Health officials seek to avoid responsibility for the spread of HIV/AIDS in rural Henan
In the face of intimidation, harassment and even violence, independent activists, journalists and doctors exposed a scandal that may have caused hundreds of thousands of poor farmers in Henan Province to become infected with HIV. After trying for years to cover up what had happened by suppressing information, writes Tom Kellogg, the provincial health bureau is now asking for help and pretending it had nothing to do with the genesis of the disaster.
On August 24, 2002, prominent HIV/AIDS activist Wan Yanhai was picked up by police after attending a film screening at a Beijing gay and lesbian film festival. He was held for just under a month before being released on September 20. Although Wans aggressive tactics had gotten him in trouble beforehis organization had lost its institutional affiliation and thus its legal registration as a result of government pressure only two months earlierhe had never before been detained. Despite his detention, Wan has vowed to continue his work on HIV/AIDS in China.
So what precipitated Wans detention? Just before he was picked up, he posted to his e-mail list an internal (neibu) government document. Issued by the Henan Health Bureau in August 2002, the blandly titled Report on Province-Wide AIDS Prevention Work gives the Bureaus account of Henans AIDS crisis. Although rife with inaccuracies and self-serving omissions (many of which Wan pointed out in a brief commentary on the report which he also circulated to members of his e-mail list), the report is not mere propaganda. It gives a brief history of provincial government tracking of the disease since the mid-1990s, assesses the current scope of the crisis and gives a list of actions Henan plans to take to deal with the mushrooming number of cases of HIV and AIDS. These plans include increasing spending on HIV/AIDS treatment and prevention, gaining assistance from international organizations and speeding the production and delivery of AIDS drugs to those infected with the disease.
What the Health Bureau Report omits entirely is its own extensive involvement in the blood market that sprang up in Henan. In fact, the document is in essence an attempt to provide an alternative history of the spread of HIV/AIDS in Henan over the last decade, one that differs markedly from the story uncovered by Chinese journalists, doctors and activists. The official history claims that the provincial Health Bureau did all that it could to limit the damage done by the so-called bloodheads, the operators of the blood collection stations who rushed to capitalize on the large market for blood and blood plasma that opened up after Beijing banned the importation of blood in the late 1980s. By neglecting to mention its own extensive involvement in the blood market, the Bureau also makes the implicit claim that it is neither responsible for the rapid rise of the unsafe and unregulated trade in blood nor for the explosion of HIV infections that were the result.
The work of Wan Yanhai and many othersincluding doctors, journalists and even whistleblowers inside governmenthas proven this story to be a lie. As Wan and others have made clear, the provincial Health Bureau was a major player in the blood market. Rather than seeking to enforce blood safety regulations crucial to eliminating the risk of the spread of HIV and other blood-borne diseases, the Health Bureau sought to make money both by selling permits to would-be bloodheads and by setting up its own paid blood collection stations. Once it became clear that the unsafe practices of the blood stations had caused a large number of HIV/AIDS cases, the Health Bureau did all that it could to prevent the crisis from being known outside of the province.
Although the attempt at cover-up ended in failure, the delay lasted several years and greatly exacerbated the scale of the crisis. Both Chinese medical experts and international aid organizations have been blocked from the villages hit hardest by the crisis. Journalists attempting to cover the story have been intimidated and, in the case of foreign journalists, forced to leave the country. Despite extensive coverage of the HIV/AIDS outbreak in Henan Province, access to the worst affected villages in Henan remains difficult, as the provincial government attempts to maintain control over information about the tragic situation wrought by its own policies.
It remains to be seen whether those provincial officials responsible for the outbreak and the subsequent cover-up will be held accountable. So far, there is no indication that they will: despite the well-documented provincial government involvement and the clear violations of domestic law, the central government has demonstrated no interest in prosecuting those responsible. Speculation over protective connections between Henan and Beijing abounds and although no information has come to light confirming the allegations, such an explanation is more than plausible and would explain Beijings willingness to let the provincial governments scandalous and embarrassing behavior go unpunished. Wan Yanhai was not arrested in Henan, after all, but in Beijing.
Blood-selling in Henan
Henan is Chinas most populous province, with an official population of over 90 million; the true population, including those children born outside of the one-child-policy system, probably surpasses 100 million. The vast majority of the population is rural, uneducated and poor and thus particularly vulnerable: they lack access to health care, education and other services that can provide the best defense against HIV infection.
Although Chinas largely unregulated domestic blood market became the focus of attention in the mid-1990s, the market has been in existence for several decades. Some Henan villagers reportedly began selling blood as early as 1975; the Health Bureau report notes that the government paid peasants for blood donations as far back as the 1950s. The pool of willing blood-sellers was created by poverty: peasants in need of cash jumped at the opportunity to get something seemingly for nothing, using the money earnedoften as much as 40 yuan per donationto buy agricultural equipment, food for hungry children, or merely to treat friends to a restaurant meal. Many peasants sold blood regularly, using their bodies as a steady source of income, and many made it their primary means of support.
