Ka-che Yip. Disease, Colonialism, and the State: Malaria in Modern East Asian History. Hong Kong University Press, 2009.
In a document entitled Country Cooperation Strategy: WHO China Strategic Priorities for 2004-2008, the World Health Organization (WHO) and China outlined areas of co-operation and the health and development agenda for the mid-decade. One of the priorities was the control of diseases with epidemic and pandemic potential including malaria, dengue, influenza, cholera, and measles. After decades of well-publicized success in the control and elimination of some major communicable diseases, by the beginning of the twenty-first century China was once again confronted with the resurgence of some diseases that had previously been under control, especially malaria and cholera. Certainly some of the major threats, for example, avian influenza and Severe Acute Respiratory Syndrome (SARS), are emergent diseases, but the fact remains that political, social, and economic changes since 1979 have critically affected China’s capability to deal with some diseases that had been under control in the past.
One of the critical factors that undermine China’s capacity to prevent and control disease outbreaks is the reduced role played by the state in the health sector. The state has allowed market forces to control, to a significant extent, the delivery of health care, resulting in a rise of problems associated with the distribution of health resources and the accessibility of care. The SARS outbreak in 2003 prompted the government to re-evaluate its health policies and reform the public health care system. Through a study of China’s anti-malaria efforts from 1949 to the present, this chapter analyzes the philosophy, strategies and implementation of anti-malaria programs in the context of the development of health care services in China before the late 1970s when new economic policies contributed to changes in such programs. It will also examine the impact of post-1979 reforms on the development of health services, especially with regard to anti-malaria efforts. A major concern of this study is an evaluation of the role of the state in the organization, administration, and delivery of health care to meet the health needs of the population.
History of Malaria before 1949
Malaria has a long recorded history in China. In the past, inhabitants of provinces like Yunnan, Guizhou, and Guangxi believed that the inhaling of zhangqi (noxious exhalations) from putrescent vegetation or dead animals in low-lying wetlands, caused the disease. The impact of the disease, especially in areas where it was endemic, had been severe, causing depopulation and retarding economic development.
Based on epidemiological data, China can be divided into four broad malarial zones. The tropical and subtropical regions south of latitude 25º N including Yunnan, Guizhou, Guangxi, Guangdong, and Hainan have malaria transmission lasting from nine to twelve months each year. Anopheles minimus is the main vector and three malaria parasites, Plasmodium falciparum, P. vivax, and P. malariae are present. Between latitudes 25º N and 33º N where P. vivax is most common, malaria transmission occurs for about six months each year. Zone three north of latitude 33º N has a short malaria transmission season with only vivax infections and A. sinensis as the vector. Yet because malaria in the region is generally unstable, severe outbreaks may occur if conditions were favorable. Finally, the malaria-free zone encompasses all high altitude and desert areas of central, northwest, and northeast China. China’s huge size, diverse topography, and multiple malaria vectors prove to be major obstacles in any national anti-malaria programs, and malaria control, let alone eradication, is not an easy task.
There was no accurate data regarding malaria cases, mortality rates or infection rates before the early 1930s since systematic epidemiological studies of the disease did not exist. In 1931, with the technical support of the League of Nations Health Organization, the first scientific survey of the distribution and incidence of malaria was carried out along the lower and middle Yangzi Valley. Chinese scientists conducted further studies of malaria in various parts of the country in the 1930s and 1940s: for example, Feng Lanzhou (L.C. Feng) from the Division of Parasitology at the Peking Union Medical College carried out studies in Guangxi province, and Xu Shiju (S.C. Hsu) from the Malaria Section of the National Institute of Health worked in Sichuan.
Throughout the pre-1949 period, the infection and mortality rates remained high. In 1932, floods along the Yangzi River contributed to the infection of about 60% of the population and the death toll reached 300,000. The absence of political stability and the paucity of both funds and trained personnel resulted in only limited efforts to control the disease under the Nationalists. During the war years, the large and unprecedented migration of people with no immunity to malaria into interior provinces where the disease was endemic contributed to the outbreak of epidemics and a surge in the rates of infection and mortality. The movement of troops and refugees in other parts of the country also contributed to malaria epidemics in many areas in central and eastern China. With the founding of the People’s Republic in 1949, the new government was confronted with a devastating malaria problem characterized by an estimated 30 million cases of which 1% proved fatal. Moreover, malaria was endemic in more than 70% of the country’s counties.
Health Policies and Malaria Control before 1978
Although malaria was a serious problem, it was only one of the many infectious and parasitic diseases that the state had to deal with. The formulation of anti-malaria policies before 1978 was closely linked to the development of health policies and health care services that were part of the national planning for political, economic and social developments after 1949. Declaring that the improvement of the population’s health was crucial for national strengthening and socialist construction, the government maintained that, as in other areas of national construction, medicine and health care would be under central guidance and control, and national and local priorities would be set for the benefit of the entire population. The linkage between economic development and health had been an important theme in the national discourse on China’s modernization and reconstruction since the 1920s, and both the Nationalists and Communists shared the belief that the debilitating impact of diseases and the poor physical health of the population had contributed to massive poverty and national weakness. For the good of the nation, the state should establish the modern health services essential to economic growth and the improvement of people’s livelihood. Individuals in turn needed to maintain good health for the sake of national strengthening and well-being—that would indeed be their patriotic duty. Not surprisingly, “patriotic health campaigns” constituted one of the central features of Communist public health activities after 1949.
