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HIV/AIDS IN CHINA: CAN DISASTER BE AVERTED?

ROUNDTABLE

BEFORE THE

CONGRESSIONAL-EXECUTIVE

COMMISSION ON CHINA

ONE HUNDRED SEVENTH CONGRESS

SECOND SESSION

SEPTEMBER 9, 2002

Printed for the use of the Congressional-Executive Commission on China

(

Available via the World Wide Web: http://www.cecc.gov

CONGRESSIONAL-EXECUTIVE COMMISSION ON CHINA

LEGISLATIVE BRANCH COMMISSIONERS

Senate House

MAX BAUCUS, Montana, Chairman

CARL LEVIN, Michigan

DIANNE FEINSTEIN, California

BYRON DORGAN, North Dakota

EVAN BAYH, Indiana

CHUCK HAGEL, Nebraska

BOB SMITH, New Hampshire

SAM BROWNBACK, Kansas

TIM HUTCHINSON, Arkansas

DOUG BEREUTER, Nebraska, Co-Chairman

JIM LEACH, Iowa

DAVID DREIER, California

FRANK WOLF, Virginia

JOE PITTS, Pennsylvania

SANDER LEVIN, Michigan

MARCY KAPTUR, Ohio

SHERROD BROWN, Ohio

JIM DAVIS, Florida

EXECUTIVE BRANCH COMMISSIONERS

PAULA DOBRIANSKY, Department of State

GRANT ALDONAS, Department of Commerce

D. CAMERON FINDLAY, Department of Labor

LORNE CRANER, Department of State

JAMES KELLY, Department of State

IRA WOLF, Staff Director

JOHN FOARDE, Deputy Staff Director

(II)

(III)

C O N T E N T S

Page

STATEMENTS

Kaufman, Joan, visiting scholar, East Asia Legal Studies Program, Harvard

Law School, Cambridge, MA ............................................................................... 2

Gill, Bates, Freeman Chair in China Studies, Center for Strategic and International Studies [CSIS]. Washington, DC ......................................................... 5

Des Jarlais, Don, director of research, Edmond de Rothschild Chemical Dependency Institute, Beth Israel Medical Center, New York City, NY ............. 9

APPENDIX

PREPARED STATEMENTS

Kaufman, Joan ......................................................................................................... 26

Gill, Bates ................................................................................................................. 27

Des Jarlais, Don ....................................................................................................... 39

(1)

HIV/AIDS IN CHINA:

CAN DISASTER BE AVERTED?

MONDAY, SEPTEMBER 9, 2002

CONGRESSIONAL-EXECUTIVE

COMMISSION ON CHINA, Washington, DC.

The roundtable was convened, pursuant to notice, at 2:30 p.m.,

in room SD–215, Dirksen Senate Office Building, Ira Wolf, (staff director) presiding.

Also present: John Foarde, deputy staff director; Susan Weld,

general counsel; Holly Vineyard, U.S. Department of Commerce;

and Jennifer Goedke, Office of Representative Kaptur.

Mr. WOLF. I would like to welcome everyone today to this 11th

staff-led roundtable of the Congressional-Executive Commission on

China.

Today, our subject is HIV/AIDS. The next roundtable will be on

September 23 on Women’s Rights: The New Population and Family

Planning Law in China. We will continue this series every 2 weeks

through the fall.

On Wednesday, October 2 at 10 a.m. in this room, the members

of the Commission will hold a press conference to release the first

annual report of the Commission.

We have three participants today. Dr. Joan Kaufman is a visiting

scholar at the East Asia Legal Studies Program at Harvard University and has been the program officer for Gender and Reproductive

Health with the Ford Foundation in China. Welcome.

Dr. Bates Gill holds the Freeman Chair in China Studies at the

Center for Strategic and International Studies [CSIS] in Washington, DC. Dr. Don Des Jarlais is from the Beth Israel Medical

Center and Albert Einstein College of Medicine in New York City.

The roundtable on HIV/AIDS is very timely. Qi Xiaoqiu, the director general of the Department of Disease Control at China’s

Ministry of Health, was quoted in the news on Saturday as saying

‘‘we need international organizations to help us in this battle to

control AIDS.’’ At the same time, Wan Yanhai, one of China’s most outspoken

advocates for AIDS patients, disappeared on August 24 and now it

appears that the State security has acknowledged that he is in

their custody, apparently for revealing State secrets.

Some people have asked how HIV/AIDS can be considered a

human rights issue as compared to just a medical issue.

I know that Dr. Gill discusses this in his testimony.

But I wanted to quote from the Office of the United Nations High

Commissioner for Human Rights.

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There is clear evidence that where individuals and communities are able to realize

their rights to education, free association, information, and most importantly nondiscrimination, the personal and societal impact of HIV and AIDS are reduced. The

protection and promotion of human rights are therefore essential to preventing the

spread of HIV and to mitigating the social and economic impact of the pandemic.

I think Dr. Wan’s detention illustrates the truth of this.

We also have the intersection of many varied themes: Development of civil society, government willingness or unwillingness to

tackle tough problems, corruption, especially at the local level, the

danger of simply speaking out in China, the problems with a system that shows little transparency, and the rights of the poor and

the most vulnerable.

Anyway, let’s get started.

Dr. Kaufman, please begin.

STATEMENT OF JOAN KAUFMAN, VISITING SCHOLAR, EAST

ASIA LEGAL STUDIES PROGRAM, HARVARD LAW SCHOOL,

CAMBRIDGE, MA

Ms. KAUFMAN. Great. Well, thank you very much. I should just

say that I am a visiting scholar at Harvard Law School this year.

I was a Radcliffe fellow last year.

What I would like to do is just give a brief overview of the AIDS

epidemic in China, then I would be happy to answer any specific

questions related to the more human rights aspects, especially related to Wan Yanhai. I just returned from 2 weeks in China. I

came back on August 30, and was there when he was arrested.

Let me just give you a very brief overview and say that, as of

just this past week, the government has raised its own estimate of

the number of HIV-infected people in China from 850,000, just announced last August, to a million. But most people still feel that

is an under-estimate.

U.N. AIDS estimates there are probably about 1.2 million infected now, and that does not take into account the unfolding information about the Henan Province blood-acquired epidemic. U.N.

AIDS also predicts that there could be 10–20 million people infected by 2010.

The key subgroups in China for the AIDS epidemic have mainly

been intravenous drug users who are officially 70 percent of the

cases. But the unfolding paid blood donors scandal in China, I

think, will dwarf that.

These are people who donated blood during the 1990s, in unclean

blood collection stations and who now are getting sick, and many

of their family members are also infected. This is likely to be at

least a million people in Henan, and similar situations are unfolding in a number of other provinces.

Female commercial sex workers are also another at-risk group,

and you have seen in several provinces increasing prevalence of

HIV among sex workers, and also homosexual men, who are a very

hidden group in China.

Let me go through each group and talk a little bit about these

epidemics and some of the issues. I was going to start off with drug

users. I am going to defer that to Don Des Jarlais, because that is

pretty much what he will be talking about. If he does not come,

maybe I will add that back in at the end.

3

The paid blood donor situation has been mainly an epidemic

among poor farmers who sold their blood for money during much

of the 1990s as a major source of income, and very related to the

economic changes going on in rural China and the disappearance

of other sources of income, especially for poor farmers.

It was a very widespread practice. Henan Province, in central

China, is the place we know the most about, but there have been

reports from at least nine other provinces of similar practices. So,

I believe it is just the tip of the iceberg and we will see this continue to unfold.

There has been rumored probable complicity by local officials in

the collection of blood, and even a supposed call from the Ministry

of Health, that this was a good way for local health bureaus to

make money.

Then there is also the as yet unrevealed role of the pharmaceutical companies, the plasma and blood products companies in

Shanghai and other cities, that will probably be revealed over the

coming years, in setting up these blood collection stations.

In Henan alone, there were over 200 sites and many people sold

their blood repeatedly over many years for about $5 a bag. The government prohibited paid blood donations in 1998, but the practice

continued in some places.

In some affected villages, over 60 percent of the adult population

is infected. With that has come sexual transmission to spouses who

were not infected themselves from paid blood donation, and vertical

transmission to children.

Henan, in particular, is on the verge of a huge orphan problem,

with two parents dying of AIDS and very little other civil affairs

arrangements made for care of these orphans who are highly

stigmatized.

There is little prevention and public education that is being done

to prevent further spread within the province, and a certain

amount of stonewalling by provincial officials because of their complicity in this problem, although on my recent trip to Beijing I was

really happy to hear that there are a number of initiatives under

way in Henan and the pending Global Fund submission is mainly

about providing care to ill people in Henan Province. So, there is

more happening now.

Let me move on to sex workers and say that there is widespread

prostitution in China now that has emerged over the last 20 years,

with very high rates of STDs, and especially in places like

Guangdong and some of the southern provinces, high rates of

syphilis, which are a harbinger of the coming AIDS epidemic.

You have had HIV rates among sex workers increasing in places

like Guangxi Province, it is almost 11 percent, and Yunnan Province, about 5 percent. So, this is really the evidence that it is going

to quickly move into a sexual epidemic in China.

It is also evidence that the time to act is at this moment, because

one could avert a major epidemic by dealing aggressively with the

sex worker HIV situation before it moves into the general population.

There is low condom use among sex workers, and, in general, a

low AIDS knowledge, particularly outside of the big cities. The

4

clients of sex workers—rural economic migrants—move all over the

country.

