Yesterday, I testified before the Congressional-Executive Commission on China (CECC) at the  “Food and Drug Safety, Public Health, and the Environment in China” hearing. My testimony focused on China’s response to public health emergencies. As the H7N9 virus appears to be burning itself out, the consensus among public health scholars and practitioners is that China has been much more transparent and open in handing this outbreak than it was in 2003 during the SARS epidemic. In fact, WHO Director-General Margaret Chan thanked China for their speed in sharing relevant information.

There is no doubt that China has made tremendous progress in building core capacities to detect, assess, notify, and respond to public health emergencies. After SARS, China constructed the largest infectious disease surveillance and reporting system in the world and put in place a legal framework aimed at releasing disease-related information in a timely, accurate, and comprehensive manner. Launched in 2004, this Internet-based disease reporting system has enabled hospitals and township health centers to directly report suspected disease outbreaks to central health authorities. Meanwhile, a civil society supported by the spread of social media is increasingly having its voices heard and its action felt in China’s policy process. The growing online vigilantism through Weibo (microblogs) is now powerful enough to force the government to be more responsive to people’s demands for transparency and openness in addressing major disease outbreaks.

But does this mean that China is moving toward greater and irreversible transparency?  My simple answer: not necessarily. At least three factors could derail the process. First, as shown in the H7N9 outbreak, most localities in China still do not have the capability to correctly and swiftly identify emerging infectious diseases. The central-local gaps in epidemiological and laboratory capacities, when coupled with an authoritarian political structure, could contribute to sustained cover-up (intentional or not), underreporting, or misreporting at the sub-national level. Second, as health is increasingly viewed as a “high politics” issue on the government’s agenda, responses to public health emergencies could be hijacked by prominent domestic political concerns, which thankfully have not happened in the current outbreak. However, in 2009 during the 60th anniversary of the founding of the People’s Republic of China, health authorities covered up H1N1 fatalities and stopped updating the disease information until the celebration was over. Third, despite the recognition of the importance of civil society groups in addressing public health emergencies, the government continues to impose constraints that made their engagement in disease surveillance difficult. Most of the health-related NGOs are focused on HIV/AIDS prevention and control. Without an effective civil society to gather information and demand accountability, both upward and downward information flows could still be intercepted or distorted in the bureaucratic hierarchy.

If you would like to learn more about China’s ability to respond to major disease outbreaks, take a look at Chapter 4 of my new book, Governing Health in Contemporary China, which Routledge has kindly made available for download here.

Beginning in February 2009, a number of self-immolation incidents have occurred in the greater Tibetan region in China. Since then, at least 116 Tibetan monks and farmers have chosen to set themselves on fire.

These acts are reminiscent of similar incidents that happened in South Vietnam 50 years ago. On June 11, 1963, Thich Quang Duc, a Vietnamese Buddhist monk burned himself to death in Saigon in protest of the government led by Ngo Dinh Diem.  Photos of this dramatic event were circulated across the world, becoming one of the most powerful images of the twentieth century that quickly undermined Diem’s legitimacy and eventually led to his assassination in November.

However, the ongoing self-immolations in Tibet are quite different from those that occurred in Vietnam. In Tibet, most of the self-immolation cases appeared to be spontaneous and each act seemed to be separate from the others.  Perhaps as a result, these ultimate sacrifices have failed to convey any consistent or clear message to the outside world. Based on the data compiled by a well-known Tibetan writer and dissident, a Chinese dissident writer and scholar Wang Lixiong identified seven motives from the wills of 26 self-immolators; and the three top motives are “to serve as an act,” to offer their bodies to Dalai Lama, and to express courage and defend dignity.  These motives are themselves abstract and ambiguous, but they clearly suggest that self-immolation in Tibet was not always out of desperation or driven by the need to seek political independence or international attention.  Sun Yan, a professor at City University of New York, recently quoted two Tibetan scholars and argued that self-immolation was a local phenomenon subject to special regional and religious influences.  It was observed by one Tibetan scholar that those who burned themselves were only from four of the 3,600 temples in the greater Tibet region.  The other Tibetan scholar noted that most of the self-immolation acts and protests in recent years were associated with the Gulden Temple in Ngawa Autonomous Prefecture of western Sichuan Province.

Unlike what had transpired in South Vietnam, the growing number of self-immolations in Tibet has, thus far, failed to generate significant international attention or cause a major shift in China’s Tibet policy.  The United States, while calling on China to permit Tibetans to “express grievances freely, publicly, peacefully and without fear of attribution,” urged Tibetans to “end the(ir) voluntary sacrifice.”  At the same time, the Chinese government has accused Dalai Lama of orchestrating the self-immolations, a charge he strongly rejects.  Instead of leading to China’s reexamination of its policy toward Tibetans, the protests might have given the hard-liners within the Party full ammunition to resist the reopening of the dialogue with Dalai Lama, and, in context of the rising nationalism, also silenced the domestic intellectuals and the general public for any rational and constructive discussion of the problem.

