China’s h2h

It is good to see China acknowledging the possibility of human-to-human transmission of bird flu. Today’s announcement was made by the ministry of health in a Webcast briefing.

The outbreak in question occurred last month in Nanjing and involved a 24-year-old man and the man’s father, who developed fever a day after his son died. Transmission seems to have stopped with the father who survived.

I have long thought that China has tried hard to do better outbreak communication in the wake of their disastrous performance during SARS. Slowly, as with any large bureaucracy, those changes are seeping into practices of the vast Ministry of Health.

While the announcement is a welcome move, I would have encouraged China to make this announcement much earlier. The son died on December 2, 2007. So today’s acknowledgment comes a full month after the fact.

Very likely, the Chinese wanted to wait until they knew that the outbreak was over, that no other cases were found, and that the molecular analysis was completed (as it appears to be) showing no worrying mutations*. In other words, that there was no continuing risk. But in an urgent public health setting, which this could have been if more people were infected, rapid disclosure of information would have been essential.

So why the delay? My experience is that it is a typical response. All technical agencies, not just in China's MOH alone, have a culture of precision which abhors uncertainty. In a situation like this outbreak, the technical people might have vigorously argue for delay until more could be known with confidence. And those responsible for making communication decisions often hide behind this technical justification since they are reluctant to deliver bad news at all. As with most outbreak communication practices, the easy way out can cause more problems.

There are ways of talking about developing and even unreliable information. In fact, early in any outbreak, poor information is about all there is available. The public can usually live with uncertainty much better than with silence. As one of my bosses used to say: You don't wait until you know what set your home ablaze before you call the fire department. Moreover, providing information as develops demonstrates trust-building transparency and helps educate the public along the way.

So, today's announcement was a step toward rebuilding the world's trust in China. Those who made this decision should be congratulated. But this delayed reporting still leaves unanswered the question of when China would have announced if the situation was more worrisome. As the China is learning, once trust is lost, it is not easily restored.

[*Mutations seem to have become a barometer of concern. Indeed, molecular analysis will help clarify the viruses potential. But wouldn't a better indicator be the epidemiology? One sick nurse, who had treated an H5N1 patient, may raise WHO's blood pressure long before sequencing is complete.]