But some recent research has shown that middle-class men, businessmen, and entrepreneurs and officials are the major clients of

sex workers, the ones, with the most frequent visits who really

need to be targeted.

So any thought that this epidemic is only going to be about poor

rural farmers and rural economic migrants, is quickly being dispelled as untrue, and there is more recognition recently that China’s productive working-age population is very much at risk

through their fraternization with sex workers around the country.

Homosexual men. Let me say, briefly, that homosexual men are

a highly stigmatized and hidden population in China. Most of them

are married and they have not been at all addressed as part of the

limited AIDS response in China.

But recent data has shown that, for instance, a third of hospitalized AIDS patients in China, in Beijing, in the year 2000 were gay

men. They have few channels for information, little prevention, and

the situation of gay men and HIV risk is really a situation of discrimination and fear of exposure, is going to be a challenge to address.

Vulnerable groups. You have youth, who are a highly vulnerable

group for HIV/AIDS in China. There is little sex education, a real

reluctance to talk about sexual matters, and a feeling that one

should never talk about sexual matters with unmarried people, and

very limited AIDS knowledge and virtually no sexual health services available for young people in China.

But this is in contrast to very rapidly changing sexual attitudes

and behaviors, as evidenced by things like the increasing rate of

abortions among unmarried people, and many behavioral surveys

which have documented early onset of sexual behavior among

young people in China. It is still nothing like the United States and

other developed countries, because in China there is still fairly late

sexual debut and limited numbers of partners.

But I have just returned from a rural county in Guizhou Province on the border of Sichuan. In that county, that very poor rural

county, there were three adolescent pregnancies in the last year. I

think that is a real statement about changing sexual behavior in

China, an unheard of situation only 5 to 10 years ago.

As with most people in China, youth have very low self-perception of risk and virtually no condom use or access to condoms, so

they are very much at risk for HIV. Rural women are also at risk

not by their own sexual behavior, but from their returning migrant

husbands.

There are 150 million people on the move in China, economic migrants, most of them men, who come home to their home villages

once or twice a year. There are underlying reproductive tract infections that make rural women very susceptible to HIV infection.

The potential impacts of the epidemic could really compromise

economic progress of the last 20 years. A couple of recent studies

have come out which show that there may be, even with a low-increase scenario, a substantial economic impact.

As I mentioned, there is a growing AIDS orphan issue in the

poor rural areas with virtually no mechanism to deal with care for

5

these kids, discrimination keeping these kids out of school, families

falling into poverty to pay for treatment, and the potential for rural

protests by innocent victims. The public is beginning to mobilize

around the issue of these innocent victims. This has been a kind

of ‘‘Ryan White’’ issue for China.

The negative constraints are that there has been very little highest-level policy leadership yet and much local inaction. I would say

the epidemic is unfolding in China because of a collection of local

public policy failures: fiscal devolution in the health system and the

budgets are strained in poor areas, make it very difficult for local

government to pay for the necessary prevention and care activities;

high levels of discrimination and fear-based laws aimed at protecting the public; a limited number of civil society organizations

that could actually take up the battle; constraints on media coverage and information which make it difficult for people to know

about the AIDS epidemic and what has worked in other countries;

and complicity by local governments and denial.

But on the positive side, there has been a recent admission of the

severity of the problem and requests for international help, and an

existing, albeit weakened, health infrastructure through which to

mount a response.

There also exists a very good public education infrastructure

through the family planning program and the Party organs that

could be mobilized to do the necessary AIDS education, and the

ability to mobilize the Party and government around a national action agenda and access to treatment and care which are just

beginning. China recently announced plans to manufacture AIDS

anti-retroviral drugs if the drug companies do not offer reasonable

prices.

So, these are basically the highlights of the China AIDS epidemic

at this point in time. Thank you very much.

[The prepared statement of Ms. Kaufman appears in the

appendix.]

Mr. WOLF. Thanks.

Bates.

STATEMENT OF BATES GILL, FREEMAN CHAIR IN CHINA

STUDIES, CENTER FOR STRATEGIC AND INTERNATIONAL

STUDIES [CSIS], WASHINGTON, DC

Mr. GILL. Thank you very much. Let me thank you, and John,

and Susan, and the rest of the members of the Commission staff

for this opportunity to speak with you.

I just want to roughly cover the testimony in three parts. First,

offer a brief overview with a focus on what information we have

with HIV-AIDS in China and why we need to be highly skeptical

and cautious in treating those so-called facts.

Second, a focus then on something I hope is more interesting to

the Commission itself, and that is the implications for issues of

human rights, rule of law, discrimination, etc., of this issue.

Third, to address what is being done in China and in the United

States to confront the Chinese HIV/AIDS challenge and what additional policy recommendations I hope you as a Commission could

put forward to our policymakers to deal with this problem. And, of

course, I look forward to the discussion following this presentation.

6

I think it is important to note that there are forces both old and

new which are exacerbating the problem inside China in dealing

with the HIV/AIDS problem. On the one hand, of course, you have

this remarkable socioeconomic liberalization and opening up which

is driving this problem.

You have relaxed residency restrictions, a large floating population of itinerant labor, liberalized social attitudes toward sex, a

dilapidated and dangerous health care system falling apart in the

wake of the reforms.

But on the other hand, you have what I would call traditional

attitudes as well, such as a preference for male children, which we

can talk about later, which is, I think, an important factor, or could

be, in driving the HIV/AIDS problem in the future in China.

As Joan mentioned, there is a general reluctance to discuss openly sexual subjects, and more generally a lack of awareness on sexually transmitted diseases. These traditional factors have also

played a part.

As Joan noted, the Chinese Government today claims that there

are about one million HIV-positive persons in China. That statement alone should make us raise our eyebrows, because it is only

a year ago that they said there were 600,000. That is a jump of

67 percent in 1 year.

That is not because the HIV-positive population is growing that

fast, it is because the China Government does not really know how

many persons have HIV and they keep revising the figure upward.

But even if you take the Chinese figures as basically right and

you take their estimate of something in the range of 20 to 25 percent annual growth, China is going to have more than 6 million

persons infected with HIV in the next 5 or 8 years, by 2010. That

puts it ahead of where South Africa currently stands, and South

Africa is the world’s most heavily infected country, at about 5.8

million.

But let me just say a few words of caution about these figures.

China only counts about 30,000 officially registered and confirmed

HIV-positive persons in the country, so again that tells you that

this estimate of one million, who knows where they are getting

that figure from.

I think, as Joan says, and I concur with her, that even the one

million figure is probably an under-estimate for both practical and

political reasons. Practically speaking, China simply does not have

the resources or expertise available to provide the necessary surveillance and sentinel sites from which they can judge accurately

the extent of their HIV-AIDS problem.

The floating population, as I am sure you have all heard about,

is just another example. This, I think, is a population which is at

risk. It is true that there are more males than females, but in the

all-important age group of 15 to 19, at early stages of sexual activity among Chinese, there are more females than males.

According to a study which we saw at the Barcelona HIV/AIDS

meeting, about 55 percent of females in the floating population are

engaged in so-called ‘‘entertainment services.’’ These are precisely

the sorts of jobs which often can lead to commercial sex work.

So the floating population I think is one we need to pay a great

deal of attention to. But the Chinese figures that we see, and efVerDate 11-MAY-2000 11:09 Nov 08, 2002 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 82348.TXT China1 PsN: China1
7

forts officially that we see for them to deal with the HIV/AIDS

problem, completely ignore the floating population as a potential

problem or factor.

Of course, you are very familiar, beyond these practical matters,

of the political problems, a wish to contain knowledge about the

problem, especially with regard to the tainted blood scandal, when

you have got local officials who may well be complicit with the

spread of HIV/AIDS. Of course, they are trying to avoid bad news,

so you do not get the accuracy that you need.

So these numbers need to be treated with a good bit of caution

and they point to an enormous challenge, even of themselves, even

if the Chinese figure of one million is correct. That sure is a huge

problem.

But, in addition, there are these exogenous factors which also exacerbate the problem of HIV/AIDS in China: the failing health care

system, a lack of adequate drug treatments.

But, even if all the drugs were available to China today, you still

would have the problem of training both doctors and patients in

their proper use and monitoring their proper regimen, because misuse of drugs can lead to the emergence of resistant strains and can

be just as complicated.

We have that problem in this country of emergent resistant

strains of HIV because, (A) some doctors do not know how to properly prescribe anti-HIV drugs and (B) patients—they can be forgiven—have difficulty adhering as strictly as they must to the

proper dosage.

But in addition, in China, of course, we have heard about the

poor education and awareness overall, which is another exacerbating problem. I think, importantly, the Ministry of Health, which

is being largely charged with this battle in China, is a weak bureaucratic actor and is going to have enormous troubles overcoming

the traditional stovepiping that you see in Chinese bureaucracies

on the one hand, and on the other hand there is a traditional wariness within the Chinese Government about grassroots organizations and civil society activism that might be able to deal with the

problem at that other end.

I think a key point that I hope you will be able to take away

from this discussion is that the Health Ministry, I think, is well

aware of this problem and I think is working extremely hard to try

to deal with this issue.

But other parts of the government may well be less enthusiastic,

I think security apparatus, for one, which see another side of this

problem. For example, criminality, linking, if you have HIV/AIDS,

then you must either be a prostitute or a drug abuser, or a

homosexual.

On the one hand, that, I think, complicates efforts by the Health

Ministry and others to deal with this problem more effectively. Or

the security apparatus is also going to be, as I said, wary of grassroots organizations such as that of Wan Yanhai that might be operating outside of party and State oversight.