In the First and Second National Health Conferences in 1950 and 1951, the Chinese Communist Party (CCP) outlined four guiding principles for China’s health policies: to serve the workers, peasants and soldiers; to stress prevention; to unite Chinese and Western medicine; and to combine health work with mass movements. The state’s emphasis on prevention rested on the premise that preventive medicine and public health improvements would help to control or even eliminate many of the common diseases that constituted the most urgent threat to the overwhelming majority of the population. The intent to eliminate this threat was, as noted earlier, partly economic, but ideological factors were also important. Chinese socialism sought to create an egalitarian society in which all members of society would enjoy access to health and other social services. The constitution of 1954 in fact committed the government to providing its citizens with the “five guarantees”: food, health care, education, shelter, and a funeral. Health care was to be a major pillar of the new society that was being constructed by the CCP.
The new state medical policies being formulated by the CCP were in many ways based on experience gained by the party during the 1930s and 1940s. A central element of that experience was the concept of the “mass line”—an approach that had been used in political, social, and economic campaigns. In practice, the mass line in health care had four priorities: to target diseases and problems that affected the majority of the population; to mobilize the population to participate in health work; to establish a health care system that would benefit the country as a whole, and to develop a close working relationship between the CCP, the government, and the people. In the context of the early People’s Republic, this model of preventive medicine would be highly labor-intensive but economically feasible since the new state simply did not have the health resources—human, financial, or technical—to engage in expensive and technologically advanced curative medicine.
In December 1952, the Second National Health Conference declared the government’s intention to eliminate such endemic diseases as schistosomiasis, hookworm, malaria, and kala-azar. The following spring, the government began to build a preventive care and anti-epidemic health network targeting specific diseases, including malaria. By 1955, 39 anti-malaria stations responsible for implementing pilot programs to investigate and control malaria were established in such provinces as Yunnan, Guizhou, Sichuan, Guangdong, and Guangxi. The CCP played a central role in all activities undertaken to eradicate the targeted diseases. In December 1955, it created a special nine-member leading team in the Party central to oversee anti-schistosomiasis work, and to co-ordinate anti-malaria efforts. This was followed by a national conference which launched a nationwide anti-malaria campaign, with the ambitious objective of eliminating the disease within seven years.
An important result of the preparatory work was the incorporation of the specialized prevention and treatment stations into a vast, nationwide preventive and anti-epidemic network. The network was headed by the Sanitation and Epidemic Prevention Department of the Ministry of Health which maintained professional oversight over anti-epidemic stations at the provincial, municipal, and county levels. The municipal anti-epidemic station supervised the work of district anti-epidemic stations and street health stations as well as anti-epidemic stations that might be established in factories and enterprises. With the establishment of the commune system in the late 1950s, anti-epidemic stations at the commune level, health clinics at the brigade level, and health stations at the team level were in charge of anti-epidemic and public health work. Units within this vast network had the mandate to carry out a broad range of preventive and anti-epidemic tasks, especially the control and surveillance of infectious and parasitic diseases, and the training of personnel. The number of anti-epidemic stations increased from 1,626 in 1957 to 2,912 in 1975.
What made this vertically organized and co-ordinated structure viable was its collaboration with the clinic-based primary health care system, which provided significant support. The combined systems served as an integrated structure for both disease control and treatment. The advantage of this integrated structure was especially evident at the basic levels in the countryside where the health services took charge of medical care, community health and disease prevention, environmental and sanitation improvements, health education, monitoring and reporting of diseases, and the implementation of disease control and treatment measures. The rural health care system was essentially based on the three-tiered structure of state medicine developed by the Nationalist in the 1930s. At the xian (county) level were the health bureau (weisheng yuan), hospital, laboratory, and maternal and child care station, in addition to the anti-epidemic station. Under the xian were qu (district) health clinics which later became commune health clinics (gongshe weisheng yuan). The third tier comprised the production brigade health stations (shengchan dadui weisheng suo) staffed by barefoot doctors who engaged both in curative work as well as preventive care, including malaria control activities such as collecting blood slides from fever cases and making a diagnosis; providing health education; gathering and reporting epidemiological information; and training helpers in the implementation of malaria control measures. The government reported that a total of 2,123 counties (about 90%) had established health bureaus by 1952. The state’s ability to extend health care and disease prevention all the way to the grassroots was crucial for the success of the anti-malaria campaign.
The government also developed programs to train anti-malaria personnel. In the early 1950s when Sino-Soviet relations were cordial, the Ministry of Health invited Soviet medical and health advisors to set up training classes for senior anti-malaria cadres. At the same time, health departments at various levels provided training for mid-and lower-level anti-malaria personnel; from 1956 to 1967, more than 3,000 persons received specialized training. Moreover, the government expanded the training and supply of medical personnel specializing in preventive care and related fields, and their ranks jumped from 532 in 1952 to 6,428 in 1963.
Mass Mobilization and Anti-malaria Work
One of the premises of the mass line approach in health work was that success depended on the people’s involvement and participation. Throughout the 1950s and 1960s, numerous mass movements were conducted by the Party to mobilize the population to achieve specific political, social, and economic goals. These included the anti-American imperialism movement during the Korean War, thought reform directed at intellectuals and the national bourgeoisie, land reform, aimed at a more equitable allocation of land through redistribution, and the Great Leap Forward which aimed to increase agricultural and industrial production. According to the CCP, such campaigns served to alter the consciousness, and release the energy, of the people through direct involvement in specific activities. The energy and initiative of the entire population would be mobilized to compensate for the lack of other resources, including funds, advanced technology, and highly trained personnel.
