Emerging Epidemics in China

(May 2003) Since gaige kaifang or “reform and opening” began in 1979, China has moved to integrate itself into the global economic system, attracting foreign investment and exporting its goods to the world. For this country of 1.3 billion people, economic integration has also required unprecedented mobility of its people and exposure to travelers from other countries. The health of China’s population is therefore increasingly linked to that of other populations in Asia and beyond. The SARS outbreak has demonstrated that in these times of heightened social, political, and economic interdependence China requires an expanded domestic and international effort to control the spread of infectious diseases.

China Is no Longer Isolated From the World

Since 1979, China’s borders have increasingly opened, resulting in massive flows of people to and from the country. An estimated 97 million people visited China in 2002.1 At the same time, an improved economy has enabled increasing numbers of Chinese citizens to travel domestically and internationally, generating an unprecedented level of commerce between the world and every Chinese province.

Most visitors to China come from Asia, particularly from the wider community of ethnic Chinese in Taiwan and Hong Kong. Indeed, the latter has been the focal point for much of the traffic to and from China over the past 25 years, culminating in the 1997 return of Hong Kong’s sovereignty to China. According to Hong Kong’s planning department, cross-border trips made at Hong Kong’s eight control points reached 117 million in 2001, more than three times the 1990 figure.2 The department projects that figure may rise to 300 million by 2020. In addition to the hundreds of daily flights and ferries, one border crossing point between Hong Kong and China is now open 24 hours a day, providing the 6.8 million Hong Kong citizens with limitless access to the mainland. Border crossings peak during traditional holidays, the most important being the “Spring Festival” or Chinese New Year.

Social and economic interactions between the people of Taiwan and China have also increased dramatically over the last 15 years. In 1988, approximately 430,000 Taiwanese visited China; in 2002, the number approached 4 million.3 This massive increase is reflected in Taiwan’s record levels of trade and investment in China, with China becoming Taiwan’s top export market this year, surpassing the United States.4 Taiwanese companies have opened offices and factories throughout China, and large numbers of Taiwanese now reside in China. Estimates vary widely, but 300,000 Taiwanese are assumed to live in Shanghai, with an additional 200,000 in cities in along the Shanghai-Nanjing corridor in Jiangsu province.5 The numbers of Taiwanese residing in southern provinces, including Fujian and Guangdong, are believed to be even higher. The majority of these estimated 1 million Taiwanese “expats” are well-educated, white-collar managers and entrepreneurs and their families, representing almost 4 percent of Taiwan’s 22.5 million citizens.6

Chinese citizens now enjoy unprecedented freedom of movement. Before reform and opening, China’s system of household registration, the hukou, restricted citizens in rural areas from moving to other provinces or urban areas, while providing urban dwellers with access to social services, including ration coupons, schooling, and medical care. Urban work units, called danwei, controlled the movement of workers, whose personnel files could only be transferred to another unit under special circumstances that required approval from the appropriate authorities.

Beginning in 2001, several provinces relaxed the hukou system, permitting increased rural-to-urban migration. A provincial identification system permits residents to work anywhere within their provinces. While educated professionals are generally free to work in cities of their choosing and have the resources for adequate medical care, most rural migrants have no health insurance and little disposable income to pay for medical treatment. Away from their registered residence, migrants do not qualify for subsidized care and have little access to fee-for-service clinics in the cities.

Policies adopted by the central government have increased opportunities for internal travel. Chinese workers throughout the country now enjoy three national holidays that last a week or longer. The Spring Festival in late January or early February lasts up to two weeks, allowing migrants to visit their families and permitting people from around the country to travel to their ancestral homes. The city of Guangzhou in Guangdong province estimated that 6 million tourists visited the city during the 2003 Spring Festival. The Oct. 1 National Day and May Day also see mass movements of people during these week-long breaks.7

Millions of Chinese citizens are also crossing their country’s borders. An estimated 16.6 million people traveled abroad in 2002 for business or pleasure.8 Chinese tourists are authorized to visit over 30 countries, including most recently, Germany, which, as a “Schengen” country, enables travelers to enter 14 other European Union countries without further immigration controls.9 Many countries, particularly those in Asia that once relied heavily on Japanese tourism revenue, now actively promote themselves as destinations of choice for Chinese tour groups.

