[Joint House and Senate Hearing, 109 Congress]
[From the U.S. Government Publishing Office]
CHINA'S RESPONSE TO AVIAN FLU: STEPS TAKEN, CHALLENGES REMAINING, AND
TRANSPARENCY
=======================================================================
ROUNDTABLE
before the
CONGRESSIONAL-EXECUTIVE COMMISSION ON CHINA
ONE HUNDRED NINTH CONGRESS
SECOND SESSION
__________
FEBRUARY 24, 2006
__________
Printed for the use of the Congressional-Executive Commission on China
Available via the World Wide Web: http://www.cecc.gov
______
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CONGRESSIONAL-EXECUTIVE COMMISSION ON CHINA
LEGISLATIVE BRANCH COMMISSIONERS
Senate
House
CHUCK HAGEL, Nebraska, Chairman JAMES A. LEACH, Iowa, Co-Chairman
SAM BROWNBACK, Kansas DAVID DREIER, California
GORDON SMITH, Oregon FRANK R. WOLF, Virginia
JIM DeMINT, South Carolina JOSEPH R. PITTS, Pennsylvania
MEL MARTINEZ, Florida ROBERT B. ADERHOLT, Alabama
MAX BAUCUS, Montana SANDER LEVIN, Michigan
CARL LEVIN, Michigan MARCY KAPTUR, Ohio
DIANNE FEINSTEIN, California SHERROD BROWN, Ohio
BYRON DORGAN, North Dakota MICHAEL M. HONDA, California
EXECUTIVE BRANCH COMMISSIONERS
STEVEN J. LAW, Department of Labor
PAULA DOBRIANSKY, Department of State
David Dorman, Staff Director (Chairman)
John Foarde, Staff Director (Co-Chairman)
(ii)
C O N T E N T S
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Page
STATEMENTS
Clifford, John R., Deputy Administrator for Veterinary Services,
Animal and Plant Health Inspection Service, U.S. Department of
Agriculture, Washington, DC.................................... 2
Elvander, Erika, Office of Global Health Affairs, U.S. Department
of Health and Human Services, Washington, DC................... 6
Gill, Bates, Freeman Chair in China Studies, Center for Strategic
and International Studies, Washington, DC...................... 11
APPENDIX
Prepared Statements
Clifford, John R................................................. 30
Elvander, Erika.................................................. 32
Gill, Bates...................................................... 36
CHINA'S RESPONSE TO AVIAN FLU:
STEPS TAKEN, CHALLENGES REMAINING, AND TRANSPARENCY
----------
FRIDAY, FEBRUARY 24, 2006
Congressional-Executive
Commission on China,
Washington, DC.
The Roundtable was convened, pursuant to notice, at 2 p.m.,
in room 2200, Rayburn House Office Building, David Dorman
(Senate Staff Director) presiding.
Also present: John Foarde, House Staff Director; Carl
Minzner, Senior Counsel; William A. Farris, Senior Counsel;
Pamela N. Phan, Counsel; and William Leahy, Research Associate.
Mr. Dorman. All right. It is 2 o'clock. Let us get started.
First of all, I would like to thank everyone in the
audience, and in particular, our very distinguished panel
today, for coming to this Issues Roundtable of the
Congressional-Executive Commission on China entitled, ``China's
Response to Avian Flu: Steps Taken, Challenges Remaining.''
Before we get started, I would like to tell everyone in the
audience about a hearing that the Commission is going to have
on March 6 from 2 to 3:30 p.m. in Dirksen 419. The title of
that hearing will be: ``Combating Human Trafficking in China:
Domestic and International Efforts.'' The announcement went out
today. If you would like more information, you can find it on
the CECC Web site.
As has been standard practice for the Commission, I will
make a brief statement, then I will introduce each of our
panelists and give each of them in turn 10 minutes to make an
opening statement. After each of our witnesses has made his or
her opening statement, I will start with a question to the
panel, and then give each staff member on the dais an
opportunity to ask a question and hear an answer, and we will
continue that process until we reach 3:30, or run out of
questions.
John Foarde told me this morning this might be our 52nd or
53rd roundtable since the Commission began operating in 2002;
to date we have never run out of questions, so I am quite sure
that we will be able to continue our discussion for 90 minutes.
With that, let me get started with a short opening
statement, and then I will introduce our panelists.
Chinese authorities recorded over 30 outbreaks of avian
influenza in poultry stocks in 2005, and have also confirmed 11
human cases of bird flu since November 2005.
In response, the central government has appropriated over
US $200 million for the creation of a nationwide avian flu
command center, initiated avian flu emergency management plans,
and
reported outbreaks to international health organizations in a
generally timely manner. Local officials have also culled and
vaccinated millions of poultry in affected areas. Still, health
experts consider China to be one of the prime incubators for a
potential human influenza pandemic. Concerns also exist about
the degree of transparency in Chinese Government reporting on
some of the outbreaks.
In its 2005 Annual Report, the Commission found that
China's State Secrets Law and related regulations hinder the
free flow of information on public health matters, both within
China and to the outside world. The Commission also found that
Chinese Government control over the flow of information had
hampered international efforts to combat the spread of the H5N1
avian flu virus.
This Commission roundtable will assess the current status
of China's domestic efforts to address avian flu and the degree
of Chinese Government cooperation with international agencies
and
bilateral partners in dealing with the same problem.
Once again, I would like to thank our distinguished panel
today for joining us.
With that, I will start with our first Executive Branch
witness, Dr. John Clifford. Dr. Clifford is Deputy
Administrator of the Animal and Plant Health Inspection
Services' [APHIS] Veterinary Services program, U.S. Department
of Agriculture [USDA]. As Deputy Administrator for Veterinary
Services, Dr. Clifford is USDA's chief veterinary officer. In
this position, he provides leadership for safeguarding U.S.
animal health and is the United States representative to the
International Animal Health Organization [OIE].
Before becoming Deputy Administrator in May 2004, Dr.
Clifford served as Acting Deputy Administrator of Veterinary
Services. He also served as the Associate Deputy Administrator
of Veterinary Services' National Animal Health Policy and
Program staff, where he led efforts to protect, sustain, and
improve the productivity, marketability, and health of the
nation's animals, animal products, and biologics. Dr. Clifford,
thank you for coming today. You have 10 minutes for your
opening statement.
STATEMENT OF JOHN R. CLIFFORD, DEPUTY ADMINISTRATOR FOR THE
ANIMAL AND PLANT HEALTH INSPECTION SERVICES' VETERINARY
SERVICES PROGRAM, U.S. DEPARTMENT OF AGRICULTURE, WASHINGTON,
DC
Mr. Clifford. Thank you very much for the opportunity to be
here today. We in the Federal Government take the threat posed
by avian influenza very seriously and we are committed to
working to carry out the President's National Strategy for
Pandemic Influenza.
USDA has many key roles to play, as outlined in the
National Strategy. In my mind, though, one of the most
important is our involvement overseas to help affected
countries take steps to combat the Asian H5N1 highly pathogenic
avian influenza virus at its source in poultry populations.
Representatives attending last month's International
Ministerial Pledging Conference on Avian and Human Pandemic
Influenza in Beijing, China, also recognized the importance of
a coordinated global effort to address this disease.
According to the European Commission, co-sponsor of the
conference, along with the World Bank and the Chinese
Government, a total of $1.9 billion was pledged by the
attending countries. This funding will help affected countries
fight outbreaks of the Asian H5N1 influenza virus, and also
assist neighboring countries in efforts to prepare for any
related human health issues. During the conference, President
Bush announced that the United States will provide substantial
funding, $334 million, to support the global campaign against
avian influenza. This represents the largest single national
contribution thus far to these global efforts.
Resources will be used, among other things, to assist
countries with national preparedness plans, improve
surveillance and response systems for domestic poultry, and
provide assistance in
establishing wild bird surveillance programs.
As part of this funding that I just mentioned, USDA
received $18 million to advance collaboration with
international organizations to help countries in Southeast Asia
take steps to enhance the veterinary infrastructure and adopt
other practical, effective programs against H5N1 Asian strain.
My boss, APHIS administrator Dr. Ron DeHaven, has traveled
recently to Southeast Asia to assess the animal disease
situation in several countries and the steps being taken in
response. The information and observations he collected are
helping USDA develop its plan to work with international
organizations, primarily the United Nations' Food and
Agricultural Organization, to deliver the best possible
technical assistance to these countries.
By effectively combating this disease in birds, I am
confident that we can help lower the virus load in countries
and prevent spread to humans, thereby reducing the likelihood
that this particular high-pathogenic AI will mutate into a
virus capable of spreading not only from birds to humans, but
then from person to person.
Before I speak more about the international efforts,
including those related to China, I would just like to say a
few words about the steps we are taking domestically to protect
against the introduction of Asian strain H5N1 in the U.S.
poultry populations. These programs, many of them longstanding,
are every bit as critical as the efforts we are undertaking
overseas to help to protect the United States. USDA is keeping
potentially infected poultry and poultry products from
countries affected by Asian H5N1 virus out of the United States
through import restrictions. We quarantine and test all live
birds imported into the United States to
ensure that they are disease-free. We carry out an aggressive
surveillance program that looks for any signs of illness in the
commercial U.S. poultry flock. We are also on the lookout for
smuggled birds or products from overseas that could harbor the
disease. USDA also maintains a stockpile of avian influenza
vaccine should the need arise to vaccinate commercial poultry
as part of a virus control and eradication effort.
We are making sure that the State-level responses in the
event of a disease detection are constantly updated and take
into account all the steps necessary to address the situation.
In total, the funding I mentioned a moment ago also directs $73
million to USDA to enhance these, and other, domestic avian
influenza-related efforts.
I think the best way to frame our discussion of avian
influenza in China is to trace significant developments in
chronological fashion, and then I will be happy to answer your
more specific questions. Evidence seems to suggest that the
Asian H5N1 AI virus emerged in Southern China and Hong Kong in
1997. We know, too, that the virus did not start causing
mortality in large numbers of birds in China until late 2003.
In response to the escalating animal health situation, in
January 2004, APHIS and the U.S. Centers for Disease Control
and Prevention issued emergency import restrictions on poultry
and poultry products from China and seven other countries in
East and Southeast Asia.
It is important to note here, however, that APHIS has had
longstanding prohibitions in place on live poultry and poultry
products from China, as well as most other Asian countries, due
to the widespread presence of exotic Newcastle disease, another
significant poultry disease in that region of the world. So, no
significant quantities of live poultry or poultry products from
China or other countries in Southeast Asia were being imported
into the United States.
Again, though, in 2004, we felt it a prudent step to issue
the emergency import restrictions due to the threat that the
Asian H5N1 virus poses to animal health, as well as concerns by
public health officials that the virus could potentially have
human health implications. Later, in 2004, APHIS placed
restrictions on imports from all countries reporting detections
of Asian strain H5N1 in poultry, and these further restrictions
prohibit the importation of all live birds, including those
previously allowed entry provided that the birds went through a
lengthy post-entry quarantine period; all feathers and feather
products, including those treated overseas or imported into the
United States for treatment; and processed or rendered poultry
products for human use or consumption.
In the summer of 2004, China requested that APHIS consider
regionalizing the country to enable the trade of poultry and
poultry products from areas of the country unaffected by Asian
H5N1 virus. Regionalization is a tenet under the World Trade
Organization's [WTO] sanitary and phytosanitary agreements.
APHIS
considers all such requests and, in order to do so, we
requested on several different occasions that the Chinese
Government provide us with information on the disease situation
in the country and steps take in response.
To date, the Chinese Government has not provided us with
this information; therefore APHIS has been unable to begin
considering the regionalization request. I would also add that,
while China has reported cases of the disease to the World
Organization for Animal Health, the OIE, there has been no
independent verification of those reported detections by
agencies outside of China.
We commend Chinese authorities for reporting detections to
the OIE, but we also feel that officials need to be more
transparent and forthcoming with information on surveillance
testing, disease control and eradication measures, and related
information. Along these same lines, I would like to
acknowledge China's lifting of its import ban on all U.S.
poultry and poultry products, which was put in place following
the detection of the high-pathogenic avian influenza virus in a
flock of 6,600 birds in Texas in February 2004. That detection
was quickly contained and eradicated without any further spread
to poultry or any human health implications. It is a testament
to the excellent surveillance and emergency response plans we
have in place for serious poultry diseases here in the United
States.
APHIS provided the Chinese Government with information on
the detection and related issues in August 2004, and Chinese
officials removed the ban in October 2004. U.S. product began
moving to the country again in January 2005.
As I said at the outset of my remarks, USDA believes that a
coordinated effort to address Asian H5N1 avian influenza in
poultry populations in affected countries is the most important
step that could be taken to prevent a pandemic situation. In
support of this international coordination, APHIS and USDA
officials have certainly been keeping an active international
travel schedule. In July 2005, we attended the Symposium on
International Animal Health Standards for the member countries
of the Asia-Pacific Economic Corporation group, as well as the
October 2005 meeting of senior officials from the International
Partnership on Avian and Pandemic Influenza, a group of key
nations and international organizations launched by the United
States in September 2005.
In addition, USDA participated in a November 2005 meeting
on avian influenza and human pandemic organized by the OIE, the
Food and Agricultural Organization [FAO], and the World Bank.
We were also part of the WHO's December 2005 meeting to develop
an international unified strategy to control Asian H5N1 virus
in birds.
