The Culture of HIV/AIDS in China: An Interview with Sandra Hyde, China '83

VIA:

What initially piqued your interest in China?

Sandra Hyde:

I’d have to say Traditional Chinese Medicine (TCM). Both of my parents were doctors—my mom a neonatologist and my father a pediatric surgeon. I was kind of a rebellious teenager so I became interested in alternative forms of medicine—Chinese medicine in particular, which led me to study Chinese in college. Someone mentioned VIA to me while I was studying at UCSC, and it sounded like a good opportunity to check out what it would be like to study TCM in China. When I graduated in ’82, I signed up for VIA. I eventually decided against remaining in China after VIA to study TCM, though.

VIA:

What changed your mind?

SH:

Living in China was really difficult, and after two years I was definitely ready to come home. I was convinced by a physician in China that to practice TCM I’d need to get a Western MD degree and then come back. I was told that I wouldn’t be taken seriously in the West if I didn’t have both an MD and a TCM degree. This was in 1985.

VIA:

What prompted you to get an MPH?

SH:

I came back to the US and decided that getting an MD would take too long. I would have to take pre-med courses since I’d studied political science and women’s studies in undergrad. So, I got a “quick and dirty” degree in Public Health at the University of Hawaii. I continued to work in public health in the islands on a lot of interesting projects. I started working with people with HIV in 1987, mostly teenagers and youth in prevention and condom promotion. After living in the islands for a while I kind of got “island fever” and was ready to leave. I’d done a sort of “exchange” program for a semester at UC Berkeley and enjoyed it very much. One course in particular focused on medical anthropology which I found very interesting, so I decided to pursue a PhD in that subject. By this point I’d lost touch with China, and getting into the PhD program at Berkeley reconnected me to my experiences there. I had planned my dissertation to be on women’s health centers in China, but while working on bioethics with Dr. Barbara Koenig at UCSF, who now runs Center for Biomedical Ethics at Stanford, the topic of HIV/AIDS arose. Someone there asked her about AIDS in China. She said plainly, “there isn’t any AIDS in China.” The person asked, “Are you sure?” She wasn’t, so she went to see what she could find.

VIA:

Had you any inkling of prostitution or STIs in your local area when you were first living in China? When did you discover the culture and politics surrounding such institutions as women’s health clinics, STI clinics, or abortion clinics?

SH:

In the summers of 1992-1993 when I worked for Dr. Koenig I pulled up some very preliminary studies that had been done. Working with Dr. Tom Gold at Berkeley, we discovered that most of the AIDS cases in China were in Yunnan Province. He happened to have a few contacts at Yunnan University, so that’s where I went to begin my research. Lin Chaomin, the Vice-President of Yunnan University, was very helpful in putting me in touch with Professor Wang Zhusheng, who taught in what was then a conjoined History/Anthropology Department. Professor Wang was actually an anthropologist who had finished his post-doc in India and completed his PhD at Stonybrook in New York State, so he had a lot of cross-cultural experience. Amazingly, he also knew exactly how to work things out in terms of Chinese requirements and the American requirements for me being there. So, in preparation for my research, I did a summer intensive language training in 1995 in Taiwan, and then came directly to China where Professor Wang suggested I take Chinese courses at Yunnan University as a way to get my visa. There, I met other foreigners who put me in touch with NGO staff. From the end of ’95 through ’96 I did much of my ground research, and came back in ’97 for three months. That’s when I began my work on prostitution in Yunnan. It really took me a long time to get into those communities. So I was there in ’97, then again in the summers of 2000 and 2002, when I collected even more data on prostitution.

As far as what I saw when I was a teacher in Hunan with VIA, with both female friends and among my male friends, we talked about things like sexuality and birth control and abortion. I was able to meet a physician in Hunan who was involved in family planning. When my parents came to visit me, my physician friend set up a meeting with the head family planning doctor in Hunan, who took them around the hospital. They’re pretty pro-forma in China about abortions since they happen all the time. People seemed to me to be pretty open about family planning and contraception, especially my graduate students and friends.