Let me turn, quickly, to some of the implications for human

rights, rule of law, and civil society. Joan has already mentioned

the problem of social stigmatization, which is fueled by poor levels

of awareness and education on HIV.

8

But the problems faced by HIV-infected individuals, their families, and other supporters goes beyond social stigma. We are aware

of laws and regulations, especially at a local level, that only reflect

the paranoia and lack of awareness, and can affect basic questions

of employment, access to health care, access to education.

You have questions of privacy and confidentiality, and even

issues of whether you are free to marry and move in search of gainful employment that can also be all affected by whether or not you

are perceived to be a victim of HIV/AIDS, either as HIV-positive,

or even as a family member of a person who is.

If persons are stigmatized, criminalized, or harassed, of course,

they are going to be far less likely to self-report or voluntarily submit to HIV testing, which is only going to drive the problem further

underground.

We see, in the case of Wan Yanhai, recently, that while there are

a number of sanctioned organizations that are accepted by the government as being legitimate in the pursuit of supporting efforts to

address the HIV/AIDS problem, such as, for example, the China

AIDS Network, which is based at Peking Union Medical College.

There are many other activists who we are more familiar with,

perhaps, from our newspaper reporting who have not fared as well,

like Gao Yaojie and Wan Yanhai. So I think a part of the Commission’s work needs to be to encourage counterparts in China to be

more open to the possibilities of these community-based organizations [CBOs] and non-governmental organizations [NGOs] in addressing what is, I think, at its root, a community and local issue

to be dealt with, first and foremost.

Let me turn, finally, to some suggested policy responses. We

should be happy that China’s 5-year plan, recently issued last year

by the Health Ministry, was done at all.

But there are many problems with it and it does not get into

many of the key social, political, and legal issues which are going

to need to be addressed by any comprehensive plan. It is mostly a

medical approach to the HIV-AIDS problem.

Targeting the floating population, for example, is missing. Reassuring those who are HIV-positive that their privacy concerns and

confidentiality will be protected. The passage of non-discriminatory

regulations and so forth. None of this is addressed in the Chinese

5-year plan that is currently out there.

So much more needs to be done in China. I am hopeful that with

the Commission’s dealings with counterparts in China, they can

make a number of suggestions.

For example, it seems to me there ought to be created a formal

and fully staffed office of national HIV/AIDS policy in China. Currently, the highest-ranking organization dealing with this issue in

China today is a kind of ‘‘lingdao xiaozu’’, or a small leading group,

led by Li Lanqing.

I would think it would be more effective to have a more permanent and day-to-day staffed organization that had both the political

and the financial resources to coordinate and come up with a comprehensive, over-arching, multi-agency approach to this problem in

China.

Nationalization of the junior high school sex education program

would certainly be effective. It is my understanding that there are

9

some pilot programs in China today, but that it has not yet been

extended at a national level, but certainly could be given, the central role of education in China.

We should also see that there is increased knowledge about sexually transmitted diseases, and an increase in the ability of China

to surveil and monitor and come up with accurate figures of what

sort of problem they are really dealing with.

Of course, much greater resources should be devoted to cleaning

the blood supply in China, and much work needs to be done to revise national HIV-AIDS-related laws to ensure civil rights

protections.

Let me close very quickly, in just 1 more minute, if I may. I note

in my testimony some ideas for the U.S. Government as well. I

think we are seeing some positive steps forward with the announcement earlier this summer of a grant of $14.8 million from

our Health and Human Services Department to assist the Chinese

CDC in training and research. But much more can be done.

I think we need to continue to remind our friends in China that

this is receiving high-level official attention here in the United

States and that we are watching carefully what sort of responses

they are undertaking in China.

I am hopeful that during the upcoming summit between

President Bush and Jiang Zemin in October, the two sides can

prominently note and support the expansion of ongoing United

States-Chinese programs on HIV/AIDS.

Our support, whether it be financial or political, should largely

be aimed at HIV/AIDS-related education, awareness, blood safety,

medical training, epidemiological research, and assistance in updating and distributing national treatment guidelines, as well as

the development of rule of law initiatives in this area of medical/

legal work.

My point here is that at this stage of China’s epidemic, it seems

to me that the best thing that we can offer would be ways to improve education, training, and knowledge about the extent of this

problem in China, and ways that HIV/AIDS can be prevented going

forward.

I also suggest that perhaps we consider initiating Peace Corps efforts in China which might offer HIV/AIDS awareness and preventive education and training programs.

Finally, that we improve within our own government our ability

to integrate HIV/AIDS issues into the inter-agency consultation

that goes on on science and technology issues with regard to China.

I will close there. Thank you very much.

[The prepared statement of Mr. Gill appears in the appendix.]

Mr. WOLF. Thanks, Bates.

We are joined by Dr. Don Des Jarlais. Please, go ahead.

STATEMENT OF DON DES JARLAIS, DIRECTOR OF RESEARCH,

EDMOND DE ROTHSCHILD CHEMICAL DEPENDENCY INSTITUTE, BETH ISRAEL MEDICAL CENTER, NEW YORK CITY, NY

Mr. DES JARLAIS. Thank you.

First, I would like to apologize for being slightly late. When I got

to the airport to catch the flight down, the only government-issue

picture ID I had was my State of New York World Trade Center

10

ID. The security people were no longer accepting that ID, so I had

to go back home and get a different one. I had an office in the

Trade Center.

I want to speak specifically on the linked epidemics of HIV and

injecting drug use in China. About 10 years ago, the U.S. National

Commission on AIDS issued a report called ‘‘The Twin Epidemics

of HIV and Drug Use’’ about those problems in the United States.

Much of that report can be applied to China, particularly the

idea that if you do not address both of these problems, you will not

be successful with either of them.

I also want to note that there is potentially very strong linkage

between injecting drug use and sexual transmission of HIV in

China, transmission from male drug users to their non-injecting

wives, transmission from male drug users to commercial sex workers, and then potentially on to other non-injectors, and although it

is still at a very early stage, the potential for female drug users to

engage in commercial sex work.

I am currently working on three different research projects on

HIV and drug use in China, and I would like to briefly describe

those and some of the preliminary findings, because I think that

those findings have implications for the country as a whole.

First is the World Health Organization [WHO] multi-site study

of injecting drug use and HIV. It is currently in its second phase.

It involves 14 different cities throughout the world, including cities

in Latin America, North America, Eastern Europe, Africa, and

Asia.

Beijing is represented in this study. Wu Zunyou of the Chinese

Academy of Preventive Medicine is the principal investigator for

the Beijing site. He is currently finishing up his data collection.

But the preliminary findings from Beijing indicate an unusually

high degree of stigmatization of both HIV and injecting drug use

in Beijing, probably more than any of the other cities participating

in this World Health Organization study.

Normally when we recruit drug users, it is quite easy to get them

to bring their peers, their colleagues, to come into the study. That

turned out to be quite difficult in Beijing. There is a lack of trust

between the drug users and the health authorities in the city that

is remarkable in terms of other cities throughout the world.

The political sensitivities of Beijing in particular seem to make

it very, very difficult to admit injecting drug use, to admit being

HIV-positive. These undoubtedly will make doing HIV prevention

work much more difficult in that city, and in some ways reflect the

policy problems that both HIV and injecting drug use pose for the

Chinese Government.

Any indication of drug use or HIV in Beijing itself is considered

to be potentially extremely embarrassing, and so trying to work in

that city is much more difficult than in most cities throughout the

world.

The second study I would like to mention is the China-United

Kingdom Project on HIV/AIDS Prevention and Care. Cheng Feng

and William Stewart are the principal investigators. This is going

on in multiple provinces in China.

11

The idea behind this is to provide comprehensive programming

to reduce both sexual and drug use transmission of HIV and provision of care for HIV-infected persons.

Now, this has involved situational assessments of sexual health

and rapid assessment of drug use risks. This study was able to obtain an understanding with the Chinese Government to permit ‘‘social marketing of sterile syringes’’ to reduce HIV transmission in

China.

This is short of approval of syringe exchange programs, which

are one of the most effective means of preventing HIV among drug

users in the world. But, instead of having formal exchange programs, the drug users are to be encouraged to go to local pharmacies to purchase sterile injection equipment.

This project has also been working on a pilot methadone maintenance treatment program in order to provide treatment for addiction. Unfortunately, that has not received final approval yet.

The third project I would like to mention is one with Ted

Hammett of Abt Associates, Liu Wei of Guangxi Province, and

Chung A of the National AIDS Standing Bureau [NASB] of Hanoi.

This is the cross-border project between China and Vietnam. We

are working to try to prevent HIV transmission among drug

injectors in the Longsong Province of Vietnam and Guangxi Province of Southern China.

That is an extremely porous border. People walk across it every

day. If you are a drug user and you hear the price of heroin is better across the border, you walk across the border and purchase

your drugs. If you hear that police activity is a little more strenuous on one side of the border, you tend to inject on the other side

of the border.

Here, I think the important point is that if we want to consider

HIV in China, we will have to consider not only China itself, but

the surrounding countries. There is clearly HIV transmission

across the southern borders with Vietnam, Myanmar, Laos, Thailand, the Golden Triangle region. There is also strong indication of

HIV spreading through China and into the Central Asian republics,

that HIV really does not respect national borders.

If it is to be controlled in China, this will involve having to work

with other countries in the region. Having successful prevention on

one side of the border will not work if the people then cross the

border and become infected on the other side, and then return to

their homes.

