```

[Joint House and Senate Hearing, 107 Congress]
[From the U.S. Government Publishing Office]

 
              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

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              CONGRESSIONAL-EXECUTIVE COMMISSION ON CHINA

                    LEGISLATIVE BRANCH COMMISSIONERS

Senate                                 House

MAX BAUCUS, Montana, Chairman        DOUG BEREUTER, Nebraska, Co-
CARL LEVIN, Michigan                 Chairman
DIANNE FEINSTEIN, California         JIM LEACH, Iowa
BYRON DORGAN, North Dakota           DAVID DREIER, California
EVAN BAYH, Indiana                   FRANK WOLF, Virginia
CHUCK HAGEL, Nebraska                JOE PITTS, Pennsylvania
BOB SMITH, New Hampshire             SANDER LEVIN, Michigan
SAM BROWNBACK, Kansas                MARCY KAPTUR, Ohio
TIM HUTCHINSON, Arkansas             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)

                            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

                          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.

    There is clear evidence that where individuals and 
communities are able to realize their rights to education, free 
association, information, and most importantly non-
discrimination, 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.
    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 
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 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.
    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 efforts 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.
    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 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 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.
    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.
    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.
    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 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.
    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?
    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., 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.
    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.
    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 
foot-wide 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.
    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.
    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 high-risk 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 
blood-infected 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 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 provinces 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 clean-up 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.
    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, multi-sectoral 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.]
                            A P P E N D I X

=======================================================================

                          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 mobi-
          lizing 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 applica-
          tion 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
         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 manu-
          facture 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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    However, dismissed in the past by Chinese officialdom as a 
``Western'' problem, the spread of HIV/AIDS has only recently gained 
serious attention from Beijing. China now faces a major epidemic and, 
even under the best of circumstances, it is difficult to be optimistic. 
It was only a year ago, in June 2001, when the Chinese Minister of 
Health, Zhang Wenkang, announced that China had as many as 600,000 
cases of HIV/AIDS. Since then, the official Chinese estimate reached 
850,000 in early 2002, and that figure was revised upward to 1 million 
in September 2002, an increase of 67 percent over 2001 figures. In 
fact, Beijing really does not know the true number of HIV/AIDS cases in 
China, and these numbers are probably significant underestimates.
    In certain parts of China the problem is already particularly 
acute. Along China's southern borders with the opium-growing regions of 
Burma, Thailand, and Laos, widespread intravenous (IV) drug use was an 
early source of HIV infection. Drug use--and with it the spread of 
HIV--has also extended along drug trafficking routes into China's 
northwestern province of Xinjiang. The central province of Henan, 
China's most populous, has apparently been hit hardest. According to 
some experts in international non-governmental organizations (NGOs), as 
many as 1.2 million people in Henan are HIV-positive, largely owing to 
an unsafe blood collection system. Chinese and Western news media 
reports have focused in particular on ``AIDS villages'' in Henan where 
up to 80 percent of inhabitants have contracted the virus, and more 
than 60 percent already suffer from AIDS.
    Even accepting Chinese estimates of 1 million persons with HIV/AIDS 
and a relatively modest annual growth rate of 25 percent, China will 
have nearly 6 million cases of HIV/AIDS by 2010, easily placing it 
among the most heavily infected countries in the world in the next 5 to 
8 years. Even Health Minister Zhang Wenkang has acknowledged that the 
number could rise to 10 million by 2010 if the infection rate increases 
significantly. (By comparison, in the United States, where the disease 
was detected 20 years ago, there are today an estimated 900,000 people 
living with HIV/AIDS, with an additional 40,000 new cases reported each 
year; South Africa, currently the country with the largest HIV/AIDS 
population, has about 5.3 million person living with the disease.)
Questionable Statistics
    However, the official Chinese figures are probably ``low 
estimates'' at best, and need to be treated with caution. The report 
from the United Nations Joint Program on HIV/AIDS (UNAIDS), HIV/AIDS: 
China's Titanic Peril aptly opened with the statement: ``Heaps of 
numbers and lots of guesses--Yet the whole story remains elusive.'' The 
UNAIDS report on China--conducted in cooperation with Chinese 
agencies--repeated the previous official figure of 850,000 for 2002, 
but also states the number may be as high as 1.2 million. As noted 
above, other independent groups argue this number is too low as there 
may be over a million HIV-infected individuals in Henan province alone.