China’s Approach to Public Health

The SARS outbreak has dramatically demonstrated the health risks posed by infectious diseases in increasingly interdependent global economies. As with many other countries, China’s health system does not reflect the economic benefits of globalization. In addition, central authorities have ceded control to the provinces, and both central and local funding and oversight have been reduced from pre-1979 levels.

China’s response to SARS over the past three months has mirrored the country’s reaction to HIV/AIDS over the past three years. In both cases, the initial response was denial. Health authorities are also constrained by a legal system designed to conceal disasters from the outside world. The state secrets law forbids local authorities from reporting an epidemic outbreak until the ministry of health has made a public announcement. Similarly, under the 1989 infectious disease law, county governments cannot “announce the designation of an epidemic area” or take emergency measures such as quarantining areas without first reporting and getting permission from “the next higher level.”

It was not until Premier Wen Jiabao and Vice-Premier Wu Yi became involved in the SARS crisis that the medical bureaucracy began to mobilize internally with provincial reports being made to Beijing and that cooperation with the international medical community began. On April 4, Wu Yi toured the Chinese Center for Disease Control and Prevention and instructed officials there to build an emergency response mechanism to deal with sudden outbreaks of public health incidents that incorporates both a public health information system and an early warning and report mechanism.

Infectious Diseases Will Continue To Affect the Underserved

Given the country’s immense population, limited resources, and political resistance, Chinese health authorities have been unable to accurately monitor and effectively respond to a range of health concerns. An underfunded public health system, inadequate rural health services, and poor surveillance preclude efficient investment of resources to control the spread of such infections as hepatitis, syphilis, HIV, and tuberculosis (TB).


Hepatitis B and C infect upwards of 200 million Chinese. Hepatitis B infects 170 million people (14 percent of the population), while the more serious hepatitis C infects approximately 40 million (3.3 percent of the population).10 Hepatitis, like HIV, is spread through sexual contact, sharing of needles, improper reuse of medical equipment, and tainted blood products. While a US$4 vaccination is available for hepatitis B, coverage has been limited, running between 10 percent and 40 percent in many rural areas, despite significant foreign assistance to help cover the cost.11 Hepatitis B and C, which cause chronic liver disease, contribute to the overall deterioration of the population’s health, particularly when people are coinfected with diseases such as HIV/AIDS. Like many infectious diseases, patients are asymptomatic for extended periods and frequently are unaware they have the disease, leading them to inadvertently infect others.


Syphilis and other sexually transmitted infections (STIs) in China present a serious health problem. From 1993 to 1999, the average growth of the incidence rate was 84 percent per year.12 Significantly, it was found first in coastal areas and was assumed to have been imported by foreigners to cities that opened to the outside earliest. Infections then spread to rural areas.13 The exponential growth rate of STIs is cause for great concern for a number of reasons. STIs are hard to control due to the highly private nature of their transmission, reluctance by those infected to seek treatment and, in some cases, the absence of symptoms for long periods. STIs also facilitate the spread of other infections such as HIV/AIDS.


HIV/AIDS is estimated to infect anywhere between 1 million and 2 million Chinese and could potentially infect 15 million Chinese by 2010 if no effective measures are taken.14 The Chinese health care system is ill-equipped to confront the spread of HIV or treat those infected due to a lack of capacity including poor epidemiology, a lack of trained doctors, limited access to effective medication, and no national prevention or education plan.


