It is not fashionable to say it, but in the view of this writer, HIV/AIDS in China is highly unlikely to have the same kind of devastating economic impact that the disease has had in sub-Saharan Africa. Even in the worst case scenarios, which point to as many as 10 million people infected with HIV by 2010, the rate of infection as a proportion of the total working population comes nowhere near the 30 percent – and counting – that has blighted the African continent.
But this ‘low prevalence’ school of thought is only useful insofar as it keeps us from panicking and giving support to the kind of draconian measures that the Chinese government has shown itself to be keen on when faced with a major problem. As well as being a medical, social, and economic issue, HIV/AIDS is also a human rights issue. A worker who admits he or she is HIV positive faces dismissal, social isolation, and increased poverty as well as the often overwhelming medical implications.
Indeed ‘low prevalence’ – a million infections in China is less than 0.1 percent of the population – also serves to hide the plain fact that China is teetering on the edge of an appalling human tragedy that has been gradually unfolding over the last 20 years. Seen as a ‘foreign problem’ throughout most of the 1990s – an attitude reminiscent of the US and Europe where it was regarded as a ‘gay’ problem during the early 1980s – most Chinese who had heard of the disease considered it far away from their own lives. Until recently, official statistics referred to AIDS patients in thousands and sufferers confined to drug smuggling areas such as Yunnan in south west China.
Moreover, local health departments were reluctant to admit the fact they were facing a growing problem and this set the pace for a culture of concealment and blame. Even today, many people believe that the disease need not concern them and is somehow the result of ‘immoral’ or illegal behaviour: drug users, sex workers, and homosexuals etc. HIV/AIDS activists in other countries will be all too familiar with this kind of scapegoating. They point to government policy and active education programmes that are not weighed down with moral judgements as vital components of efforts to limit infection.
While the situation in China is grave, there are signs of hope. As Michael, who is HIV positive and active in promoting HIV/AIDS related awareness and help to sufferers, points out in his own testimonial, “If society can come together and take AIDS seriously, we can beat this problem.” Just five years ago, it would have been more or less unthinkable for an individual who is openly HIV positive to get access to the media in order to make such an argument. From at best ignoring the problem and at worst encouraging ignorance, media outlets in China are at last beginning to play a more positive role. The recent relaunch of the state-owned magazine MCP (Xiandai wenming huabao) in 2002, which for years carried turgid pictures of happy and loyal citizens, is a case in point. The first issue of the magazine in the new format was devoted to homosexuality in China which was discussed candidly and without prejudice – too candidly for one Hong Kong commuter who moved away from the writer while he was reading it on the bus to work!
In the introduction, the MCP editorial team admitted they had begun their research full of the usual prejudices that homosexuals were ‘ill’, ‘different’ or ‘unacceptable’. By the time the magazine was published, they had collectively come to the view that “â€¦ the only difference between homosexuals and heterosexual were unimportant sexual preferences.” This example is not given to suggest that HIV/AIDS is a homosexual problem, but rather from the opposite perspective: that openness, honesty, and equality are part of the solution to HIV/AIDS in China – as anywhere else.
There is an enormous amount of work to do be done in China if we are to control the disease. Even as ALU goes to press, there is news of police attacks on villagers in the province of Henan where the practice of blood selling (see below) has brought infection and despair to millions of peasants. Problems of discrimination and even violence remain, as does their legacy in the villages of poor provinces.
The remainder of this short article will take a snapshot look at four issues concerned with HIV/AIDS in China: government policy; urbanisation; freedom of association; and non-government initiatives.
The government and the Ministry of Health at local and national level got off to an extremely poor start in facing up to the spread of HIV/AIDS in China. Perhaps the worst illustration comes from Henan, China’s most populous province. Estimates vary, but there could be as many as one million HIV positive people in Henan’s villages. The situation has been nothing short of appalling for many of these people, one of who said, “The first person in our village died of AIDS in 1999. At the time, we didn’t know what this disease was; we just knew that those who had it would have severe diarrhoea, low fever, and would get thinner and thinner. When they got near to death, they became skeleton-like. Some would have only 10 days between the onset of the sickness and death. And so people died one by one. We called the disease the plague, and we thought someone had put a curse on our villageâ€¦ We were terrified – what were we going to do? We could only watch as more people passed away.” After China banned the importation of blood products in the mid-1980s, a market opened up for local blood. Instead of enforcing safety regulations at blood donor stations that sprang up all over Henan, government officials colluded with people known as ‘blood heads’ and directly profited from the lucrative trade. A farmer could get up to Rmb40 (US1 = Rmb8.2) per donation and this could be used to buy much needed farm fertiliser or pay for children’s education. The results were disastrous as HIV-tainted blood began to spread through the villages. Lack of access to medicine and poor living conditions had direct implications on the speed with which farmers began dying. The situation was finally dragged into the spotlight following courageous reporting by Chinese journalists, doctors, and activists such as the Gao Yaojie whose work forced the Henan government to publicly address the dire situation. The Henan Health Bureau issued a report in August 2002 in which it admitted the extent of the tragedy even while covering up its own role in creating it. An alternative report written under the alias of He Aigang and available on the Internet gives a much more accurate picture of just how involved Henan government officials were in profiting from the sale of infected blood. The Henan government has promised to scale up its measures to deal with HIV/AIDS including providing affordable drugs and allowing access to international organisations.