But I really don’t remember having any conversations about STIs, AIDS or anything like that. I was a student at UCSC even before it was diagnosed as “GRIDD” (Gay-Related Immune Deficiency Disorder) in the early ‘80’s, so it wasn’t really even talked about here in the US either. I don’t remember seeing anything like the barbershop brothels I see today in China. In Shanghai, I saw some incredibly well made-up women in some of the bars and restaurants, but I don’t remember getting the sense that they were prostitutes. Really, it was a combination of me not looking for it and it not being as common as today. Pan Suiming, a sociologist who specializes in sexuality in Renmin University in Beijing targets the date of emergence of the commercial sex industry in China at the late ‘80s to early ‘90’s. At that time, the hukou system changed, migrant labor became more common, and there was more of a floating population because people weren’t tied down to one job for life.

People have said if you read the “scar” literature (literature that describes the horrid things that happened during the Cultural Revolution) there is much talk about a sexual awakening and “blossoming”. Youthful Red Guards were sent out all over the country, were unsupervised, and didn’t have a lot to do. There was an unbelievable time of sexuality, of people having secret abortions, secret babies, and so on. That’s why we have to be careful when answering questions like “When did prostitution start or become rampant?” Is it really a transformation, or a transition?

VIA:

You describe the Chinese perspective of HIV/AIDS in southern Yunnan Province as being based on social status rather than behavior. Why is this distinction important, and how can this perspective be changed among those cultures whose policies lean towards this misrepresentation?

SH:

In the early days this statement was true. It’s really just the way that public health as a science looks at risk groups. Generally with public health, risk is not assigned to behavior; it is assigned to risk groups. So it is easy for the conservative element to end up looking at risk groups, and grouping people who tend to have risky behaviors as the same. Using this type of evaluation, in China, the HIV/AIDS epidemic begin among drug users in western Yunnan where there is high heroin trafficking.

There are basically two methods of looking at disease, how it starts, and how it spreads. The first is looking at risk groups in particular geographic areas. Cindy Patton talks about “tropical thinking,” as in the idea that we have to contain and control tropical disease. You can see this in diseases like malaria: There was the thought that we had to keep malaria “there” and not bring it back to the metropolis of Europe. On the other hand, there is epidemiological thinking, which focuses on groups of people instead of geography. We end up with a competition between these two ways of thinking. In China, they wedded risk categories to geography, but the problem there is that then the government starts focusing its outreach and education only on specific, targeted areas. The highest risk area is said to be Yunnan, then the Hainan Islands, then injection drug users in Xinjiang. But looking at it this way, they totally miss the rural Henan infections because those people were not minorities, not prostitutes, not injection drug users and not in a typical geographic area for HIV infection. They never received any kind of preventative education because they weren't deemed "at risk." So the problem with geographical thinking is that it doesn’t make space for thinking that it is a problem everywhere. By the time I went to China in 1997, there wasn’t a province, municipality or autonomous region that didn’t have a case of AIDS.

Upon realizing this with the lack of preparation and awareness during the Henan infections, the same kinds of debates have been prompted in China that were going on in the States in the ‘90’s. Across the globe, it’s still something that is very much a part of public health discourse.

However, there is still a lot of education that needs to be done. A lot more people are susceptible because the Universal Blood Precautions that are internationally accepted are not used in China. I have literally seen, in Jinghong, a doctor who took a syringe and used it on the whole family without cleaning it between uses. Getting people to think that the needle is contaminated is something wholly new. It’s not just about AIDS—the entire health care system is in disarray. At one time there was socialized health care in China, when they had work units, but now less and less people have health care at all. To make matters worse, unlike the US, if you don’t have any money the hospital will reject you because you can’t pay. Truly, it’s not just a question of education, though that’s helpful—the whole system needs to change. We need to provide money and equipment to rural doctors so that they’ll actually be able to sterilize that needle.

