Sovereign Dignity, Nationalism and the Health of a Nation: A Study of China's Response in Combat of Epidemics.

This paper seeks to understand the role of nationalism in China's policy towards the combat of emerging infectious diseases. By locating nationalism as a factor which facilitates or impedes global governance and international collaboration, this paper explores how nationalism influences China's political decision-making. Given her historical experience, China has in its national psyche an impulse never to become 'the sick man of the East' again. Today, China's willingness to co-operate with international bodies emanates out of reputational concerns rather than technical-medical considerations. This was clearly manifested in her handling of two epidemics in recent years: the Severe Acute Respiratory Syndrome (SARS) and HIV/AIDS episodes. This paper concludes that China's nationalism plays an inhibiting role in China's attempts to further incorporate herself into the architecture of global health governance in the long run. Journal compilation

Introduction: Globalisation and Emerging Infectious Diseases

The transnational spread of infectious diseases in an era of globalisation poses a new challenge for the global health community. In particular, the outbreak of Severe Acute Respiratory Syndrome (SARS) in 2002–2003 drastically changed the perception and degree of collective engagements of states and other institutions towards infectious diseases. SARS was distinct from the pathogens that emerged in the past in the sense that it offered an unprecedented opportunity to test contemporary global collaboration as well as a regulatory approach to a new disease outbreak. SARS demonstrated that simple divisions between national and global health policy do not work in practice. During the outbreak, governments had to realise that a disease in any one part of the world is a threat to the rest of the world. However, ironically governments were in general reluctant to acknowledge the existence of the outbreak. Most notably, the Chinese government's response to SARS was critical to the functioning of global governance in infectious disease control. It is a classic textbook example and a fundamental test case of how nationalism can impede or facilitate global governance and international collaboration.

China had initially covered up the outbreak, but later reversed its stance to fully co‐operate with the World Health Organization (WHO). Scholars viewed China's initial response to SARS within the context of China's poor public health infrastructure, ineffective and fragmented bureaucratic system, and political transition in leadership at the time of the outbreak. At the same time, China's remarkable U‐turn towards international collaboration was demonstrated in the framework of the tremendous power of international organisation (i.e. WHO) in facilitating China's submission and the changing nature of international politics where sovereignty has been curtailed (Eckholm 2006: 28). Some scholars have even gone further to argue that China's SARS episode demonstrated the governance transition from Westphalian to post‐Westphalian strategies (Fidler 2004; 2005).

Yet, despite some scholars' claims based on China's initial reluctance and subsequent acquiescence to international forces, there is no evidence that China's sovereignty has been curtailed or that China has been integrated into global health governance. While the existing literature has focused on China's stunning reversal during the SARS outbreak, less attention has been paid to the extent to which this turnaround has continued during the aftermath of SARS. Indeed, in light of the Chinese leadership's attitude and commitment towards other infectious diseases such as HIV/AIDS and the recent cases of avian influenza, China's newfound openness did not seem to be genuine. This leads to the following questions: What were the factors that inhibited and then facilitated the collaboration during the outbreak? What eventually brought China back to ‘business as usual’ after the outbreak? What ultimately motivates the government's agenda and actions towards infectious diseases?

This paper argues that nationalism in the form of national pride and security consciousness in China are enduring driving forces that have shaped Chinese policy towards emerging infectious diseases. By locating nationalism as a factor which facilitates or impedes international collaboration, this paper explores how the Chinese leadership has exhibited ways in which nationalism affected much of their political decision‐making in their quest to restore national pride and to secure China's developmental goals and national interests. It is argued that more often than not, nationalism hindered the formulation and implementation of health policy at both the provincial and national levels. Maintaining a positive image of China in the international arena and securing the interests of the regime were key driving forces that affected policy‐making. More specifically, this usually revolves around the ruling elites' competency in the handling of a national crisis and in its foreign policy.

Given the historical experiences of China, it has in its national psyche an impulse never to become the ‘sick man of Asia’ again. The reaction of the Chinese authorities at both the central and provincial levels towards unknown health threats is often to deny and cover up the disease's existence. This could be in part to avoid the stigma of being a ‘sick’ nation as well as to buy time in order to search for an indigenous solution to the problem. This sort of mentality belies a negotiated basis of existence behind the modern Chinese nation – as if to say that there are no problems that modern China cannot handle or solve. Yet it is also the same desire to appear ‘healthy’, ‘confident’ and a ‘responsible’ member of the international community that often swings Chinese response to disclosure and collaboration. However, the latter only happens when the disease in question and China's handling of it is put under international scrutiny and often criticism. In short, China's compulsion to co‐operate with international bodies emanates out of reputational concerns rather than medical considerations.

