China’s HIV/AIDS Crisis:
Implications for Human Rights, the Rule of Law and
U.S.-China Relations

Testimony before the Congressional-Executive Commission on China
Roundtable on HIV/AIDS

September 9, 2002

Dr. Bates Gill
Freeman Chair in China Studies
Center for Strategic and International Studies, Washington, D.C.

A Looming Catastrophe

HIV/AIDS looms as a major humanitarian catastrophe for both urban and rural Chinese, and possibly for citizens in the orbit of “Greater China”, such as in Taiwan and Hong Kong.  The Chinese government needs to act quickly and effectively to limit HIV/AIDS’ impact on society, minimize economic damage, and relieve strain on an already overburdened, and increasingly ineffective healthcare system.  However, while HIV/AIDS has been identified in China since the mid-1980s, the official response has until recently been slow at best and deceitful at worst.  While the Chinese government – particularly its health-related agencies – has launched a more serious public campaign over the past year to address the country’s HIV/AIDS problem, it is still difficult to fully assess how well the Chinese government will respond in terms of political attention, financial resources, dedication of expertise, outreach to foreign assistance, and propagation of information and awareness campaigns.

Moreover, of particular interest to the Commission, protecting the rights and dignity of persons afflicted with HIV/AIDS (and their supporters) remains problematic, as the recent case of Wan Yanhai demonstrates.  Unfortunately, early indications on the political, financial, medical, educational, and humanitarian fronts are not promising, and there is much more the Chinese government and interested outsiders will need to do, not only to combat a potentially disastrous health crisis, but to do so in a way that meets international humanitarian and legal standards.

To review some of these questions, this testimony proceeds in three principal sections.  The first section will touch briefly on what we know about the Chinese HIV/AIDS problem, why that information is sketchy, and present some of the political, social, and economic factors which exacerbate the HIV/AIDS dilemma in China.  The next section will focus on the implications of China’s HIV/AIDS crisis for issues of human rights, rule of law, discrimination, and civil society activism.  A third and concluding section details what is being done by China and by the United States to address the Chinese HIV/AIDS challenge, and includes additional policy recommendations for the Commission to consider.

What We Know and Don’t Know (and Why)

China’s socioeconomic opening, reform, and liberalization – both its good sides and bad – helped enable HIV/AIDS to enter the mainstream population by the mid- to late 1990s.  Relaxed residency restrictions and a large “floating population” of itinerant labor, liberalized social attitudes towards sex, a burgeoning sex industry, increased drug abuse, and a dilapidated and dangerous healthcare system all have a hand in fueling the spread of HIV/AIDS in China.  On the other hand, “traditional” attitudes – such as a preference for male children, reemergence of concubinage, avoidance of sexual subjects, and a lack of awareness sexually transmitted diseases (STDs) – have also played their part.[1]

However, dismissed in the past by Chinese officialdom as a “Western” problem, the spread of HIV/AIDS has only recently gained serious attention from Beijing.  China now faces a major epidemic and, even under the best of circumstances, it is difficult to be optimistic.  It was only a year ago, in June 2001, when the Chinese Minister of Health, Zhang Wenkang, announced that China had as many as 600,000 cases of HIV/AIDS.  Since then, the official Chinese estimate reached 850,000 in early 2002, and that figure was revised upward to 1 million in September 2002, an increase of 67 percent over 2001 figures.  In fact, Beijing really does not know the true number of HIV/AIDS cases in China, and these numbers are probably significant underestimates.

In certain parts of China the problem is already particularly acute.  Along China’s southern borders with the opium-growing regions of Burma, Thailand, and Laos, widespread intravenous (IV) drug use was an early source of HIV infection.  Drug use – and with it the spread of HIV – has also extended along drug trafficking routes into China’s northwestern province of Xinjiang.  The central province of Henan, China’s most populous, has apparently been hit hardest. According to some experts in international non-governmental organizations (NGOs), as many as 1.2 million people in Henan are HIV-positive, largely owing to an unsafe blood collection system.  Chinese and Western news media reports have focused in particular on “AIDS villages” in Henan where up to 80 percent of inhabitants have contracted the virus, and more than 60 percent already suffer from AIDS.

Even accepting Chinese estimates of 1 million persons with HIV/AIDS and a relatively modest annual growth rate of 25 percent, China will have nearly 6 million cases of HIV/AIDS by 2010, easily placing it among the most heavily-infected countries in the world in the next 5 to 8 years.  Even Health Minister Zhang Wenkang has acknowledged that the number could rise to 10 million by 2010 if the infection rate increases significantly.  (By comparison, in the United States, where the disease was detected 20 years ago, there are today an estimated 900,000 people living with HIV/AIDS, with an additional 40,000 new cases reported each year; South Africa, currently the country with the largest HIV/AIDS population, has about 5.3 million person living with the disease.)

Questionable Statistics

However, the official Chinese figures are probably “low estimates” at best, and need to be treated with caution.  The report from the United Nations Joint Program on HIV/AIDS (UNAIDS), HIV/AIDS: China’s Titanic Peril aptly opened with the statement: “Heaps of numbers and lots of guesses - Yet the whole story remains elusive.”  The UNAIDS report on China – conducted in cooperation with Chinese agencies – repeated the previous official figure of 850,000 for 2002, but also states the number may be as high as 1.2 million.  As noted above, other independent groups argue this number is too low as there may be over a million HIV-infected individuals in Henan province alone.

