Effect Measure

Swine flu in China: no problem

Since the way Chinese public health officials traditionally save face is by covering their ass, when I hear things like this I don’t automatically believe it:

“With initial efforts of containment, actually we not only reduced the impact of the first wave to China, but we also won time for us to prepare the vaccine” now being given to China’s people, [Chen Zhu, China's health minister] said in an interview during the Havana meeting of the Global Forum for Health Research.

After the swine flu first appeared in Mexico last spring, China put Mexican visitors ? and people from other countries who had set foot in Mexico ? in weeklong quarantines and monitored them for the virus, whether or not they seemed sick.

Chinese authorities also isolated entire planeloads of international visitors if someone on board experienced flulike symptoms. They pulled passengers off trains and blocked access to villages if someone got sick after coming into contact with a foreigner.

Such measures are easier to impose in an authoritarian state. They sparked protests around the world, but when asked if they were successful, Chen said: “Exactly, very successful, exactly.”

“We are confident the situation is under control,” he said. (AP via Chicago Tribune)

While the New York Times China correspondent Edward Wong seem to find these assertions credible, others (including us) aren’t quite so credulous:

Health experts say extraordinary measures against swine flu ? most notably quarantines imposed by China, where entire planeloads of passengers were isolated if one traveler had symptoms ? have failed to contain the disease.

Despite initially declaring success, Beijing now acknowledges its swine flu outbreak is much larger than official numbers show.
China’s official count of nearly 70,000 reported illnesses with 53 deaths is dwarfed by estimates of millions of cases with nearly 4,000 deaths in the United States, a nation with about a third of China’s population. (Maria Cheng, AP via Google News)

Earlier we put up a detailed post about a tour group outbreak of swine flu where all of China’s containment measures failed miserably. The Chinese have a terrible record on leveling with the world on disease outbreaks — their cover-up of SARS is exhibit one — so there is more than some suspicion the Draconian swine flu measures were as much about show as about public health (this is something all governments do, including the US). And now China’s alleged transparency on swine flu is being questioned by the same specialist who helped blow the whistle on his government during the SARS outbreak:

Zhong Nanshan of Guangzhou Institute of Respiratory Diseases in southern China, called into question the official number of deaths from H1N1, telling the Southern Metropolis Daily newspaper that the quoted figure of 53 was too low. ?I just don?t believe that there have been 53 H1N1 deaths nationwide,? he said.

[snip]

While many have pointed out that limitations on testing capacity have led to an underreporting, Zhong suggested that some hospitals were intentionally not testing those who died from pneumonia for H1N1.

His words carry weight because he shot to fame during the Sudden [sic] Acute Respiratory Syndrome (SARS) outbreak in 2003 for quickly recognizing and reacting to the threat posed by the new virus while government officials around the country tried to cover it up. (David Cyranoski, Nature blog The Great Beyond)

China has a sorry record on bird flu as well. While we tend to think of authoritarian central governments as all-powerful, they are often unable to control what goes on in far flung provinces at or beyond the periphery of their reach (we see the same thing in US federal agencies where regions often act autonomously against the orders of the headquarters). It would not be surprising to find that many deaths have been covered up or just ignored in provincial hospitals. There could be all sorts of motives for this, none of them praiseworthy.

Katherine Todrys and Joe Amon of Human Rights Watch have pointed to another factor that might be making the toll from swine flu less visible in China:

Worldwide, far more people migrate within than across borders, and although internal migrants do not risk a loss of citizenship, they frequently confront significant social, financial and health consequences, as well as a loss of rights. The recent global financial crisis has exacerbated the vulnerability internal migrants face in realizing their rights to health care generally and to antiretroviral therapy in particular. For example, in countries such as China and Russia, internal migrants who lack official residence status are often ineligible to receive public health services and may be increasingly unable to afford private care. (Todrys and Amon, Commentary in Globalization and Health, Human Rights Watch)

There are vast numbers of internal migrants in China and it is likely many of them have very little or no access to health care. They die unattended and perhaps buried unrecorded.

Unlike China’s health minister, I an not confident swine flu is under control in China. At least no more confident than I am that Sarah Palin is an expert on energy policy.

Comments

  1. #1 Phil
    November 22, 2009

    Well written sir, well written.

  2. #2 gao
    November 22, 2009

    It is understood the “under-control” is optimistic wording. In case of measures.

    count the sick people, dead people by swine flu and divide by the total population.

    Compare the correlation between that number against countries with strong measures (like china, japan) and let’m-get-it countries (like US)

  3. #3 Eamon
    November 22, 2009

    Gao@2

    Compare the correlation between that number against countries with strong measures (like china, japan) and let’m-get-it countries (like US)

    I think it’s simplistic to define Japan as a country with strong measures against swine flu – some of the things that are done in Japan are good measures – i.e. closing schools, others are bad, e.g ‘the facemask will catch everything’ attitude prevalent over here.

