site stats


Seminar on "Public Health Surge Capacity Building in China: From SARS to HFMD"

Assoc Prof Yanzhong Huang, Director, Center for Global Health Studies, John C. Whitehead School of Diplomacy and International Relations, Seton Hall University

10 July 2008, 2.30- 4pm, Conference Room 1, RSIS, NTU

In this seminar, Dr Huang noted that the need to mitigate and ameliorate the consequences of disease outbreaks makes it imperative for China to strengthen its health system capacity to effectively respond to public health emergencies. As demonstrated in the 2003 SARS epidemic, the system lacked not only “sensitivity” (early recognition of a disease) but also “connectivity” (effective risk communication). In the wake of the crisis, the central leadership has placed greater emphasis on the public health surge capacity building. Yet as the recent outbreak of hand, foot, and mouth disease (HFMD) in eastern China has indicated, while the central government has become more transparent and responsive in dealing with public health emergencies, central-local capacity gap remains the biggest challenge the Chinese leaders have to face in surge capacity building.

(1) Defining Surge Capacity

According to the US’ Human Health Services, surge capacity is defined as “a health care system’s ability to expand quickly beyond normal services to meet an increased demand for medical care.” Dr Huang however noted that such a definition is problematic as the focus would be solely on medical treatment and does not allow adequate role to play for actors other than health professionals such as policy makers and civil society. Hence, Dr Huang offers a modified definition, that is “the ability of a state to expand quickly beyond normal services to effectively respond to public health emergencies”. Measuring the state’s surge capacity would therefore be based on 3 forms of capacities:

  • Surveillance, Laboratory and Epidemiological capacities
    • the first line of defence in being sensitive to detecting and identifying pandemic threats
  • Effectiveness in Risk Communication (“connectivity” in two forms)
    • Horizontal “connectivity” - requires open and effective communication between multidisciplinary groups in multiple sectors
    • Vertical “connectivity” - the ability of health professionals to utilize available technologies and information systems to formulate reports to health authorities in a timely manner (bottom up); or the ability to publicize the presence of a disease outbreak through media outlets in a way that minimizes disturbing effects (top-down)
  • Ability to effectively implement prophylactic and non-prophylactic measures.
    • the ability to meet increased demand for medical care and to provide prophylaxis for populations at risk (vaccination, disinfection, isolation, quarantine, etc.)

(2) The Importance of Surge Capacity in China

There are several reasons why surge capacity is critical in China. Firstly there is the need to mitigate the consequences of disease outbreaks. The lack of surge capacity can lead to rapid spread of infectious disease and panic. This in turn could lead to a destabilizing effect on a state’s economy. Such was the case during the 2003 SARS epidemic, in which China’s gross domestic product dropped by 0.7%. Secondly, there is the need to prevent a spillover effect, whereby a national issue could turn into a global issue given the transnational nature of infectious diseases. Thirdly, China plays a critical role in global health security as it has a fifth of the world’s population and its disease burden rate is 1 out of every 7 people. It is also a major player in the international system and has a history of some the major epidemics in the world. Fourthly, surge capacity has become a priority in China’s health system capacity building after the 2003 SARS experience, where China failed to respond adequately.

(3) The SARS Experience

During the SARS breakout in 2003, Dr Huang noted that China faired poorly in all 3 capacities. Firstly, there was poor sensitivity in detecting and identifying the viruses. Secondly there was a lack of connectivity within the system. There was a lack of interdependence amongst the various organs as seen in the fact that the military hospitals, for instance, withheld vital statistic from civilian hospitals. The lack of vertical connectivity was reflected in the information clampdown which resulted in the masses not being informed about the threat; and also the tendency of lower-ranking government officials to distort information to display to higher levels of government that the situation was under control. This cover-up by officials thus contributed to the lack of medical capabilities as hospitals and medical personnel were not aware of the situation and thus totally unprepared for the stream of victims that came in. Fortunately, a change in Chinese leadership brought about a shift in focus in the national agenda. The post-SARS period in China was characterized by a greater emphasis on social justice, with increased funding for the public health sector. An online disease system was also created to ensure greater efficiency in the reporting of new cases, without the information being distorted in the process. A legal framework was also established facilitate greater connectivity amongst various government bodies.