Specifically, mass health campaigns aimed to educate the people about the government’s health policies as well as the nature of diseases and methods of health protection. Mao Zedong had insisted on the primacy of practice and the people’s participation in such campaigns would, according to Mao, not only educate and change attitudes but also make the health habits that were being promoted part of the people’s lives. Moreover, as noted earlier, health campaigns were deemed part of the patriotic movement dedicated to national strengthening and modernization—objectives that would be accomplished only if the people were physically fit and the country’s health indicators vastly improved.
Health campaigns in the 1950s and 1960s varied in duration and locality. Some, such as street cleaning and vaccination, lasted for several days or a few months and were carried out in specific localities with limited objectives and activities. Others were nationwide movements that could last for several years and were organized and co-ordinated directly by the government and Party.
One of the first health campaigns was the “Anti-American Imperialism Patriotic Health Movement” during the Korean War. Accusing the United States of engaging in biological warfare, the Chinese government used a nationwide health movement to publicize the alleged crime of the United States as well as educate the people about the germ theory of disease and the need to protect the country through the adoption of such public health measures as protecting water sources, sanitation, and vaccination. In December 1952, the government established the Committee on Patriotic Health Movements in the State Council to direct patriotic health movement committees that were being set up at all administrative levels. This structure, working side by side with the sanitation and anti-epidemic stations, helped to mobilize the masses in health work. In 1961, the Committee on Patriotic Health Movements merged with the Sanitation and Epidemic Prevention Department.
The mid-1950s saw the launching of a nationwide movement against the “four pests”: flies, mosquitoes, rodents, and sparrows (later replaced by bedbugs). The movement revealed clearly the central role played by the party-state in combating infectious and parasitic diseases. Using propaganda, publicity campaigns, exhibits, and mass organizations, the apparatus of the Party and government initiated mass mobilization efforts to carry out the destruction of the “pests” through labor, accompanied by sanitation and environmental improvements, promotion of hygienic habits, and public health work. The lack of insecticide was compensated by people swatting mosquitoes and flies with whatever tools were available, while the clean-up of collections of stagnant water and the cultivation of larva-eating fish in ponds and rice paddies helped to eliminate environmental conditions favorable to mosquito breeding. These mass movements undoubtedly contributed to the decline in malaria’s infection rate from 102 per 10 thousand people in 1955 to 21.6 per 10 thousand people in 1958.
It is important to remember that while the participation of the community was essential, success also depended on the co-operation of units within the patriotic health movement and the backing of the entire health care system and political structure. Indeed, even army units were recruited in the mass health campaigns. The need to correctly implement the party line in health matters, however, made such mobilization campaigns highly political. Local cadres sometimes would rather follow guidelines rigidly than make necessary adjustments to local conditions for fear of punishment, even though central directives had stressed the need to pay attention to regional variations. Leaders might also set goals that were unrealistic for certain mass movements, as in the case of the Great Leap Forward in the late 1950s, or movements could be manipulated by rival political factions within the Party in their internal power struggles, as in the case of the Cultural Revolution in the mid-1960s. The Great Leap Forward and the Cultural Revolution led to confusion and disruptions in anti-epidemic and public health activities, with serious consequences for the anti-malaria effort, a point which will be discussed in greater detail below.
Epidemiological Diversity and Regional Co-operation
Chinese health leaders were fully aware of the tremendous diversity that existed in the country with regard to the specific vectors in a particular area, the relative severity of the malaria problem, and local conditions that might facilitate or hinder the implementation of anti-malaria control measures. Instead of adopting a unitary approach, for instance relying on DDT residual spraying as was promoted by WHO in the 1950s and 1960s, the government allowed for variations in the methods used and time needed to bring about desirable results as well as the degree of success in different areas. In the tropical and subtropical areas where A. minimus was the main vector, insecticides were applied to reduce the high infection rate, although DDT was not used in large quantities at the beginning. China was able to mass produce benzene hexachloride (BHC) which proved to be quite effective even though its insecticidal effect was not as long-lasting as DDT. In areas north of latitude 33º N where only vivax infections were prevalent, more emphasis was placed on the use of larvicides, pisciculture in flooded rice fields, environmental engineering, and bed-nets.
An innovative approach was the establishment of co-operative agreements between provinces, as well as between counties within a province or in adjacent provinces, to enable collaboration and co-ordination on a larger scale in malaria control and surveillance. The movement of people across borders often made it difficult to prevent the introduction of imported cases into areas which had already interrupted local malaria transmission. Through working together, surveillance was facilitated while the initial alliance could be gradually broadened to encompass larger areas. The first such co-operative effort was organized by the Ministry of Health in 1964 and included the three provinces of Hebei, Shandong, and Henan. Anti-malaria organizations in these provinces received additional funding for personnel training and the purchase of drugs and other supplies. The outbreak of the Cultural Revolution in 1965 disrupted the expansion of such collaboration, and it was not until 1973 that the government once again organized a collaborative relationship between Jiangsu, Shangdong, Anhui, Henan, and Hubei. Government statistics showed that the number of malaria cases in these provinces declined by over 54% from 1974 to 1977 as a result of their co-operation and concentrated efforts.
Treatment and Care
Another feature of the anti-malaria efforts before 1978 was encapsulated in the slogan pucha puzhi (mass investigation and mass treatment). The state rejected previous treatment routines which might be more suitable for clinics or hospitals, insisting that to be effective, the attack on the malaria problem should involve mass treatment in the countryside. The therapies must be simple, safe, economical, of short duration, and use remedies that China could produce in large quantities. Extensive epidemiologic and entomologic studies had been carried out since 1950, and pilot projects on mass chemotherapy were introduced in provinces in central China where the use of residual insecticides would not be very effective or was too expensive. Health workers carried out extensive blood examination, case treatment, and anti-relapse treatment. In areas where both vivax and falciparum malaria existed, combined measures of residual spraying and mass treatment were implemented. At the beginning, China had to import almost all anti-malaria drugs, but by the early 1960s, it was able to produce in large quantities such drugs as chloroquine, paludrine, pyrimethamine, and primaquine, and studies on mass treatment with various drugs were carried out.
