The Chinese State and Everyday AIDS Practices in the Borderlands
Issue #39, September 1998
The government office is a banquet of bareness -- green paint strategically mopped up the sides of the walls, just high enough for a three-year-old to stand and point with her thumb to a dividing line where whitewash flows to the ceiling, marked with ink splatters and small knife holes. A scattering of yellowing Renmin Ribao (The People's Daily) lays in a pile beneath tea cups made of recycled glass jars. A sparse supply of pens. A key poster of Deng Xiaoping, a large map of China, and a quiet smoldering hiss that disturbs the ticking of a clock. A faraway Chinese government office wakes, and as Napoleon Bonaparte said, "when China wakes, it will shake the world."
HIV/AIDS in China
Globally, HIV/AIDS infections have risen exponentially in the last five years. In 1995 alone approximately 4.7 million people were infected with HIV, an average of 13,000 new infections each day. By January 1996, Southeast Asia accounted for 23 percent of all HIV infections worldwide, compared to north America and northern Europe which accounted for less than 4 percent. Today, southern China is beginning to look similar to northern Thailand in terms of an indigenous AIDS epidemic that is attributed to the rise in injection drug use and prostitution. The Chinese epidemic has grown from 2,000 people infected with HIV in 1995 to an estimated 200,000 by 1998. While the epidemic may be transmitted and experienced by local bodies, many Chinese view AIDS as not only a foreign disease, but a barbaric one at that. This notion of barbarian diseases has everything to do with how AIDS first appeared in China in the minority prefectures along the Myanmar and Lao border.
AIDS was first identified as a problem of injection drug use in the Dehong-Dai minority prefecture in Yunnan Province and later framed as a problem of sexual transmission in the Xishuangbanna-Dai and Menglian Lahu-Wa autonomous minority prefectures that border Laos and Myanmar. In the Xishuangbanna-Dai prefecture, the capital city of Jinghong -- formerly the capital of the Tai kingdom of Sip Song Panna for over 800 years -- is a new tourist destination for Chinese who can afford vacations. Jinghong's ethnic tourism market involves a journey into a place that is famous as a tropical paradise and is linked to sexual pathology and an urban ethnic erotic subculture within China. Jinghong has a cosmopolitan sex industry that has brought the city both fame and fortune, as well as a disease that knows no borders. AIDS here brings with it a public health crisis of epic proportions. In these Chinese border minority prefectures, it not only challenges fundamental cultural systems of sexuality, gender, and ethnic relations, it also presents problems for representatives of the Chinese state in handling the prefecture's anti-epidemic stations, public security bureaus, and international non-governmental health organizations (NGOs). Fieldwork in 1996 and 1997 in Jinghong (the present capital of the Xishuangbanna-Dai autonomous region), Menglian (the capital of Menglian Lahu-Wa autonomous region), and in Kunming (the capital of Yunnan province), reveals often shifting and contradictory positions of state agents in response to local experiences of AIDS.
The Everyday Practices of Bureaucrats in Controlling AIDS
How are certain representatives of the Chinese state implicated in controlling and succoring the HIV/AIDS epidemic in border regions? Akhil Gupta points out that studying the state ethnographically sBetween a Rock and a Hard Placehould involve attention to analyses of the everyday practices of bureaucrats and the way the idea of the state is articulated in public culture. By focusing on different bureaucracies, this approach allows for a disaggregated view of the state without prejudging a certain coherence or unity. In this way the workings of a translocal institution (such as the Yunnan Provincial Department of Public Health) can be made visible in localized practices (the prevention of AIDS). As sociologist Pierre Bourdieu reminds us, the quotidian practices of bureaucrats tell us something about the reach of the state in the everyday lives of people who represent it. How do individuals who work in the drug security center in Jinghong, and the anti-epidemic stations in Menglian and Kunming, react in the face of an epidemic? The impact of what state agents say and do is crucial to understanding the decisions that the state makes, and how ideas about AIDS are created, circulated, and disseminated through the everyday practices of these people. For example, why would a physician/epidemiologist decide to treat AIDS as a problem of borders and policing rather than one of sexual and behavioral practices? It is important to understand that the individuals I introduce here are often in contradictory positions: their social and professional roles intersected with other institutional roles. One might be a physician, a health worker, an academic researcher, and a state official all rolled into one.
