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The Respiratory Disease Capital of the World: What Guangdong Province May Mean for Health Policy in a Globalizing World

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Guangdong Province in China is widely considered the primary point of origin for the Chinese Diaspora, as evidenced by the predominance of Cantonese–a Guangdong dialect–across the world’s Chinatowns. Unfortunately, this region is also the birthplace of many infectious diseases now posing a significant threat of global contagion, including SARS and more recently, the H5N1 avian influenza virus.  

Over the past three decades the emergence of more than 30 new infectious diseases has created a tremendous growth in awareness surrounding the possibility of a global pandemic.  In the past decade especially, almost all emergent diseases have begun as zoonotic–or, animal–diseases, mutating to make the leap to human-to-human transmission. The last flu pandemic in 1918 infected 30% of the global population, causing roughly 50 million deaths. Throughout the 2002 SARS outbreak, Chinatowns worldwide suffered significant business losses due to widespread fear of infection, despite a lack of cases reported in those communities. Such losses were intensified by the highly-publicized story of a doctor from China who traveled to Hong Kong where he spread SARS to 16 hotel guests, who in turn infected people in Canada, Singapore, Taiwan and Vietnam. The Chinese government further aggravated the situation as they attempted to cover-up the SARS outbreak out of fear that an epidemic would disrupt social order and  damage the tourism sector.

As global migration increases the distance germs can travel, it raises the question of whether diaspora communities like the global Chinatowns constitute particular micro-zones of risk for infection. Thus, policymakers must address the need for international cooperation and transparency in combating infectious diseases so that the dual status of Guangdong Province, as the source of the world’s largest diaspora population and some its most dangerous diseases, does not become undue cause for concern as we combat the current threat of avian influenza.

BACKGROUND

Possibly the world’s reigning respiratory disease capital, Guangdong Province has produced SARS, the H5N1 and H3N2 avian influenza viruses, and has a high incidence of pulmonary disease and porcine reproductive and respiratory syndrome (PRRS). The region has roughly 6% of China's population (2004) but was responsible for roughly 13% of the nation's hospital visits in 2005.


SARS was the 21st century’s first acute and readily contagious disease and served as a powerful indicator of how quickly illnesses can spread across the globe via international air travel. The disease began with a Guangdong region farmer in November, 2002 but Chinese government officials, in order to maintain public confidence, did not inform the World Health Organization (WHO) of the outbreak until February of 2003, at which point the epidemic had already spread to Vietnam. A WHO alert was not issued until four months after the first outbreak and, just one month later, the epidemic had spread to twenty countries, infecting upwards of 8,000 people. The disease had no vaccine and no treatment but was contained within a year. 

The Chinese government’s lack of transparency severely delayed worldwide efforts to control the epidemic, prompting heavy criticism from the international community. The actual number of SARS-related deaths in China far exceeded the officially reported number and each level of government suppressed situational awareness reports.  In April of 2003, when a whistle-blower disclosed statistics confirming the higher numbers , authorities were forced to acknowledge that incorrect information had been relayed and, as a conciliatory gesture, subsequently removed the health minister from his post. 

The socioeconomic impact of SARS for Chinatowns worldwide was severe, particularly in the United States where Chinatowns in New York, Boston, Seattle, and San Francisco reported devastating drops in business, particularly for restaurants. Although public health officials investigated widespread rumors of contamination in Chinatowns and no cases were identified, the incidence of discrimination against Asian-Americans was widespread. Officials attributed the fear to media sensationalism of perceived close ties with China. The majority of Chinatown residents originate from Guangdong Province and neighboring Hong Kong, and many have close relatives there. In Boston, for example, 40 percent of Chinatown residents have resided in the United States for under five years. 

Although the Chinese government apologized for its actions and promised to implement an early warning system, there have been similar stumbles in its avian influenza reporting. Today, H5N1 avian influenza -- which is fast-mutating and highly infectious from animals to humans -- poses the largest threat of a global pandemic, although human-to-human transmission is still limited. The strain was first identified in Guangdong in 1996 and had spread to Hong Kong by 1997. Between 2003 and 2008, human cases were reported in more than 15 countries, although China did not confirm human cases until 2005. As in the SARS outbreak, Beijing has been criticized for its reluctance to cooperate with the WHO and for the delayed sharing of virus samples with international health authorities. Within the past few weeks, China has reported eight cases of avian influenza since December after reporting no human infections for almost a year, suggesting improved transparency.  

ANALYSIS

If a global avian influenza pandemic were to occur, it has been estimated it would kill roughly 142 million people and cause economic losses totaling 4.4 trillion USD. However, preparedness is still lacking despite the consequences of the SARS epidemic. Although the WHO coordinates the sharing of virus samples and cooperation in vaccine development and is currently developing an electronic flu tracking system, there is precious little international cooperation on the tracking of travelers who may be visiting affected areas despite causal links between airline travel and disease spread. The WHO tracked travelers to high-risk SARS areas for under a year and efforts to track passengers remain limited to ‘passenger locator cards’ passed out on certain flights. In the U.S., the Global Pathogens Surveillance Act – a 2007 initiative to detect, monitor, and respond to sudden disease outbreaks - has yet to become law. Furthermore, because there is no WHO requirement that country notification reports include many of the most threatening diseases, such as anthrax, many countries choose not to report due to tourism and trade considerations. Ironically, it is this lack of transparency which contributes to fear and related economic losses.

The Chinese development of an early disease warning system and official statements that agencies responsible for delayed reports will be punished are both positive signs of improvement. However, given the unusual case of Guangdong Province and the business impact of the SARS epidemic, it is clear that global public health officials must acknowledge the need for improved international monitoring of undocumented travel and immigration between infection zones and associated diaspora communities. Only by addressing such issues head-on can officials reassure the public and protect businesses from avian influenza-related losses, as well as establishing a global health and security policy that fosters an atmosphere of international cooperation rather than fear.

About the Author

Jaclyn Selby