China's H1N1 Response and Public Opinion: Promise and Potential Challenges
November 6, 2009
The swine flu epidemic has not spared China. According to the latest available numbers, the country has registered 48,748 infections on the mainland and another 31,544 in Hong Kong. The Chinese government quickly implemented prevention and containment policies in response to early cases, even receiving some criticism for its extreme measures. In June, the People’s Republic commissioned 11 biotech companies to develop a swine flu vaccine. Sinovac succeeded, creating the world’s first approved vaccine with its Panflu 1. These efforts, described as the world’s most active response to the virus, earned substantial praise from the World Health Organization.
On Monday October 26th, however, a widely reported China Daily survey claimed that “more than 54 percent of Chinese people do not plan to receive the A/H1N1 flu vaccine because they doubt its safety and quality.” The storyline paralleled rising vaccine skepticism in the U.S., and the week saw a series of responses. Michael O’Leary, the WHO’s representative in China, vouched for the vaccine’s safety on Tuesday. Two days later, chief Chinese epidemiologist Zeng Guang called for greater willingness to be inoculated. “If people do not have themselves vaccinated now,” he said, “there will be endless troubles in the future.”
The survey that fueled these worries solicited internet submissions on the front page of search engine sohu.com. The sample that resulted comprised 2200 people in a nation of 1.3 billion, few of whom own a computer, on a website primarily trafficked by the college educated. Perhaps the respondents’ wealth and education only makes the result more worrisome. On the other hand, China’s internet population may be particularly untrusting of government programs like the pandemic response. Either way, sohu.com likely did not provide a scientific or representative sample. A survey on the same website found in September that 78% of China was eagerly awaiting the vaccine. Poor sampling seems more likely at work than a seismic shift in opinion in one month’s time.
Even if the study is accurate, the implications of 54% skepticism are minimal. The Chinese government has placed H1N1 vaccine orders with Sinovac and two other companies, totaling 34.22 million one-shot doses, enough for 2.6% of the population. The PRC’s most optimistic goal for the entire vaccination program is to inoculate 5% of the country. That result would still not reach the “390 million people [who need] the flu shots including service personnel of the People's Liberation Army and armed police forces, police, medical staff, teachers, students, people working at key public service posts, and patients with chronic or cardiovascular diseases.” The fear that more than 50% of China will go unvaccinated actually falls far short of the reality, for reasons of scale that are unrelated to public skepticism.
Size and complexity, both of the government and the country itself, underlie most of the challenges China faces in responding to pandemics. The world’s most populous country has given few details as to how it will implement the National Immunization Program, especially at the township and village level. Critically important is the capacity of local health departments and Center for Disease Control and Prevention offices to carry out vaccinations. Noticeably, the earliest and most promising reports of vaccination regard Beijing and other urban centers where the central government is strongest. This may indicate difficulty in funding public health, distributing vaccines, and implementing policy in China’s vast rural areas, whose limited resources are already being sapped by massive healthcare system reform. A study by the Development Research Center of the State Council estimated the total debt held by local governments at over 1 trillion yuan.
Doubting the furor over the China Daily survey results is also not to say that China’s pandemic response will see no challenges from the public. Although we may not know how much doubt and mistrust exists, Chinese news coverage provides anecdotal evidence that it does. Ironically, the speed with which China responded may found many of the fears. “The vaccine has been developed and administered so quickly that I couldn’t help questioning its quality and reliability,” said a mother in Beijing, refusing inoculation for her 8 year old boy. Despite clinical testing and approval of the vaccine, another mother registered similar concerns: “I am worried about the potential health hazards since it has yet to be thoroughly tested.”
The need for government credibility in the eyes of the public while responding to infectious disease is no secret. We saw in 2003 the consequences of its absence, when China’s bungled and opaque SARS response lost it the public’s cooperation and triggered an epidemic. As the Chinese government and media face this new virulent disease in the coming months, they must remember that lesson and produce reliable metrics on the public’s cooperation and concerns.
Credit: Seth Gannon, CSIS Global Health Policy Center