Rao Yi on China's Public Health System

Rao Yi, Sick with the Coronavirus, Shares his Questions concerning China’s Policy for Epidemic Prevention and his Ideas for Reform[1]
 
Introduction and Translation by David Ownby
 
Introduction
 
Rao Yi (b. 1962) is a neurobiologist and the president of Capital Medical University in Beijing.  He studied and worked in the United States for some years before returning to China, and has a very impressive record both as a scientist and an administrator.
 
The text translated here was published on the online platform of The Intellectual—which in terms of content appears to resemble Scientific American—on December 8, 2022, as China rolled back its zero-covid policy.  What struck me about Rao’s piece was its gruff impatience.  He says nothing about the “glorious successes” of the past battles against the pandemic, nor even mentions the change in policy (although the fact that the title notes that Rao is currently sick with covid may be part of current efforts to the regime to cast omicron as no worse than a bad cold).  Instead, he writes as a public health expert, suggesting that China, like the rest of the world, has a great deal to do to prepare for the next pandemic.
 
Many public health experts the world over are long-suffering pessimists, and for obvious reasons:  no one pays much attention to them, or funds their programs, until the crisis is upon us, by which time their counsels are often ignored because the horse is already out of the barn.  And when the crisis is over, no one listens to public health experts because, well, the crisis is over.
 
Still, it was surprising to me that Rao Yi talks about China’s public health establishment in the same way as many public health experts elsewhere in the world take about theirs.  He is quite critical of most aspects of the structure and function of China’s system, and does not seem to think China has learned anything particularly useful in its three-year battle against covid, except for what urgently needs to be fixed.  Strikingly, he compares China’s public health system unfavorably to that of the United States, whose performance over the course of the pandemic hardly drew rave reviews from the home crowd.  Like Sun Liping, who commented on the Chinese economy as China dropped its zero-tolerance policy, Rao Yi seems delighted that China may be on the point of rejoining the world.
 
I should note that I am by no means an authority either on public health in general or on the Chinese system, so some of my translation may be approximative.  Do not use it for specific information about Chinese public health practices.
 
Translation 
 
In China, we are currently extremely concerned about the lives and health of the people. To give priority to life, it is urgent to undertake a comprehensive examination of the existing health care system in the new era, and on that basis propose an effective, sustainable public health system that includes epidemic prevention.  It is solely when we are fighting a war against such an epidemic that this system is activated, and the rest of the time, it is put on the back burner.  Epidemic control and public health are in general underfunded, understaffed, with new students in these areas in short supply.

The guiding principles of  China’s current system lack a scientific basis, an international perspective, and a sense of history.  The development of China’s epidemic control and public health system continues to be impacted by a lack of seriousness and by a short-sighted attitude.  In the absence of comprehensive reform of the system, once current interest fades, ten years after the end of the epidemic we’ll be right back where we started, and even if a new epidemic occurs every 20 years, it will be difficult to rely on the epidemic control and public health system, meaning that authorities will have a hard time putting together effective sustainable personnel and mechanisms to curb the virus, and society will continue to suffer.
 
1.  Existing problems in China’s epidemic prevention system 
 
Lack of Focus

For a relatively long period, people the world over believed that with economic development, improvements in sanitation, and advances in medicine and vaccine technology, the importance accorded to the prevention of epidemic diseases would decline or perhaps even become obsolete.  Given these widespread views, humanity has not only failed to use social resources and new technologies to establish a sound epidemic prevention system in public health practice and education, but has gradually abandoned epidemic prevention and even shifted the focus of the public health and epidemic prevention to chronic and non-communicable diseases.  China is no exception in this international context. 
 
An important task before China’s health and epidemic prevention systems is to come to a new understanding of the importance, the long-term nature, and the difficulties posed by infectious diseases outbreaks.  The attitudes displayed within these systems must be comprehensively reviewed.  Just as the core task of the fire-fighting system must always be to put out fires, so the core task of the epidemic and public health systems must always be to respond effectively to outbreaks of infectious disease, and all other tasks must be seen as secondary.  Reversing the priorities suits the needs neither of the people nor of the nation.  Chronic, non-communicable diseases should be divided up among various academic disciplines for further study, but are not the concern of the a state-built epidemic and public health system.
 
There are currently some within China’s epidemic prevention and public health system who disagree with this point. They hardly realize that this is both the starting point of epidemic prevention and public health and the consensus of humanity and the nation today. The fact that epidemic prevention and public health are in their current state because they have not had to deal with a major epidemic for some decades is nothing to be proud of.  We are not learning from our experiences but rather waiting for the next shoe to drop.  When the facts clearly show that the danger of sudden infectious diseases not only has not disappeared, but instead may exist for the indefinite future, clinging to the idea of "developments in academic research" (many research papers are published in many fields under the name of public health), and ignoring the basic purpose of epidemic prevention and public health is wrong.
 
