III. Monitoring Compliance With Human Rights

III(h) PUBLIC HEALTH

Rural Poverty and Public Health | Infectious Disease and Public Health | HIV/AIDS | State Control of Information Relating to Health

FINDINGS

• The two greatest public health challenges facing China today are infectious diseases and rural poverty. The central government is taking steps to improve the public health infrastructure in rural areas, but China's poorest citizens lack preventive healthcare, and weak implementation of laws that provide for free vaccinations leave many adults and children unprotected.
• Central government efforts to address China's HIV/AIDS epidemic continue to expand and deepen, but local governments often harass Chinese activists who work on HIV/AIDS issues.
• Government controls inhibit the flow of health-related information to the public, potentially affecting public health in China as well as international disease monitoring and response efforts.

Rural Poverty and Public Health

The central government is taking steps to address public health issues associated with a crumbling rural health infrastructure and rural poverty. During the 1980s, the government abolished its previous rural healthcare system, which was based on village clinics staffed by "barefoot doctors" and financed by cooperative insurance. Central government authorities, however, did not establish a substitute system to replace the old healthcare regime. As a result, most Chinese farmers could not afford the high cost of treatment.¹ By 2002, the central government was encouraging the formation of rural healthcare cooperatives,² which receive local government subsidies and cover the medical expenses of any farmer who can pay a modest annual premium.³ The central government established 12 rural medical cooperatives in Liaoning province in early 2005,⁴ and provincial governments announced similar programs at the same time in other areas of China,⁵ including pilot programs in five cities and counties in Sichuan province. By April, about 1.04 million farmers in Sichuan had received reimbursement for medical expenses.⁶ The success of this program has stimulated local government efforts to build township medical centers that would provide a higher level of healthcare after citizens exhaust the resources available from local medical cooperatives.⁷

While these efforts at reconstructing the rural healthcare system are promising, senior Chinese officials have acknowledged that serious challenges remain. Critical evaluations of China's healthcare system began to cascade into the public view beginning in late July 2005, when Ge Yanfeng, a senior State Council researcher, questioned the fairness and efficiency of the medical and health system.⁸ The poorest residents in rural areas frequently do not enroll in the cooperatives because they cannot afford the required fee. For participants, the cooperative plan covers only between 30 and 40 percent of hospitalization costs,⁹ leaving many farming families in debt after serious illness. As many as 50 percent of farmers who fall ill do not seek healthcare for economic reasons, according to a number of reports,¹⁰ and half of all children who die in rural areas have not received medical treatment.¹¹ Malnourishment among rural children also remains a serious problem. As many as 29.3 percent of children in China's poorest areas may be malnourished, according to one news account.¹²

Infectious Disease and Public Health

Among the results of underinvestment in healthcare has been the persistence of diseases that require a coordinated and long-term investment of funds and organization to control. One such disease, tuberculosis (TB), is one of China's worst health problems, with 4.5 million patients with active TB, 1.45 million newly diagnosed cases, and 130,000 deaths each year.¹³ Some provinces have registered sharply rising rates of TB, with the incidence in Zhejiang province, for example, rising 30 percent in 2004 compared to 2003.¹⁴ A few provinces have responded by instituting "directly observed treatment methods" to fight the development of drug-resistant disease when patients fail to pursue a full course of treatment.¹⁵

Naturally occurring infectious diseases are a serious threat in China, according to senior Chinese healthcare experts.¹⁶ Despite strong reported immunization statistics and the 2005 regulation on state-funded immunizations,¹⁷ the child vaccination program as implemented has not been effective, since several outbreaks of preventable diseases occurred in 2005.¹⁸ The Ministry of Health (MOH) reported a sharp rise in both cases and deaths from measles in the first quarter of 2005.¹⁹ The Ministry concluded that the outbreak resulted from the government's failure to address the health problems of the migrant population and failure to vaccinate with effective vaccines.²⁰ Anhui statistics for the first quarter of 2005 showed that one of the top five diseases causing death was infant tetanus; routine postnatal and pediatric vaccination can prevent this disease.²¹