The United Nations’ ‘Titanic’ report on the spread of HIV/AIDS in China, which warned of a nationwide epidemic also played a major role in dragging the issue out where it belongs – in the open. When the report was released in 2002, the government initially responded by demanding a halt to ‘accusations’ against China.
But, despite this initial negative reaction, the UN report does seem to have concentrated minds in high places. On International AIDS Day in 2002, the state media was flooded with articles on HIV/AIDS, many addressing previously taboo topics such as blood selling, AIDS orphans, and sex work with some papers even suggesting that the latter be legalised in order to regulate the industry and promote safe sex. The reaction from the Ministry of Health was a flat ‘No’.
Media coverage on AIDS Day is not enough. Sustainable educational projects that reach the majority of those with HIV or at risk from it are urgently required. Approximately 71 percent of HIV positive persons live in the countryside and according to a survey conducted by the State Family Planning Commission in 2000, 23 percent of them had never heard of AIDS.
The central government’s ’100 Counties’ flagship policy introduced this year is a head-on attempt to slow the spread of HIV in rural areas and is certainly a welcome sign that the government is now extremely concerned. While this stops short of providing free medical care, it does appear to be a serious attempt to create a sustainable model by training local doctors and increasing HIV awareness. It is too early to judge its success.
Urbanisation and Migrant Labour
The economic reforms in China have had a dramatic effect on employment structures and internal migration in search of work. While the latter has always been a feature of the Chinese economy, it was limited by the strictly enforced residential system that for the most part kept farmers and their children in rural areas.
Over the last 20 years however, the shift away from a command economy to a looser form of capitalism has encouraged young people to leave the land and find work in nearby towns or in the prosperous coastal centres, Special Economic Zones, and Free Trade Zones. The shift away from farm work has been encouraged by the government’s plan to build small- and medium-sized towns to soak up surplus labour in the countryside resulting in the biggest migration in search of work in human history. Moreover, a massive road-building programme and new railways have facilitated it.
These are ideal conditions for the spread of HIV, which has followed road construction projects and migration in search of work all over the developing world. Membership of the World Trade Organisation (WTO) and a consequent rise in the import of cheaper cereals and grain from abroad will also drive more farmers off the land. The recent – and welcome – relaxation of residential regulations will remove more formal barriers against internal migration.
Yet these conditions do not have to lead to the pandemic that the UN report and Chinese specialists warn of. China has a long experience and excellent record in education campaigns – the literacy campaign of the 1950s is perhaps the most successful ever undertaken anywhere. HIV and health education stations – ideally combined with labour rights education – could be set up at bus stops and train stations where migrants congregate. Hostels for migrants are dotted all over Chinese cities and could also serve as a distribution point for educational material. This writer recently stayed three days in a hostel for young migrants from Hunan. While all the workers staying in the hostel were aware of HIV/AIDS and knew most of the means of transmission, accurate knowledge was not comprehensive. Probably inspired by government guidelines of severe acute respiratory syndrome (SARS) one 25-year old male migrant from the countryside around the city Zhengzhou was under the impression that “â€¦ good hygiene is the best way to avoid HIV infection”.
The labour press is currently full of articles praising the new labour and legal advice centres that are being set up in many cities, some run by the official All China Federation of Trade Unions or concerned law students. These too would be ideal centres for HIV/AIDS education. In fact the Guangzhou Federation of Trade Unions (GFTU) undertook a pilot project to hand out free condoms to migrant workers. While this approach should be welcomed, it is clearly sensitive work that needs to be carried out with skill. A GFTU official told the writer that the project ran into difficulties when migrant workers expressed anger at the fact that they alone had been singled out for free condoms. The implication drawn was that outside workers were more promiscuous than local ones.
Freedom of Association and Civil Society
Despite constitutional assurances, Chinese people do not enjoy freedom of association. Workers cannot form independent trade unions and citizens in general have to go through a complicated process to set up a non-governmental organisation (NGO) that must be registered and affiliated with a state institution or department. These restrictions have been and will remain a serious obstacle to the prevention of HIV and sustained pressure to lift them from within and outside China is essential.
