Influenza is caused by a virus and can be very dangerous. Each year it infects 30 million to 60 million, killing 36,000 people, most of them elderly. The flu pandemic of 1918-19 killed at least 20 million people.

The flu spreads easily through tiny droplets that are exhaled by carriers and picked up by others through inhalation or touching surfaces that have come in contact with the flu virus. The virus has the ability to jump from species to species and mutates very quickly so that no one ever is completely immune.

The reason that we are able to easily fend off most influenzas is that our bodies have seen most flu viruses before or at least viruses similar enough to them that our immune system can muster an appropriate response. Deadly influenzas are the ones that are different enough from the others that the immune system has difficulty providing protection. Many of these are caused by viruses that have made a recent leap from another species to humans.

The word “influenza” comes from the Italian word for “influence” or visitation.” Flu vaccines are made of viruses grown in fertilized chicken eggs.

Websites and Resources

Good Websites and Sources on Disease in China: The Chinese Center for Disease Control and Prevention ; Center for Disease Control on China CDC World Health Organization on China ; Wikipedia article on Public Health in China Wikipedia ; Rare Diseases in China , Lancet Article ; Burden of Disease in China pdf file ; AIDS-HIV: Article on AIDS in China ; WHO China Office Report on AIDS ; China AIDS Info China AIDS Medica Project ; SARS : CDC Paper on Origin of Sars ; SARS Map ; SARS Book Stanford University ; Influenza and A/H1N1 Flu: Flu in China ; Paper on Flu and Ducks ; Paper on effects of Flu Pandemic in China ; Bird Flu: Avian Influenza Info ; WHO Avian Influenza Reports ; Flu in China ; Bird Flu Center; CDC on Bird Flu

Good Websites and Sources on Health in China: Center for Disease Control on China CDC World Health Organization on China ; Wikipedia article on Public Health in China Wikipedia ; Short UNICEF Article on Health Issues in China ; On Health Care in China: Health Care in China, an IBM pdf file ; Pape on Chinese Helat Care from the 1990s ; Library of Congress Country Studies Paper on Chinese Health Insurance ; Ex-Pat Report ; China Health Care Blog Asia Health Care Blog


Influenza Biology

Most flus have two proteins, hemagglututinin (H) and nuramnidase (M) on their outer shells that act like hooks and allow them to invade other cells. Together H and N provide the virus’s chemical appearance and identity to the immune system.

There are number of different strains of virus. Some don’t event cause sickness. There are 15 forms of H and N proteins in the most populous class of flu viruses---influenza A (less common and less dangerous influenza B has only one type of H and N). When a virus with a new H-N combinations appears immunity to old forms of the H-N viruses don’t work.

All flus are believed to have orignated with ducks or waterfowl. Many carry the virus without getting sick. Strains among wild ducks spread through feces shed in the water but don’t affect the ducks because they have a resistance to the disease. Infected birds migrate and bring the disease to new places. If they had been dead or seriously ill they couldn’t spread it. When the disease comes in contact chickens who have no resistance they became very sick.

Influenza in China

Most strains of influenza from the past and virtually all new strains of the disease originated in China. By one estimate 80 percent of the influenzas that appeared in the last couple of decades originated in southern China, particularly in Guangdong, where there are millions if ducks, chicken, pigs and other animals believed to be the source of many of the flu-causing germs. [Source: Tim Appenzeller, National Geographic, October 2005]

Genetic analysis by teams who published their work in the magazine Nature and Science indicates that flu viruses evolve freshly somewhere in East or Southeast Asia every year and fan out from there around the globe, for nine months or so, and then die out.

Influenza and Animals

Many influenzas are thought to have evolved in places where farmers keep ducks, chickens and pigs together. Pigs and ducks, common on Chinese farms, carry flu viruses, and perhaps they are where the new strains first get cooked up. In southern China, where many of the world's newest influenzas originate. a typical two-room brick house is occupied by a family on the top floor and animals on the bottom floor. Viruses grow well in hot climates and are active in live animal markets, where viruses can spread from animal to animal

Unlike most viruses which only infect a couple of species, flu viruses can strike a variety of animals including humans, horses, pigs, seals and many species of birds. When animals of different species are intermixing as they do in China it creates a situation in which viruses are being exposed to many kinds of different genetic material, making it possible for new strains to evolve.