China continues to have a high rate of Hepatitis B infection, with one-third of the world's total reported 385 million chronic Hepatitis B carriers. Notwithstanding these figures, only 70 percent of the population has been vaccinated for the disease, according to a Chinese expert.²² At the same time, the Chinese government has made progress since 2004 on eliminating discrimination against Hepatitis B carriers in government employment.²³ The new Law on the Prevention and Control of Infectious Diseases also prohibits discrimination against carriers of infectious diseases.²⁴

HIV/AIDS

The central government has become more active on HIV/AIDS issues during the past year.²⁵ In June 2005, Premier Wen Jiabao chaired a State Council meeting on anti-AIDS work that reinforced earlier decisions promising free antivirals to HIV carriers, free anonymous testing, free medicine for pregnant women, free schooling for the orphans of AIDS victims, and help for families afflicted with AIDS.²⁶ Premier Wen also reiterated the need to "protect the legitimate rights and interests of HIV carriers and oppose discrimination against them," as well as to educate them about their responsibility to prevent further spread of the disease.²⁷ Since late 2003, the Central Party School in Beijing, which provides leadership training for senior Communist Party cadres, has offered a course on responding to HIV/AIDS. In September 2004, the State Council HIV/AIDS Prevention Work Committee issued guidelines making AIDS education mandatory for secondary and university students in 2005.²⁸

Several provinces and localities undertook new programs in 2005 to address HIV/AIDS-related public health problems. Hubei province began a program in May 2005 to prevent accidental occupational exposure to HIV.²⁹ Programs to educate mid-career officials about HIV/AIDS are growing after the Central Party School held similar seminars for future Party leaders.³⁰ Yunnan province joined with two prestigious universities to train senior provincial officials about drug control and AIDS prevention,³¹ and Jiangxi province launched an education campaign in May 2005 on AIDS and venereal disease prevention.³² The Guangzhou city education department released a regulation in January 2005 that promised free education for all children affected by HIV, and guaranteed such children confidentiality and protection against discrimination.³³ The central government has also taken steps to support these local and provincial efforts. The MOH, for example, began a program to disseminate AIDS prevention information to high-risk groups such as intravenous drug users, homosexuals, and prostitutes.³⁴ In addition, in August 2004 the MOH and the National Development and Reform Commission invested 230 million yuan in 1,004 mobile hospitals to reach victims of HIV and other diseases in remote parts of China.³⁵

Some local anti-AIDS initiatives, however, still show an official tendency to address the problem by using coercive measures.³⁶ In Yunnan province, new rules require mandatory annual HIV tests for people working in the entertainment industry.³⁷ The head of the provincial health department said that such testing in 2004 had led to the detection of 13,000 HIV positive individuals, but the China coordinator for the UN anti-AIDS program warned that mandatory testing can lead to discrimination against those infected.³⁸

Local government harassment of Chinese NGOs dealing with HIV/AIDS has undermined efforts to combat the disease. A U.S. NGO report described the violent closure of a privately-run orphanage for children with AIDS in Henan province, and also reported other incidents in which Henan officials and police detained, beat, or otherwise obstructed Chinese activists working on HIV issues.³⁹ Another U.S. group reports that local authorities in Henan province have organized militias to prevent journalists and NGO observers from visiting AIDS victims.⁴⁰ Li Xiang, the Director of the Mangrove Support Group, notes that cumbersome government regulations complicate the work of Chinese NGOs working on AIDS.⁴¹

State Control of Information Relating to Health

The State Secrets Law and related regulations⁴² hinder the free flow of information on public health matters both within China and to the outside world. Some government agencies have worked to improve the internal flow of information from local governments to the center. In Jiangxi province, for example, authorities built a system for county, town, and township medical entities to make direct online reports to higher authorities about health issues.⁴³ Delayed and inaccurate reporting by provincial authorities continues, however, reflecting an official tendency to cover up health problems and the outbreak of disease. Many local officials fear that such news will discourage investment and affect local economic growth, which remains the most important factor in the annual performance evaluations of officials.⁴⁴