Nationalism can then be rapidly conjured up as a force which legitimises the draconian measures taken in the name of the nation to defend its sovereignty. One of the most immediate effects is that public health threats are often securitised and political‐security solutions are sought rather than technical‐medical ones. This means that any information pertaining to the outbreak is treated as classified, and is revealed on a ‘need to know’ basis, and collaboration is discouraged. It also means that the development of treatments is often seen as an opportunity to showcase the work of indigenous scientists who are ‘able’ to come up with a cure. An interrelated point pertains to the prospect of China's integration into global health governance. Unless and until the Chinese leadership examines the nationalistic element embedded in their approach towards growing disease epidemics and globalising health challenges, China's ascendance to great power status will actually be harmed rather than helped.

The Imagery of Health in History and in Chinese Nationalism

History is replete with examples of nationalist wars, where historical enemies and entire cities were wiped out, territories annexed and glory won, often at an exorbitant cost. History is equally manifested with examples where massive genocide has taken place in the name of the nation to realise some deranged nationalist blueprint, such as Hitler's efforts to achieve a pure and superior Aryan race or Pol Pot's infamous Year Zero project to restart civilisation in pursuit of a Communist utopia. Yet, such apocalyptic devastation is not always wrought by genocides or wars, but often through inaction, ineptness or impotence by national leaders who fail to defend the nation against aggression, man‐made disasters, and pandemics.

Just as the great Athenian statesman Pericles learnt from the Athenian Plague in the fifth century BC and the Roman Emperor Marcus Aurelius from the outbreak of smallpox, epidemics could besiege large segments of any given population with quick and lethal consequences on a scale far greater than imperialistic wars or disastrous famines. The primitive state of medical science, limited understanding of hygiene, poor sanitary conditions, and widespread poverty often enable plagues and epidemics to thrive and spread with ease. The Plague of Justinian (sixth century AD), the Black Death (fourteenth and fifteenth centuries AD), and the Bubonic Plague (1665–1666) stand in testimony throughout the ages to remind the world of the imagery of the Four Horsemen of the Apocalypse described in Revelation 6:8: ‘And I looked, and behold, a pale horse; and his name that sat on him was Death, and Hell had followed him’. It was not until the advent of modern advances in science and technology that the verse was more associated with nuclear weapons than with epidemics.

Since the Peloponnesian War in 430 BC, when a plague that originated in Ethiopia spread to the Persian Empire and to Athens, the world has seen nation‐states combat these epidemics at a localised and, at most, a national level (Hays 1998: 39; Porter 1999; Watts 1997). Health policy on disease epidemics was a matter of sovereign discretion and exclusively dependent on the concerned nation's capabilities. When the Black Death (Bubonic Plague) in the fourteenth century spread through international travel and trading routes afflicted Europe and North America, quarantine measures aimed exclusively at preventing disease threats from entering a nation from outside its borders were taken in major European nations. As in defence or foreign policy, health policy is most certainly an exclusive jurisdiction of the national government or ruling regime, and on numerous occasions, great rulers who have built their empires on military conquests have seen their legitimacy to rule crumble very quickly with the unbridled spread of pandemics in their nations. Religion, as opposed to science, became the salvation from diseases and epidemics until the eighteenth century. Nonetheless, the combat of plagues and epidemics has always invariably been seen and recognised as a national ‘problem’ for leaders, even though pathogens, bacteria and epidemics in general have no respect for political borders or sovereign rights over territory or people.

However, as the rapid growth of populations and intensified human interactions in the sixteenth century and the process of industrialisation from the eighteenth century offered many communicable diseases opportunities to spread more widely, nations began to contemplate types of global response. One dimension of this response was a nascent form of international conferences. These early conferences were widely supported by the economic and political elites, as they believed that the spread of epidemic diseases would hamper the expansion of trade and the development of commerce. Therefore, in retrospect, most nations' responses to epidemics were not born out of historically nationalistic gestures underpinned by a Statist discourse to protect and defend against Westphalian notions of sovereign dignity. Instead, the nations' responses were traditionally based on more rationalistic and interest‐based considerations.

Elites regard the protection of the nation's health to be of paramount importance, sometimes not so much to defend the citizen's right to life or liberty, but out of a less altruistic desire to ensure that the state's interests are maintained (e.g. keeping the economy vibrant, harvesting crops, maintaining troop levels, and rendering services and goods). As Norman Howard‐Jones observed, the very first international health conferences in the nineteenth century were not motivated by a wish for the general enhancement of the world's health, but by the desire to protect certain favoured (European) nations from contamination by their less favoured (Eastern European) counterparts (Howard‐Jones 1975: 10–32). Therefore, earlier forms of collaborative action illuminated these politicians' concerns about the impact of outbreaks on their nationals and, in particular, the rationale that underpinned the sense of nationalism behind the ruling elite's orientation towards healthy policy.

