In February 2003, a Chinese physician crossed the border between Mainland China and Hong Kong and spread a novel influenza-like virus to over a dozen international hotel guests, who then carried it to Toronto, Singapore, and Hanoi. Severe Acute Respiratory Syndrome (SARS) went on to kill about 800 people worldwide and sicken 8,000. Of these, 349 reported deaths and 5,327 cases occurred in China (WHO 2003, 13).
After initially denying the scope of SARS within China, the country’s highest leaders admitted error on April 20, 2003, following a whistle-blower’s report. Under immense international pressure to contain the outbreak, the central government discharged the Minister of Health and the mayor of Beijing, promised to cooperate with all international disease control efforts, and began encouraging local municipalities to institute aggressive measures to control the outbreak.1 Measures included quarantining thousands of people, even sealing off entire hospitals, schools, and apartment buildings; rapidly building SARS treatment facilities, including an entire SARS hospital in Beijing in one week; closing down movie theaters, Internet cafes, and other public spaces; setting up neighborhood watch systems to root out potential carriers of the disease; and drowning thousands of civets—suspected animal reservoirs of the SARS virus—in disinfectant. The World Health Organization (WHO) praised China’s efforts and credited the Chinese government with playing a critical role in the successful global SARS containment effort (Fidler 2004; Saich 2006).
In Tianmai, a large city located near the epicenter of the initial SARS outbreak in southeastern China’s Pearl River Delta region, those who worked in public health faced a period of sudden and intense political and professional pressures unlike any they had ever experienced.* One woman told me, “It was like being a soldier on the frontline of a war.” A flu specialist at the Tianmai Center for Disease Control and Prevention (TM CDC) described her experience with SARS this way:
I worked to the point of crying, worked to the point of xinku, hen xinku [bitter hardship]. There was a lot of pressure. As soon as something happened, the leaders would always push you for a result, “What is it? Is it SARS or not?” . . . We were afraid of reporting the wrong thing. . . . So, at the time, our hearts were tired, and our bodies were also tired.
Xiao Lin, a young man who joined the TM CDC just prior to the appearance of SARS, recounted how during the epidemic he worked feverishly all day distributing disinfectant materials.2 Every few days he also had to take a turn answering a hotline on the night shift. “We couldn’t really sleep at all, because we’d maybe doze off and then get a call at one or two in the morning and then have to write up our report,” he told me. He said that the TM CDC leaders were so anxious to show that they were putting together a strong response that when he failed to pick up a call one night while he was in the bathroom, the leaders installed a telephone in the bathroom stall to make sure that such an oversight never happened again.
By July 2003, SARS had disappeared. The profound impact that this brief epidemic had on public health in China, however, had only just begun to take shape. This book tells the story of how the first global health crisis of the twenty-first century transformed a Chinese public health apparatus—once famous for its grassroots, low-technology approach to improving health—into a professionalized, biomedicalized, and globalized technological machine that frequently failed to serve the Chinese people.3
The system that under the otherwise deeply problematic leadership of Chairman Mao Zedong nearly doubled life expectancy in the world’s largest country had, in the several decades preceding SARS, sunk into unfunded obscurity. Overshadowed by an economic development agenda that left little room for mundane concerns like measles and diarrhea, public health in China became both invisible and ineffective. But in a serendipity of timing, the year that SARS arrived also marked the year that thousands of crumbling Mao-era local public health posts known as Anti-Epidemic Stations (fangyizhan) reopened their doors as shiny new Centers for Disease Control and Prevention (CDCs, jibing yufang kongzhi zhongxin). The Chinese state had begun in the 1990s to develop the CDCs as part of its vision of establishing a modern, professional research and disease control system—but until SARS hit, local leaders lacked the funds, trained personnel, and political capital to implement this grand vision. SARS provided all of these things, remaking an administrative experiment into a sophisticated new system of disease control and transforming what had been a technical trade into a prestigious biomedical profession.