In regard to China, APHIS and USDA officials met with their
counterparts in Beijing in November 2005 as part of a poultry
health symposium. Much discussion took place on issues such as
regulatory measures, disease surveillance, and international
animal health requirements for the disease. The meeting was
followed by a WTO ministerial meeting in Hong Kong in December
2005. During the meeting, an annex was approved for a
Memorandum of Understanding already in place between USDA and
the Chinese Ministry of Agriculture. The annex details the
formulation of working groups that will meet on a regular basis
to discuss technical animal and plant health issues. We are
currently working to arrange the first meeting of the Animal
Health Working Group, and our goal is to engage in a sustained
dialogue with our Chinese counterparts on many important
issues. Chief among them is domestic surveillance in China for
Asian H5N1 avian influenza.
It is our strong desire that this type of regular
communication with Chinese officials will help encourage
further transparency on the animal disease front. It is our
hope, too, that China will engage more fully in international
efforts to formulate effective strategies against Asian H5N1
avian influenza virus.
With that, I conclude my statement. Thank you, again, for
the opportunity to be here today.
[The prepared statement of Mr. Clifford appears in the
appendix.]
Mr. Dorman. Dr. Clifford, thank you very much for that very
useful and interesting testimony.
I would like to introduce our next witness from the
Executive Branch, Ms. Erika Elvander. Ms. Elvander is from the
Office of Asia and the Pacific, Office of Global Health Affairs
at the U.S. Department of Health and Human Services [HHS]. Ms.
Elvander has coordinated East Asia and Pacific policies since
2001 for the Office of Global Health Affairs, Office of the
Secretary, U.S. Department of Health and Human Services. She
currently focuses on bilateral and multilateral U.S. health
cooperation with a number of key countries in the region,
including China, Japan, the Republic of Korea, Singapore,
Thailand, Vietnam, and the U.S. territories in the Pacific, and
with the Freely Associated States. The bilateral activities
touch on a number of important disease issues, but recently
have included Severe Acute Respiratory Syndrome [SARS], HIV/
AIDS, pandemic and avian influenza, and tuberculosis [TB].
Ms. Elvander, thank you very much for joining us today. You
have 10 minutes for your opening statement.
STATEMENT OF ERIKA ELVANDER, OFFICE OF ASIA AND THE PACIFIC,
OFFICE OF GLOBAL HEALTH AFFAIRS, U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES, WASHINGTON, DC
Ms. Elvander. Thank you so much for having me.
In December 2003, the global community learned of reports
from Korea of its first-ever cases of Avian Influenza (A) H5N1.
Shortly after this, H5N1 appeared among poultry in a number of
countries in East Asia, including Thailand, Vietnam, and China.
Since then, H5N1 has spread to Central Asia, Europe, and the
Middle East. As we know, in recent weeks Nigeria reported the
deaths in its northern provinces of over 40,000 birds from
H5N1, bringing the disease to Africa.
In addition to these avian cases, human cases are appearing
sporadically across the globe. As of February 20, 2006, the
World Health Organization [WHO] confirmed 170 human cases, of
which 92 have been fatal. In all but a very few cases, all
confirmed human cases could be linked to contact with sick
poultry or animals.
While 92 human deaths may not be considered significant in
the context of other diseases such as tuberculosis and HIV/
AIDS, the high rates of mortality, the lack of predictability
about who could contract the disease, and fears of genetic
changes within the virus cause great concern about human cases
of H5N1.
Globally, the emergence of a new strain of influenza with
pandemic potential has public health officials extremely
concerned. Thus, multilateral organizations such as the World
Health Organization, the World Organization for Animal Health,
and the Food and Agricultural Organization of the United
Nations, as well as larger donor governments such as the United
States, Japan, and the European Union, have begun to apply
political pressure and provide financial and technical
assistance to help countries around the world affected by the
animal disease epidemic in hopes of stemming a possible human
pandemic.
H5N1 is one of many strains of influenza, or flu, of which
only some affect humans, or birds, or both, and some that
affect other species. Not all strains are highly infectious or
cause high rates of morbidity or mortality, but the mere fact
that influenzas change and mutate is why specialists carefully
watch flu strain patterns every year to predict which strains
will be responsible for the regular, seasonal human flu, which
causes about 36,000 deaths in the United States a year.
Beyond seasonal flu, H5N1 specifically is of concern for a
couple of reasons. First, flu pandemics tend to come in cycles
of 30 to 50 years. The ``Spanish'' flu of 1918 is thought to
have caused between 20 and 100 million deaths worldwide, and
more than 500,000 deaths in the United States. While subsequent
pandemics have been less deadly--the last true flu pandemic
occurred in 1968 and caused 1 million deaths worldwide--the
specter of the 1918 pandemic lingers on.
Second, the H5N1 strain in circulation among animals seems
to cause extremely high rates of mortality among humans. Third,
while vaccines specific for H5N1 are in development, they are
still being tested and, if proven to be effective, will take
time to manufacture and distribute. In the interim, other
drugs, such as amantadine and oseltamavir, commonly known as
Tamiflu, are in limited supply and are of limited use.
While it is clear that direct exposure to diseased birds
seems to be a necessary link in humans contracting disease,
other information about how, when, and why H5N1 causes disease
in its human victims is still a mystery. The ability of flu
viruses to mutate quickly causes public health officials to be
on the lookout for sustained effective human-to-human
transmission. This makes health ministers lose sleep at night,
and their agricultural counterparts toss and turn, worrying
about the drop in trade that the die-offs in poultry are
causing.
H5N1 has appeared before and, as my colleague from
Agriculture noted, it first appeared in Hong Kong in live bird
markets in 1997. Appearing to only affect chickens at first,
public health officials became alarmed when six people died
from it. Alarmed by what appeared to be a possible harbinger of
a pandemic, the Hong Kong health authority, led by Dr. Margaret
Chan, now with the WHO, made the courageous decision to order
the destruction of every single chicken, duck, and egg in Hong
Kong. Over 1 million birds were culled, and human cases of H5N1
seemed to abate at 18 cases and 6 deaths.
Biosecurity measures in live markets were put in place that
ensured better separation between humans and poultry, and
policies were instituted that ensured tissue and blood samples
from every shipment of poultry from China--mostly Guangdong and
Shandong provinces, where most poultry in Hong Kong
originates--were taken and tested for H5N1. The goal was an
effective animal surveillance system that would catch as
possible outbreak before human cases could occur.
H5N1 did reappear in February 2003, when two human cases
were detected in Hong Kong from travelers returning from
Southern China, suggesting that H5N1 was circulating, at least
among domestic poultry, during the prior year.
While the Ministry of Agriculture of China never officially
confirmed new avian cases linked to these human cases, these
cases were quickly overshadowed by what became the Severe Acute
Respiratory Syndrome, or SARS, outbreak that dominated public
health and global media attention that spring and summer. When
Korea reported its first case of H5N1 in December 2003, the
current outbreak officially began.
A couple of words on Hong Kong. Hong Kong is, of course, a
unique situation. In 1997, it became a Special Administrative
Region of the People's Republic of China. However, with the
``one country, two systems'' policy, it is still, to a large
extent, an economic entity entirely separate from the mainland,
with different
infrastructures, business practices, and economic development.
China cannot afford to lose the technological, economic, and
academic advantages that Hong Kong brings to it, and thus
allows it to continue to function, at least economically, at
some level on its own. Furthermore, Hong Kong is always at
``Code Orange'' for avian influenza, and as such maintains
animal husbandry and biosecurity practices far different than
most of rural mainland China.
As such, until as recently as last month, Hong Kong managed
to keep itself relatively H5N1 free, even in the face of
continued outbreaks around it in the surrounding areas. And
while no human cases from Hong Kong have been reported since
2003, it has an urban population still smarting from the
memories of SARS, the economic wherewithal to pursue these
high-level biosecurity measures, the geographic limits, and the
community will to maintain this so-called ``orange alert''
status for H5N1.
Now, as many of you know, recently Hong Kong reported H5N1
cases in native magpies, which has caused great concern for
local health authorities, who fear H5N1 may have been brought
to Hong Kong from the mainland, and worse yet, that H5N1 may
now be endemic within the territory. Indeed, scientists support
their suspicions of importation of the disease from China, as
recent studies from Hong Kong, but funded from HHS's National
Institutes of Health, have demonstrated that the H5N1 virus
endemic throughout China is the likely source of outbreaks
among poultry in surrounding countries and territories.
Now, then, to China. As you know, about 60 percent of its
population lives in rural areas. There are--or rather, were--15
billion domestic fowl in China last year. That is to say, one-
fifth of the world's poultry--mostly chickens, but also
significant numbers of ducks, turkeys, and geese that are
raised for domestic consumption come from China. China has both
large-scale production facilities and family backyard farms.
Indeed, most rural families have about 10 to 25 chickens and
ducks which are kept for food and income.
So what is a country, scared by their SARS experience and
faced with an economic and possible public health disaster like
H5N1, to do? As my colleague from USDA has already mentioned or
discussed, outbreaks amongst birds must be contained;
monitoring and reporting of suspect animal and human cases must
continue in a transparent manner. However, given that most
strategies for containment among birds include the culling and
eradication of flocks where exposure to H5N1 is suspected,
posing a huge loss for farmers, the disincentives for reporting
animal cases are high. Compensation for lost flocks is a
complicated issue that an economist can address far better than
I can, or will. Moreover, for countries that export poultry,
and China is one of them, mostly to Japan and Hong Kong,
reporting cases to the international community can be viewed as
a trade risk and economic considerations sometimes take
precedence over public health concerns.
Having said that, I think that lessons learned from HIV and
SARS both appear to have encouraged Chinese authorities to
recognize the need to investigate openly and report at least
suspect human cases of H5N1.
Up until the summer of 2002, China continued to deny that
HIV/AIDS had epidemic potential within its borders, preferring
to place blame on outside forces. As my colleague from CSIS
knows too well, U.N. organizations, donor countries, as well as
NGOs such as CSIS, applied both public and private pressure on
the government of China, trying to convince officials that the
economic and health impacts of not acknowledging and dealing
with the burgeoning HIV/AIDS problem were far greater than
continuing to deny it.
As a result, Chinese officials began to open up
internationally--and more importantly, domestically--about HIV/
AIDS in China, and within a year China had successfully
competed for a $32 million two-year grant for HIV from the
Global Fund to Fight HIV, TB, and Malaria. At the same time,
the United States and other donors made financial commitments
to China's Ministry of Health for both research and technical
assistance in confronting HIV. China had learned that openness
about public health issues of global concern would not
necessarily bring shame, but might actually bring financial
resources.
However, the lessons from HIV/AIDS did not seem to apply
until late in the game with SARS. Reports of a strange new
respiratory illness with high levels of mortality began to
appear in late February 2003. When what became the SARS
outbreak finally ended later that summer, over 8,000 cases
would be reported, with 775 deaths in 30 countries and 6
continents.
As noted earlier, public health practitioners were
originally concerned that the SARS outbreak was the next flu
pandemic, and indeed, two early suspect SARS cases proved to be
H5N1. Early on, Chinese officials were concerned about the
impact and outbreak that a disease of unknown origin would have
on travel on the Chinese New Year, the largest travel day of
the year worldwide. The government chose to delay entry to
international experts and continued to question if SARS had
epidemic potential domestically. It was only when rumors about
the disease began to have an impact on tourism, as well as
rising international outcry at cover-ups, that China opened its
borders to scrutiny, but as usual, in a carefully monitored and
controlled fashion.
By the end of the SARS outbreak, according to the World
Bank, the impact on the Gross Domestic Products of countries in
the
region was between 0.4 and 0.5 percent, or between $20 and $25
billion for the region, not limited just to China. In the
process, a number of high-level Chinese officials, including
the Minister of Health and the Mayor of Beijing, lost their
jobs.
And yet, embarrassingly for China, it was not over yet. In
March 2004, an accident at the National Institute of Virology
in Beijing, China's premier virology laboratory, infected two
researchers with SARS and the Institute closed.
I note that China's idea of transparency and openness is
still one with a degree of control involved. All decisions and
reports on human cases are made by the central government, not
by local officials, which can add time to official
announcements; further anecdotal reports suggest that some
restrictions have been placed on the press.
I also want to note that when the first suspect human case
of H5N1 finally appeared in late October 2005, the Ministry of
Health engaged the international community by inviting
outsiders in to work side by side with Chinese experts in
investigating the cases. Government announcements come with
clearly defined solutions already in place, suggesting that the
government has the situation under control. Nevertheless, the
Ministry of Health's willingness to open itself to
international scrutiny is a huge step, and China has been
publicly praised internationally and promised further
assistance in dealing with human cases.
Unfortunately, the lessons learned from SARS by the
Ministry of Health do not seem to have translated well to the
Ministry of Agriculture, as my colleague from USDA has noted.
When wild birds began dying in Qinghai province in April 2005,
the Ministry of
Agriculture delayed allowing international scientists and
observers into the actual areas where the deaths had occurred,
citing so-called security concerns, although the deaths were
largely in nature preserves.
Finally, late last summer, as wild and domestic birds
continued to die across China, international observers were
invited to see the veterinary lab in Harbin, which had tested
tissue samples. The Ministry of Agriculture continued to refuse
to share samples with international bodies, and, equally
challenging, continues to refuse to share samples with the
Ministry of Health, claiming flatly that this is not a human
health issue, but rather a trade issue.
While the Ministry of Agriculture has recently been more
forthcoming with reports of outbreaks, the timing of its
willingness to share seems to coincide with both reports of
human cases, large-scale ministerial poultry vaccination
campaigns, and Premier Wen Jiabao's January 2006 commitment at
the Beijing Donors Conference to cooperate with the
international community.
