AIDS IN CHINA - A Personal View

By Michael "Mick" Alkan, M.D.

I met Miss T during my initial visit to the prefecture. She was one of three patients being treated with anti-AIDS medicines at a drug rehabilitation clinic in town. All three patients were seated along a table.

Officials from the public health office were also there, and I was brought in to ask medical questions. The two male patients looked like anybody on the street. Miss T., however, was dressed in white high-heeled boots, very tight jeans to outline her slender figure, and a white fur collar coat. She wore perfect makeup. Her eyebrows were shaven and painted. Her lips were bright red with a black slender line separating them from her pale face. She did most of the talking. She was not married, but had a partner. She had a small place in town, but no family.

Miss T. had just had a bad skin rash from one of the HIV medications. I knew what to do. We needed to switch one of her HIV medications to Zidovudine. A female doctor asked if the drug was on the National list, so that it would be free to the patient. Knowing the book, I nodded that it was available. After I was finished, the director of the health bureau began barking at the three patients, "You should be grateful to our government that takes such good care of you!" The patients leave, and the director of the clinic, who lights one cigarette with the butt of the previous one, says, "[Miss T.] is a prostitute, a drug addict, and an AIDS patient."

My next visit to the drug rehabilitation clinic is during my first week of official work. I ask about the patients, and they tell me that Miss T. was doing well on the medication I had recommended, but had now developed anemia. Her hemoglobin had dropped from 10 to seven. I suggest that we give her iron preparations and folic acid tablets and reduce the dose of the drug that gives her this toxicity. I also suggest obtaining another blood count in two weeks and ordering a new HIV drug, suspecting that these other efforts will be futile. Miss T. sits there with tears in her eyes and a little white dog in her lap. Although I feel that the dog is her real partner, the local doctors want the dog out of the room. I notice that there is no table in the examining room, so I suspect that she has never received a full physical examination.

I return after two weeks and ask about her blood count. I almost explode when they tell me the time for her count is in three weeks. I take a deep breath and then politely ask if they would do the test today. Her hemoglobin is now six! I ask about the new drug. "Well, it has not been ordered," someone says. They stop all the medications and call Beijing. Then they tell me that the specialist in Beijing doesn't agree with my opinion. I smiled in exasperation knowing that the people here really do not tell it like it is, and I leave.

A week later, Miss T. feels worse. Her face has never been so white and her pulse is a thin thread. I demand another blood count. To my surprise, it was done yesterday. Now her hemoglobin is 3.8! They only plan to give her more iron pills. This time I lose my cool. "She will die if you don't give her a transfusion!"

"Well, she cannot afford it, and we don't have the 1,000 Yuen to pay the hospital," someone replies. The cost of a donated pint of blood is US $125. 'What has capitalism done to these socialists?' I think to myself. As we leave this sad place, I promise myself to bring this case up with the public health bureau.

The director of the public health bureau, Jong, is dark-skinned with a great sense of humor and a wide smile. Whenever I feel like I am at my wit's end, I go to see him, and many times he helps me out. Even if he cannot help me out, I usually leave his office with his smile on my face. So, I storm his office, and tell him about Miss T. Director Jong listens carefully. He then orders his assistant to call the blood bank and get a special price on blood, which his office will cover.

Then, he looks me straight in the eyes and says, "You will see a lot more cases like this, where our resources are limited, and the Central Government does not acknowledge our needs. They expect the local government to cover costs, and we are poor, and have no budget for this kind of thing. I understand and appreciate your concern and compassion for the patient, but I am more worried about the program. If a patient dies because of our anti-AIDS treatment, it will be bad for our program. Testing of the blood should cost no more than 60 Yuen, but the final price is decided by the Provincial Government; it is not in our hands. Look, the price for manufacturing a dose of methadone is 3 Yuen, and they sell it for 10. This is also bad for the Party."