That said, the government is trying to expedite reform of the health care system. Rapid response to the SARS epidemic in China has influenced the way they’re looking at how HIV is spread. There is a new infectious diseases hospital in Beijing, and there is now a government ministry that deals just with HIV. China is quickly putting in place surveillance and testing facilities. In fact, they excel on the level of outreaching to the community to get people tested. There’s a new “rapid test” that costs less than the traditional Elisa test, and you have your results in 20 minutes as opposed to 7 days. The problem isn’t so much with surveillance and testing, but what to do with the people who already have HIV. Do we provide drug cocktails to all people infected with HIV? There was an article last year from Jean-Francois Dechamp and Odilon Couzin from a policy conference at Harvard’s Kennedy School that raised many questions about some of the challenges of getting these drugs on the market. Then there is the question of prevention. How would we handle that? We can make condoms available, but nobody changes their behavior overnight, particularly their sexual behavior. What happens when nobody uses the condoms we distribute? We can look at Thailand as a success case in that they have a 100% condom use policy in brothels. Rather than turning to the West, China has a model right in their backyard in terms of what works for Asia.

Dr. Nagib Hussein was influential in getting Chinese officials into Thailand and showing them what they’re up against. This exposure made a huge impact on officials who saw the epidemic in Thailand, and were then able to observe what the Thai government has done.

VIA:

What local Chinese groups have taken steps towards accurate HIV/AIDS education among prostitutes, drug users, and vacationers in these so-called exotic locations?

SH:

Save the Children Foundation (SCF) connected with the Chinese Army—the one ministry willing to tackle HIV/AIDS—to take steps toward education and outreach. The Australian Red Cross’s (ARC) counterpart is the Yunnan Red Cross. The ARC was one of the first organizations to put together peer education for students from elementary school up through college. SCF is active not only in education, but also in providing access to clinical care for those who suspect they may be infected. One clinic in particular is geared towards prostitutes around Ruili. There are probably something like 100 organizations working towards outreach and support. Most of them are small, and funded by Hong Kong Chinese and Taiwanese nationals. Dr. Gao Yaojie, the 75-year old doctor who discovered the HIV infections in blood-donating peasants in rural Henan, single-handedly worked on producing materials to educate peasants on how to give blood safely, including cautions for those who may have already given unsafely. Unfortunately, one problem is that all these groups aren’t really coordinated with each other; it’s very piecemeal. Dr. Emile Fox, the first UNAIDS representative to China, says that the issue in China is at the county level and the local governments. Basically, if the county government is keen on something, it’ll happen; if they’re not, it won’t. Even if the central ministry in Beijing says, “We want 100% condom use in brothels,” if the local government doesn’t comply, it doesn’t happen. Most of the anti-epidemic stations and drug treatment centers in Yunnan have been at the forefront of trying to curb the epidemic. We really have to stand up and pay attention to this. I’ve seen people diligently plug away at local officials to say, “You have to pay attention to this.” They say, “A drop of water on a rock will eventually make an indentation.” People have slowly worn officials away. Once the work that Gao Yaojie was doing became exposed to the public eye, the news was sent ‘round the world, and everyone started paying attention. We’re fortunate to have the internet and “information highway” because then the government really picks it up. In fact, things are already beginning to change: As of 2003, “anti-epidemic stations” no longer exist under that name. They’re now called “centers for disease control”—but, instead of just one, China has thousands that bring information down to the county level.

VIA:

In your opinion, should this—or can this—be a government problem, or will it be more effective if the local people focus on self-education?

SH:

It should be both. Problems can arise when the government gets involved too heavily, as that often means that local NGOs don’t need to form, and if they do form and become more innovative than the local government, they get squelched. The rise of civil society and NGOs in China is still in its infancy, and currently there are many challenges facing NGOs, including situations where innovative individuals are put under house arrest when they get too “feisty.” Overall, though, the situation has changed dramatically in the last 10 years, and with the amount of intervention, money and resources on this issue, I can only have hope that a generalized epidemic can be prevented. I am optimistic about the situation.

VIA:

How can American volunteers work with the Chinese government in assisting in grassroots education and stopping the spread of HIV/AIDS in China and throughout Asia?

