The Not-So-Great Wall of China

Nobody in Zhang Rong's village in coastal China knows much about the danger of a bird-flu pandemic. The 37-year-old farmer has enough to worry about. A nearby business park wants to take over her mushroom farm. Neighbors are dying of untreated cancers that some believe came from eating pesticide-tainted produce. One tenth of the family's annual income is spent on medical expenses, including sending Zhang's two kids to a public hospital when they get sick. Much of that cash goes into so-called red envelopes--bribes--for doctors who otherwise prescribe expensive medicines in retaliation for not getting a "gift." Few of the 4,000 villagers have medical insurance. "The government doesn't pay for a thing," she gripes. Ask about bird flu and Zhang tosses out a chilling wish: "I hope bird flu ravages China--to prove to the leadership what's wrong with health care in the countryside."

Zhang may be closer to getting her apocalyptic wish. Bird-flu jitters are spreading worldwide, as the tempo of new cases continues to escalate. Last Wednesday, in China's first reported H5N1 outbreak in months, mainland authorities revealed bird flu had killed 2,600 birds on a poultry farm in the Chinese province of Inner Mongolia, less than a day's drive from Zhang's home. Taiwanese authorities discovered the H5N1 virus among exotic fowl on a ship from mainland China. Suspected cases have emerged from Moscow to Macedonia.

As health officials gird for what some scientists fear could eventually turn into a global health crisis, one of the weakest links in the world's defenses is China's tattered health-care system. Many experts think China could be the epicenter of any bird-flu pandemic. Indeed, China has ideal conditions for fostering a new human flu pathogen. On top of China's 1.3 billion people, it also has 14 billion poultry and 70 percent of the world's wild waterfowl coming to visit, says Dr. Julie Hall, a WHO representative in Beijing. It also has half the world's pigs, which tend to harbor human viruses that can combine with bird-flu bugs to form human pathogens. Although Beijing said last week that it would close its borders if a mutated version of H5N1 infected humans, experts fear that the virus would slip through China's surveillance system in the first crucial weeks and quickly overwhelm its health-care system. "In big cities, control is good, but in remote areas, maybe not," says Christine Liu of Taiwan's CDC. "There's nobody to take samples, nobody to test the samples."

During the SARS epidemic two years ago, China took a lot of heat from health officials for its slow response and secrecy. Beijing instituted reforms in its hospital system that led to greater transparency and speed in reporting outbreaks. But these reforms haven't trickled down to all the provinces. SARS reporting took place mainly at the hospitals, where doctors would observe the number of patients who came in with fever and other symptoms, and pass that information to Beijing. In health-department surveys during the summer, nearly a third of Chinese said they don't go to the hospital when they need to, and half avoid seeing a doctor.

A big problem is a collapse in China's social safety net. Once upon a time, the country took care of its citizens' health care from cradle to grave. Chinese were poor, but Mao's policies were egalitarian. Back then, Maoist "people's communes" handled everything from providing medical services to transporting harvested crops to the state. But market reforms launched in the 1980s dismantled the communes and allowed family farmers to sell their own crops for a profit. Peasant incomes surged but nothing replaced the health-care void. Although three quarters of China's 1.3 billion people live in rural areas, virtually none of them has medical insurance. Even in cities, quality health care is often a privilege of the wealthy. "The present reform of the medical and health system is basically not successful," says Ge Yanfeng, a senior official at a State Council think tank who contributed to a recently released critique of the post-Mao public-health system. "It's run into a dead end."

Chinese complain of soaring prices, bad service and rip-offs in the health system. Today doctors chase kickbacks and wealthy patients. Weaned from government subsidies, hospitals hike prices to survive the marketplace. Corruption is rife because the rising costs of drugs and overhead means fees charged at traditionally low rates cannot help make ends meet.

These problems leave China's health-care system highly vulnerable to a flu pandemic. According to officials at the World Health Organization, to avert a pandemic that begins in China the government's surveillance system would have to detect an outbreak before it is able to infect more than 20 people, and no more than three weeks have passed since exposure. With numbers higher than this, the virus is likely to spread too far for quarantines and antiviral treatments to be effective. Meanwhile many poor Chinese simply don't bother with hospitals until they're virtually at death's door. And that requires a shift in China's hospital-based surveillance system, says Hall: "Things have improved, but we need to get surveillance mechanisms out into the community, by tracking school absenteeism or drug sales. It's a huge challenge."

Beijing has been particularly slow to resolve the turf battles and lack of coordination between ministries and departments. Right now, the hidebound Agriculture Ministry is in charge because the virus is killing poultry. When it attacks humans, the Health Ministry will take the lead. But in the meantime nobody's held responsible for scrutinizing that crucial point of bird-to-human transmission.

Beijing also needs to be more forward-leaning in its public education. Chinese leaders are so obsessed with maintaining social order that they may opt to sacrifice transparency for the sake of keeping citizens blissfully in the dark. That may be far too high a price to pay.