Stanford, CA, Stanford University Press, 2016, 252 pp.
Review by Justine Rochot
The 2003 SARS (Severe Acute Respiratory Syndrome) epidemic marked a turning point in recent Chinese history. In the years that followed the epidemic, a number of texts were published that analysed the effects of the event on Chinese society, contributing to the growing body of work on the anthropology of health in China.
In her first book, published 13 years after the epidemic, Katherine Mason, an anthropologist at Brown University, casts a fresh eye over the evolution of local public health policies in China. Infectious Change is the product of 13 months of ethnographic research, conducted between 2008 and 2010 at a Centre for Disease Control and Prevention (CDC, or jibing yufang kongzhi zhongxin) in a city in Guangdong, as well as among public health actors in China and further afield. The city where the research was carried out has been given the pseudonym of “Tianmai,” but the description of a large, cosmopolitan city developed during the early reform period and sharing a border with Hong Kong leaves little doubt as to its true identity.
The author’s goal is to show the impact that SARS may have had on the way in which Chinese public health policies are put into practice today. She explains “how the first global health crisis of the twenty-first century transformed a Chinese public health apparatus – once famous for its grassroots, low-technology approach to improving health – into a professionalized, biomedicalized, and globalized technological machine that frequently failed to serve the Chinese people” (p. 3). In her view, the professionalisation of public health since the early 2000s has led to a side-lining of health’s ethical issues, and to the governance of “dangerous” fringe elements of the population, in the name of an idealised world of modernity and science, or what she terms the common. In addition, Chinese health policies are seen to have turned “toward the protection of global, rather than local, interests and toward the protection of a cosmopolitan middle-class dream rather than toward the betterment of the poor” (p. 3), leading to a process of bifurcation between the common that they are supposed to serve and the populations they are supposed to govern.
The structure of the book reflects the pluralist hierarchies that shape Chinese public health practices: each chapter shifts in scale from the local toward the global, presenting an aspect of the hierarchies that are being established among the members of the CDC in question, with the populations they hope to govern, or with the institutions for health and international research with whom they collaborate.
The introductory chapter contextualises the research within the evolution of Chinese public health policy, from the great Mao-era health campaigns at a local level, via the opening-up of the economy, to the institutional consequences of SARS. While the 1980s saw a massive reduction of state investment in health, and a resurgence of infectious and chronic diseases, the author also highlights the way in which, during the 1990s, the Chinese state copied the American model and transformed local Mao-era Anti-Epidemic Stations (fangyizhan) into CDCs. This reform took place following the first outbreak of avian flu in Hong Kong in 1997, but it was SARS that really allowed the CDCs to take a central role, and to benefit from the significant funding and political support that were again mobilised following the 2008 Sichuan earthquake and the 2009 epidemic of swine flu (H1N1). In fact, the CDCs embody the emergence of a new variety of actors and views on public health in China, based on the management of groups (qunti) and crowds (renqun) rather than individuals.
The first chapter, “City of Immigrants,” examines the image that the CDC employees in Tianmai have of the individuals they help on a regular basis. The author explains that “in their attempts to serve a civilized immigrant common emblematic of the Tianmai dream (…), Tianmai public health professionals built and maintained precarious (…) boundaries between themselves and the 12 million-strong floating population” (p. 38). In their eyes, the migrant population is dirty and backward, and its terrifying mobility and lack of education is probably the reason for the increased propagation of disease: in this sense, the migrant population – far from being portrayed as a beneficiary of the state’s public health policies in the name of social justice – is considered a threatening group that has to sacrifice itself in the name of the “common good” of the urban middle classes.