The Chinese government’s emphasis on the study and utilization of indigenous medicine also yielded important dividends in the fight against malaria. Chinese physicians had experimented with using acupuncture to remove the clinical symptoms of malaria during acute attacks. After much study, Chinese scientists also showed that a Chinese herb, qinghao or Artemesia annua L. (popularly known as sweet wormwood), which had been mentioned in ancient medical texts, possessed anti-malarial properties. In 1972, the active ingredient, qinghaosu (known in the West as artemisinin), was identified, and it proved to be an extremely effective anti-malarial, especially for falciparum malaria. This anti-malarial would become a most powerful new drug in the arsenal against global malaria.
Pre-1978 Efforts: An Assessment
Statistics of malaria cases and morbidity during the period from 1949 to 1978 clearly pointed to the success of the government’s anti-malaria strategies. In 1954, there were 6.97 million cases of malaria, accounting for about 62% of the total recorded cases of acute infectious diseases, and the morbidity was 1.2%. By 1979, 2.38 million cases were reported with a morbidity rate of 0.246%. More significantly, in 1979, government statistics showed that 948 counties (40.7%) with a combined total population of about 285 million were malaria free, while only 131 counties (5.6%) with a combined population of 74.4 million had an incidence above 100 per 10 thousand. Most of the areas in the south where malaria had been endemic had successfully kept the disease under control.
Many factors contributed to this success, but the active role played by the party-state was certainly critical. It set the policies and possessed the political will and determination to implement them nationwide as well as ensure their continuation. The anti-malaria effort was defined in both nationalistic and ideological terms—national strengthening and socialist construction. Thus, anti-malaria activities became a patriotic duty of every citizen and the full force of the Party and government would be used if necessary to ensure compliance, as well as provide direction and support. The closed socialist political economy and central control allowed for planned allocations and use of resources by the government in a manner that was not possible in most other countries. The long arm of the party-state also ensured compliance and enforcement of policies at the grassroots level where state control had been minimal or non-existent in the past. Mass mobilization in anti-malaria work made it possible for the state to publicize and implement anti-malaria measures through community and mass organizations, as well as through propaganda and education campaigns. Individual participation not only helped to promote and reinforce health habits, but also compensated for the lack of more advanced technological alternatives in combating malaria. Of course, the state’s constant exhortation and indeed pressure on the population to work together to build a strong China—physically and in other ways—served to remind the people of their patriotic duties and obligations to the motherland.
One of the first tasks that the state set for itself was the building of a health care infrastructure that could provide both preventive and primary care, although the emphasis was on prevention. The woefully inadequate health services in the pre-1949 period ensured that the vast majority of the population did not have access to basic care. The deplorable hygiene conditions, especially in the countryside, aggravated the situation; it is no surprise that communicable diseases were rampant and epidemics widespread, The People’s Republic was able to incorporate the vast population in the countryside into the three-tiered primary care and anti-epidemic system to ensure that both prevention and treatment would be available. Integration into this system also facilitated the detection, examination, reporting, and surveillance of malaria cases, and it provided a first line of defense against the potential spread of the disease.
It is interesting to note that during the 1950s and 1960s, under the direction of WHO, a global effort to eradicate malaria based mainly on the use of DDT encouraged many countries to devote a tremendous amount of resources to building a vertically organized anti-malaria structure which remained separated from any clinic-based health care system. Moreover, WHO’s plan envisioned specific time periods for the various stages in the campaign against malaria, an approach that encouraged countries to concentrate resources to fight the disease within a specific time frame. The failure of the DDT anti-malaria campaign left these countries without a comprehensive health infrastructure that could have provided preventive and primary clinical care for the people.
There were, however, problems in China’s approach. The role played by the party-state was critical but also meant that the anti-malaria campaign—and other health movements—were subject to political uncertainty. Any power struggles in the Party or shifts in the party line would not only create uncertainty but also potential policy changes that pose threats to the incremental improvements in the anti-malaria program.
There were two major surges in malaria cases owing to the breakdown of the anti-malaria and anti-epidemic structure. The first was in 1960 when a major epidemic broke out in north China. The ambitious program of agricultural collectivization that led to widespread confusion and mismanagement in the countryside during the late 1950s, plus the devastating consequences of natural disasters, disrupted the work of the anti-epidemic system, and from 1959 to 1961 anti-malaria activities came to a halt. The number of malaria cases jumped from 1.58 million in 1959 to more than 10 million in 1960. Hebei, Shandong, Henan, Jiangsu, and Anhui provinces were hit the hardest. The number of malaria-stricken people gradually declined toward the mid-1960s, but the outbreak of the Cultural Revolution created even more chaos and turmoil in the country with a devastating impact on the anti-epidemic system as a whole. The urban health structure was severely affected, and even though rural health services expanded and barefoot doctors became a mainstay of rural health care, the social unrest and dislocation disrupted or paralyzed many established preventive measures. Almost all anti-epidemic stations were shut down and many health personnel were purged, exiled, or imprisoned for re-education. The mass migration of people mandated by the xia-fang (sending-down to the countryside) program exposed vast numbers of people with no immunity to malaria. The number of malaria cases surged rapidly to more than 24 million in 1970; what was particularly worrisome was that many parts of the country where malaria had been under control witnessed a resurgence of the disease. A gradual rebuilding of the system began in the early 1970s, and it took almost an entire decade before the number of malaria cases subsided to 2.38 million in 1979. The Chinese government later officially attributed the disasters of 1960 and 1970 to an erroneous left line, but it is clear that the lack of autonomy on the part of health professionals as well as the politicization of health care made the health sector vulnerable to any shifts in policy or to political power struggles. The passing of Mao and the rise of Deng Xiaoping after 1978 did not necessarily guarantee that anti-malaria efforts would not be affected by political changes and policy shifts.