I agree, stating that this is 'the ugliest face of capitalism'. The assistant comes back; he has arranged a transfusion for tomorrow. Director Jong wishes me a safe journey home. I wish him a happy new year, knowing that it will be a family reunion with a large group feasting on pork and drinking too much alcohol while they are deafened by the many firecrackers that will explode to welcome in the Year of the Dog.

My work in China

The history of HIV/AIDS in China started with two separate stories, which later merged to become one large problem in the mid-1990s. The first is the story of drug trafficking and abusing. This is as old as China's opium wars and delicate pipes that have been part of the culture here for centuries. Under economic changes in Asia, poor Afghanistan and Burma (Myanmar of today) became big producers of opium. These regimes made huge amounts of money from the sale of opium and its products. The major route of drug trafficking goes through the Yunnan and Sichuan provinces in southwest China. This avoids the Himalayas and allows the supplies to branch into two main 'highways', one to Moscow, serving eastern and western Europe, and the second to Hong Kong, where ships will carry the opium around the world.

The opium-growing countries developed an industry of extracting morphine from the opium poppy and acetylating it into heroin. The couriers of heroin would finance their trips by selling small amounts to clients along the way, leaving behind them a dirty trail of drug users. Injecting heroin became the cheapest way to 'get high'. In China, 80 percent of all injection drug users are using heroin. Sharing syringes and needles is another way to cut costs. Thus, injection drug users (IDUs) became a hotbed for transmission of diseases like hepatitis C (HCV) and HIV.

The second story started in 1992, with the implementation of the naïve idea that the Chinese government could protect China from this 'Western disease' by banning any import of blood or blood products. This created a demand for plasma and its products, which was preyed upon by a group of very corrupt and cruel entrepreneurs. These business people went to poor, remote areas in southwest China, mainly the Hunan province, and offered $5 to poor farmers in exchange for blood. They would pool the blood, spin off the plasma, and return increments of the pooled red cells to the donors. They made numerous trips to 'harvest' more plasma from the same donors, selecting those who did not become anemic in the process. Only in 1999 did the government introduce HIV testing for all transfused blood or blood products. Thus, to use an analogy, the government closed the stable doors after the horses had already escaped.

Both of these stories of HIV/AIDS were centered in the rural southwest provinces of China. Recognizing the intersection of these two stories is southwest China helps explain the high prevalence of HIV/AIDS in that region. It is widely estimated (no data available) that over one million Chinese people are infected with HIV, although the government recently reported a lower figure. Whatever the prevalence may be, the numbers are growing. While this is not a high percentage of the population (less than 0.1 percent, compared with 34 percent HIV prevalence in Botswana), the rapid rise in the rates of sexually transmitted diseases through-out China has alarmed the medical community. IDUs are now financing their addiction through prostitution, and their clients are 'the population at large'. Soon, China will see HIV expand from afflicting a relatively small, marginalized population to affecting the general public. Prostitution has been rooted in Chinese culture for centuries; so far, no government regulation has succeeded in curbing it. The next wave of HIV-positive people will be the clients of commercial sex workers. Then, they will bring the virus home to their families. Women might infect their newborn children, and from there, the road to hell is an open highway.

The Chinese government has acknowledged HIV, openly admitting that the disease exists in China. The Merck foundation has signed a partnership agreement with the Chinese Ministry of Health to help stop the spread of the disease and train Chinese doctors to treat HIV-positive patients. Merck has brought $30 million to the partnership, and ever since this was announced, everybody has sought a piece of the pie. My job description is thankfully much more modest. I am here to train a group of local doctors to treat HIV-positive patients. My role will hopefully serve two purposes: to 'train the trainers' and to establish a pilot project that could be extended to other parts of the country.

The prefecture of Liangshan in the Sichuan province was chosen for the project. A list of local doctors, which was extended and improved upon after discussions with the local health authorities, now includes 13 doctors. My plan is to visit with each of them on a weekly basis at their workplace as well as gather them once a week at the office in Xichang city for a lecture and a discussion of cases. My hope is that the doctors will bring specimens to the central laboratory on this day and receive the results of the tests performed on the previous week's specimens. This, I believe, is needed to overcome the long turnaround time for HIV-related tests, which is crippling the program right now.