There is no question that we see an increased level of
commitment and cooperation by the Chinese Government. Both in-
country coordination between Ministries and communication with
outside organizations have improved. More importantly, the
Ministry of Health has shared samples from human cases through
the WHO network.
However, it is important to point out that human cases of
H5N1 in China are often recognized before recognition of
disease in poultry in the same locales, indicating the
shortcomings of the animal surveillance system. In some of the
human cases reported over the past few months, the victims came
from regions in which no previous bird infections had been
reported, even though the transmission occurred from contact
with infected poultry.
China has also recently begun a policy of being both a
donor and a recipient of international assistance, reaching out
politically and financially to partners in the region and, even
at the Beijing Pledging Conference last month, made a point of
being a donor as well as a recipient.
We have already referenced what the U.S. Government is
doing. What I would simply say is that, in 2004, HHS alone
funded more than $34 million worth of biomedical research in
basic public health activities with China, and we foresee this
figure increasing, not decreasing. The U.S. Government recently
established a platform with China, the program of emerging and
reemerging into diseases that will promote cooperation between
the two countries on a number of infectious diseases, but first
on avian flu. In part of that, HHS will be assigning three new
staff to China to work specifically on emerging diseases.
It is our belief that by working with China as a partner to
confront issues of public health import such as avian flu, we
will be able to create an environment that will not only
promote scientific and biomedical transparency and sharing of
data, but also will improve China's public health surveillance
and disease reporting network so that epidemics may be
prevented and contained, not left to fester quietly.
I would also encourage everyone to go to a number of good
Web sites, including www.pandemicflu.gov, which is the U.S.
Government's primary site for all things related to flu, and
there are a number of others as well.
I will answer any questions. Thank you for your time.
[The prepared statement of Ms. Elvander appears in the
appendix.]
Mr. Dorman. Good. Thank you very much for that testimony.
It will generate, I am sure, many questions in the next hour.
Thank you.
I would like to introduce, next, Dr. Bates Gill.
Dr. Gill is the Freeman Chair in China Studies at the
Center for Strategic and International Studies. Dr. Gill has
held the Freeman Chair in China Studies at the Center for
Strategic and International Studies since July 2002. He
previously served as a Senior Fellow in Foreign Policy Studies,
and inaugural Director of the Center for Northeast Asian Policy
Studies at the Brookings Institution. A specialist in East
Asian foreign policy and politics, his research focuses
primarily on Northeast Asian political and social issues,
especially with regard to China. His current projects focus on
U.S.-China-European Union relations, on China as a growing
influence in Asian regional affairs, and on China's challenging
domestic policy agenda, especially with regard to the social
safety net and China's HIV/AIDS crisis.
Thank you very much for joining us today, Dr. Gill. You
have 10 minutes for an opening statement.
STATEMENT OF BATES GILL, FREEMAN CHAIR IN CHINA STUDIES, CENTER
FOR STRATEGIC AND INTERNATIONAL STUDIES, WASHINGTON, DC
Mr. Gill. Thank you very much, Mr. Dorman. Let me also
thank the Commission chairmen and the whole staff for inviting
me to provide my views this afternoon. I commend very much the
Commission for taking up these issues and look forward to
having a discussion with you on them.
It is clearly a very important and timely topic. We have
noted already that the disease has spread from Asia, to the
Middle East, Europe, and Africa, and the prospect, of course,
that it may, in the coming season or beyond, spread in a more
deadly way into the Americas and elsewhere. The World Bank has
made an estimate that the first year of an avian flu pandemic
could cost the world economy up to $800 billion.
Given the interest of the Commission, and given topics
which have already been covered by my two colleagues, I would
just like to briefly touch on three areas.
First, some of the issues of the current situation
concerning avian flu in China which maybe we have not discussed
quite yet; some of the steps that the Chinese Government has
put in place; and I would like to focus most of my remarks on
what I think might be of most concern to the Commission, and
that is the challenges that are remaining in China's approach
to avian flu, and what is being done about it, especially
within the government and among civil society.
China is not only the most populous Nation in the world, as
we have heard, it also has the most poultry. According to the
Food and Agricultural Organization of the United Nations, fully
one-fourth of the world's chickens, two-thirds of the world's
domesticated ducks, and a remarkable nine-tenths of the world's
domesticated geese are living in China.
Now, just the sheer size of the populations, both human and
among poultry and birds, makes China a pivotal point for all of
us to consider the potential spread of this disease.
According to the World Health Organization, as of February
13, 2006, China reported the country's 12th laboratory-
confirmed case, and eight of those have been fatal. I find it
interesting that cases have now occurred in a pretty widespread
area in China, covering seven different provinces, including
Anhui, Fujian, Guangxi, Jiangxi, Hunan, Liaoning, and Sichuan.
As has already been noted by Ms. Elvander, another
interesting point I think we should take note of is that about
one-third of China's reported human cases thus far have
occurred in areas where there were no reported poultry
outbreaks. This is, I think, some cause for concern going
forward.
Second, what steps have been taken? I agree with my
colleagues that, generally speaking, we should all be
encouraged that, at least in comparison to China's response to
other infectious diseases, such as HIV/AIDS, and of course the
SARS outbreak of 2003, this time, I think, Beijing deserves
some praise for its efforts to control the avian flu. Senior
officials at international organizations, as well as from
across governments, are generally positive that at the central
level, at least, there has been a strong political commitment
to tackling the avian flu problem.
A number of specific steps have been taking in organizing
the bureaucracy, at the central level, at least, to address
this problem more effectively, including the announcement of
specific contingency plans by the Ministry of Health in
September 2005.
Also, I found it interesting that the State Council, at the
early part of this year, announced national response plans for
nine different types of emergencies, one of which included
public health incidents, thereby putting the central government
very strongly on the record and mobilizing bureaucracies to be
more responsive in an emergency mode as different crises might
emerge, including on the health front. Also, official
structures within the bureaucracy have been established beyond
just simple pronouncements. The Ministry of Health has set up a
special department, apparently, to deal with avian flu. The
Ministry has also established 192 monitoring spots throughout
the country to try and cover the potential for flu outbreaks.
Following the State Council's emergency response plans, the
Ministry of Health announced the formation of a national expert
team, consisting of some 105 experts, which could be quickly
brought together, mobilized, and sent to areas of concern,
should, and when, there be outbreaks of disease.
I think all of these steps are obviously to be welcomed. I
would say that it is still too early to know, having been only
about a half a year that these various steps have been taken,
to know how effective it would be in the case of a real
emergency.
I would also remind all here of the traditional difficulty
that a stovepiped bureaucracy in China has had in trying to
effect cross-bureaucratic cooperation, not unfamiliar to us
here in our country, but China seems to be especially
difficult, having invented the bureaucracy so many thousands of
years ago. This point, I think, is critical, because obviously
one single ministry, in the case of an avian flu outbreak,
cannot possible be capable of addressing the emergency on its
own.
On the international cooperation front, too, I think
Beijing should be commended, especially for hosting the
International Pledging Conference, and pushing ahead on a
Beijing Declaration resulting from that conference, which has a
number of effective recommendations. It calls for increased
cooperation and openness across the international community.
Let me spend the rest of my time talking about what we
might call the remaining challenges. I see three big
challenges. All of these are areas in which the United States
and China can cooperate, and I think all of these are areas
about which the Commission has particular interest.
During the SARS outbreak two years ago, we saw China
encounter intense criticism from the international community
for its
delayed response and its cover-up in the initial stages of the
epidemic. This time around we do see some improvement, but
there are lingering problems about which we should be
concerned. First is transparency. Fearful of censure, Chinese
provincial and county officials sometimes might choose to
conceal infection outbreaks from the central government. That
was surely the case during the SARS outbreak. Additionally, as
has been already noted, predominantly poor Chinese farmers will
be often reluctant to report potential health risks, giving
them an incentive to hide an outbreak for economic reasons.
I would point, too, to the recent benzine spill in the
Songhua River in northeast China as an example of how local
authorities will, at least in the early stages, seek to
suppress bad news.
Second, we have to talk about technical capacity and
financial resources. Even with the degree of political
commitment, which I think we can be convinced of, at the
central levels in Beijing, the lack of capacity and resources
at local levels remains a very large question mark in China's
handling of avian flu. This is particularly so since we can
expect that, should major outbreaks occur, they are going to
occur in rural and poorer parts of the country.
None other than Health Minister Gao Qiang himself has
identified his largest concern about this in a press conference
in November 2005. He said, ``the inability of our medical and
quarantine
personnel at the local level to diagnose and discover epidemics
in a timely fashion due to lack of skills and relatively
backward equipment is my largest concern.'' The country still
faces a shortage of experienced and qualified professionals,
resulting in misdiagnosed patients, some of whom were said to
have pneumonia instead of avian flu. There is a great need for
qualified and experienced veterinarians, especially in the
rural areas. Meanwhile, many villages and towns do not have
effective surveillance systems; recall that they have only set
up 192 of them in a country as vast as China. Also, it is
typically only after patients are admitted into hospitals and
are identified as having H5N1 that local officials would begin
to investigate the patients' villages.
But it is not just a technical question. The overall
healthcare situation in China, I think, raises additional
concerns. As reported from the Development Research Center of
the State Council, a think tank directly under the Cabinet, 90
percent of China's rural population is not covered by any form
of medical insurance. The same report also notes that China's
medical reform has been unsuccessful because it has become
unbearably expensive to patients, and many dare not go to the
hospital when they fall ill.
Lack of medical insurance, together with ill-equipped
countryside clinics and hospitals, makes rural China an
extremely vulnerable spot when facing infectious disease
outbreaks. In other words, cases may well go unreported simply
because people do not choose to go to the doctor or to the
hospital.
Last, let me discuss a third area that I think is still a
challenge, and that has to do with public awareness. As a
result of poor educational conditions and the lack of available
resources, especially in rural parts of China, public awareness
and knowledge of a possible pandemic is limited, particularly
in rural areas. This adds an enormous barrier to overcome in
terms of avian flu education and prevention.
Basic information about the symptoms, how it is contracted,
and where the breeding grounds for H5N1 virus are, and other
general information should be distributed more widely to the
public, particularly the rural population, in order to
implement preventive measures.
The ``Beijing Declaration,'' which came out of the Pledging
Conference last month, called for the mobilization--I thought,
interestingly--of all social sectors, including non-government
civil society, to effect a coordinated response and that
community-based NGOs ought to be encouraged to partner with the
government to promote public education and enhance public
awareness, in particular in hard-to-reach populations and
areas.
The case of China HIV/AIDS-related NGOs may be instructive
here. We have learned that such groups have tentatively begun
to assist the government to reach out to socially marginalized
groups and provide training, care, support, and preventative
messaging. Thus, I think the role of NGOs and the fight against
avian flu and other highly pathogenic and infectious diseases
should be expanded in China as well.
Let me conclude on the note that the possibilities for
public/private cooperation on these questions, both on the U.S.
side and in China, are increasingly open. The examples that we
could point to, Ms. Elvander and I, of informal cooperation
between public and private actors in trying to encourage more
open and more responsive policies on the part of Beijing toward
some of its infectious disease challenges, I think, are
instructive.
We see in China today an increasing openness and acceptance
in the idea of partnering, even with foreign private entities,
with the Chinese public sector to help tackle these kinds of
infectious problems.
Just generally speaking, I think it speaks to a greater
openness and possibility for civil society and private actors
to have a role in China in dealing with these kinds of
problems. Thank you very much.
[The prepared statement of Mr. Gill appears in the
appendix.]
Mr. Dorman. Dr. Gill, thank you very much.
Witness testimony is very important to the Commission. At
least since 2003, and perhaps before, our Commission Members
have identified the issue of public health, in general, and
specifically the Chinese Government's record in dealing with
the international community in containing global health
challenges, as an important part of the Commission mandate.
Public forums such as this one are among the most important
ways that the Commission receives information on these issues,
so I thank all of you, on behalf of our Chairman and Co-
Chairman, for being here.
I have seen my colleagues on the dais scratching down what
must be hundreds of questions during your testimony, and I
think most of the questions are going to focus on Chinese
Government efforts to combat avian flu, and the degree of
cooperation with both international and bilateral partners.
But before we go in that direction, I would like to take my
couple of minutes to expand the scope of our discussion by
asking each of you to help the Commission understand the
complexity and difficulty of the problem that China is facing.
There have been news reports over the last couple of days
mentioning that the Netherlands and France have received EC
approval to begin vaccinating poultry stocks. All of these
reports point to the fact that measures like these usually only
occur in countries that face an avian flu problem that has
become ``entrenched.'' The Netherlands and France are
developing preventative responses before a problem develops or
becomes ``entrenched,'' regardless of whether or not we might
agree that this is the right response.
China has been vaccinating poultry flocks and I believe it
would be accurate to describe the avian flu problem there,
unlike the Netherlands and France, as ``entrenched.'' What does
it mean for a disease to be ``entrenched'' in a society, and
second, how does it become ``entrenched? '' Has this
``entrenchment'' resulted from a unique agricultural situation,
a unique human situation, or do diseases like this become
``entrenched'' because of the lack of a serious, early response
by government actors, or is it a combination of all of the
above?
Mr. Clifford. I will go first. I think with regard to these
types of diseases becoming entrenched in countries, it is
probably initially either a lack of infrastructure or a lack of
action to be able to appropriately address these diseases. I
think that is basically summing it up.