Post-1978 Reforms and Health Care
To revitalize China’s lagging economic development, Deng launched the Four Modernizations—in industry, agriculture, science and technology, and defense—to transform China into a modern socialist power. Deng rejected Mao’s emphasis on collectivism and absolute egalitarianism, opting instead for the building of a “socialist market economy.” The government sanctioned economic incentives, and farmers prospered as collective agriculture gradually disappeared. Centralized state planning and state administration were reduced, and private individuals or groups of private citizens could take over state-owned enterprises on contract or set up their own businesses. Foreign investment and joint ventures were encouraged. Economic liberalization, however, did not mean that Deng and most of his colleagues had given up the firm belief in Party supremacy, and political openness was not part of the reforms. But rapid economic changes and the increased power of the coastal regions and cities had undermined central political control and a general loosening of administrative authority over lower level units became evident. These changes were also accompanied by sectoral rivalries and various degrees of corruption that created problems in the co-ordination and implementation of central policies. Moreover, they contributed to a widening gap in incomes, and when internal controls over migration collapsed, the coastal regions and cities attracted large numbers of migrant workers and job seekers whose lack of health insurance and protection helped to aggravate the health care problems that had emerged.
For many, the improved living standards and general prosperity also resulted in better living conditions, diet and nutrition, and general health status. In fact, China experienced an epidemiological transition with an increase in chronic degenerative diseases such as heart diseases and cancer. But endemic diseases had not disappeared; in fact, some of them reappeared in the 1980s and 1990s as a result of the negative impact the changes discussed above had on the health care system, especially in the countryside. The co-operative medical schemes in the countryside had virtually collapsed, with only 9.5% of the rural population enjoying coverage in 1986. From 1975 to 1987, the number of village doctors (former barefoot doctors) declined by 18%. Many of them joined community practices or private fee-for-service clinics which in 1989 accounted for about 60% of village clinics.
The urban health care system, on the other hand, had far more resources. In 1986, the per capita health service fund allocated by the state was 4.34 times more than that in the countryside, and there were 2.69 times more hospital beds and 3.07 times more doctors per 1,000 people in the urban areas. The drive to modernize China’s medical system led to a bias towards curative medicine, biotechnology, pharmaceuticals, and research. The new focus represented to some extent a response to the changing disease pattern of the Chinese population as a whole, but the profit motive also created irrational incentives for hospitals to emphasize new biotechnology and drugs as well as charge excessive fees. At the end of 2002, there were more CAT (computed axial tomography) scanners in Beijing (population 13 million) than in England (population 49 million), according to a researcher at the China Academy of Health Policy at Peking University.
For the urban health sector, the issues of primary importance are financing, organization, and cost-containment. In short, ever since the early 1980s, there has been a shift in the concentration of resources from rural to urban areas, and from public health to curative medicine. State funding for health care declined in the 1990s; indeed, the percentage of total government spending on health dropped from 22% in 1991 to 14% in 2000. The World Health Report 2000 in fact ranked China a low 139th for health expenditure per capita and 188th for equity of financing. As the state continued to scale back the national health care system and relied increasingly on the market mechanism to determine service provision and funding, public health programs that did not generate profits suffered.
The decline in investment in public health was at least partly responsible for the reappearance of some diseases that had been under control. Schistosomiasis reemerged as a major problem in parts of China in the early 1990s, and the absence of anti-schistosomiasis health education apparently contributed to the lack of preventive measures taken by many people when fishing, swimming, and rice planting in areas where the disease had been endemic. Some even confessed to a complete lack of knowledge of the disease. Parasitic infections continued to be a major problem: 87% of the country is endemic for cystic echinococcosis, and the rate of some nematode infections was close to 50%. The nationwide immunization program also suffered with the prevalence of fee-for-service health care. Immunization coverage dropped to 60% in urban areas and 33% rural areas, and the re-emergence of diphtheria in Beijing in 1990 was apparently linked to a reduction in regular immunization.
Controlling Malaria in a New Era
Citing examples of health care problems that developed in the post-1978 period does not mean that the accomplishments in disease control since 1949 have been completely lost. There have not been any major surges in malaria cases since 1970 and much of the anti-malaria work has continued. The number of reported malaria cases declined steadily from 117,359 in 1990 to 24,088 in 2000.
To repair the rupture in anti-malaria efforts caused by the Cultural Revolution, the government established the National Committee on Malaria in the Ministry of Health in 1981 to co-ordinate the organization, management, and implementation of anti-malaria activities as well as the research, development and production of anti-malaria drugs. The Committee was not only responsible for co-ordinating activities at different administrative levels but also for co-ordinating the activities of the various institutions, agencies and departments involved in anti-malaria efforts, including universities and research institutes, the Commerce Department, the National Institute for Control of Pharmaceuticals and Biological Products, and the Ministry of Health.
