Infectious Change
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Infectious Change

Reinventing Chinese Public Health After an Epidemic

Katherine Mason

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Infectious Change

Reinventing Chinese Public Health After an Epidemic

Katherine Mason

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About This Book

In February 2003, a Chinese physician crossed the border between mainland China and Hong Kong, spreading Severe Acute Respiratory Syndrome (SARS)—a novel flu-like virus—to over a dozen international hotel guests. SARS went on to kill about 800 people and sicken 8, 000 worldwide. By the time it disappeared in July 2003 the Chinese public health system, once famous for its grassroots, low-technology approach, was transformed into a globally-oriented, research-based, scientific endeavor.

In Infectious Change, Katherine A. Mason investigates local Chinese public health institutions in Southeastern China, examining how the outbreak of SARS re-imagined public health as a professionalized, biomedicalized, and technological machine—one that frequently failed to serve the Chinese people. Mason grapples with how public health in China was reinvented into a prestigious profession in which global recognition took precedent over service to vulnerable local communities. This book lays bare the common elements of a global pandemic that too often get overlooked, all of which are being thrown into sharp relief during the present COVID-19 outbreak: blame of "exotic" customs from the country of origin and the poor bearing the most severe consequences. Mason's argument resonates profoundly with our current crisis, making the case that we can only consider ourselves truly prepared for the next crisis once public health policies, and social welfare more generally, are made more inclusive.