One of the fundamental pillars of understanding in the Westphalian notion of sovereignty in the modern fraternity of nation‐states is the very fact that all nation‐states are sovereign entities, with their own jurisdiction over territories and peoples. Extrapolating from this, all nations are therefore born ‘equal’ in this fraternity of nations, as enshrined in Article 2 of the Charter of the United Nations that membership in the UN is ‘based on the principle of the sovereign equality’. The stark reality is that the members in this community of nations can hardly be equal. We hear of ‘Great Powers’ all the time, as much as we hear of the influence of the ‘bi‐polar’ or the ‘uni‐polar’ world. The logic that drives and motivates nations in this fraternity today is the quest to become ‘Great’, and this desire for nationalism underpins most nationalist thinking and discourse within any given state. While there is no definite statistical evidence for this, it would not be an exaggeration to say that most nations wished that they could at least play in the finals of the World Cup. For that matter, Americans beam with pride as the US is consistently regarded as the only superpower left in the World, just as a significant number of Russians look back nostalgically with pride to a glorious past. The French are convinced that they are the most superior civilisation and culture left in the world, and point to the vibrancy and the romance of their capital, Paris, and the French dominance in luxury and designer goods industry. It is also quite clear that the Chinese are extremely proud of their economic rise and perceive the hosting of the 2008 Olympic Games as a sign that it has made it in the world. In short, nations thrive on pride and sovereign dignity.

Most nations regard themselves as ‘strong’, founded on science, rationality, and progress. This vocabulary is found not only in discourse pertaining to health but also politics and economics. A healthy nation is strong, resilient, and able to withstand any political, economic, or health crisis. In 1832, the French medical community thought that the disease creating havoc in the Eastern Mediterranean would never affect France, expecting that it be confined to weaker and less civilised populations experiencing a poor and unhealthy climate. The cholera killed 15,000 people in four days in Paris (Delaporte 1986), thus confounding most of the elites. Today when political leaders speak of a healthy nation, they more often use ‘health’ as an analogy to draw comparisons, alluding to their aspirations for the country to be strong in all dimensions. The ‘health’ of a nation is therefore founded on both symbolic and substantive terms, and they are often intertwined in reality. In symbolic terms, a ‘sick’ nation is one that is weak. Tsar Nicholas I described the crumbling Ottoman Empire as the ‘sick man of Europe’, just as Russia has been tagged with the same label in the last two decades after the demise of the Soviet Union. In Asia, one saw the Japanese labelling the decaying Qing China the ‘sick man of East Asia’. Qing China was not only weak economically, militarily, and politically, but was also plagued by internal stifle, unrest, and opium addiction. The most potent symbol of this ‘sick man of East Asia’ was the imagery of Chinese men hooked on opium, a drug introduced by the British to reduce its trade deficit as its demand for Chinese tea, silk, and porcelain increased. This imagery has underpinned various versions of Chinese nationalism ever since.

William A. Callahan (2004) eloquently discusses the role of shame in Chinese nationalism. As Callahan argues, nationalism in China very often commemorates its weaknesses rather than celebrating the glories of Chinese civilisation (2004: 202). The official narrative of modern China is generally a tragic tale of its fall from being the ‘centre of the Universe’ beginning with the Opium Wars, to the incursion of Western powers into imperial China, to the grand finale of the invasion of China by the Japanese. This is intricately linked with the rise of the Communist Party of China (CPC) and the founding of the People's Republic of China (PRC), and provides the very basis of the legitimacy with which the CPC stakes its political right to reign.

It is this deeply seeded shame that motivates the modern Chinese state never to fall behind again – whether in economic or political terms – as modern China seeks to erase the ‘shame and humiliation’ today. This quest for greatness is a significant impetus for China's economic rise. In essence, ‘achievement’ is used as a remedy to get rid of the shame that China has written into much of its official discourse over the past developmental trajectory. One need not look far for evidence. China's national anthem written in 1932 (translated below), one year after the Japanese invasion of China, poignantly documents the sense of shame behind the ‘sick’ nation:

Arise,

Ye who refuse to be slaves!

With our very flesh and blood,

Let us build our new Great Wall!

The peoples of China are in the most critical time,

Everybody must roar his defiance.

Arise!

Arise!

Arise!

Millions of hearts with one mind,

Brave the enemy's gunfire, March on!

Brave the enemy's gunfire, March on!

March on! March on!

Numerous scholars have documented how the obsession with ‘humiliation’ and the goal of turning ‘grief’ to ‘strength’ have significantly influenced China's foreign and security policy towards the United States and Japan (Dittmer and Kim 1993; Gries 2004; Shambaugh 1991: 81–93). One of the most important dimensions is China's obsession with sovereignty or perceived infringements of her sovereignty or pride. This has made China hypersensitive to any sort of international criticism, it as an infringement of her sovereignty or meddling in her internal affairs. Obviously one could argue that this is a political strategy of the CPC to deflect any sort of political challenge, but given the rise of nationalism within China over the last decade, one cannot help but realise that these sentiments might be more widespread than conceived.