To understand these contradictions it is pivotal to tease out how AIDS prevention policy is manipulated by agents of the county and provincial Yunnan governments. The construction of a disenfranchised "other" -- comprised of prostitutes, transients, foreigners, and drug addicts -- creates a test population that fits into international epidemiological risk categories for HIV/AIDS. Furthermore, certain agents of the Chinese state's provincial anti-epidemic stations conflate HIV/AIDS in Yunnan with China's Dai minority. This congruous mapping of the Dai people and diseases leads to a whole series of regulatory practices, which social theorists Michel Foucault calls "governmentalities." These governmentalities include mandatory HIV testing in a procedure where videotaping the handing out of AIDS test results to an HIV-positive woman without her knowledge is done for the sake of what one informant called "research." In other cases, Dai women who have crossed the border to work in Thailand are also tested for HIV. It is important to contextualize these practices ethnographically to avoid essentializing representatives of the Chinese state -- people like policemen, teachers, bureaucrats, and health workers who actually enforce these regulations -- because the organizations comprised by these individuals are neither monolithic nor cohesive in their regulatory capacities.
Prevention strategies are never easy. Because China has focused on demographic categories in identifying AIDS risk, as opposed to risky behaviors, an edifice of state controlling practices and regulations that accompany these categories has been brought to AIDS prevention strategies. This leads to the problem of fighting an imagined disease with imaginary figures, because the questions of who gets tested for HIV, and who is marked as an AIDS carrier, have everything to do with who someone is demographically, rather than how that person behaves. To illustrate these politically motivated and contested decision-making processes, I present in this essay four stories about three different kinds of local state agents: Drs. Li and Sun, who are epidemiologists/physicians, Chen, a health worker, and Lao Yan, a public security guard. The stories of these indivisuals will show how AIDS prevention involves a subtle interplay of the pressures of prestige, political maneuvering, personal ethics, and geography. While the stories told here are true, all names used are pseudonyms.
Dr. Li and the AIDS Bureau in Kunming
Shortly after the first case of AIDS in Kunming was discovered in 1985, the Ministry of Health in Beijing set up a working group for the prevention of AIDS. By 1995 the state council established a Coordinating Conference for the Prevention and Treatment of Sexually Transmitted Diseases and AIDS, and provided special funding for three regional centers in Guangdong, Jiangsu, and Yunnan. Dr. Li was the appointed head of this government AIDS center in Yunnan. He was instrumental in establishing the third regional center; however, since its inception he has been out of the province to learn English with the explicit goal of going abroad to study. He went through the appropriate personal connections necessary to enroll in an English course offered by a Medical Center in Hunan province that had formerly been funded by a U.S. university. I met Dr. Li at a Yunnan Red Cross meeting that had been called in June 1996 to discuss the Yunnan province disease control plan. The provincial government was to invest some 500 million yuan (roughly 60 million dollars) to build a disease-prevention zone along its border and work from 1996 to the year 2000 to set up an AIDS control network (China Daily, April 16, 1996).
I asked Dr. Li what the rationale was behind this new AIDS directive to tighten controls along the Yunnanese border, to erect new guard posts, and to test people coming back and forth across the border for a variety of diseases including AIDS. He told me, "the biggest problem in the Xishuangbanna is its freedom, its openness. What we need to do is secure our borders." I questioned him again, "If AIDS knows no borders, and the locals know where to cross in the jungle, trying to place an iron-clad AIDS prevention belt around Yunnan just doesn't make sense epidemiologically." Again he repeated, "as a public health measure, we need this disease prevention belt around the province." In quiet exasperation I said, "what about the sex industry in Banna, what about putting AIDS prevention announcements on all the flights, and free condoms in hotel rooms?" He laughed, "In China, that would be impossible."
