Coughing Dragon, Sneezing Elephant: China, India, and Global Health Governance

The recent H7N9 flu scare in China has shown once again that we live in “an epidemiologically interdependent world.” If so, the future of global health will depend mightily on the evolving policy choices and growing material capabilities of the world’s emerging powers. My insightful colleague Yanzhong Huang explores the implications of these trends in a fascinating new CFR paper, “Enter the Dragon and the Elephant: China and India’s Participation in Global Health Governance”.

That public health decisions made in Beijing (or New Delhi) may have consequences for us all should be commonplace by now, a decade after the outbreak of SARS and in the throes of the latest (bird) flu scare. While the H7N9 virus has not yet proven capable of human-to-human transmission, a mutation could easily occur to permit this—with disastrous implications, given the disease’s apparently high mortality rate. The result could be a global influenza pandemic, with potentially catastrophic economic, as well as human, costs. Epidemiologists estimate that humanity suffers one such pandemic on average each century—the last being the so-called “Spanish influenza” of 1918–1919 , which infected approximately a third of humanity and killed between 20 and 100 million people worldwide. We are, alas, due for another.

Huang’s paper asks how China and India have sought to contribute to “global health governance” (GHG)—a phrase describing the sometimes messy collective efforts of national governments, international agencies (like the WHO, UNAIDS or the World Bank), public-private partnerships (like GAVI or the Global Fund) and non-state actors (like the Gates Foundation) to formulate new global health norms, cooperate in battling diseases, and help build capacity in the world’s poorest countries. He focuses on the role that the Chinese and Indian governments have played in delivering foreign assistance to other countries and, at the multilateral level, in shaping new rules for global health cooperation. His findings are instructive. While seeking to strike out new profiles as aid donors and occasionally complaining about existing multilateral structures, the two countries are not yet pulling their weight at the global level; neither has offered a compelling, alternative vision for a new global health regime tailored to the twenty-first century and to their own preferences. Finally—and perhaps most worrisome—China and India have embraced global health activism without addressing persistent deficiencies in their own domestic public health systems. Until they address these daunting needs, their global health diplomacy and aid programs will remain largely symbolic.

The rapid emergence of China and India as players in global health is a surprising development. At the turn of the century, epidemiologists and public health experts warned that the two countries were on the cusp of a public health catastrophe—HIV/AIDS seemed poised to move rapidly from sub-Saharan Africa to the more populous states of Eurasia, infecting tens if not hundreds of millions. Fortunately, these fears proved overblown. Although prevalence in both countries rose, public health interventions and unique societal norms curtailed the pace of new infections. Contrary to the alarmists, the “next wave” of AIDS was no tsunami.

But there were other indications that the big emerging GHG players, particularly authoritarian China, might not be ready to play a constructive global health role. The nadir came during the SARS epidemic of 2003, which Chinese leaders lied about for months to avoid jeopardizing trade and tourism. Such egregious conduct—which facilitated the transnational spread of a disease that killed nearly a thousand people and cost the Asian region at least $25 billion—suggested that disastrous governmental decisions (particularly when a ruling regime monopolizes information and control) can make an otherwise “strong” state a weak link in responding to global public health crises.

As Huang documents, China and India have ramped up their development assistance for health, particularly in Africa, focusing primarily on health infrastructure. As of 2011, “China had built one hundred fully stocked hospitals in fifty-two countries,” while India was leveraging its information and communications technology to improve standards of care. Overall, China and India are shifting from net recipients to net donors of assistance—though their spending on global health (in the hundreds of millions in recent years) remains dwarfed by U.S. aid and that of other traditional OECD donors. Moreover, neither government has effective interagency mechanisms to design and coordinate health interventions, leading to fragmentation and lack of strategic focus.

At the multilateral level, China and India have expanded their involvement in cooperative efforts to prevent and control infectious disease. Stung by the SARS debacle, Beijing has embraced regional and global health arrangements, including the WHO—a body in which Margaret Chan, a Chinese national, was elected Director-General in 2006. Beijing also adopted a welcome openness in responding to the H5N1 and H1N1 pandemics. India has staked out a leadership position in calling for urgent global action against non-communicable diseases (NCDs).

More negatively, Huang criticizes China and India for clinging to a narrow “state-centric approach” toward new global health norms, rules, and standards. This approach privileges national sovereignty, while undercutting deeper cooperation with either international agencies, other governments, or civil society actors. Huang considers it shortsighted, since it “limits the scope and effectiveness of international cooperation in an era of interdependence.” For China, the one important exception has been acquiescence to the revised International Health Regulations (IHRs). Indeed, “China now boasts the largest infectious disease surveillance and reporting system in the world,” well placed for cooperation with the WHO’s Global Outbreak Alert and Response Network. India has also faithfully implemented the revised IHRs.

The Achilles heel of Chinese and Indian aspirations to shape GHG may be their common failure to translate dynamic economic growth into health sector gains at home. Belatedly, the two countries have recently increased investment in the health of their citizenry. But they have a long way to go. The two countries account for fully one third of the global disease burden. India hosts the world’s largest TB-infected population, with 1.21 million new cases a year (China has 870,000). Both countries confront a massive threat from NCDs, which could account for two thirds of all deaths by 2020 (up from 53 percent today). Another public health challenge is tobacco: China is world’s largest producer and consumer, India the second. And when it comes to covering health costs, citizens are often on their own, spending 48 percent out-of-pocket in China and 70 percent in India.

As with so many other transnational challenges, China and India’s ability to contribute to global governance in health will require difficult trade-offs along the domestic-international frontier. Meeting national health goals will likely take precedence, at times limiting tangible contributions to multilateral global health initiatives.