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Year
2016
ISBN
9780804798952
Chapter One
City of Immigrants
Like millions of others from all over China, public health professionals migrated to Tianmai throughout the 1980s, 1990s, and 2000s to pursue what residents called, in a purposefully American fashion, the “Tianmai dream” (tianmai mengxiang). Predating by several years the broader “China dream” (zhongguo meng) later popularized by current Chinese president Xi Jinping, the “Tianmai dream” was for my interlocutors a natural outgrowth of Tianmai’s identity as a “city of immigrants”—a moniker that implied freedom, possibility, and openness. Many of those whom I met in Tianmai told me that they came to the city because they saw it as a beacon that would free them from the small, stifling world of guanxi obligations, family ties, and dead-end jobs that they felt awaited them in their hometowns. Several also told me that they came because Tianmai was less “paiwai” (excluding of outsiders) than other big Chinese cities with similar opportunities, such as Guangzhou, Shanghai, and Beijing. My non-Cantonese informants in particular found this diverse enclave in the middle of Cantonese-dominated Guangdong province to be a breath of fresh air in a context in which they otherwise felt excluded linguistically and culturally. Yet after settling into their new homes and new jobs, most of the public health professionals I knew then went on to exclude the majority of their fellow migrants from this Tianmai dream.
In this chapter I argue that in their attempts to serve a civilized immigrant common emblematic of the Tianmai dream—as well as to protect their own preferred identities as privileged members of this common—Tianmai’s public health professionals built and maintained precarious spatial, legal, historical, biological, moral, and professional boundaries between themselves and the 12 million strong floating population (liudong renkou) of rural-to-urban migrant workers that dominated the city. In building these boundaries, they established the majority of the residents of Tianmai as a population that had to be governed—but one that would not and could not be a part of a common to be served.1
The floating population and the civilized immigrant common reflected two sides of my interlocutors’ “divided selves” (Kleinman et al. 2011). On one side was their past as members of poor peasant or worker families who toiled and suffered under a backward Maoist regime: the “population.” On the other side was their future, as educated, cosmopolitan immigrants, living in a modern city that was uniquely free of the ghosts of a Maoist past: the “common.” In this way, the migration of poor, rural people into the pristine modern city of Tianmai reflected a lingering fear on the part of that city’s public health professionals that the side of their divided selves that they had left behind in the countryside would threaten the side that they had come to Tianmai to embrace.
The Floating Population
As of 2010, of Tianmai’s estimated 16 million residents, 60 to 80 percent were categorized as floating—a term that describes the continuous movement of rural migrant workers from job to job and from the countryside to the city and back again.2 According to C. Cindy Fan (2008), as of 2006, official estimates of China’s floating population totaled about 150 million people nationwide. Informal estimates that my informants gave me in 2014 put the number somewhere closer to 250 million and growing. Rural villagers fled the Chinese countryside in the 1990s and 2000s, drawn to the cities by factory jobs and a chance to take part in the economic reforms that followed Mao’s death. Legal residency requirements, however, prevented most of them from settling down permanently. As holders of rural household registrations (hukou), rural migrants living in cities continued to be tethered to their hometowns.
The central Chinese government established the hukou system of household registration in the 1950s as a means of monitoring and controlling population mobility between the countryside and the cities. All citizens were assigned at birth either rural or urban hukou status and generally were eligible for only the welfare and social services provided in their hometowns. This meant that a large majority of Chinese people was systematically excluded from many of the benefits associated with urban citizenship, including health care (Chan and Zhang 1999; Solinger 1999).
Governments at the central and local levels relaxed hukou restrictions with the start of the reforms in the early 1980s and continued to modify the law to be more permissive in the decades that followed. Nevertheless, in the late 2000s urban hukous remained difficult to obtain—especially in the big cities and especially if one was not highly educated—and many rural residents who migrated to the cities remained excluded from the cities’ benefits. Those who migrated to Tianmai without a hukou could apply for temporary or permanent “residence cards” that would qualify them for some of the benefits of urban registration, but migrants could get these only after going through extensive paperwork, meeting strict eligibility requirements, enduring long waiting periods, and often paying high fees.3 In addition, as Li Zhang (2001) has described, many migrants feared that they would be found out by birth control authorities and fined for violating the one-child policy if they attempted to register. As a result, despite official assertions that the residency system accounted for all migrants, much of the floating population remained unaccounted for. Although they made up the backbone of Tianmai’s economy and the majority of its population, a large proportion of migrants were officially not there.4 And even where recent legal reforms began guaranteeing certain basic benefits for the migrants, laws were rarely enforced. For example, the state began granting certain limited legal rights to pensions (in 2006), health insurance (in 2008), and unemployment insurance (in 2013) to rural-to-urban migrants in the 2000s, but access and utilization remained quite limited (Mou et al. 2009; Lam and Johnston 2012; Magnier 2014).
One of the many implications of the hukou system was that Tianmai’s public health professionals did not have to concern themselves as much as they otherwise might have with the mundane health concerns of its residents and in particular with the rising rates of chronic illness that were weighing down other health systems in urban China (He et al. 2005; Yang et al. 2008). Dr. Mi, a virologist, explained it to me this way: “Tianmai is a particular case because we depend on the wailai renkou [the outside population], but we don’t take responsibility for their security. So if they get sick or old, or if they can’t compete, they go home, and a new group of young people replaces them. So some people say that Tianmai exploits these young people. Actually, it is that way! Everyone gets old, but our burden for taking care of people who can’t work anymore is small.” As Pun Ngai (2005) has described, the transience of migrant labor was what the local Chinese state depended on, for in this way the state could extract labor from a population without having to take responsibility for the long-term well-being of the people who made up that population.
Though most major cities in China have significant floating populations, few are dominated by this population in quite the way Tianmai is. Shanghai and Beijing have large populations of migrants now, but they also are ancient cities with entrenched dominant local cultures. As Dorothy Solinger (1999) points out, Chinese internal migrants differ fundamentally from transnational migrants elsewhere in that “in this case the ‘strangers’ who were despised were China’s own people” (4). Migrants in most Chinese cities, however, at least can still be categorized as out-of-place intruders, who by virtue of speaking a different dialect, eating a different cuisine, and having a different history, do not belong. Tianmai is different. Built just thirty-five years ago on land previously inhabited by only 30,000 people, there are very few people living in Tianmai today who are not migrants.
Tianmai thus has great ambivalence toward migration. Many of the TM CDC members I knew, like the migrants who made up the floating population, originally came from the countryside. But in informal conversations and interviews, public health professionals differentiated between “immigrants” (yimin), white-collar workers like themselves who had settled in Tianmai permanently and enjoyed legal and moral personhood, and migrants, sometimes referred to as “peasant workers” (nongmingong), or just peasants (nongmin), but usually simply grouped together as the “floating population” (liudong renkou). In calling Tianmai a “city of immigrants,” my interlocutors compared it to the United States in a way that implied a forward-thinking, modern, creative society that attracted the best and brightest and offered freedoms not found elsewhere in China. The members of the floating population, being the wrong kinds of migrants, were not part of this immigrant dream.5