The government also promulgated national indicators to guide the various stages of anti-malaria work. Control (kongzhi) is considered to have been achieved when an incidence rate of not more than 1 per 1,000 population over a period of at least two years is reached at the county level. Basic elimination (jiben xiaomie) is achieved when an incidence rate of not more than 1 per 10,000 population over a period of at least three years is reached at the county level. Finally, when a county has achieved basic elimination for more than three years and no new local cases have occurred in the last three years, then malaria is considered to have been successfully eliminated (xiaomei). Of course, because of China’s huge size and topographical diversity, not all areas can achieve the same stage at the same time. When an area has reached the stage of basic elimination, it enters into the consolidation phase when the development of an effective surveillance system to detect new local foci of transmission or imported cases becomes especially important.
With the gradual re-establishment of malaria control mechanisms, the government’s anti-malaria strategy in the 1980s increasingly focused on the consolidation of gains. The anti-vector strategy continued, although with reduced funding. This involved environmental improvements to eliminate larval breeding places, and experiments to combine methods of agricultural production, soil-moistened irrigation, and water drainage at regular intervals to control the rice-field breeding species of mosquito vectors. Selective residual spraying was carried out to target specific mosquito species. For instance, in Hubei, DDT indoor residual spraying in houses and animal sheds was applied at the end of May for two consecutive years in areas where Anopheles anthropophagus was the main vector. Success has been reported with the use of bed-nets impregnated with chemicals. Studies from Sichuan between 1987 and 1989 involving 2.42 million bed-nets in 40 counties proved that bed-nets sprayed with deltamethrin were an effective means of vector control. In Henan, malaria incidence was also significantly reduced in 1990 with the use of alphamethrin-impregnated bed-nets. This method of control became a standard anti-malaria measure and its use was also promoted by WHO.
The use of mass mobilization to promote anti-malaria activities was de-emphasized; this might reflect the fact that the post-Mao leadership was less inclined to adopt such Maoist tactics, but in fact, mass movements proved to be difficult to organize in the post-1978 environment. Moreover, they are not very effective in the consolidation stage of anti-malaria efforts. But the use of mass propaganda continued to be important. There was a new message, however. Anti-malaria propaganda stressed not so much the individual’s patriotic duty to the state, instead, it appealed to economic motives; controlling malaria was a way out of poverty. This argument was widely publicized, especially in poorer regions and border areas.
Treatment and Training of Personnel
One of the most important initiatives in the detection and treatment of malaria patients was the creation in the early 1980s of a large number of stations for the microscopic examination of febrile patients, especially in endemic areas. By 1986, government statistics indicated a total of 15,310 township stations, which provided coverage for a population of 462 million, and which had examined 20,203,000 blood slides by microscopy. The expansion of the number of stations was accompanied by the training of additional microscopy technicians. Such stations proved to be critical in the detection, treatment and control of malaria. The strategy of mass treatment, whenever and wherever feasible, was continued and sustained. China had been successful in the large-scale synthesis of anti-malarial drugs in the 1960s and 1970s as well as the use of chloroquine-resistant drugs such as qinghaosu derivatives, which had proved to be particularly effective in the treatment of falciparum malaria. From 1979 to 1989, government data showed that 14.58 million cases had been cured, and 187 million people treated during the quiescent phase of transmission. Moreover, prophylactic drugs were given to 343 million people during transmission seasons. Similar activities continued throughout the 1990s and the operational malaria control activities focused mainly on case management, vector surveillance, and blood surveys.
Village doctors continued to be key in providing treatment and care, as well as co-ordinating and disseminating propaganda at the grassroots level. Changes brought about by new market forces, however, created problems in some areas. Before the dissolution of the communes, barefoot doctors were primarily responsible for much of the preventive and curative work in the countryside. The decline in the number of barefoot doctors and new requirements for certification had, as noted earlier, resulted in a gradual exodus of the barefoot doctors. Some did continue in their positions and ultimately met the certification requirements to become certified village doctors. But the reduced numbers of these health personnel who had been responsible for preventive work and public health programs such as disease reporting, surveillance, and health education contributed to a gradual degrading of the state of rural health. Many of these village doctors received little professional supervision, and a survey in 1998 revealed that about 95% of health stations run by these village doctors were independent operations, competing with other private healthcare facilities for patients. The government had to resort to financial inducement to mobilize them to perform much needed public health work. These village doctors are now contracted to provide anti-malaria treatment and care for patients as well as organizing anti-vector activities in a specific number of villages, but reports point to inferior quality of service, or even a breakdown in the service in some areas.
The attempt to re-establish the anti-malaria structure in the early 1980s was accompanied by the government’s effort to train and replenish specialized anti-malaria personnel as the health system became increasing fragmented with the commercialization of care. Beginning in the early 1980s, China co-operated closely with WHO to train specialists in epidemiology, entomology, parasitology, and malaria control. WHO also used designated areas in Hainan Province in 1982 as field study sites for the training of personnel. Provincial health departments, working with universities and research institutes, offered long- and short-term programs to train personnel in infectious and parasitic diseases, including malaria. It has been estimated that by 1991, more than 280,000 senior, mid- and lower-level personnel had been trained and many filled positions in county and township health agencies and anti-epidemic stations. Unfortunately, these numbers proved to be inadequate, and the fragmentation of the health system as well as the commoditization of health care services often made it difficult for these specialized health workers to provide the necessary supervision of the work of village doctors or enforce health regulations. In fact, the anti-epidemic stations were also adversely impacted by economic changes, and they increasingly have to depend on revenue-generating activities, including the provision of annual physical examinations for workers and students, to support their work. The percentage of state funding in the total income of the anti-epidemic stations actually declined from 80% in 1985 to less than 40% in 1997. In 2002, when China established the national Center for Disease Control and Prevention (CDC), many local anti-epidemic stations were consolidated, renamed CDCs, and charged with broad responsibility for public health functions.