Why is there such a wide discrepancy between the Chinese government’s statistics and other organizations’ estimates?  It comes down to both practical and political reasons.  First and foremost, China simply does not have the resources available to conduct accurate sampling and estimates for HIV prevalence.  China has about two dozen persons working at the central government level focusing on this relatively new and growing epidemic (compare that with several hundred persons at the U.S. Centers for Disease Control and Prevention who work on the HIV/AIDS epidemic in the United States).

Resources in the localities are spread even thinner in China.  For example, according to UNAIDS and the WHO, in 2002 China had only 127 sentinel sites in operation, targeting four population groups (sexually transmitted infection [STI] clinic attendees, 74 sites; female sex workers, 23 sites; IV drug users, 26 sites; and pregnant women, 4 sites).  While this represents almost twice the number sites that were operational in 1997, it is insufficient to effectively monitor a population the size of China’s.

Moreover, the dominant focus of these sites on high-risk groups (sex workers, IV drug users, STI patients) tends to skew figures by potentially ignoring infection rates within the general population.  An additional risk of only monitoring high-risk groups is the mistaken notion that they are the “cause” of an HIV/AIDS epidemic, leading only to greater discrimination, marginalization, and public calls for isolation.  Of the 100 surveillance sites reporting in 2000, only a handful monitored pregnant women and long-distance truck drivers.  The great majority of sites monitored IV drug users, prostitutes and sexually transmitted disease clinics.  On the other hand, Yunnan province, which has an extremely high IV drug use rate, only hosts surveillance sites to monitor sexually transmitted diseases and prostitutes.  As such, the relatively small sampling focusing largely on high-risk groups tends to divert attention away from the true extent of the problem, especially as it may affect more “mainstream” parts of society.

The so-called “floating population” or “liudong renkou” provides a good example of the monitoring problem.  This group of itinerant workers – estimated at between 100 and 120 million persons – have left their official residences, typically in the poorer countryside, to seek gainful employment in urban areas.  Leaving official educational, housing, and health care assistance behind, these workers migrate to the least desirable jobs and live a semi-clandestine, marginalized existence.  The vast majority of the floating population is in the most sexually active period of their lives – some 80 percent are aged between 15 and 45, and half are between 20 and 30.  According to a recent study, there are more women than men among the young (15-19 years old) in the floating population; among all females in the floating population, some 55 percent are in the “entertainment/service” industry, which for some may include some commercial sex work at restaurants, tea houses, karaoke bars, and the like.[2]  The “floating population” likely represents a major new source of HIV infection in the coming years, but their situation on the fringes of society renders HIV/AIDS education, awareness, monitoring and treatment practically impossible to provide.

There is also a political element that distorts official HIV/AIDS statistics.  The Chinese government officially denied its HIV/AIDS problem for years, and discouraged accurate monitoring and independent surveillance.  The Chinese government has also considered the number of HIV infected people in China to be a politically charged topic, with a great deal of national “face” riding on the official statistics.  In areas with high infection rates, local officials have attempted to cover-up independent reporting.  This is due partly to the officials’ concerns about their career prospects, as well as the stigma potentially attached to their region, which could stymie investment and tourism.  Some observers have pointed out that local officials in Henan province financially benefited from blood collection centers that were responsible for extensive HIV infection amongst poor donors.  Public disclosures of official corruption and ineptitude in handling the Henan blood collection scandal also makes local officials all the more opposed to revealing the true extent of the problem.  To some extent, the central government has taken advantage of local officials’ reticence to deflect blame and responsibility for the national HIV/AIDS crisis.  But in the end such attitudes only distort accurate reporting and complicate effective responses.

Tainted blood and “AIDS Villages”

Owing to the efforts of certain courageous Chinese activists and persistent reporting by Chinese and Western journalists, a good deal is known about the most insidious HIV/AIDS-related development in China to date: the corruption of its voluntarily-donated blood supply and the subsequent appearance of “AIDS villages.” In the early 1990s, blood collection centers opened in Henan province, encouraging peasants to donate blood and blood plasma for fees.  Unsanitary collection and reinjection methods resulted in donors being infected at a rate as high as 65 percent in many instances.[3]  Chinese and Western media reports have focused in particular on “AIDS villages” in Henan – such as Wenlou – where up to 80 percent of inhabitants have contracted HIV, and more than 60 percent already suffer from the symptoms of AIDS.  The official Gongren Ribao [Workers’ Daily] newspaper reported in January 2002 that 80 percent of the inhabitants of Henan’s Houyang village tested positive for HIV, 400 people had developed AIDS and 150 had died in the 12 months from November 2000.[4] 

While the “AIDS Villages” in Henan are a well-documented humanitarian tragedy, they have remained relatively isolated incidents in the medical and political sense.  Unfortunately, because knowledge of these incidents is not widespread amongst the Chinese peasantry, the work of unregulated “blood heads” continues in China’s vast hinterland in such provinces as Sichuan, Shanxi, Hubei, Hebei, and Gansu, and elsewhere in spite of official prohibitions against such illicit blood collection schemes.  Given China’s chronically low blood supply, the law of supply and demand, and the inability (or complicity) of officials to deal with the problem, such hazardous practices will certainly continue.