(4) Assessing Capacity Building’s effectiveness – the HFMD experience

Dr Huang then turned to assess the effectiveness of China’s capacity building by examining the breakout of Hand, Food and Mouth Disease (HFMD) amongst children. He noted that while HFMD is rarely fatal and caused by a less exotic and better understood bug, there was still an unusually high fatality rate in China’s Fuyang province in early 2008. This, Dr Huang, explained was due to the lack of sensitivity. For instance, although the first cases of HFMD were detected in late March, there were only correctly diagnosed in late April. Nevertheless, the central government provided strong technical and political support for addressing the outbreak. Dr Huang also noted that while local authorities were well connected, there was less efficiency in alerting central authorities and in turn to the general public.

In conclusion, Dr Huang noted several lessons learnt from China’s pandemic outbreaks. Firstly, while the central leaders may address the issue of disease outbreaks with a sense of gravidity and urgency, local leaders still find it difficult to alter their existing behavioral patterns in crisis management, in particular with regards to (1) the continued lack of local surveillance, epidemiological, and laboratory capabilities at the local level; (2) problems in the risk communication; and (3) problems in implementing prevention and treatment measures in a timely and effective manner. Secondly, the central-local capacity gap remains to be the biggest challenge in surge capacity building. Finally, there is the problem of bureaucratic incentive structure – which thrives on economic growth and the regime’s paramount concern of stability – and the absence of genuinely engaged civil society. These two factors would therefore still sustain strong incentives of cover-up, misinformation, and inaction, and ultimately lack of efficiency in addressing disease outbreaks in China.


In response to a question as to whether civil society would pose a threat to Chinese officials with regards to the dissemination of information when addressing pandemic issues, Dr Huang noted that it varied for various cases. While civil society was largely absent in the SARS experience, they have been able to play a more constructive role in creating greater awareness for HIV/AIDS, though local government officials have at times harassed them. It was also mentioned that if civil society members are not well-connected, it could potentially incite panic due to the lack of accurate information (sent via mobile phones and internet). Hence, it is not an issue of controlling information, but rather ensuring that it is properly managed. It was also noted that China has been increasing its level of cooperation with other states and international organisations in addressing pandemics. This has been facilitated via international summits, ministerial level meetings and vice-ministerial meetings, which include participation from think tanks and foundations.

In response to a question regarding surge capacity in a post-earthquake situation, Dr Huang, made the distinction between the varying challenges and responses needed for addressing infectious diseases and natural disasters. Firstly, knowing the source or origin of the infectious diseases is vital, whereas it is of secondary concern in a natural disaster. And secondly, infectious diseases are transnational in nature whereas disaster zones are confined to specific area. As such, it is easier to contain the spread of diseases in disasters, such as cholera, which would just require proper water and sanitation facilities. SARS and other unknown diseases however, would require a higher degree of medical capabilities and specific laboratories to deal with mutating viruses.

About the speaker

Yanzhong Huang is Associate Professor and Director of the Center for Global Health Studies at the John C. Whitehead School of Diplomacy and International Relations, Seton Hall University. He is currently a Visiting Senior Research Fellow at the East Asian Institute (EAI), National University of Singapore.

His research and teaching cover issues of global health governance, health security, and China’s public health politics. His current research interest focuses on China’s health governance and health diplomacy. He is the founding editor of Global Health Governance (, a peer-reviewed online journal for the new health security paradigm, and an associate editor of the International Journal of Healthcare Delivery Reform Initiative.

Dr. Huang is frequently consulted by major media outlets, the private sector, governmental and non-governmental organizations on global health and China. He has testified before the Congressional Executive Committee (CECC) on SARS, briefed U.S. Senate Chiefs of Staff on avian flu, and provided consulting services to Foreign Affairs Canada (FAC) on pandemic flu and human security. In 2004-2005, he joined a small group of foreign policy experts to advise the Canadian Prime Minister on the proposed L-20 meeting of key world leaders.

He is an adjunct professor at the School of International and Public Affairs (SIPA), Columbia University, a Term Member of the Council on Foreign Relations, a Public Intellectuals Fellow of the National Committee on US-China Relations, and an Associate Fellow of the Asia Society. He also serves on the advisory boards of Frontier Strategy Group (U.S.) and China Global Fund Watch (China). He was a visiting fellow at the Center for Strategic and International Studies (CSIS) in Washington, DC. He received his Ph.D. degree in political science from the University of Chicago in 2000