Thus we need to correct our attitudes and get our goals straight:  the first mission of epidemic prevention and public health is the prevention of acute infectious disease.
 
Medicine is out of sync with prevention
 
There is a serious disjunction between China’s public health system and its epidemic prevention system.  Not only have the two been managed separately in an administrative sense for a long time, but personnel in the epidemic prevention system cannot work within the medical system, and the medical system is generally not on the front lines of the epidemic prevention system.  In addition, when people are sick, they go to the hospital, and do not think about the epidemic control system; nor will new infectious diseases automatically be reported to the epidemic control system.  The two systems need to be closely and organically connected. 
 
Infectious disease hospitals in China are managed by the system of hospital administration 医管局, just like ordinary hospitals—and not by the epidemic prevention system. As a result, it is unavoidable that in the early stages of an epidemic, infectious disease hospitals do not report to the epidemic prevention system, but report only to their superiors to whom they are responsible. The epidemic prevention system cannot obtain information from infectious disease hospitals in a timely manner, delaying epidemic prevention and control.  Although the metaphor is not quite right, this is like the fire brigade being managed by the water company.
  
Epidemic prevention is out of sync with society

In the absence of an outbreak, China’s epidemic prevention system is not linked closely enough to residential areas. 
 
Salaries are in general low in China for people who work in epidemic prevention, in public health, in infectious disease hospitals, and in community public health services.  Nor are these jobs highly sought.  This festering problem has created a situation where there is a lack of talented people in epidemic prevention, public health, and infectious disease work.  Not only is it difficult to recruit excellent students, it is also difficult to hire good workers and to keep excellent workers who are already in the system, because such people are constantly leaving. Why would an exceptional person want to study a field or discipline where, once you get a job, everyone around you worries you are going to make them sick, and where their salaries are particularly low?  Of course there is a minority of people who are very noble, but you can’t build an epidemic prevention system on the foundation of this minority.
 
As long as we don’t have a solution to this basic problem, all other solutions are no better than quick fixes, and won’t have a lasting impact.  Yet if we merely throw money at the problem without defining the mission of everyday work, then having a bunch of well-paid people sitting around doing nothing will not enable us to build an effective epidemic prevention and public health system either.
 
In the long run, no slogan and no amount of persuasion will do the trick in the absence of an effective plan.

2.  Respiratory viruses are the most dangerous 
 
At present, there is no way for us to predict what infectious diseases will be coming down the pike.  That said, there is a consensus, based on scientific understanding and our experience with epidemics, that for the foreseeable future, infectious diseases spread by respiratory viruses will be the most dangerous.  It is not by chance that both SARS and Covid-19 are infectious diseases spread by respiratory viruses.  Non-infectious diseases cannot produce epidemics, even if they are widespread and can affect a large number of people (as in the case of diabetes and cardiovascular disease).
 
Why viruses?
 
In the past, many kinds of bacteria caused great damage to humanity, but due to medical advances, such as the invention of antibiotics, we can now cure many bacterial infections.  But because viruses are tiny and numerous, and mutate very rapidly, it may well be a long time before we can cure viral infections.  Although we have effective vaccines for a number of viruses (such as hepatitis B), there remain many others for which we have no confidence that we will quickly create a vaccine. 
 
Why respiratory transmission? 
 
For non-respiratory infectious diseases, the path of infection can be avoided or easily cut off (blood-related infectious diseases, such as HIV/AIDS, require contact with bodily fluids, and transmission can be stopped through avoiding close personal contact, the shared use of household objects, and blood transfusions; for gastro-intestinal infectious diseases, transmission can be stopped by not eating and by avoiding contact with human waste).  But the respiratory system is a matter of breathing in and breathing out, and has always been the most difficult path of disease transmission to control.  It is clear that respiratory viral infectious diseases pose the greatest long-term danger, which suggests a set of targeted reforms of medical education and of the health care and epidemic prevention systems.

3.  Strengthening and reforming the administrative system 
 
The administrative framework
 
In the same way that China focused on agriculture because of food concerns in the past, we should build a similar administrative mechanism to focus on China’s health now. 
 
Because of long-term worries about food grains, we built an entire set of mechanisms to promote agriculture. Now that this problem has been solved, and particularly since China has achieved a basic level of moderate prosperity, we should build a system for health that replicates the previous focus on agriculture and extends from the State Council to the grass roots level, taking into account our national conditions and our stage of development.  Of course, health is different from agriculture in that increased health needs in a growing number of cities means that health work will be more focused on the cities than was agricultural construction, which gave concrete priorities to villages. 
 
