Investigative piece on AIDS in rural China.

December 2001

By STEVE FRIESS

Enter the Dragon

China finally breaks its infamous silence about AIDS. But will the regime loosen its iron fist enough to save millions of lives?

By Steve Friess

Her creaky, hopeful voice leaped out of the shadows of a doorless doorway.

"Are you a doctor?" she asked me in Chinese. "We don't feel good."

"No, Kong Lin," my friend answered on my behalf. "But he is here for you. We must come in now, please."

Kong Lin, now standing in the light that showed her torn teal dress and bare feet, recognized this voice. "Zeng Hao," she rasped, reaching her hand out for his. "Come in. But I have no tea or water tonight."

I followed Zeng Hao, bumping my head on the top of the wooden door frame as I entered a home that included a tiny kitchen and a sleeping area the size of a hospital supply closet. A pile of soupy diarrhea sat openly in a plastic bowl on the floor near the bed Kong Lin shares with her husband.

She apologized for the stench, but then shrugged, "We must go somewhere, and we are too weak to make it to the toilet." Her home had none, for in a rural Central China village like this, the water closet is down the dirt path somewhere. It is shared by hundreds of neighbors, requires squatting instead of sitting and reeks even worse than her diarrhea bucket.

Zeng Hao took the bowl out to clean it, as he says he does most nights. As we waited for him to return, I sat on a wood stool in the tiny bedroom across from Kong Lin and her sleeping husband. Although she says she’s in her 40s, she looks at least 60. Her arms were veiny and bony, her soiled gown hanging flatly over her waif-like body. The eyes were sunken, but her visage somehow still offered a cheerful smile.

Even before this calamity, Kong’s life had been harsh, a typically squalid existence tending to some postage stamp of assigned land and living in her government-issued hovel. She and her husband, however, now rely on neighbors to farm because they’re both too weak.

I had wondered how I would know for sure whether these people had AIDS, for no doctor had ever been here to diagnose the infection or offer medications. But the purple lesions sprinkled across his face and the wasting obvious across her body answered that.

She and her husband suffer ‘the nameless fever,’ she says. She knows she is dying.

* * *

I had arrived at one of several epicenters of the Chinese AIDS pandemic: Henan Province is the most densely populated province in China. This is the nation’s heartland, a vast plains area where corn, soy, peppers and other crops are harvested on a patchwork of fields around villages overflowing with thousands of people. Archeaologists have found evidence of settlements in Henan dating back more than 3,800 years, and Henan cities were capitals for two of the many Chinese dynasties. Today, though, it is a synonym for what ails China, with large, unattractive cities of white-tile buildings like capital Zhengzhou, population 6 million, that anchor poverty-stricken, low-tech farming regions.

Zhengzhou is where Dr. Gao Yaojie, China's most renowned AIDS activist, lives. One day earlier, she had begged me not to seek out a scene such as the one I'd found in Kong Lin's home. She'd heard that Public Security Bureau officers were stationed outside most of the worst-stricken villages, poised to arrest foreigners who attempted to enter. Gao, a 74-year-old gynecologist who brought this plight into the international media spotlight, estimates more than 20 percent of the people in many villages in Henan are HIV-positive.

Despite her warnings, she used my yellow highlighter to circle on my Henan map the counties that contain such villages. When she was done, she'd bathed in yellow the vast areas south of Zhengzhou, where I had traveled from Beijing to visit her home.

I didn't believe every village could really be as guarded as Gao said, but the first translator I had hired here in Zhengzhou wasn't interested in finding out. As we left Gao's home, this translator quit, crippling my prospects of reaching those regions.

That night, I visited Zhengzhou University to find a replacement translator, but none of the English majors I met there were willing to take this risk with me. Tellingly, none of these college-educated men and women had heard of the Henan AIDS problem despite the fact that the story has raged in the Western media for more than a year. Only a few believed the articles I carried with me on the subject, either.

But I met Zeng Hao on a rickety bus that evening. He sat in the back at first but, overhearing me speak English on my cell phone, he switched seats with the man besides me and began a conversation that immediately focused on why an American would travel these parts.

By now, I was accustomed to local people doubting my contention that there was a serious AIDS crisis brewing in Central China. I told him I am a journalist trying to do a story and that, while he wouldn't believe it, AIDS was hitting Henan hard.

"I am believing you," Zeng Hao said.

This caught me off-guard. "You are?" I asked.

"Yes, " he said. "This is my village, too."

I pulled out my Henan map, still shocked. "Where is your village?" He pointed to one of the many areas Gao had colored.

"I know it is AIDS that many people have," he said. "Nobody calls it this but me. They don't know what to call this. And we have no doctor.’