If the self-immolations have failed to galvanize international support, why hasn’t Dalai Lama used his moral authority to issue a public statement asking for Tibetans to stop the practice? It is widely believed that self-immolation cases would drop significantly if he makes such a move.  But Dalai Lama is facing a major dilemma over this issue. As a voice of peace and reason, he privately does not support self-immolation. Indeed, from the outset, he was said to be skeptical of how effective this approach would be.  But he has refrained from calling for an end of self-immolation. While he is still the unrivaled spiritual leader among Tibetans, his Middle Way Approach to resolve the Tibetan issue—which does not accept the status quo or political independence—through nonviolent means is increasingly challenged by the young generation, as represented by the Tibetan Youth Congress, the largest NGO in the exile community.  They are increasingly frustrated and many have been radicalized by the lack of breakthrough in the negotiation between Dalai Lama’s representative and the Chinese central government that began in 2002.  Against this backdrop, self-immolation has been viewed by some as an extreme form of collective frustration and anger among the Tibetans.  Unless Dalai Lama is able to offer a viable alternative, his call for ending the practice would likely alienate his supporters, even draw backlash from the radical wing of his own constituency.  It’s because of this that he has expressed respect for the courage and motives of the self-immolators, despite his general disapproval of their behavior.  But allowing self-immolation to continue is in neither China’s nor Dalai Lama’s interest.  For Dalai Lama, it would undermine his moral authority and become a political liability in pursuing his Middle Way Approach.  For Beijing, failure to take the issue seriously might cultivate a sense of desperation among Tibetans, which in turn could lead to the escalation of violence against the Chinese rule (as has been found in the northwestern Xinjiang Uighur Autonomous Region).  It’s therefore in both sides’ interest to break the impasse by reopening the dialogue that was stalled in 2010.

It’s been a busy week for global health. With the Indian Supreme Court’s landmark decision to dismiss Novartis AG’s attempt to patent its cancer drug Glivec, the doors for low-cost generic drugs will remain open. At the same time in China, as it’s been covered by me and my colleague Laurie Garrett,  the rise  of  a deadly new bird flu strain has already infected nine people, three of whom have died, in Southeast China. Both developments have tremendous implications for global governance for health.

In my new working paper, “Enter the Dragon and the Elephant: China’s and India’s Participation in Global Health Governance,” I examine these two leading emerging countries’ role in global health governance (GHG) and how further participation can be complicated by domestic health challenges.

Focusing on three dimensions of GHG (health-related foreign assistance, the development and implementation of global health rules, and the ideational foundations of their participation), I conclude that both countries have been increasingly active in participating in GHG. However, China’s and India’s contributions thus far not only fall short of international expectations, but also fail to offer a viable, sustainable alternative to the existing governance paradigm.

In the paper, I also argue that the future direction and effectiveness of each country’s participation in GHG will ultimately be determined by the ongoing power shift and the two countries’ ability to address domestic health challenges. Combined, China and India account for 33 percent of the global disease burden, measured by disability-adjusted life year. Both face acute problems in combating infectious disease and confronting the looming threat of non-communicable diseases (NCDs). These challenges highlight a fundamental lack of capacity in both countries to provide adequate care for their populations and control potential disease outbreaks. Not surprisingly, despite growing pressures to become full global health donors, China and India continue to focus attention on their domestic development challenges. China argues that taking care of its people’s health care is itself the biggest contribution to world health. India also attaches greater importance to addressing its domestic health challenges rather than assisting other developing countries. The rapid rise of NCDs, especially cancer, and inability to afford patented medicines is likely to open a new battlefield over drug access between the developed and developing world, similar to the trade disputes over access to antiretroviral drugs more than 13 years ago.

Take a look at the paper and let me know what you think.

China has long been perceived as the epicenter of major infectious disease outbreaks. The 2003 SARS crisis was the most recent and notable example. However, over the past months, China has been caught up in a series of public health-related crises, including air pollution in Beijing and dead pigs in Shanghai. So when reports came out over the weekend that a new lethal strain of bird flu, H7N9, was identified in China, it should not be a surprise to anyone.

Despite the lack of surprise, there are reasons that we should be alarmed about the new virus. First, the social-economic cost could be huge. While SARS killed about 800 people worldwide, it developed into the most serious social-political crisis for Chinese leaders since the 1989 Tiananmen crackdown and cost nearly $40 billion globally in losses. Second, this type of bird flu has never been seen previously in human beings and has never been known to previously kill people. While the chances of human-to-human transmission may be low for now, the virus must have undergone significant mutations in order to jump from animals to humans. Third, two of the three H7N9 cases were reported in Shanghai, where more than 20,000 dead pigs were retrieved recently. Given that pigs serve as mixing vessel for influenza viruses, it is legitimate to link the dead pigs to the deadly new strain of virus. Indeed, one of the fatal cases, the 27-year-old man from Shanghai, was reported to be a pork broker. Last but not least, one of the victims had two sons, both of whom were suffering from acute pneumonia, and one has already died.  With three people in one family acquiring acute pneumonia, the World Health Organization’s China representative did note that “it raises a lot of concern.”