While China maintains a discourse of equality and camaraderie of friendship with other nations of the world, its actions and its policies often belie China's real intention of ascendance and greatness. As such, China is not only concerned with building capabilities associated with a great power, it is also extremely concerned with portraying an image that it is one. Most interestingly, China's obsession with sovereign dignity and pride and its place in Chinese nationalism is clearly manifested in its handling of two health‐related issues: China's approach towards the handling of the AIDS epidemic and its response to the SARS epidemic in 2002–2003.

Chinese Nationalism and Sovereign Dignity

The Impulse for China's Reticence on SARS

Perhaps the most pertinent question discussed in this paper is why the Chinese leadership tried to cover up the extent of SARS and later took decisive action. Answering this entails an understanding of a number of factors, but it is argued that nationalism and sovereign dignity played a part in China's response to SARS. Despite all the changes that the country has undergone, the traditional so‐called ‘face‐saving’ approach seemed to be as intact as ever and even deeply engrained in the mentality of the Chinese leadership. Therefore, when there is an event that could damage national pride, it is highly embarrassing for them to admit. The best way to resolve the troublesome event is to actively avoid or deny. Thus the mode of dealing with national calamity is to identify a problem before the outside world discovers it, take measures to address it, and only afterwards report the improved situation. These mechanics have been generally at the heart of the Chinese leadership's crisis management, particularly with regard to emerging infectious diseases. This was evident in China's response to SARS.

The crucial feature of the SARS outbreak in China from early January 2003 through early February 2003 was that the provincial authorities kept the lid on the situation. The CPC has tended to suppress negative news such as diseases and disasters out of fear that such information would disrupt national stability. Cover‐ups are usually started by local officials who want to avoid embarrassment in front of their superiors due to their incapability to control the situation themselves. Therefore, there is no incentive for local officials to pass the information up the chain of command.

When early cases occurred in Guangdong province, the local authority was at least aware of the situation. Anxious to avoid criticism for their mishandling of earlier outbreaks and in an effort to maintain Guangdong as a location of commercial dynamism and economic growth, the provincial leaders concealed the gravity of the disease. Later, provincial party secretary Zhang Dejiang, the highest‐ranking official in Guangdong, stated: ‘if we made a contrary decision, it would have been impossible to achieve a GDP growth rate of 12.2 per cent’ (CCTV interview, 9 June 2003). This denotes the fact that the Guangdong leadership feared the impact of the disease's outbreak on national development. The potential ‘loss of face’ also contributed to provincial leaders' concealment, as the disastrous public health problem would eventually contribute to the negative effects on the CPC's legitimacy. SARS was considered something that needed to be defeated before it became embarrassing. Therefore, the suppression of information at the provincial level was not only motivated by development goals for the nation but was also prompted by the desire to save face and maintain reputation.

Once the virus spread internationally, the nature of the problem and the possibilities for resolution broadened significantly. When the Chinese government failed to address the growing epidemic, the health problem in China became a political issue and an embarrassment for the central government. However, the central government's long‐overdue response to growing infectious diseases was not reversed abruptly. Beijing's initial reaction to the epidemic was silence and an unwillingness to co‐operate. Until early April 2003, an international team of experts was not permitted to investigate hospitals in Beijing. China's Health Minister Zhang Wenkang declared at a press conference that there were twelve SARS cases in Beijing but claimed that the disease had not spread to other parts of China (Abraham 2005: 45).

The discourse that SARS was under control was also backed by Hong Tao, the esteemed Chinese microbiologist, who asserted that the cause of the disease was chlamydia and that the outbreak was dying down. Due to systematic problems in the Chinese scientific community – a lack of coordination; stifling political influence; hesitation to challenge authorities; and isolation from the rest of the world – the chlamydia hypothesis was firmly established in China (Enserink 2003: 294). When the world‐leading scientific labs confirmed that the causative agent was a coronavirus that had never before been seen in humans, China's persistent assertion had to be withdrawn. It was another national embarrassment that the emerging power was short of a scientific solution.

Restoring National Pride

There was a major turning point on 20 April 2003. Faced with widespread international criticism of China's unresponsiveness, President Hu Jintao and Premier Wen Jiabao finally declared a war against SARS, calling for accurate and timely information about the disease to be provided and shared amongst units and international partners. This announcement was widely reported by Chinese newspapers and television. Shortly after the declaration, Health Minister Zhang Wenkang and Beijing Mayor Meng Xuenong were dismissed, ostensibly for their inadequate response to SARS. Premier Wen went on to attend the ASEAN‐China Leaders Meeting in Bangkok on 29 April and stated that ‘the Chinese government is here in a spirit of candour, responsibility, trust and cooperation’ (Macan‐Markar 2003). In hindsight, as the country's reputation suffered abroad, the leadership needed to re‐establish itself as a responsible member of the international community in the eyes of its international counterparts. Having exposed the emerging power's incapability of handling a disease crisis, the only way of restoring national pride was to show the world that the great China had the capacity to deal with the national threat efficiently and effectively in a short period of time.