As a result, the Chinese blood supply is tainted with the HIV virus, and infections from transfusions have appeared throughout the country.  In 2001, Deputy Health Minister Yin Dagui presented the media with figures revealing that one in every 2,500 blood transfusions transmitted HIV in the worst hit areas.[5]  China’s official Action Plan for Reducing and Preventing the Spread of HIV/AIDS (2001-2005) aims to reduce the national infection rate from transfusions to 1 in 10,000 in hot spots, and 1 in 100,000 nationally.[6]  (A 1996 study in the United States determined that the rate of infection from transfusions in this country is 1 in 493,000 – and was likely to improve between 27 and 72 percent in the near future as new and better screening tests become available.[7])  Blood transfusion recipients in China will clearly be at risk of contracting HIV for the foreseeable future, but may not be recognized within official statistics for years to come.  As one senior physician in China put it, “A lot of people who received blood have not fallen sick yet.”[8]

Problems in the Healthcare and Social Welfare System

HIV/AIDS poses a major strain on the Chinese state-supported healthcare system which is overburdened in urban areas, and almost non-existent in most rural areas.  Economic pressures have forced the State to cut back on healthcare, and private providers have not materialized to take the government’s place.  When private providers are available, the cost for their services is often prohibitive, certainly for most persons living in the countryside.  Basic health services are simply not available to a large portion of the population.  Services which do exist are normally stretched beyond safe limits.  Cost-cutting and unsound medical practices result, which can further fuel the spread of HIV/AIDS infection.  For example, illegally re-used syringes are commonplace in hospitals, especially .n the interior.  The U.S. Embassy in Beijing reported in June 2000 that “large volumes of low quality, substandard and dangerous ‘illegal’ hypodermic syringes and blood transfusion equipment are now flooding the Chinese market.  One million substandard syringes are shipped daily from one region of Zhejiang province alone…”[9]

Medicines to suppress HIV and address the symptoms and complications of HIV/AIDS are expensive and hard to come by in China.  Herbal medicines are widely used in the countryside to combat the symptoms of AIDS, but are generally useless in retarding the growth of the virus.  A local pharmaceutical company in China has announced that they have received permission to begin distributing a generic version of AZT in China beginning in September, which is expected to cost about one-tenth the U.S. price.  Merck had previously been negotiating with the Chinese government to supply discounted AZT, but no public announcements have been made announcing the success of those talks.  But it is well-known that a single drug such as AZT is most useful only against certain strains of HIV, and that ultimately a mixture or “drug cocktail” of two or more drug compounds are ultimately more effective and help counter the emergence of resistant strains of HIV.  The China Northeast Pharmaceutical Company, which is producing the knock-off AZT, has also expressed interest in producing other anti-HIV drugs used in “cocktails” to help suppress HIV.

Even if medical treatment, such as “drug cocktails,” were available, affordable, and clinically effective, the medical profession and afflicted patients in China would need to be trained in proper dosing and regimen monitoring; poor practices in this regard only result in the emergence of new, drug-resistant strains of HIV (a serious problem in Western countries), only further complicating the HIV problem in China when they are transmitted back into the population.  No effective vaccine exists for therapeutic treatment for or protection from HIV infection.  One Beijing doctor at a hospital that specializes in HIV/AIDS treatment said, “In the countryside many doctors don’t know how to treat HIV….  We know how.  But patients can’t afford the medicines, and the supply is extremely limited.  So even if we want to treat, we often can’t.”[10]  At best, doctors in China are left with treating the symptoms of HIV/AIDS, but are largely helpless in stemming the fatal progression of the disease in their patients.

One social welfare issue that has gained very little attention thus far is the question of HIV/AIDS orphans.  This problem seems most acute at the moment in the “AIDS Villages” of Henan, some of which are reported to have hundreds of orphans.  UNAIDS estimated in 2002 that there are some 76,000 children under the age of 15 “who have lost their mother or father or both parents to AIDS.”.[11]  Noted Chinese HIV/AIDS activist Wan Yanhai, founder of the “AIDS Action Project” in Beijing, reported in June 2002 that in the Henan village of Houyang, with a total population of 3,806 people, there were 108 orphans, 26 of whom were HIV positive.[12]  Orphans and HIV-positive children, often cannot even turn to relatives in their villages because their aunts and uncles are also infected or dead, or owing to their isolation and stigmatization by fellow villagers.  This is a problem that will continue to grow, placing a further burden on China’s healthcare and social welfare system, especially in the countryside.

Changing Demographic Picture Affects HIV/AIDS

Changing demographic factors in China also fuel the spread of the disease.  As mentioned above, the floating population presents a particular concern.  This group of primarily young adults from the countryside is largely uneducated, at their sexual prime, and far from the restricting social mores of their home villages.  While these migrants generally do not interact socially with urbanites, they do return home to their families at least once per year, and can potentially infect spouses and/or other sexual partners, further spreading the deadly virus.

Migrants also account for a large percentage of sex workers.  The incidence of IV drug use among construction workers is on the rise as well, due in part to their dislocation and despair brought on by economic hardships.  HIV rates amongst them are impossible to track, since they live outside of official government oversight.  Given that many of the workers are illiterate, passive prevention methods such as posters are ineffective.  Workers frequently speak non-Mandarin dialects, and are therefore harder to reach by health care workers. 