Government control over the flow of information has hampered an international effort to combat the spread of a new strain of avian flu virus. In May, the Ministry of Agriculture confirmed the first evidence of deaths of migratory birds in Qinghai province, apparently from an avian flu virus, more than two weeks after the initial deaths. In June, a U.S. newspaper reported that Chinese officials were encouraging farmers to protect their flocks by using amantadine, an antiviral drug meant only for use in humans.⁴⁵ Foreign scientists criticized the Chinese government, saying that such use of antivirals leads to resistant strains of the disease.⁴⁶ A spokesman for the Ministry of Agriculture denied encouraging the misuse of amantadine,⁴⁷ but he also announced that the Ministry would send out inspection teams to check on the possibility that it had been misused.⁴⁸ The most recent assessments of dead birds in Qinghai and Xinjiang reveal that the strains that killed the birds are not yet resistant to the amantadine.⁴⁹

In July 2005, the WHO and other international health organizations complained that Chinese authorities had not shared key details about three outbreaks of avian flu in western China. The information sought by these international bodies included virus samples, genetic analysis, and information about the extent of the outbreaks and Chinese government efforts to contain them.⁵⁰

Notes to Section III(h)—Public Health

1 Cao Haidong and Fu Jianfeng, "20 Years of Health Care Reform in China" [Zhongguo yigai 20 nian], Southern Daily (Online), 5 August 05; 19562 "Chinese Red Cross Sets Up Charity Fund To Help Rural Poor With Medical Bills," China Daily (Online), 11 August 05; Ofra Anson and Shifang Sun, Health Care in Rural China (Ashgate, Aldershot, Hants, 2005), 15–17.

2 "Cooperative Medicare System Helps Prevent Farmers Becoming Poorer," China's Human Rights (Online), 7 January 04.

3 See, e.g., "Nearly 2 Million Farmers in Heilongjiang Benefit From New Rural Cooperative Medical Scheme," Heilongjiang Daily, 15 April 05 (FBIS, 16 April 05).

4 Yu Tian and Jin Rongsheng, "New Rural Cooperative Medical Scheme Warmly Received by Farmers in Liaoning's Youyan Autonomous County," Liaoning Daily, 18 April 05 (FBIS, 14 May 05).

5 A pilot program of rural medical cooperatives instituted in Qinghai in 2004 was expanded in 2005, and the number of rural citizens covered rose from 2 to 3 million. In Qinghai, the effort to establish basic-level health care through these cooperatives was led by the Provincial Leading Group for Rural Health Work. "Qinghai Province Plans to Expand Coverage of New Rural Cooperative Medical Scheme by End of 2005," Qinghai Daily, 16 April 05 (FBIS, 14 May 05). On May 20, 2005, the governor and Party of Hainan announced a project to expand the rural coop scheme to all residents by 2010, as well as to build a few high-standard general and special hospitals on the island. "Hainan Governor Wei Liucheng Chairs Meeting on Construction of Township, Town Medical Centers," Hainan Daily, 21 May 05 (FBIS, 30 May 05).

6 "With the Help of Rural Medical Coops, Farmers in Jiangjin, Chongqing Speed Towards Prosperity" [Nongcun hezuo yiliao bangzhu Chongqing Jiangjin nongmin ben qianmian xiaokang], Chongqing City Statistics Bureau Web site, 3 June 05.

7 "Farmers in Sichuan Province Speak Highly of New Rural Medical Cooperative System," Sichuan Daily, 22 April 05 (FBIS, 14 May 05); see also "China to Promote Rural Cooperative Medical System," Xinhua (Online), 10 August 05.