An hour later, Zeng Hao and I got off this bus along the side of an unmarked, unlit road. The bus still had an hour to go to Zhengzhou, but Zeng and I disembarked here as Zeng, a 24-year-old migrant worker in Gongyi, did every day. He walked me along dirt paths and between cornfields for about 40 minutes until we came to rows of attached brick houses. Contrary to Gao's prediction, no officers guarded the village entrance.

It was dark.

"This is a good time," Zeng Hao whispered. "Maybe only a few people will notice you."

Zeng Hao chose to have us duck into Kong Lin's home because it stood at the edge of the village. He also trusted her not to report us, because as he grew up with her son, she was like a second mother to him. Her own son, a childhood pal of Zeng Hao's, was crushed to death two years ago in one of the routine industrial accidents that take the lives of hundreds of Chinese people each year.

After Zeng Hao returned from washing out the pail, he and Kong Lin were talking about me. I heard the word meiguoren, or American, and I heard the word aizibing, Chinese for AIDS. She pointed at the Canon camera hanging around my neck, and Zeng Hao informed me that she would speak, but only if I put it away and promised not to mention this village by name. I agreed.

Kong Lin didn't pour her heart out to me, but through her neighbor's son she did, bit by translated bit, reveal an echo of the basics of the gruesome tale we'd heard in the Western media for months. She and her husband were very poor, so they welcomed the opportunity in the late-1990s to sell their blood to a "blood head" who came around offering money. The pay seems obscene to Western sensibilities, only about $5 per turn, but this is a society where the average monthly wage is around $73.

Blood selling became so regular—sometimes daily—that the blood would be returned to donors' veins after the desired plasma and whole blood was skimmed off. Kong Lin's blood would be mixed with others of her blood type, some of which contained HIV, then injected back into her arms. She began feeling sick around 1999, about a year after the blood-selling stopped in her village, she said.

It was impossible to know if this was one of those villages with astronomical HIV infection rates. Kong Lin said he believed only about 500 villagers here had been involved in the blood-selling scheme before the "blood head" suddenly stopped visiting, stiffing some of the donors of money owed to them.

* * *

Dr. Gao is overwhelmed by the extent of AIDS just in Henan alone. She encountered her first AIDS patient in 1996, an emaciated woman named Ba who had a high fever, a distended abdomen and the purple lesions of Kaposi's sarcoma. Ba, 42, died 10 days later. She'd contracted HIV through a blood transfusion during the removal of a uterine tumor, indicating to Gao that the blood supply was contaminated. Gao started writing and lecturing around Henan, raising the hackles of provincial authorities who may have been personally involved in the booming business of buying blood and selling it for profit to biological research companies and hospitals in major Chinese cities.

By 1999, when the blood-sales stories started to come out in the Western media, Gao was spending her own pension on prevention materials and handing out AIDS drugs in some regions. She says some of her lectures were canceled and she was warned to stop talking to reporters. "I'm so old," she tells me, "I don't have many years to live. So I keep on doing this."

Now Gao is under surveillance, having been threatened with arrest for a 1999 interview with The New York Times and having been barred from traveling to Washington D.C. to receive the US-based Global Health Council's Jonathan Mann Award for Global Health and Human Rights.

She continues to speak to journalists despite frequent warnings, although they have taken their toll in muting her somewhat. She speaks about the health problem, but her previously blunt attacks on authorities are now replaced by evasive smirks and indications that she doesn't want to say anything overtly critical.

Nevertheless, Gao has spent the past year assembling a groundbreaking new Chinese book on AIDS prevention. Her three-room flat is cluttered with hundreds of cubic packages containing the books, about 120,000 of which were printed on $25,000 in donations from the Ford Foundation and individual Westerners. These books are authorized by the government and are shipped to Gao’s allies in major cities around the nation.

That my visit comes a week after the Chinese Ministry of Health stunned the Western press with a blunt press conference admitting its AIDS epidemic does not impress or relax Gao. At that Aug. 23 event, Deputy Health Minister Yin Dakui indicated that reported HIV infections were up 67.4 percent in the first half of 2001 from the first half of 2000.

Yin even criticized provincial authorities for failing to take action sooner. These disclosures were preceded in June by a speech to the United Nations in which Health Minister Zhang Wenkang said 600,000 Chinese people have HIV. The goal, he said, was to contain the figure to 1.5 million by 2010. Yet the UN puts that figure at about 1 million for the start of 2001 and predicts 20 million could be infected by 2010.

Still, for a traditionally silent regime to even acknowledge the figures and the permission for Gao to publish the book were both seen as a breakthroughs. These developments seemed to reflect a government ready to tackle a problem it had insisted as recently as the late 1990s did not exist. A Henan official went on Zhengzhou television in 1999, in fact, to declare there wasn't a single HIV case in the province, Gao said.