One of the most disquieting demographic trends in China is the growing divide between the number of males and females born each year.  The rapid socioeconomic changes of the 1980s and 1990s, combined with the one-child policy, have tended to reinforce the traditional preference for male heirs who carry on the family name, are expected to take care of aging parents, and tend to bring in more income.  Now that ultrasound technology allows parents to identify the gender of their child before birth, sex-selective abortions, although illegal, are further altering the makeup of Chinese society.  The natural ratio of males to females born worldwide each year is about 105:100.  However, according to Tyrene White, a scholar at Swarthmore College, China’s ratio in 1995 was 117.4 boys for every 100 girls, and in 1997 it was skewed even further to 120 males for every 100 females.  China’s official statistics for the 2000 census report that 116.9 boys were born for every 100 girls in that year as a national average.  However, the figure in the countryside and among certain provinces is much higher: 130:100 in Hubei province, 130:100 in Guangdong province, and 135:100 in Hainan province.[13]  Figures compiled by the CIA show an imbalance that is not as great, but still dramatic: in the Chinese population aged under 15, the ratio is about 110:100.  Even this disparity means that over the next decade more than 15 million Chinese men will come of age with bleak prospects for finding female partners, let alone wives.  According to a study by Valerie Hudson and Andrea Den Boer which appeared in International Security in May 2002, China will have 29 to 33 million unmarried males between the ages of 15 and 34 by 2020.

The consequent dearth of available brides fuels demand for commercial sex workers, helps accelerate male migration into cities, increases the numbers of women who are kidnapped and sold into prostitution or as “unwilling brides”, and may be in part responsible for the rise in men having sex with men in China.

Political Obstacles

Until recently, the Chinese government largely ignored its HIV/AIDS problem, dismissing it as a “foreigners’ disease” and a peripheral concern for nearly 15 years.  By 2001, Chinese health officials could no longer ignore the issue, due largely to the rise in “involuntary” infections to blood donors and recipients, the potential impact of HIV/AIDS on China’s economic growth and weakened healthcare sector, and the growing human toll.  Nevertheless, the Chinese Ministry of Health is a comparatively weak bureaucratic actor in China, and lacks both the financial and political clout to deal with the HIV/AIDS crisis more effectively.  In any event, the nature of the problem requires a comprehensive interagency effort, pulling together the resources and expertise of other important bureaucracies in China, including the State Family Planning Commission, the State Drug Administration, the Ministry of Foreign Affairs, the Ministry of Education, communication and information agencies, and the Public Security Bureau.  However, some agencies, such as the State Family Planning Agency and the Public Security Bureau, are among the most disliked and distrusted among China’s citizens, which will further complicate education, awareness, monitoring and treatment efforts.  Moreover, as the recent case of Wan Yanhai seems to suggest, not all agencies in the Chinese government view the HIV/AIDS problem through the same lens, and may work at cross purposes with other parts of the bureaucracy.

Even if central authorities are able to work together in implementing an effective strategic plan to combat HIV/AIDS, questions arise about how to implement the strategy at its source in local and grassroots level jurisdictions far from Beijing.  Media reports and discussions with central government health authorities bemoan the difficulties in working with local officials who are disengaged from the problem or actively deny the problem exists within their jurisdiction.  Local officials may be complicit in promoting illicit blood collection operations, may fear harsh criticism will jeopardize their career prospects, or may simply not have adequate resources and information to implement central government directives.  HIV/AIDS sufferers in Henan have protested to the local government, demanding medical care reparations for the damage done by the blood-buyers, but they have been faced with stonewalling, detention and minimal help.  In the words of one protester, “To them we are like bubbles.  They know if they turn away and ignore us, we will soon pop and be gone.”[14]

In another instance in Yunnan province, a local official complained that their efforts were stymied by a fearful and misinformed citizenry:

I asked Wang Dazhang, the local Communist Party boss and much more powerful than the town’s mayor, what he was doing to educate people about HIV/AIDS.  He spread his hands and sighed.  Local officials had, he said, put up notices warning people and urging the use of condoms.  But local people had complained bitterly about the notices and their illustrations.  He had been forced to order the warnings taken down.[15]

On the other hand, it should be said that both central and local officials are less than enthusiastic about nongovernmental and community-based organizations (NGOs and CBOs) which operate beyond the authority of the state and party apparatuses.  But the spread of HIV/AIDS occurs at the grassroots, and needs to be addressed at that level, as well as by the strategic resources and planning apparatus of the central government.  However, China not only lacks the resources of experts and capital to focus on the grassroots level; in addition, central and provincial authorities are politically wary of semi- or wholly-autonomous organizations operating outside of government and party supervision.  The preference for Leninist “democratic centralism” – another term for a top-down, Party-led approach – still prevails in China, and complicates Beijing’s ability to deal fully with its HIV/AIDS problem.

Implications for Human Rights, Rule of Law, and Civil Society

Social Stigma

Chinese citizens, faced with a lack of reliable information about HIV/AIDS, fear the worst.  Various studies have shown that a majority of the population does not know how HIV is spread.  For example, a study conducted in seven counties in China, surveying 7,053 individuals aged 15 to 49, from a cross section of economic and social backgrounds, showed that 16.9 percent had never heard of HIV.  Of those who had heard of HIV, 73.3 percent did not know its cause and only 9.6 percent of those surveyed could identify primary ways of preventing HIV infection.  Over 80 percent of those surveyed were unaware that HIV infection could be contracted by sharing needles or by mother-to-child transmission.[16]  With such poor or misinformed understanding, the stigmatization of those with HIV/AIDS is commonplace.  According to Western media reports and studies by Chinese HIV/AIDS activists, for example, HIV-positive farmers cannot sell their produce in neighboring towns, and urban sufferers risk of job loss, school expulsion and eviction from government housing.  One farmer from an “AIDS village” in Henan said, “We have no income.  When people from the village try to find work, nobody wants to hire us because we are HIV positive….”[17]