One of the things that we have encouraged, through the FAO
and as well as the OIE, is basically an assessment tool to
assess a number of these countries that have had this disease
for some time and have been unable to eliminate, eradicate, and
control this from their domestic poultry populations. I think
it is important that we do an assessment to make sure that we
provide the right kind of resources, training, and support that
they need to be able to not only eradicate or control this
disease in the short term, but also be able to sustain that and
have the infrastructure to deal with these types of things in
the future.
Ms. Elvander. The other thing I would add is that we are
talking about chickens. They have a short life span to begin
with. What you are seeing, where H5N1 has occurred, is in
countries which probably already have Newcastle's disease, fowl
cholera, and other avian diseases. If a pig gets sick, a farmer
is probably going to take better care of it, or if a cow gets
sick, because there is a longer term investment. But you are
dealing with chickens. Fifty percent of chickens, in some parts
of this part of the world, die anyway and no one really knows
why, and you can usually eat the ones that die for unknown
reasons. So if you are talking about a backyard farmer
situation, such as in Vietnam, where 90 to 95 percent of all
chickens are in backyard farms, you are asking local farmers to
not eat and/or kill off potential sources of protein because of
unpredictable disease that in terms of total numbers--compared
to other human diseases--has directly affected very few people.
Further, the financial investment and the protein
investment is very different than if you are dealing with a cow
or some larger animal which is going to live longer and give
you a different
resource.
The other thing I would point out is that the slaughtering
practices in this part of the world are important to think
about. Most Asian farmers or Asian consumers of chickens want
to see their chicken slaughtered in front of them in a live
bird market or they will slaughter it themselves. So, there is
a certain sanitary/hygiene aspect of poultry slaughter going on
here that is perhaps not as significant in the Western
community. I do not know if you want to build on that or not.
Mr. Clifford. I would agree. In the United States, our
poultry operations on the commercial side, the majority of
ours, are highly integrated operations with good biosecurity.
It is a totally different situation than you see in many of
these countries as far as the practices in which poultry are
raised, as well as the incentive issues. We have incentives in
the United States for reporting these types of diseases.
Mr. Dorman. Dr. Gill, did you want to add anything?
Mr. Gill. To answer your direct question, I think it is
obviously a combination of both. It strikes me that while
technical solutions to these problems, such as widespread
vaccination or something similar, are often attractive, I am
not sure, in the case of massive vaccinations, if something
very massive had to occur. I am not sure that at this point
there would be the technical resources or prompt enough access
or delivery capability of that kind of a program to wide parts
of China. So, I would fear that, while it might be an
attractive, immediate answer, given the scale and the numbers
that we are talking about, as well as the relative technical
difficulties that we would face, especially in rural parts of
China, that I do not think we can necessarily see that as a
good answer.
Mr. Dorman. Good. I think I would just paraphrase what I
have heard from each of you. The Chinese Government is building
a public health infrastructure to deal with diseases like avian
flu, but it is building this capability after the fact. All of
you have pointed to efforts by the Chinese Government to do
this. But, of course, the challenge is very large.
I am going to turn the dais over to my colleague, John
Foarde, who serves as Staff Director for Representative Jim
Leach, who is our Commission Co-Chair. John.
Mr. Foarde. Thank you, Dave. Thanks to all three of our
panelists. Two, Dr. Gill and Ms. Elvander, are friends that
have helped us many times before. It is Dr. Clifford's first
time, and I hope it will not be the last one.
Mr. Clifford. Thank you.
Mr. Foarde. We appreciate you sharing your expertise with
us this afternoon. Dr. Clifford, you discussed during your
presentation the request for regionalization that the Chinese
Government made in 2004, and that raised the question, when you
were discussing the lack of response to APHIS' request for
information, about the reasons behind the Chinese Government's
lack of response. I was trying to understand, in other words,
what the problem is in China. All three of you have talked
about capacity problems. I am wondering, what is your
assessment of the capability for information gathering,
particularly by, say, provincial and local health bureaus, or
even the Ministry of Health itself? How good is it or does it
need to improve? Is that the problem that prevents these sorts
of requests from being responded to, or is it a political
problem or a problem of some other sort?
Mr. Clifford. Actually, others here may be able to answer
that particular component better than I can. I know that we
have not been able to get that type of information. Even our
people in Beijing, when they have asked for that type of
information, it is not provided to them. So, I do not know if
it is a case of a lack of capacity or if it is a case where it
has just not been provided.
Mr. Foarde. Does anybody else want to comment?
Mr. Gill. In this particular case of monitoring for avian
flu, I do not have any direct or personal experience or
information. If it is fair to base an answer on experience,
looking at the way these sorts of surveillance mechanisms are
employed and utilized in other infectious diseases, I think we
have a problem because I do not think necessarily that it is
conscious obfuscation, or an effort to try to lie, or
misinform. It may be more likely simply a problem of having
good information at the central level of what is going on at
more localized levels. There is reporting going on, but the
question has to arise: is that reporting good?
It strikes me that the incentives at the local level to be
less open are greater and the technical capacity to accurately
gather and collate and process, analyze, and put forward data
is also weaker.
So if we are seeking information at a central level, I
think they will probably do the best they can or they will just
say they do not know. That may well be the case.
Mr. Foarde. That is useful. Thank you. Erika, I have a
minute to ask one more thing. I was very intrigued by the
``Code Orange'' in Hong Kong comments that you made. I just
wondered, are there any other avian diseases, such as
Newcastle, avian cholera, or other things that Hong Kong is
``Code Orange'' or above for at the moment?
Ms. Elvander. I used that sort of as a metaphor based on
our own homeland security system. I do not know. In direct
answer to your question, I do not know. But I know that Hong
Kong has the political will to do this, and NIH is funding a
lot of what they are doing on the borders. Everyone has heard
of Dr. Rob Webster in the news out of St. Jude's. He spends
three months of his year at Hong Kong University doing this
sort of research.
Do you know if they do the same?
Mr. Clifford. Actually, Hong Kong has a lot more
progressive program. As stated, they took action immediately.
In fact, with regard to avian influenza, at first we had placed
Hong Kong on the initial list. Hong Kong came to us with the
data and support that we needed to be able to remove them from
that list, assuring us that they no longer had the H5N1 Asian
strain in their domestic poultry population, and in fact it
never got into the poultry population. I think it was a
particular wild bird, or an eagle, or something. I cannot
remember.
Ms. Elvander. It was an egret and a Peregrine falcon.
Mr. Clifford. Egret. Yes. There you go. Thank you very
much. They had found it had H5N1 in subsequent cases.
Mr. Foarde. Thanks very much.
Mr. Dorman. Good. Next, I would like to turn the
questioning over to Will Leahy, who is a Research Associate
with the Commission. Of course, as our witnesses know, Will did
all the difficult work that helped put this roundtable together
today. So, thanks for that, Will.
Mr. Leahy. I just want to thank all three of you for being
here. It has really been very helpful.
My question builds on the one that John Foarde asked.
Recently, the WTO's top pandemic flu official described Hong
Kong's practices as the gold standard in flu prevention. Ms.
Elvander, you said that clearly Hong Kong is a unique
situation, but I was wondering what best practices you think
could be taken from Hong Kong and realistically applied to the
mainland. If that is something that all of you feel comfortable
commenting on, that would be great.
Ms. Elvander. I am going to turn to my Agriculture
Department colleague for this response.
Mr. Clifford. When you are talking about best practices, I
think, you are talking about good biosecurity practices, you
are talking about good surveillance activities, you are talking
about incentives for producers to be able to submit sick birds.
But on the human health side, you mentioned issues about the
way animals are slaughtered and good hygiene practices. So, all
of those things are critically important to this issue.
There is a long list of things that can be done, but again,
I think that requires a tremendous amount of training and
capacity to get in there and train and to develop that
infrastructure and capacity to be able to do those things and
sustain them.
Ms. Elvander. From a human health side, I would also say
that one of the great things that you find out about surveying
and getting good data on human cases of avian flu is that you
find all the other influenza-like illnesses that can start
tracking your seasonal flu.
This is one of the things that we have learned from our
activities with our partners in Bangkok, with whom HHS has had
a partnership for over 25 years in the Ministry of Public
Health--they actually now know when their seasonal flu happens
and they can
predict and plan for that sort of thing, which, from an
economic standpoint, means you can plan for when you are going
to have worker shortages. Then you an also start to be
predictive for your pandemic flu. Hong Kong has the political
will and the financial will to do those things as well.
Mr. Dorman. Next, I would pass the microphone to Carl
Minzner, who is a Senior Counsel on the Commission. Carl.
Mr. Minzner. Thanks to all three panelists for coming here
to talk to us today.
On Wednesday, the Chinese central authorities in the Party
and the State Council released ``their number-one document''
setting out some of their leadership priorities for the coming
year. It has a strong focus on rural reform. Two issues in
particular that they flagged are larger investment in rural
healthcare, particularly over the next two years, and the
development of rural health clinics.
Assuming Chinese authorities pursue reform of the
healthcare system, what specific suggestions might you have for
things they might include in the development of relevant
projects for the purpose of warding off an avian flu pandemic?
Ms. Elvander. I will try to answer that question. I think
Bates and I have known for a long time that the biggest
domestic priority for health in China right now is their rural
healthcare. Minister Gao said as much to Secretary Leavitt in
October when they visited together; he said it again in several
forums. There have been a number of white papers from China.
It is very clear to everyone that China has a healthcare
delivery problem, and that public health, primary care
delivery, ensuring preventive healthcare, like immunizations,
things like that, are all things that are going to be important
to any rural healthcare
reform.
I am not by any means a health economist, so I am not going
to pretend to address those kinds of issues. I will say that
HHS and the Department of Commerce have had a joint activity
with the Chinese on healthcare and healthcare delivery with
their Ministry of Commerce and Ministry of Health. They had a
two-day forum in July and that began a process for us to
interact with them.
There was one other thing that I was going to say and it
slipped out of my head. Oh, yes: one piece of evidence to show
that China really has to invest in preventive healthcare is the
data that we have in the Western community demonstrating that
folic acid supplementation alone in the first trimester of
pregnancy dramatically lowers the risk of neural tube defects.
This data comes from China, but it is not being used there. It
comes from a long-term HHS-Ministry of Health study of many
women in Northern China, demonstrating that folic acid lowers
rates of neural tube defects by some number that I cannot
remember off the top of my head. But that data is not being
used in China, and I think that demonstrates the need for them
to commit to preventive healthcare.
Mr. Gill. Carl, it is going to be really interesting to see
how this new, or renewed, attention to the plight of Chinese
peasants is going to play out. We can hope it will play out in
a positive direction, but there are big challenges. If we just
narrow the focus enough to look at just dealing with infectious
diseases in the local areas, I guess there would be, I think,
two areas in which one would have to focus.
One, obviously, is on the technical and the capacity
building side. At the village level, persons at the village
level who are known as ``doctors'' are really lucky to have
completed high school. They might have received some basic
training in first aid and are able to dispense drugs and
diagnose some simple ailments. So, obviously, if we are worried
about these sorts of things emerging at that level, some sort
of technical and educational capacity is going to have to be
built there.
On the other side, though, I think--and I have tried to
make a point of this in the testimony--is how the economics of
healthcare in China are structured. I am not a health economist
either, but one thing that is going to have to be done is to
build incentives into the remuneration structure of physicians
and other healthcare workers so that they would be more prone,
willing, eager, and able to be more proactive in a preventative
way and not simply wait for the patient to show up and give
them money, if that is a possibility. The other side of this
coin is the health insurance problem. It has gotten so bad, the
market has become so expensive for the delivery of healthcare--
and this is not just true in China, but in many parts of the
world, including our own--you do not do anything until you are
sick because you cannot afford to see a doctor.
As we know in our country, that is not an optimal
situation,
especially when you are talking about infectious diseases. I am
encouraged to see that the government recognizes the problem
and appears prepared to devote political and financial
resources to it, but I think, as outside observers, that this
is going to take a long time to restructure.
Ms. Elvander. One thing I would note is that the World Bank
is aware of this issue. I think you will be finding some
interesting data and strategic planning coming out of the World
Bank in the coming months about this problem.
Mr. Dorman. Good. Thank you very much.
I would like to turn the questioning over next to William
Farris, who is a Senior Counsel on the Commission. William.
Mr. Farris. Thank you.
Some of you have touched on the issue of local and
provincial officials concealing information, possibly for
economic reasons. I would like to ask a question related to
that. The Chinese Government prevents people from publishing
newspapers and magazines and practicing journalism; unless they
have been licensed by the government, it is illegal. I would be
interested in getting your assessments of the Chinese
Government's contention that one of the reasons that this
licensing is necessary is a fear of people spreading false news
about issues similar to this one. I want to also get your ideas
or thoughts on how you think a free and open system for foreign
press--Reuter, AP, wire service stringers--being able freely to
go into China and report and cover these issues might enable
the international community to have a better capacity to
monitor the potential spread of this disease in China. Thank
you.
Mr. Gill. I will take that little hot potato. [Laughter.] I
think all governments have a right to be concerned about the
spread of false information. I mean, that concern is not unique
to the Chinese Government. So, we have to be somewhat
sympathetic to that concern. I think they probably do overplay
it in a way so that they can better control, or have
justification to better control, what kind of information the
public is hearing and seeing. It is unfortunate, I think, that
there is not a greater degree of independence among
journalists, whether they are from China or from abroad, so
that not only this sort of social health problem could be more
readily recognized and dealt with, but other problems beyond
the healthcare issues could also be addressed, and to introduce
a greater degree of accountability or oversight, a watchdog
function that the press can often play.