Compared to its response in the initial stage of SARS outbreak, China appears to have done a better job so far of handling the new H7N9 virus. The newly formed National Health and Family Planning Commission—the successor of China’s Ministry of Health—shared information about the disease with the WHO, Taiwan, Hong Kong, as well as “related countries.” The health authorities in China have also tracked and are monitoring 88 people who came into close contact with the three cases.

But questions have also been raised about the government’s effectiveness in handling the novel virus. The two fatal cases both occurred when China’s parliament convened to elect the fifth-generation leadership. The two victims died on March 4 and March 10, respectively, but the government did not publicize the disease until March 31. Some have questioned whether the government deliberately covered up or delayed reporting the disease. However, the government explained that H7N9 was not a reportable disease under the Law on the Prevention and Control of Infectious Diseases, and it needed time to confirm the virus. But even accepting the government explanation, one still wonders why it took the government more than three weeks to confirm the virus. This is troubling because maybe ten years after SARS, China still has not built adequate laboratory and epidemiological capacities, which is crucial to detect, assess, notify, and respond to public health emergencies of international concern.

Last week, thousands of dead pigs were discovered floating in the Huangpu River, which supplies drinking water to Shanghai’s 23 million residents. As of Tuesday evening, sanitation workers have retrieved nearly 6,000 carcasses from the river. The municipal authorities insist that the city’s water supply has not been contaminated, but they did admit that the dead pigs have tested positive for the PCV virus (which causes a sometimes fatal pig disease) as well as other pathogens, including foot and mouth disease (FMD), swine fever, hog cholera, and blue-ear pig disease. Initial investigations have also identified Jiaxing, a city in the neighboring Zhejiang province, as the origin of the dead pigs.

This incident in Shanghai is eerily similar to a Bible story in which demons entered a herd of swine and as a result, about 2,000 swine were drowned. While the pigs certainly didn’t drown, a strong case can be made that undesirable forces—unresponsive regulators and immoral villagers—are indeed responsible for dumping of several thousand pigs in the Huangpu River.

Ensuring a steady supply of low-priced and safe pork is an important component of China’s food security and is a major contributor to its social-economic stability. Pork is the most produced and consumed meat in China. In 2011 alone, China produced more than 50 million metric tons of pork, accounting for nearly half of the worldwide pork production. Further, Jiaxing is a major pork supplier for Hong Kong and Shanghai. In 2012, 7.78 million pigs were raised annually in the city, which is nearly one-quarter of all pigs raised in Zhejiang province. Pork is so important that some joked that CPI should stand for China pork index instead of consumer price index. According to a report published by the official local newspaper Jiaxing Daily, in some areas, the total pig housing area is larger than the total living area for people. Raising pigs in high densities not only results in the discharge of pollutants amount exceeding the carrying capacity of the environment, but also facilitates the swine pathogen transmission. Indeed, the city’s Bureau of Commerce noted in a report that “a large number of piglets died of epidemics after the 2012 spring festival.” The local newspaper also reported many deaths of hogs in Jiaxing since January 2013. From January to February, an average of 300 pigs died daily. Normally, pigs that have died from disease are not sold, but buried. Seeking to recoup their losses, however, some unscrupulous pig farmers have sold problematic carcasses to slaughterhouses, which would harvest pork from such carcasses. Between January 2009 and November 2011, a slaughterhouse in Jiaxing reportedly slaughtered 77,000 dead pigs and sold them for 8.65 million yuan ($1.4 million).

As the illicit trade of dead diseased pigs has become rampant in the past few years, the Ministry of Public Security has kicked off a nationwide campaign cracking down on gangs involved in the marketing of sick pigs. In one operation last year, police in Jiaxing reportedly arrested 12 suspects and confiscated nearly 12 tons of unsafe pork meat. During the celebration of the Lunar Chinese New Year in February, the police reportedly stepped up efforts to rid the market of tainted pork meat. In absence of collaboration from other departments, however, these well-intended efforts led to unintended outcomes: farmers simply dumped the large number of unmarketable dead pigs into the local river, which happens to be upstream from Shanghai.

Since these crimes have been committed after the melamine powder scandal, one might wonder why such food safety problems continue unabated despite tightened government regulation. Indeed, the Food Safety Law, which went into effect in 2009, aimed at providing a legal basis for strengthening food safety regulation “from the production line to the dining table.” Yet, as I noted in my recent book Governing Health in Contemporary China, the law maintains the fragmented regulation model with the departments of health, quality supervision, agriculture, public security, and industry and commerce all having a say in overseeing the food safety issues. This fragmented regulatory structure exacerbates what I call “buck-passing polity”, which not only makes coordination and information sharing difficult, but also encourages shirking and buck-passing in regulatory enforcement. It was joked in China that “six ministries were unable to regulate a pig.”