A Deputy Prime Minister/State Councilor heads the National Health Commission, the National Center for Disease Control and Prevention, the State Food and Drug Administration, the State Food and Drug Administration, and the National Institutes of Health (NIHC).  Each province has a similar set of institutions.
  
The Chinese Center for Disease Control and Prevention (CDC) should manage infectious diseases nation-wide 
 
The existing CDC is a research institution, and has no administrative powers.  If the former Bureau of Disease Control of the National Health Commission and the original CDC were to be merged, this would create a new center for disease control, endowed with comprehensive and internationally accepted CDC management functions.  The research institutions originally belonging to the CDC would no longer be called the CDC, but would be renamed the "Institute of Disease Control and Prevention."  With the exception of certain existing research units, most could be absorbed into corresponding institutions elsewhere in the country, such as: the Wuhan Institute of Virology, the Institute of Microbiology, and the Institute of Pathogen Biology. The Kunming Institute of Zoology might also consider increasing research and testing of local pathogens. The creation of new institutes might also be considered in Guangdong and Guangxi, where people and wild animals come into frequent contact.
 
The National Institute of Health
 
From the perspective of realizing China’s national rejuvenation, comprehensive social progress, and improvement of the people's well-being, the protection of the health of the people as a whole should be placed in a strategic position of priority development. The Chinese people's growing demands for medical care and China's development of its own biomedical industry constitute pressures and challenges China is facing, as well as the opportunities and driving forces for the country’s development.
 
Biomedicine is closely related to people's health, and high-quality equipment, drugs, and treatment methods are closely related to high-quality health care. The latest drugs can directly affect the lives of thousands of people. Biomedicine is also one of the core pillars of modern high tech, and the biotechnology industry is the fastest growing industry in the world, while in China, the industry is still in a fledgling state.
 
Achievements in biomedicine win uncontested respect throughout the world.  The existing National Natural Science Foundation of China (NSFC) is on the same order of magnitude as the U.S. National Science Foundation (NSF), but the NSFC lacks the 130 year history of its American counterpart, focuses solely on medical science, and has nearly five times the current funding of the National Institutes of Health (NIH), an agency of the NSF. There are also special medical research foundations in Britain and France. However, health situations differ according to population groups and regions, and there are some common diseases in China (such as hepatitis B) that are not common in the West, and have not received due attention and research. Autonomous production of medicines and medical devices that China urgently needs is of great significance to national security, to improving the health of the Chinese nation, and to seizing the initiative in worldwide human health concerns. 
 
At the same time, the research necessary to ensure health outcomes is not limited to biomedical research, but must be integrated in a multidisciplinary way. Therefore, the establishment of the NIHC is conducive to health research in China and to the development of interdisciplinary science.
 
The National Institutes of Health (NIH) in the U.S. are not only better funded than the National Science Foundation (NSF), but they predate NSF by decades. China's Natural Science Foundation Council (NSFC) was established 36 years after the NSF was established in the United States, at a time when China's economic situation was far worse than it is today. Today, 135 years after the establishment of the NIH in the United States, and at a time when all of us in China are very concerned about our health, it is not too early to establish our National Institutes of Health.
 
Management of medical care
 
National and local health commissions, as well as hospital management bureaus should concentrate solely on managing medical care, and not require hospitals and doctors to produce research papers.  It is reasonable for hospitals affiliated with medical schools to have requirements for research, and for some of their professors to have research requirements. However, it should be up to the medical school and its affiliated hospitals to set reasonable rules. 
 
At the same time, it is generally not appropriate to require hospitals and physicians to conduct research in hospitals that are not affiliated with a medical school. This can be done at the discretion of the physician when the physician has the time and ability to do so. 
 
However, many local health care committees and medical boards require general hospitals and their doctors to carry out research and publish papers because of hospital rankings and other factors. This approach is not appropriate. It often backfires, not only because poorly written papers directly affect a hospital’s credibility, but also because they get in the way of doctors’ work with patients.  Health care commissions and medical board should focus on managing medical care and should not overstep their authority in managing scientific research. 
 
The critical checkpoint for monitoring the outbreak of infectious diseases should be moved forward, quite possibly to every hospital and residential community.

4.  Reform of the epidemic prevention system
  
The CDC should manage the "integrated health departments" of national epidemic prevention stations, infectious disease hospitals, and general hospitals. 
 
With the exception of the existing epidemic prevention system, the management department of CDC should vertically manage every infectious disease hospital in the country. In general hospitals, there should be a deputy director appointed by the CDC, who is responsible to the CDC and provides information to it on a daily basis. In non-communicable disease hospitals which nonetheless have departments focused on infectious diseases, intensive care medicine, and fever, these department heads should be nominated by the deputy director and have dual appointments to the CDC and the hospital. These department heads should report daily to the deputy director. 
 