8 "Expert Says China's Medical Reform 'Basically Not Successful,' " Xinhua (Online), 29 July 05; Josephine Ma, "Think-tank Lashes the Mainland's Health Care," South China Morning Post (Online), 30 July 05; "Health Ministry Says Rural Medical System Still Facing Several Major Problems," China Daily (Online), 4 July 05; "A Half-Baked Reform Leaves Patients Unsatisfied, Hospitals Unsatisfied, Government Unsatisfied" [Huanzhe, yiyuan, zhengfu wuren manyi; yigai zhaishengfan; yuan zi liang dian mixin], Xinhua (Online), 4 August 05; "State Must Lead Medical Reforms," China Daily (Online), 4 August 05 (citing Yanzhao Metropolis Daily); "Gao Qiang, Minister of Health, Urges More Investment in Health Care" [Wesiheng buzhang Gao Qiang: Zhengfu ying jiada yiliao touru], Number One Economic Daily (Online), 5 August 05; Wang Zhenghua, "Hospitals Overcharge Patients for Profits," China Daily (Online), 5 August 05; "PRC Health Ministry Report Details 'Serious Problems' Facing Sector," Agence France-Presse (Online), 5 August 05; "Gaps Within Troubled China's Health Sector," Xinhua (Online), 8 August 05; "Heated Disputes Over Privatization: Rethinking China's Healthcare Reform" [Jibian "shichanghua" Zhongguo yigai fanse yu chulu], 21st Century Economic Journal, 8 August 05;"Health Reform Plan to be Launched By End of the Year" [Yigai xin fang'an huo niandi qidong], Beijing News (Online), 8 August 05; "China Premier Under Fire Over Rising Medical Costs, "Reuters (Online), 11 August 05; "Half of all Children Who Die of Illness in the Countryside Had Not Received Medical Treatment" [Wo guo yin bing siwang de nongcun ertong reng you yibanwei dedao yiliao], People's Daily (Online), 17 August 05; "What are the Root Problems of Healthcare Reform? " [Yigai de sixue zai nar?], Southern Weekend (Online), 18 August 05; "China's Health Care System is Sick: Patients' Complaints Mount up, Many Turn to Violence" [Zhongguo yiliao xitong bingle; huanzhe tousu jizeng; shiyong baolizhe zhong], Asia Times (Online), 18 August 05; "Fujian Suicide Bombing: A Wake-up Call for Health-care Reform? " South China Morning Post (Online), 18 August 05; Zhang Feng, "Rural Kids 'Need Better Healthcare,' "China Daily (Online), 18 August 05; "China's Exorbitant Healthcare Fees Spark Suicides," Reuters (Online), 18 August 05. See also David Blumenthal and William Hsiao, "Privatization and its Discontents—The Evolving Chinese Health Care System," 353 New England Journal of Medicine 1165 (15 September 05).

9 "Health Ministry Says Rural Medical System Still Facing Several Major Problems," China Daily.

10 "Half of All Farmers Do Not Seek Care for Illness" [Zhongguo nongmin yiban kanbuqi bing], Beijing News (Online), 6 November 04; "Half of All Children Who Die of Illness in the Countryside Had Not Received Medical Treatment," People's Daily.

11 "Half of All Children Who Die of Illness in the Countryside Had Not Received Medical Treatment," People's Daily.

12 "China's Children Severely Malnourished," China Youth Daily (Online), 7 July 05.

13 "China Ranks Second in World in Terms of TB Patients; Nearly 10,000 People in Guangxi Die of Tuberculosis Every Year," Wen Wei Po, 24 Mar 05 (FBIS, 27 March 05).

14 "Zhejiang's TB Incidence Noticeably Rises," Zhejiang Daily, 24 Mar 05 (FBIS, 27 March 05).

15 "Jiangxi To Fulfill Tuberculosis Control Task in 2005," Jiangxi Daily, 25 March 05 (FBIS,27 March 05).

16 "Experts Say Infectious Diseases Biggest Biological Threat to Modern China," China Daily (Online), 6 April 05.

17 UNICEF, "At a Glance—China," available on the UNICEF Web site. The report indicates that over 90 percent of all one-year-olds were fully immunized against TB, DPT3, and polio and 84 percent were fully immunized against measles in 2003. On March 16, 2005, the State Council issued the Regulation on the Management of the Circulation of Vaccines and Preventive Inoculations [Yimiao liutong he yufang guanli tiaoli], issued 24 March 05, providing for free provision to citizens of the vaccines specified under the State Immunization Plan.