I have my work cut out for me. There are three major obstacles. The first is language and cultural barriers. I am new to this culture and must learn fast. Many of the patients belong to the Yi minority, so I need to learn two cultures. A bright light is my interpreter, Ms. Luo Qianlai, who is smart, sensitive, and ethnically Yi. The second obstacle is the complex logistics of the project. Transportation, workspace, financing small items, HIV drug procurement and availability of test kits in the laboratory are all major challenges. Finally, the doctors I am working with have had different levels of education and clinical experience. Most of them studied only for three years before being sent to their clinical post. Furthermore, they practice with very little supervision and receive almost no continuing medical education. I hope to broaden the scope of teaching to enrich these knowledge-thirsty doctors.

Visiting the villages

I push through the strong winds, walking with a local doctor, who seems to know every house in the village. He leads the way to our patients' homes. As we meet a candidate for treatment, the whole village gathers around to see the new attraction. However, I recognize that we cannot do this in any other way, as there is no clinic in the village. We are torn between a patient's privacy and our need to assess this patient to decide if he will be able to adhere to the difficult regimen we are about to offer him. The cold wind is dampened by the mud brick walls, and the naked silver poplars are evidence of the heart of winter.

We climb a treacherous hill to reach the house of our next patient. He introduces us with pride to his wife and two children. He says that he will do anything to care for his family. I feel that to observe this alone - this genuine expression of devotion and love - was worth the arduous trip. The drying corncobs under the roof rafters and the chicken running around the yard only serve to further illustrate his sincerity.

"He says that he will do anything to care for his family. I feel that to observe this alone - this genuine expression of devotion and love - was worth the arduous trip."

In the afternoon, we go to a district where no organizations are active in the fight against HIV. I refuse the suggestion that we wait for the district officials and insist on finding the local doctor before beginning our journey into the remote villages. The local doctor, who has worked in these villages for eight years, greets us with a wide smile. The rough road leads down into the valley. As the truck splashes across a wide stream, I find myself gripping the seat in front of me, hoping for the best. The road uphill is even worse as we are occasionally lifted off our seats due to the large potholes in the road. Women, in dark traditional dresses and large black hats, use wooden mallets with long handles to break up the large lumps of earth in order to plant the region's famous potatoes. However, we must be frank - not much else will grow at an altitude of 2,400 meters.

The village is poor. The houses are built of mud bricks. The roofs are tiled in a sad gray, and in very few homes the owner made an effort to paint the rafters in red and yellow, most of which is fading from the harsh weather. We walk along the main path, with the hogs and buffaloes. Many children run by, rolling wire rings guided by a long, bent wire. It is not easy to run after a homemade wheel down a steep slope, and yet, these agile boys are masters of their art. Two weeks ago, it had been fashion-able to play with a top, a coneshaped piece of solid wood, twirled around on its tip by a string tied to the end of a stick. Most children here make all of their toys, deriving joy from simple wooden sticks or balls of wire.

We locate our first patient and discover that he is angry. He complains that he was due to have tuberculosis tests three months ago, but when he went into town he was told that the clinic was too busy to take his sputum samples. Was this a drug-addict-con-man's attempt at avoiding trouble or was it a cry for help? Either way, we cannot start anti-HIV medications before learning the state of his tuberculosis treatment. The local doctor is silent, as he does not know this patient at all. I feel that this is not the right setting to take care of such a complicated case, so I ask that this matter be transferred to the county hospital where one of my trainees is working. With better supervision, there is a good chance that this man's condition will improve.

We drive back to the main road and beyond another mountain-pass lies the second county of the project. We happen to find a decent hotel and an internet cafe called 'cafe-acute'. When the power fails in the town, which apparently happens often, it is the farseeing 'cafe-acute' with its generator that relieves the utter darkness. The evening is cold, and I am grateful for the heat in my hotel room.