So if we want to think about controlling HIV in China, we are

also going to have to address the region as a whole and not just

one country.

The preliminary findings from this study are relatively positive.

There are good working relationships between the Chinese health

authorities and the Vietnamese health authorities. Peer education

programs have been implemented on both sides of the border.

Unfortunately, however, we are running into some indications of

difficulties with the police, that the drug users are being encouraged to use sterile injection equipment, but they are afraid that

they will be arrested for carrying sterile injection equipment, which

greatly reduces the chances of practicing safe injection.

12

There are four main points I want to make with respect to HIV

and drug use in China. The first is the potential for extremely

rapid spread of HIV among drug users. There are incidence rates

of 20 to 50 percent of the local population of drug injectors becoming infected in a single year, so you can go from no one infected

to half of the local population within a single year. We have seen

rapid transmission like that in India, in Thailand, and in a few

places in China already.

We have also noted that HIV is present in drug injectors in all

Chinese provinces, so there is the potential for very, very rapid

transmission, forming a pool virus that would then spread to both

new injectors and sexual partners.

At the same time, there is also the potential for extremely effective HIV prevention among drug users. Arguably, HIV prevention

programs for drug users have been among the most effective in the

world. There are countries such as the United Kingdom and Australia that have kept their HIV infection rates to under 5 percent

of all injecting drug users for the last 20 years.

So, while there is the potential for extremely rapid spread of the

virus, there is also the potential for very effective prevention programs. The three characteristics of effective prevention programs

for drug users are to, first, begin the programs early. Do not wait

for the rapid spread, but begin the programs as soon as possible.

Second, provide trusting communications between health workers

and drug users. This usually involves doing outreach in the

community rather than waiting for drug users to come into institutions.

Third, provide good access to sterile injection equipment, and

specifically the ability to use that injection equipment.

I would also like to talk a little bit about the growth of illicit

drug use in China. We have a tendency to think of drug using populations as relatively stable. In some parts of the world, such as

East Asia and Eastern Europe, that is the exact opposite.

At present, there are officially registered 860,000 drug users in

China. That number has increased by over 50 percent in the last

year. The actual number of drug users is probably much greater

than the officially registered. Illicit drug use in China would be a

major public health problem even without the additional problem

of HIV.

Now, just a few, short recommendations. Clearly, there is an immediate need for programs to prevent HIV transmission among injecting drug users, for programs to prevent spread to their sexual

partners, for programs to prevent initiation into injecting drug use.

There is a need for treatment programs, health-based treatment

programs such as methadone maintenance for drug addiction.

There is a need to do all of these at a public health level, not

a pilot program level. Pilot programs can be wonderful demonstrations, but they will not affect epidemics.

Finally, certainly, limited resources are an important problem in

China, but the need for policy commitment is probably a much

greater problem. Thank you.

[The prepared statement of Mr. Des Jarlais appears in the

appendix.]

Mr. WOLF. Thanks very much.

13

Bates, could you address the broader issue of civil society? One

theme throughout the roundtables we have been having, whether

it is on labor, religious freedom, almost every issue, is the inability

of the government to deal with the economic and social stresses,

with many participants talking about civil society as one solution.

As these problems build in sector after sector, do you see any

changes in the thinking in think tanks or by government officials

that there should be some move in the direction of encouraging

civil society developments, despite the traditional fear that this will

undermine the regime?

Mr. GILL. I do not think we can detect that movement very

strongly. I suppose that depending on what sort of organization you

were talking about and what sort of issues they might be trying to

address, there might be some degree of flexibility about that organization’s ability to operate.

For example, I would presume—although this is not an area of

my own expertise—for example, that efforts to, say, develop economic opportunity, organizations that might be lending assistance

in the way of improving economic situations for persons, perhaps

there there might be a greater degree of flexibility because it was

engaging in an overall effort which the central authorities could

support, and probably did not have the tinge of politics attached to

it that I think often gets in the way of other civil society actors

from having much more success.

Another reason, I would suspect, is that there is an underlying

fear or understanding among persons in China, that to organize

one’s self in bodies that are not related to the Communist Party is

something that can be risky and something you want to try to

avoid.

It is especially true if you are going to be doing it in issue areas

that are sensitive and problematic and known to cause trouble for

persons in the past.

So on the one hand you have the government, where the top

down way of looking at this is that there is going to be wariness,

skepticism, and caution toward groups that want to engage in

these sorts of activities, but from the bottom up perspective, as

well, there is fear, and concern, and risk, so that the incentives are

not particularly great from that side, either.

It is also my understanding—at least this is communication with

Wan Yanhai, and I do not know beyond his statement how true

this is—that to be registered as a kind of non-governmental organization, whatever that really means in China, costs money, and is

sometimes prohibitively costly.

That, I think, is another disincentive. Even if one could argue

that your operation was not politically sensitive, perhaps it was too

costly. That is another reason for not doing it.

My short answer, Ira, is that I do not detect any significant

movement or appreciation for these sorts of efforts in dealing with

the whole range of problems that you have suggested.

Mr. WOLF. Joan, on AIDS assistance, should the United States

be focusing bilaterally or are we better off working through multilateral organizations with China?

Ms. KAUFMAN. Yes. I think that bilaterally is the way to go.

There are a number of bilateral agreements other countries have

14

with China on HIV/AIDS, particularly the British, the Australians,

AUSAID have bilateral support programs. The way to go is a bilateral program that goes beyond medical assistance and surveillance.

I know there is some activity planned or under way through the

CDC to improve blood supply, voluntary blood collection practices

and surveillance, and voluntary HIV testing and counseling. But I

think there is much more that can be done that really leverages

the extensive U.S. experience in helping to develop some of the

international best practices in prevention and care, and also in the

public policy response. This is something that really did not come

up in the other recommendations.

I do feel that this is a critical contribution we can make: explaining how government organized itself in the United States to deal

with the AIDS issue, what is the coordination between legislation—

for instance, anti-discrimination legislation—and what is the relationship between the State and Federal system in terms of the

AIDS response.

As I said in my testimony, China is a collection of local public

policy failures. There are probably about 20 people at the national

level who are the counterparts for everybody working on the AIDS

epidemic. There is an enormous need to train up people who know

the international experience and how to learn from the last 20

years.

I do think that there are some good civil society organizations in

China. They have a different role and it is more of a patronage

type relationship with government. Civil society is different in

China, but there has been a tremendous growth of non-governmental organizations [NGOs] in the last 10 years, certainly the 5

years I was living there, up to 2001.

I think that there is the potential to draw some of these emerging research organizations and new service organizations into the

AIDS battle. For instance, some recently established groups that

are working with people living with AIDS, representing people living with AIDS.

There has been much movement in the last few years. There is

the potential to engage with civil society. Certainly, the Ford Foundation did, and supported many of those groups.

Mr. WOLF. Thanks. This is an issue that Susan Weld will focus

on in the coming year for the Commission.

Next is John Foarde, who is deputy staff director of the

Commission.

Mr. FOARDE. Thank you. First, I would like to thank all three of

you for joining us this afternoon. We are particularly grateful to

Dr. Kaufman and Dr. Des Jarlais for coming here from far away

under trying circumstances, both in personal life and just trying to

travel any more. It must have been a real hassle. But we are delighted and grateful that you have come to share your expertise

with us.

A couple of questions. Joan you mentioned that you thought that

the Chinese Government had an opportunity to mobilize and use

some of the tools that the government and party has to mobilize

public campaigns on HIV/AIDS, similar, for example, to that which

is currently under way against Falun Gong.

15

Do you have a view as to why the Chinese Government is focusing on Falun Gong when this particular crisis is more immediate?

I mean, even assuming that Falun Gong is a problem, that this crisis is so immediate and so urgent and could be addressed, or at

least partially, by the use of these tools.

Ms. KAUFMAN. I guess I asked for that. I would say that it is because the Chinese Government at the national level, and the party

in particular, does not see AIDS as a threat to them, where they

do see Falun Gong as a threat to their rule.

That is the simple answer. I think if you unpack it a little bit,

it is because I think there is really a lack of appreciation at the

national government level about what this epidemic potentially is

going to do to economic and social development in China.

China is a very closed society. And while there is a lot more information than there was 20 years ago, I do think it is very

predigested information. I think that there is always this feeling

that ‘‘it is not us, that AIDS cannot affect the United States like

in sub-Saharan Africa.’’

Also, because it is happening in rural China and until recently

it has affected mainly IV drug users, it is really not about the people who are sitting in Beijing or the economically productive, sort

of mobile part of the population. I think that is where the fallacy,

the misconception, is.

Part of the role, I think, of cooperation, is the international responsibility to help bring an awareness to the leadership of China,

which I think is happening. The announcement this week, indicates

much more high level attention and is an important signal to the

provincial authorities who really control this issue in their

provinces.

This is going to undo a certain amount of economic and social

progress of the last 20 years and it is going to be a social and economic disaster in some places, as it already is.

So it is about not really seeing it as a threat to themselves, and

it also speaks to the inability of, on some issues, Beijing to make

the provinces act—I think health is a weak player in the political

system, and the Health Ministry alone, or the Chinese CDC, Academy of Preventive Medicine, cannot make the provinces respond to

the AIDS epidemic. You have many people in Beijing who absolutely know what has to be done, the 20 or so people.

But you do not have counterparts at the provincial level who see

it happening, and you do not have the authority among the health

folks to make it happen without the pressure from the party and

the national government, the highest levels of leadership.