The new public health profession that emerged had a very different mandate from its Mao-era predecessor. Because the blame initially put on China for the SARS epidemic led to highly public shaming and economic losses for the Chinese Party-state, the motivation to do whatever was necessary to prevent another SARS was extremely strong. And because SARS came onto the scene just as the Chinese state was reinventing its public health system, these motivations, and the mission they implied, became hardwired into the new public health system itself. Local public health in China became geared toward the protection of global, rather than local, interests and toward the protection of a cosmopolitan middle-class dream rather than toward the betterment of the poor.
Chinese public health professionals learned to govern local populations on behalf of what I call the common: an idealized world of modernity, science, and trust that they hoped through their work to be able to find abroad and build at home. The separation that arose between the common being served and the populations being governed—what I refer to as the bifurcation of service and governance—had significant consequences for the professionalization of public health in China. The potential for this separation to occur anywhere where professionals serve an aggregate also has important implications for the ethics of public health, and global public health, more broadly.
Tianmai, City of Immigrants
Based primarily on thirteen months of ethnographic fieldwork conducted at the TM CDC and other local public health institutions between 2008 and 2010, this book traces the transformation of public health in China after SARS by following the lives of dozens of public health professionals who worked in and around a city that I call Tianmai. Tianmai is located near the border between Mainland China and Hong Kong in China’s Pearl River Delta region, in the heart of Guangdong province—the region of China associated with Cantonese culture and language. But Tianmai is not Cantonese. It is, as its residents call it, a “city of immigrants” (yimin chengshi). It is a cacophony of cultures, cuisines, and languages from all over China, a medley of high-rise apartment buildings and villages, rice fields and traffic and factories. “We are like a small country,” several informants told me. And indeed Tianmai, with approximately 16 million people at the time of my fieldwork, is larger than many small countries.4 The vast majority of Tianmai’s population migrated from the interior of China to search, as the “city of immigrants” mantra suggests, for a better life.
Filling Tianmai’s urban villages, luxury hotels, narrow alleyways, and open-air markets are smells from every one of China’s cuisines. Hot Sichuan oils sting the nose, steaming Chaozhou seafood arrives at tables straight from tanks that line the first floors of massive restaurants, American-style steaks fill staid dining halls at resort golf courses, and barbecue and beer are served at outdoor picnic tables, as men with long fingernails, moist cigarettes hanging from their mouths, scrape scales from still-flopping fish. There are squares of Hakka tofu with succulent pork in the middle, Hunanese balls of taro in hot sauce, Shanghai dumplings, and Beijing duck. And there are Starbucks and McDonalds and KFCs, Italian bakeries and Irish pubs and pizza with ketchup served as tomato sauce. There are pigeons roasted on sticks and, nestled between high-rises and sprawling for miles at the far ends of the city, there are fields of rice and grazing cattle.
Tianmai was founded in the early 1980s, at the dawn of Deng Xiaoping’s economic reforms, on land that at the time was occupied by 30,000 rural villagers. Deng is a hero to middle-class Chinese all over the country, but he is especially revered in Tianmai. A giant billboard carrying his portrait is one of the most recognized landmarks in the city; a stone statue of Deng rises over Tianmai’s highest point, standing guard over a spectacular view of the city; and a museum commemorating the city’s history devotes several rooms to Deng’s accomplishments and his keepsakes. Comparable iconography of Deng’s predecessor, Chairman Mao, is noticeably missing: His portrait is absent from the museum, from classrooms, and from public squares, though it still dangles from the occasional taxi dashboard. Tianmai’s public health professionals spoke frequently of their bitterness toward Mao. They blamed him for their families’ past suffering, for China’s overpopulation problem, for what they perceived to be the country’s continued relative backwardness, and for the stifling of ideas that still emanated from the direction of Beijing.
Such bitterness toward the Mao years is not unique to Tianmai. Ann Anagnost (1997) has described how educated Chinese everywhere now look at the Mao years “as an irrational derangement of China’s ‘natural’ course of development” (165). But the directness and passion with which Mao was blamed and Deng celebrated in Tianmai were notable. My informants spoke freely and in detail of things I had rarely heard Chinese friends elsewhere speak of so candidly: the madness of the Great Leap Forward and the starvation they or their parents experienced; the godlike cult that surrounded Mao; the hatred that they felt as children when they stared at Mao’s portrait in their classrooms back in Hunan and Hebei provinces; and their nightmares of the Cultural Revolution that left them feeling that the fragile stability they had built for themselves and their families might crumble at any moment. When I climbed Plum Mountain with one of my closest Tianmai friends, she demanded that I take a picture in front of Deng’s statue to show my respect. “Deng Xiaoping is China’s greatest hero,” she told me sternly. “If it weren’t for him, you wouldn’t be allowed to be here.”
