China's HIV/AIDS outbreak among blood donors is arguably the worst medically-caused HIV/AIDS epidemic in the world. The outbreak started among the rural poor who sold their blood in an unregulated industry in the 1990s. Today, at least four provinces are known to be involved, including Henan, Hubei, Anhui, and Shaanxi. Tragically, the HI V/A ID S crisis in China is iatrogenic, caused by medical intervention itself Furthermore, official denials, suppression of scientific evidence, and government harassment of those attempting to respond have caused this public health and human disaster to be only partially understood. While the full scale of this tragedy is unclear, what is known has implications for China that go well beyond the already serious HIV/AIDS problem. China's stalled responses to the outbreak, and its treatment of those few courageous citizens who have exposed it, reflect the state of civil society, rule of law, rights of citizens, and emerging center-periphery dynamics of the new China. The rural blood donor epidemic cannot be understood without taking into account such diverse forces as corruption, complex interactions of for-profit enterprises run by rural officials, and the hopes of China's huge cash-poor rural majority.
Beijing has yet to allow a thorough investigation of the problem, and urgently needed treatment and prevention programs have not been implemented in the affected provinces. Even if effective programs begin immediately, the death toll in some provinces will likely be in the millions. Transmission of HIV from infected donors to their partners and children is almost certainly ongoing, making outreach to hard-hit communities a priority. China must respond, however belatedly. The prognosis for action, though, is poor. Official denial and restrictions on science continue in 2003, at what is likely to be a very high cost for the country.
Death in the Country
How serious is the blood donor outbreak, and what is known about it? Epidemic transmission of HIV, the virus that causes AIDS, was first identified in China in the late 1980s, principally among injection drug users and members of ethnic minorities living in the southwestern border zones of Yunnan Province. There had been earlier cases reported in gay and bisexual communities along the eastern seaboard, and a well-documented out-break among Chinese hemophiliacs who had received an imported clotting factor made from human sera in the early 1980s, before HIV had been identified; apparently, these early cases did not lead to widespread transmission. The outbreak among drug users did continue, however, and has led to increasingly severe epidemics in Yunnan, Guangxi, Sichuan, and Xinjiang provinces; drug users and their sex partners accounted for the majority of reported cases in each province in 2001. Taken together, these outbreaks amount to an estimated 500,000 to 1.2 million cumulative HIV infections by the en d of 2002, approximately 70 percent of whom are among drug users. These estimates are somewhat controversial, but have been generally accepted by the Chinese government, the Joint United Nations Programme on HIV/AIDS (UNAIDS), and others. While prevention programs targeting drug users have been limited, these drug use epidemics have been extensively investigated by Chinese scientists and international partners and are a part of China's official acknowledgment of the HIV/AIDS situation. Provincial- and central-level leaders in the health sector have been admirably forthright in dealing with these problems.
These HIV infections spread through drug use have the potential to lead to considerably wider spread in the People's Republic of China (PRC). Given China's enormous population, however, these estimates suggest a relatively low overall population rate of HIV among PRC citizens, less than one per 1,000 adults. Cambodia had the highest prevalence in Asia in 2001, with roughly 40 per 1,000 adults; in Botswana, the rate was roughly 380 per 1,000. …