So I think it is an intricate problem, but has mostly to do with

the lack of appreciation of the real threat and the threat to

themselves.

Mr. FOARDE. Thank you.

Dr. Des Jarlais, you suggested that to address the HIV/AIDS

problem among intravenous drug users, you really had to look regionally. Are you aware of any multilateral or bilateral consultations, other than the one you mentioned with Vietnam, between the

Chinese Government and, say, the ASEAN countries, either individually or multilaterally, and what is the nature of it?

16

Mr. DES JARLAIS. There is work in that area going on. There is

the Asian Harm Reduction Network based in Chiang Mai, Thailand

that is attempting to create more international cooperation. But

things are still at a relatively low level.

Mr. FOARDE. Is it focused on IV drug use prevention or treatment

or is it focused on HIV/AIDS?

Mr. DES JARLAIS. Equally on both. The feeling, again, is that if

you do not address both of those problems, you will not be successful with either one. If you allow the burgeoning drug epidemic to

continue without providing either prevention or treatment for drug

use itself, you will always be playing catch-up with HIV. But if you

do not also provide for safer injection and reducing HIV transmission, the catastrophe will happen anyway.

There is one additional comment I would like to make with respect to Joan’s comments. The problem is not only with the Chinese Government, but there is a similar problem with the Indian

Government and the Russian Government. There is a tendency to

see HIV as a problem of the socially marginalized and of small,

weak countries.

I think, to the extent that those three very large countries in

Asia and Europe could start to realize that this will be a catastrophe for each of them, there may be potential synergy. If you

could get one of those countries to move, it might be easier to get

the other two to move.

Mr. FOARDE. Thank you. Really useful.

Mr. WOLF. Thank you. Jennifer Goedke works for Congresswoman Marcy Kaptur of Ohio.

Ms. GOEDKE. Thank you all for being here as well.

My first question, I guess, would go to anyone on the panel. If

any, what are the differences in education and access to health

care between men and women in China?

Ms. KAUFMAN. I am happy to speak to that. I think in the urban

areas you find virtually no differentials, but in the rural areas you

really do find substantial differentials, given the much lower social

status of women and girls in the household.

I worked on women’s health issues in rural China in my Ford position. I think you really do see much lower levels of health seeking

and much less control over very limited household resources which

are prioritized for male health seeking, and for the health seeking

for baby boys. I think it is particularly problematic when you look

at the 0–5 mortality rate for girls versus boys.

Now, the recent evidence from Henan Province, really reinforces

that, that in these families where the husband and the wife are

sick, money is prioritized for treatment and care for the male, the

breadwinner in the family, for the most part, usually depleting

family resources.

Ms. GOEDKE. Also, are there many international programs or

other domestic, non-governmental—if there is such an organization—distributing educational materials, or condoms, or clean syringes, and if so, is there any success rate that has been tracked

with those? For anyone on the panel.

Ms. KAUFMAN. I am happy to answer that. There are many,

many organizations working on HIV/AIDS in China doing education. There are international NGOs like Save the Children U.K.,

17

Oxfam, many, many organizations that are working in pilot

projects around the country, supported by the international donors,

by the multilateral institutions, the U.N. agencies, bilateral donors.

There are many excellent pilot projects demonstrating some of the

international best practices.

But the problem is, they are pilot projects. There really needs to

be a rapid scaling up, even within the provinces where they are operating international programs.

Mr. DES JARLAIS. And just a note, some of those are against the

official policies of the central government. Syringe exchange in

Yunnan Province looks fairly effective, even though the official policy prohibits syringe exchange. So, there are these successful pilot

projects, but going to scale is a huge problem.

Ms. GOEDKE. And my final question is actually for Dr. Gill. You

said that there were some school-aged health and sex education

courses being offered now, and you recommended that they go

national.

Where are those courses falling short right now?

Mr. GILL. We saw reports of one such program being instituted

in Shanghai.

Ms. GOEDKE. And that is the only one that you are aware of?

Mr. GILL. Shanghai and Guangzhou, which of course is to be applauded. But I think, in line with what we are hearing from our

other panelists, these are among the most sophisticated, urbanized,

highly educated and affluent cities in China.

One could suspect that the populations of those cities may well

be better educated to begin with, which is welcome, of course, but

that these sorts of small programs simply cannot compare with a

more comprehensive effort.

I would just add in response to one of your previous questions

that, again, even if it were possible to establish nationwide programs of condom usage or other important steps, it seems to me

that the resources would still be lacking in China, at least as it

presently stands, to do a very adequate job of gauging the success

or failure of them.

One real problem with the numbers, as I mentioned, is that the

focus is entirely on high-risk groups at the moment. My guess—I

do not know if this is true—is that the Chinese figure for 70 percent of HIV-positive persons are HIV drug users, my guess is that

that figure comes strictly from the data that has been generated

at the 100 or so sentinel sites inside China where they are testing

IV drug users, or sex workers, or truck drivers. In other words, the

data is skewed precisely because of who they are testing.

So until we are able to introduce, or others are able to help

China introduce, more accurate epidemiological assessments and

other ways of surveilling and monitoring the implementation of

programs, then we cannot know how successful they can ultimately

be.

Ms. GOEDKE. Thank you.

Mr. WOLF. Thanks.

Next is Holly Vineyard, who works for Under Secretary of Commerce Grant Aldonas.

Ms. VINEYARD. Thank you for joining us today.

18

Dr. Kaufman, you were a little rushed at the end, so I would like

to give you a little more time to expand on your final point in

which you discuss compulsory licensing.

Some of the initial press reports on this have not been entirely

clear. Some have hinted that China may be in violation of its WTO

[World Trade Organization] commitments.

But our initial read is that China’s intentions do seem consistent

with TRIPS and the Doha declaration on the TRIPS agreement on

public health. So, if you could expand a little.

Ms. KAUFMAN. Yes. I think that is precisely the spirit of the announcement that the government, I think, is facing.

In fact, I was in a lunch with a very senior health official last

week who was saying to me, we have calculated the cost of treating

all the HIV people in China, and it is this number. It was so beyond the scale of possibility within the currently available budgets,

that I was not surprised to see this statement a week later.

I do feel that I think the issue is that they would like to give the

drug companies every opportunity to bring the price down to an affordable level. Even the currently available treatments are

something like 10 or 20 times the per capita income of most rural

farmers who need it.

There is absolutely no way that people can pay for anti-retroviral therapy in China. I believe that, even if it is brought down to $300

a year, it is still about equal to per capita income for most rural

farmers.

But it is much closer to a range that is affordable of the public

health system to be able to think about selectively deploying some

kind of co-payment system. There has to be an enormous amount

of subsidization of treatment in China.

Bringing the price down and making the drugs available is the

first step. I was very pleased to see some move in that direction,

because even as recently as a year ago, the discussion on treatment

for AIDS-infected people was really that we cannot afford to do

that. That is not an option we have.

I am glad to see that it is part of the discussion at this point and

there is planning and thinking, including submission to the Global

AIDS Fund that will include treatment for people in Henan.

I believe it is within the spirit of the WTO, and it has been carefully considered. I think there have been some trial balloons over

the last 6 months to really see how the international community

responded.

Ms. VINEYARD. Thank you.

Dr. Des Jarlais, I was interested in your characterization of China’s border as being ‘‘porous.’’ I was hoping you could expand on

that with some examples.

Mr. DES JARLAIS. Yes. In this project across the border of China

and Vietnam, you just walk across. There is one point where you

can pay a 1 yuan fee if you want. There was another place where

there was just a small ditch about a foot wide that you stepped

over. In others, it was just a path.

This is in sort of the hill country of Southeast Asia, with a lot

of hill tribes that live across the borders. On market day in the

Chinese town, the Vietnamese villagers walk over to do their

marketing.

19

There are official border crossings where you see large trucks

lined up and it takes them a day or so to get past, but for the ordinary people that live in the area, there is essentially no border.

That is true in a lot of places in Southeast Asia, where the borders

are not necessarily even marked.

Ms. VINEYARD. Thank you.

Mr. DES JARLAIS. Yes. It is somewhat surprising. I wish I had

my PowerPoint slides with me, but I took a picture of that footwide ditch that constitutes the border in one place.

Ms. VINEYARD. That is interesting. Thank you.

Mr. GILL. Ira, may I make one response to Ms. Vineyard’s question regarding anti-retrovirals in China? I think we need to be very

cautious on this issue. Not only will it be expensive to provide the

necessary treatment, just the tablets themselves.

Then you have to add on distribution, logistics, training of barefoot doctors. I am not kidding. Training of barefoot doctors in villages in China as to the proper dosage, regimen, oversight, and

monitoring. This is a huge amount of money, well beyond even if

it is $300 per annual dosage. The cost goes well beyond the basic

cost of what the medicines will be.

If you do not see it that way, you are only going to fuel the

spread of this disease in China by improper dosing, improper regiments, improper usages of the anti-retrovirals. I think today in

China the money will be much more wisely spent on prevention,

awareness, education so you do not get the disease in the first

place.

If we can alleviate the suffering of the people who have contracted the disease, and by all means we certainly should, I think

we have to recognize that in China’s case of a resource-constrained

environment, I think they may have to take other choices and put

their money behind awareness and prevention.

Ms. VINEYARD. Thank you.

Mr. WOLF. Susan Weld is the general counsel for the

Commission.

