Structural inequalities and demographies of HIV infection
In addition to the social problems arising in such a diverse and unequal society, the country’s patterns ofpublic health investment and education, its diagnostic technologies and capabilities, and government-business corruption, among other factors, continue to shape China’s experiences and perceptions of HIV, health, and healthcare more generally.
The reform of social medicine that occurred when China marketised its health sector in the 1980s was one of the major structural factors to impact China’s ability to manage an HIV crisis. China’s ability to detect and report new infectious diseases was weakened considerably by this reform, a trend that the SARS debacle partially reversed with the following reinvigorated state commitment to health (Lin 2012: 427—40). Lack of financing in the 1980s and 1990s also meant that many rural hospitals closed and doctors were unable to keep apace of changing epidemiological trends and training. The few who did specialise in HIV practised and researched far from areas where the virus was actually spreading (Shao 2001: 431-32; Zhang 2005; Wang 2012c). The diagnosis and treatment for HIV was in urban hospitals, yet those who carried the virus and those most at risk could usually not afford such care and transport costs.
A second factor which negatively affected China’s experience with HIV has been its choices about where and how to implement modernisation reforms. China’s modernisation prioritised the advancement of urban over rural and of coastal over inland and focused on the nation-wide marketisation of state-run services. As outlined above, people from areas and classes which did not benefit from these reforms quickly fell prey to the so-called plasma economy (xiejiang jingji) as blood-selling became an easily accessible source of income for them (Guo 1997; Qi 1997: 8). As both blood sellers and blood collection workers typically lacked education, and were driven to profit from the blood trade, most did not know what HIV was (or considered it a disease that only affected Africans or EuroAmericans). They were not aware of safe procedures for donation or they chose to ignore them. In contemporary China, commercial sex work has become a viable source of income for many women who only earn meagre wages in factories or are uneducated and cannot find other employment. Although many sex workers understand how HIV is transmitted, they are exposed to the risks of HIV through their clients, who are willing to pay extra for sex without condoms (Jeffreys in this volume), a particular problem among older sex workers (Huang 2010: 43-66). Finally, rising levels of unemployment, inflation, and social and economic stress for those who do not have the education and skills to navigate and succeed in China’s new society have led to an increase in drug use. Injection is a key path for the direct spread of HIV, while the use of recreational drugs leads to risky sex as it impairs judgment regarding protection and when to use it. The links between modernisation, drugs, rising unemployment, and ethnicity have also been well established. In a time of HIV, those who are left behind (for whatever reasons) are the worst affected. Regarding China’s social geography of infection, ‘the majority of those who have borne the brunt of the HIV epidemic in China live at the bottom of Chinese society’ (Jing and Worth 2010b: 14).
The lack of appreciation for local disease economies forms a third factor informing China’s HIV experience. This problem was further exacerbated by local governments’ resistance to reporting health problems and the under-valuation of peasants’ lives (Yun et al. 2005: 1149-63). Dominant international understandings of at-risk populations guided health personnel in their decisions on where to look for HIV and target their prevention efforts. Many key local and international personnel involved in HIV prevention, treatment, and policy were trained in Western epidemiology and public health methods. They worked in urban areas and maintained ties to international networks. This exposure and the relationships formed reinforced understandings about who was believed to be at risk from HIV. For example, as China’s blood trade was practically unheard-of internationally, much less connected with standard risk groups, commercial plasma donors were not identified as a risk group in a timely fashion. Similar understandings about local populations’ risky behaviour, and in particular ethnic behavioural norms, also played a role in policy development (Hyde 2007).
As in other countries, the way HIV spreads and the length of time it takes to manifest symptoms further hindered detection. Although Chinese people were catching HIV through sex or tainted equipment when selling blood and using drugs, the delayed appearance of symptoms meant that HIV was not connected with the practices that facilitated its rapid transmission. In Henan, when HIV first appeared, it was known as a strange illness, or guai bing.
The multiple factors that impact HIV transmission in Chinese society, combined with the fact that healthy adults often live for years without experiencing severe symptoms or secondary infections, have posed difficulties in understanding and controlling the spread of HIV. Below, I explore how the international scientific research and corporate investment and responsibility platforms have influenced China’s experiences of HIV. These international influences keep the virus as a focus of China’s public health and media reports, and thus as a key illness in the public sphere.