The Chinese leadership made a lot of effort to inform the general public of the dangers of SARS and to mobilise society in the name of the ‘national’ spirit. Depicting the combat against SARS as a ‘baptism of fire’ for the entire nation and urging the public to unite around the communist leadership to defeat the national crisis, the Chinese government set up the ‘SARS Control and Prevention Headquarters of the State Council’ headed by Vice Premier Wu Yi. The government created a fund for new building projects and the provision of more healthcare services (Balasegaram and Schnur, 2006: 80). Amazingly, the government was able to build a dedicated hospital for the treatment of SARS within a week.

Apart from government initiatives, the propaganda department made an effort to ‘nationalise’ a regional outbreak into a national crisis and, in doing so, mobilised an entire nation into the battle against SARS virus. The People's Daily (15 May 2003) used traditional Maoist revolutionary rhetoric, such as calling for the people to ‘Build out a new Great Wall – on the great spirit of the fight against SARS’ (Ren Zhongping, 2003). The propaganda department worked towards alerting the people about the disease and instilling in every individual a sense of patriotism and national duty to rally around the CPC. In Guangxi province, minority groups sang songs about SARS; in Inner Mongolia, murals were painted to depict the SARS experience; and in Beijing, banners spurred comrades on, harkening back to Mao's campaigns during the Cultural Revolution (Balasegaram and Schnur 2006: 81–82). Having decided to be transparent, the media sprung into full action with reports of ‘white‐coated warriors’ and ‘angels in white coats’, describing heroic stories of doctors and nurses working for love of their nation and its people.

Community leadership also re‐introduced the traditional neighbourhood committee by revitalising the grassroots party structure. This committee, mainly consisting of elderly residents, barred outsiders and checked for SARS symptoms in their neighbourhood. These committees created groups of ten households and appointed one volunteer. The volunteers were in turn grouped in tens and reported to a higher authority. This structure continued upwards until it meshed seamlessly with the Communist Party system that ruled the country ( ).

Yet, what is important to note here is that this nationalism extends beyond making SARS an immediate enemy of the nation. The image of a China being ‘sick’, the inability of Chinese scientists and people to eradicate the virus independently, the ineptness of the Chinese health system to effectively contain the outbreak were all smudges on the Chinese image that the leadership wanted erased. By encouraging the national spirit and mobilising the energy of the entire population, the government was able to show the international community that China in fact had the capacity to deal with the national crisis, thereby restoring the national pride and dignity that was commensurate with China's international reputation and image as a rising great power. The success of this reversal did ameliorate the damage done to China's image by its previous bungling.

China's Long‐Standing Position on HIV/AIDS

China's handling of the SARS crisis, unfortunately, does not represent its approach to epidemics in general. Scrutinising the PRC's approach to the HIV/AIDS epidemic in the country, China's reticent approach to international co‐operation is clear. Compared to the recent SARS episode, the AIDS epidemic has been around for more than two decades. Although its effects are less ‘visible’ than the SARS outbreak, in reality, the AIDS epidemic is probably more devastating and has had a much higher death toll than SARS. AIDS, however, did not receive much attention from the central authorities until very recently.

In January 2006, China's Ministry of Health estimated that 650,000 people were living with HIV in China, including about 75,000 AIDS patients (Ministry of Health, People's Republic of China, Joint United Nations Programme on HIV/AIDS, and World Health Organization 2006). This figure is lower than the previously published estimate of 840,000 in 2003. However, the actual number of AIDS carriers is believed to be much greater. The inaccuracy of the estimate is due to the fact that there is massive underreporting of the disease, especially the rural areas. There are many reasons for underreporting, but a shortage of adequate resources and a lack of openness in confronting the epidemic at many levels of government (provincial and local levels) are some of the major factors that contribute to China's slow response. Exact figures are difficult to gauge because the government at the local level is very reticent to report on actual cases (Human Rights Watch 2003).

When AIDS was first reported in Beijing in 1985, the initial cases were treated with disdain and the disease was labelled as ‘foreign’. The government warned that young women having sexual relations with foreigners could be in danger, and that ‘foreigners’ would facilitate AIDS becoming an epidemic in the PRC. The government also tightened immigration controls and required all foreign students entering China to present a certificate from their country of origin testifying that they were not infected with AIDS. During the 1990s, although AIDS began to spread from Yunnan province to other parts of country, the Chinese government officially denied that it had an HIV/AIDS problem. This was exposed as a lie by a few whistleblowers, at least one of whom was imprisoned for revealing ‘state secrets’ (Watts 2006: 804).

