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AIDS in the countryside – How China struggles to control the epidemic

The other day I was discussing infectious diseases with a group of doctors. The question was relatively simple, “How do diseases spread?” They quickly offered: through coughing, sharing chopsticks, touching, mother to infant, and even mosquitoes. I continued, “those are all correct, but how about viruses like HIV or hepatitis?” A few perked up with “Blood transfusions!” I waited another minute before giving in, and adding, “and sexual intercourse.” When I said those two words, everyone’s eyes dropped to the floor (keep in mind these are doctors in their 30’s and 40’s). I had mentioned a taboo topic.

The problem, as in most cultures, is that even though the topic is off limits, it doesn’t mean that Chinese youth are celibate. Chinese youth have a poor understanding of contraceptives and reproductive health. Attitudes in China’s younger generation towards sex seem to have shifted rapidly from the more puritanical morals of their parent’s generation, and no one seems willing to fill this knowledge gap.

When I worked in rural Guangxi, I was encouraged by former volunteers from VSO to teach a lesson on AIDS in connection with World AIDS Day. In the days leading up to the class, I was terrified of having to say words like “sexual intercourse” in front of 30+ mostly female students, but if I didn’t talk with them about HIV, nobody else was going to. I planned to spend the first 40 minutes of class explaining how HIV is transmitted and how to prevent transmission. The second half of class would be opened up for anonymous questions written on a slip of paper. It was one of the more surprising days of my life as a teacher.

I explained to them that a decade earlier I would have been able to focus on the danger of intravenous drug use and blood transfusions, but for a woman in Guangxi, the highest risk for transmission is through sexual activity (as of 2007). This is due to the fact that AIDS has spread beyond drug users, and has moved into the more general public. An AIDS activist in Nanning told me AIDS was most prevalent in the cities along the freeways between Vietnam and Guangdong. AIDS infected long-distance truckers were having unprotected sex with prostitutes in towns along their route. These prostitutes than spread the disease to local men, who communicated it to their wives.

At this time AIDS had become a growing problem in China, and since little action had been taken in the first years of infection, a strong stigma against AIDS infected patients was almost encouraged. At first the official attitude was that it was a foreign problem. An OB/GYN nurse told a foreign guest at the hospital that she didn’t need to be careful about fluids in the delivery room because “Chinese women don’t have as many STD’s as foreigners”. Then it was acknowledged as a problem for those living at the margins of society. Finally it was admitted that there were a large number of people infected through tainted blood, poor hospital sanitation, and marital relationships (~2003, when Wen Jiabao became the first Chinese premier to shake hands with an AIDS patient). But the damage had already been done. In 2009 I visited a small town in Guangxi that had a large number of AIDS patients. Many of them had been forced to live in tents outside of their family homes due to an irrational fear of the disease.

After I carefully explained the planned material in class, I started answering questions. At least one person in every class asked if AIDS could be spread by mosquitoes or handshakes, which made it clear how limited their knowledge of AIDS really was. What surprised me most though was that the most common question in every class was, “My boyfriend wants to have sex, how do I say no?” The second most common was, “How do I tell my boyfriend to use a condom?”

Even in the countryside, where traditional culture still supposedly reigned, it appeared that many of the ~20 year old students were already engaging in sexual activity.  In urban areas the age for beginning sexual activity is even younger, as I was informed by teachers and students at a middle school in Chengdu.

While China is making progress in the diagnosis and treatment of AIDS patients and the stigma is gradually fading (the recent increase in AIDS patients could actually signify a greater number of people being diagnosed who in the past would have suffered silently due to social pressure and lack of treatment options), health education for prevention is still lacking. Until medical professionals are willing to discuss this disease with their patients, it is doubtful that teachers or even parents will.

Note: When I asked a roomful of doctors what the most common means of transmission for AIDS in China was they said: #1 Intravenous drugs #2 Tainted blood transfusions #3 Sexual intercourse #4 Mother to infant. This outdated knowledge leads people to create programs that do not effectively address the problem at the source. In actuality it is #1 Sexual intercourse (Heterosexual sex 42% of new cases, Homosexual sex 32% of new cases, totally 74%) #2 Intravenous drugs #3 mother to infant and tainted blood (both have improved dramatically in the past few years) Source: UNAIDS


  1. Chinese Officials will give the same amount of importance to AIDS as they did SARS when it broke out 7 years ago. They are too proud to think they can get diseases that westerners get, so they choose to ignore the dangers. This of course affects the masses everywhere in China (and the world!) which is of no concern to them since they never give any amount of concern to their people. There are simply too many people (mostly poor and uneducated) in China for them to care enough about to protect. So, until the government here chooses to do something about the complete ignorance at every level regarding AIDS, the country will continue to suffer from it’s own intolerance and stupidity.