In view of the malaise in China’s buck-passing polity, the recent decision to consolidate food safety bodies into a ministerial-level General Administration of Food and Drug is a meaningful and important step toward addressing the fragmented regulation problem and building a unified and authoritative agency for food safety control. But as my colleague Liz Economy indicated in her new blog post, China lacks the supporting institutions (e.g., rule of law and official accountability) for regulating its food safety, without which China’s regulatory capacity building is like, to quote Austrian philosopher Otto Neurath, “sailors who must repair their ship at sea, never able to put in to dry dock to build from solid ground.”

In the past few months, I wrote about the food the Chinese eat, and, more recently, Liz Economy wrote about the water the Chinese drink. But the air that the Chinese breathe is now a major concern. As the nearly 3,000 delegates of the National People’s Congress (NPC) arrive in Beijing to attend the yearly event to formally endorse nominees for key government leadership posts and important national policies, it would be hard for them to ignore the poor air quality in the country’s capital. Last Thursday morning, readings near Tiananmen Square measured the concentration of PM2.5—fine particles in the air that are smaller than 2.5 micrometers in diameter and are considered dangerous because they tend to penetrate the gas exchange regions of the lungs—at 469 micrograms per cubic meter, which corresponds to a U.S. EPA Air Quality Index reading of 479 (the scale stops at 500). Anything above 301 is considered “hazardous” in that it can cause “serious aggravation of heart or lung disease and premature mortality in persons with cardiopulmonary disease and the elderly,” and there is a “serious risk of respiratory effects in general population.” The PM2.5 levels in other famously polluted cities pale in comparison to those in Beijing; for instance, the highest PM2.5 level in a 24-period recorded in Los Angeles was 43 micrograms per cubic meter.

The poor air quality, according to a leading Chinese public health expert, is worse than SARS because nobody can escape it. Research suggests that air pollution can raise the risk of cardio-respiratory death by 2 to 3 percent for every increase of 10 micrograms per cubic meter of pollutants. Only 1 percent of China’s 560 million urban residents breathe air considered safe by European Union, according to a 2007 World Bank study.  A report released by China’s Ministry of Environmental Protection in November 2010 showed that about one-third of 113 cities failed to meet national air standards.The 2012 Cancer Registry Annual Report revealed that lung cancer is top among all types of cancer in terms of the number of cases and deaths in China. Indeed, the number of lung cancer-caused mortality in China has increased by 465 percent in the past three decades. In Beijing, the number of lung cancer patients has increased by 60 percent in the last ten years. The rising incidence rate of lung cancer coincides with drastic reduction in the incidence rates of stomach cancer and cervical cancer, which is thought to be a result of improvements in public health standards.

For years, public health experts considered smoking the leading risk factor of lung cancer. Yet a recent report prepared by some prominent Chinese public health experts and economists did not find any significant change in China’s overall smoking rate over the last decade. A group of scientists analyzed historical records of aerosol particles and lung cancer incidence in Guangzhou and found that a dramatic increase in the occurrence of air pollution from 1954 to 2006 was followed by a large increase in the lung cancer incidence rate despite the drop in the overall smoking rate. It was found that 750,000 Chinese die prematurely each year, primarily because of air pollution in large cities. According to more recent estimates by Greenpeace and Peking University’s School of Public Health, exposure to PM2.5 contributed to more than 8,500 premature deaths in Beijing, Shanghai, Guangzhou, and Xi’an in 2012 alone.

The thick haze served as a wake-up call for the government, which seems to become more transparent in discussing air pollution in China. As public awareness of the problem grew, pressure on the government to address the underlying causes also increased. To improve the air quality, the Beijing municipal government has taken some emergency measures, including temporarily shutting down more than 100 factories and ordering one-third of government vehicles off the streets. However, given that coal burning in neighboring provinces and cities is a major contributor of the PM2.5 concentration in Beijing, the effectiveness of these steps has been limited. Moreover, while emissions from motor vehicles and coal-burning operations are responsible for the worsening air pollution in China, economic growth requires increased energy use. Since the regime’s legitimacy hinges upon delivering robust economic growth, governments at all levels continue to pursue growth at the expense of environment. We are going to see more NPC delegates pushing for better environmental protection measures, but don’t expect any fundamental change until the government has shifted to a new legitimacy base and restructured the state-society relationship to allow for more effective participation of civil society groups in the public policy process. In the words of Chinese premier-to-be Li Keqiang, “It will be a long process to resolve environmental problems.”

Last week, I was in Beijing for an international conference while the city experienced record levels of air pollution. I had a feeling of déjà vu as I saw people wearing face masks. Ten years ago, at the height of the SARS epidemic, a sea of people in white masks—most of them scared migrant workers and university students—flocked to train and bus stations and airports in the hope of fleeing the city. Then, face masks were a symbol of the fear of a deadly and seemingly omnipresent virus that was responsible for 349 deaths and over 5,300 infections in China alone. As the first severe infectious disease to emerge in the twenty-first century, SARS caused the most serious socio-political crisis for the Chinese leadership since the 1989 Tiananmen crackdown.