Malaria Surveillance
Anti-malaria work in the post-1978 period has been marked by a broadening and intensification of malaria surveillance as the government tries to protect and consolidate gains made in the past. One of the strategies has been to expand the regional anti-malarial alliances which allowed for the co-ordination of efforts and facilitation of surveillance. The co-operative relationship between the five provinces of Jiangsu, Shandong, Anhui, Henan, and Hubei that was formed in 1973 developed into a highly successful model for other regions. By 1986, the number of people in these five provinces infected with malaria had dropped to 230,000 from a high of 13,070,000 in 1973, and 81 counties had achieved basic elimination of the disease. Henan, which had the highest annual malaria incidence rate in the country in 1970, officially entered the consolidation phrase in 1993. The government reported that by 1998, 15 provinces and autonomous regions had intra- or inter-provincial co-operative agreements, encompassing a population of about 490 million.
Co-operation in surveillance through such regional alliances is especially important in view of the increased mobility of the population since the early 1980s. Internal migration has become increasingly common as people from poorer provinces seek work elsewhere, especially in coastal regions and cities. Most of this “floating population” lack medical insurance of any sort, and their medical problems contribute to an increased burden for their temporary hosts. Many are seasonal workers who are from malaria-free areas and thus have no natural immunity to the disease. If they work in an area where malaria is present and became infected, they take home with them malaria parasites which could be transmitted by anopheles mosquitoes. Eradication remains elusive, therefore, unless a province or region can stop the importation of infection. Regional anti-malaria alliances are designed to encourage co-ordinated efforts to achieve this, and one of their tasks is to offer health education and protection to the migrant population. In 1985, the government promulgated detailed regulations governing malaria control and surveillance of mobile populations. Anyone relocating from a malarious region must obtain a certificate proving that examination for malaria infection has been undertaken before a residency or work permit can be obtained. Local governments involved in the importation of workers for large-scale construction projects must present to the appropriate government agencies detailed anti-malaria plans, including the hiring of specific numbers of health personnel during the construction. There has been, however, no uniformity in the enforcement of the law. Moreover, since the province-based reporting did not include migratory migrants, and reporting at the community level would most likely miss or undercount cases, the actual number of malaria cases tends to be higher than reported.
International travel along Yunnan’s borders with Myanmar, Laos, and Vietnam—all three are countries where malaria is endemic—pose additional problems for the control of malaria. The rather unfettered movement of people along the 4,000 kilometer border has been boosted by economic motives: many are seasonal workers, traders, and even smugglers or other illegal traffickers. Each year, an estimated 10 to 20 million crossings are made. Some become infected with malaria and act as transmission sources and there is “an extensive interchange of parasite strains, which accentuates drug resistance spread.” China has responded to the threat by tightening surveillance. In Yunnan, the government maintains 34 surveillance centers and 390 blood examination stations to monitor the situation and provide treatment when necessary. But complete control would be impossible unless all countries in the border region adopt vigorous anti-malaria programs. In 2004, after the SARS outbreak subsided, the government established the Reporting System of Communicable Diseases and Unexpected Public Health Events which was to be used in the CDCs. This information and surveillance system enables direct, online, case-by-case reporting of communicable diseases, including malaria. The coverage of the system has now reached county level in most parts of the country, and township level in some endemic regions. With the support of WHO and the Global Fund to Fight HIV, Tuberculosis, and Malaria, China has also been developing malaria control and surveillance programs to co-ordinate with disease surveillance projects in the Mekong Region since 2004.
Assessment and Prospects
China has indeed accomplished much in malaria control even with the emerging health care problems in the post-1978 period. The number of malaria cases declined from more than 3.3 million in 1980 to 117,359 in 1990 and to 24,088 in 2000, while the percentage of malaria cases among the total number of acute infectious diseases has been reduced from 61.84% in 1954 to 1.3% in 1998. Yet there was a resurgence of malaria for three consecutive years from 2000 in which 24,088 cases of malaria were reported; there were 26,945 cases in 2001, 35,298 cases in 2002, and 40,681 cases in 2003. Although the number of cases reduced to 27,201 in 2004, it is clear that malaria remains a major health problem and the potential for focal epidemics still exists. In fact, both Yunnan and Hainan witnessed rather pronounced increases in malaria cases: in Yunnan, from 8,775 in 2000 to 15,431 in 2003; and in Hainan, from 1,600 in 2000 to 6,357 in 2003. Smaller increases took place in Anhui, Hubei, and Henan in the same period. The resurgence of malaria in Yunnan is undoubtedly related to increased population movements, while in Hainan, results of malaria control have fluctuated as the chief vector in the hilly region is exophilic and residual spraying or the use of insecticide-treated bed-nets has not been effective. As for the other provinces, the problem has been linked to poor case management and poverty, the latter an important issue that will be discussed in greater detail below.
It is useful to compare conditions in the pre-and post-1978 periods to gain a better perspective of China’s anti-malaria efforts. Before Mao’s passing, the anti-malaria campaign took place when the party-state was in firm control, and the country was largely insulated from external forces. The policies of the government, including health policies, were formulated, implemented, and enforced in a top-down fashion, using tactics such as mass mobilization, propaganda, and political and social pressure to ensure compliance and participation. The creation of a sound primary care health care system alongside the anti-malaria structure allowed for easy access to integrated clinical and preventive services.