    • Lorin Yochim says:

      Being fairly new to the blogosphere, I’m not sure if it’s best to ignore comments like this or to respond carefully. Rather than getting upset, I’ll try the careful response tactic. Before pointing out the more troublesome political claims in this response, I’ll point out a number of factual errors, some more important than others:
      1. SARS broke out in China with great vigour in early 2003 (I believe that it originated in late 2002).
      2. The SARS outbreak led to an absolute panic and a rapid progression of restrictions to control it. It was not ignored.
      3. The link between poverty and education in China is a complex one. China is not, however, an uneducated population overall.

      Tom has written a very good post (one of your best, in my opinion, Tom) that reports his personal experience, the opinions of clinicians he works with, discusses the facts such as they are available, and considers from his own perspective what gaps remain. He also, notably, looks at the response of high level officials to the AIDS crisis. The link to the UNAIDS reports backs up what Tom has to say.

      Now, on the question of arbitrary power and the maintenance of power, to suggest that the CCP/Chinese government governs exclusively through lying and deception and that it lacks entirely in concern for the Chinese people is both factually incorrect and politically naive. Setting aside for the moment the notion that the Party is a characterized only by top down rule (it is, of course, to some degree, but this begs the question of how the policies of top down rule are formulated), if it were the case that China’s leadership class ruled by deliberately keeping unhealthy and uneducated, then they would have long ago ceased to be in the position they are. At present, China is a pseudo-socialist, one-party/totalitarian state, bureaucratically administered in line with neoliberal principles that more or less dominate all of the world’s major economies. Despite the exercise of arbitrary power, the Party maintains its legitimacy in part by based upon its people’s well-being and, perhaps even more importantly, the continued expansion of economic opportunity. It has a vested interest in the health and education of its people and pursues the advancement of these areas with great vigour. Currently, this provision is radically imperfect, exasperatingly inequitable, and often desperately ham handed, as many posts on this blog detail. However, and here is where many involved in this blog might find a point of disagreement, corruption and arbitrary is only part of the cause of these conditions. The much larger problem is the ideological commitment to neoliberal market principles which, in fact, presuppose inequality of the kind we see in all aspects of the Mainland society.

      On the SARS crisis, having lived through the fog of that event, the response of certain jurisdictions was indefensible with respect to the provision of information. The response on the ground, however, was most definitely about stopping infection. That many officials were found to be protecting their careers merely underlined their ignorance about the role of good information in public health promotion. Which, of course, brings us back to the essence of Tom’s post.

      • Tom says:

        I think again it is important to separate the actions of the central gov’t and the local gov’ts. With AIDS, local gov’ts usually tried to cover up the infection until it was so widespread they could no longer hide it. They did this out of fear that no one would by produce from their region and factories wouldn’t invest there (which was a rational fear). Whenever the central gov’t discovered these AIDS villages, they did provide AIDS medication, even though much of the damage had already been done.
        With H1N1, the gov’t in many ways over reacted, knowing that it would be next to impossible to control if it spread beyond the cities. They learned a lesson in the mismanagement of SARS.
        I don’t think this is the result of the gov’t not caring about the people, but a symptom of a gov’t model that does not always respond well to crisis (from the great famine to AIDS).

  2. kingtubby1 says:

    While some of your pieces read like 101s for newbies, this is excellent and on a subject which doesn’t get much blogging attention. Just like the spread of HIV in Russia and middle Europe, you can map the demographic spread via major highway networks.

    • Tom says:

      Well, like I say in the About section of the blog, I’m trying to create a complete guide to China, from the newbie stuff to everything else.

  3. kingtubby1 says:

    Apologies. Never overestimate the levels of public awareness of good sexual health knowledge even among the better educated urban middle classes. Rural communities still reside in the 13th century.

    • Joel says:

      But a good proportion of the urban university students come from small towns or villages, bringing their lack of education with them. But I don’t know that urban students fair all that much better, from what we’ve seen. It seems like the only place people “learn” about “sex” in China is porn.

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  5. Joel says:

    Not only are students having more sex than many people realize, the women are unempowered and having sex when they don’t really want to. A good friend of ours in Tianjin teaches an interactive AIDS education and sexual health and values course at TianDa, and just like in your lecture experience, one of the biggest issues is girls trying to avoid being pressured into sex they don’t really want to have, but ‘just can’t say no.’ They even role-play refusal scenarios in one class. You can see this theme in the list of anonymous questions from one of the classes we attended: Sex, drugs, and Tianjin University students

  6. […] Seeing Red in China Your guide to modern China Skip to content HomeAbout…About TomAbout Yaxue CaoAbout CaseyComplete ArchiveSuggested SitesChina Books to ReadThe Best China MoviesMap of China中文 ← AIDS in the countryside – How China struggles to control the epidemic […]

  7. Sasha says:

    I remember reading in Rob Giffords book “China Road” about an Aids village where the entire population were HIV positive. Most of these people had contracted the disease through blood transfusions and in an attempt to stop word from spreading that people had been infected they put all the affected people in one segregated village where no one was allowed to enter or exit unless officially approved.