While SARS wreaked havoc for approximately nine months from November 2002 to August 2003, it is no match for the HIV/AIDS pandemic in terms of duration, which has lasted for more than 30 years. However, SARS has had a lasting impact on our collective psyche. In September 2012, a novel coronavirus was identified in two patients from the Middle East, raising the specter of a new SARS-like outbreak.  To better prepare for the next disease outbreak, it might be necessary to unravel the following myths about SARS and other infections:

Myth #1: Strong political commitment and a centrally coordinated response was the most important factor in the control of SARS in China.

Not really. Once the initial dilly-dallying gave way to decisive and swift state action, resources were effectively mobilized against the epidemic and policy coordination was significantly improved. Yet many of the measures widely credited for stopping the spread of the virus, such as isolation and quarantine, were only implemented after the virus reproduction number or Rt—a critical value below which sustained transmission of the virus is impossible—dropped below one, or when the epidemic was already dying down. According to a study published in Tropical Medicine & International Health, those decisive government measures might have played a role in speeding up the disappearance of SARS or preventing the outbreak in yet unaffected regions, but they “contributed little to the factual containment of the SARS epidemic.”

Myth #2: Those patients who survived SARS lived happily ever after.

Not true. As a novel virus, SARS defied treatment and proved fatal in many cases. Zhong Nanshan, a Guangzhou-based doctor, initiated steroid therapy to treat SARS patients. This therapy, widely used during the SARS outbreak, was believed to have saved the lives of many SARS patients in China—indeed, during the 2009 H1N1 outbreak, steroid glucocorticoid was also used to treat critically-ill H1N1 patients. However, there have been adverse effects of this aggressive treatment. In late 2003, doctors began to suspect that the use of high doses of steroids for an extended duration was responsible for the crippling of hundreds of SARS patients.  According to China Daily, roughly 30 percent of SARS survivors in China who received the therapy have developed severe bone degeneration. A study carried out in the Beijing municipality found that 88 percent of the SARS survivors had symptoms of osteonecrosis, 80 percent were forced to quit their jobs, 60 percent saw their families break up, and about 39 percent suffer from severe depression.

Myth #3:  Government cover-up is no longer a major concern in the post-SARS era.

Not true. The SARS crisis has forced the Chinese leaders to take steps to be more open and transparent in disease reporting and information sharing. Yet as shown in the 2008 hand, foot, and mouth disease (HFMD) outbreak, local government officials found it difficult to adjust their existing behavioral patterns for crisis management, which still value secrecy and inaction. Similar communication problems also bedeviled the government’s response to the 2009 H1N1 outbreak. China’s SARS crusader Zhong Nanshan publicly expressed his distrust in government data on H1N1 fatalities. Political expediency continues to be put before epidemiological reality in sharing disease-related information with the public. The health authorities stopped updating the spread of H1N1 cases between September 30 and October 9, apparently fearing that reporting H1N1 deaths would ruin the celebrations planned for October 1, the National Day that marked the 60th anniversary of the People’s Republic of China. That said, government cover-up and inaction are not unique to China; India’s response to the 2012 dengue fever epidemic was riddled with similar problems.

Myth #4: Poor or failed states pose a bigger infectious disease threat to the international community than stronger developing countries.

Not necessarily. In his thought-provoking book, Weak Links, my colleague and a leading global governance expert, Stewart Patrick, argues that stronger developing countries such as China and Indonesia “may actually pose a bigger infectious disease threat to the United States and the global community than weaker states.” In these countries, the rapid economic development and land use change has significantly increased the chances of human exposure to natural hosts who are carrying novel and lethal viruses of zoonotic origin. Coronaviruses that were implicated in the SARS outbreak, for example, have been detected in multiple species of bats. As described in the movie Contagion, the eating habits in some countries make it more likely for a virus to jump from one species to another. Indeed, In Guangzhou in southern China, 20,000 wild birds are estimated to end up in the human stomach every day. The integration of these countries into the global economy means that a lethal virus can travel at jet speed to other parts of the world. It is no coincidence that SARS was first discovered in Guangdong, a highly developed province with a robust export sector, and arrived in Toronto before it first appeared in Beijing. It also came as no surprise that Cambodia and Myanmar, two of the least developed countries in Asia, were spared by SARS in 2003.

Myth #5: Infectious disease outbreaks remain the primary public health concern in the Asia-Pacific region.

Wrong. According to the World Health Organization, non-communicable diseases or NCDs, which includes cancer, cardiovascular diseases, chronic respiratory diseases, and diabetes, are the most frequent causes of death in most countries in the region. Today, NCDs account for 85 percent of mortality in China and 70 percent of total disease burden. Indeed, even in sub-regions of Asia-Pacific that are still facing the double burden of communicable and non-communicable diseases, NCDs will soon be the predominant cause of mortality. According to the World Bank, the share of total deaths attributable to NCDs will increase to 72 percent in 2030 from 51 percent in South Asia in 2008.