In China, 550 million people are infected with the tubercle bacillus, with 4.5 million developing active TB and between 120,000 to 250,000 dying per year. Some 80 percent of TB sufferers in China live in rural areas, and 63 percent of them are young or middle-age, resulting in a significant economic burden to affected families.15 Because tuberculosis is so prevalent in poor areas and treatment is long and expensive, many patients stop taking drugs before their treatment cycle is completed, resulting in drug resistance rates approaching 30 percent, further contributing to the spread of the disease. For 15 years, the United Nations, World Bank, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and Japanese and British aid agencies have contributed to TB treatment programs in China. Despite the hundreds of millions of dollars invested, the World Health Organization claims that China still faces significant challenges in controlling TB, particularly because of the vastness of the country and its population and in terms of political commitment.16

What Is the Outlook for China?

Increased economic integration into the global economy and more travel to, from, and within China will further expose the immense challenges facing the Chinese public health system. The vast majority of the population has no health insurance. Hospitals have become dependant on fees for services to stay in business, making it difficult for the poor and lower middle-class to seek care for illnesses or preventative care. Although China’s economic situation has improved in the last 30 years, central government spending on public health has been inadequate, and international assistance has not built sufficient capacity within the sector to prepare it for emerging diseases like HIV or SARS.

Andrew Thompson is a research associate with the Freeman Chair in China Studies at the Center for Strategic and International Studies (CSIS) in Washington, DC. Mr. Thompson has traveled extensively throughout China and speaks, reads, and writes Mandarin.


  1. Xinhua, “China’s Cross-Border Tourism Prospers in 2002,” Dec. 31, 2002.
  2. Antoine So, “500,000 in Weekly Trips Across Border,” South China Morning Post, May 22, 2002.
  3. Department of Economic Affairs, Mainland Affairs Council, Taiwan, data accessed online at, on May 2, 2003.
  4. Taiwan’s export statistics combine Hong Kong and China. For all of 2002, 24 percent of Taiwan’s exports went to China, compared to 20 percent to the United States. Source: Directorate General of Customs, Ministry of Finance, Republic of China, accessed online at, on May 2, 2003.
  5. Joseph Kahn, “With One Stop, Flight to Taiwan From China Ends a 50-Year Freeze,” New York Times, Jan. 27, 2003.
  6. Carl Haub, 2002 World Population Data Sheet (Washington, DC: Population Reference Bureau, 2002).
  7. William Kazer, “The Mainland Attraction,” South China Morning Post, May 31, 2003. See also Financial Times Information, “Tourism Brings Guangzhou US$240M During Spring Festival,” Feb. 10, 2003.
  8. “Lives of Chinese People Improve Markedly in Five Years,” People’s Daily, March 5, 2003.
  9. Mark O’Neil, “Chinese Tourists Set To Rise as EU Prepares To Ease Visa Restrictions,” South China Morning Post, Jan. 23, 2003. See also “Chinese Tourists Bring Vitality to German Market,” Xinhua/People’s Daily, March 5, 2003.
  10. Z.T. Sun, L.H. Ming, X. Zhu, J.H. Lu, “Prevention and control of hepatitis B in China,” Journal of Medical Virology 67, no. 3: 447-50. See also Chinese Foundation for Hepatitis Prevention and Control, statistics accessed online at, on March 15, 2003.
  11. BBC News, “China Launches Battle Against Hepatitis,” June 1, 2002.
  12. X. Gong et al., “Epidemiological Analysis of Syphilis in China Through 1985 to 2000,” Chinese Journal of Sexually Transmitted Infections 1, no. 1 (2001): 1-6.
  13. Gong et al., “Epidemiological Analysis of Syphilis in China.”
  14. Stephen Morrison and Bates Gill, Averting a Full-Blown HIV/AIDS Epidemic in China (Washington, DC: Center for Strategic and International Studies, February 2003).
  15. “Rural Areas Need Help to Fight TB,” China Daily, March 25, 2003. See also Deutsche Presse-Agentur, “WHO Urges China To Curb Growing TB crisis,” June 4, 2001. See also World Health Organization, WHO Report 2003 — Global Tuberculosis Control: Surveillance, Planning, Financing.
  16. WHO, WHO Report 2003 — Global Tuberculosis Control: 30, accessed online at, on May 2, 2003.