    There is also a tendency to only go into action when ordered from above, and to only undertake the measures suggested. An example of the former, from my own experience – hand washing with soap was only undertaken in my school when rules on fighting the infection were promulgated. An example of the latter is that the reusable facemasks our students use when giving out lunch are still stored together in a sealed plastic box between lunch sessions!

  4. #4 Shay
    November 23, 2009

    Compare the correlation between that number against countries with strong measures (like china, japan) and let’m-get-it countries (like US).

    Swine flu response in the US is different, largely because the active measures are not top-down but rather being conducted by local authorities (county health departments) under the direction of their states and of course under CDC guidelines. Response will vary from county to county, but most of the health dep’t officials with whom I come in contact are reacting with mass vaccination clinics as vaccine becomes available, as well as prevention education and as much public health presence in the local media as the local media allows (which sadly, at least here, is not a great deal. For our local news outlets H1N1 is considered to be “old news.”)

    The vaccine is free and in this county we have done about 10K vaccinations (for a total county population of 170K). Our intent is to keep vaccinating until we have no more vaccine left, and to keep reminding the public of the importance of having the highest-risk groups–children, pregnant women, residents with underlying health conditions–vaccinated.

    I am seeing the same aggressive campaigns being conducted in surrounding counties.

  5. #5 K
    November 23, 2009

    I don’t work in a health field but in my experience the typical way American co-workers and bosses save face is to cover their ass. I hope you are right and that non-Asian public officials as less likely to try to save face. As we know American politicians are keen on saving face. I know that saving face is supposed to be part of the culture of Asia, but frankly I think it is part of the culture of all humanity and it is the form that is different in different countries.

    For example “Peace With Honor

    President Nixon hailed the agreement as meeting “the goals that we considered essential for peace with honor.” Nixon ran for president in 1968 on a pledge of bringing the war to an end, but only by achieving what he called “peace with honor.” He was unable to achieve it in his first term but then settled with the North Vietnamese on terms that were exactly the same as the Johnson Administration had negotiated shortly before the election in 1968.”
    http://www.super70s.com/Super70s/news/1973/january/23-Vietnam_Peace_Treaty.asp

    Just who was saving face here – the Asians or the USA. Peace with honor my foot, we were bested and ran home with our tail between our legs.

  6. #6 BostonERdoc
    November 23, 2009

    Quarantine should be a by-gone infection control measure. In our open and mobile societies it wont work since the success of quarantine depends upon the transmission characteristics of the outbreak, namely the R0, theta value and serial interval. Compliance by the public is another important factor. Just look at the EID article reviewed on this blog several months ago of the US tour group in china in which 9 secondary cases developed during either air travel or in a bus. The index and 3 secondary casees were symptomatic during travel but lied on their health questionaires likley fearing being escorted off by someone in a goon suit. Some how I dont think this reluctance to fill out the questionaire truthfully was an exception rather than the rule with travellers. Talk to anyone in CDC and they will fess up: It is viturally impossible to contract trace flu in any meaningful fashion with current technology so there lies the ultimate case against quarantine. There is a dearth of scientific support of quarantine use in 21st century influenza pandemics. In fact, the only support come from pie in the sky computational modelling looking at the effectiveness of home quarantine with H5N1 when combined with isolation of the sick and antiviral use. But these studies–reviewed by the IOM–are riddled with either unrealistic or uncertain assumptions and parameters used in their design. For H1N1 the low R0, low CFR, medium high theta and extremely short serial interval argues that quarantine is useless and a fools paradise in Western socities anyway. It is time for the chinese and other govts to see this reality and to stop feeding into the “bug of the month” mentality that just adds to public anxiety.

  7. #7 Don S
    November 23, 2009

    The apparent failure of the Chinese government to have learned from its past loss of face that resulted from hiding information until it became clear that continuing to do so was impossible is unfortunate.

    Obviously some are fixated on mutations noted in various other locations – my concern is placed most on what happens in China (and a few other countries, like Indonesia and Thailand).

    It is hard to imagine that these high population density countries are not having more spread than is being reported (sort of like the election in Iran) and the yet these are the countries that are most likely to create an avian-swine hybrid or a mutation of potential badness.

    Real information in real time would be useful but it seems like we’ll be unlikely to get it.

  8. #8 revere
    November 23, 2009

    Don: Not to mention Indonesia’s continued refusal to share viral isolates (see the many posts < a href="http://scienceblogs.com/effectmeasure/vaccines/">in the vaccine category) before April of this year or search on the Google search bar for Indonesia.