China must respond to AIDS in the way it has to SARS

Before I launch into the subject of this week's column, I feel compelled to report my outrage of the month: After the Associated Press reported last week that 966 people were massacred in the Democratic Republic of the Congo, I called the New York Times and The Washington Post to see whether those papers had correspondents in the country. Unacceptably and irresponsibly, neither newspaper had a single correspondent covering the Congo.

Recent reports from China indicate a fatal disease is exploding exponentially among the population, with the government now acknowledging that its initial estimates of infection were too low — what's more, the disease is spreading rapidly in Southeast Asia and around the world. Think I'm talking about severe acute respiratory syndrome (SARS)? Wrong. I'm talking about HIV/AIDS.

Last week, the Chinese leadership significantly stepped up its efforts against SARS, firing the health minister and the mayor of Beijing over their failure to contain SARS, though it is still unclear whether the order to ignore the threat came from a higher level. In days, China revised its estimates of SARS infections from 39 to over 400. In days, China went from proclaiming SARS "under effective control" to calling the disease a grave danger to society. China's deputy health minister declared that, "No delays in reporting nor any underreporting or cover-ups will be allowed" and all responsible officials "will be held accountable." President Hu Jintao demanded local health officials provide "accurate, timely, and honest reporting about the disease," and said any official caught covering up the spread of the virus would face severe punishment.

The period of time it has taken China to become aware of the epidemic, deny its severity and then admit its mistakes and attempt to redress them has been remarkably fast — in comparison with its slow awakening to AIDS, a disease with far more dangerous consequences in China than SARS. Different models of the potential impact of AIDS in China suggest the country's overall growth rate could be cut by more than one-third, and more pessimistic scenarios predict even "more dramatic economic repercussions for the Chinese economy." Even China's Ministry of Health, not known for its candor, has said that China could have 10 million infections by 2010. One should keep in mind that the history of AIDS shows that the actual devastation of the disease almost always exceeds predicted worst-case scenarios.

In the past year, China has taken small steps in the right direction. But what is needed is a leap in the right direction. When I visited China last summer, HIV-positive activists met under pseudonyms in a Beijing hotel to plot strategy for pushing the government to action — they met under pseudonyms because they feared they would be expelled from their rooms if the government knew they were gathering. The result of China's inaction has been catastrophic, with government officials at every level denying the scale of the disease and abrogating their responsibility to fight it.

There are a number of reasons why the government's responses to SARS and AIDS have been so different. While global media coverage and pressure are critical, the spread of AIDS in China is linked to government-run blood banks that carried the disease around the country, and it is also linked to prostitution and drug use, both illicit practices. If the government acknowledged the full scale of the epidemic, it would acknowledge not only its own complicity in the spread of the disease, but the scale of illegality in the country, which could undermine the government's authority. Not to mention that AIDS, unlike SARS, is inherently linked to the taboo subject of sex — and those who have HIV are often perceived to have done something "immoral" to "deserve" their "sentence." SARS, by comparison, does not carry the same moral, cultural or political baggage as AIDS.

In addition, the economic impact of SARS on tourism in Hong Kong and elsewhere has been immediate and visible — while the economic impact of HIV, though ultimately greater, is more longterm, affecting things like worker productivity, absenteeism, and health care costs. The Chinese government realizes there is less political risk and more immediate economic gain in fighting SARS than fighting AIDS — but this is not necessarily true in the long run.

When Hu Jintao rose to power, China observers predicted that it would be years before an accurate picture of his own influence emerged — so powerful was the lingering influence of Jiang Zemin. And yet, one must hope that the accountability and transparency that Hu Jintao is demanding in response to SARS reflects a broader commitment to transparency and accountability in his approach to government — and perhaps even presages a similar commitment to fighting the most pressing public health crisis in China: AIDS.