The public health system response to the 2008 Sichuan province earthquake: a literature review and interviews.

doi:10.1111/disa.12079

The public health system response to the 2008 Sichuan province earthquake: a literature review and interviews Leesa Lin, Isaac Ashkenazi, Barry C. Dorn and Elena Savoia1

This paper describes and analyses the public health system response to the deadly earthquake in Sichuan province, China, in May 2008. Drawing on an experiential learning project consisting of a literature review and field research, including a series of interviews with medical and public health professionals, policy-makers and first responders, a conceptual framework was developed to describe the response. This approach emphasises the pre-existing preparedness level of the medical and public health systems, as well as social, economic and geo-political factors that had an impact on mitigation efforts. This framework was used to conduct post-disaster analyses addressing major response issues and examining methods employed during the public health response to the disaster. This framework could be used to describe and analyse the emergency response to other disasters. Keywords: crisis, disaster, earthquake, emergency response, preparedness, public health, leadership, Sichuan, Wenchuan

Introduction On 12 May 2008, China’s Sichuan province was shaken by an earthquake with a Richter scale magnitude of 8.0. The Government of China reported that, as a consequence of this disaster, 69,227 Chinese citizens were killed, 374,643 were injured and 17,923 were missing (Zhu, 2008). The earthquake affected a very large area, with the epicentre in Wenchuan county in Sichuan province, at a depth of 19 km (12 miles). This paper presents the results of an experiential learning project consisting of a literature review and notes derived from a series of semi-structured interviews conducted with medical and public health professionals, policy-makers and first responders of the earthquake in China. Public reports and documentation from official Chinese responding agencies, the United Nations (UN), the World Health Organization (WHO) and the media were consulted before the interviews were undertaken. The study’s main objectives are to: 1) describe and analyse the public health system response to the Sichuan province earthquake; and 2) develop a conceptual framework that may be used by other researchers to describe and analyse the public health system response to other disasters. Disasters, 2014, 38(4): 753−773. © 2014 The Author(s). Disasters © Overseas Development Institute, 2014 Published by John Wiley & Sons Ltd, 9600 Garsington Road, Oxford, OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

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Leesa Lin, Isaac Ashkenazi, Barry C. Dorn and Elena Savoia

Conceptual framework development and analysis The literature review included scientific publications as well as public reports and press releases from the Chinese government, reports from international organisations and news reports from the media. As part of an experiential learning project, a Master of Science in Public Health student undertook fieldwork for this study and conducted interviews with 24 key informants in January 2009 and again in August 2009. The interviewees were selected through existing contacts with academic partners for expert consultation and asked to provide information on their agencies’ activities in responding to the earthquake. Table 1 lists the organisations represented by the interviewees. The interviews focused on the rescue efforts as well as medical and public health aspects of the response to the disaster. More specifically, the following topics were discussed: • • • • • •

government agencies’ roles during the response; coordination efforts between the local and central government; contingency planning; communications; the timeline of the response; and the population’s reactions and needs.

Table 1 Organisations represented by interviewees Organisation

Type of organisation

Number of interviewees

Beijing Emergency Response Center

Local government

1

Beijing Normal University*

Academic institution

2

Chengdu Center for Disease Control and Prevention

Local government

1

Chinese Center for Disease Control and Prevention*

Central government

4

Tsinghua University*


3

Wenchuan Center for Disease Control and Prevention

Local government

2

Wenchuan County Mayor’s Office

Local government

2

Wenchuan Health Bureau

Local government

2

Wenchuan People’s Hospital

Local hospital

2

Wenchuan Yingxiu Township Health Center

Local hospital

1

West China Hospital, Sichuan University

Local hospital

2

West China School of Public Health at Sichuan University


2

Total

24

Note: * Member of the Emergency Management Experts Committee under the State Council. Source: authors.

The public health system response to the 2008 Sichuan province earthquake: a literature review and interviews

Main themes related to medical and public health response challenges were identified based on the interviewer’s notes. These themes and the results of the literature review were combined to develop a conceptual framework, with the dual purpose of analysing the response to the Sichuan earthquake and providing suggestions to other researchers and practitioners interested in identifying and describing emergency response challenges to similar disasters. The framework includes the following four major domains: leadership, medical response, public health response and societal response. Each domain has sub-domains considered to be major issues in the overall emergency response to the earthquake. A graphical representation of the conceptual framework is shown in Figure 1; details on the response to the Sichuan earthquake for each of the domains and sub-domains described in the framework are presented below. Figure 1 Conceptual framework

Source: authors.

