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 HIV/AIDS 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 outbreak 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 end 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. So China’s HIV epidemic, if the estimates used are correct, would be characterized by most epidemiologists as “concentrated,” meaning limited to high risk individuals whose behaviors —in this case, needle sharing among heroin injectors—put them at substantial risk for HIV exposure. However, current estimates that there are between 500,000 and 1.2 million infections largely exclude blood donors. There may be more than 500,000 infections due to blood collection in Henan province alone. Blood donor cases could well outnumber the drug use epidemic by several-fold, yielding a much higher overall rate of HIV in China and suggesting a much more grave epidemic than is generally recognized.

Mechanisms of Transmission

Blood and blood products, especially plasma, are important components of modern medicine. In addition to blood products transfused for trauma, they are commonly used for surgeries where blood loss is expected as well as for a range of medical therapies. In developed countries, volunteers make up the great majority of blood donors, and recruitment drives by Red Cross Societies and others for blood donation are a regular feature of civic life. While there are some risks to receiving blood products, blood donation is generally extremely safe for healthy adults.

In China, however, blood donation is relatively new and has been viewed with suspicion. The traditional view fostered by Chinese culture holds that blood is a precious and vital body component; losing blood, even through donation, is thus viewed as a threat to health. Hence, maintaining a significant supply of blood has always been a challenge for modern medicine in China, and voluntary donations and blood drives have been limited. China’s dramatic economic growth after 1986, combined with rising demands on the part of the emerging middle class for modern medicine, surgery, and trauma care, led to sharply increased demand for blood products. In the face of limited supply, rising demand, and a vast population of poor farmers, a lucrative industry was born. The epidemics in China’s blood system appear to have been among donors, a unique situation. What happened to infected units of blood, and subsequently to the recipients of these products, is an unknown, but potentially enormous, problem as well.

Starting in the early 1990s and continuing until at least 1996, for-profit agencies collected blood mainly for its plasma components in rural districts of the four densely populated affected provinces. In the case of Shaanxi, the companies involved appear to have been largely privately owned. In Henan, Hebei, and Anhui, the relevant parties were for-profit companies owned in whole or in part by provincial officials, blurring the line between public and private ownership and management in a way that unfortunately characterizes Chinese society today.