“Immigrants” made up the civilized immigrant common to be served. The “floating population,” on the other hand, made up the backward migrant population to be governed. The use of the term population (renkou) in describing the floating migrants was important. As we saw in the Introduction, renkou in China is a statistical entity representative of a collective biology that needs to be tamed; it is the classic Foucauldian biopolitical object (Greenhalgh and Winckler 2005). For Tianmai’s public health professionals, renkou, and especially liudong renkou, like the “masses” of Mao’s time, functioned only as an undifferentiated aggregate. Public health professionals highlighted the undifferentiated nature of the floating population by speaking often of its high level of internal interchangeability. My informants told me that it was usually useless to try to reach this population with health messages that might benefit it, for example, because if one person was reached that person would soon be replaced by another—leaving the population as a whole unchanged and maddeningly incapable of internalizing healthy change. Dr. Mi explained, “If you go there and try to educate them, say about HIV, then a few days later they all switch . . . and you have to start over.” Mi’s effort to serve the floating population ran up against the constraints of a mobile existence. He told me that many of his colleagues reasoned that urban public health professionals should not even make the kinds of outreach attempts that Mi did, both because they would inevitably fail and also because when members of the floating population got sick or their health deteriorated in old age they would—and should—just “go home” (huijia) to their rural villages.
The assumption that rural migrants would eventually just “go home” bolstered the case for my interlocutors that the floating population could not become part of a civilized immigrant common. Another assumption that bolstered this case was the association that public health professionals made between migrants’ mobility and their assumed filth. To migrate is to breach boundaries; thus all migrants are, in Mary Douglas’s (2002) sense at least, unclean. Indeed the trope of migrants as dirty has stubbornly persisted over time and in a wide range of local contexts (Markel 1997; Shah 2001; Molina 2006; Horton and Barker 2009). But while Tianmai’s public health professionals cleansed themselves of the countryside by building new lives as urban citizens, on arriving in the city the floating population failed to do the same, instead constantly recrossing boundaries from city to countryside and job to job. In continually rebreaching the boundaries between rural and urban, these new migrants made it impossible to “rid [themselves] of the contamination of their ‘feudal’ past” (Anagnost 1997, 11). Dr. Ying, a parasitologist at one of the district CDCs told me in an interview:
The countryside in China is very dirty, very chaotic, very inferior [cha]. This is true in some parts of Tianmai too—have you been to the chaotic parts of Tianmai? . . . [These places] are even more serious [than the countryside]. Why? Because where people live, it’s not their own home, they are renting, they don’t plan to stay for a long time, so they don’t care about keeping it clean, they figure they will be leaving soon, so why bother? So it is filthy.
Dr. Ying, who himself grew up in a fishing village in rural eastern Guangdong, saw the peasants who littered his pristine modern city as an unwelcome reminder of his own rural past and a contaminating presence in the new life he had tried to build for himself.
Especially after the arrival of SARS, the floating population’s supposed filth also became indicative of the risk of contagious disease spread. TM CDC members blamed the floating population for Tianmai’s failure to eliminate certain diseases that they associated with backwardness, such as measles; for exposing the common to certain endemic diseases, such as hepatitis; and for threatening to incubate new diseases, such as H1N1 influenza. One informant noted, for example, that even after multiple vaccination campaigns, as of 2009 Tianmai had the highest measles rates in Guangdong province. With each attempt at citywide eradication, he complained to me, came a new wave of immune-deficient migrants from the countryside, who, he said, crowded into factories and tenement housing and spread the disease like wildfire.
In a kind of inversion of Adriana Petryna’s notion of biological citizenship, the migrants’ inferior biology thus established them as threats to the city that needed to be controlled, rather than as citizens of the city who needed to be helped. For Petryna (2002), biological citizenship in post-Chernobyl Ukraine was a means of gaining access to social services, whereby “the damaged biology of a population has become the grounds for social membership and the basis of staking citizenship claims” (5). In post-SARS Tianmai, the situation was just the opposite: The supposedly inferior biology of the floating population became grounds for a lack of social membership and for a denial, rather than a granting, of citizenship claims.
This is not a new story: In many ways, the biological noncitizenship of Tianmai’s migrant population mirrors a situation common to immigrants throughout history, whereby allegations of poor hygiene and disease among immigrant groups often served as an excuse for exclusion and persecution and as a powerful mechanism for turning persons into biological threats (Markel 1997; Shah 2001; Briggs and Mantini-Briggs 2003; Molina 2006). The contemporary Tianmai case was peculiar in at least two respects, however: The group doing the excluding was itself made up almost entirely of migrants, often hailing from the same regions as those they were excluding, and the group being excluded was, on the surface, quite similar to the group that played an essential role in eliminating disease in China in the past.
Before their transformation into a “population” and their migration to the cities, rural peasants made up the bulk of the qunzhong (“masses”)—that undifferentiated group of Communist foot soldiers that fueled Chairman Mao’s public health campaigns. Although the masses were blamed for the spread of infectious disease even during Mao’s time, they also served as the solution to their own problem. Their large numbers and ideological commitment meant that they could be made to participate in mass sanitation work and mass vaccinations (see Introduction). The floating population of today, however, posed a problem without offering a solution. Mao’s methods could never be repeated in the present day, my informants told me: It would simply be too hard to locate people who were always in motion, and those people could not be counted on to comply with public health measures.
The inability to control the floating population created considerable anxiety for those charged with preventing another SARS-like event. Huang Qing, an epidemiologist who worked on infectious disease surveillance, told me in an interview during the 2009 H1N1 influenza outbreak:
The floating population really terrifies me. [The migrants] are a really special problem here—everyone is terrified of them! (xia si ren!) Because there is no way to keep track of them, no one has any idea where they are, and if there is really a pandemic, then we’re in big trouble! Their wenhua [cultural level] is low; a lot are from the countryside, they don’t understand basic biological facts, and they don’t have any responsibility, no sense of that at all, and so if we come looking for them to check up if we think they have flu, they’ll just think, “You’re trying to do what?” and they’ll run away to some other place and go find work there. And then we’ll have no idea where they are—we can’t keep track—we find this very scary! There is no way to maintain social stability in that situation.
Huang’s comments suggest that the potential social instability associated with the floating population was at least as frightening as—and inseparable from—their potential contagiousness. As Ann Anagnost (1997) argues, “Although [the migrants’] cheap labor fuels the explosive expansion of the reform economy, their very presence raises...

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