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Summary of findings Geography, environment and timing The earthquake occurred on a weekday at 2:28 p.m., while most people were at work or at school. As a consequence of the poor structural state of many of the school buildings, more than 5,000 children died (Branigan, 2009). The earthquake struck in rugged, mountainous terrain, 3,000 m above sea level, causing numerous environmental consequences, such as landslides, rock avalanches and debris flows. The rough terrain and the close proximity to the earthquake’s epicentre made it difficult for responders to access the inhabited rural regions of the affected area. Visibility was diminished by debris in the air, rendering access by helicopters impossible and prompting the mobilisation of response teams on foot. Moreover, aftershocks—more than 33,000 of which had been recorded by 21 October 2008—and landslides constituted significant barriers to relief efforts as they prevented rescuers from accessing the disaster-affected areas and limited their ability to evacuate survivors and victims. Large landslides had blocked many rivers and more than 30 ‘quake lakes’ had formed behind the blockages, posing a significant flood risk to millions of people living downstream. Interviewees reported that the response included major engineering efforts to reduce pressure on the new dams and to restore the water flow. Local agencies took the lead in coordinating the evacuation efforts of entire villages because of the flooding. Furthermore, in the city of Shifang, the collapse of two chemical plants caused a leak of more than 80 tons of liquid ammonia, which killed several hundred people (Hooker, 2008). In the aftermath of the earthquake, heavy storms occurred and wrecked roads, hampered efforts to reach affected areas, triggered mudslides and placed additional pressure on weakened dams. Leadership Prior to the disaster, China had developed an emergency contingency plan for earthquake disasters and conducted regular exercises and drills to test evacuation plans. From the moment the earthquake struck, China established an emergency response command body, with the premier taking the post of commander-in-chief. China has had a long history of earthquakes, with the first documented in 1177 BC (USGS, 2013). The deadliest on record occurred in Shaanxi in January 1556, with an estimate of more than 800,000 casualties. As soon as the 2008 Sichuan earthquake struck, China’s National Committee for Disaster Reduction initiated a level II emergency contingency plan, which was raised to level I eight hours later. Under level I, all government agencies are activated and the Ministry of Finance is authorised to release the national emergency fund in support of relief operations (PRC, 2006a; 2006b; Li, 2008). The delay in activating level I was attributed to the fact that the chair of the National Committee for Disaster Reduction, China’s vice president, Liangyu Hui, was abroad. In the Committee chair’s absence, the vice chair had initiated the level II disaster relief plan while trying to contact him. The Wenchuan earthquake was the first test of China’s level I emergency contingency plan since its enactment into law on 11 January 2006.

Sources: UN–China (2008); author interviews.

Figure 2 The Wenchuan earthquake response timeline


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Minutes after the earthquake, President Hu Jintao ordered an all-out effort to help the victims and communicated to the public that the disaster response would be rapid. Premier Wen Jiabao flew to the area 90 minutes after the earthquake to direct the rescue efforts. As interviewees reported, his presence on the scene had a positive impact on subsequent decisions, as the premier made such decisions with direct knowledge of the situation and an understanding of the magnitude of the disaster. Premier Wen Jiabao declared the need to engage the People’s Liberation Army, armed police and fire fighters, all under the unified guidance of the Central Military Commission, so that they might ‘strive to get into the epicentre by whatever means, land, air or sea!’ (Liu, 2008). His presence was meant to instil trust in the population, demonstrate empathy and show that the government was in close contact with those affected by the disaster. Figure 2 presents the timeline of major response events led by the government during the first ten days of the aftermath. Immediately after the earthquake, the Political Bureau of the Central Committee of the Communist Party of China activated the Earthquake Disaster Relief Headquarters of the State Council, temporary command centres consisting of nine subordinate working groups made up of government officials, military and disease control experts and chaired by Premier Wen Jiabao (see Table 2). In China, there is no national disaster management agency and disaster management policies are made and implemented at different administrative levels in a vertical manner, as led by the State Council. Interviewees reported that, in this case, the verticalised system may have led to excessive intervention of supervising agencies, which may have restricted the ability of local disaster response and relief departments to carry out their duties. A few Table 2 Earthquake Disaster Relief Headquarters of the State Council Commander-in-chief: premier (Wen Jiabao) Vice chief commanders: vice premiers (Li Keqiang and Hui Liangyu) Subordinate working groups

Lead agency

Rescue and relief

Headquarters of the general staff of the Chinese People’s Liberation Army

Public livelihood support

Ministry of Civil Affairs

Earthquake monitor

China Earthquake Administration

Epidemic control

Ministry of Health

Publicity

Publicity Department of the Central Committee of the Communist Party of China

Production restoration

Ministry of Industry and Information Technology

Infrastructure assurance and post-disaster reconstruction

National Development and Reform Commission

Water administration

Ministry of Water Resources

Social security group

Ministry of Public Security

Source: PRC State Council (2008a).