    Why is there such a wide discrepancy between the Chinese 
government's statistics and other organizations' estimates? It comes 
down to both practical and political reasons. First and foremost, China 
simply does not have the resources available to conduct accurate 
sampling and estimates for HIV prevalence. China has about two dozen 
persons working at the central government level focusing on this 
relatively new and growing epidemic (compare that with several hundred 
persons at the U.S. Centers for Disease Control and Prevention who work 
on the HIV/AIDS epidemic in the United States).
    Resources in the localities are spread even thinner in China. For 
example, according to UNAIDS and the WHO, in 2002 China had only 127 
sentinel sites in operation, targeting four population groups (sexually 
transmitted infection [STI] clinic attendees, 74 sites; female sex 
workers, 23 sites; IV drug users, 26 sites; and pregnant women, 4 
sites). While this represents almost twice the number sites that were 
operational in 1997, it is insufficient to effectively monitor a 
population the size of China's.
    Moreover, the dominant focus of these sites on high-risk groups 
(sex workers, IV drug users, STI patients) tends to skew figures by 
potentially ignoring infection rates within the general population. An 
additional risk of only monitoring high-risk groups is the mistaken 
notion that they are the ``cause'' of an HIV/AIDS epidemic, leading 
only to greater discrimination, marginalization, and public calls for 
isolation. Of the 100 surveillance sites reporting in 2000, only a 
handful monitored pregnant women and long-distance truck drivers. The 
great majority of sites monitored IV drug users, prostitutes and 
sexually transmitted disease clinics. On the other hand, Yunnan 
province, which has an extremely high IV drug use rate, only hosts 
surveillance sites to monitor sexually transmitted diseases and 
prostitutes. As such, the relatively small sampling focusing largely on 
high-risk groups tends to divert attention away from the true extent of 
the problem, especially as it may affect more ``mainstream'' parts of 
society.
    The so-called ``floating population'' or ``liudong renkou'' 
provides a good example of the monitoring problem. This group of 
itinerant workers--estimated at between 100 and 120 million persons--
have left their official residences, typically in the poorer 
countryside, to seek gainful employment in urban areas. Leaving 
official educational, housing, and health care assistance behind, these 
workers migrate to the least desirable jobs and live a semi-
clandestine, marginalized existence. The vast majority of the floating 
population is in the most sexually active period of their lives--some 
80 percent are aged between 15 and 45, and half are between 20 and 30. 
According to a recent study, there are more women than men among the 
young (15-19 years old) in the floating population; among all females 
in the floating population, some 55 percent are in the ``entertainment/
service'' industry, which for some may include some commercial sex work 
at restaurants, tea houses, karaoke bars, and the like.\2\ The 
``floating population'' likely represents a major new source of HIV 
infection in the coming years, but their situation on the fringes of 
society renders HIV/AIDS education, awareness, monitoring and treatment 
practically impossible to provide.
---------------------------------------------------------------------------
    \2\ S. 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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \3\ Wan 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.
---------------------------------------------------------------------------
    While the ``AIDS Villages'' in Henan are a well-documented 
humanitarian tragedy, they have remained relatively isolated incidents 
in the medical and political sense. Unfortunately, because knowledge of 
these incidents is not widespread amongst the Chinese peasantry, the 
work of unregulated ``blood heads'' continues in China's vast 
hinterland in such provinces as Sichuan, Shanxi, Hubei, Hebei, and 
Gansu, and elsewhere in spite of official prohibitions against such 
illicit blood collection schemes. Given China's chronically low blood 
supply, the law of supply and demand, and the inability (or complicity) 
of officials to deal with the problem, such hazardous practices will 
certainly continue.
    As a result, the Chinese blood supply is tainted with the HIV 
virus, and infections from transfusions have appeared throughout the 
country. In 2001, Deputy Health Minister Yin Dagui presented the media 
with figures revealing that one in every 2,500 blood transfusions 
transmitted HIV in the worst hit areas.\5\ China's official Action Plan 
for Reducing and Preventing the Spread of HIV/AIDS (2001-2005) aims to 
reduce the national infection rate from transfusions to 1 in 10,000 in 
hot spots, and 1 in 100,000 nationally.\6\ (A 1996 study in the United 
States determined that the rate of infection from transfusions in this 
country is 1 in 493,000--and was likely to improve between 27 and 72 
percent in the near future as new and better screening tests become 
available.)\7\ Blood transfusion recipients in China will clearly be at 
risk of contracting HIV for the foreseeable future, but may not be 
recognized within official statistics for years to come. As one senior 
physician in China put it, ``A lot of people who received blood have 
not fallen sick yet.'' \8\
---------------------------------------------------------------------------
    \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.