Since 2003, tremendous progress has indeed been made in improving global health security, especially in areas of capacity building for disease surveillance and response. However, our ability to effectively address the next SARS-like disease outbreak is still constrained by our lack of understanding of the evolving biological and political worlds.

Mr. President, as you begin your second term, you and your Chinese counterpart Xi Jinping both face the challenge of building a mature and mutually beneficial bilateral relationship.  There is no need to belabor the strategic importance of the Sino-American relations for the United States.  Indeed, one may argue that it is precisely the strategic dynamics driven by China’s rise that led to your critical decision to pivot to Asia.

While we are told that a critical element of the U.S. pivot strategy is to nurture partnerships to address important common challenges, our rebalancing efforts thus far have focused almost solely on security and trade.  They are certainly crucial in promoting U.S. economic growth and regional stability, but our relationship with China and other Asian countries has become so multifaceted and complex that other issues, like health and the environment, challenge us to promote jointly the welfare of people in the Asia-Pacific region, which still accounts for a majority of the global disease burden.  As a result of the epidemiological transition, non-communicable diseases such as cancer, cardiovascular diseases, and diabetes are increasingly becoming the dominant cause of mortality.  China, which has surpassed India to become the world’s diabetes capital, also accounts for 20 percent of the world’s total cancer-caused deaths.  By increasing individual and household impoverishment and hindering socioeconomic development, the non-communicable diseases are a major cause of poverty and an urgent development challenge in the region.

In addition to the rising threat of non-communicable diseases, the Asia-Pacific region also faces growing health security threats.  With extensive animal trade and cross-border human movement, the region remains a center of global concern for the emergence of pandemic influenza or a SARS-type novel, zoonotic respiratory virus.  The lowered barriers to entry and reduced costs of bioengineering only increase the risks of accidental or intentional release of dangerous pathogens. In addition, there has been an increase in drug-resistant infections (e.g., artemisinin-resistant malaria and drug-resistant tuberculosis) and vector-borne diseases including dengue and Japanese encephalitis. These infectious diseases threaten U.S. military forces in the region, disturb international trade and travel, and even undermine regional stability.  As you and Senator Lugar wrote in a 2005 New York Times op-ed, a major disease “outbreak could cause millions of deaths, destabilize Southeast Asia…and threaten the security of governments around the world.”  Your concern was recently echoed by Mr. Xi Jinping, who said, “at present, world health problems are in close relationship with international issues, including politics, economy and social development, and have an impact on international relations and foreign policies.”

Building an enhanced global health agenda into the pivot strategy would contribute to a win-win outcome, which is precisely what Beijing hopes to achieve in what it calls a “new major country relationship.” As a Chinese scholar said, the ability to achieve such a relationship depends, among others, on how the two countries “develop their potential” for win-win cooperation.  Health is an area that is politically neutral and about which each side feels strongly.  Indeed, demographic and epidemiological transition and China’s move toward universal health coverage not only generated huge demand for more and better healthcare, but also ushered in forces supporting private and overseas investment in a sector that is traditionally monopolized by government actors.  Given the U.S. comparative advantage in pharmaceutical-related research and development as well as healthcare management and service quality, health system transition in China  would generate more business opportunities for U.S. companies and contribute to the narrowing trade deficit with China.  Equally important, tackling a common health challenge helps countries in the region build trust and reduce tensions around more contentious policy issues such as territorial dispute.  While substantial cooperation over health may provide Beijing an additional reason to focus more on domestic welfare and internal transition, improved U.S.-China relations contributes to regional security, which helps strengthen the United States’ position in the region.

In your first term, Mr. President, your administration was active in conducting health diplomacy by proposing a set of innovative guiding principles and objectives as well as launching new initiatives.  While the results of these programs were mixed, the inclusion of an enhanced global health agenda within the pivot strategy would serve to strengthen your leadership in this area and the administration’s ability to effectively handle health diplomacy.  When integrated into the pivot strategy, such an agenda would include:

1. Actively engaging China’s healthcare sector.  While promoting opportunities for U.S. biopharmaceutical firms, hospital groups, and insurance companies to do business with China, we should also demonstrate our willingness to work with China to address issues of immediate concern to the Chinese people, including their ability to access effective and affordable medicines.
2. Increase U.S.-China military-to-military exchange on health issues, including humanitarian assistance and disease surveillance.  A working relationship, for example, could be established between Armed Forces Health Surveillance Center and the Chinese PLA Center for Disease Control and Prevention.
3. Jointly launch several major initiatives aimed at strengthening the health system in the region.  Potential areas of cooperation include control of artemisinin-resistant malaria, dual-use research dilemma, and prevention and control of non-communicable diseases.  Doing so is in both countries’ enlightened self-interest because it not only contributes to regional security and development but also allows each side to benefit from improved soft power status.
4. Continue to encourage Beijing to shoulder more global health responsibilities while exploring with it the best practices and institutional requirements of development assistance for heath.