medical and public health professionals involved in local responses confirmed that the duties and responsibilities of the relevant government agencies were not always clear. The Chinese government quickly mobilised resources and trained manpower, including more than 170,000 troops, air force, armed police, paramilitary forces and rescue workers (UN–China, 2008); it deployed various measures to ensure the provision of medical and blood supplies, food, clothing, temporary shelter for the people in the disaster areas and their subsistence. The medical supply group, under the Earthquake Disaster Relief Headquarters of the State Council, was established to coordinate the logistics of the delivery, storage and distribution of food and other supplies. The interviewees reported that a ‘life necessities market’ tracking and monitoring system was initiated. Food, daily household supplies, lighting instruments and disinfecting equipment were identified as priority items and their prices were monitored under the supervision of the Chinese National Development and Reform Commission and the Ministries of Commerce and Agriculture (UNDP–China, 2009).

Communication with the public and use of the media In the aftermath, the Chinese government made unprecedented use of the media. The Chinese state and local news media provided around-the-clock live coverage and updates on death tolls, damage, search and rescue operations and the government’s overall response. The Chinese Ministry of National Defense came forward for the first time in Chinese history and provided detailed information to domestic and international audiences about the rescue operations performed by the People’s Liberation Army (PRC, 2008a; 2008b). As interviewees reported, the decision to establish a more open relationship with the media may have been based on lessons learnt from the 2003 Severe Acute Respiratory Syndrome crisis and the toxic spills in the Sanghua River in 2005. For the Chinese leaders, the disaster in Sichuan became an opportunity to humanise the country’s image abroad while struggling to recover from severe criticism of its military actions in western regions of China. Openness to the media became a stabilising factor both internally and with the outside world. International journalists, who were allowed to visit the disaster scene, issued positive reports on the response efforts in the immediate aftermath of the earthquake. In a review of news reports conducted for this study, the study team identified relevant comments provided by international leaders. The UN praised the leadership of China’s president and premier, calling the national response to the earthquake ‘decisive and swift’ (UN–China, 2008). WHO’s representative in China, Hans Troedsson, hailed China’s medical and public health emergency response for its quickness, effectiveness and organisation (WHO China, 2008), which was often attributed to the leadership and their prompt activation of military forces (Elegant, 2008). The Economist in London notes that China reacted to the disaster ‘rapidly and with uncharacteristic openness’ (Economist, 2008). Time magazine reports that the earthquake changed the world’s perception of China (Elegant, 2008). After her visit to the disaster zone in June 2008, US Secretary of State Condoleezza Rice said she

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was ‘really impressed by the recovery effort’ and ‘how the human spirit can overcome great devastation’ (Lyle, 2008; Cornwell, 2008). However, such wide coverage started to diminish a few months after the event, by which time stories on rescue efforts were of little interest and difficult political issues, such as poorly designed and constructed school buildings, were becoming major points of debate.

International relations Interviewees confirmed that, despite past diplomatic controversies, China sought disaster relief experts and rescue operation equipment from neighbouring countries. Indeed, China accepted help from at least three private relief teams in Taiwan, with whom China has long had tense relations. This cooperation was facilitated by direct communication between President Hu Jingtao of China and the honorary chairman of Taiwan’s ruling Kuomintang party, Lien Chan, aided by significantly improved relations between Taiwan and China since 2008, when the Kuomintang party had regained power (Zhang, 2008; Deng, 2008). Taiwan’s Tzu Chi Foundation was one of the first external relief forces to join rescue efforts and one of the last forces to leave (Zhou, 2008; Zhu, 2011). Yet historical sensitivities limited the scope and delivery of aid from Japan. The plan to have the Japanese Air Self-Defense Force transport aid into China caused great resentment among the Chinese population, as it would have been the first arrival of Japanese military planes in the country since the end of the Japanese invasion and occupation during World War II ( Jin, 2008). As interviewees reported, this reaction underlines the importance of taking into consideration geo-political circumstances in emergency planning, as they may have an impact on relief efforts. As has been the case elsewhere, the disaster in China challenged governments to overcome political boundaries in an effort to contain the loss of life. Eventually, a compromise was reached: commercial aircraft delivered the Japanese supplies. A few days later, access was extended to teams from the Russian Federation, Singapore, South Korea and the United States, strengthening ties among these countries. The UN and WHO also provided experts and a wide range of essential medicines, health supplies and equipment, including water purifiers and portable X-ray machines. Unfortunately, local health care and military personnel were not always adequately trained in how to use such equipment or on how to store the medication. Interviewees reported that processing and managing medication with foreign labels was especially challenging.