    \6\ State Council Office Document 2001-40, Action Plan for Reducing 
and Preventing the Spread of HIV/AIDS (2001-2005) (in Chinese).
    \7\ George 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 Transfusion-Transmitted Viral 
Infections,'' New England Journal of Medicine, June 1996, p. 1685-90.
    \8\ Daily Telegraph, Aug 21, 2001, p. 4.
---------------------------------------------------------------------------
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\
---------------------------------------------------------------------------
    \9\ See 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
---------------------------------------------------------------------------
    Medicines to suppress HIV and address the symptoms and 
complications of HIV/AIDS are expensive and hard to come by in China. 
Herbal medicines are widely used in the countryside to combat the 
symptoms of AIDS, but are generally useless in retarding the growth of 
the virus. A local pharmaceutical company in China has announced that 
they have received permission to begin distributing a generic version 
of AZT in China beginning in September, which is expected to cost about 
one-tenth the U.S. price. Merck had previously been negotiating with 
the Chinese government to supply discounted AZT, but no public 
announcements have been made announcing the success of those talks. But 
it is well-known that a single drug such as AZT is most useful only 
against certain strains of HIV, and that ultimately a mixture or ``drug 
cocktail'' of two or more drug compounds are ultimately more effective 
and help counter the emergence of resistant strains of HIV. The China 
Northeast Pharmaceutical Company, which is producing the knock-off AZT, 
has also expressed interest in producing other anti-HIV drugs used in 
``cocktails'' to help suppress HIV.
    Even if medical treatment, such as ``drug cocktails,'' were 
available, affordable, and clinically effective, the medical profession 
and afflicted patients in China would need to be trained in proper 
dosing and regimen monitoring; poor practices in this regard only 
result in the emergence of new, drug-resistant strains of HIV (a 
serious problem in Western countries), only further complicating the 
HIV problem in China when they are transmitted back into the 
population. No effective vaccine exists for therapeutic treatment for 
or protection from HIV infection. One Beijing doctor at a hospital that 
specializes in HIV/AIDS treatment said, ``In the countryside many 
doctors don't know how to treat HIV. . . . We know how. But patients 
can't afford the medicines, and the supply is extremely limited. So 
even if we want to treat, we often can't.'' \10\ At best, doctors in 
China are left with treating the symptoms of HIV/AIDS, but are largely 
helpless in stemming the fatal progression of the disease in their 
patients.
---------------------------------------------------------------------------
    \10\ Elisabeth Rosenthal, ``AIDS Patients in China Lack Effective 
Treatment,'' New York Times, November 12, 2001.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \11\ ``UNAIDS/WHO Epidemiological Fact Sheet 2002 Update,'' p. 2. 
Accessed at: http://www.unaids.org/hivaidsinfo/statistics/fact--sheets/
pdfs/China--en.pdf
    \12\ Wan 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.
---------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
    \13\ See 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.
---------------------------------------------------------------------------
    The consequent dearth of available brides fuels demand for 
commercial sex workers, helps accelerate male migration into cities, 
increases the numbers of women who are kidnapped and sold into 
prostitution or as ``unwilling brides,'' and may be in part responsible 
for the rise in men having sex with men in China.
Political obstacles
    Until recently, the Chinese government largely ignored its HIV/AIDS 
problem, dismissing it as a ``foreigners' disease'' and a peripheral 
concern for nearly 15 years. By 2001, Chinese health officials could no 
longer ignore the issue, due largely to the rise in ``involuntary'' 
infections to blood donors and recipients, the potential impact of HIV/
AIDS on China's economic growth and weakened healthcare sector, and the 
growing human toll. Nevertheless, the Chinese Ministry of Health is a 
comparatively weak bureaucratic actor in China, and lacks both the 
financial and political clout to deal with the HIV/AIDS crisis more 
effectively. In any event, the nature of the problem requires a 
comprehensive interagency effort, pulling together the resources and 
expertise of other important bureaucracies in China, including the 
State Family Planning Commission, the State Drug Administration, the 
Ministry of Foreign Affairs, the Ministry of Education, communication 
and information agencies, and the Public Security Bureau. However, some 
agencies, such as the State Family Planning Agency and the Public 
Security Bureau, are among the most disliked and distrusted among 
China's citizens, which will further complicate education, awareness, 
monitoring and treatment efforts. Moreover, as the recent case of Wan 
Yanhai seems to suggest, not all agencies in the Chinese government 
view the HIV/AIDS problem through the same lens, and may work at cross 
purposes with other parts of the bureaucracy.