Mr. President, since Beijing is not used to making any major initiatives on the global health front, you should feel free to raise these issues with Mr. Xi at the next summit.  Once you both reach an understanding on these issues, the Strategic & Economic Dialogue would be an ideal venue for moving this agenda forward.  Depending on the issue areas, several government working groups can be established, including officials from the State Department, U.S. Agency for International Development, Department of Health and Human Services, Defense Department, and the Food and Drug Administration in the United States, and the Ministry of Commerce, Ministry of Health, the State Food and Drug Administration, the Ministry of Foreign Affairs and PLA General Logistics in China.

Forty years ago, when the first batch of American health workers were allowed to visit China, Milo Leavitt, then director of the Fogarty International Center, noted in Medicine and Public Health in the People’s Republic of China that “for those who believe that the universal desire for health and relief from disease and suffering may be the strongest key to peace and international cooperation, it is significant and heartening to observe that physicians were among the first groups granted permission to visit the People’s Republic of China.” If cooperation over health contributed to the opening of China in the early 1970s, now it can and should play a much larger role in building strategic trust and contributing to the success of your pivot strategy.  We look forward to your leadership in shaping this global health agenda.

If there is a buzzword one needs to know to understand U.S. foreign policy toward Asia in 2013, it is “rebalancing,” or in the words of President Obama “pivoting.” Rebalancing is of course not solely about military redeployment. Indeed, a critical element of the U.S. rebalancing strategy in the region is to nurture partnerships with countries and international institutions to address common threats in areas such as regional health security.

Being the epicenter of major endemic and epidemic diseases, Southeast Asia has often been perceived as a major threat to global health security. Last week, Indonesia identified a more virulent strain of bird flu that has killed more than 300,000 ducks on the island of Java since November. That said, China and Southeast Asia share a range of health challenges, from SARS to HIV/AIDS and H5N1. Altogether, China and Southeast Asia account for approximately 90 percent of SARS cases and two thirds of the human cases of avian influenza.

Since the wake of the SARS debacle in 2003, Beijing has been actively engaging Southeast Asian countries in health-related cooperative efforts. Today, China’s partnership with countries in this region and other stakeholders (e.g. the United States) around health security has never been so important. There are at least three reasons that make China’s engagement in regional health security imperative.

The first reason why this commitment is vital is tied to regional trade and economic concerns. Economic and trade links are perceived by Beijing as the foundation for cooperation between China and Southeast Asia. While the United States remains the most powerful military power in this region, China is the most robust economic power on the block. U.S. rebalancing efforts in Asia highlight the importance for China to continue sending clear and positive message that China’s rise is more of an economic opportunity than a security threat for Southeast Asia.  Thanks to the launch of the China-ASEAN Free Trade Area (FTA), bilateral trade surged to 362.8 billion dollars in 2011. China is now the largest trading partner of the Association of Southeast Asian Nations (ASEAN), with ASEAN being China’s third-largest trading partner. Last year, personnel exchanges reached 13.6 million. Beijing certainly does not want the flow of trade and people ruined by a SARS-like disease outbreak.

Another reason for greater engagement in regional health security is geostrategic. Beijing initially engaged Southeast Asian nations on health issues as part of efforts to allay fears about rapidly rising Chinese power. Today, the need for such strategic reassurance becomes all the more important given the growing concerns about China’s assertiveness in the South China Sea and the U.S. strategic pivot to Asia. Every country in this region wants to develop better relations with China.  However, with the changing strategic landscape Beijing may find additional reasons to conduct active health diplomacy as a tool to project “smart power.” A growing consensus among foreign policy makers is that expanded cooperation around addressing common challenges helps nations build trust and reduce tensions around more contentious policy issues. By scaling up its health-related cooperative efforts, China will also benefit from an improved image in its “not-so-beautiful neighborhood.” In addition, given the tremendous health challenges China is facing, it is in Beijing’s interest to avoid being seen as a source of health problems in Southeast Asia. More than one third of the anti-malaria drugs today are either fake or substandard in Southeast Asia (which is associated with the rapid rise of drug-resistant malaria in the region), and much of the counterfeiting is believed to take place in China.

China also needs to be more actively involved in efforts for ensuring region health security because of domestic social-political considerations. Increasing trade links within Southeast Asia can serve as conduits spreading infectious disease. The 2002-2003 SARS epidemic resulted in one of the most serious social-political crises in China. The domestic social-political repercussions of major health problems coupled with the growing sense of insecurity among the Chinese leadership render health challenges in Southeast Asia a political stability concern for China. At the subnational level, two Chinese border provinces – Yunnan and Guangxi – would be critical stakeholders in China-ASEAN cooperation on health issues. Bordering Vietnam, Laos, and Myanmar, the two provinces should be seriously concerned about resurging vector-borne diseases such as dengue and Japanese encephalitis, and drug-resistant infections such as arteminsinin-resistant malaria and MDR/XDR-TB in the region. The spillover from a disease outbreak in the region may become more likely due to a lack of core capacities in many ASEAN countries to detect, assess, notify, and effectively respond to public health emergencies.

