This podcast episode is part of the National Committee’s Coronavirus Impact Series.
As the United States’ confirmed coronavirus cases increase rapidly and China’s continue to decrease, Dr. Elanah Uretsky delivers an overarching analysis of how both countries’ public health responses already have—and will continue—to mitigate the pandemic’s spread.
Dr. Elanah Uretsky is an assistant professor in international and global studies and anthropology at Brandeis University. She is a medical anthropologist who is also broadly trained in public health. Her research and teaching take a critical anthropologic approach to examining global health responses to disease, with a specific focus on China. She is the author of, Occupational Hazards: Sex, Business, and HIV in Post-Mao China. Dr. Uretsky received her Ph.D. in medical anthropology from Columbia University. She is a National Committee on U.S.-China Relations Public Intellectuals Program fellow and a National Committee member.
How does the Chinese government’s response to the coronavirus compare with its response to SARS in 2002?
Elanah Uretsky: In 2002, when SARS emerged, we didn’t know it was happening at first. There were a lot of government cover-ups. When the government finally admitted to what was happening, in response to a lot of international pressure, and they let the World Health Organization (WHO) into China, they jumped into operational mode immediately.
They mobilized all of their resources and they did what only China can do. There was a lot of self-quarantining in Beijing. They built a hospital in a matter of a week. Because it’s China, they got a lot of people to dedicate themselves, a lot of healthcare workers to dedicate themselves to responding to the epidemic. Schools were closed, transportation was closed. All of a sudden, people started riding their bikes again. And in about three or four weeks, I think the number of cases was dramatically reduced to almost nothing, and within a couple of months, SARS was over. It was like a blip. There were impacts on other parts of the world, but not anything like what we’re seeing today.
So it was interesting, when this started (COVID-19), we saw the government mobilize its resources a lot quicker. There was a lot more transparency. They sequenced the virus within a week, I think, and sent that sequencing out to the rest of the world. So they were sharing information and there was transparency. And they mobilized their resources. But I think, they didn’t know a lot about the virus and, for some reason, this epidemic seems to just transmit in a much more wild fashion. I think we thought China would be prepared if SARS came back; if it re-emerged, I think we thought China would be prepared.
After SARS, China modified their healthcare system. They put into place a very advanced surveillance system that goes all the way from the lowest municipal level, in the township level, all the way up to the central level in Beijing. And I think maybe this was something that no country could be prepared for. It was an unknown virus, and it broke out in a large city, and it went undetected for a while, from what we know. We still really don’t know how the virus behaves, but it seems to be transmitted by people who are asymptomatic. So, we probably don’t even know how long the virus was out there in humans before it was detected by Dr. Li.
But again, China mobilized everything and quarantined entire cities. You know, 50 million people were quarantined. So, I know the response was similar. It’s been much more drastic this time, much, much, much, much more drastic. And, again, they’ve gotten it under control. As far as we know, there are almost no new cases in most of China. There are a few cases in Wuhan and Hubei province, and they’re continuing to be very, very vigilant. You can’t go into Beijing right now from outside of Beijing without being quarantined for 14 days. So, I think there’s a lot more vigilance because they know that they need to be more vigilant. They have no idea what’s gonna happen now that they’re letting people go back to wherever they were living, and if there will be another outbreak.
How has the global health system’s response to infectious disease evolved since the SARS epidemic?
Uretsky: SARS was an interesting turning point in global health. While SARS was happening, the WHO went to China and said, “Why didn’t you report this to us?” You know, the International Health Regulations require countries to report outbreaks of infectious disease. And the Chinese government said, “Well, we didn’t know it was.” There was no name for it. It’s something that had never been identified before, and it’s not on the list of reportable diseases. The original International Health Regulations only required countries to report three diseases. And this was a totally novel disease. And so that did cause the global health community to go back and update the International Health Regulations. So in 2005, really in reaction to SARS, they updated the International Health Regulations so that reportable diseases include a much wider category of diseases, and countries are required to report. But they’re also required to develop surveillance systems, and preventative systems, and laboratory capability, and human resource capability. So they can not only report, but be prepared to address an epidemic.
Unfortunately, that’s difficult. It requires an incredible amount of resources, and most countries don’t have those resources. So I would say, even though China improved its surveillance system after SARS, and probably in response to the new International Health Regulations, there’s a lot about the expectations in the International Health Regulations that is not developed in China, probably all kinds of human resource capabilities. And, aside from monitoring systems, preparedness includes things like actually going through scenario exercises and things like that. The IHR lay out a perfect system, but I don’t think that perfect system exists anywhere at this point.
From an epidemiological standpoint, what state has China’s COVID-19 outbreak reached? Is it possible to estimate when China’s quarantine policies could safely be lifted? Policies around remote work, school closures. In a limited way, they are already lifting some of them. But is there any concern amongst health experts that the lifting of the policies is premature and that people going back to work at this point could cause a resurgence of cases?
Uretsky: I think there is that concern. But, again, how long can you keep the country closed? And if we’re at a point where we’re seeing very few incidents, is that a reason to keep people away from work, from school? A quarter billion people migrate around China, and depend on itinerant forms of labor to support themselves and their families. And that’s not something that you can continue to stop, both because of their contribution to the economy, the economy’s need for them, and their need to support their families, their need to get back to where they live.