A recent survey of 4,000 Chinese showed that less than four percent of respondents understood what HIV and AIDS are and how HIV is transmitted, and over half believed that sharing utensils with HIV/AIDS carriers can transmit HIV.  Not only do individuals with HIV or AIDS feel alienated in their hometowns, but they may even be rejected by their own families.  Unfortunately, there is even a great deal of ignorance in the public health sector, as illustrated by the many cases of hospitals and clinics refusing to treat afflicted patients.  Official government attitudes do little to dispel these fears.  When HIV-positive persons appear on government-run television, they do so with a disguise and under a false name.  Unfortunately, the stigmatization of HIV/AIDS forces the problem deeper into the shadows of society.  As one observer wrote, “Denial, stigma and discrimination are the three horsemen driving China…towards a potential AIDS apocalypse….”[18]

Discrimination against HIV/AIDS-afflicted persons

But the problems faced by HIV-infected individuals, their families, and other supporters goes beyond social stigma.  According to reports from Western journalists and as well as Chinese activists, it is often the case that their basic rights are not properly protected, including their rights to employment, health care, education, privacy, marriage, and freedom of movement.  Law enforcement often treats HIV/AIDS-afflicted individuals as criminals, assuming they contracted the virus through drug use, prostitution or homosexual sex.

As early as 1995, the State Council promulgated a statement entitled “Opinions in Regard to Reinforcing the Prevention and Control of AIDS” which demonstrated a short-sighted, narrow-minded and discriminatory understanding of the disease.  It stated, in part:

The prevention and control of AIDS must be conducted with every effort as a part of the construction of a socialist spiritual civilization.  The prevention of AIDS is closely related to the prohibition against narcotic drugs and prostitution, to the purification of social atmosphere, and to the construction of socialist spiritual civilization.  Only when drug use, prostitution, whoring and other ugly behavior [an oblique reference to homosexuality, which in 1995 was considered a psychological disease] are consistently prohibited, can the spread of AIDS be prevented, and the construction of socialist spiritual civilization be secured.[19]

The regulations also require medical personnel to “immediately report” on all “Class A” infectious diseases “including HIV/AIDS.”  Additional laws require that HIV/AIDS patients be “isolated for treatment,” and for “those who refuse treatment in isolation or break away from treatment in isolation before the expiration of isolation period, the public security department may assist medical care institutions in taking measures to enforce the treatment in isolation.”[20]  In another instance, the “Maternal and Infant Health Care” law of the People’s Republic requires that males and females in the HIV “infective period “shall postpone their marriage for the time being.”[21]

The Ministry of Health has been supportive of voluntary testing, and encouraged local regions to protect the rights of HIV/AIDS sufferers.  The ministry has not encouraged the enforcement of mandatory testing outside of high-risk groups, or enforced the isolation laws in any part of China.  Since the late 1990s, the Ministry of Health has taken a more proactive role in trying to educate the population about HIV/AIDS through national mass media, and trying to limit the discrimination faced by infected people throughout the country.  However, consistent with the Chinese saying “the mountains are high, and the emperor is far away”, Beijing authorities are increasingly ineffective in seeing to the adherence of central government directives, and this is particularly true of a weak bureaucratic actor such as the Ministry of Health.  As a result, the worst discriminatory abuses against HIV/AIDS sufferers tend to occur at the direction of local governments.

For example, in 2001, Chengdu – a city of some 10 million inhabitants in central Sichuan province –enacted restrictive laws against HIV/AIDS victims, even though the city only had 38 registered HIV cases at the time.  According to one report:

The Chengdu City AIDS Prevention and Management Regulations prohibit AIDS patients and people who have tested positive for HIV from marrying.  They order police to test people in high-risk groups, such as prostitutes and drug users, within five days of an arrest, and require separate incarceration facilities for those who have tested positive.

The regulations mandate AIDS tests for returning Chinese who have been abroad for more than a year, and they suggest that pregnant women with AIDS may be persuaded to abort their fetuses if medicine that could prevent the transmission of the virus to the child is unavailable.  A part of the law that has not been made public, as can happen in China, also bans people with HIV or AIDS from working as kindergarten teachers or surgeons, among other professions. [22]

Government owned newspapers, as well as officials in Beijing complained openly about the regulations before they went into effect.  The only result was dropping a clause banning HIV-positive people from public swimming pools.

Central and local authorities appear to be relying on past experience to control HIV/AIDS, treating it as a conventional infectious disease, and managing it with traditional public health measures.  Prior to 1949, diphtheria, typhoid and cholera were endemic in China, small-pox and even plague outbreaks occurred regularly in some areas.  Through often draconian testing, reporting, contact tracing, isolation and treatment regimes, the Communists were able to virtually eradicate these diseases.  Prior to the early 1980s, in similarly strict fashion, they had effectively eradicated prostitution and illicit drug use as well.  China’s current laws and enforcement procedures vis-à-vis the HIV/AIDS epidemic appear to reflect these approaches. However, coupled with widespread social discrimination against HIV/AIDS victims, government efforts prohibiting marriage, threatening confinement, and requiring mandatory reporting likely ensures that HIV-infected individuals will be reluctant to undergo voluntary screening.  This in turn will lead to further propagation of the disease.