Rescue operations The emergency response to the Wenchuan earthquake became China’s largest noncombat airlifting operation in history. Within 14 minutes after the earthquake, the first military rescue teams were dispatched to the disaster area (Qi, 2008). Many villages could only be accessed by foot or air. As is the case in many disaster-affected areas, certain areas have only one access route connecting them with the outside


world. Interviewees confirmed that ‘isolated islands’ were formed due to failures in communication and transportation. Despite the dangers posed by aftershocks and landslides, the People’s Liberation Army headed for the hard-hit areas by road, air and water; assisted in reopening lifeline systems, such as roads and communications; provided security and order, logistics and transportation; and led the effort to channel quake lakes. Helicopters brought soldiers, engineering corps, explosives specialists and other personnel as well as heavy earthmoving tractors to the disaster area. One unit of 600 armed police officers reached Wenchuan County after marching for 21 hours—covering a distance of about 90 km—with heavy relief supplies (Liu, 2008). By 15 May, all the disaster-affected counties, including the hard-hit townships and towns, had been reached (UNDP–China, 2009).

Mass evacuation Chinese engineers were on alert for potential secondary disasters. In particular, expert consultation sessions were held on the risk of floods, a likely consequence of the breaching of quake lakes. Of the more than 15 million earthquake survivors who evacuated the area, the majority self-evacuated during the first three days, due to the risk of flooding and potential secondary disasters caused by the heavy rains. The Mianyang and Suining municipal governments alone reportedly evacuated more than 200,000 people (UNDP–China, 2009). Interviewees reported that within four days of the event, emergency workers had built hundreds of thousands of temporary houses and tents for the displaced. Medical response

Mass care Rescuers in China and Taiwan often refer to the first three days after an earthquake as the ‘golden 72 hours’, the critical window when those trapped under rubble have the best chance of survival if they are rescued and treated. The rapid restoration of lifeline systems to the heavy-hit areas, the mobilisation of medical resources and the provision of necessary care are thus critical (Schultz, Koenig and Noji, 1996). In the hardest-hit area, Mianyang, the earthquake destroyed 88% of the local health care system and caused massive casualties in a very short period of time (Lei et al., 2008). Together, Mianyang and the Aba prefecture accounted for 77% of the total number of deaths (Zhang et al., 2010). It is reasonable to assume that most rescue efforts were carried out by ‘bystanders’ who acted as first responders and helped family members, friends and strangers, saving thousands of trapped victims. In mass casualty events, such bystanders are often the first responders before rescue teams come to the scene (Ashkenazi et al., 2012). This phenomenon is common and familiar in almost every disaster (Falk and Ashkenazi, 2012). The Chinese medical response to the Wenchuan earthquake may be divided into four stages:

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• • • •

search and rescue (days 1–3); treatment of the injured (day 1–week 2); resumption of health services (weeks 3–5); and health system recovery and rebuilding (week 6 and beyond).

Search and rescue Minutes after the earthquake, the local headquarters for earthquake disaster relief operations was activated and local medical staff promptly began to set up first-aid stations for emergency medical treatment. About 71% (n=35,880) of the responding medical staff reached the frontline during the first three days (Dai et al., 2008; 2009). All the first responders interviewed in Wenchuan County Hospital and Yingxiu Township Health Center reported that, as a result of road and communication disruptions during the first hours of operations, they were cut off from the outside world. Interviewees emphasised that most of the infrastructure—including roads and transportation, telecommunications, the water supply, electricity and gas distribution—were destroyed. Since most of the equipment and medical supplies were also destroyed or buried, the shortage of medical supplies and equipment became the greatest challenge during the first 48 hours after the earthquake. Interviewees recounted their efforts to save equipment and pharmaceuticals after saving and stabilising inpatients at the time of the earthquake. In the worst-hit counties in the Mianyang area—such as Chingchuan, Lixian, Maoxian, Pingwu and Wenchuan—local health care workers were on their own for two days as they provided assistance to 28,340 wounded patients (Dai et al., 2009). These health care workers themselves were survivors who had just lost family members, colleagues and friends, and, in most cases, their own homes. Interviewees from the region reported that because the earthquake hit during the day, when people were at work or in school, family members were separated for weeks with no means of finding each other and no way to know whether loved ones were alive or dead, healthy or injured, or simply missing. Many health care workers reported to duty, but many others attended to their own family members instead. Interviewees reported that among the challenges facing clinical personnel were the shortage of medical supplies (such as oxygen, fluids and antibiotics) and equipment, limited visibility due to dust and dirt, and numerous aftershocks. Some interviewed officials reported that the use of the military to deliver medicines and medical equipment—a strategy designed to overcome logistical and security issues—turned out to be less effective than hoped because of their lack of training in handling medical supplies. Tent wards and field operating rooms were set up at the frontline (Dai et al., 2008; 2009; Shen et al., 2009). Treatment of the injured The Ministry of Health and relevant departments launched a special mechanism to mobilise 375 hospitals from 20 provinces to accept injured patients. The wounded were transferred to 14 provincial and city-level hospitals across China (Dai et al., 2009). With 4,300 beds, West China Hospital of Sichuan University is one of the