Blood collected from the blood stations was not only used by hospitals, but also by private companies that produced various health products containing human blood. According to the Health Bureau report, the fad for such health products spurred the growth in the market for donated blood. As a result, the number of blood stations rose dramatically in the early 1990s. By the mid-1990s, by one count Henan Province had roughly 200 legal blood stations and an unknown number of illegal ones. In his commentary on the Health Bureau report, Wan Yanhai puts the number at over 270 official blood stations. All sorts of groupsincluding county-level Peoples Congresses and Peoples Consultative Congresses, the military and the Health Bureau itselfopened the legal blood stations. Despite the dangerousness of their collection practices, the blood stations were largely run by government officials or their family members. One journalist separated the bloodheads into three groups:
First are the Public Health Epidemic Prevention Bureau workers, some of whom are doctors, others are state blood station or epidemic prevention station staff; second are the relatives and friends of these people; and the third type are those very clever types who have good connections [with government officials] in an area
Those running the blood stations set up a system designed to maximize profit, with no real concern about attendant health risks. Needles were used over and over again on different donors, there was no screening of donors for HIValthough donors were often tested for anemia and sometimes for hepatitisand there was virtually no testing of the blood collected. Perhaps most fatal, however, was the method of collecting blood plasma and returning the remaining red blood cells to the peasant blood-sellers. In order to separate out the plasma, the bloodheads would take blood from several donors of the same blood type and spin it in a centrifuge. Then they would reinject what remained back into the donors, putting all of them at risk for HIV.
Despite the extreme danger, the process of reinjecting red blood cells was touted by bloodheads as a health measure, which may have helped to combat traditional Chinese views that blood donation is bad for ones health. Bloodheads recruited peasants with the slogan: Blood comes out and goes back in, better for your health, and claimed that this practice meant normal, healthy individuals could donate twice in one day. Local government figures were called in to shill for the blood stations, urging peasants to take advantage of the opportunity for easy money. One peasant remembered seeing a prefecture chief making a strong pitch for blood donors on local television:
Friends, do you want to get rich? Do you want to win the struggle with poverty? If you do, then I have something to say to you: if you want to be better off, go and sell blood. You can earn as much as 50 yuan a day. Is there a better deal out there? Im telling you the way to riches; you should think about it.
The effect of these practices was devastating. HIV spread rapidly through the populationfirst among those who sold blood, and then to family members and others through sexual contact and childbirth. Given the prolonged incubation period of HIV, the earliest victims were not discovered until the mid-1990s.
The conditions at the blood stations varied widely. Many of them apparently did test would-be donors for anemia and turned away those who showed signs of being anemic. Some stations even tested for hepatitis and rejected all donors who tested positive. Such rejections may have had little effect, however: many peasants, after being rejected by one blood station, would immediately head to another with more permissive standards. There is no indication that any blood station tested donors for HIV.
Full-time blood donors sought to earn their keep in a number of different ways. Some traveled across the province to various blood stations, selling blood as often as possiblesometimes falsifying or hiding their blood station-issued donor record books. Others would set up camp near a particular blood station and sell at that station several times a week for a period of months. As the blood stations proliferated, more and more peasants were able to go to a blood station near their home village, thus obviating the need for travel and allowing them to recruit family members into the trade more easily.
Profits over safety
The Health Bureau report does not attempt to deny the existence of the blood market: it also identifies blood-selling and the proliferation of blood stations as the main transmitters of the virus. What the report neglects to mention is the Health Bureaus own extensive role in the expansion of the blood-selling market in Henan. The key document describing official involvement in blood-selling in Henan is a scathing essay entitled Revealing the Blood Wound of the Spread of HIV/AIDS in Henan ProvinceWritten on the Eve of the First AIDS Day of the New Millennium. Though published under the pen name He Aifang, which can be translated as lover of virtue, and apparently available only online, the document is regarded as authentic by informed sources. The allegations of official involvement made by He Aifang have been corroborated both by journalistic accounts and by the testimony of peasant blood-sellers.
According to Blood Wound, the Henan Province Public Health Bureau began its push to set up a network of blood collection stations in Henan in the early 1990s. A new administration led by bureau chief Liu Quanxi took over the Health Bureau in 1992, and it immediately began to look for ways to make money. Lius strategy was twofold: he would sell Public Health Bureau permits and also, with the help of members of his family, set up stations of his own. Liu set up six stations in six different counties, including one in his own hometown, using public funds and equipment to cover startup costs. He Aifang paints a picture of rampant corruption and unchecked arrogance:
Liu Quanxi set aside 200,000 yuan of public money in capital as well as equipment and then directed his younger sister to set up a blood station in his own hometown of Yancheng County, Henan. With the support of the then director of the Luohe Health Bureau Liu Xuezhou, six blood collection stations were established in Xiping, Shangcai, Xihua, Xuchang, Taikang and Weishi counties. These six blood collection stations belonged to the Liu family. These stations followed no rules, they took blood any way they pleased and even beat and cursed some blood donors. For example, as one bloodhead said to a small newspaper that had reported on this persons activities, You go tell the Department of Health. Im not afraid!