After the presentation of the fifth generation of communist party leaders in China, my colleague Liz Economy noted that the 18^th Party Congress was a victory for the Party’s conservative clique in terms of personnel and policy. Liz was certainly not the only leading China hand who thought that the Party Congress was a heartbreaker. A former US government official recently even said to me that the late Hu Jintao era (which officially ends in March 2013) could be “the beginning of the end.” Many Chinese scholars were equally disappointed.  At a roundtable discussion held on November 16, Zi Zhongyun said that she felt “upset and hopeless” with the results of the Party Congress.  Another leading Chinese public intellectual even suggested that the Party might not be able to make it to the 20^th Congress.

Thanks to the Public Intellectuals Program (PIP) of the National Committee on United States-China Relations, last week I had the opportunity to travel with other PIP fellows to Washington to hear many other influential China watchers speak about the prospect of political change under Xi Jinping, the new party chief. While noticing the difference in personality between Xi and his predecessor Hu Jintao – Xi appears more easy-going and relaxed than Hu, who was more formal and rigid – most agreed that Xi has yet to reveal his true color.  Indeed, prior to the 18^th Party Congress Xi had sent out mixed signals. In July, Xi reportedly met in private with Hu Deping, a supporter of political liberalization and the son of the late reformist leader Hu Yaobang. But just one month earlier, during his visit to Renmin University, Xi stressed the need to read classic works of Marxism-Leninism, saying that Marx’s Capital “shines forth eternally.”

Few scholars or government officials in the United States write off the possibility of the new leadership undertaking major reform initiatives.  After all, prior to the 20^th Congress of the Communist Party of the Soviet Union no advance warning was given that Nikita Khrushchev was to give his “secret speech,” which kicked off the process of de-Stalinization. The good news is that we may not have to wait until the 20^th Party Congress of the Chinese Communist Party in 2022 to witness significant political change. According to the current “retire-at-70” rule, five of the seven members of the current Politburo Standing Committee (PBSC) will have to vacate their seats in 2017, leaving Xi Jinping and Li Keqiang as the only two members who will remain on the committee after that year. Those who had the opportunity to observe Xi closely suggested that he is eager to learn about the outside world, and that he is a quick learner. It is also worth noting that Xi’s father Xi Zhongxun was a liberal party leader who condemned the Tiananmen military crackdown in 1989 and was the only high official who protested the dismissal of Hu Yaobang in 1987. As a member of the “princelings” or the group of descendants of prominent and influential senior party officials, Xi may have sustained interest in maintaining the one-party dictatorship.  But like his father, he is a pragmatist. This is evidenced in his recent low profile visit to Shenzhen. By paralleling Deng Xiaoping’s 1992 tour that revived the stalled economic reform, Xi signaled that he would continue the process of reform and opening up. In the meantime, by making himself more approachable to bystanders and by minimizing traffic controls arranged for the trip, Xi showed his willingness to break with past protocol and shift to a new leadership style.  In view of Xi’s first moves as China’s leader, Premier-in-waiting Li Keqiang’s recent calls for a deepening of reforms, and the apparently stepped up efforts against corruption, a reform-minded triumvirate consisting of Xi, Li, and CPC watchdog chief Wang Qishan seems to be emerging in China.

However, even these so-called reformers will continue to be constrained by retired party elders and their conservative counterparts in the PBSC. As I noted in my piece posted on China-US Focus, the greatest dangers are the special interests that hijack China’s reform process. The clout of special interest groups has been reinforced by the marriage of power and wealth in China.  For example, repeated calls to reform state-owned enterprises in monopoly industries (e.g., banking, power, oil, tobacco, and telecommunication) have been stonewalled, in part because some former and current governmental leaders, who have family members involved in the business activities, do not want to see their own interests undermined by reform.

If powerful, vested interests are allowed to hijack economic reform, sooner or later the top leaders may face the tough choice between passing the buck to the next generation of leaders and implementing meaningful political reform to circumscribe the vested interests. The former will only exacerbate the mounting challenges and is a recipe for ultimate social and political breakdown. A leading China expert recently told me that if China does not reform the current economic model, it is going to collapse. Yet, as I suggested in my China & US Focus article, the latter choice is not necessarily a better one. Implementing serious political reform measures may intensify factionalism at the top (which is made more likely by the oligarchy where Xi is only the first among equals). As we have seen in the Bo Xilai scandal, the intensified factionalist politics may further undermine the power and legitimacy of the party-state. In absence of a functioning state apparatus, reform-minded leaders are unable to push reform forward. This in turn may worsen the economic situation and, given that the regime legitimacy depends on delivering robust economic growth, trigger a large-scale political crisis. As Steven Solnick illustrated in his book on the control and collapse of Soviet institutions, sensing the game might end soon, self-serving government officials and state managers may rush to “steal the state” (grabbing everything that is fungible). The state may fail as a result of this organizational equivalent of a huge bank run.