I think, though, that we should not expect that this sort
of control on the press in China is going to change any time
soon, especially with regard to foreign journalists. We have to
accept there has been a remarkable opening as compared to 10 or
even 20 years ago and marvel at the degree to which foreign
journalists can, and do, manage to get around the country and
report quite remarkable stories about what is going on at local
levels in China. That has happened, but obviously issues of
such sensitivity as the effectiveness of local officials, or
even the malfeasance of local officials, is something that, for
the foreseeable future, the Chinese are going to be very
reluctant to allow a lot of reporting on. So I take your point.
I think it would be a big help, both for Chinese journalists
and foreign journalists. I just think that we should not have
overly high expectations that that is going to be able to
happen anytime soon.
Mr. Dorman. Good. Thank you.
Next, I would like to turn the questioning over to Pamela
Phan, who is a Counsel on Commission staff. Pamela.
Ms. Phan. I just wanted to echo our thanks to the panelists
for coming and sharing your expertise with us here today.
I have questions regarding the risks of smuggling. I am
hoping that the panelists can help us better understand the use
and effectiveness of not only preventive, but also punitive,
measures.
With respect to preventive measures, aside from
compensation, are you aware of any other specific incentive
schemes that have been discussed or may be available, which
would involve participation by the public--particularly the
poultry farmers whose livelihoods are affected by the culling
of chickens?
With respect to punitive measures, I am wondering if you
could provide your assessment of any punitive measures that
might exist, such as criminal sanctions or criminal punishment
of those who smuggle or might be related to smuggling issues.
Mr. Clifford. A point of clarification. Is your question
related to China specifically, or even within the United
States?
Ms. Phan. Both.
Mr. Clifford. I can speak to what we do in the United
States. We actually have within the United States, besides the
Department of Homeland Security's Customs and Border Protection
component that would look for and be involved with smuggled
products at our ports of entry, within APHIS and plant
protection and quarantine, we have smuggling and interdiction
teams that actually are trained full-time in looking for
smuggled products. I cannot quantify it for you today, but
basically they have been very effective in being able to find
and confiscate smuggled products that have come into the United
States. In fact, $7.5 million of the President's supplemental
request is to bolster and enhance that effort by APHIS in that
area.
We also have penalties in place that we bring against
smugglers that are part of both the Animal Health Protection
Act, as well as the Plant Protection Act. Those penalties can
be substantial, depending upon the case.
Mr. Gill. I might just say a couple of words. It is my
understanding that there are regulations on the books in China,
at least issued at the central level, that farmers need to be
compensated for their animals, or chickens or other poultry,
that are culled. But it is also my understanding that there is
a sort of caveat within the regulations that says ``depending
on local conditions,'' in other words, basically leaving it to
local officials and local financial resources to make a
determination about what level of compensation is going to be
adequate and necessary to the farmers. So, it clearly leaves a
wide-open scope for malfeasance or just simple non-payment,
whether that is through some sort of corrupt practice in which
the official ends up pocketing that allocation, or it could
also be that there just simply is not the money to do it at
local levels. So I think the situation is ripe for abuse or
ineffectiveness.
On the punitive side, I am not aware of there being any
national law which specifically addresses the question of avian
flu-related criminal activity. There are other laws, however,
that relate more broadly to knowingly spreading infectious
disease and other, I think, more broadly interpreted
regulations under which someone could probably be punished.
But it gets down to what it is that the local level wishes
to do. You can bet that there is a law that could be applied to
a farmer if somebody locally wanted to have that law applied,
and then that farmer would have little recourse.
What this really boils down to, both on the incentive and
the punitive side, is the unpredictability of the Chinese legal
system and the lack of the rule of law, which, in a certain
case, could actually exacerbate this problem because the farmer
(A) cannot be guaranteed that he is going to be incentivized
correctly; and (B) he is also uncertain of just how badly he
might get punished if he does something wrong. Both of those, I
think, could be recipes for suppressing information, hiding,
putting things under wraps, trying to avoid reporting a problem
if you might have one.
Mr. Dorman. Good. Thank you.
A question for Dr. Clifford. Two-part. Is China a member of
the OIE? If so, what sort of obligation or expectation is there
that the Chinese Government would allow independent
verification of disease reports?
Mr. Clifford. Actually, I do not think China is a formal
member of the OIE. I am not sure how to describe China's
standing with the OIE, so there are some issues there, but it
is my understanding that they are part of the WTO. Therefore,
commitments under the WTO would require them to base trade
decisions and particularly restrictions upon good science, and
the World Organization for Animal Health, the OIE, sets those
standards for animal health-
related issues.
Mr. Dorman. Good. Thank you.
Ms. Elvander talked about Premier Wen Jiabao's statement, I
think, at the January 2006 Donors Conference, where he pledged
China's cooperation with international efforts to combat avian
flu.
I would like to ask the panel, how significant do you judge
this statement to be? We have seen in the past where a
statement from China's most senior leadership on an issue like
this would have a strong impact on implementation and
cooperation at both the central and local levels.
Is that the first statement from China's most senior
leadership on this particular problem? If so, how should we
judge that statement?
Ms. Elvander. This is the first such statement that I am
aware of, although when Secretary Leavitt and Minister Gao met
in October, Minister Gao admitted to openness around human
cases. I think the key piece of Premier Wen Jiabao's statement,
though--it is interesting--is that he announced that the
Chinese Government would contribute $10 million and reaffirmed
that the government would release the genetic sequences of
influenza and viral strains. He did not say, however, that
Chinese authorities would actually share virus isolates and
samples, which I think is a key piece here.
We have seen that the Ministry of Health wants to
collaborate with WHO and has been quietly doing so, but we have
also seen that the Ministry of Agriculture has not. So, the
commitment to transparency was couched in those terms.
Nevertheless, I think that with the commitments we have seen
with other diseases, such as with HIV and with SARS, et cetera,
that a commitment on such a high level does permit leadership
both on the central level, and then flowing down to the
provincial and local level, to at least start going through the
motions of being engaged.
The other piece of this is that this is not just a human
health disease, it is a multiple-ministry disease. As Dr. Gill
has noted, the Chinese Government's decisionmaking system is
stovepiped. So until Premier Wen says ``thou shalt collaborate
with your colleagues in the Public Security Bureau, the
Ministry of Agriculture, and other ministries. . .'' it is
probably not going to happen. So, I do think that is a positive
sign. I do not know if others want to comment.
Mr. Gill. I agree. I think you are aware of the
difficulties across the bureaucracy for coordination in China,
although I think we have seen a lot of interesting steps taken
at the central level to try to improve that and to establish
more of what we might call an inter-agency process. I note in
the testimony, for example, that apparently in November 2005, a
kind of cross-bureaucratic office for avian flu prevention was
created, which is intended to bring together six different
agencies concerned with the various issues, food security,
animal health, and medical prevention science. At least on the
books, we are seeing a level of cooperation. It does take
something like a statement from Wen Jiabao to get people to act
a little bit more forcefully on these fronts, but I think it is
still too early to tell what the result will be.
But, to the degree that our government could do it, it
would not be a bad idea to seek some sort of cross-bureaucratic
exchange, which would force mobilization of that kind of inter-
agency process in China.
Mr. Dorman. There is a rather remarkable article in the
Wall Street Journal today. I am not sure if you have seen it,
but it moves the discussion away from a simple lack of
transparency or coordination, and instead points directly at
the chief veterinarian in the Chinese Ministry of Agriculture
as the source of the decision, and further describes concerns
by Chinese scientists over attribution as a key reason disease
samples are not being shared.
Apparently, in the past some research generated by Chinese
scientists was used in articles outside the country, but was
not properly attributed, and this has led to the current block.
The article very carefully points out that China is not
alone in this sort of phenomena, and describes a similar
situation that occurred in the United States.
That was the lead-in to this question: is there a
scientific reason that China would not be sharing information
regarding scientific samples on diseased poultry?
Mr. Clifford. Not from the animal health side that I would
know of.
Ms. Elvander. There is a degree of face. I mean, we saw,
with Vietnam, their neighbor to the south, a rather critical
article in Nature come out right before the World Health
Organization meetings last year, and Vietnam felt very much
affronted by what they perceived as untoward criticism. It took
a lot of ground work by staff in Hanoi with the World Health
Organization and other donors to regain the momentum that we
had in collaboration with the Vietnamese on this particular
issue, to get that going again. China wants to be an
international partner, so does Vietnam, so there is a degree of
face involved. But as far as for scientific reasons, there is
absolutely no reason not to share.
Mr. Dorman. Good. Thank you.
I will turn the microphone over to John Foarde for another
question.
Mr. Foarde. Thank you, Dave.
One of the sets of issues that we are really interested in
understanding better on the Commission staff is differences
between
regions in China and the way laws, regulations, policies are
formulated and implemented, and even differences within
provinces and localities.
So, Erika, you made a comment, I think, about the source of
live poultry for Hong Kong being--and correct me if I
misinterpreted--Guangdong province, which is right next door,
and then Shandong province in the northeast. Right?
Ms. Elvander. Yes.
Mr. Foarde. That raised in my mind the question whether or
not you are seeing any differences between the two provincial
governments and how they handle either the animal or the human
disease prevention and control efforts with respect to these
exports?
Ms. Elvander. Go ahead.
Mr. Clifford. I was just going to say, I would not be able
to
respond to that at this time.
Ms. Elvander. And I cannot really answer about the animal
health aspect, and I cannot really address Shandong province. I
will say that, after SARS, Hong Kong felt very much like,
``here we are at the edge of it, and it all happened in
Guangzhou.''
So they have been able at least to establish conversations
with the Guangzhou Department of Health that do not have to get
vetted by Beijing, and I think that was very important for them
from a human health perspective. I cannot answer the rest of
your question.
Mr. Foarde. I appreciate your trying anyway.
Ms. Elvander. All right.
Mr. Clifford. We will see if we can find out some more
information for you.
Ms. Elvander. Yes.
Mr. Foarde. I wonder if this is something that your folks
at the U.S. Embassy in Beijing even have time to track.
Mr. Clifford. We will see what we can do.
Mr. Foarde. It is something that, when I was assigned to
the U.S. Embassy in Beijing, we were always trying to figure
out in another context and did not do as well as we would have
liked.
Bates, you were talking in your presentation about
challenges ahead, and one of them, of course, is lack of public
awareness, especially in rural areas. One of the things we are
interested in is the whole question of the Internet and the use
of the Internet for just this type of public purpose.
Here in the United States, really from the beginning of the
time that we had Internet access, you had Web MD and all kinds
of other public health Web sites, some of them of very high
quality and some of them not so high quality. Do you think that
the Internet or Web resources could have an impact on the
availability of information in rural areas for rural people in
China, and is that an area that the government could invest in
productively?
Mr. Gill. I think the answer, obviously, is yes. I would
assume that there are similar resources already available in
China. I do not know for a fact, but I am assuming they would
be. Surely, if not mainland generated, then mainland-based
individuals could surely access useful information from other
places, such as Hong Kong, Singapore, and elsewhere. The
problem, obviously, is that this most recent estimate that
there are 111 million Internet users in China today, which is a
fantastic number given where it was even five years ago, that
is still less than 10 percent of the country's population.
Obviously, it is predominantly concentrated in the wealthier
eastern coastal region.
So if an Internet network answer were to be feasible, it
would require, I would assume, infrastructure of all kinds. I
suspect that we will see China leapfrog once again, and perhaps
down the road as part of this effort to modernize, what are
they calling it? ``Countryside socialism,'' or something like
that. We may well see yet
another leapfrog, where this kind of information would not
necessarily have to be channeled out to the remote parts of
China through fiber, but would rather be done wirelessly, and
just leapfrog over the whole land line idea entirely. That is
within reach.
I suspect, if that becomes a greater reality, that we will
see more and more of that in the Chinese countryside.
Mr. Dorman. We have time for, I think, two more short
questions, so I will give one to Carl Minzner to ask.
Mr. Minzner. Dr. Gill, you flagged the possibility of
cooperation between Chinese and U.S. civil society
organizations as a positive development. Dr. Clifford and Ms.
Elvander, you flagged inter-
governmental cooperation as a positive step. What restrictions
or problems currently exist on that cooperation, and what
usefully could be done to address this? You mentioned
particularly that there was some information that you had
difficulty getting directly out of your counterparts in
Beijing. What usefully could be done to advance cooperation
between relevant organizations?
Mr. Clifford. I think that some of that cooperation is
happening through the Memorandum of Understanding we talked
about, the agreement we have over the next five years. We are
talking about more technical level discussions. Also, we have
got, through our Foreign Agriculture Service within USDA, there
is actually a group of Chinese officials, about 15 to 20, who
are going to be visiting the United States soon, and we are
going to be taking them through how we do risk assessments, how
we handle SPS issues, and just give them a flavor and
background of how we handle rulemaking and things like that, to
try to have a better collaboration and understanding of the
different approaches and systems. So, I think we are doing
that.
Ms. Elvander. I would echo my colleague from Agriculture's
comments. As I said, last year the HHS funded $34 million worth
of activity within China. Now, most of that was through NIH
grants, and 90 percent of NIH grants go to academic
institutions. They are ``extramural,'' which means that grant
funds go to Harvard, UCLA, but also some directly to the
Chinese, and, I think, building that staff level partnership.
We also signed this Memorandum of Understanding in October
that is going to expand the number of people we can place in
China, and I think the trust issues will build from there. We
will be able to demonstrate that we view them as partners,
technically and scientifically, but provide that technical
assistance. I think it is a case of trust in that particular
case.