SH:

There are a lot of NGOs and other organizations throughout China that have internships for students. The difficulty is that you have two different kinds of volunteers: Those with language ability and no background, or health background with no language ability. These groups really need money, not bodies, from international sources. Dr. Vincent Gil is a physician in Southern California who has been involved in HIV work in China since the early ‘80’s. He believes that we really need to train American and international physicians in treating HIV who are willing to offer short, free training courses in China. In terms of young volunteers like those with VIA, they’re very useful in helping to organize peer education projects. The problem is that until the organizations figure out what they need, there will be a lot of people just hanging around, doing nothing until they find someone with language ability to give trainings. I got invited to work with the organizations I mentioned because of my language ability. The English-speaking director had health knowledge but no Chinese language skills. There is really a great need for people who have language skills, public health skills, and Universal Precautions training skills. Yale-China has a huge program working with Chinese nurses, and the Global Fund on AIDS is putting in significant funding on projects in Ruili which focus on the drug trade and prostitution.

I currently have a three-year research grant with the Social Science and Humanities Research Council of Canada to look at cross-border health issues among female workers, and to figure out how to take a more holistic approach to how AIDS prevention is targeting these women. My research will focus on questions like how many are actually working in sex trade, what are their risks, how aware are they of these risks, etc. I am looking at several border field sites and currently working with a Yunnan Medical College physician in locating good field sites in Yunnan, most likely Linsang in Samao Prefecture. The scope of this project is to go beyond just looking at HIV, and beginning to link it to other health issues, including trafficking of women, cross border health care, and also other diseases like malaria and tuberculosis that have high rates in China. Currently there is so much activity around HIV prevention in Yunnan. Everywhere one turns, something is going on, which is completely different from ten years ago.

VIA:

Can you share a list of further reading, as well as reputable up-to-date sources of information on HIV/AIDS in China?

SH:

Your best bets are to look at the China AIDS info website as they have a complete list of resources; in particular, translations of new articles ( www.china-aids.org). Also, books have been written by Dr. Xia Guomei of the Shanghai Academy of Social Sciences, and two new books in English will come out in 2006, one by Dr. Joan Kaufman, a demographer by training who has worked in the area of public policy and HIV/AIDS in China for more than ten years, and the other being my own book - Eating Spring Rice: The Cultural Politics of AIDS in Southwest China by the University of California Press. There are many new researchers working on HIV/AIDS in China; in fact there is quite a large pool of them, from epidemiologists, to preventative medicine physicians, to anthropologists and sociologists – both foreign and local Chinese. I know of at least ten anthropologists/sociologists working on HIV/AIDS in China right now, and I am sure there are more I do not know about!

VIA:

How has Southern Yunnan, your research area, changed since you were there in the late ‘90’s?

SH:

The last time I was in Jinghong was just a few weeks ago in November 2005. It’s more tourist driven, as ecotourism is the goal of the area, but much of the surrounding countryside is being destroyed by the current rubber boom. Rubber trees and monocropping are evident everywhere in Xishuangbanna.

Between ‘97 and 2000, Jinghong had changed immensely. All the old bilingual signs were taken down, although for tourist purposes in 2005 there were Dai phonetics added back to signs. However, they aren’t really true Dai words, just a Han Chinese approximation of them. The old part of town that led to the Buddhist temple became sleazy. There were more hotels, the airport is big and flashy, and it’s really tourist-economy driven. I had noticed it before, but it had really changed by 2000 and even more so in 2005.

VIA:

What impact did VIA have on you?

SH:

VIA had a huge impact on me. There are a ton of China scholars who have come out of VIA. Links that VIA created are and were invaluable. In fact, I know of three medical anthropologists who all went on VIA, and are now scholars in the US: Nancy Chen at UCSC, Sydney White at Temple, and me in Canada at McGill. As a vol in China 20 years ago I had more the sense of the "Berlin Wall effect." China was still very much a communist country that restricted its borders. Borders now feel very porous, and that "wall" has come down.