    Even if central authorities are able to work together in 
implementing an effective strategic plan to combat HIV/AIDS, questions 
arise about how to implement the strategy at its source in local and 
grassroots level jurisdictions far from Beijing. Media reports and 
discussions with central government health authorities bemoan the 
difficulties in working with local officials who are disengaged from 
the problem or actively deny the problem exists within their 
jurisdiction. Local officials may be complicit in promoting illicit 
blood collection operations, may fear harsh criticism will jeopardize 
their career prospects, or may simply not have adequate resources and 
information to implement central government directives. HIV/AIDS 
sufferers in Henan have protested to the local government, demanding 
medical care reparations for the damage done by the blood-buyers, but 
they have been faced with stonewalling, detention and minimal help. In 
the words of one protester, ``To them we are like bubbles. They know if 
they turn away and ignore us, we will soon pop and be gone.'' \14\
---------------------------------------------------------------------------
    \14\ Elisabeth Rosenthal, ``Spread of AIDS in Rural China Ignites 
Protests,'' New York Times, December 11, 2001.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \15\ Jonathan Manthorpe, ``Why China won't admit its growing 
incidence of AIDS,'' The Vancouver Sun, July 9, 2002.

    On the other hand, it should be said that both central and local 
officials are less than enthusiastic about nongovernmental and 
community-based organizations (NGOs and CBOs) which operate beyond the 
authority of the state and party apparatuses. But the spread of HIV/
AIDS occurs at the grassroots, and needs to be addressed at that level, 
as well as by the strategic resources and planning apparatus of the 
central government. However, China not only lacks the resources of 
experts and capital to focus on the grassroots level; in addition, 
central and provincial authorities are politically wary of semi- or 
wholly autonomous organizations operating outside of government and 
party supervision. The preference for Leninist ``democratic 
centralism''--another term for a top-down, Party-led approach--still 
prevails in China, and complicates Beijing's ability to deal fully with 
its HIV/AIDS problem.
     implications for human rights, rule of law, and civil society
Social stigma
    Chinese citizens, faced with a lack of reliable information about 
HIV/AIDS, fear the worst. Various studies have shown that a majority of 
the population does not know how HIV is spread. For example, a study 
conducted in seven counties in China, surveying 7,053 individuals aged 
15 to 49, from a cross section of economic and social backgrounds, 
showed that 16.9 percent had never heard of HIV. Of those who had heard 
of HIV, 73.3 percent did not know its cause and only 9.6 percent of 
those surveyed could identify primary ways of preventing HIV infection. 
Over 80 percent of those surveyed were unaware that HIV infection could 
be contracted by sharing needles or by mother-to-child 
transmission.\16\ With such poor or 
misinformed understanding, the stigmatization of those with HIV/AIDS is 
commonplace. According to Western media reports and studies by Chinese 
HIV/AIDS activists, for example, HIV-positive farmers cannot sell their 
produce in neighboring towns, and urban sufferers risk of job loss, 
school expulsion and eviction from government housing. One farmer from 
an ``AIDS village'' in Henan said, ``We have no income. When people 
from the village try to find work, nobody wants to hire us because we 
are HIV positive. . . .'' \17\
---------------------------------------------------------------------------
    \16\ D. 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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \18\ Richard Ingham, ``Aids-Asia: Asia's Big Three tread road to 
AIDS disaster,'' Agence France Press, July 8, 2002.
---------------------------------------------------------------------------
Discrimination against HIV/AIDS-afflicted persons
    But the problems faced by HIV-infected individuals, their families, 
and other supporters goes beyond social stigma. According to reports 
from Western journalists and as well as Chinese activists, it is often 
the case that their basic rights are not properly protected, including 
their rights to employment, health care, education, privacy, marriage, 
and freedom of movement. Law enforcement often treats HIV/AIDS-
afflicted individuals as criminals, assuming they contracted the virus 
through drug use, prostitution or homosexual sex.
    As early as 1995, the State Council promulgated a statement 
entitled ``Opinions in Regard to Reinforcing the Prevention and Control 
of AIDS'' which demonstrated a short-sighted, narrow-minded and 
discriminatory understanding of the disease. It stated, in part:

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

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

    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 China 
Foundation for AIDS Prevention and the Beijing Association of STD/AIDS 
prevention and control.
---------------------------------------------------------------------------
    \23\ ``We Care . . . Do You?,'' U.N. Theme Group on AIDS, accessed 
at: http://www.unchina.org/unaids/eus4right.html.