Mr. Gill. As you probably are well aware, there is an
enormous amount of activity being undertaken by private
entities, philanthropic organizations, charities, faith-based
organizations, foundations, and even think tanks over in China,
and doing it, I would say, predominantly on what we might call
a private/public basis, that is to say, private foreign
organizations that are working, at least at the initial phase,
with government-related entities, and even directly with
bureaucracies.
So I think the model is clearly there, and I think on the
issue of health in particular, it has been flagged as an area,
I believe, where the Chinese are prepared to expand that kind
of activity, even well beyond our relationship with strictly
government entities, but I think there is even an opening to
improve more private-to-private or NGO-to-NGO type activity.
So, I think there are some promising ways forward there.
Mr. Dorman. Well, unfortunately our time is up. I actually
have to apologize to our witnesses because we have kept you a
few minutes longer than we promised already. I would also like
to thank all of you again for sharing your knowledge, insights,
and expertise.
This topic is important to our Commissioners, and each of
you has done a superb job in illuminating the issue, and
providing ideas to improve cooperation and efforts in this
particular area.
Before I call the roundtable to a close, I would like to
remind everybody in the audience again that the next public
event by the Commission will occur on March 6. It will be a
full Commission hearing, chaired by Senator Hagel, that will
look at the issue of human trafficking in China. It will be
held in the Dirksen Senate Office Building, Room 419, 2 to 3:30
p.m.
So with that, on behalf of our Chairman and Co-Chairman, I
call this roundtable to a close. Thank you very much.
[Whereupon, at 3:37 p.m. the roundtable was concluded.]
A P P E N D I X
=======================================================================
Prepared Statements
----------
Prepared Statement of John R. Clifford
FEBRUARY 24, 2006
Thank you very much for asking me to take part in this roundtable
discussion. My name is Dr. John Clifford, and I am the Deputy
Administrator for Veterinary Services with the Department of
Agriculture's Animal and Plant Health Inspection Service, or APHIS. In
this position, I also serve as USDA's Chief Veterinary Officer.
We in the Federal Government take the threat posed by avian
influenza very seriously, and we're committed to working to carry out
the President's National Strategy for Pandemic Influenza.
USDA has many key roles to play as outlined in the National
Strategy. In my mind, though, one of the most important is our
involvement overseas to help
affected countries take steps to combat the Asian H5N1 highly
pathogenic avian influenza virus at its source--in poultry populations.
Representatives attending last month's International Ministerial
Pledging Conference on Avian and Human Pandemic Influenza in Beijing,
China, also recognize the importance of a coordinated global effort to
address this disease. According to the European Commission, cosponsor
of the conference along with the World Bank and the Chinese government,
a total of $1.9 billion was pledged by the attending countries. This
funding will help affected countries fight outbreaks of the Asian H5N1
avian influenza virus and also assist neighboring countries in efforts
to prepare for any related human health issues.
During the conference, President Bush announced that the United
States will provide substantial funding--$334 million--to support the
global campaign against avian influenza. This represents the largest
single national contribution thus far to these global efforts.
Resources will be used, among other things, to assist countries with
national preparedness plans, improve surveillance and response systems
for domestic poultry, and to provide assistance in establishing wild
bird surveillance programs.
As part of this funding I just mentioned, USDA received $18 million
to advance collaboration with international organizations to help
countries in southeast Asia take steps to enhance their veterinary
infrastructure and adopt other practical,
effective programs against Asian H5N1.
My boss, APHIS Administrator Dr. Ron DeHaven, has traveled recently
to Southeast Asia to assess the animal disease situation in several
countries and the steps being taken in response. The information and
observations he collected are helping USDA develop its plan to work
with international organizations, primarily the United Nations' Food
and Agriculture Organization, to deliver the best possible technical
assistance to these countries. By effectively combating this disease in
birds, I am confident that we can help lower the virus load in
countries and prevent spread to humans, thereby reducing the likelihood
that this particular highly pathogenic avian influenza will mutate into
a virus capable of spreading not only from birds to humans, but then
from person to person.
Before I speak more about our international efforts, including
those related to China, I'd just like to say a few words about the
steps we're taking domestically to protect against the introduction of
the Asian H5N1 avian influenza virus into the U.S. poultry population.
These programs--many of them longstanding--are every bit as critical as
the efforts we're undertaking overseas to help protect the United
States.
USDA is keeping potentially infected poultry and poultry products
from countries affected by the Asian H5N1 virus out of the United
States through import restrictions. We quarantine and test all live
birds imported into the United States to ensure that they are disease-
free. We carry out an aggressive surveillance program that looks for
any signs of illness in the commercial U.S. poultry flock. We're also
on the lookout for smuggled birds or products from overseas that could
harbor the disease.
USDA also maintains a stockpile of avian influenza vaccine should
the need arise to vaccinate commercial poultry as part of a virus
control and eradication effort. And, we are making sure that our State-
level response plans in the event of a disease detection are constantly
updated and take into account all the steps necessary to address the
situation.
In total, the funding I mentioned a moment ago also directs $73
million to USDA to enhance these and our other domestic avian influenza
related efforts.
H5N1 AVIAN INFLUENZA IN CHINA: TIMELINE
I think the best way to frame our discussion of avian influenza in
China is to trace significant developments in chronological fashion.
I'll then be happy to answer your more specific questions.
Evidence seems to suggest that the Asian H5N1 avian influenza virus
emerged in southern China and Hong Kong in 1997. We know, too, that the
virus did not start causing mortality in large numbers of birds in
China until late 2003. In response to the escalating animal health
situation, in January, 2004, APHIS and the U.S. Centers for Disease
Control and Prevention issued emergency import restrictions on poultry
and poultry products from China and seven other countries in east and
southeast Asia.
It's important to note here, however, that APHIS has had
longstanding prohibitions in place on live poultry and poultry products
from China (as well as most other Asian countries) due to the
widespread presence of exotic Newcastle disease, another significant
poultry disease, in that region of the world. So no significant
quantities of live poultry or poultry products from China or other
countries in southeast Asia were being imported into the United States.
Again, though, in 2004 we felt it a prudent step to issue the emergency
import restrictions due to the threat the Asian H5N1 virus poses to
animal health, as well as concerns by public health officials that the
virus could potentially have human health implications.
Later in 2004, APHIS placed restrictions on imports from all
countries reporting detections of the Asian H5N1 avian influenza virus
in poultry. These further restrictions prohibit the importation of all
live birds, including those previously allowed entry provided that the
birds went through a lengthy post-entry quarantine period; all feathers
and feather products, including those treated overseas or imported into
the United States for treatment; and processed or rendered poultry
products for human use or consumption.
In the summer of 2004, China requested that APHIS consider
regionalizing the country to enable the trade of poultry and poultry
products from areas of the country unaffected the Asian H5N1 virus.
Regionalization is a tenet under the World Trade Organization's
Sanitary and Phytosanitary (SPS) standards agreement. APHIS considers
all such requests, and, in order to do so, we requested on several
different occasions that China provide us with information on the
disease situation in the country and steps being taken in response.
China, to date, has not provided us with this information;
therefore, APHIS has been unable to begin considering the
regionalization request. I'd also add that while China has reported
cases of the disease to the International Animal Health Organization
(OIE), there has been no independent verification of those reported
detections by agencies outside of China. We commend China for reporting
detections to the OIE, but we also feel that officials need to be much
more transparent and forthcoming with information on surveillance
testing, disease control and eradication measures, and related
information.
Along these same lines, I'd like to acknowledge China's lifting of
its import ban on all U.S. poultry and poultry products, put in place
following the detection of a high pathogenic avian influenza virus in a
flock of 6,600 birds in Texas in February, 2004. That detection was
quickly contained and eradicated without any further spread to poultry,
or any human health implications. It is a testament to the excellent
surveillance and emergency response plans we have in place for serious
poultry diseases here in the United States. APHIS provided China with
information on the detection and related issues in August, 2004.
Chinese officials removed the ban in October, 2004, and U.S. product
began moving to the country again in January, 2005.
NEXT STEPS
As I said at the outset of my remarks, USDA believes that a
coordinated effort to address Asian H5N1 avian influenza in poultry
populations in affected countries is among the most important steps
that can be taken to prevent against a pandemic situation. In support
of this, APHIS and USDA officials have certainly been keeping an active
international travel schedule. In July 2005 we attended the symposium
on international animal health standards for the member economies of
the Asia-
Pacific Economic Cooperation group, as well as the October 2005 meeting
of senior officials from the International Partnership on Avian and
Pandemic Influenza, a group of key nations and international
organizations launched by the United States in September 2005. In
addition, USDA participated in a November 2005 meeting on avian
influenza and human pandemic influenza organized by the OIE, the World
Health Organization, the FAO, and the World Bank. We were also a part
of the WHO's December, 2005, meeting to develop an international
unified strategy to control the Asian H5N1 virus in birds.
In regard to China, APHIS and USDA officials met with their
counterparts in Beijing in November, 2005, as part of a poultry health
symposium. Much discussion took place on issues such as regulatory
measures, disease surveillance, and international animal health
requirements for the disease. This meeting was followed by the WTO
Ministerial meeting in Hong Kong in December, 2005. During the meeting,
an annex was approved to the Memorandum of Understanding in place
between USDA and China's ministry of agriculture. The annex details the
formulation of working groups that will meet on a regular basis to
discuss technical animal and plant health issues. We are currently
working to arrange the first meeting of the animal health working group
and our goal is to engage in a sustained dialogue with our Chinese
counterparts on many important issues, chief among them domestic
surveillance in China for Asian H5N1 avian influenza.
It is our strong desire that this type of regular communication
with Chinese officials will help encourage further transparency on the
animal disease front. It is our hope, too, that China will engage more
fully in the international efforts to formulate effective strategies
against the Asian H5N1 avian influenza virus.
With that, I'll conclude my statement. Thank you again for the
opportunity to be here today. I look forward to your questions.
______
Prepared Statement of Erika Elvander
FEBRUARY 24, 2006
In December 2003, the global community learned of reports from
Korea of its first ever cases of Avian Influenza (A) H5N1. Shortly
after this, H5N1 appeared among poultry in a number of countries in
East Asia, including Thailand, Vietnam, and China. Since then, H5N1 has
spread to Central Asia, Europe, and the Middle East. As we know, in
recent weeks Nigeria reported the deaths in its northern provinces over
40,000 birds from H5N1, bringing the disease to Africa. In addition to
these avian cases, human cases are appearing sporadically across the
globe. As of February 20, 2006, the World Health Organization (WHO)
confirmed 170 human cases, of which 92 have been fatal. In all but a
very few cases, all confirmed human cases could be linked to contact
with sick poultry or animals.
While 92 human deaths may not be considered significant in the
context of other diseases such as tuberculosis and HIV/AIDS, the high
rates of mortality, the lack of predictability about who could contract
the disease, and fears of genetic changes within the virus that could
create an environment for efficient human-to-human transmission, cause
great concern about human cases of H5N1. Globally, the emergence of a
new strain of influenza with pandemic potential has public health
officials extremely concerned. Thus multi-lateral organizations such
the WHO, the World Organization for Animal Health (OIE), and the Food
and Agriculture Organization of the United Nations (FAO), as well as
larger donor governments such as the United States, Japan, and the
European Union, have begun to apply political pressure and provide
financial and technical assistance to help countries around the world
affected by the animal disease epidemic in hopes of stemming a possible
human pandemic.
Influenza (A) H5N1 is one of many strains of influenza or flu, of
which only some affect humans, or birds, or both and some that affect
other species such as pigs and cats. Not all strains are highly
infectious or cause high rates of morbidity and / or mortality. The
fact that influenzas change and mutate is why specialists carefully
watch flu strain patterns every year to predict which strains will be
responsible for the regular, seasonal human flu which causes about
36,000 deaths in the United States a year.
Beyond seasonal flu, H5N1 specifically, is of concern for a couple
of reasons. First, flu pandemics tend to come in cycles of thirty to
fifty years. The ``Spanish'' flu pandemic of 1918 is thought to have
caused between 20 and 100 million deaths worldwide, and more than
500,000 deaths in the United States. While subsequent pandemics have
been less deadly (the last true flu pandemic occurred in 1968 and
caused 1 million deaths across the globe), the specter of the 1918
pandemic lingers on. Second, the H5N1 strain in circulation among
animals seems to cause extremely high rates of mortality when it
infects humans. Third, while vaccines specific for H5N1 are in
development, they are still being tested and if proven to be effective,
will take time to manufacture and distribute. In the interim, other
drugs, such as amantadine and oseltamivir (Tamiflu) are in limited
supply and are of limited use.
While it is clear that direct exposure to diseased birds seems to
be a necessary link in humans contracting disease, other information
about how, when and why H5N1 causes disease in its victims is still a
mystery. The ability of flu viruses to mutate quickly causes public
health officials to be on the lookout for sustained human-to-human
transmission. This makes health ministers lose sleep at night and their
agriculture counterparts toss and turn worrying about the drop in trade
that the die-offs in poultry are causing.
H5N1 has appeared before. It first appeared in Hong Kong live bird
markets in 1997. Appearing to only affect chickens at first, public
health officials became worried when six people died from H5N1 as well.
Alarmed by what appeared to be a possible harbinger of a pandemic, the
Hong Kong Health Authority led by Dr. Margaret Chan (now with the WHO)
made the courageous decision to order the destruction of every single
chicken, duck and egg in Hong Kong. Over 1 million birds were culled
and human cases of H5N1 seemed to abate at eighteen cases and six
deaths. Biosecurity measures in live markets were put in place that
ensured better separation between humans and poultry; and policies were
instituted that ensured tissue and blood samples from every shipment of
poultry from China (mostly Guangdong and Shandong Provinces, where most
poultry in Hong Kong originates) were taken and tested for H5N1. The
goal was an effective animal surveillance system that would catch a
possible outbreak before human cases could occur.