Ms. WELD. Thank you all for coming, and thank you, Don. I am

sorry about your ID. That kind of thing happens to me all the time.

I wanted to ask you, first, about the border in Central Asia. Is

that a significant place where IV drug use and HIV have come together, and is that a growing problem? The governments on the

other side there are not very organized, from my impression. I do

not know whether there could be cooperation across that border.

Mr. DES JARLAIS. Unfortunately, there is tremendous cooperation

in terms of shipping drugs across those borders. There is molecular

epidemiology showing the spread of HIV among drug users across

those borders.

Getting government cooperation for HIV prevention, I think,

would be a challenge, and certainly was a challenge for us in Vietnam, in China. It took us 5 years to get that project going. I want

to acknowledge Joan’s help, and the Ford Foundation, in doing it.

However, I think that it is very, very important to try to set examples of successful international cooperation and the Central

Asian republics are another place where cooperation really is going

to be needed, because the virus is clearly spreading across the

international borders there.

20

Ms. WELD. Thank you.

Now, Bates, I have a question about leadership. When I talk to

people from U.N. AIDS, they say for the countries which have been

successful, one of the factors of success has been some figure at the

national level that has taken possession of the issue and has decided to stand up and say, this is a hugely important issue for our

country, we are going to go forward and really emphasize it. Is

there anybody in the leadership in China that you can see taking

that kind of a role, either now or after the transition?

Mr. GILL. No. No one is readily identifiable to us at this point.

There may well be such a figure, although I think that would run

somewhat contrary to the way things normally work in the Chinese

political system as it is presently constituted, to have a kind of risk

taker, a person that is willing to stick their neck out, especially on

a sensitive issue like this.

You do not find many people like that in China. I think the current situation of socioeconomic transition in China today only

makes risk taking all the more risky and unlikely.

The one figure, if I understand it correctly, who people would

most closely identify as a kind of ‘‘leader’’ on this issue, is Vice Premier Li Lanqing, who is also on the standing committee of the

Politburo.

He, I think, is about 70. He is not a fourth-generation leader. He

may survive the succession. Some people speculate that, because of

his relative experience and ‘‘relative youth,’’ in his early 70s, he

may be retained either as a vice premier, or that he might continue

with his seat in the Politburo.

If there was one person you wanted to point to, it would be him,

because apparently he is leading what amounts to a kind of largely

ceremonial, inter-agency leading small group effort that is trying to

coordinate the various agencies in the Chinese Government to address this problem.

But he is not high profile. He has got a lot of other portfolios that

he is dealing with. So, I do not see him necessarily emerging as the

kind of figure that you suggest.

I am very impressed with Health Minister Zhang. I think he has

shown some leadership and boldness in going public last year. But

I am not so sure it was just him alone who had a vision, who saw,

as an individual, that he could take charge and move this issue forward. He may well have been prompted from lots of other forces

that he had to take the step and make this a much more public

issue.

So I do not see anyone in particular. There may be other views

on that. But it is not consistent with the way things get done in

China. What it requires, is Hu Jintao to say, this is important and

we are going to deal with it, if he becomes the paramount leader,

as we suspect he will.

Unfortunately, I think, much like, say, in the problem of corruption in China, it is going to be ignored at the upper reaches of the

government for the reasons that Joan suggested, because it is not

seen as a threat yet, but also because it reflects poorly upon the

party for all the mistakes that have been made by the government

in letting the HIV/AIDS problem get as out of hand as it has.

21

So that is going to limit any leader from wanting to get their

head chopped off for taking a prominent role, but I think it is going

to have to be done at that high level.

Unfortunately, it is going to take vice mayor of Guangdong to

come down with this disease, or something like that, unfortunately,

before you can expect, I think, a higher level of mobilization above

the Health Ministry. It has to happen above the Health Ministry.

Ms. KAUFMAN. Could I add something to that? I would just say

that Li Lanqing has been the most senior government official in

charge of the AIDS epidemic, actually the State counselor responsible for health issues within the government, over the last 4 or 5

years and has not risen to the occasion in that way.

I think it is too politically sensitive and I doubt he would do it

in the future. I think the task will fall upon somebody else after

the transition. But I am more hopeful, because I think public opinion is really shifting dramatically, and that the government attitude at the national level has shifted a lot.

I do believe that someone will rise to the occasion within the next

year and take a leadership role on the AIDS response. I think there

are many signals pointing in that direction, actually. At least, I am

hopeful. I am an optimist.

Mr. WOLF. Thanks. I do not have any other questions. Does anyone? John.

Mr. FOARDE. I would like to ask, probably Bates and Joan, about

regional variation in infection rates. Are the rates, as far as we

know it judging from the data that is available, more in eastern

China, western, northern, southern? Are there certain pockets? You

talked about 11 provinces earlier. Are those just the ones we know

about or do we have a good sense of whether there are regional

variations?

Ms. KAUFMAN. Would you like me to go first?

Mr. FOARDE. Sure.

Ms. KAUFMAN. Well, certainly if you look at the surveillance system data, which is the basis for—Bates was right. The 70 percent

drug user figure is from the national surveillance data, which is in

110 surveillance points, I think, around China, mostly among highrisk groups.

If you use that as the indicator, you have got the most cases in

Yunnan Province, which is where the epidemic started, on the Burmese border, and very high prevalence also in Xinjiang Province,

which is bordering on Central Asia.

You also have then the other big epidemic in Henan, which has

been less documented by the surveillance system data. Actually

what you do have, is a border area, southwestern and western border area, epidemic.

For central China, we just do not know the extent of the bloodinfected people in central China. Certainly, we are getting an idea

about what is happening in Henan, but we do not know about

these other provinces that have also used these same blood collection practices, where they did not have somebody break the story

and have a lot of attention focused on it.

I think you do have probably nine or so other provinces where

you have had documented cases in some counties and villages. So

22

I think you are going to find some central China concentration beyond Henan, plus these western boundary areas.

You have not really seen it on the northern border. In the south,

it is starting in places like Shenzhen and Guangdong, where you

have had high rates of syphilis, which is especially effective as a

co-transmitter of HIV.

So, I think it is mostly in the southwest. That is what is known.

The center, in places like Henan and other places, will come out.

Then you will also see the sexual transmission really unfold, I believe, in the south around Guangdong and Shenzhen. That is my

best estimate.

Mr. GILL. I would concur with everything that Joan has said, but

would only just add a couple of caveats, perhaps.

As far as I know, HIV has been identified in all 31 provinces and

municipalities of China, so it is everywhere. I guess it is a question

of, how intensive has it become in certain areas.

Now, just take this statistic, for an example. Of the 100 to 110

sentinel sites which are being officially operated by the Chinese

Ministry of Health, something like 44 of them are in Yunnan Province. So if we are trying to answer your question by looking at the

official data as generated by the sentinel sites, you get a completely

skewed understanding.

You are going to see all kinds of different HIV infection happening in Yunnan, because there they are dealing with sexually

transmitted disease clinics, they are testing detained IV drug

users, and others. So, you might get three or four different risk

groups being looked at because there are so many sentinel sites.

Up in Urumqi, there is one antenatal test site. So there, the

numbers are off the charts for how high mother-to-child transmission of HIV is. But that is not a very accurate way of understanding it.

I think there really is no answer—no good answer—to your question. I think Joan has laid it out right, that we have a sense, a

speculative sort of understanding of where we think the worst of

it is, but I do not think we really, really know.

Mr. FOARDE. That, itself, is worth knowing.

A question for Don Des Jarlais, please. What is your assessment

of the State of Chinese science on HIV/AIDS, and particularly with

respect to transmission from IV drug users? How much money, how

many resources are going into training, labs, surveillance, etc., and

how extensive has their own research been?

Mr. DES JARLAIS. There has been a moderate amount of research

for 10, almost 15 years now, particularly focused on Yunnan and

the drug users. Their labs are fully sophisticated.

In our projects, we are using domestic labs for the HIV testing.

They are sophisticated in terms of human rights, research protection, institutional review board, ethical review, not uniformly

throughout the country, certainly, but they have the basic understanding of how to conduct research and the facilities for doing it

in many places.

The National Institutes of Health has been awarding considerably more money over the last year. The CDC is going in with some

money. So, while there is always a need for capacity development

and infrastructure development, particularly in many of the provVerDate 11-MAY-2000 11:09 Nov 08, 2002 Jkt 000000 PO 00000 Frm 00026 Fmt 6633 Sfmt 6633 82348.TXT China1 PsN: China1
23

inces where work has been done, there is a good, solid foundation

there to work with.

Mr. WOLF. Susan.

Ms. WELD. Yes. Sure. I wanted to ask something about the local

governments. Now, I have heard about the leadership. It seems

that Dr. Gill does not think that there will be national-level, conspicuous leadership, which leaves it to be done at the local level.

I wonder where the money will come from for that.

Will it just be funded the same way that the health care institutions are currently funded or not funded at the local level, or will

there be extra money being poured down from the central government to the local level? How will that funding go to do the preventive education?

Mr. GILL. Well, I am just skeptical that there will be a national

leader. I am not saying there will not be on this issue. I think we

should expect, over the coming several years, that the central government allocation aimed at addressing the HIV/AIDS challenge in

China will certainly increase.

There has been a dramatic increase in just the past year, and

hopefully we can expect those sorts of increases to continue.

So I think, again, the Ministry of Health understands what

needs to be done. I think, if given the resources, they could probably do a relatively good job of it, as long as they are sort of given

the political clout from above that is necessary so that, if and when

they do need to knock heads among other bureaucratic actors to

see that effective policies are implemented and resource allocations

reach the places they are supposed to, then it will. But that is a

big if.