largest medical centres in China, located about 97 km (60 miles) from the epicentre. During the disaster relief efforts, the hospital served as a strategic base of operation and storage; it became the leading agency in the relief efforts, especially in the initial stage. Interviewees confirmed it had enough supplies to operate for 72 hours. Within 15 days, West China Hospital received 2,283 earthquake victims, with 1,572 (68.9%) admitted to the wards (Nie et al., 2011). Soft tissue injuries and leg, arm and pelvis fractures were the most common injuries. Crush syndrome was common among those who had been buried under rubble for days before being rescued. Interviewees reported that faculty and medical students at West China Hospital formed rescue teams while orthopaedic surgeons and emergency medicine doctors were leading the effort. China established a three-tier medical evacuation–transfer system. After receiving first-aid and emergency care in the temporary field hospitals and tent clinics, the injured were triaged and transferred to frontline and second-line hospitals for treatment, depending on the severity of their injuries(Dai et al., 2008; 2009; Shen et al., 2009). In 15 days—from 17 to 31 May— 10,015 inpatients were transferred to hospitals outside the Sichuan area (Dai et al., 2009). Resumption of health services The number of earthquake victims at the hospital peaked within the first three days and started to decrease after ten days (Nie et al., 2011). After the acute care stage, treating non-earthquake-related illnesses and meeting the needs of chronic disease patients became the main medical focus (Dai et al., 2008; 2009; Dai, Huang and Wang, 2008; Zeng, 2008). As cited in the literature and confirmed by interviewees, 40% of patients in Wenchuan county were over 60 years old, reflecting the fact that working-age people had moved to urban areas for better job opportunities in preceding years (Chan, 2008). Vulnerable populations—such as older people, women and children—were highly represented, and the need for chronic health care was great. Hospitals, including West China Hospital, sent medical teams daily to the temporary settlement areas to provide primary care services and health education (Dai, Huang and Wang, 2008). More tent stations and field hospitals were set up across Sichuan province to provide regular clinical services. Health system recovery and rebuilding In stage four, medical professionals started to reorganise the health care system in the disaster area while also running regular clinics. Because of this shift in focus, starting from 20 June, the local ‘medical rescue headquarters’ in Mianyang city and Aba prefecture were regrouped and renamed the ‘public health and disease control headquarters’ and local rehabilitation centres were re-opened to receive inpatients (Y. Huang et al., 2008; Lei et al., 2008).

Mental health As early as 13 May 2008, hospitals in the affected areas sent out first teams of experts to the resettlement sites to provide medical care and psychological assistance (Lei et

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al., 2008; Mao and He, 2008). China’s Ministry of Health mobilised 247 experts in psychological intervention and 2,000 volunteers to offer mental health and social services (Dai et al., 2009). Three months after the earthquake, more than 40% of the survivors in the heavily damaged counties still exhibited symptoms of post-traumatic stress disorder (Kun et al., 2009a; Wang et al., 2009b). Risk factors included being female, living in a temporary shelter, low socio-economic status, sustaining severe injuries, and belonging to an ethnic minority group.2 Studies show that the mental health status of survivors, patients, first responders (such as soldiers and medical staff ) and vulnerable populations was significantly affected.3 An important factor affecting the population and having a profound negative impact on mental health was the loss of a child, in particular for families that were subjected to the ‘one child policy’. Established by Chinese leader Deng Xiaoping in 1979, the policy is restricted to the ethnic Han Chinese living in urban areas and limits couples to having one child. Interviewees reported that for these couples, the experience of losing a child was equivalent to losing their family and their future.