Dr. Sun and the Provincial Anti-Epidemic Station in Kunming
Dr. Sun was a fragile-looking physician and epidemiologist in her mid- forties who had trained in Yunnan, Australia, and Beijing. She was someone I frequently came into contact with during my fieldwork. While working at the provincial anti-epidemic station, she was determined to translate cultural factors into seemingly clear units of analysis. Just before I was to leave for Jinghong in February 1996, she said: "We need you to help us to understand the lifestyles and cultural habits of the Dai. The Dai people are soft, they only want a comfortable life, and are easily manipulated into drugs and prostitution." As a result of her research in two Dai villages in the Xishuangbanna in 1995, she had concluded that many Dai youth are prone to sexual promiscuity, and that this cultural practice would lead to an increase in the spread of HIV. She said: "Where you can help us is to learn and understand these cultural practices so we can design prevention programs that will get Dai youth to change their promiscuous ways." But by the time I completed my fieldwork in August 1997, Sun had changed her professional position, because by 1996 epidemiological findings attributed the majority of the new HIV infections to the Han Chinese. Of course this statistic does not account for or problematize the methods of collecting AIDS statistics in Yunnan.
Chen and the Menglian Anti-Epidemic Station in Simao County
In December 1995, I went to Menglian Lahu-Wa autonomous region to the township of Menglian as a member of the Australian Red Cross team. The purpose of this trip was to conduct a survey of 400 residents in 9 villages from 4 ethnic groups (the Wa, Lahu, Dai and Han). The goal of the survey was to ascertain local peoples' knowledge of practices and behaviors that put them at risk for AIDS, and to compare that knowledge across ethnic and village boundaries. These findings were to be compared to a similar survey conducted in the center and suburbs of Kunming.
Chen, while working at the Menglian anti-epidemic station, was trying desperately to get the Yunnan Provincial level health department and the AIDS office to pay attention to her county's needs. During the survey training, she repeatedly explained to me that she had been criticized for permitting a Beijing-based television production team to videotape people with AIDS in Simao county. The critiques were not based so much on the validity of the coverage as on the concern that Menglian would be publicly marked as a diseased site within China. Chen noted that many people want to believe that AIDS comes from somewhere else.
When I first met Chen in December 1996, she had just returned from a visit to a Dai village where there was a 22 year-old mother with a 1-year-old child who were both HIV positive. She considered the scope of her work to include alerting people to the dangers of transmission in a relatively remote area where little or no prevention information was available. The only evidence of AIDS prevention activity in the entire Menglian county, the armamentarium of health education, was the result of Chen's work. Chen quietly explained to me that without disclosing their identities or violating her personal sense of confidentiality, she wanted to invite local young women who were HIV positive to attend the Australian Red Cross introductory AIDS training for the anti-epidemic stations staff. She was also eager to work on the repatriation of young female prostitutes from Thailand back to China. However, one week later, Chen confessed to me that while she tries to encourage young women to get tested rather than force the police to arrest them, "I bring in the police because these women need to get tested to protect their families from AIDS."
Lao Yan and the Jinghong Security Drug Center in the Xishuangbanna
On one sweltering afternoon in the summer of 1996, I took a taxi over the Lancang river bridge in Jinghong to the next town. Driving up the long winding dirt road filled with pot holes and muddy water, amidst landscape peppered with rubber plantations and rock quarries, I arrived to find a small colony of inmates in the middle of the jungle. As there is no equivalent word in English for Qiangzhi Jiedusuo, which literally means "admonish drug center," I have translated it as "security drug center," but it is more like a prison for drug addicts. Vines cover the high red brick walls, an old Beijing jeep lies in the heap by the side of the road, scroungey mongrel dogs bark, and a few inmates and guards squat in the noon-day sun, smoking tobacco out of long water pipes. It was here that I first met Lao Yan, a member of the local Dai minority and one of the guards, who welcomed me by showing off his small zoo. He was raising bamboo rats (which he promised tasted great), fruit trees, a few chickens, and dogs.