Ducks and shorebirds carry flu viruses that are not harmful to them but can kill chickens and sometimes people. Southern China lies along a major fly route for water fowl migrating to and from Siberia. New flu viruses are thought to arrive in the area with waterfowls and are transferred to poultry in the area.

Pigs can carry flu viruses found in both humans and ducks. Scientists believe that many new flu strains evolve first in birds who pass the viruses on to domestic ducks. The viruses are then picked up by pigs and passed on to humans. Some think pigs act as a “mixing vessels,” taking on bird viruses from ducks and flu virus from farmers, allowing the flu viruses to “reassort,” creating a new potentially-lethal hybrid.

Early History of the Flu

In 412 B.C., Hippocrates described an outbreak a disease that was probably influenza in the city of Perinthus. It was the first recorded incident of the flu. The disease is believed to have originated with ducks, which were first domesticated around 2500 B.C.

There have been several pandemic of influenza, caused by strains of flu in which humans had little immunity. The first recorded pandemic was an outbreak that occurred n 1580 in Europe and parts of Asia and Africa. In 1889, an unknown influenza subtype, called the Russian flu, began in Central Asia and spread to Europe and parts of Asia and Africa.

The great pandemic of 1918 that killed between 15 million and 50 million people was caused by H1N1, a new flu strain that was identified in 1930 and later called swine flu. The flu was called the Spanish flu because the king of Spain got it not because it originated there. The disease was very deadly. It killed five percent of the people who caught it, some in two or three days. Some people woke up healthy, developed a severe headache and joint pain and were dead by bedtime.

In many cases victims died after the virus multiplied rapidly in the lungs and provoked an immune system response that devastated the lung’s dedicate tissues and caused them to fill with bloody fluid, turning victims a sickly purple color and causing them to suffocate to death from the fluid in their lungs.

It is not clear where the H1N1 virus originated. The outbreak reached pandemic levels in Europe and thrived in conditions created by World War I, where sick and wounded men were packed together. Many victims were young adults who normally shrug off the flu. By the time it had run is course it had spread across the globe. Except for a few Pacific islanders everyone on Earth was exposed to the disease and half got sick.

Later History of the Flu

The H2N2 strain that appeared in 1957 in southern China triggered a pandemic of “Asian flu” that killed 70,000 people in the United States alone, and around 1 million worldwide. It was created by a bird flu and human flu that swapped genes, probably after infecting a pig.

The Hong Kong flu in 1968 was caused by H3N2. It killed about 750,000 people worldwide. Again, it was caused when bird and human influenzas swapped genes, probably after infecting a pig. The strain was similar enough to the 1957 strain that people had some immunity reducing the number of deaths.

In 1977, H1N1 appeared again. By that time nearly everyone under 20 had never been exposed it and it caused a mini-pandemic. In 1976 a strain of swine flu appeared in New Jersey and 40 million Americans got vaccinations. In 2003 there was an outbreak of the highly pathogenic H7N7 strain of bird flu in Germany and the Netherlands

H-N viruses are plentiful in other species, particularly birds. They can cause great damage in poultry industry and sometimes---as is the case with H5N1-make the species leap from birds to humans. The creation of potent flu viruses is especially dangerous in today’s world, where people and birds are crossing borders and can easily spread disease.

A/H1N1 Flu in China

The first domestic case in China of the A/H1N1 flu---erroneously known as swine flu---was in Guangzhou in May 2009. The 24-year-old woman who tested positive for the disease is believed to have contacted it from a Chinese-American man who came to her photo studio not long after arriving on China from New York, Other cases has been reported before that but they all had contacted the disease overseas. The first reported case of the disease was a 30-year-old student just back from the United States were he caught it. Immediately after he was discovered 349 people who had come in contact with him were quarantined.