18 "China's Immunization Scheme Makes Progress Amid Problems," Xinhua (Online), 8 June 05.

19 A total of 30,017 measles cases resulting in 20 deaths were reported in the first quarter nationwide. The number of cases and mortality rate are significantly higher than those reported for the same period in 2004. Most victims are pre-school age children. "Infectious Disease Data, 1st Quarter, 2005," Ministry of Health, 4 April 05 (FBIS, 1 June 05).

20 Ibid.; see also "Migrant Workers Get Vaccines," China Daily (Online), 25 December 03. This article reports on the administration of free vaccinations to migrant workers in Beijing. It cites Li Guoying, an official with the Municipal Disease Control and Prevention Centre, as saying that most of the 800,000 rural migrants in Beijing at the time had never been vaccinated before due to weak rural health care.

21 "Anhui Province Issues Report on Epidemic Situation in First Quarter of 2005," Anhui Daily, 21 April 05 (FBIS, 14 May 05). 13618.

22 "Experts Urge Government To Improve Vaccination Program Against Hepatitis B," China Daily (Online), 18 July 05.

23 "PRC Public Opinion Defeats Hepatitis B Virus Discrimination," China Net (Online), 23 September 04.

24 PRC Law on the Prevention and Control of Infectious Diseases, enacted 29 February 89, amended 28 August 04. See also CECC, 2004 Annual Report, 61. China's first hepatitis B health discrimination case was filed by Zhang Xianzhu in 2003 when his application to work for the city of Wuhu in Anhui province was rejected because of the illness. Although the court in that case held for Zhang, it did not invalidate the underlying regulation that prohibited the hiring of hepatitis carriers. The amended national law should prevent such discrimination in the future.

25 "China Pushes for AIDS Legislation," China News Agency, 3 July 05 (FBIS, 5 July 05) 19889; Jasper Becker, "AIDS in Asia: China Becomes Proactive," San Francisco Chronicle (Online), 9 February 04.

26 "PRC State Council Sets Steps for Fighting AIDS at Meeting With Wen Jiabao Presiding," Xinhua (Online), 15 June 05. See also UNICEF—China, "For Every Child: Progress Report for UNICEF-China, 2003/2004" (2005), 5.

27 "PRC State Council Sets Steps for Fighting AIDS at Meeting With Wen Jiabao Presiding," Xinhua (Online), 15 June 05. The same meeting added "it is necessary to strengthen the building of the legal system for the prevention and control of AIDS and standardize and give guidance to the prevention and control of AIDS according to law and in an orderly manner."

28 "AIDS Prevention Classes Included in University," Agence France-Presse (Online), 10 September 04; but see "Students Find Sex Education Inadequate," China Daily (Online), 26 July 04; Bao Xinyan, "Jiangsu Intensifies AIDS Prevention," China Daily (Online), 2 August 04.

29 "Hubei Province Issues Preemptive Plan for Prevention and Control of Occupational Exposure to AIDS Virus," Hebei Daily, 18 May 05 (FBIS, 30 May 05).

30 "HIV/AIDS Controversy at the Central Party School" [Zhongyang dangxiao de aizi guannian jiaofeng], Southern Weekend (Online), 23 June 05.

31 "Yunnan Province Holds Seminar for Provincial Leading Cadres on Drug Control and AIDS Prevention," Yunnan Daily, 2 May 05 (FBIS, 30 May 05).

32 "Jiangxi Province Draws up Plan for Province-Wide Propaganda and Education Campaign on AIDS Prevention and Control," Jiangxi Daily, 21 May 05 (FBIS, 30 May 05).

33 "Free Education for HIV Children in Guangdong," Shenzhen Daily (Online), 19 January 05; "HIV Rate Soars in Southern China City," United Press International (Online), 30 March 05.