When I arrived at two in the afternoon, the seven guards and three staff were playing cards and quite drunk. On my visits to the center, the guards appeared to do nothing except to complain that there is never enough money to do counseling or to make repairs, let alone do HIV testing and counseling with their intravenous drug using charges. Money was so scarce that the resident nurse hadn't received her monthly salary of 300 yuan (or $36 US dollars) for a couple of months. Although the security drug center lacks money to pay its employees, money is spent on lavish meals and alcohol. However, Yan said, "we really try to economize, in fact even Premier Li Peng encouraged us not to buy expensive foreign cars but local jeeps." Later, on reflection, I noted that it was the Premier who had donated 100,000 yuan (over $12,000 dollars) to build a new brass and gold-glittered gate in Jinghong's new tourist district designed as a facsimile of a Dai Buddhist temple. It was ironic to see a new city gate, when the only minority technical training school in the Xishuangbanna had to close its doors for lack of money. On the drive back to Jinghong, Lao Yan said that the provincial security bureau had sent 35 middle level police officers on a trip to northern Thailand to review the highland tribal police efforts in Thailand's minority tourist belt, followed by a trip to Phuket for rest and relaxation. Lao Yan proudly told me that this trip cost hundreds of thousands of yuan.
The stories of these four representatives of the Yunnan Provincial government and local township government agencies show that as state practitioners they are often placed in contradictory positions. For example, as officials they balance between positions of personal gain (trips to Phuket, Thailand) and their work to control AIDS (testing women for HIV who cross the border into Thailand). They also balance between practices that understand AIDS as a fundamentally personal and confidential issue, and practices that treat it as a disease that requires forced police intervention. Furthermore, when epidemiologists like Dr. Sun try to map cultural prejudices onto risk variables, the results reflect what Cindy Patton calls their own prejudices rather than situations on the ground.
Personal mobility within China can be used by people as a tool to exercise power and resistance to orders of the socialist state. In the case of AIDS, the state reacts to the exercise of this individual power by trying to recreate new sets of boundaries and borders. When geography and politics are wedded in this way, AIDS ceases to be a disease without borders and becomes a disease with distinct borders, as if it only seeps though at certain points on a map with no room "for the natives to slip through." This idea of border building mirrors Dr. Li's notion of how to keep AIDS out of the population, as if the great wall of China could be erected once again, this time to keep not only barbarians out, but barbarian diseases as well. Chinese historians note that even on the eve of liberation in 1953, the Xishuangbanna was perceived as a desolate wasteland of malaria and leprosy-infested jungles, full of barbarians. These conceptions of barbarians and barbaric diseases live on in the perceptions of Kunming physicians and health bureaucrats working in these autonomous regions.
In such a context, AIDS prevention policies become cloaked in the language of openness, mobility, hyper-mobility, transgression, and resistance to a previous state regime that did not permit people from the countryside to move into the cities. For these minority prefectures, the regulatory practices of the state express not only the contradictory positions of officials, but the contradictory locations of these places, places not entirely controlled by the central Health Bureau in Beijing, the provincial bureau in Kunming, or even the county health departments in Jinghong and Simao. People and places become mired in relationships that dance between the different levels of the state government that embraces the Chinese idiom the "mountains are high and the emperor is faraway." In AIDS policy the question remains, how high and how far?
Sandra Teresa Hyde is a Ph.D. candidate in the joint Medical Anthropology Program at UC Berkeley and UC San Francisco. She spent 18 months, between 1995 and 1997, conducting fieldwork on the emergence of the HIV/AIDS epidemic in Yunnan Province in southwest China.