In the morning we meet our two trainees - two great guys. One is 45-year old and ethnically Han, but speaks Yi with his patients. He hopes to build an AIDS treatment center at his clinic in the country. I am well aware of the many hoops he needs to jump through, and I am also certain that there are many more that I am not aware of. The other trainee is ethnically Yi, young and very goodlooking. He is tall with a smooth hazelnutcolored face and a captivating smile. Our trainees lead us toward a distant village, and the excursion has us traveling high above the town into a frost-covered pine forest.

We reach a high altitude and continue climbing higher than the tree line. The road is icy, narrow and bumpy, and the valley beneath us is covered with a silk cloud carpet. I find the situation frightening, especially since I am helpless sitting in the backseat. The driver proceeds at a snail's pace. Across a high pass and down the other side we find the village. It is built on a slope so steep that the road inside the village is made of cast cement slabs. We find the local clinic, which was built with funds donated by some external organization, all white-washed and clean, but with no patients. We chat with the local team and they report seeing about ten patients per day. It is 11 am this weekday morning, and the first patient has yet to arrive.

We sit in the sun, shaded from the wind by the high walls of the clinic. The group makes a fire in a tin bowl to bake potatoes. A sheep and a chicken are slaughtered in our honor, and the testicles, stomach and brain are grilled along with the potatoes. I feel like I am visiting with the Bedouins, except that a case of beer bottles is opened. I make sure that the driver abstains, and I succeed in convincing my interpreter to keep a level head, for my sake. A long time passes while the large cauldron of mutton is boiling over the wood fire. Finally, the meat is done, and we eat from one big bowl, using our hands and chopsticks to get to the best pieces. The meat is not very well-cooked, and the hygiene of this place is less than perfect, but I have to be polite. It was bad enough that I refused the beer. We part when the sun, painting the gray dusty air with orange rays, is already in the west. The descent is easier. The ice has melted and the pine forests have been rejuvenated from frosty white to lively green.

We reach yet another town and visit the third of my trainees at a local hospital. He suggests that we see an AIDS patient who is hospitalized on the ward. The room is stuffy and the color of the blankets suggests that this is not the first patient to use them. The patient can hardly move. His pulse is 130 beats per minute and his respiratory rate is 32 breaths per minute. The man is in dire straits. I suggest oxygen, hoping that it is available here. The answer hits me like a brick on my head. "Yes, there is oxygen, but it costs 7 Yuen per hour (almost $1), and the family cannot afford this." I inquire as to why it is so expensive, and the answer is simple. "It costs half in the prefecture, but they have to bring it all the way here." I ask to become a partner in this business, where driving oxygen for two hours makes 100 percent profit. We look at the patient's X-ray and discover that he has a large pneumonia. We discuss the treatment options, only to realize that penicillin is all that is available.

We eventually leave for the long drive home, in the direction of the setting sun, which now hangs like a huge orange sphere on the horizon. On the way home I think about the blatant lack of basic medical services and the limited access of the poor that seems to pervade throughout China. I cannot help but curse capitalism in my heart, while knowing that it still is better than the Cultural Revolution.

MICHAEL ALKAN, MD is currently a Professor of Medicine at Ben Gurion University of the Negev in Beer Sheva, Israel, where he helped develop the curriculum for the joint international health medical degree program by Columbia University and Ben Gurion University. For 25 years, he served as Chief of Infectious Diseases at the Soroka University Medical Center in Beer Sheva. He has taught medicine and advised curriculum development at Moi University in Kenya (1989-1997) and at Catholic University in Quito, Ecuador (1995-1997). He has served as a WHO special advisor on reforming medical education in Kyrgyzstan and Tajikistan (2001). Recently, he has worked as an AIDS preceptor in Botswana (2004) and is currently working in a similar capacity in rural China. This story took place between November 2005 to February 2006.

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