The second chapter, “Relationships, Trust, and Truths,” covers the ways in which CDC employees work together and collaborate with different institutions. The author highlights a strong tension between two opposing conceptions of work within the CDC. On one side, the older members of the Centre respond to orders from their superiors by using guanxi and banquets to achieve “satisfactory” results, and are less concerned with scientific precision than they are with meeting the necessary targets and ensuring stable, trusting relationships. On the other side, the younger employees who arrived during the time of SARS are often better educated, and may have trained abroad. They insist on the need to move beyond guanxi in order to act in the name of modern science and abstract professional ethics, and in doing so pave the way for the creation of data that corresponds to biomedical truth.
The “Scientific Imaginaries” chapter offers a detailed examination of the statements of principle made by the young CDC employees and their concrete scientific practices, now that research is becoming increasingly central to the work of the CDCs. Using an approach similar to that of Bruno Latour, which seeks to understand the materiality of scientific production, in this chapter the author provides valuable accounts of the ways in which the CDC’s young researchers collect their data. We learn, for example, how some of them manage to fill out questionnaires without obtaining the subjects’ consent; this method helps them sidestep the issue of refusal, which in their eyes guarantees the “scientificity” of the results. Packed with examples of big data harvesting in the name of the common good (gongyi), the chapter reminds us that the use of such ethically questionable practices to attain “scientific truth” is not unique to China: not only do these researchers see themselves as working in accordance with internationally standardised methods for producing truth, but their international partners also often turn a blind eye to the ways in which their Chinese colleagues gather their data. This case therefore attests neither to an anomaly of Chinese research nor to an attempt to mimic Western science: on the contrary, “the story of public health research in Tianmai [also] offers a window (…) into the deeply conflicted ethics of the international scientific common as a whole” (p. 112).
The position of Chinese health policies in an international context is examined in the final chapter, “Pandemic Betrayals,” which returns specifically to the treatment of H1N1 in 2009 and the various tensions that were brought to light by the epidemic. The author shows how H1N1 was first seen by the CDC operators as an opportunity to set up “what they thought would be a globally laudable, professional response to H1N1 that would prove their worthiness both as members of the civilized, modern world – a ‘global common’ – as well as members of the world of public health officials devoted to controlling border-crossing diseases – a ‘global health common’” (p. 145). But in the wake of the CDC’s initial enthusiasm when faced with such a noble task, there followed a series of disappointments. The well-structured system of quarantine and movement control (especially for foreigners), of which the CDC members were so proud, was condemned as a breach of human rights, and China was accused of xenophobia. Betrayed by the global common they had hoped to join, the CDC members retorted that their authoritarian behaviour was entirely rational. Similarly, suspicions of withholding information (since no one dared take responsibility for declaring the first case of flu in Tianmai) meant that overall, for the members of the Centre, H1N1 seemed to “degenerate into a crudely political game” (p. 172) between the leaders and the international community, thus destroying the employees’ ideal of scientific professionalism.
In her conclusion, the author reminds us that the issues tackled in this book are every bit as crucial in other cultural and national contexts. Reflecting on the ways that a local public health policy might genuinely serve the individuals it represents, she cites the example of the only CDC programme that is actually founded on a meaningful relationship: the Department of HIV/AIDS Prevention and Control. She shows how practices of guanxi and engendering human feelings (renqing) have helped to create an authentic community that transcends the opposition between professionals and the group that is governed. In this regard, the quality of the descriptions provided in the extracts from field journals and the emphasis Katherine Mason places on the meanings that individuals give to their actions and choice of words provide a valuable model for the construction of an ethics of public health; one that goes beyond the distant governance of abstract populations. Moreover, as well as adding to the existing knowledge of contemporary China, this book makes a stimulating contribution to the anthropologies of science, health, and public policy.
Translated by David Buchanan.
Justine Rochot is a PhD candidate in sociology at the Research Center on Modern and Contemporary China (CECMC), EHESS, Paris (email@example.com).
 Arthur Kleinman and James L. Watson (eds), SARS in China: Prelude to Pandemic?, Stanford, CA, Stanford University Press, 2006; see also Deborah Davis and Helen F. Siu (eds), SARS: Reception and Interpretation in Three Chinese Cities, London, Routledge, 2007.