral relationship.”

Deputy Director of APARC and Director of the Asia Health Policy Program Karen Eggleston recently spoke to Bloomberg Markets about the new cases and the further spread of the COVID-19 coronavirus in the United States.

"There has been widespread international collaboration on the scientific side to try and get ready for a vaccine and for therapies, but that takes time. In the meantime, you have to rely on tried and true public health measures."

Eggleston stressed the importance of people remaining calm and avoiding both complacency and panic in response to the growing public health crisis. Instead, being proactive, science-based, and utilizing clear, organized communications channels are the keys to protecting individuals and communities and in making timely, informed, effective decisions about future steps as the outbreak continues. Typical practices for flu season such as frequent handwashing, staying away from public spaces when ill, and following recommended self-quarantine guidelines are all measures people can take to support their well-being and the health of those around them.

"It's important to remember that both the transmissibility and the fatality rate [of COVID-19] can be changed by the way we respond. The way we trace the contacts and isolate can reduce the transmissibility. And the resilience of our public health system and investment in prevention and supporting our healthcare workers — and having the right equipment in place for the severe cases — can affect the fatality rate and protect people."

Watch the full interview below to hear more recommendations on how to prepare.

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.

Jointly with partners throughout Asia, the Asia Health Policy Program (AHPP) at Shorenstein APARC has developed comparative research on health care use, medical spending, and clinical outcomes for patients with diabetes in the region and other parts of the world as a lens for understanding the economics of chronic disease management. Karen Eggleston, AHPP director and APARC deputy director, recently traveled to South Korea, where she led three project-related events.

On November 29, a workshop on Net Value Diabetes Management was held at Seoul National University (SNU) School of Medicine. This was the third such workshop convened through the project, following two previous ones held in Beijing at the Stanford Center at Peking University. Another workshop, on diabetes modeling, hosted by the Mt. Hood Diabetes Challenge Network, was held at Chung Ang University on December 1. Finally, on December 5, Eggleston held an information session, titled Comparative Economics Research on Diabetes, during the 2019 International Diabetes Federation (IDF) at BEXCO in Busan. These events were also made available through video conferencing to enable remote participation by collaborators who were unable to travel to Korea.

[Learn more about AHPP’s Net Value in Diabetes Management research project]

Diabetes Net Value Workshop

The workshop brought together team members from multiple health systems — including South Korea, Japan, Taiwan, Hong Kong, Thailand, India, the Netherlands, and the United States — to discuss comparative research on the economics of diabetes control. Eggleston shared the results of a study outlined in a working paper on the net value of diabetes management in Japan, the Netherlands, Taiwan, and Hong Kong. This research is part of a broader series of studies aimed to help address the policy challenge of finding the best strategies to improve health through cost effective prevention and healthcare productivity in chronic disease management.

The key to this research was to measure changes in quality or health outcomes over time by predicting mortality risk using blood pressure, blood sugar, and other factors amenable to patient and provider control and improvement (controlling for age and duration of diabetes diagnosis). The research seeks to understand how we can control cost and eliminate waste without cutting out the things that are valuable and improving people’s quality of life. Further studies probe determinants of relative net value of a pay-for-performance program in Taiwan, adherence to medications and vertical integration in Japan, and net value based on a randomized controlled trial in India.

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Young Kyung Do of SNU reported that according to his evaluation project for diabetes care, the quality of care and treatment in South Korea has improved and is similar to Hong Kong and Singapore. The goal of the program is to provide more comprehensive care to diabetes patients.

Talitha Feestra of the Netherlands net value team presented her proposal for joint research to develop new prediction models for specific populations as a core component of health economics decision models in Diabetes. Feestra will take the lead to develop the plan and time frame for the continuation of this research in 2020.

Several additional comparative studies were proposed and discussed. Participants who attended the workshop and contributed to discussion included Junfeng Wang from the Netherlands net value team; Jianchao Quan and Carmen Ng from Hong Kong University; Daejung Kim from the Korea Institute for Health and Social Affairs (KIHASA); Taehoon Lee, Eun Sil Yoon, and Hongsoo Kim from SNU; Piya Hanvoravongchai from Chulalongkorn University; and Gregory Ang from National University of Singapore. Remote participants included Vismanathan Baskar from Madras Diabetes Research Foundation; Wasin Laohavinij from Chulalongkorn University (visiting Stanford University autumn quarter); and Rachel Lu from Chang Gung University.

Mt. Hood Diabetes Challenge Workshop on Diabetes Modeling

Philip Clarke from the Health Economics Research Center, University of Oxford, presented the history of insulin as a cure for diabetes and discussed in detail methods for economic modeling of diabetes, including quality of life and diabetes cost, drawing from his rich experience developing the UK Prospective Diabetes Study outcomes model. The second presenter was Andrew Palmer of University of Tasmania, Australia. His presentation included many additional economic modeling pointers, especially regarding drawing in the literature for building models.

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We are grateful to Professors Clarke and Palmer for graciously allowing the AHPP network researchers to join the workshop both in person and remotely, adding to their chronic disease modeling skills, and for inviting Karen Eggleston to present a keynote at the Mt Hood conference that took place before the modeling workshop.

Information Session: Comparative Economics Research on Diabetes

The third and final component of the diabetes research events was held on December 5 as part of the International Diabetes Federation congress in Busan, Korea, and presented the network to clinicians and public health researchers. Participants from China, India, and Australia attended. They shared updates on their individual projects and discussed methods and ideas for future collaboration.