The border that separates Tianmai and other Pearl River Delta cities from Hong Kong once represented the line between Mao’s China and the West.5 It was a line across which refugees from China swam, climbed, and ran in a slow trickle for thirty years following the Communist victory in 1949 and across which Hong Kong villagers then watched as quiet Mainland rice fields gave way to skyscrapers (Watson 2004). In 1997, British Hong Kong rejoined the People’s Republic of China as a “Special Administrative Region,” and this line rapidly became one of the most porous borders in the world, with hundreds of thousands of people flowing with relative freedom in both directions every day.
In addition to serving as a destination for millions of Chinese from the interior of China, Tianmai also became an initial Mainland stop for many of the cross-border travelers. It was a place to change currency, buy clothes at Mainland prices, get a foot massage, visit a prostitute, and then go home or onward into the interior. Its mega-malls seemed to flow uninterrupted from the Hong Kong side of the border; its subway system and regional trains ferried Hong Kong travelers rapidly into the Mainland. All that lay between Hong Kong and Tianmai was an increasingly anachronistic wall of customs agents stamping a stream of hundreds of thousands of passports and “cross-border passes” per day.
The stamps in their passports, however, served to remind those who crossed this border that with the “one country, two systems” policy, Hong Kong remained a quasi-foreign land. Instead of suddenly disappearing with reunification, the border between Hong Kong and the Mainland continued to keep people out and keep people in (Berdahl 1999). This ability to exclude and include ensured that the borderlands of Hong Kong and Tianmai would continue to serve as places where national identities were defined (Newendorp 2008).
By the late 2000s, the border between Mainland China and Hong Kong functioned less to control the mobility of people and more to control the mobility of the microbes (and other undesirable things) those people might be carrying. From the time the SARS virus crossed the border into Hong Kong and then spread around the world, Tianmai’s public health professionals found themselves on the front lines of China’s biosecurity apparatus (Kleinman and Watson 2006). The Hong Kong border took on outsized significance as the site where frightening diseases were likely to pass between China and the rest of the world. Having initially failed to contain SARS, public health professionals throughout the Hong Kong border region were determined to keep future infections from crossing the border into their cities. Thus one of the first sights travelers encountered on either side of the border in the several years following SARS was a foldout table covered with a white cloth and staffed by nurses in loose-fitting masks, who handed out literature with messages like “Prevent Avian Flu!” in English and Chinese. Overhead monitors carried spooling red admonitions warning tourists that they should see a doctor if they felt ill; at times, the nurses pointed menacing fever guns at suspicious foreheads.
1. The Ministry of Health (MOH) in 2013 merged with the State Family Planning Commission to form the National Health and Family Planning Commission (NHFPC). In this book I will continue to refer to the MOH, as it was called at the time of my research.
2. All names in this book are pseudonyms, with the exception of nationally or globally recognizable public figures. Certain identifying details of my sources and their institutions, and certain details about the projects they were working on, have been changed for the purposes of protecting confidentiality.
3. This book focuses on urban public health as practiced in government-affiliated, nonclinical public health work units. For the most part I do not examine public health nongovernmental organizations (NGOs), which were few in number and relatively noninfluential in urban southeastern China in the late 2000s. NGOs appear in this book only in the context of their collaborations with the work units studied (see Chapter Two and the Conclusion).
4. Tianmai had an estimated 16 million people as of 2010. By the time I returned in 2014, the estimated population had risen to 20 million.
5. Following my Chinese informants, I use the terms Western and the West throughout this book to denote the countries of North America, Western Europe, and Australia. Though many scholars have rejected these terms in favor of “Global North,” I found it more appropriate in this case to use the terms that my informants used (xifang, or xifang guojia—the West or Western countries).