China's HIV/AIDS epidemic is not yet the world's worst ("An Epidemic of Denial," Summer 2003). However, its most recent wave is definitely one of the most bizarre. Not since the Romanian episode in which newborns received HIV as a result of contaminated "therapeutic" mini-transfusions has the AIDS virus been presented with so ideal an opportunity to rapidly infect large numbers of vulnerable people as apparently occurred among rural blood donors in China.
This particular Chinese epidemic is all the more distressing because, while exactly what happened remains unclear, it was almost certainly unnecessary. Reuse of unsterile phlebotomy equipment, re-infusion of pooled red cells to donors, secondary sexual and maternal-infant transmission, and contamination of biological products all contributed to epidemic growth. To this day, the dearth of reliable epidemiologic data precludes understanding the relative importance of each of these factors and limits the development of effective prevention strategies.
But to characterize China's rural blood donor epidemic as "nosocomial" or "iatrogenic" misleads through the implication that the practices that created this epidemic were therapeutic in intention. In Romania, doctors believed that small transfusions of whole blood to frail infants would boost their immunological systems and improve their nutritional state. The small amount of blood administered in each transfusion meant that blood from a few HIV-positive donors infected many children. The medical intervention was flawed, but the intent was to improve the health of the children.
In contrast, the driving force behind the rural blood collection system in China was profit, pure and simple. This epidemic is not the result of medical intervention, but of rampant, unregulated capitalism in the production and marketing of biological products, many of which are of dubious value. Given what is known about the workings of this system, one is hard pressed to attribute altruistic or therapeutic motives to any of the players. Everyone other than the purchasers of the products was in it for the money, although the peasants who sold their blood and ended up with AIDS would surely not have made that trade-off knowingly.
Official responses to the revelation of the blood donor epidemic suggest a lack of appreciation for basic principles of epidemiology and public health and do little to address the specific behaviors that led to the problem. For example, the Henan Health Bureau claims to have shifted to a completely voluntary blood donation system and says that the change has halted disease transmission. Yet, the primary source of the epidemic was not donor payments, but blood collection behaviors. The great majority, of donors were almost certainly infected by the re-infusion of contaminated whole blood cells. If the practice of pooling and re-infusing continues, then donors, whether voluntary or paid, will continue to become infected. A voluntary blood collection system will be safer only if the blood collection procedures are reformed as well. …