So in the interim, while there may be increased amounts of funding—and we are not talking about a lot of money, by the way. I

think the most recent budgetary allocation in China for dealing

with HIV/AIDS-related prevention and awareness and blood cleanup programs is only the equivalent of about $15 million. Tommy

Thompson signed a check to China for $15 million over 5 years,

probably without even batting an eye.

So it is not a lot of money, given the extent of the problem. So,

even if that is doubled or tripled, it is hard to know. It will have

some impact, certainly, but it is hard to know how effective it can

be.

You have learned in your other hearings of the difficulty that the

central authorities have in exercising authority and property implementing policy directives at provincial and local levels, and I do not

think that this particular issue is going to be any different.

So much of the burden, I think, will have to be somehow picked

up at the local level, both in terms of sort of political awareness

issues, but also in terms of just monetary and financial resources

being devoted to treatment and care, and awareness and education

programs. There is not a lot of resources at the local and provincial

levels, either. Some, better than others, of course.

But in some of the cases that we are talking about, where we believe the problem is especially acute, these are not wealthy provinces, but are rather inland, detached from the economic vibrancy

of the eastern coast.

24

So, again, I hate to be pessimistic about this, but I just do not

think there is either the political will or the financial resources

available to tackling the problem either at the central or the local

levels yet.

Ms. WELD. I have heard some of the people I have talked to

say—and this is for anybody who wants to answer—that it is possible to devise best practices in legislation, local, provincial, and

sub-provincial legislation that would address some of the problems

of HIV/AIDS.

Anybody who wants to speak on this, are there models for this

kind of effort in China? Is this something that the United States,

either at the Federal, State, or local level, could perhaps help out

with?

Ms. KAUFMAN. I am happy to address that. I do not think there

are models in China that I know of, of local public policy, multisectoral coordination on an issue in a way that is required for responding to the AIDS epidemic.

But I do certainly think that within the United States there are

models at local government, coordinating the laws protecting the

rights of HIV-infected people, with programs on voluntary testing

and counseling, ensuring access, getting social services

involved.

I think the multi-sectoral model is the model that has been

shown to be the absolute requirement for dealing with AIDS at the

local level, not just a health response. I do think we have enormous

experience in this country on that.

I was happy to see Bates had in his recommendations setting up

kind of a White House Office on AIDS at the State Council level

in the Office of the President in China.

I think these types of models of how we have organized ourselves

in this country over many years after our own fits and starts 20

years ago, are highly useful for China to really look at, what do we

do, how do we coordinate our agencies, what is the role of Federal

and local, and how do you bring all of it together at the local level

in the right way. It is not just a health issue, actually, as I think

we all know.

Ms. WELD. Thanks a lot.

Mr. DES JARLAIS. Just on a slight note of optimism, Joan mentioned looking at what we are doing in this country. We have had

confusion, tension, and political conflict around AIDS for 20-some

years already, but we have still done a reasonable amount of effective prevention at the local level. So, I think if we used the United

States model of confusion, conflict, and antagonism, we can be

somewhat more optimistic for China.

Mr. WOLF. This has been a useful session for us.

Again, thank you very much. We appreciate your coming and

spending time with us all today.

[Whereupon, at 4 p.m., the roundtable was concluded.]

(25)

A P P E N D I X

26

PREPARED STATEMENTS

PREPARED STATEMENT OF JOAN KAUFMAN

SEPTEMBER 9, 2002

1. Official Estimates: • 1 million HIV infected as of September 2002 • UNAIDS Estimates: 1.2 Million infected now, 20 million by 2010

2. Key Sub groups • Intravenous Drug Users (officially 70 percent of cases) • Paid Blood Donors and their families (the innocent victims who are mobilizing the public response) (probably most of cases) • Female Commercial Sex Workers • Homosexual Men

3. Drug Users • Increasing numbers • High relapse rates/no methadone • Needle sharing and high HIV infection rates • Transmission to sexual partners • Mixing between IVDU and Sex Workers (drug use by sex workers)

4. Paid Blood Donors • Acquired during the 1990s through paid blood donations by poor farmers • Henan best known but at least 9 other provinces • Widespread practice: e.g. in Henan over 200 sites and many people sold blood

repeatedly over years for about $5 a bag as income supplement • Paid blood donations prohibited in 1998 but continued in some places • Affected villages: over 60 percent of adult population infected in some Henan

villages • Sexual/vertical transmission to spouses/offspring

• Little prevention/public education being done to prevent further spread

• Virtually no treatment/care available (although pending Global Fund application is for care/support in Henan and for Voluntary Testing and Counseling—

gateway to other services)

• Major orphan problem emerging

5. Sex Workers

• Widespread prostitution

• High rates of STDs

• HIV rates among sex workers increasing (Guangxi 11 percent, Yunnan 5

percent)

• Low condom use

• Clients: rural economic migrants and middle class men

6. Homosexual Men

• Highly stigmatized and hidden, most married

• 1⁄3 of hospitalized AIDS patients in 2000 in Beijing

• Few channels for information and little prevention

7. Vulnerable Groups

• Youth:

Little sex education and limited AIDS knowledge

Changing sexual attitudes and behaviors

Low self perception of risk and low condom use

• Rural Women

Returning migrant husbands

High rates of reproductive tract infections

8. Potential Impacts

• Compromise economic progress of last 20 years

• Huge orphan issue in poor rural areas

• Families falling into poverty to pay for treatment

• Rural Protests by innocent victims

9. Negative Constraints

• No highest level policy leadership yet

• Local inaction (collection of local public policy failures)

• Fiscal devolution: health system and budgets strained in poor areas

• High levels of discrimination/fear based laws to protect public

27

1 An overview of China’s HIV/AIDS challenge is offered in Bates Gill, Jennifer Chang, and

Sarah Palmer, ‘‘China’s HIV Crisis,’’ Foreign Affairs, March/April 2002. Portions of this testimony draw from this article.

• Limited civil society organizations • Constraints on media coverage and information • Complicity by local governments and denial

10. Positive Potentials • Recent admission of the severity of the problem and asking for help • Existing (albeit weakened) health infrastructure • Existing IEC/public education infrastructure (Family Planning IEC/Party

Organs) • Ability to mobilize party/government around a national action agenda • Access to treatment and care beginning: recently announced plans to manufacture AIDS anti-retroviral drugs if drug companies don’t offer reasonable

price

PREPARED STATEMENT OF BATES GILL

SEPTEMBER 9, 2002

CHINA’S HIV/AIDS CRISIS: IMPLICATIONS FOR HUMAN RIGHTS, THE RULE OF LAW

AND U.S.-CHINA RELATIONS

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.

28

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, Chi- na’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.

29

2S. S. Liao, et al., Rapidly changing sex industry in rural communities of Hainan and

Guangxi, China: implications for HIV/STD interventions, presented at the XIV International

AIDS Conference, Barcelona, Spain, July 7–12, 2002. 3Wan Yanhai, ‘‘Henan AIDS Prevalence and Effect,’’ self published in Chinese, March 8, 2002,

and made available to Freeman Chair in China Studies, Center for Strategic and International

Studies, Washington, D.C. See also: Elisabeth Rosenthal, ‘‘Spread of AIDS in Rural China Ignites Protests,’’ New York Times, December 11, 2001; Leslie Chang, ‘‘AIDS Epidemic Spreads

Unchecked Through Another Chinese Province,’’ Wall Street Journal, December 19, 2001. 4 ‘‘China—AIDS Some 80 Pct of Chinese Town’s Population Tests Positive for HIV,’’ Financial

Times, January 5, 2002.

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.

30

5 ‘‘China’s Bleak AIDS Figures Underestimate Accelerating Epidemic: Not Wanting to be

Known as an ‘‘AIDS Area,’’ Local Officials are Suppressing Data, Experts Say,’’ Daily Telegraph,

August 21, 2001. 6State Council Office Document 2001–40, Action Plan for Reducing and Preventing the

Spread of HIV/AIDS (2001–2005) (in Chinese). 7George B. Schreiber, D.Sc., Michael P. Busch, M.D., Ph.D., Steven H. Kleinman, M.D., James

J. Korelitz, Ph.D., for The Retrovirus Epidemiology Donor Study, ‘‘The Risk of TransfusionTransmitted Viral Infections,’’ New England Journal of Medicine, June 1996, p. 1685–90. 8Daily Telegraph, Aug 21, 2001, p. 4.

9See the U.S. Embassy Beijing Report, PRC AIDS: Mid 2002 Overview, From the U.S.

Embassy Beijing website, accessed at: http://www.usembassy-china.org.cn/sandt/

aidsoverview2000.html

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 .in 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

31

10 Elisabeth Rosenthal, ‘‘AIDS Patients in China Lack Effective Treatment,’’ New York Times,

November 12, 2001. 11 ‘‘UNAIDS/WHO Epidemiological Fact Sheet 2002 Update,’’ p. 2. Accessed at: http://

www.unaids.org/hivaidsinfo/statistics/fact—sheets/pdfs/China—en.pdf 12Wan Yanhai, AIDS Action Project, ‘‘Henan Province, Shangcai County, Houyang Village Orphan Record,’’ self published in Chinese, and made available to Freeman Chair in China Studies, Center for Strategic and International Studies, Washington, DC. 13See data at the China Population Information and Research Center website, accessed at:

http://www.cpirc.org.cn/enews20020514.htm; see also Paul Wiseman, ‘‘China thrown off balance

as boys outnumber girls,’’ USA Today, June 19, 2002, accessed at: http://www.usatoday.com/

news/world/2002/06/19/china-usat.htm.