Despite the restrictions, semi-independent organisations have made great headway even in the face of police arrests and intimidation. Perhaps the most successful are the informal ‘tongzhi’ or ‘comrade’ groups which are springing up in most major cities. Inspired by the gay community, these groups aim to provide information on HIV/AIDS via the Internet, pamphlets, and safe houses. These initiatives are extremely welcome, but they will have to be accompanied by effective and non-authoritarian government measures, regulations, laws, and policies, especially given the size and mobility of China’s population. The box below briefly describes the inspiring story of an AIDS activist in Guangzhou.
Access to Medicine; TRIPS and the WTO
In the view of this writer, the current HIV/AIDS situation in China demands that the government issue compulsory licensing permitted by Article 31 of the Trade Related Intellectual Property Rights (TRIPS) Agreement. This would allow cheaper copies of the HIV drugs to be produced and sold at lower costs in China itself, and crucially, with no immediate obligation to negotiate with international pharmaceutical companies beforehand. The conditions for such an arrangement are a ‘national emergency’ which China is clearly facing, whichever way one defines the term.
Until recently, the Chinese government has been keen to show adherence to TRIPS and chosen to negotiate with the transnational corporations (TNC) producing the drugs rather than issue compulsory licensing. This tactic has extracted some price drops from the TNCs, but the current monthly cost of treatment is still US$361, which is way beyond the budget of most people who have contracted HIV. The Northeast China Pharmaceuticals Group Company has begun manufacturing a legal imitation of the AIDS drug AZT as the patent has already expired, and the Shanghai Desano company is producing another three drugs. These imitations will bring the cost down further to between US$30 and US$100 per month. Yet this is still way too expensive for workers who are currently facing major reforms in China’s medical insurance system that are far from perfect and unlikely to meet such costs. Moreover, migrant workers are generally not included in employer health insurance schemes; there is no health cover or insurance for farmers at all.
At this juncture it is unclear whether China will actually take the plunge and allow large-scale production of generic AIDS drugs as Brazil and India have done, or whether it will use its rights under the TRIPS agreement to issue compulsory licensing against the objections of drug TNCs.
There is certainly pressure from the local media and many doctors inside the health system to do so. In October 2002, the Beijing Youth Daily encouraged the government to “â€¦ consider using the benefits that the TRIPS Agreement affords and establish the technical, market, and legal conditions that would facilitate compulsory licences”.
For their part, the pharmaceutical TNCs have hardly been co-operative and have used China’s partial reliance on foreign investment to drive economic development as leverage. An example of their attitude can be seen in their reaction to general drug purchasing measures in Shanghai. In 2002, the city issued a set of regulations aimed at reducing hospital drug budgets via centralised bidding and purchasing methods. Space precludes from explaining these complex regulations in detail, but according to a recent report in the 21st Century Economic Herald, the net result was a substantial drop in the sales of pharmaceutical TNCs in Shanghai. The companies, represented by the Foreign Pharmaceutical Manufacturer Association in Beijing, responded with undisguised threats. On 28 April 2003, the association sent a fax to the Shanghai Department of Health demanding that the government “â€¦ reconsider the said policy”. The fax continued “â€¦ we originally planned to continue investment in Shanghaiâ€¦but will change our thinking”.
Whether they do or do not ‘change our thinking’ is a moot point. But this reaction to attempts to lower the budget for ‘high-cost medicines’ in general hardly bodes well for price reductions of HIV/AIDS-related drugs.
Conclusion: Act Now
This article has done no more than scratch the surface of HIV/AIDS in China. In many ways, the pattern of denial, concealment, corruption, lack of access to drugs, and social prejudice is no more unique to China than are the emerging signs of hope. Moreover, almost all the issues around HIV/AIDS are relevant to the creation of an ‘all round healthy society’ that former President Jiang Zemin committed the Party and government to before he stepped down recently.
But we are still far off that goal. Corruption and even criminal behaviour will, if allowed to continue, further lock HIV/AIDS treatment and prevention into a cycle of lack of treatment, poor testing procedures, and an overall lack of balance in responses. Earlier this year, China presented its third application for funds from the UN Global Fund to fight AIDS, Tuberculosis, and Malaria. The two previous applications were turned down as the government was deemed to be too secretive. It is likely that this third application will be successful and the US$98 million will help top up the money the government has already provided.
If the money is not to be wasted, we need to fight for an overall sea change in the political and medical environment in which government policies are implemented and activists operate. International NGOs and small local groups inside China are beginning to make progress. But they need the support of labour groups and trade unions outside China as well as the official state-run union inside China to move on.
HIV/AIDS is going to become a workplace issue in China and we need to get it on the agenda of the labour movement – NOW!
John Chen is an independent labour researcher based in Hong Kong. This article also appeared in the August 2003 issue of Asian Labour Update.