So probably, at this point, the best mechanism, now that they understand a little bit more about this virus, would be to let people go back to work, let people go back to where they come from, and hopefully, there are more local, regional modes of prevention that they can put in place once they have people back to where they come from, and once they have people working again. I think people who are going back to work are taking preventative measures. Any business that wants to open at this point has to pass a test of five different types of evaluation.
One piece of evaluation is whether they are promoting good public health practice. So, it’s not just, “Oh, let people go back to work, let people go back to school,” it’s, “Let people go back to work because we need them to go back to work. The country needs them to go back to work. But we’ll also put in place preventative health measures to make sure that businesses that are reopening are doing that in a responsible public health way.”
Do you think that China’s health policies, like the quarantine and travel restrictions, changed the trajectory or the timeline for the virus to become a pandemic?
Uretsky: Absolutely. So, now when we’re talking about “Flatten the curve,” that comes from a lesson that we learned from the 1918 Spanish Flu. There’s a graphic that’s been shown that tells us what happened in Philadelphia. Philadelphia did not put into place quarantine measures during the 1918 flu. And so, the curve in Philadelphia is extremely steep. It’s not as long, but it’s a very steep curve and results in a lot of deaths. But because other cities could see what was happening in Philadelphia, their curve can be laid over a curve in St. Louis, which is longer, but much, much flatter.
Flatter meaning lower mortality rate?
Uretsky: Yes. So, the length of the epidemic in St. Louis was longer, but the mortality rate was much, much lower. And that was a lesson learned by our country, by the world, that if you put in place quarantine measures, it may not help the original location of the outbreak, but, knowing what’s going on in one area informs people in another area.. And if you can restrict the spread of the epidemic from the original location, then other locations have time to prepare. Why that didn’t happen in this country, I don’t know. That’s going to be one of the biggest questions. We should have been more prepared. We see second by second, minute by minute what’s going on in China. There’s no problem these days with social media, and we just should’ve been more prepared.
But that being said, you know, the outbreak is slowed down here, and it definitely is, because we know how to prevent it. And, you know, we do know that if someone’s diagnosed, then we should be tracing their contacts and quarantining those people. And sometimes even to a second level, to a second relationship, people are being self-quarantined. And so, you know, despite what’s happening in this country, we still have a very, very little incidence and prevalence of disease, and the outbreak, it’s slowed down here.
Our worry, and this is something else that we should have learned from Wuhan, and Italy should have learned from Wuhan, is that our public health system will be overloaded, our hospital system will be overloaded. That’s what’s happening in Italy, and that’s what we’re afraid of in this country. I think the people who are probably driving things like university policies, that are bringing courses online and moving students off-campus, will very soon, I think, drive closures of elementary schools, probably because major hospitals are afraid of their resources being overloaded. They can see what’s coming down the pike. And I would not be surprised at all if it’s the major hospitals that are driving all of these policy implementations.
I think a lot of people in the U.S., both healthcare workers in the public health system and also regular people are looking to China a lot for statistics. To be able to say: “China implemented this policy, and this is what happened.” Things like people learning that most spreading of the disease is coming from close contact, close family members as opposed to out on the streets. So I think we’re looking to China for a lot of this information about how the outbreak will progress.
So, do you think people should also be looking at China moving forward, as China starts to bounce back and recover and open up, send people back to work, lift travel restrictions? Do you think people should be, as a silver lining, looking at this as: in two or three months we’ll also be there? Or will the public health responses be different enough that we can’t really continue to see China as an example?
Uretsky: That’s a great question. And I would say yes, but I would qualify that. Because I don’t think we’ve paid enough attention to what’s happened to China already, to the actions that China already took. And if we were paying enough attention, we probably would have quarantined people already. We have a hard time doing that. We have a really hard time doing that for a couple of reasons. One is because we’re not ruled by an authoritarian government, and so it’s hard to tell people what to do.
But I think one of the other reasons why we have a hard time doing that is because we’re a very individualistic society. And I can’t tell you the number of people I hear around me, when they hear a suggestion that they should be quarantined. They’re all in favor of someone else being quarantined, but when you tell them that they may have to self-quarantine or when you tell them that there’s a new policy in the organization that “We don’t want people traveling for business, and we strongly discourage people from traveling for personal reasons,” which is an imperfect policy, to begin with. You can contract disease just as easily if you’re traveling for business purposes as for personal reasons, but we think, in our neoliberal society, that we can’t tell people to not travel for personal reasons. So when you release these policies people say, “Oh yeah, that’s great. But what about that trip I was supposed to take?” It’s hard for us to think in terms of protecting society. It’s hard for us to give up our individual rights.
The other thing that I think hinders our response is the fact that we don’t have much of a social safety net in our country. So it was interesting in comparing the SARS outbreak with the Ebola outbreak in West Africa in 2014. China went to West Africa in 2014, brought 1,200 healthcare workers, and tried to help them institute a quarantine policy, and it could not be done. People rioted because they wouldn’t have food. When people were quarantined in their homes in Beijing in 2003, the government assured them that they would have food and there are social safety nets.
We don’t have social safety nets here of, for example, ensuring food. What happens if we’re quarantined? I’m fine, right? I have the wherewithal to have gone out over the past couple of weeks and increase my stock of food at home. But there are a lot of people around me who don’t have that ability. What will happen to them? What about childcare? What about people who ive paycheck to paycheck? So, that creates another level of challenge for us in following what China did. So, if we didn’t follow what China did, can we necessarily look towards what they’re doing and what they’re going to do? I don’t know that we’re on the sort of right level of playing field at this point to do that.