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.

32

14 Elisabeth Rosenthal, ‘‘Spread of AIDS in Rural China Ignites Protests,’’ New York Times,

December 11, 2001. 15 Jonathan Manthorpe, ‘‘Why China won’t admit its growing incidence of AIDS,’’ The Vancouver Sun, July 9, 2002.

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

33

16D. Holtzman, et al., HIV/AIDS-related knowledge among residents in seven counties in

China: implications for action, presented at the XIV International AIDS Conference, Barcelona,

Spain, July 7–12, 2002. 17 Cindy Sui, ‘‘Henan AIDS sufferers win partial victory following protest,’’ Agence France

Press, March 27, 2002. 18 Richard Ingham, ‘‘Aids-Asia: Asia’s Big Three tread road to AIDS disaster,’’ Agence France

Press, July 8, 2002. 19The 21st Notice of the State Council 1995, paragraph 10 is quoted and translated in Qiu

Renzong, ‘‘A Proposal to the Legislation and Law Reform in Relation to AIDS,’’ self published

in English by the AIDS Action Project, and made available to the Freeman Chair in China Studies, Center for Strategic and International Studies, Washington, D.C. 20Law of the People’s Republic of China on the Prevention and Treatment of Infectious Diseases, Chapter 4, Article 24, paragraph [5], as reported by Qiu Renzong, ‘‘A Proposal to the Legislation and Law Reform in Relation to AIDS,’’ self published by the AIDS Action Project, and

made available to the Freeman Chair in China Studies, Center for Strategic and International

Studies, Washington, DC.

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 4 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/AIDSafflicted 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

34

21 As reported by Qiu Renzong, ‘‘A Proposal to the Legislation and Law Reform in Relation

to AIDS,’’ self published by the AIDS Action Project, and made available to the to the Freeman

Chair in China Studies, Center for Strategic and International Studies, Washington, DC. 22 John Pomfret, ‘‘Chinese City Is First to Enact Law on AIDS Controversial Rules Set for Infected People, High-Risk Groups,’’ Washington Post, January 15, 2001. 23 ‘‘We Care . . . Do You?,’’ U.N. Theme Group on AIDS, accessed at: http://www.unchina.org/

unaids/eus4right.html.

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 5 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-a-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

35

24 Xinhua, April 15, 2002, accessed at http://www.china.org.cn 25Leslie Chang, ‘‘New Breed of Activist Braves China’s AIDS Crisis,’’ Wall Street Journal,

April 2, 2002.

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 ‘‘nongovernment 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) 9 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 NGOs 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.

36

26Quoted in Philip Pan, ‘‘As China Faces Crisis, People with HIV are Kept Largely Invisible,’’ Washington Post, Nov 20, 2001. 27Dr. Gao Yaojie, ‘‘My ‘AIDS Prevention’ Journey,’’ accessed at http://www.aizhi.org/jkwz/journey.htm. 28State Council Office Document 2001–40, Action Plan for Reducing and Preventing the

Spread of HIV/AIDS (2001–2005) (in Chinese). Article II, Section 2. 29 As an example, see the recent reportage in Renmin Ribao [People’s Daily], July 24, 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 NGO’s 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 NGO’s 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.29 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 3 to 4 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

37

30 From the U.S. Embassy Beijing website, http://www.usembassy-china.org.cn/sandt/uschinahivaids.htm. 31 ‘‘We Care . . . Do You?,’’ U.N. Theme Group on AIDS, accessed at: http://www.unchina.org/

unaids/eus4right.html.

the case in the Chinese civil court system, court orders are not always enforced,

leaving the plaintiff without effective recourse.

The 5-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 NGO’s to work in close cooperation with

counterpart organizations. Through CHANGES, Australia has plans to spend

AUD$14.7 million over 5 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 Kingdombased 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

38

32 ‘‘Fact Sheet,’’ The Global Fund to Fight AIDS, Tuberculosis and Malaria, accessed at: http:/

/www.globalfundatm.org/journalists/fsheets/fs.htm

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 NGO’s.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 fully-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.

39

• Recognizing and encouraging the importance of grassroots and communitybased organizations (CBOs) working in China to address the HIV/AIDS

problem.

• Sustaining and expanding U.S. Government funding in support of HIV/AIDSrelated 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

In preparation for this testimony, Wan Yanhai was contacted to solicit his insights and provide suggestions for U.S. Government involvement in the Chinese

fight against HIV/AIDS. The day before he was detained, he sent this e-mail:

I think, as the leading country of the world, U.S. Congress and U.S. Administration should take responsibilities for improving the lives of HIV/AIDS sufferers in China. But how to influence Chinese policies and attitudes is not an

easy question. In one hand, US could work with our government, in another

hand, your Congress and government should support those who are working in

the grassroot communities.

For preventing discrimination against HIV/AIDS sufferers in China, and promoting grassroot organizations, funding for research, education and community

activities is important. People are now willing to organize and help themselves,

but they lack resources. It is very important to set up a fund for NGOs or CBOs

in the bilateral cooperation.

Best Regards, Wan Yanhai

PREPARED STATEMENT OF DON DES JARLAIS

SEPTEMBER 9, 2002

THE TWIN EPIDEMICS OF HIV AND ILLICIT DRUG USE IN CHINA: COPING WITH BOTH

OR COPING WITH NEITHER

LINKED EPIDEMICS OF INJECTING DRUG USE AND HIV

70 percent of HIV cases among injecting drug users [IDUs]

POSSIBLY ADDITIONAL LINKAGE TO SEXUALLY TRANSMITTED DISEASES

Use of commercial sex workers by injecting drug users

Potential sex work by drug users

STDs facilitate HIV transmission

CURRENT PROJECTS IN CHINA

World Health Organization Multi-Site Study of Drug Use and HIV, second phase

Investigators: Vladimir Poznyak, WHO Geneva; Don Des Jarlais, BIMC/NDRI

New York; Gerry Stimson, ICM London; Wu Zunyou, Chinese Academy of Preventive Medicine Beijing

Sites: Fourteen cities in Africa, Asia, Eastern Europe, North America, South

America

Design: Rapid Assessment and Response (RAR) of drug use and HIV situation in

each city, followed by structured risk behavior and HIV surveys of 400 drug users

in treatment and recruited from the community. Analyses to determine similarities

and differences in HIV/AIDS among drug users in different developing countries.

Comparison with data from industrialized nations in WHO Study phase one.

Preliminary Findings: High degree of stigmatization of both injecting drug use

and HIV in Beijing. Lack of trust between health officials and drug users. Community recruitment of active drug users quite difficult because of the lack of trust. This

would make HIV prevention programming very difficult. Beijing in official spotlight

on political issues.

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China-UK project on HIV/AIDS Prevention and Care

Investigators: Cheng Feng and William Stewart

Sites: Multiple provinces

Design: Comprehensive programming to reduce sexual and drug use transmission

of HIV and provision of care for HIV infected person. Situational Assessment of Sexual Health for sexual risk behavior and sexually transmitted diseases, and Rapid

Assessment for drug use risks. Additional evaluation designs to be developed.

Preliminary Findings: Gained official approval of ‘‘social marketing of sterile syringes,’’ encouraging drug users to purchase and use sterile injection equipment, but

not syringe exchange. Possible implementation of methadone maintenance treatment for heroin addiction on a pilot basis.

Cross Border Project China-Vietnam

Investigators: Ted Hammett, Abt Associates Boston; Don Des Jarlais, BIMC/NDRI

New York; Lui Wei, Guangzi Province, China; Chung A, NASB Hanoi

Sites: Guangzi Province in southern China and Lang Son province in northern

Vietnam

Design: Peer education for active drug users combined with social marketing of

sterile syringes (China) and syringe exchange (Viet Nam) and community education.

First attempt to coordinate HIV prevention for drug users across an international

border. Cross sectional risk behavior and HIV prevalence surveys every 6 months.

Preliminary Findings: Good working relationships between health officials and

drug users. Working peer educator program. Drug users concerned about carrying

(and using) new injection equipment because of possible arrests by police.

POINTS FOR CONSIDERATION

1. Potential for extremely rapid spread of HIV among drug injectors

a. Incidence rates of 20 percent to 50 percent per year, has occurred in some

areas of China

b. HIV among drug users in all provinces

2. Potential for highly effective prevention of HIV transmission among drug

injectors

Possible to keep total HIV infections to 5 percent or less in populations of injecting drug users

a. Begin early

b. Trusting communications between health workers and drug users

c. Good access to sterile injection equipment

3. Potential spread of HIV to sexual partners of IDUs

a. To regular sexual partners (wives)

b. Through commercial sex work to general population?

4. Growth of drug use in China

a. 860,000 officially registered drug users

b. The number of registered drug users has increased by 53.3 percent over

the last year

c. The actual number of drug users is undoubtedly much greater than the

number officially registered

d. Would be a major social and health problem even without HIV

Immediate need for programs to

1. Prevent spread of HIV among IDUs

2. Prevent spread to sexual partners

3. Prevent initiation into injecting drug use (Wu and Detels)

4. Provide treatment for drug addiction, chemotherapy treatment such as methadone maintenance

5. Need to do all of these at public health scale

6. Limited resources an issue but need for policy commitment even greater

problem

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