And yet, one Henan village, Wenlou, was so widely discussed in The New York Times and elsewhere that the government in August claimed it had sent health experts in and set up a 24-hour clinic to care for the sick. Yin said a test of 1,645 villagers in April found 318 were HIV-positive, a 19 percent infection rate. Of 568 who said they sold blood, 244 had HIV, a 43 percent rate.

Yin pledged $12 million each year nationwide for AIDS prevention and control and another $117 million to improve the safety of the blood supply through new blood banks and testing facilities. That’s on top of $900 million allocated earlier this year for blood supply improvements, says Ray Yip, a senior health adviser for UNICEF in China. The country even held its first national conference on its HIV/AIDS problem, complete with speeches from visiting World Health Organization dignitaries, in mid-November.

‘In 2001, we are seeing a real signficant shift, at least in the governmental level,’ says Yip, whose job is to raise awareness of the potential consequences AIDS problem among government officials. ‘It’s improving by the day. People at the highest level of the Chinese government have already shown a strong commitment reflected in allocation of funding. If I look down in the details, the efforts may not be most cost-effective measures, but senior scientists here were daring and courageous enough to raise this issue with the people who needed to hear it. The fact is that, however awkwardly the whole process has been, after five or six years of denial, they basically came clean in that (August) press conference.’

Yet with the local officials shutting off these regions to the Western press and the domestic, state-owned media so mute on the matter that even educated Henan residents are unaware of the epidemic in their midsts, people like Gao wonder how anybody will ever know the results.

Henan is hardly the only AIDS-infested region in China. In fact, at the August press conference, the health ministry named five other regions more seriously impacted and noted that most transmissions seemed to be occurring through unsanitary practices in intravenous drug use. The largest foreign AIDS group, the China-UK HIV/AIDS Prevention and Care Project, is spending its $21.7 million on education efforts in Yunnan and Sichuan Provinces in the far southwest reaches of the nation and among those Yin named. (US AID, the American agency that conducts such outreach overseas, is barred from working in China because the US Congress opposes China's family planning regime, including a policy of forced abortions.)

"We have to focus on some specific areas and build up relationships with the local authorities there first," project coordinator Billy Stewart said. "We can't be everywhere. China is too large and the problem is too big."

Stewart and others noted that statistics on HIV in China are hopelessly flawed. The only people tested on a consistent basis are prostitutes and drug users—upon their arrest. This leaves experts with little reliable data on sexual transmission or the prevalence of AIDS in China's gay male population. Stewart wants to set up testing efforts in the gay bars of major cities solely for the purposes of gaining statistical insight. Yet the concept of testing in China that is anonymous and untraceable to the patient would violate Chinese law requiring reporting of HIV, Stewart says.

Ignorance of HIV continues to run rampant largely because the government-sponsored AIDS awareness program is devoid of substance. One poster up earlier this year in several health facilities offered no tips to avoid HIV, instead showing a smiling, handsome, red-ribbon-wearing man and the words in Chinese for ‘AIDS is everybody’s problem.’ The government encourages condom use, but the discussion of this centers around averting unwanted children and not sexually transmitted diseases.

Disclosure of HIV status, if a Chinese person is even aware of their seropositivity, creates the sort of panic America saw in the days of Ryan White. Children are often expelled from school, parents lose their jobs and neighbors move away. In several cities, HIV-positive people are now legally forbidden to marry, and some workers at hotels, restaurants, travel agencies, swimming pools and beauty salons must be tested.

The courts have stepped in in rare cases. A 10-year-old Henan boy won $47,000 in a groundbreaking lawsuit in 2000 against his county health department after he was infected through a blood transfusion, and a family this year was awarded more than $1 million. But none of this addresses the discrimination or public scorn in a culture where conforming is key and anything that distrupts the homogeny is a problem. ‘The intensity of discrimination is going to make people who know they have HIV not seek treatment and people who wonder not to get tested," Yip says. What’s needed, he continues, is stronger leadership at the government level. "Once you start doing the legislative work, then people understand that those people have rights, too."

These factors—prejudice, discrimination, barriers to prevention and care—hardly make China unique. "This is all part of a process. The US also has a very ugly chapter on this in its past, too. The Chinese just happen to be about 10 years behind.’

* * *

Zeng Hao returned to Kong Lin’s home long before daybreak to walk me back to the road where we'd gotten off that rickety bus. He waited with me for an hour before another bus enroute for Zhengzhou swept by and let me on.

In that hour, he quizzed me more about AIDS, and I realized he actually knew little about it. To him, it came through blood-selling. He'd heard vague warnings about sex or drug use, but nothing about how to avoid becoming infected. I handed him a copy of Gao Yaojie's book; she'd given me several.

"You are thinking China is backward," he told me just as my bus motored toward us. "Maybe we are. But we learn quick. All we are needing is to be told."

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