International medical assistance Relief fund and material aid worth nearly 5 billion yuan ($785 million) poured in from more than 170 countries and regions and from more than 20 international organisations (UNDP–China, 2009). More than 270 international specialised workers from Japan, Korea, the Russian Federation, and Singapore arrived in Sichuan on 16 May to participate in rescue efforts; they were followed by more than ten other international delegations (UNDP–China, 2009). At least 11 medical teams, consisting of 304 members from Hong Kong, Macao, Taiwan, and eight other countries, stayed until 18 June to set up temporary hospitals and provide treatment for the victims ( Jiang and Dai, 2009). Interviewees reported that it was initially a challenge for local medical workers to collaborate with these groups because of differences in background, styles of practice and familiarity with equipment. Ultimately, temporary field hospitals, pharmacies, intensive care units, laboratories and operating rooms were set up and at least 24,587 patients were treated, 594 operations performed and 3,164 clinical shifts executed; in addition, more than 2,800 first responders attended several seminars and academic meetings ( Jiang and Dai, 2009). Public health response Public health professionals strived to achieve the goal of ‘no major post-disaster epidemic’, as set out by the Ministry of Health on 15 May 2008 (PRC State Council, 2008b). According to China’s Ministry of Civil Affairs (MCA), the earthquake destroyed 6.5 million homes, affecting 46.25 million people and a total area of about 500,000 km 2. As a result, 15 million people were evacuated from their homes, while 5 million became homeless and were hosted in temporary shelters.


Interviewees reported that despite heavy casualties among the personnel, a severely damaged health care system and destroyed networks, the Chinese Center for Disease Control and Prevention in Sichuan province activated emergency response contingency plans for major natural disasters within two hours of the earthquake, prepared and revised the technical guidelines for post-earthquake disease control and prevention, and deployed response teams. The Chinese public health response effort was organised in three response areas: • needs assessment and surveillance (starting week 1); • disease prevention and control (weeks 2–4); and • public health services restoration (months 2–4). China’s State Council announced the goal of restoring the basic public health services in the affected areas by the end of the year and that target was met on time (PRC State Counil, 2008c; Chen, 2008).

Needs assessment and surveillance The earthquake destroyed about 75% of Sichuan’s infectious diseases reporting network system, which consisted of 422 surveillance sites. During the first two months after the earthquake, 53% of the total cases of infectious diseases—such as encephalitis B, chicken pox and parotitis—were reported by mobile phone (Ma et al., 2009; Wu et al., 2008; Xie and Wu, 2008; Yang et al., 2009). Subsequently, public health professionals directed their attention and resources to the control of other infectious diseases, such as HIV/AIDS and tuberculosis. By the end of May 2008, people living with HIV and AIDS were able to rely on a stabilised drug supply; in major cities, the centres for disease control designated personnel to provide them with support (UNHIVETT, 2008). Furthermore, the UN formed an Emergency Task Team to monitor the supply of HIV/AIDS-related drugs, share information and address issues, and ensure that people and families living with HIV/AIDS could access services (UNHIVETT, 2008; UNICEF-China, 2008).

Disease prevention and control The main risk factors for an increased burden of communicable disease were: the interruption of access to safe water and sanitation; population displacement and overcrowding; increased exposure to disease vectors (such as the Japanese encephalitis virus-carrying mosquito); and poor access to health care services. Within ten days of the earthquake, 116,700 public health professionals had been mobilised; within two weeks, the Ministry of Health and the Sichuan provincial government published a series of vaccine administration guidelines, giving specific instructions on mass vaccination campaigns and vaccine stockpiles. In June 2008, for example, an immunisation campaign against hepatitis A and encephalitis B covered approximately 677,000 people in Sichuan province, including children, medical staff, military personnel and frontline workers (Shen et al., 2009; Wu et al., 2008). As a result, more