Therefore, the real extent of HIV/AIDS cases remains unknown as the government's long‐standing position towards this epidemic has always been that AIDS is a ‘foreign’ disease requiring surveillance and border control, as well as action against social undesirables such as prostitutes, drug users, and blood brokers. The Chinese government's response to AIDS was initially persistent silence and a refusal to acknowledge that the issue was serious.

Chinese Leaders' Limited Openness on the AIDS Epidemic

A major factor behind the government's recent change in its attitude towards the AIDS epidemic seemed to be the outbreak of SARS in China in 2003, which exposed the dangers of not reacting to emerging infectious diseases. Yet, it took almost two decades and a lot of pressure, internationally and domestically, before the Chinese government decided to institute measures to ‘contain’ the AIDS epidemic.

Despite some candidness surrounding the discussion of AIDS in China, the scale of the problem is still being played down, mainly due to the government's tight control on media and infected AIDS patients not coming forward for fear of discrimination. Thus the true extent of the problem remains unclear. Yet, the Chinese government was actually forced to address the AIDS epidemic for reasons very similar to those that led to the disclosure of the SARS epidemic. It was sparked by the revelation of the very controversial case of an entire AIDS village in Henan province, where thousands of poor farmers were infected by HIV while selling blood to the health authorities. Initially the villagers were isolated and ostracised, and local authorities acted in the name of the national interest and the public good to cover up this outrageous negligence on the part of the health authorities.

Due to the mounting weight of evidence that China is in the grip of a major epidemic, the Chinese government came under tremendous international criticism for their inaction over AIDS. The government seems to have increased efforts to fight AIDS by reversing some policies. In 2003, the Chinese government launched China CARES (China Comprehensive AIDS Response), a community‐based HIV treatment, care and prevention programme. Shortly after China CARES was started, the Global Fund to Fight AIDS, Tuberculosis and Malaria awarded China a five‐year grant to help the country fight its HIV/AIDS epidemic (The Global Fund to Fight AIDS, Tuberculosis and Malaria 2003). On World AIDS Day in 2003, Wen Jiabao became the first Chinese Premier to shake hands with an HIV‐positive person. The handshake, broadcast in close‐up, was believed to set the seal on a fundamental shift in the government's approach to the HIV/AIDS epidemic. The Chinese government is showing a new willingness to be more candid about the HIV/AIDS situation within the PRC.

Despite enhanced intervention measures and infrastructure, stigmatisation, fear, and hidden infection constitute a vicious circle that fuels the AIDS epidemic in China. The prevalent societal attitude in China towards AIDS was and still is very prejudiced. AIDS is regarded as a ‘foreign’ disease and is associated with promiscuity, perversion, and homosexuality. HIV carriers are shunned by society as social outcasts and are seen as ‘deserving’ the disease because of their ‘morally’ decadent lifestyles. According to a survey conducted in China, seventy‐five per cent of respondents said they would avoid HIV/AIDS carriers and forty‐five per cent responded that the disease was a consequence of moral degeneration (The UN Theme Group on HIV/AIDS in China 2002). The dominant narrative in China of these unknown diseases is characterised by a lack of understanding and education, and is ‘nationalistic’ in the sense that biological threats and diseases are still perceived by the majority of people to be ‘foreign’, even though germs do not respect political boundaries. It is very unlikely that health policy towards epidemics will be reconfigured overnight without a corresponding change in societal attitudes and government perceptions.

Nationalism, Legitimacy and Security

There are other factors at work that have prevented the Chinese state from addressing the AIDS issue openly and candidly. Chinese nationalism has often compelled the Chinese state to securitise any issue it perceives to be damaging to its national interests. The literature on AIDS has long highlighted that it is a significant security threat. Significantly, other than the direct impact of AIDS on the constituent population, AIDS has grave consequences for the ‘affected’ nation. AIDS heightens the prospect of wars internally and externally and hollows out military and state capacities, weakening both to the point of failure as this is a disease that targets the most economically active and demographically most reproductive segment of any nation's populace (Singer 2002). Moreover, AIDS will also have a tremendous and significant impact on the demographics of the population, as the disease has demonstrably killed off the most productive and strongest segment of the population first, rather than the infirm and weak segments. AIDS will dramatically increase health costs per capita within a relatively short period of time. It could possibly affect prospects for inward investment and long‐term economic development.