Non-communicable disease hospitals often set up "integrated health units" to integrate clinical medical personnel trained in preventive medicine into the hospital to meet both "peacetime" work needs (i.e., when there is no outbreak) and "wartime" work needs (during an epidemic). This is because the majority of long-term virulent infectious diseases in the future will be viruses, whose detection relies heavily on nucleic acid testing, and many important diseases faced by hospitals in “peacetime” also require diagnosis, detection, and treatment through nucleic acid-related technologies.

During “wartime,” the newly established "integrated health units" can carry out virus surveillance and contribute to the front line of disease control. During "peacetime," they can carry out gene monitoring, clinical trials, and clinical research to help the hospital with gene diagnosis, gene therapy, and research statistics. In this way, they not only solve the hospital’s need for the further development, but also put disease control on the front lines, and solve the existing CDC’s problem of being out of touch with the hospital, which makes it impossible for the CDC to have cutting-edge information.  Because these "integrated health departments" grasp Big Data and are integrated into the scientific research activities of the hospital, they can also serve the function of increasing the quality of research. 
 
Large hospitals should have little difficulty setting up infectious disease control mechanisms.  Should small hospitals monitor things in a similar fashion?  Or should small hospitals focus on treating minor problems?  If there were no possibility of an epidemic, then yes, small hospitals should mainly treat minor problems. However, when an epidemic affects the entire country and mankind as a whole, small hospitals should also be on the front lines of monitoring infectious diseases, because they are actually the first point of contact with patients.
 
Monitoring via nucleic acid tests in residential communities
 
Residential communities should conduct nucleic acid testing. In addition to monitoring viruses with which everyone is familiar, they can also monitor some common diseases.  Questions like which sequences to detect, at what time intervals, and in what spatial distribution, etc., need to be scientifically studied and explored. 
 
This is because virus monitoring is done through nucleic acid texts, which is also true in monitoring chronic genetic conditions.   Thus, the same people can test for "diseases of poverty," commonly seen illnesses, and “diseases of affluence.”  In this way, in the absence of an epidemic, the money spent on common diseases and diseases of affluence pay the salaries of the people necessary when there is an outbreak of a “disease of poverty.”  In this way, routine peacetime work also sustains the technical level necessary for wartime. 
 
Only through the establishment of the system described above can we “merge peacetime and wartime” and cure “diseases of poverty and affluence.”

5.  Reform of public health education 
 
Schools of public health around the world, including those in the United States and China, were established in response to outbreaks caused by infectious diseases.  However, with the significant decline in the number of epidemics in advanced countries, schools of public health have been forced to seek out other missions in the absence of frequent outbreaks.  Schools of public health in the United States have led the way in establishing multiple specialties. Based on the traditional statistical and epidemiological strengths of schools of public health, such schools in America (and later China) developed multiple disciplines, including techniques provided by statistics and epidemiology, and study major chronic diseases, ranging from cancer to metabolic diseases, to mental illness. These developments, which have kept pace with changing times, are extremely necessary.  As a result, the core strengths of most schools of public health are now genetic analysis of chronic diseases, toxicology, and other specialty areas in which it is easy to produce research papers on a regular basis.
 
However, we must insist that prevention and control of epidemics remain the fundamental raison d’être for schools of public health and the fundamental goal of training students. If epidemics were to disappear, we could massively reduce the scale of our schools of public health, preserving only the departments of statistics, epidemiology, and environmental health. All other work can be done by specialists (endocrinologists, oncologists), specialized research scientists (human geneticists, genomicists), who can ask for the assistance of statistical and epidemiological experts, without the need for a huge, specialized school of public health. 
 
The purpose of establishing specialized institutes of public health is always to prevent and control epidemics. But because it is likely that there will be long periods without epidemics, what to do with these institutes and their personnel when there is no epidemic, and how to maintain their combat readiness, are extremely important issues. 
 
The general medical school curriculum should be enhanced with training in molecular biology, virology, epidemiology, and statistics. The general practitioner’s daily work in the community should also be extended to include nucleic acid analysis to monitor viruses and perform genetic analyses of common diseases. These improved skills will provide a more comprehensive and higher quality service to the people in the community, which will also allow for a reasonable income, thus enhancing the attractiveness of the general practitioner’s position and facilitating the establishment of a win-win structure for both the community and the general practitioner.

Notes

[1]“饶毅感染新冠，今公布他近年对中国防疫系统问题和改革的思考,” published on the online platform of The Intellectual/知识分子 on December 8, 2022.