I have been working on a report on AIDS in China. As I read the latest UN materials, I have to admit that even I was startled at just how awful the situation has become and how atrociously the government has dealt with it.. Equally startling are the reasons AIDS has had such an easy time spreading, basically unchallenged, throughout the country. It all goes back to the government and its obsession with “looking good.” The parallels with the current SARS crisis are abundant and rich.
Below are some of the paragraphs I’ve written over the past few days (an ideal cure for insomnia). This was a true “learning experience,” one that gave me a new and deeper understanding of this mysterious land that I am getting ready to leave….
AIDS in China
As this document is being prepared, China finds itself embroiled in controversy over the way that it has handled the outbreak of SARS (Severe Acute Respiratory Syndrome). The New York Times has written, “China’s Ministry of Health still says that there is no evidence that the disease can be acquired in Beijing. What is clear, though, is that Chinese doctors knew a lot about SARS long before it had a name or had left China’s borders, and chose not to share that information for many months.”
Unfortunately, this scenario more or less mirrors the way China has handled its AIDS crisis, the process being denial, resistance, grudging acceptance of the need to cooperate, followed by the nightmare of a full-blown health crisis that could have been lessened had the government taken action earlier.
All indicators show that China is on the brink of an unprecedented explosion of the AIDS epidemic. The latest data, prepared by UNAIDS, the Joint United Nation Program on HIV/AIDS, indicate there were well over 1 million cases of AIDS at the end of 2001 and that this number will most likely mushroom to 10 million by 2010. About 70 percent of those infected are peasants living in rural areas.
Only in the mid-1990s did China start to acknowledge the worsening crisis, and the central government has been slow to take action. Currently only a few Chinese hospitals, all in the big coastal cities and far from the vast majority of infected citizens, are equipped to treat AIDS, and the cost of treatment is far too high for average citizens to afford. These factors, combined with the unwillingness of the government at the local level to take actions such as prevention awareness, converge to increase the likelihood of a future AIDS tragedy in China.
The main cause of AIDS in China has not been sexual transmission but contaminated needles, mainly those shared by injection drug users, but also needles used in unsanitary ways during paid plasma collection. In poorer parts of China, selling blood is a common way to earn extra money, especially for drug users and commercial sex workers. Tragically, many of the blood-collecting companies are unlicensed and illegal, and their use of contaminated needles has been a major factor in spreading the disease. Furthermore, those who sell blood to these companies are often in the most high-risk groups and have already been infected with HIV. Their blood is not tested, and is mixed into the blood pool and sold. Most of this occurs in poor, remote areas of China where there is less likely to be interference from authorities.
The epidemic is worse in provinces with a higher level of commercial sex and intravenous drug abuse. It is not surprising that the most severely affected area is along China’s southwest territory, bordering “The Golden Triangle” along the Myanmar, Laos and Thai borders, a region famous for its heavy trade in heroin, methamphetamines and other illegal drugs. In the northwest province of Xinjiang there has also been a huge outbreak due to prostitution, sharing of needles for drug injection, and little to no awareness of AIDS and its prevention.
AIDS in China has been a taboo topic for years, and to a large extent it remains so today. This is key to understanding the evolution of the AIDS epidemic in China, and why confronting it is so challenging.
The Chinese culture and government tend to frown on sex education and to discourage open dialogue on controversial subjects like AIDS, which has made it difficult to raise awareness, especially in the rural parts of the country. Most Chinese citizens, especially in rural areas, are frightened to discuss sex-related topics, and have a hard time gathering the courage even to purchase condoms. Their local governing officials usually harbor the same fears.
As the current SARS crisis demonstrates, both the central and provincial governments are highly reluctant to discuss anything that might reflect poorly on the image of China, as this might have an adverse effect on tourism and/or foreign investment. Officially there is still no prostitution, no drug abuse, and no blood donation scandal in China.
While in recent years the central government has become more involved in raising awareness of AIDS and taking steps to prevent and contain it, the local and provincial governments have been slow to follow suit. Often they make the situation more difficult by refusing to acknowledge the AIDS crisis as it might reflect poorly on them. It is at the local/provincial level that most of China’s 1.2 billion citizens deal with their government, and where they turn for help.
Because of the government’s avoidance of the issue, the general public has little knowledge of AIDS and how it is affecting China. This in turn creates fear of AIDS patients, who are often fired from their jobs or banned from attending school. This contributes to a vicious circle, where the AIDS victims chooses not to seek help for fear of losing their job or facing public disgrace.
Even today AIDS has “no face” in China; it was only in 2001, at the Beijing International AIDS congress, that the first infected man was allowed to speak to a public audience. This was after the central government had implemented its “Five-year Plan of Action to Contain and Control of HIV/AIDS” with a set of specific goals for grappling with AIDS. Since that time, in 2002, there was actually a public wedding of an AIDS-infected couple, indicating a further shift toward coming to terms with the disease.
Still, the five-year plan continues to present AIDS strictly as a medical problem without considering the broader social-economic implications of the crisis. Thus, public awareness remains low. Some of the legislation has actually made the situation worse, especially at provincial and local levels. Many local governments simply do not want to know or let others know about AIDS in their respective regions, as it might make them look bad. So information is suppressed. In addition, local officials worry that an honest assessment of prostitution, illegal plasma collection and drug abuse in their region would lead to their being accused of incompetency.
Laws based on prejudice and fear exacerbate rather than curb the epidemic. Employers in Beijing, for example, are required to report “suspected AIDS patients” to local health authorities, reinforcing the notion that AIDS victims will be punished. In Hebei, all citizens with STDs are banned from entering school, getting married or working in service-related fields. Local and provincial laws are frequently in direct contradiction to national AIDS guidelines prepared by the central government’s Ministry of Health.
International experience shows that restrictive laws and punitive measures have little effect in curbing AIDS, while there is no question that they can have a negative impact on both prevention and care. In a punitive environment, vulnerable people will be more inclined to avoid preventive outreach, and people will decline getting tested for HIV for fear of punishment and/or stigmatization.
At the heart of the entire problem is awareness. When AIDS first surfaced in the US, the mantra for years was “Siilence equals death.” Sadly, that formula has proven to be totally correct when it comes to China. Keeping silent and ignoring the reality of AIDS has made the situation in China infinitely worse than it could/should have been.
Simply acknowledging the existence of these issues, let alone taking bold action on them, is challenging in a cultural environment that is inclined to minimize or ignore its problems, especially those related to traditionally “untouchable” topics like drugs, prostitution and homosexuality. Let us hope that the small steps China is only just beginning to take continue to accelerate, gathering increased momentum and determination. There is no time to waste.
Richard Burger is the author of Behind the Red Door: Sex in China, an exploration of China's sexual revolution and its clash with traditional Chinese values.