As discussed above, post-1978 reforms have contributed to significant administrative, economic and social changes that have weakened the public health system. More than two decades of underfunding public health and preventive services has left the country vulnerable to the resurgence of communicable diseases and other public health crises. This is especially true in the rural and urban floating populations as well as in poorer regions in western China where communicable diseases and malnutrition are still major health problems. The state’s role has been critical in these developments. It has included public health in the market reforms and cut back on the investment in the public social sector during a period of rapid economic growth. Its policy of relying on market incentives and service fees to deliver public health services has led to increased inequities in access to health resources and services. Moreover, the switchover to fee-for-service health care discourages services that have public health benefits but little potential for profit. Even the local CDCs have had to turn to revenue-generating activities to maintain themselves. Such is also the case with anti-malaria surveillance, outbreak response capacity, and epidemiological research.
The diminished role of the state in health administration is reflected in fragmented authority and responsibility for the delivery and supervision of public health services. At least ten ministry-level agencies have “significant health authority,” including over malaria control, while key public health institutions that play a role in anti-malaria work, such as national and local CDCs and the Chinese Academy of Medical Sciences, receive only partial government funding for their work. At the local level, preventive health care services have suffered from the commercialization of care, and underfunding, as noted, has contributed to weakness in malaria surveillance, infection control and case management capacity—the very focal point of the government’s current anti-malaria strategy.
A recent study on malaria control in Henan clearly illustrates some of the consequences of the state’s policies. Henan began the consolidation stage of malaria control in 1993. But at the same time, the government was reducing its funding of anti-malaria programs: in 1992, it withdrew its support for free insecticide impregnation of privately-owned bed-nets, and the following year, it ended insecticide spraying of houses. Although access to diagnosis and treatment for malaria continued to be available, and the government continued to contribute towards vector surveillance and blood surveys, the cost of malaria treatment sky-rocketed. It now costs the average income of ten days in rural areas for each case of suspected malaria to be examined and treated. There was also delay in treatment, especially in the administration of anti-malaria drugs, as village doctors often profited from prescribing non-malarial treatments at the beginning. The government’s malaria control policy of case-management, vector surveillance, and blood surveys evidently has not been enough to eliminate the resurgence of malaria; in fact, malaria incidence remains relatively high in the southern counties of the province. Further cuts in malaria control funding will increase the risk of epidemics.
The expanding gap between the rich and poor has increased poverty in parts of the country, especially in the western regions and remote inland provinces, as well as among the migrant population. In 1999, the rural population in Gansu, for instance, consumed less than 35 kilograms of vegetables per person; only about one-third of the national average. In Shanxi, the consumption of meat by farmers was about one-third of the national per-capita average of 15.3 kilograms, while by contrast, in Guangdong, the figure was double that of the national average. The tremendous variations in the level of development in the post-1978 period between different provinces as well as between different counties within a province have created significant concentrations of poverty. In 2004, it was estimated that there were 200 million rural poor and 100 million urban migrants. It is ironic that the theme of the government’s anti-malaria propaganda is that controlling malaria is a way out of poverty. Yet, it is poverty that has contributed to the inability of many to receive prompt diagnosis and treatment for malaria infection, and as government contributions to basic anti-malaria activities such as anti-larval work diminishes, and as fees for primary health services continue to rise, many patients remain reluctant to seek treatment. In fact, since malaria patients usually become ill during the summer months when they would normally be busiest in their agricultural work, their loss in income would be even more significant, and there is even less incentive for them to seek medical help. This vicious cycle is likely to continue and the potential for malarial transmission increases if current policy priorities remain.
The Chinese government might not have abandoned its ideological commitment to providing health care for all, but the consequences of post-1978 health policies have made it increasingly difficult to realize that objective. In the drive to modernize and rapidly develop the economy, the state has opened public health services to market forces. Our discussion has identified two major consequences: it allows what can be considered to be public social goods to become a commodity subject to the fluctuations of the market; and secondly, when social spending, especially health spending, is largely decentralized to the county and township levels, central control of the health system and vertical lines of communication are weakened. While the government has tried to rebuild a nationally integrated public health infrastructure with the establishment of the National Center for Disease Prevention and Control in 2002, the process is on-going and the success of this effort will depend on the extent to which the government is committed to the ideal that public health is a function and responsibility of the state—even at a time when investment in other sectors seems to promise greater returns for the country’s economic growth. The state needs to assume a greater role in the public health sphere, providing it with steady and sustained funding to ensure that public health institutions can focus on performing the functions of public health without having to generate revenue from other activities.
During the Maoist era, the state had, through its highly centralized system of political, social, and ideological control, developed a health structure capable of providing, for the most part, equal access to medical care for its people. Yet, it had also created irrationalities in political, social, and fiscal policies as well as stagnation in intellectual, scientific and technological development. The post-1978 reforms have moved China in the opposite direction: the decentralization of its fiscal system and the reduction of the state’s role in public health care have contributed to inequities in health care access as well as reduced capability to control resurgent and new diseases. There is nothing inherently wrong with the current policies of decentralization and marketization of the health system as long as the state recognizes that public health services are public goods that may need to be insulated from the vicissitudes of market forces. Ultimately, the state’s role is critical in the reorganization, financing, and strengthening of the public health system. If China cannot find a balance between the two extreme positions, outbreaks of known and preventable diseases, such as malaria, cholera, influenza, and dengue—diseases that possess epidemic and pandemic potential—could once again undermine China’s remarkable progress.