34 "China to Fight AIDS With Free Condoms, Needle Exchanges," Associated Press (Online), 8 June 05; "New Ministry of Health Prostitute, Addict AIDS Plan 'Controversial,' " China Daily (Online), 13 June 05; Edward Cody, "In China, an About-Face on AIDS Prevention: Once-Reluctant Government Increasingly Promoting Efforts to Battle Spread of Disease," Washington Post (Online), 8 December 04.

35 Fu Jing, " 'Hospital on Wheels' to Offer Farmers Health Care," China Daily (Online), 2 August 04; "Taking Affordable Medical Service to Farmers," China Daily (Online), 11 June 05.

36 Zhang Feng, "HIV/AIDS Proposals Announced for 2005," China Daily (Online), 19 March 05.

37 Zeng Liming, "Yunnan Plans To Give HIV Tests to Targeted Groups of 300,000 in 2005," Xinhua (Online), 14 June 05 (FBIS, 14 June 05). Similar rules are in effect in Henan province. "Health Checks for Sex Workers—Boon or Bane? " Beijing Review (Online), 7 April 05.

38 "Chinese Province Wants Its Hospitality HIV-Tested," Associated Press, reprinted in Lexis-Nexis, 23 March 05.

39 Human Rights Watch, Restrictions on AIDS Activists in China, June 2005, 19; International Federation for Human Rights, Alternative Report to the Committee on Economic, Social and Cultural Rights: China: 'At a Critical Stage,' Violations of the Right to Health in the Context of the Fight Against AIDS, April 2005.

40 Pierre Haski, "A Report from the Ground Zero of China's AIDS Crisis," Yale Global (Online), 30 June 05.

41 "NGOs Active in China's Fight Against AIDS," China Daily (Online), 20 June 04.

42 See, e.g., Ministry of Health and Bureau of State Secrets Explanation on the Regulation on the Specific Scope of the National State Secrets Law and Classification of State Secrets in Health Work, issued 1 March 91.

43 "Highlights: PRC Domestic Public Health Topics 2 — 30 May 05," Foreign Broadcast Information Service, 30 May 05 (FBIS, 19 May, 2005) (citing the Jiangxi Daily, 19 May 05).

44 Many news stories refer to the Chinese authorities' tendency to hide or downplay disease outbreaks. "China Defends Failure to Report Hoof and Mouth Disease Outbreak," Xinhua (Online), 30 May 05; "China Denies Foot and Mouth Disease in Beijing Suburbs," Wen Wei Po, 24 May 05; Zhao Huanxin, "Bird Flu Outbreak in Qinghai An 'Isolated' Case," China Daily (Online), 25 May 05; "Report: Local PRC Media Reveal Meningitis Outbreak in December," Foreign Broadcast Information Service, 7 February 05 (FBIS, 7 February 05); "Let's Talk About Pork— and All Food Safety," South China Morning Post (Online) 18 August 05. A quick-moving and virulent strain of pig-borne streptococcus sickened 215 humans and caused 39 fatalities in Sichuan province in July 2005. Only after the Chinese health authorities had completed their own investigations were they willing to share their results with the World Health Organization (WHO). "Outbreak Associated With Streptococcus Suis in Pigs in China: Update," World Health Organization Newswire, 16 August 05; "Media Blackout as Pig-Borne Disease Spreads," Radio Free Asia (Online), 2 August 05.

45 Alan Sipress, "Bird Flu Drug Rendered Useless," Washington Post (Online), 18 June 05.

46 Debora MacKenzie, "China to Stop Using Human Drug on Poultry," The New Scientist (Online), 22 June 05.

47 Alan Sipress, "China Denies Promoting Use of Drug on Chickens," Washington Post (Online), 22 June 05.

48 Shi Ting and Vivien Cui, "PRC Teams To Ensure Anti-Viral Drugs Not Used on Poultry," South China Morning Post (Online), 22 June 05.

49 "Recombinomics Commentary," Recombinomics Web site, 9 July 05.

50 Alan Sipress, "China Has Not Shared Crucial Data On Bird Flu Outbreaks, Officials Say," Washington Post (Online), 19 July 05.