The Chinese state realises that the AIDS epidemic might well have more disastrous and far‐reaching consequences than previously thought. Yet, at the same time, the Chinese government realises that the inability to handle and contain any epidemics would have repercussions for their legitimacy to govern internally and China's reputation externally. Given China's historical experiences, China has an obsession with sovereign dignity which has been rigidly built into her strategic and political culture. China therefore has a propensity to construe issues critical to China's interests as a zero‐sum game, as the Chinese outlook is very much influenced by neo‐realist thinking. This has rendered China hypersensitive to any threats and often to frame its responses to any challenges to its well‐being by securitising these challenges. As such, China's initial reaction to the infectious diseases is most distinctly characterised by securitising the disease, as opposed to taking a biomedical and technical approach. China's incomplete turnabout on AIDS is in large part due to her reticence and inability to adjust her approach to perceive AIDS as something beyond a security issue. This is also significantly highlighted in the SARS episode.

Right from the beginning of the SARS outbreak, information about the disease was deemed to be a state secret. Divulging data regarding infectious disease outbreaks could make one a defendant in a treason case (Saich 2006: 77). Therefore, there was no reason to go public regarding a curious incident or with rumours of a new disease. Despite recent changes, China is still characterised by its obsession with the notion of security and much information remains confidential, including information about infectious diseases. The scope of classified information is wide and can be flexibly applied to anything considered related to national security (Human Rights Watch/Asia and Human Rights in China 1997: 21–25). While a 2001 regulation had amended a 1996 regulation that classified high‐level infectious diseases as highly secret with the secrecy extending from the first occurrence of the disease until the day it was announced, infectious diseases still remained national security matters.

When a report on earlier cases of SARS was produced in January 2003 in Guangdong, the report was labelled neibu or ‘top secret’, which meant that information about the situation must be kept among only the highest national officials (Human Rights Watch/Asia and Human Rights in China 1997: 25). The classification of SARS as a secret may have been motivated not only by the post‐Cold War legacy (i.e. their obsession with security), but also the leadership's desire to hide from other nations vulnerable issues which could be regarded as national threats. In order to deal with the national secret, the top officials needed to close the lid tight. An array of actions and policies demonstrated this. For example, the Ministry of Health explicitly ordered the heads of Beijing hospitals to report SARS only through channels upward on a confidential basis but not to any media. According to one Ministry of Health official, they had been told by higher levels that the outbreak was a closed matter: ‘This came from quite high up in our ministry. … We did not have that information and once we were told that the outbreak was officially closed, we could not secure cooperation’ (Greenfeld 2006: 87).

HIV/AIDS has been securitised in much the same way as SARS. AIDS activists in China have been either detained or arrested by the Chinese officials for ‘harming the State security’ or ‘revealing state secrets’ (Benjamin Kang Lim 2007). With regard to releasing official figures on AIDS patients, the government withheld information from the public while they checked political matters and prepared for immediate economic repercussions. National interests and security maintained precedence over transparency.

This sort of ‘secrecy’ with regard to national security issues is typical of post‐Communist regimes and of most countries. It also characterises what might be a first response for any country that is sensitive to the judgement of international opinion. Interviews with the Chinese scientists involved in the aftermath of SARS revealed that many of them felt that it was a great shame that the virus was not first identified by Chinese scientists, since the virus outbreak occurred primarily in China and the majority of the victims were Chinese (Ensernik 2003: 294–296).

In fact, many of the scientists were frustrated by the way information was ‘partitioned’ and the epidemic ‘securitised’. Yet, it is not only that securitisation of this epidemic that would pose a problem. A more important problem is how the PRC elites could possibly believe that there could be a response other than a bio‐medical solution to a health threat. This situation may be slowly changing as the Chinese government becomes more amenable to outside co‐operation as long as their regime and defined national interests are not compromised.

Moving beyond a Biomedical Response to a Health Threat

There seems to be an inverse correlation between China's propensity to co‐operate internationally and her desire to protect her core national interest and national aspiration i.e. reunification with Taiwan. This aspiration is intricately linked to the regime's legitimacy and political survival and if threatened would lead the Chinese government to become more hardline and nationalistic, and less willing to discuss any form of cross‐border co‐operation. The SARS episode saw the regime's legitimacy challenged by the fact that the authorities appeared to be quite inept at handling the crisis, but more importantly the SARS episode was also politicised as a reunification and a security issue.

Chinese nationalism complicated the handling of this medical crisis across the Taiwan Straits. Preventing Taiwanese independence has been a foremost Chinese national priority. In that respect, China has consistently exerted tremendous political and diplomatic pressure to prevent Taiwan from gaining membership in any international organisation. Taiwan has made seven efforts to join the WHO. China insists that Taiwan is an ‘inalienable’ part of China and should therefore not be recognised as an individual entity. When SARS cases mounted in Taiwan, the Taiwanese government asked the WHO for assistance. In response to this, Zhang Wenkang, China's Minister of Health, stated: ‘We hope that the leaders of Taiwan authority no longer spread rumours with ulterior motives, or even use the disease as an excuse and in the name of human rights to try to enter the WHO, which is only opened to sovereign nations’ (Mirsky 2003).