H5N1 did reappear in February 2003 when two human cases were
detected in Hong Kong from travelers returning from Southern China,
suggesting that H5N1 was still circulating at least among domestic
poultry during the prior year. While the Ministry of Agriculture of
China never officially confirmed new avian cases linked to these human
cases, these cases were quickly overshadowed by what became the Severe
Acute Respiratory Syndrome (SARS) outbreak that dominated public health
and global media attention in the Spring and Summer of 2003. When Korea
reported its first ever case of H5N1 in December 2003, the current
outbreak officially began.
A couple of words on Hong Kong. Hong Kong is, of course, a unique
situation. In 1997, Hong Kong became a Special Administrative Region of
the People's Republic of China. However, with the ``two systems, one
government policy,'' it is still, to a large extent, an economic entity
separate from the mainland with different infrastructures, business
practices, and economic development. Then as now, China cannot afford
to lose the technological, economic, and academic advantages that Hong
Kong brings to it, and thus allows it to continue to function--at least
economically--at some level on its own. Further, Hong Kong is always at
``Code Orange'' for avian influenza and as such maintains animal
husbandry and biosecurity practices far different than most of rural
mainland China. As such, until as recently as last month, Hong Kong
managed to keep itself relatively H5N1 free, even in the face of
continued outbreaks around. And, while no human cases from Hong Kong
have been reported, it has an urban population still smarting from the
memories of SARS, the economic wherewithal to pursue these high-level
biosecurity measures, the geographic limits, and the community will to
maintain this ``orange alert'' status for H5N1.
As many of you know, recently Hong Kong reported H5N1 cases in
native magpies, which has caused great concern for local health
authorities, who fear H5N1 may have been brought to Hong Kong from the
mainland, and, worse yet, that H5N1 may now be endemic within the
territory. Indeed, scientists support their suspicions of importation
of the disease from China, as recent studies from Hong Kong and funded
by the National Institutes of Health of the U.S. Department of Health
and Human Services have demonstrated that the H5N1 virus endemic
throughout China is the likely source of outbreaks among poultry in
surrounding countries and territories.
Now then to China. As you know, about 60 percent of its population
lives in rural areas. There are (or were) 15 billion domestic fowl in
China last year. That is to say, one fifth of the world's poultry--
mostly chickens--but also significant numbers of ducks, turkey and
geese--raised for domestic consumption come from China. China has both
large scale production facilities and family ``backyard'' farms.
Indeed, most rural families have 10-25 chickens and ducks, which are
kept for food and income.
So what is a country scared by their SARS experience and faced with
an economic and possible public health disaster like H5N1 to do? As my
colleague from USDA will discuss, outbreaks among birds must be
contained, monitoring and reporting of suspect animal and human cases
must continue in a transparent manner. However, given that most
strategies for containment among birds include the culling and
eradication flocks where exposure to H5N1 is suspected, posing a huge
loss for farmers, the disincentives for reporting animal cases are
high. Compensation for lost flocks is a complicated issue that an
economist can address far better than I can. Further, for countries
that export poultry (and China is one of them--mostly to Japan and Hong
Kong) reporting cases to the international community can be viewed as a
trade risk, and economic considerations sometimes take precedence over
public health concerns.
Having said that, lessons learned from HIV and SARS both appear to
have encouraged China to recognize the need to investigate openly and
report at least suspect human cases of H5N1. Up until the summer of
2002, China continued to deny that HIV/AIDS had epidemic potential
within its borders, preferring to place blame on outside influences. As
my colleague from CSIS knows too well, United Nations organizations,
donor countries such as Japan and the United States, as well as non-
governmental organizations like CSIS applied both public and private
pressure on the government of China, trying to convince them that the
economic and health impacts of not acknowledging and dealing with a
burgeoning HIV/AIDS problem were far greater than continuing to deny
it.
As result, Chinese officials began to open up internationally (and
more importantly, domestically) about HIV/AIDS in China. Within a year,
China successfully competed for a $32 million two-year HIV grant from
the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria. At the
same time, the United States and other donors made financial
commitments to China's Ministry of Health for both research and
technical assistance in confronting HIV. China had learned that
openness about public health issues of global concern would not
necessarily bring shame, but might actually bring financial resources.
However, the lessons from HIV/AIDS did not seem to apply until late
in the game with SARS. Reports of a strange new respiratory illness
with high levels of mortality began to appear in late February 2003.
When, what became the SARS outbreak finally ended later that summer,
over 8000 cases would be reported, with 775 deaths, in 30 countries on
6 continents. As noted earlier, public health practitioners were
originally concerned that the SARS outbreak was the next flu pandemic
and indeed, two early suspect SARS cases proved to be H5N1. Early on,
Chinese officials were concerned about the impact an outbreak of
disease of unknown origin would have on travel on the Chinese New
Year--the largest travel day of the year worldwide. The government
chose to delay entry to international experts, and continued to
question if SARS had epidemic potential domestically. It was only when
rumors about the disease began to have an impact on tourism, as well as
rising international outcry at cover-ups, that China opened its borders
to scrutiny, but as usual, in a carefully monitored and controlled
fashion.
And, by the end of the SARS outbreak, according to the World Bank,
the impact on the Gross Domestic Products of countries in the region
was between 0.4 and 0.5 percent, between $20 and 25 billion. In the
process, a number of high-level Chinese officials, including the
Minister of Health and the Mayor of Beijing, lost their jobs.
And yet, embarrassingly for China, it wasn't over yet. In March
2004, an accident at the National Institute of Virology of China in
Beijing, China's premier virology laboratory infected two researchers
with SARS and the Institute closed. By the end of the investigation,
nine new cases of SARS were discovered, and one person died, all linked
to the laboratory accident. While the global health community quickly
commended the Chinese government for taking swift action in reporting
the cases and for quickly closing the facility, the government lost its
only internationally
accredited laboratory with high enough bio-safety and bio-security to
deal with infectious agents such as SARS and H5N1.
This double whammy of HIV/AIDS and SARS clearly affected the
internal culture of the Ministry of Health. The WHO has positively
commented on how quickly the Ministry of Health reports any outbreak of
human disease. When the first suspect human case of H5N1 finally
appeared (as many outside observers were predicting) in late October
2005, the Ministry of Health engaged the international health
community in inviting outsiders in to work side by side with Chinese
experts in
investigating the cases.
I will note that China's idea of transparency and openness is still
one with a degree of control involved. All decisions and reports on
human cases are made by the central government not by local officials,
which can add time to official announcements; further anecdotal reports
suggest that some restrictions have been placed on the press.
Government announcements come with clearly defined solutions already in
play, suggesting that the government has the situation under control.
Nevertheless, the Ministry of Health's willingness to open itself to
international scrutiny is a huge step, and China, has been publicly
praised internationally and promised further assistance in dealing with
human cases as a result.
Unfortunately, the lessons learned from SARS by the Ministry of
Health do not seem to have translated as well to the Ministry of
Agriculture. For example, international observers have long suspected that H5N1 has been circulating among backyard poultry in China (the 1997 outbreak in Hong Kong supports this idea). Nevertheless, the Ministry of Agriculture
reported no outbreaks of H5N1to the OIE until April 2004, when other
countries in the region reported cases. Further, when wild birds began
dying in Qinghai in April 2005, the Ministry of Agriculture delayed
allowing international scientists and observers into the actual areas
where the deaths had occurred, citing so-called security concerns,
although the deaths were largely in nature preserves.
Finally, late last summer, as wild and domestic birds continued to
die across China, international observers were invited to see the
veterinary laboratory in Harbin, which had tested tissue samples from
dead birds. The Ministry of Agriculture continued to refuse to share
samples from their avian cases with international bodies such as the
FAO and OIE. Equally challenging, the Ministry of Agriculture
refused to share samples with the Ministry of Health, claiming flatly
that this was not a human health issue; merely an agricultural and
trade issue. While the Ministry of Agriculture has recently been more
forthcoming with reports of outbreaks, the timing of this willingness
to share seems to coincide with both reports of human cases, large-
scale Ministerial poultry vaccination campaigns targeted at the
backyard farmer, and Wen Jiabao's January 2006 public commitment at the
Beijing Donor's Conference to cooperate with the international
community in containing the spread of disease in the region.
There is no question that we see an increased level of commitment
and cooperation by the Chinese Government in addressing the avian
influenza threat. Both in-country coordination between Ministries, and communication with outside organizations have improved. More importantly the Ministry of Health has shared samples from human cases through the WHO network.
However, it is important to point out that human cases of H5N1 in China
are often recognized prior to recognition of disease in poultry in the
same locales, indicating the shortcomings of the animal disease
surveillance and reporting system. In some of the human cases reported
over the past few months, the victims came from regions in which no
previous bird infections had been reported--even though the
transmission occurred from contact with infected poultry. In general,
areas needing strengthening include (1) surveillance--both human and
animal; (2) general public and farmer awareness about the disease and
the need to report; and (3) multisectoral cooperation.
China has also recently begun a policy of being both a donor and
recipient of international assistance, reaching out politically and
financially to partners in the region. Due to its economic progress, it
has become ineligible for certain kinds of very-low or no- interest
loans from the World Bank and its regional organizations. Even with the
Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, China made a
point of donating $10 million to the Fund before becoming a recipient
of its grants. More recently, China showed great leadership in hosting
the Beijing Pledging Conference for Avian Influenza last month, and
made a point of being a donor with a pledge of $10 million.
Now, I would like to say a couple of things about the U.S. response
to avian influenza, and then our relationship with China in particular.
As you know, the United States takes avian and pandemic influenza
extremely seriously, and is mobilizing resources both at home and
abroad to cope with a potential pandemic. The U.S. Government, for
example, has formed the International Partnership to Fight Avian and
Pandemic Influenza, affectionately known as IPAPI. Over 80 countries
participated in the IPAPI's first meeting in October 2005, and
activities under IPAPI to coordinate donor efforts, maintain
transparency of data, and develop global strategies to prepare for and
contain a possible pandemic continue to develop. At the Beijing
Pledging Conference last month, $1.9 Billion was raised for
international flu efforts. The United States was the largest single
country to make a pledge, with its pledge of $334 Million in grant
funding from fiscal year 2005 and 2006. (The World Bank made the
largest overall pledge--$500 Million in reprogrammed funds). These
funds are for international efforts to prepare for and contain an avian
and, possibly a human influenza pandemic.
While no specific amount is targeted at China as of yet (those
decisions are being made as I speak), funds will be coordinated with
other donor activities, and will be aimed at countries and regions
where animal disease has recently appeared, or shows no signs of
abating, or where there are human cases. In addition to these
international activities, the U.S. Government has established a
platform with China, the Program on Emerging and Reemerging Infectious
Diseases, that will promote cooperation between the two countries on a
number of infectious diseases, but first on avian influenza. This
platform builds on long-standing health and science cooperation between
the United States and China that dates back to 1977. In 2004, HHS alone
funded more than $34 million worth of bio-medical research and basic
public health activities with China and we foresee that figure
increasing, not decreasing. HHS also has a staff of seven on the ground
in Beijing, led by our Health Attache, Dr. Craig Shapiro. Because of an
agreement that HHS Secretary Leavitt signed in October of last year, we
hope to be able to increase that staff by as many as three bringing us
to a total of 10, all aimed at emerging infections such as H5N1. It is
our belief that by working with China as a partner to confront issues
of public health important such as avian influenza, we will be able to
create an environment that not only promotes scientific and bio-medical
transparency and sharing of data, but also will improve China's public
health surveillance and disease reporting networks, so that epidemics
may be prevented and contained, not left to fester quietly. China, the
fourth largest country with 1/5 of the world's population and 7 percent
of the world's arable land, must be a partner in any global effort to
prepare for an influenza pandemic.
Lastly, before I end, I would like to point you all to a number of
valuable web sites for further information.
1. www.pandemicflu.gov is the U.S. government's primary site for
all things flu. It includes the U.S. Government's national domestic
plan for pandemic influenza and has links to HHS, to USDA, and other
U.S. Government partners in the pandemic influenza efforts.
2. http://www.who.int/csr/disease/avian--influenza/en/ is the web
site for all things influenza for WHO.
3. www.oie.int is the web site for the OIE.
4. www.fao.org is the FAO web site. FAO has some great maps that
show the distribution of H5N1 globally, and is also an excellent
resource for information about food safety and economic issues and
H5N1.
I have also brought copies of Wen Jiaobao's speech from the Beijing
conference and am happy to share copies. Last, if you haven't already
done so, I would encourage you to thumb through a copy of John M.
Barry's, The Great Influenza: The Epic Story of the Deadliest Plague in
History, Penguin Books, 2004. As you may have heard, this is the flu
``bible'' at HHS, and Secretary Leavitt, after he traveled to Southeast
Asia in October 2005 (5 countries, 10 days, we were tired but he
wasn't) gave copies of Barry's books to heads of state with key
sections marked with post-it notes.
Thank you very much for your attention. I'm glad to answer any
questions at this time.
______
Prepared Statement of Bates Gill
FEBRUARY 24, 2006
INTRODUCTION
Let me begin by thanking the Commission Chairman and Staff Director
for inviting me to provide my views this afternoon. I commend the
Commission for taking up issues related to China's response to avian
flu.
This is clearly an important and timely hearing. To date, the
disease has spread from Asia to the Middle East, Europe and Africa with
the prospect that it might also spread to the Americas and elsewhere.