Rise (and Fall?) of HIV/AIDS Activism

There are a number of official and semi-official organizations in China set up to help address the HIV/AIDS crisis in the country.  For example, the China AIDS Network, based at the Peking Union Medical College, conducts research and intervention and provides policy recommendations to the Chinese government.  Founded in 1991, it is made up of some 34 experts from medical schools, research academies and institutes, as well as the Public Security Bureau, the civil court, and several provincial health inspection and prevention units.  Its funding comes largely from the Ford Foundation.  Other NGOs supported by the Ford Foundation include the Yunnan Reproductive Health Research Association and the China Family Planning Association.[23]  Other “government sanctioned” semi-official organizations include the China Foundation for AIDS Prevention and the Beijing Association of STD/AIDS prevention and control. 

In addition, several cities and regions in China now have telephone hotlines that provide callers with “personalized” information on HIV/AIDS transmission, symptoms, and treatments.  Because of the stigma attached to HIV, the hotlines provide a valuable method for communicating with sufferers and at-risk groups in an anonymous, non-threatening environment.  In another example, a professor at the Qingdao Medical College started the bi-monthly Friends Newsletter in 1998, the first openly published gay-community magazine in China.  Professor Zhang Beichuan’s newsletter carries much-needed information on HIV prevention to China’s marginalized and largely underground gay community.  Xinhua recently reported another “non-government service center”, the first of its kind set up in Kunming, Yunnan province.  The center, going by the name “Aizijia”, was jointly established by the Red Cross Society of Yunnan and the Salvation Army of Hong Kong and Macao, and provides preventive education, information, and counseling on HIV/AIDS.[24]

The Internet is also providing a forum for relatively affluent and literate HIV-infected people and their supporters to voice their frustrations and fears to the general public.  Several on-line diaries have appeared, chronicling the experiences of HIV-positive Chinese, often with tales of discrimination.  One site tells the story of a boy, Song Pengfei, who was from a relatively wealthy family in Shaanxi province.  Song was infected from a blood transfusion he received after a relatively minor accident.  After his HIV infection was discovered, the hospital notified local officials, and the Song family was driven from town.  The family owned a coal mine, and was “dispossessed” of their property by the local government, and promised a regular stipend if they moved to Beijing to seek treatment.  The local government soon reneged on the arrangement, and left the Songs to their own devices.  Song started his website (www.songpfhiv.com) and became an outspoken HIV activist, challenging Health Minister Zhang Wenkang to shake his hand on national TV, addressing journalists, and attending international HIV/AIDS conferences.  Notably, he is one of the few HIV-positive Chinese actively taking anti-HIV “drug cocktails,” paid for by a New York charity.  Many activists hope that Song Pengfei can demonstrate to the Chinese people that HIV-positive individuals, properly treated, can enjoy more normal lives.

However, the HIV/AIDS crisis, particularly the plight of blood donors in Henan, has also given rise to “a new breed of activist” in China.[25]  Individuals have risked detention by local authorities by visiting “AIDS Villages” in Henan, bringing free medicine, and reporting on the villagers’ plight to the local and foreign media.  Noted activists include Dr. Gao Yaojie, a 79-year old retired gynecologist who delivered medicine to HIV/AIDS victims, and photographed and reported on the medical condition of several villages.  She was awarded the Global Health Council’s Jonathan Mann Award in 2001, but was refused permission to leave the country to accept it.

Wan Yanhai, a former HIV/AIDS researcher with the Chinese Ministry of Health, founded the AIDS Action Project (Aizhi Xingdong) nine years ago after he was dismissed from the ministry for speaking out about health issues.  He also helped set up one of China’s first HIV/AIDS telephone “hotlines” in 1992.  The AIDS Action Project has received funding from overseas groups such as the Elizabeth Taylor AIDS Foundation.  When Dr. Gao was not allowed to travel to accept the Jonathan Mann award, Mr. Wan accepted it from United Nations Secretary General Kofi Annan on her behalf.  Mr. Wan, who spends part of his time in Los Angeles while remaining a Chinese citizen, has traveled and lectured around the world to discuss China’s HIV/AIDS crisis.

In June 2002, Wan Yanhai published “death lists” and “orphan lists” of two villages in Henan province where local officials repeatedly denied the presence of HIV.  Four days later, the AIDS Action Project was evicted from its space at a private university in Beijing.  Health Ministry officials refuse to acknowledge his NGO’s existence, since he has not been able to register with the appropriate authorities.  Mr. Wan explains that the high cost of official registration – equal to US$12,000 – is prohibitive.  Wan Yanhai’s website (www.aizhi.com) contains extensive documentation in Chinese about the Henan AIDS crisis.  Mr. Wan and his staff have been the subject of police harassment after Henan officials came to Beijing to complain about his activities.  Mr. Wan readily admits that he has been very frank about the situation, as well as the government’s slow response.  He has been under plainclothes police surveillance since early July 2002.

On August 24, 2002, Wan Yanhai disappeared, and on September 4 it was announced he is being detained by the Public Security Bureau in Beijing for “revealing state secrets.”  It is believed his public revelations of a sensitive internal Henan province document – which demonstrates that provincial authorities in Henan and elsewhere were aware of the HIV-tainted blood problem as early as 1995 – is the cause of his detention.  The day before his detention, Mr. Wan provided information specifically for this testimony, including a recommendation for this Commission, knowing that it would become public information (see below).