This symbolised China's long‐standing position towards Taiwan, which denies Taiwan's place in the international system. But it also reflected how Chinese leaders regarded sovereignty issues over other impending issues such as the immediate crisis of the epidemic. For China's leadership, the health crisis was no longer a health issue but a political one. There is no guessing how the ruling elites would choose when deciding between political survival and enhancing international co‐operation.

Conclusion

The process of globalisation significantly impacts the socio‐political context of health. Emerging infectious diseases, in particular, have triggered the political aspect of public health because the threat of the trans‐border spread of disease challenges the traditional state‐centric approach to infectious disease policy. The pathogenic threats highlight the inability of states to act alone to prevent the spread of infectious diseases amid globalisation. As a consequence, emerging infectious diseases have forced a reconceptualisation of public health governance both nationally and globally, leading to an increase in the process of global collaboration. The concept of global health governance has therefore emerged in this context, characterised by the relative decline in the salience of states alone and the increased involvement of new ways of norm setting and compliance processes. The question that this article considers is whether nations and national dignity have been virtually impacted and eventually weakened by the new health governance mechanism which is able to set and control the rules of health at a global level. It is argued that global health governance may influence the nation's response to the threats posed by emerging infectious diseases such as SARS or AIDS as a mode of building political compromises but does not considerably alter the nation's behaviour, at least for China. It is argued that in case of China, sovereign dignity and nationalism outweighed the global values in the response to infectious diseases.

The Chinese government's initial silence on SARS and AIDS, and its lack of co‐operation despite its awareness of the extent of the epidemic, demonstrated the nature of national pride inherent in China's response to national crisis. In pursuit of national prosperity through foreign investment and international trade, any discourse or narrrative on potential disasters such the SARS or AIDS epidemics would naturally be suppressed at the first instance. In addition, the Chinese leadership's obsession with issues of national security further allowed the SARS virus to spread across the world. No one could disclose information about the epidemic unless they had security clearance, because sharing information pertaining to or even acknowledging the existence of any infectious disease is regarded as a crime by revealing ‘state secrets’. If anything, the SARS and AIDS episodes have shown that the existence of epidemics cannot be contained by censorship, regulation or legislation alone.

However, once the information about the SARS outbreak was divulged, the growing epidemic was beyond the national public health capacity, and to make matters worse, other nations began to criticise China's unresponsiveness, the Chinese government had to institute ‘damage control’ measures by denying that it had any role in intentionally concealing the disease's existence. This would undoubtedly further damage China's national pride and dignity by announcing to the world that China was not able to deal with domestic public health problems. By the same token, the Chinese government therefore had to show the international community that as an emerging power, it could still address the public health crisis, this time through mobilising the nation to participate in international efforts to stem the epidemic. With the help of international health expertise, China was able to successfully curb the SARS epidemic in a very short period and with remarkable efficiency. Its successful efforts somewhat ameliorated the embarrassment it caused itself by the bungled handling of the disease outbreak, and to a certain extent restored some of its lost national pride and international reputation. In the aftermath of the incident, China's successful story of controlling SARS was a sign that China was incorporated into the global health governance where international health problems are resolved for the greater global public good.

It seems, however, that China's leadership was only prepared for limited and selective openness. In light of China's response to recent cases of avian influenza, the need to preserve an infallible national image still takes precedence over public health concerns in the minds of China's leaders (Cyranoski 2005a: 542–543; Cyranoski 2005b: 1009). Indeed, the incidents surrounding reporting of avian influenza in China clearly demonstrate how the Chinese government has hindered progress towards halting the epidemic, denied the presence of an outbreak, prevented the exchange of information on the flu virus, and allegedly promoted widespread misuse of antiviral vaccination in chickens. Scientists were often faced by less than cooperative local and central officials, whose primary concern was how health problems would negatively impact on national development goals. Therefore, China's long tradition of avoiding sensitive questions and denying negative developments has yet to change. Rather, it appears that national pride in a great China invariably contributes to the national response to emerging infectious diseases.

In an era of rapid globalisation, it remains uncertain to what extent the Chinese leadership's concern with nationalism and sovereign pride would modify itself to fit into the global governance if a more serious threat posed by a new transnational but more lethal disease than SARS emerges. Clearly, China's national pride and security would do little to further the achievement of China's incorporation into global health governance, not to mention the health of the population of an emerging world power.

Sung‐Won Yoon is a PhD candidate at the WHO collaborating Centre on Global Change and Health, London School of Hygiene and Tropical Medicine (LSHTM). Prior to coming to LSHTM, she completed her graduate studies at Seoul National University and Ewha Womans University in Korea. Sung‐Won has worked as a policy researcher for various Korean universities, think‐tanks and the Parliament of the Republic of Korea for several years, principally researching on social and health care issues. She was awarded a fully funded research fellowship by the Korean government to undertake research work at London School of Economics and Political Science before she embarked on her work at LSHTM.