    When I asked some Chinese friends about aids and told them about this story they didn’t believe me. “Aids is not a problem in China” they said. I then posed the question “Is China a developing country?” despite myself not really feeling like China can still justify calling itself a developing country most Chinese still think it is and they were no different. I then asked why did they think that aids was a problem in other developing countries around the world but not in China? Apparently they think that 1. China is cleaner then these countries 2. The government would stop such a disease from spreading 3. People are traditional and don’t go around banging randoms.

    It’s a pretty scary thought to think that in today’s modern China, people can still hold on to such backward view thanks to a lack of public awareness and education!

    • Chip says:

      Without getting into everything else, which has been covered pretty well in the post and comments, China is ABSOLUTELY a developing country. GDP per capita is little over $4000 annually (94th in the world according to the IMF), and China ranks 101th on the Human Development index. If you think China is a developed country, you need to leave Macao or Shanghai or whatever city you’re living in and actually look around at the real China.

      • Tom says:

        However, China’s healthcare spending as a percentage of GDP is lower than many developing countries too, according to WHO it’s ranked 116th. So even accounting for its massive population, China could be doing much more in terms of healthcare as opposed to high speed trains and space stations. This article from March indicates that people “covered” by China’s national insurance are only allotted around 120RMB So yes, China is still a developing country (something I’ve covered in earlier posts) but still falls short of international norms when it comes to spending as a percentage of GDP on health care, education, and other public services.

      • Sasha says:

        I’ve been around the real China, in fact I’ve lived in Rural cities, I’ve spent extensive amounts of time in poor rural areas. Have you thought about the reason why China is still a developing country? It’s by government choice! The government funds huge amounts of money into flashy public projects so they look like they’re “equal” or more importantly to China “better” then the west. China funnels funds into the hands of the corrupt rich instead of into vital public infrastructure projects like better hospitals and schools in rural areas. In Shanghai alone I’ve taught in some of the richest most flashy public schools only to then go an hour away to the outer districts full of migrant workers to teach at schools with appalling conditions. Why is this the case, because “no one” goes out there, no one has to see just how bad it is and in China it’s all about appearance.

        Inner Mongolia is a perfect example. It is one of and most likely soon to be the most economically prosperous ‘provinces’ in the whole of China yet the people barely see a cent. I spoke to Chinese teacher’s there who told me about the bad conditions of the schools beyond that the roads of the capital Hohhot are full of massive potholes, many of the ethnic Mongolian’s are extremely poor yet it is because of them there is a thriving tourism industry in Inner Mongolia. So I ask you where all those mining $ going?

        To call something a developing country is far more then about the GDP per capita, it’s about society. China is not a poor country, its economy is booming yet that money is rarely seen by the people who need it most! Look at so many of the other developing countries in the world, they don’t even have the money to spend in the right areas to begin with, some are war torn, others have a raging famine. In India, massive disease ridden slums lie right next to newly developing areas. So yes maybe China is a “developing” country, but it’s by government choice, to put it on the same level of all the other developing countries out there really is like slapping them in the face!

  8. Lorin Yochim says:

    I’m not familiar with the numbers for health spending, Tom, but I am more so with education spending. In general, government spending as % of GDP numbers are deceptive and don’t give a full picture of overall spending (a similar comment could be made about health spending in the US). Government spending on education amounts to something like 13% (for 2009) of the budget [1]. As % of GDP it has struggled to reach 4% [2]. However, private spending on education is massive and should be considered [3]. From a Canadian perspective, these numbers are, respectively, low (Canada, 4.4$ish) [4] and shockingly high (Canada, 1.3% of GDP) [5]. $ spent on private education, I would suggest, do not lead to outcomes espoused by both Chinese government and common folk, such as the commitment to either a more equal or just society; in fact, I would make the opposite claim. They do, however, indicate something about broad-based commitment to education and aggregate levels of education, not to mention, of course, desperation in the face of government failure to provide $.

    So, I’m wondering about the private $ spent on health care. I’ll leave it to you or others to fill in these numbers. In terms of the stats that Tom links to above, I do know from recent experience that retirees/pensioners seem to receive more consideration than the 120rmb suggests. This was in Beijing and the injury would have been deemed catastrophic/emergency. I’m certainly not clear on the overall situation, which no doubt varies mightily.

    [3] Old data, sorry!

  9. […] AIDS in the countryside – How China struggles to control the epidemic […]

  10. […] In one of the small cities we attended a presentation on AIDS education projects started by one church that was supported by the local CDC. The CDC leader proudly said, “We have always had a policy of being open about the scale of the challenge when it comes to AIDS in this city.” He also made sure to point out that the first case of AIDS diagnosed in the city was in 1994, it was a middle aged man who had worked for a foreign company (AIDS initially was viewed in China as a symbol of contamination from the West and a symptom of openi…). […]

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