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than 95% of the children in the affected area were immunised against hepatitis A and encephalitis B (Zeng, 2008). By August 2008, most of the regular vaccination clinics had reopened (Jing et al., 2008; Wu et al., 2008) in addition, the ‘patriotic health campaign’ was reintroduced in the affected area to promote healthy behaviour and improve sanitation. According to the local officials interviewed, the result was a 15% decrease in the number of infections reported in Wenchuan county. Interviewees also confirmed that no disease outbreak was reported in any of the affected areas and that after the first weeks, the public health response shifted from disease control and prevention to the restoration of local medical and public health systems, the establishment of local infectious control working teams and relationship-building with partner provinces. Societal response China’s leaders repeatedly emphasised the Chinese saying, ‘When disaster struck, help came from all sides’—which characterised the entire response and recovery operations. On 22 May, in the acute phase of relief efforts, the Ministry of Civil Affairs announced a ‘One-to-One Assistance and Support System’. The State Council approved a slightly modified version of this system on 11 June to guide the threeyear period of reconstruction. The system involved ‘twinning’ the affected counties with other Chinese provinces and municipalities that could provide assistance through resources, personnel and moral support for recovery. Through this programme, Wenchuan county was paired with the wealthy Guangdong province for long-term reconstruction and assistance, including the provision of medical personnel to replace staff members who had died during the disaster and the training of Wenchuan-based staff in teaching hospitals in Guangdong (Hoyer, 2009). Charges for medical services in the disaster areas were waived until the end of 2008. Furthermore, Chinese leaders took immediate and necessary measures to ensure the safety and well-being of children who had lost their parents in the earthquake. Right after the disaster, the MCA made an announcement that the child welfare institutes would provide shelter to the thousands of children orphaned by the earthquake. After media coverage of the plight of children prompted more than 20,000 families to express interest in adoption, the MCA and local government made absolutely clear that no adoption would take place until order had been restored, family members traced and children confirmed to be orphans. Eventually, 634 children were confirmed orphaned in the earthquake; the majority of them (78%) were placed with extended family members under guardianship or kinship arrangements (UNICEF– China, 2010). The MCA enhanced the quality of care provided by untrained adoptive or foster families by working with the United Nations Children’s Fund (UNICEF) to develop training manuals, guidelines and standards, and workshops for the new caregivers. Together, the MCA and UNICEF developed a tracking system to monitor the wellbeing of orphaned children, analyse their situation, improve family- and community-


based safety and protection services, conduct research and provide recommendations to the government in the aftermath of the emergency. The Wenchuan earthquake prompted an unexpected mass mobilisation outside official channels. Shortly after the earthquake, millions of people from all over the country offered help with rescue and relief efforts. Since the disaster received unusually dramatic coverage in the state-run news media, and given the active and ever-growing Chinese online community, the public response grew exponentially in a matter of days. The year 2008 was soon referred to as ‘the first year of the era of Chinese volunteers’ (UNDP–China, 2009). As highlighted in the literature, the earthquake had a significant effect on members of China’s younger urban generation and others who had previously shown little interest in the plight of people living in the countryside (Yardley and Barboza, 2008). Volunteers played an unprecedented role in the medical response. The Chinese Center for Disease Control and Prevention partnered with local hospitals, such as West China Hospital and the People’s Hospital of Deyang city, to set up a management system for thousands of volunteers, who arrived at the hospital scene hours after the quake. As interviewees reported, volunteers assisted in post-earthquake evacuation of patients, emergency reception, ward care, on-call service, epidemic prevention and control, psychological intervention, telecommunications, the facilitation of tracking and reunions of family members and other major tasks. The Wenchuan earthquake inspired an unprecedented outpouring of individual donations to charity. According to the MCA, as of 13 May 2009, China had received cash and in-kind donations worth 76.71 billion yuan ($12 billion) from within the country and abroad (Huo, 2009). The disaster also led to a change in attitude towards charitable giving in China’s corporations. Attention was drawn to corporate philanthropy, which was a new concept among China’s corporations and public leaders (Makinen, 2009). As interviewees confirmed, the active Chinese online community blacklisted those who gave too little, which led to public apologies and gifts of hundreds of millions of yuan from some CEOs to ease public anger.

Discussion Disasters and their aftermath have significant potential to affect the political environment and society of a nation. The 2008 earthquake in Sichuan is no exception. Images of Premier Wen Jiabao on the disaster scene within two hours of the event, in close contact with the population and open to communicating with national and international media, marked a significant change in the political history of China. The leadership sought to have a positive impact on disaster management operations and international affairs. The Chinese news authorities impressed both the domestic and overseas audience by showing openness and responsiveness to information flow in the media, including the online community. For the first time, Chinese authorities recognised the