The first death in China from the A/H1N1 flu was in Tibet in October 2009. The second and third were in Qinghai and Xinjiang, A woman from coast Zhejiang Province who initially was said have died from it, it turned out, was electrocuted in a hospital shower. After being informed of the her death, 50 relatives of the dead woman stormed the hospital and threw rocks.

As of December 2009, 648 deaths has been reported. By then the disease was spreading into rural areas and there were concerns about a major outbreak during lunar New Year. One survey found that half of Chinese didn’t want to get a A/N1H1 vaccine over concerns about its safety.

H1N1 flu seemed to peak in China in late 2009, with 5,000 new three days in mid November pushing the total to more than 59,000. As of late November 2010, only 53 deaths had been attributed to H1N1 flu.

Zhong Nashan, a respected doctor involved with uncovering the extent of the SARS epidemic, told the Southern Metropolis that he believed the N1H1 death figures were too good to be true and guessed local governments were under-reporting or concealing case and many H1N1 deaths had been misdiagnosed as something else. Beijing vowed to punish anyone involved in covering up H1N1 deaths.

In November 2009, it was reported that two dogs in Beijing and four pigs in Heleongjiang Province had come down with the H1N1 flu. The animals are believed to have contacted the disease from humans.

Chinese Plan Against H1N1 Flu

China also began administering a vaccine for swine flu in early September, the first country to do so. Foreign officials said China demonstrated an unusual openness to sharing information about H1N1 with its citizens and other governments, in contrast to its secretive approach to the near pandemic of severe acute respiratory syndrome, or SARS, a few years ago. [Source: Edward Wong, New York Times, November 11, 2009]

Chinese and Western officials say Chinese leaders put in place a comprehensive plan for a pandemic outbreak after the disastrous experience of SARS. This includes, at least in the first stages, some of the stringent quarantine measures of the SARS era, but also emphasizes educating the population about the disease: A red banner hanging from the balcony of a rural school building here in Guangdong Province says: H1N1 flu is preventable, controllable and curable, and not terrifying. [Ibid]

The government was so anxious to stay ahead of H1N1 that officials decided in June to start developing a vaccine even though testing kits for measuring the dosage of the agent in the experimental vaccines had not arrived from the W.H.O., said Zhao Kai, a virologist who advises the government. It was an unusual step, but on September 5 China became the first country to declare that it had discovered a vaccine, and by late October it had produced nearly 53 million doses. [Ibid]

China’s Tough Measure Against H1N1 Flu

As of August, 56 million people had been screened for flulike symptoms at China’s borders, said Feng Zijian, director of the emergency office of the Chinese Center for Disease Control and Prevention. Feng said he did not know the number of travelers who had been quarantined. The United States Embassy in Beijing said that 2,046 American citizens had been quarantined by the end of October, with 215 of those testing positive for H1N1. [Source: Edward Wong, New York Times, November 11, 2009]

Local authorities canceled school classes at the slightest hint of the disease and ordered students and teachers to stay home.

Quarantines of entire school groups from overseas ignited outrage in the home countries and led some American officials to complain to the Chinese government. The State Department implicitly criticized the Chinese policies by issuing travel warnings on the quarantine procedures. [Ibid]

One of the most extreme cases took place in July, when a group of 65 students and seven chaperons from St. Mary’s School in Oregon was quarantined twice, once in Beijing and once in Henan Province. The first time came after a girl pulled aside at the airport tested positive for H1N1. Then in Henan, a boy running a high fever also tested positive, leading to a second quarantine session. During that time, a dozen students tested positive for H1N1. Most of the students and chaperons flew back to the United States on July 31, having spent 12 of 17 days of their trip in quarantine. [Ibid]

China was virtually alone in taking such harsh measures. At the time, it seemed extreme, and it seemed restrictive, because I had never experienced an infectious disease outbreak, said Scott Dewing, director of technology at the Oregon school and one of the trip chaperons. [Ibid]

A/H1N1 Flu Quarantines in China

The disease entered China despite severe Communist-Party countermeasures to keep it out, namely the quarantining of people---including foreigners---who displayed symptoms---even slight temperatures or runny noses--- or who came in contact with people that had symptoms of the disease. In Beijing, most of 650 people quarantined in April and May 2009 were identified at the city’s airport where passengers with fevers were identified using a thermal forehead scanner. China acted so aggressively in part to avoid a repeat of what happened during the SARS crisis in 2003.

