Where Will Ebola First Appear in China?

DENNIS WANG examines China’s readiness for a first case of Ebola, its impact and implications.
Last Sunday marked another first in the ongoing Ebola epidemic: the first case of transmission in the United States. Health officials assured the public that a second case was not surprising. Another upcoming first that will not be surprising: the first case of Ebola in China.
The first case
China is perhaps more connected than any other country to the continent of Africa through trade, investment, and people-to-people exchange. The country’s expatriates number about 2500 in Liberia, 1200 in Guinea, and 900 and Sierra Leone. Because of these interests abroad, China has deployed health workers to the Ebola-ridden countries of West Africa. Given the nature of Ebola transmission, however, it seems inevitable that at least one asymptomatic patient will soon enter China during the latent period – the time between infection and clinical onset as well as infectiousness.This should be a cause for concern for the world. Chinese cities are densely populated, potential breeding grounds for infectious disease. The Hong Kong International Airport is the 10th busiest in the world by passenger volume, serving 1,000 flights and 200 thousand passengers per day, and connecting directly to more than 30 countries. As their website ominously declares, “We are well connected with the world.” In 2003, SARS spread from Hong Kong to 18 other countries, infecting 8,000 people and killing 800, costing the world $50 billion in economic losses in three months. Ebola has now infected 8,000 people and killed 4,000, with no signs of stopping.From an epidemiological perspective, who will be the first case of Ebola in China, where will the first case arrive, and when will it all happen? The first case is not likely to be a repatriated Chinese expat because expats tend not to be in extended contact with those most affected. Chinese expats usually live together and typically do not care for West Africans or bury their dead, so their network is more separate from the network that represents West Africans and now the health workers caring for them. The first case could be a Chinese health worker, but from a public health perspective, the Thomas Eric Duncans of the world are a significantly greater threat than the Nancy Writebols or the Kent Brantlys. Adding to this, if a Chinese health worker or expat returns with Ebola, he or she is much more likely to seek out and have access to healthcare services. Travel numbers and transmission patterns suggest that the first Duncan, an uncontrolled case that enters the country, will likely be a citizen of a West African nation.

As a result, the first case, as well as the first transmission, will likely appear in Guangzhou, China’s “Chocolate City,” a place with anywhere from 10,000 to 100,000 West African expats (there are no official estimates), including sizable numbers of Guineans and Liberians. Models can predict when Ebola might reach China, but the truth is that it is impossible to know. It could be next week or next month, but it will likely happen.

China’s advantages
China has learned from its experiences during the SARS epidemic in 2003, with its social, economic, and political fallout, and its authoritative and centralized government can be very effective during emergency situations. Case in point: in August 2014, a city of 100,000 was successfully quarantined for a single death due to plague.

Traveling between the U.S. and China, the lessons of the SARS epidemic are hard to miss. Heat sensors at immigration, immigration officers wearing face-masks, clearly marked quarantine areas. Large screens presenting information about the signs and symptoms of Ebola were up as early as May.

It is difficult to assess the capacity of China’s clinical and laboratory infrastructure to deal with Ebola until they are stress-tested, but the Chinese government has the money and human resources to rapidly scale up crisis management measures. A decade after the Minister of Health was fired for his handling of the SARS epidemic, the Chinese public health system seems more ready, with an empowered Chinese CDC that places greater emphasis on prevention and that better coordinates with the WHO, the U.S. CDC, and internally.

Room for improvement
Ebola is not SARS; the epidemiology is different, and the context is different. To prepare for the first Ebola case, China needs to engage and prepare its marginalized domestic African population, especially in Guangzhou. Relations between Chinese officials and these populations are already strained: many West African expats enter legally, but then stay illegally. Because there is so little information about these populations, contact tracing will be hard, and many undocumented West Africans will actively seek to avoid detection. Failure to control the initial spread through contact tracing and case detection will result in a failure to prevent an epidemic.

West African expats are at no higher biological risk for contracting Ebola than Chinese, but are more susceptible to contracting the disease and to worse outcomes due to their social circumstances. Though few West African expats move between China and Africa, the same networks that put West Africans at greater risk in West Africa will also put West Africans, who by living together have extended contact with one another, at greater risk in Guangzhou. Like many immigrant populations, African populations in China tend to be poorer and less integrated in society than Chinese natives. These same networks and social determinants have resulted in African communities having some of the highest HIV prevalences in China. By being at greater risk, African populations also pose a risk to the Chinese populations. Many African expats in Guangzhou work with or are married to Chinese individuals, forming close contacts between the two networks.

The West African community is a tinderbox waiting for a spark in the form of an infected new arrival, a new Thomas Eric Duncan. An Ebola outbreak in the West African expat community would be devastating to that community and to the broader Chinese population, and an outbreak in the Chinese population would be catastrophic for the rest of the world.

China must therefore establish trust with its West African communities, most notably in Guangzhou. This could be in the form of looser or tighter visa enforcement so long as it provides for more knowledge of African communities. Ebola education and health services need to be made more accessible in these poor and marginalized populations. China needs to accept the reality that the first case may very well appear in the West African population, and that the cooperation of that community will be essential to stopping transmission before it begins.

The other option is potentially counterproductive. China is already screening, but screening will not detect asymptomatic cases, and closing off or limiting travel from affected countries will have outsized economic and political ramifications for Sino-African relations. The right course of action is to address the tinderbox, rather than to assume that fanning away the sparks will be enough. The first case is coming, and connections between China and Africa are too extensive for China to turn a blind eye to the inferno in West Africa. Targeted prevention is necessary to fight the fire when it reaches China.

Every epidemic is an opportunity not to be wasted. If China is interested in becoming a responsible global power and in improving relations with Africa, Ebola presents an imperative to engage with African populations not only on the continent, but also those living in China.

The greatest test of China’s health system since SARS may already be on its way, and the rest of the world can only hope that China will rise to the challenge.

Dennis Wang is a graduate of Yale University and will return to the Yale School of Public Health to study the epidemiology of infectious diseases. He is currently doing public health research in China on a Fulbright. Contact him atdennis.wang@yale.edu

Note: The views presented here are my own and do not represent the views of China Hands. African populations in China are diverse, like the countries they come from. It is a generalization that Africans necessarily associate more with each other than with Chinese, but based on living arrangements, epidemiological trends, and anecdotal evidence, this does appear to be the case. Though unfair, the results of preferences and actions on the part of African immigrants, the Chinese government, and Chinese nationals have encouraged this division. The same pattern is noted in immigrant populations in the US.

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