Early in the 1990s, large numbers of commercial blood donors in rural central China, most notably in Henan Province, were infected with HIV. According to conservative estimates released by the provincial government, more than 30,000 people in this province alone were infected. This ‘separate epidemic’, as it is often referred to in the HIV epidemiological reports in China, defied the well-recognised patterns of progression in this epidemic, particularly in terms of the male-to-female ratio of the infected; from the start, it claimed both men and women as victims in equal numbers but by a transmission route that was far more efficient than sex. Infection occurred when contaminated blood cells were returned to the donor after the harvesting of plasma from their blood, allowing the epidemic rapidly to establish itself over several central provinces.
Labour, blood and HIV/AIDS
The term ‘rural resident’ is a bureaucratic category that ensures that rural migrants who provide a vast source of cheap labour are excluded from basic social services in urban areas.In the context of economic liberalisation, technological developments have only facilitated the transformation of traditional labour-intensive agricultural systems into capital-intensive enterprises. The value of agricultural labour had thus become increasingly insecure, a surplus with no profit. Under these conditions, ‘rural residents’ in China’s agricultural heartland were compelled to convert their labour surplus into cash by migrating to urban and coastal industrial centres to look for work.
When blood plasma collection began, it was perceived as an attractive alternative way of generating revenue without migration, as it seemed to only take the insubstantial part of their blood, the part not essential to their vitality, physical strength and force.
Many HIV-infected women had returned from working in manufacturing in the cities where they had worked for several years to build dowries. They returned, got married and raised their children in their home villages. Selling plasma gave them an opportunity to continue supporting their families by bringing in cash that could no longer be obtained through out-migration. Plasma in a cash-starved agricultural economy becomes cash by virtue of the demand for the albumin it renders up to a health industry hungry for expansion.
The market for blood products, principally albumin, was created by economic reform in China’s health sector. Public hospitals and other health-care facilities, which previously had been supported by state subsidies, now had to compete in the market and generate revenue through the services they provided and the drugs they sold. This arrangement encouraged serious conflicts of interest in health care. More expensive treatments were promoted to patients, and the prices of the drugs became a bogus proxy for their efficacy. In this context, albumin quickly became a favourite drug at hospitals, prescribed often in the absence of any specific indications to patients who were convinced of its restorative efficacy and could afford to pay for this luxury.
The fledgling plasma fractionation industry in China was boosted by a ban in 1985 on all imported blood products which was aimed at keeping HIV and AIDS outside China’s borders. The industry grew quickly in the following decade as did the demand for source plasma (i.e. plasma for further manufacturing). In addition to exporting labour to the coastal and urban industrial centres, the central provinces could benefit more directly by supplying them with source plasma.
Pathways of pathology
None of these historical processes – economic reform in the agricultural sector, the economic reform of health care, and the emergence of a plasma fractionation industry – created the necessary conditions for the outbreak of the HIV epidemic. But the pathological confluence of these historical processes determined the geography and demography of the HIV epidemic among plasma donors in rural central China.
In the current atmosphere of overwhelming attention to curbing the spread of HIV in the general population, it is easy to forget that the same social and political conditions and cultural logic that have led to the epidemic in central China continue to shape the experience of the disease of those already infected. Among the earliest symptoms of the progression of HIV disease, and the one most keenly felt by these hardworking villagers, is fatigue. The irreversible loss of their labour power due to HIV infection was a shocking price to pay for money they had made selling plasma years before.
In the midst of intensifying media attention on the AIDS-related deaths in a few villages in Henan, the government hastily rolled out a free antiretroviral (ARV) treatment early in 2003. This limited programme distributed ARV drugs but without adequate medical services to deal with side effects and ensure adherence. Nausea and vomiting were among the most common side-effects of the ARV regime in the free government treatment programme, resulting in loss of appetite or inability to keep anything down, as well as dizziness and sore muscles, which further weakened them. These common side-effects were experienced as life threatening by these agricultural producers, exactly because they seemed to assault the most essential dimensions of their lives: food and labour.
The lack of comprehensive treatment delivery is only part of the reason for the failure of the programme. The villages that saw the greatest decline in participation and adherence were all well-known ‘AIDS villages’, favoured by pharmaceutical manufacturers and traditional medicine practitioners chasing lucrative dreams of finding a cure for ‘the plague of the millennium’. Major research hospitals recruited clinical trial subjects from these villages for pharmaceutical developers. In these villages, government-supplied ARV drugs, which promised only the suppression but not the eradication of the disease, competed poorly with the plethora of free samples of hope represented by remedies of uncertain efficacy but without the pain of the feared side-effects. This epidemiological pattern makes a mockery of the compassion and hope that highly active antiretroviral therapy (HAART) is meant to inspire.
The parallels to be drawn between the out-migration of rural labour, source plasma collection and clinical trials are stunning. Construction companies relied on ‘labour contractors’ from the villages for their supply of workers; plasma collection centres used ‘scouts’ to recruit and transport donors; and infectious disease hospitals supplied clinical trial data on drugs under development with the assistance of the same cast of intermediaries living among HIV-positive villagers.
This HIV outbreak and its aftermath highlight the price that China’s ‘rural residents’ have had to pay for their multiple experiences of ‘liberation’. A price has also been paid by women, particularly among rural communities, for their even more dubious liberation. The majority of the epidemiological subpopulation categorised as ‘commercial sex workers’ are also ‘rural to urban migrants’. Their entry into China’s booming sex industry is aided by that industry’s ubiquity and its many disguises. The high turnover of those who work in this industry and their extreme mobility are both significant. Freed to sell sex, for a period of time, with anonymity and perhaps impunity, away from the social world to which they hope to return, very much as they would after working in factories, the population of ‘commercial sex workers’ is difficult to identify and track. Risk taking, often despite knowledge, motivation and skills, is then not simply a behaviour but integral to the temporary nature of the work itself.
How do we, then, effectively block the pathways of pathology? The answer can come from quite unexpected quarters. In 2006, the Chinese government abolished all agricultural taxes, which for decades had been an indispensable source of revenue. A little more than a year later, many hospitals were suffering shortages of albumin. This time, the shortfall was directly caused by the modest amount of money the government now gives to rural residents, which has made selling plasma less attractive and less necessary. An unintended but happy outcome of this shift in economic policy is the reduction of the risk of HIV infection among plasma donors and blood product users.
Shao Jing (email@example.com) teaches anthropology at Nanjing University, Nanjing, China.