As noted above, Chinese authorities are wary about “independent” bodies that operate outside of State and Party supervision.  True NGOs and activists currently operate in a gray-area, like the AIDS Action Project, always on the edge of eviction or harassment.  Unfortunately, such Chinese government views hamstring efforts to combat HIV/AIDS.  It will be imperative for “home grown” Chinese NGOs to engage the population to combat the HIV/AIDS problem.  “China needs a Ryan White,” said one Chinese health official, referring to the HIV-infected American boy whose plight helped shift U.S. public opinion about the disease in the 1980s.  “But the government is afraid of what China’s Ryan White might say.”[26]

Policy Responses

China’s Action Plan and Other Efforts

In May 2001, the State Council published the Action Plan for Reducing and Preventing the Spread of HIV/AIDS (2001-2005).  The plan defines objectives for 2002 and 2005, however, makes little mention of how these goals will be accomplished.  Emphasis is placed on ensuring blood supply safety, raising public awareness, and making care available to HIV-infected persons.  Overall, the goals appear wildly optimistic given the limited resources available to see to their implementation.

One such goal for 2005 is to have 45 percent of the population in the countryside know about voluntary blood donation and how HIV is transmitted.  It should be noted that the availability of timely and accurate information in the countryside is extremely limited.  Dr. Gao Yaojie, on a trip to the countryside to deliver medicine, reported peasants asking, “Did Chairman Mao send you?”[27]  Educating the countryside is a lofty goal.  A more realistic objective is to educate 95 percent of high-risk groups, while they are in “drug detoxification centers, re-education centers, prisons, and education through labor [camps].”[28]

The plan also sets out to improve the health care system.  Year-end targets for 2002 include providing 50 percent of people living with HIV/AIDS access to community and home care.  At least 70 percent of general hospitals should be able to provide HIV/AIDS diagnosis, treatment, counseling and care by the end of 2002 as well.  The plan also calls for national radio, television and press to broadcast information messages related to HIV/AIDS and sexually transmitted infections at least once per week.

Xinhua, the official state news agency, has run articles on HIV transmission in recent months.  The government owned, though quasi-independent Nanfang Zhoumou [Southern Weekend], published extensive accounts of the HIV/AIDS crisis in Henan province.  However, the government controlled press remains uncomfortable talking about sexually transmitted diseases.  There is a long-standing cultural taboo in China about discussing sex openly.  As a result, newspaper articles still emphasize that HIV is spread through “sharing needles for drug-taking,” with only a passing mention of how the disease is also sexually transmitted.[xxix]  Homosexuality is still a taboo subject in the national press, and not addressed at all.  Perhaps most importantly, there is no mention of the dangers of receiving blood transfusions or the danger from “illegal” syringes or reusing needles within clinical settings. 

In the past three to four years, Chinese consumers have become more aware of their rights, and are now more sensitive to the dangers of sub-standard products.  Consumers have demanded that suppliers provide them with adequate protections and assurances.  It is very conceivable that Chinese citizens will begin to apply their new found “consumer rights” to the health care system, forcing healthcare providers to improve quality.  Chinese courts have recently awarded damages paid to several victims of HIV tainted transfusions.  While this is a positive development, it remains to be seen if the court ordered restitution is actually paid to the victims.  As is often the case in the Chinese civil court system, court orders are not always enforced, leaving the plaintiff without effective recourse.

The five-year action plan released in 2001 does not directly address funding issues, but does encourage local governments to self-fund projects, as well as look to international donors for cooperation and financing.  In 2001, the Central government increased its annual budget for HIV/AIDS prevention and care from 15 million RMB (US$1.8 million) to 100 million ($12 million).

The 2001 action plan is lacking in several respects.  It continues to marginalize vulnerable populations, emphasizes punishment and segregation, and does little to address the socio-economic factors that encourage the spread of AIDS.  No mention is made of responsibility for the floating population of migrant workers.  The word, “orphan” does not appear at any point in the plan.  No provisions are made for the social welfare of HIV/AIDS sufferers.  No mention of outreach to non-Han citizens is made.  Some ethnic minorities such as the Yi in Yunnan, and Uighurs in Xinjiang have already been very badly hit by drug use and HIV infection.  Homosexual transmission is not addressed.  Cross-country truck drivers are an especially high-risk group but are not mentioned in the action plan.  Nevertheless, publication of the plan indicates a far more serious approach by Beijing toward this problem, and efforts aimed at achieving ambitious goals should be applauded.

On a more positive note, the recent introduction of “sex ed” to the middle-school curriculum in several cities is a welcome sign.  While it is not yet a nation-wide program, it is a step in the right direction, and will prepare future generations to deal with sexually transmitted diseases, as well as basic health care issues, and reproductive concerns.

Assistance from the United States

U.S.-China government-to-government efforts on HIV/AIDS have been somewhat limited to date.  In late June 2002, during the visit to Washington of Chinese Health Minister Zhang Wenkang, Secretary of Health and Human Services Tommy Thompson announced a US$14.8 million grant to the Chinese CDC for training and research.  Two U.S. CDC personnel will be assigned to the Chinese CDC to “provide assistance in responding to China’s HIV/AIDS epidemic.”[30]  The CDC has conducted a preliminary in-country assessment with Chinese counterparts in China, and has formally proposed possible areas of bilateral cooperation, to include work on improving HIV awareness and education, increasing interventions in China among high-risk populations, and enhancing surveillance, voluntary testing, blood safety, training, and care for infected persons.  The United States government is increasing the number of persons posted to China who will work on health-related issues and Chinese scientists are working on HIV-related issues in the National Institutes of Health. 