Without prompt and effective detection and containment, the spread of
avian influenza could potentially cause severe human casualties and
catastrophic socioeconomic consequences, and threatens regional and
global prosperity and security. The World Bank has predicted that the
first year of an avian flu pandemic could cost the world economy up to
USD 800 billion.\1\
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\1\ BBC, ``$1.9 Billion Pledged for bird flu fight,'' January 18,
2006, accessed at: http://news.bbc.co.uk/go/pr/fr/-/1/hi/world/asia-
pacific/4622982.stm.
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With this in mind, and in response to the Commission's request, I
have divided the remainder of this testimony into three parts,
covering:
A brief overview of the current situation concerning avian flu
in China
Steps that have been taken by the Chinese government in
response
Challenges that are remaining in China's approach to avian flu
A BRIEF OVERVIEW OF THE CURRENT SITUATION
China is not only the world's most populous nation, but also the
world's biggest poultry producer. According the Food and Agriculture
Organization of the United Nations (FAO), China has one-fourth of the
world's chicken, two-thirds of the world's domesticated ducks, and
almost nine-tenths of the world's domesticated geese. The sheer size of
China's human and poultry populations make the country a pivotal point
in the global efforts to prevent and prepare for a possible human
influenza pandemic.
According to the World Health Organization (WHO), as of February
13, 2006, China has reported the country's 12th laboratory confirmed
case of human infection with the H5N1 avian influenza virus, eight of
which have been fatal.\2\ The most
recent death was a 20-year-old female farmer from the county of Suining
in the south-central province of Hunan. China announced its first
confirmed human case of infection in mid-November last year, and since
then sporadic human cases have occurred in seven provinces and
regions--Anhui, Fujian, Guangxi, Jiangxi, Hunan, Liaoning, and
Sichuan.\3\
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\2\ WHO Avian influenza--situation in China--update 4, February 13,
2006, accessed at: http://www.who.int/csr/don/2006--02--13a/en/
index.html.
\3\ WHO Avian influenza--situation in China--update 3, February 9,
2006, accessed at: http://www.who.int/csr/don/2006--02--09/en/
index.html.
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China has recently experienced an intensified recurrence of highly
pathogenic avian influenza (HPAI) in poultry. According to WHO, since
May 2005 Chinese agricultural authorities have reported over 32 poultry
outbreaks across the country, the majority of which were reported in
October and November 2005. However, about one-third of China's reported
human cases of avian flu occurred in areas where no recent poultry
outbreaks have been officially reported.\4\ This has become a growing
cause for concern. Some health experts suspect that environmental
pollution by sick or dead birds might be to blame for such human cases.
---------------------------------------------------------------------------
\4\ Xinhua, ``PRC officials blame environmental pollution for human
cases of bird flu,'' February 10, 2006.
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STEPS TAKEN
China's health and agriculture authorities have become increasingly
vigorous to contain HPAI among poultry and prevent its spread from
birds to humans. The
government has conducted large-scale poultry culling in known avian
flu-infected regions. China has also launched tightened quarantine
measures, extensive vaccination, and preventive measures against human
infection. Meanwhile, Beijing has called for enhanced cooperation among
all countries, between governments and international organizations,
among governments, business and non-governmental organizations (NGOs)
to curb the epidemic. Compared to the period of Severe Acute
Respiratory Syndrome (SARS) outbreaks in 2003, Beijing this time has
been praised for its efforts to control the avian flu. A senior WHO
official for communicable diseases has recently commented that ``the
Chinese government has taken very effective measures, and they are
making improvements every month, even every day.'' \5\ Another WHO
regional director for the western Pacific said Beijing's response to
avian flu so far had been ``aggressive and thorough once the outbreak
was recognized.'' \6\
---------------------------------------------------------------------------
\5\ Xinhua, ``WHO praises China's efforts in controlling avian
influenza,'' February 4, 2006, accessed at: http://www.china.org.cn/
english/2006/Feb/156852.htm.
\6\ South China Morning Post, ``Optimism surrounds bird flu
conference,'' January 18, 2006.
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DOMESTIC EFFORTS
China's central government leadership exhibits a strong political
commitment to tackling the avian flu outbreaks. The Chinese Ministry of
Health (MOH) launched the national contingency plan for preparedness
against a possible outbreak of pandemic influenza in September 2005.
MOH also urged all localities to draft their own contingency plans in
accordance with local conditions and make good preparations for a
possible flu pandemic. According to the plan, the MOH is held
accountable for organizing and coordinating epidemic contingency work,
health authorities above the county level should ensure the collection,
registry and delivery of flu virus samples for testing, and the
national Center for Disease Control and Prevention (CDC) should
establish a national system to manage the surveillance information.\7\
---------------------------------------------------------------------------
\7\ People's Daily, ``China launches contingency plan for possible
pandemic flu,'' September 29, 2005, accessed at: http://
english.people.com.cn/200509/29/eng20050929--211570.html.
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More recently, the State Council published national response plans
for nine types of emergencies, one of which is public health incidents.
The emergency plans are believed to be the first comprehensive and
detailed crisis management plans in China. The new plans, which were
released in January this year, listed preparedness, coordination of
related parties and information transparency among the key elements of
emergency management.\8\ With new and strengthened emergency planning,
China is demonstrating a greater awareness of the need for a prompt and
effective response to such crises as the SARS epidemic in 2003 and
potential future avian flu outbreaks.
---------------------------------------------------------------------------
\8\ China Daily, ``Emergency planning to help crisis response,''
January 24, 2006.
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Changes in official structures have been an encouraging part of the
government's anti-flu efforts. The MOH has set up a special department
to deal with avian flu. The Ministry has also established 192
monitoring spots throughout the country for flu outbreaks. Following
the State Council's emergency response plans, the MOH announced the
formation of a national expert team in response to emergent public
health incidents, consisting of 105 experts in the field including
communicable diseases, poisoning treatment and early warning
networks.\9\ In early November 2005, the central government set up a
general directorial office for avian flu prevention, bringing together
six agencies in charge of food security, animal health and prevention
science under a unified system, in order to coordinate the internal
bureaucratic response.\10\
---------------------------------------------------------------------------
\9\ Xinhua, ``PRC health ministry sets up team of experts to deal
with disease outbreaks,'' January 23, 2006.
\10\ Beijing Review, ``Threat Management,'' December 15, 2005, Vol.
48, No. 50.
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INTERNATIONAL COOPERATION
Beijing has demonstrated greater openness and commitment on the
international front as well. On January 17 and 18, 2006, the
international pledging conference on avian and human influenza was co-
hosted in Beijing by the Chinese government, the European Commission
and the World Bank. The meeting of the delegates from more than 100
countries, regions and international organizations has led to USD 1.9
billion to fight avian flu worldwide, a higher figure than
expected.\11\ Chinese Premier Wen Jiabao pledged that China would
donate USD 10 million to help the global fight against the avian
flu.\12\
---------------------------------------------------------------------------
\11\ BBC, ``$1.9 billion pledged for bird flu fight,'' January 18,
2006, accessed at: http://news.bbc.co.uk/1/hi/world/asia-pacific/
4622982.stm.
\12\ Xinhua, ``Wen Jiabao says PRC to donate $10 million to support
avian flu prevention,'' January 18, 2006.
---------------------------------------------------------------------------
The conference endorsed the ``Beijing Declaration,'' which promised
to enhance sharing of information and relevant biological materials,
increase cooperation on global research and development of safe and
effective animal and human vaccines and antiviral medicines for humans,
and to periodically evaluate the impact of
national pandemic influenza preparedness and action plans.\13\ This
meeting was another positive example of China's effort to become a more
responsible global player on international health issues.
---------------------------------------------------------------------------
\13\ FAO, Beijing Declaration at the International Pledging
Conference on Avian and Human Pandemic Influenza, January 17-18 2006,
Beijing, accessed at: http://www.fao.org/ag/againfo/subjects/documents/
ai/beijingdeclaration.pdf.
---------------------------------------------------------------------------
Beijing has also worked with the United States to bolster avian flu
prevention. On October 31, 2005, Chinese Health Minister Gao Qiang
visited Washington and signed with U.S. Health and Human Services (HHS)
Secretary Michael Leavitt a Memorandum of Understanding (MOU) on
collaboration on emerging and remerging infectious diseases between the
United States and China. As an important step for further cooperation,
the MOU set up the mechanism for a biennial health ministerial meeting,
and aimed to strengthen bilateral collaboration on emerging infectious
disease including avian flu, HIV/AIDS, and West Nile virus. In
particular, the United States pledged to help enhance the capacity of
Chinese public health laboratories, train biomedical research,
prevention and control personnel, conduct emerging infectious disease
surveillance, and cooperate on research and development of vaccines and
drugs.
REMAINING CHALLENGES
During the SARS outbreak two years ago, China encountered intense
criticism from the international community for its delayed response and
cover-up at the initial stages of the epidemic. Facing a potential
influenza pandemic, the Chinese government has made noticeable progress
in terms of transparency of information and international cooperation.
However, there are still a range of lingering problems, particularly at
the local level, which may limit the success of Beijing's efforts to
bring the disease under control.
Transparency
The growing political determination within the central leadership
needs to be translated into local action. Fearful of censure, Chinese
provincial and county officials sometimes might choose to conceal
infection cases from the central government. This was at least the case
during the early stages of the SARS outbreak.
Additionally, to some predominantly poor Chinese farmers, economic
damage brought by anti HPAI-measures is often a more pressing concern
than potential health risks, giving them an incentive to hide an
outbreak. Transparency and accountability mechanisms need to be
introduced and strengthened to avoid potential underreporting at all
levels. Involving community groups in disease monitoring and reporting
can be an effective approach to enhance transparency.
Technical Capacity and Financial Resources
Lack of capacity and resources at local levels remains a large
question mark in China's handling of avian flu. Health Minister Gao
Qiang identified his largest concern in a press conference in November
2005 as ``the inability of our medical and quarantine personnel at the
local level to diagnose and discover epidemics in a timely fashion due
to lack of skills and relatively backward equipment.'' \14\ The country
still faces a shortage of experienced and qualified professionals,
resulting in misdiagnosed patients as having pneumonia instead of avian
flu. There is also a great need for qualified and experienced
veterinarians. Meanwhile, many villages and towns do not have effective
surveillance systems, leading to delayed reporting of outbreaks. Only
after patients admitted into hospitals are identified as having the
H5N1 virus do local officials begin investigations in patients'
villages.
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\14\ Beijing Review, ``Threat Management,'' December 15, 2005, Vol.
48, No. 50.
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The reality is that much of the country's poultry is raised in
backyard farms in close proximity to humans in rural China, where 70
percent of the nation's population lives. Close contacts between people
and birds are so frequent that the risk of human infection is high.
However, according to a report released by the Development Research
Center of the State Council, a think-tank directly under the cabinet,
90 percent of China's rural population is not covered by any form of
medical insurance. The same report also notes that ``China's medical
reform has been unsuccessful because it has become unbearably expensive
to patients and many dare not go to hospital when they fall ill.'' \15\
Lack of medical insurance, together with ill-equipped countryside
clinics and hospitals, makes rural China an extremely vulnerable spot
in the face of infectious disease outbreaks.
---------------------------------------------------------------------------
\15\ Beijing Review, ``The Medical Reform Controversy,'' September
22, 2005, Vol. 48, No. 38.
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China's animal epidemic prevention statue requires that local
authorities cull all domesticated birds within a 3-kilometer, or 1.8
mile, radius and vaccinate the remaining birds in a 5-kilometer radius
vicinity. To date, over 24 million birds have been culled.\16\ Farmers
face a significant loss in business and livelihood without appropriate
compensation or reimbursement, which represents a substantial financial
commitment for local governments. As a matter of fact, the Ministry of
Finance and the Ministry of Agriculture jointly issued a regulation
that compensation for each bird destroyed for avian flu prevention
would be approximately RMB 10 (about USD 1.25), with local governments
allowed to set the exact standard in accordance with local
conditions.\17\ Even at that seemingly low cost, the mass culling of
birds would surely strain local governments' finances.
---------------------------------------------------------------------------
\16\ WHO Avian influenza--situation in China--update 2, January 25,
2006, accessed at: http://www.who.int/csr/don/2006--01--25a/en/
index.html.
\17\ Caijing Magazine, ``Flu outbreaks challenge grassroots
epidemic prevention system,'' November 14, 2005, Issue 146.
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Public Awareness
As a result of poor education conditions and lack of available
resources, public awareness and knowledge of a possible pandemic is
limited in many parts of China, especially in rural areas. This adds a
great barrier to overcome in terms of avian flu education and
prevention. Basic information about the symptoms, how it is contracted,
and where the breeding grounds for H5N1 virus are and other general
information should be distributed to the public, particularly the rural
population, in order to instill preventative measures to combat this
deadly virus. As the ``Beijing Declaration'' called for mobilization of
all social sectors including nongovernmental civil society to effect a
coordinated response,\18\ community-based grassroots NGOs should be
encouraged to partner with the government to promote public education
and enhance public awareness, in particular in hard-to-reach
populations and areas. China's HIV/AIDS NGOs have tentatively begun to
assist the government to reach out to socially marginalized groups and
provide training, care and support. The role of NGOs in the fight
against avian flu should be expanded as well.
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\18\ FAO, Beijing Declaration at the International Pledging
Conference on Avian and Human Pandemic Influenza, January 17-18 2006,
Beijing, accessed at: http://www.fao.org/ag/againfo/subjects/documents/
ai/beijingdeclaration.pdf.
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