---------------------------------------------------------------------------
    In addition, several cities and regions in China now have telephone 
hotlines that provide callers with ``personalized'' information on HIV/
AIDS transmission, symptoms, and treatments. Because of the stigma 
attached to HIV, the hotlines provide a valuable method for 
communicating with sufferers and at-risk groups in an anonymous, non-
threatening environment. In another example, a professor at the Qingdao 
Medical College started the bi-monthly Friends Newsletter in 1998, the 
first openly published gay-community magazine in China. Professor Zhang 
Beichuan's newsletter carries much-needed information on HIV prevention 
to China's marginalized and largely underground gay community. Xinhua 
recently reported another ``non-government service center,'' the first 
of its kind set up in Kunming, Yunnan province. The center, going by 
the name ``Aizijia,'' was jointly established by the Red Cross Society 
of Yunnan and the Salvation Army of Hong Kong and Macao, and provides 
preventive education, information, and counseling on HIV/AIDS.\24\
---------------------------------------------------------------------------
    \24\ Xinhua, April 15, 2002, accessed at http://www.china.org.cn
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \25\ Leslie Chang, ``New Breed of Activist Braves China's AIDS 
Crisis,'' Wall Street Journal, April 2, 2002.
---------------------------------------------------------------------------
    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.
    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\
---------------------------------------------------------------------------
    \26\ Quoted in Philip Pan, ``As China Faces Crisis, People with HIV 
are Kept Largely Invisible,'' Washington Post, Nov 20, 2001.
---------------------------------------------------------------------------
                            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\
---------------------------------------------------------------------------
    \27\ Dr. Gao Yaojie, ``My `AIDS Prevention' Journey,'' accessed at 
http://www.aizhi.org/jkwz/journey.htm.
    \28\ State Council Office Document 2001-40, Action Plan for 
Reducing and Preventing the Spread of HIV/AIDS (2001-2005) (in 
Chinese). Article II, Section 2.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \29\ As an example, see the recent reportage in Renmin Ribao 
[People's Daily], July 24, 2002.
---------------------------------------------------------------------------
    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 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.
---------------------------------------------------------------------------
    \30\ From the U.S. Embassy Beijing website, http://www.usembassy-
china.org.cn/sandt/uschina-hivaids.htm.
---------------------------------------------------------------------------
    (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 
Kingdom-based Save the Children organization is involved in grassroots, 
children's education projects in Yunnan, Tibet, Xinjiang, and Anhui.)
    Multilateral organizations under the United Nations umbrella have 
made a major contribution to China's fight against HIV/AIDS. From 1996 
to 2000, UNICEF managed two major projects, one in Yunnan Province and 
one nationally, with total funding of $2.2 million. The World Bank has 
supported several HIV/AIDS projects in China since 1991. A major 
project in 1999, with funding over US$33 million, helped the Chinese 
government develop relevant policies and institutional capacities. As 
part of this program, additional grants of AUD$2 million from Australia 
and $400,000 from Japan promoted NGOs' participation in HIV/AIDS 
prevention and care. The World Bank together with the DFID is preparing 
a new project to support the Chinese government's long-term effort to 
control tuberculosis, and build links between HIV/AIDS and tuberculosis 
prevention.\31\
---------------------------------------------------------------------------
    \31\ ``We Care . . . Do You?,'' U.N. Theme Group on AIDS, accessed 
at: http://www.unchina.org/unaids/eus4right.html.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \32\ ``Fact Sheet,'' The Global Fund to Fight AIDS, Tuberculosis 
and Malaria, accessed at: http://www.globalfundatm.org/journalists/
fsheets/fs.htm
---------------------------------------------------------------------------
    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.
         Recognizing and encouraging the importance of 
        grassroots and community-based organizations (CBOs) working in 
        China to address the HIV/AIDS 
        problem.
         Sustaining and expanding U.S. Government funding in 
        support of HIV/AIDS-related education, awareness, medical 
        training, and epidemiological research, including assistance in 
        updating and distributing national treatment guidelines and a 
        national training program.
         Consider military to military exchanges to further 
        study HIV/AIDS prevalence in China, possibly making use of 
        epidemiological data derived from PLA screening of all 
        recruits.
         Initiating Peace Corps efforts in China which offer 
        HIV/AIDS awareness, preventive education and training programs.
         Improving interagency cooperation and consultation on 
        HIV/AIDS in China, perhaps as part of the interagency science 
        and technology consultation process.
Some closing words from Wan Yanhai
    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.

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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