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Internet as mainstream media, a laurel previously granted only to state news agencies. Chinese leaders acknowledged that in the aftermath of a disaster, despite the difficulty of managing ‘rumour control’, open information could be a stabilising factor for internal and external relationships. The response of the Chinese government to this and previous disasters had been characterised by a heavily centralised command structure and military engagement, which allowed logistical challenges to be overcome. However, the absence of a national disaster management agency may have contributed to the lack of coordination across governmental agencies from the State Council down to the cities and townships, as well as a lack of multi-sector relationships. Although China has experienced countless disasters over the centuries, government officials at the local level, health care professionals and the general population acknowledged the lack of a clear central–local coordination mechanism and related education for emergency preparedness and response in the context of the earthquake in 2008. This may be the side effect of an over-centralised emergency response system and of an excessive focus on national rather than local response, and on reconstruction efforts rather than community resilience. In the aftermath of the disaster response, Chinese experts concluded that current emergency plans were inadequate and relevant governmental departments unclear about their own functions and responsibilities. They also found that even though relevant departments acquired large amounts of information from the frontline, the information acquisition and analysis was not as timely as needed. Another lesson learnt was the need for a designated management agency to supervise, examine and distribute donations. Donated drugs and equipment did not always meet the local needs or were inappropriately used or handled because of a lack of training. Interviewees reported that a large proportion of the donated products were not properly labelled with manufacturing information (such as the place and date of manufacture) and that some were expired or spoiled. Interviewed public health officials pointed out that medication with foreign labels needed to be translated before reaching people in need; as a result, deliveries were delayed and additional manpower was required at a critical time. In view of these concerns, officials argued that cash donations to the proper agencies would be more effective in helping victims than the donation of goods. The Sichuan earthquake also had a tremendous impact on society and Chinese people as individuals. Since the 1949 revolution, all charitable volunteer work had been organised by the government and had to be under the leadership and control of the state party. Yet the 2008 earthquake ushered in a new phase in volunteer work. For the first time in modern Chinese history, individuals decided to go to a disaster area, donate money and volunteer their time, often while resisting the orders of political leaders. For emergency management personnel, this development introduced the need to control crowds of untrained volunteers. As in many other disasters, the lack of coordination of non-governmental organisations also turned out to be problematic.


Conclusion One of the lessons learnt from the response to the Sichuan earthquake was that the presence of the premier at the scene of the disaster a few minutes after the earthquake had a positive impact on building general trust in the government and ensuring a deployment of resources proportional to the magnitude of the event. Furthermore, the government’s openness to the media helped to establish and reinforce relationships with foreign governments and international organisations that contributed to the response efforts. The need to establish a management agency to supervise, examine and distribute donated drugs was also recognised as an important part of the response and recovery process. A centralised response and military involvement was necessary to overcome logistical barriers; however, centralisation in the response may have led to uncertainty in the role of local administrations, difficulties in the flow of information and an overall lack of community resilience.

Acknowledgements The authors acknowledge Yuanli Liu, the director of the Harvard School of Public Health China Initiative, for his instrumental support during the fieldwork, as well as Stacey Hoyo, Alberto Montrond, and John Mazza for their editing and comments. The authors also thank the staff and students of the Department of Global Health and Population (2008–09) at the Harvard School of Public Health for providing and contributing to the experiential learning opportunity to make this manuscript possible. Leesa Lin also thanks the Michael von Clemm Traveling Fellowship Fund for providing part of the financial support for the field research.

Correspondence Leesa Lin, Division of Policy Translation and Leadership Development, Harvard School of Public Health, 677 Huntington Avenue, Landmark Center, 3rd Floor East, Boston, MA 02115, United States. Telephone: +1 617 632 6142; e-mail: [email protected].

Endnotes 1

Leesa Lin is a Project Manager in the Division of Policy Translation and Leadership Development, Harvard School of Public Health, Boston, United States, and was a student in the Department of Global Health and Population, Harvard School of Public Health at the time of the experiential learning activity; Isaac Ashkenazi is an Adjunct Professor at Leon Recanati School for Community Health Professions, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel, and Adjunct Professor at the Rollins School of Public Health–Emory University, Atlanta, United States; Barry C. Dorn is Associate Director of the National Preparedness Leadership Initiative, Harvard School of Public Health and Kennedy School of Government, Cambridge, Massachusetts,

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United States; and Elena Savoia is a Scientist in the Department of Biostatistics and Deputy Director of the Preparedness and Emergency Response Learning Center in the Division of Policy Translation and Leadership Development, Harvard School of Public Health, Boston, United States. Leesa Lin conducted the field study and literature review, analysed and interpreted the data, helped design the conceptual framework and drafted the manuscript. Isaac Ashkenazi helped review the manuscript and provided comments. Barry Dorn helped review the manuscript and provided comments. Elena Savoia developed the conceptual framework for data analysis, helped analyse and interpret the data and revised and reviewed all drafts of the manuscript. All authors agree with the manuscript results and conclusions. All authors read and approved the final manuscript. The authors declare that they have no competing interests. 2 See Guo et al. (2008); Kun et al. (2009a; 2009b; 2010); B. Wang et al. (2010); L. Wang et al. (2009a; 2009b); and Xu and Song (2010). 3 See W.W. Huang et al. (2008); Jia et al. (2010); Li et al. (2009); Liu, Ma and Dong (2009); Liu et al. (2011); Ning et al. (2008); and L. Wang et al. (2010).

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