Dozens of U.S., high school students were quarantined in Yichang on the Yangtze River after several students came down with the disease. An Australian lacrosse team spent five days in isolation after one player tested positive after arriving in the country. An American whose temperature was 98.9 degrees F, a mere 0.3 degrees above normal, was taken off a plane, placed in an ambulance and rushed to a quarantine facility where forced to spend three days separated from his family in small single room, enduring checks by doctors in biohazard suits and meals pushed through a small hole in a door even though he didn’t have the flu. He told the Washington Post, “It’s really weird to interact with people who are completely covered, It’s strange not to see anybody’s face. Being there so long, I was freaking out a little. What if I do have swine flu---Am I ever going to see my wife, my family, my friends again. That was the worst.”

About 150 Mexicans were put under strict quarantine even though most showed no symptoms and had not come in contact with anyone with the disease. In some cases they had not been to Mexico for months and seem to have been quarantined simply because they were Mexicans. The Mexican government chartered a plane to repatriated 136 Mexican nationals who has been held incommunicado. One of them told AP, “There were soldiers who won’t let us past the gate. This is like a kidnaping for us.”

Mexico is the country where the disease originated and more than 50 people died. China banned direct flights from Mexico and stopped imports of Mexican pork and sent a plane to Mexico to pick up Chinese tourists stranded by the flight ban. Mexico accused China of discrimination and called the confinement measures “unacceptable” and “without foundation” and advised its citizens not to travel to China.

China’s Tough Measure Against H1N1 Flu Appear Effective

Chinese and foreign health officials insisted their strict measures helped slow the spread of the disease in the world’s most populous country. China did a much better job than India in combatting the disease, . Like China, India has more than a billion people, many living in poor, rural conditions, and was exposed to the virus after it had been diagnosed in the West. The Indian Health Ministry has reported 505 deaths as mid November 2009. The United States, where the virus was spreading even before it was diagnosed in the spring, has reported more than two million cases and about 4,000 deaths in a population of 300 million. [Source: Edward Wong, New York Times, November 11, 2009]

“I think there were a variety of measures put in place by different countries, and it’s difficult to say what worked best and what didn’t, but China’s has worked very well, I think,” said Michael O’Leary, the director of the Beijing office of the World Health Organization. [Ibid]

If these strict measures had not been taken, and if there had been a sudden outbreak of the disease, there would have been a huge panic among the Chinese population, Feng said. Although there were many criticisms from outside, people should understand China’s considerations. [Ibid]

But Feng and Dr. O’Leary also say that the social and financial costs of China’s tough measures will have to be evaluated to see whether they were worth the benefits. And it is unclear how decisive those actions were in slowing the transmission of H1N1---the summer heat in much of China was likely a critical factor in slowing the spread, and most schools were out of session at the time. [Ibid]

Image Sources: Landsberger Posters, Environmental News

Text Sources: New York Times, Washington Post, Los Angeles Times, Times of London, National Geographic, The New Yorker, Time, Newsweek, Reuters, AP, Lonely Planet Guides, Compton’s Encyclopedia and various books and other publications.

Page Top

© 2008 Jeffrey Hays

Last updated July 2011

This site contains copyrighted material the use of which has not always been authorized by the copyright owner. Such material is made available in an effort to advance understanding of country or topic discussed in the article. This constitutes 'fair use' of any such copyrighted material as provided for in section 107 of the US Copyright Law. In accordance with Title 17 U.S.C. Section 107, the material on this site is distributed without profit. If you wish to use copyrighted material from this site for purposes of your own that go beyond 'fair use', you must obtain permission from the copyright owner. If you are the copyright owner and would like this content removed from, please contact me.