(Other governments, such as Australia have channeled millions through government sponsored NGOs, such as the China-Australia NGO Scheme (CHANGES), which provides assistance to Australian NGOs to work in close cooperation with counterpart organizations.  Through CHANGES, Australia has plans to spend AUD$14.7 million over five years in Xinjiang, and an additional $3 to $5 million in Tibet.  The Australian Red Cross has also been active in grassroots education projects.  The United Kingdom Department for International Development (DFID) will spend GBP$15.3 million between 2000 and 2005 in Yunnan and Sichuan provinces on surveillance, and increased access to at-risk groups.  The United Kingdom-based Save the Children organization is involved in grassroots, children’s education projects in Yunnan, Tibet, Xinjiang, and Anhui.)

Multilateral organizations under the United Nations umbrella have made a major contribution to China’s fight against HIV/AIDS.  From 1996 to 2000, UNICEF managed two major projects, one in Yunnan Province and one nationally, with total funding of $2.2 million.  The World Bank has supported several HIV/AIDS projects in China since 1991.  A major project in 1999, with funding over US$33 million, helped the Chinese government develop relevant policies and institutional capacities.  As part of this program, additional grants of AUD$2 million from Australia and $400,000 from Japan promoted NGOs’ participation in HIV/AIDS prevention and care.  The World Bank together with the DFID is preparing a new project to support the Chinese government’s long-term effort to control tuberculosis, and build links between HIV/AIDS and tuberculosis prevention.[31]

The United States also funds multilateral organizations that contribute to the fight against AIDS, including The Global Fund to Fight AIDS, Tuberculosis and Malaria which was founded in 2000 at the G8 summit in Genoa, Italy.  It is well funded by the G8 nations, as well as private foundations such as the Bill and Melinda Gates Foundation.  Secretary Thompson sits on the board of directors, along with representatives from other donor countries as well as recipient countries and international NGOs.[32]

U.S. non-governmental organizations have been very active in China, funding some Chinese “NGOs” and independent groups.  Many American foundations, including the Ford Foundation, the Elizabeth Taylor Foundation, the Packard Foundation, and the Bill and Melinda Gates Foundation have all participated in funding independent groups in China, including the AIDS Action Project. 

Additional Recommendations

What the Chinese Government Should Consider

China’s health-related ministries and agencies are facing an uphill battle, and are keen to develop new and effective policies to combat the spread of HIV/AIDS in China.  With proper resources and greater political commitment, a number of important steps could be taken:

• Create a formal and fully-staffed and –funded “Office of National HIV/AIDS Policy” within either the President’s office or directly under the Premier in the State Council.  This would provide greater day-to-day oversight and coordination than presently exists under the loosely organized interagency process, or “lingdao xiaozu” [“leading small group”] system currently tasked with the HIV/AIDS issue and headed by Vice Premier Li Lanqing.  The new office would carry more political weight and would be better positioned to overcome bureaucratic “stovepiping” and competition with currently thwarts an effective, multi-agency approach in China.
• Draw from other country’s experiences in combating the spread of HIV/AIDS.  Emphasis should be placed on needle exchange and methadone programs, as well as condom use among prostitutes and customers.  Prevention education focused on long distance truck drivers and along West to East rail lines should occur nation-wide. 
• Nationalize a junior high school sex education program that would include information about HIV/AIDS and other STDs, and how to prevent infection.
• Encourage the establishment and growth of grassroots organizations and community based organizations (CBOs) to help prevent HIV/AIDS spread in the countryside.
• Increase the HIV/AIDS and sexually transmitted disease surveillance carried out in China.  This would include, in part, an increase in the increasing the number of HIV/AIDS sentinel surveillance sites and distributing these sites more evenly among provinces and among population groups.
• Conduct more frequent voluntary screening for HIV/AIDS within the general population.
• Invest greater resources in cleaning the blood supply and enforcing prohibitions against unregulated blood donations and distribution.
• Revise national HIV/AIDS related laws to ensure civil rights protections.  Clear policies on confidentiality and the legal use of test results must be developed and widely disseminated to both central government authorities and local level officials, as well as health officials.

What the U.S. Government can do

U.S.-China cooperation in combating HIV/AIDS stands out as a potentially positive area for bilateral relations, both at the governmental and non-governmental levels.  Practical actions should include:

• Focusing cooperation in certain key areas, especially assistance and training in surveillance, epidemiological studies, HIV awareness and preventive education, legal and regulatory reform, blood safety, and community health care.
• Continuing high-level, official attention to this issue by Americans with their Chinese interlocutors: members of Congress, members of relevant Executive Branches, and the White House itself need to keep this issue at the top of the bilateral agenda.  During the upcoming summit between Presidents Bush and Jiang in late October, the two sides should prominently note and support expansion of ongoing U.S.-China programs focusing on HIV/AIDS.
• Recognizing and encouraging the importance of grassroots and community-based organizations (CBOs) working in China to address the HIV/AIDS problem.
• Sustaining and expanding U.S. government funding in support of HIV/AIDS-related education, awareness, medical training, and epidemiological research, including assistance in updating and distributing national treatment guidelines and a national training program.
• Consider military to military exchanges to further study HIV/AIDS prevalence in China, possibly making use of epidemiological data derived from PLA screening of all recruits.
• Initiating Peace Corps efforts in China which offer HIV/AIDS awareness, preventive education and training programs
• Improving interagency cooperation and consultation on HIV/AIDS in China, perhaps as part of the interagency science and technology consultation process

Some closing words from Wan Yanhai