In essence, the governments regulatory and enforcement roles were more or less abandoned as the provincial Health Bureau focused on maximizing profits from blood-selling. Although the Health Bureau report admits: The macro-level regulation was not reliable, its own abandonment of oversight in favor of profits is not discussed. Instead, the report argues that the national regulatory framework was underdeveloped and thus created a gap that was easily exploited by the bloodheads. While it is true that a number of key HIV/AIDS prevention provisions did not go into effect until the mid-1990s, preexisting law required a number of safety precautions that the Health Bureau and others routinely ignored, including the use of disposable needles for drawing blood. As for Liu Quanxi himself, he is mentioned by name in the official report just once: he and other Health Bureau officials are praised for their effectiveness in shutting down illegal blood stations.
The move to shut down the blood stations began in 1995, as the provincial government began to discover significant HIV contamination in the blood being collected at blood stations and more and more cases of AIDS began to appear. Ironically, peasants often resisted moves by the Health Bureau and the Public Security Bureau to shut down the blood stations: the Health Bureau report cites one incident in which a Public Security Bureau vehicle sent to deal with an underground blood station was attacked by peasants, presumably frustrated over the threat to an important source of income.
At the same time that the Health Bureau was breaking up the blood station network (including, presumably, shutting the doors on its own collection stations), it was moving to suppress those who would sound the alarm over the emerging epidemic. Perhaps Henans most famous whistleblower, Dr. Gao Yaojie, came across her first AIDS patient in April 1996; her involvement continued as the number of cases grew in the late 1990s. Dr. Gao, 70, began visiting some of the villages hardest hit by the epidemic and began giving regular interviews to journalists covering the story. The provincial government responded with threats and harassment: Dr. Gaos phone was tapped and her movement was severely restricted. Years later, she is still closely watched. Local journalists seeking to cover the story received similar treatment: a number of journalists were threatened and those who actually broke the story lost their jobs.
Dying in the dark
The cover-up was so successful that many peasants became ill and died of AIDS or AIDS-related illnesses without even knowing why they were dying. Peasants began showing signs of illness and dying in large numbers in the late 1990s, years after the Health Bureau became aware of the problem. The Health Bureaus complicit silence left the peasant blood-sellers completely in the dark as to what was going on, and without any idea about what to do. One villager recalled the confusion as the epidemic broke in his village:
The first person in our village died of AIDS in 1999. At the time, we didnt know what this disease was, we just knew that those who had it would have severe diarrhea, low fever and would get thinner and thinner. When they got near to death, they became skeleton-like. Some would have only ten 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 village We were terrifiedwhat were we going to do? We could only watch as more people passed away.
Villagers were often seized by panic when a member of their family showed signs of the illness; many sold everything they had to buy medication and pay hospital bills, thus wiping out what little savings the family may have had. This pattern played itself out over and over again as household after household in the hardest hit villages discovered that one or more family members were sick with the disease.
Since the discovery of the outbreak in 1995, the number of cases has skyrocketed: some villages have infection rates as high as 60 percent, according to unofficial estimates. Both the Health Bureau report and Wans rebuttal guess at the number of peasants and others who have died from AIDS; until a full study is undertaken, the number is essentially unknowable. The total number of persons currently infected, both in Henan and nationwide, has been estimated through educated guesswork rather than hard facts.
As a statement of political commitment to future action, the Health Bureau report offers a glimmer of hope: the report pledges renewed efforts to survey the problem, increased cooperation with international aid organizations and a strengthened government response. The report is an unacknowledged change of policy: instead of denying the existence of a major outbreak of HIV/AIDS in Henan, the Health Bureau has decided to confront the ongoing crisis. This is indeed progress. But the report also makes clear that the provincial government is only willing to address this problem on its own terms. While treatment has moved onto the Health Bureaus agenda, the first priority remains self-preservation and maintenance of the fiction (despite clear evidence to the contrary) that the provincial governments hands are clean. This presents the international community with an unpleasant choice: international aid organizations must either go along with the provincial Health Bureaus rewriting of recent history or continue to be denied access to those infected.
Response to the epidemic
There is no reason to suspect that what happened in Henan has not also happened elsewhere; there are currently scattered reports of widespread blood-selling and attendant HIV outbreaks in other parts of China. Since the discovery of the Henan outbreak, the central government in Beijing has slowly improved its national response to the disease. But if it continues to allow local protectionism to trump the needs of people infected with HIV and suffering and dying from AIDS, then it will likely fail to fend off the major nationwide epidemic that international observers have warned of.
As a result of extensive international pressure, Wan Yanhai was released after spending less than a month in detention. The international community should continue to urge Beijing to investigate the HIV/AIDS outbreak in Henan and to bring charges against those responsible, regardless of their position. Doing so will send the message that in addition to a change in rhetoric, Beijing has initiated a change in policy toward HIV/AIDS and it is serious about stemming the spread of the disease in China. t
Tom Kellogg is a student at Harvard Law School.