China’s HIV/AIDS epidemic is not yet the world’s worst (“An Epidemic of Denial,” Summer 2003). However, its most recent wave is definitely one of the most bizarre. Not since the Romanian episode in which newborns received HIV as a result of contaminated “therapeutic” mini-transfusions has the AIDS virus been presented with so ideal an opportunity to rapidly infect large numbers of vulnerable people as apparently occurred among rural blood donors in China.

This particular Chinese epidemic is all the more distressing because, while exactly what happened remains unclear, it was almost certainly unnecessary. Reuse of unsterile phlebotomy equipment, re-infusion of pooled red cells to donors, secondary sexual and maternal-infant transmission, and contamination of biological products all contributed to epidemic growth. To this day, the dearth of reliable epidemiologic data precludes understanding the relative importance of each of these factors and limits the development of effective prevention strategies.

But to characterize China’s rural blood donor epidemic as “nosocomial” or “iatrogenic” misleads through the implication that the practices that created this epidemic were therapeutic in intention. In Romania, doctors believed that small transfusions of whole blood to frail infants would boost their immunological systems and improve their nutritional state. The small amount of blood administered in each transfusion meant that blood from a few HIV-positive donors infected many children. The medical intervention was flawed, but the intent was to improve the health of the children.

In contrast, the driving force behind the rural blood collection system in China was profit, pure and simple. This epidemic is not the result of medical intervention, but of rampant, unregulated capitalism in the production and marketing of biological products, many of which are of dubious value. Given what is known about the workings of this system, one is hard pressed to attribute altruistic or therapeutic motives to any of the players. Everyone other than the purchasers of the products was in it for the money, although the peasants who sold their blood and ended up with AIDS would surely not have made that trade-off knowingly.

Official responses to the revelation of the blood donor epidemic suggest a lack of appreciation for basic principles of epidemiology and public health and do little to address the specific behaviors that led to the problem. For example, the Henan Health Bureau claims to have shifted to a completely voluntary blood donation system and says that the change has halted disease transmission. Yet, the primary source of the epidemic was not donor payments, but blood collection behaviors. The great majority of donors were almost certainly infected by the re-infusion of contaminated whole blood cells. If the practice of pooling and re-infusing continues, then donors, whether voluntary or paid, will continue to become infected. A voluntary blood collection system will be safer only if the blood collection procedures are reformed as well.

Similarly, both the local and central authorities have made much of what they claim are successful campaigns to “ban illegal blood collection business” in Henan. But it is not at all clear that the source of the dangerous practices was the illegality of the blood collection business, nor that these practices have ended in a meaningful way. In Henan, the Health Bureau itself was an active collaborator in the blood collection system, and risky practices (re-use of equipment, re-infusion of cells) occurred at official collection stations. Indeed, the complicity of local officials in the scandal significantly hampered efforts by Beijing to investigate and continues to block real data gathering, education, and provision of care.

Precisely because the roots of China’s HIV/AIDS epidemic and the ineffective official response to it lie in the growing tensions among a rapidly evolving economy, an emerging civil sector, and a sclerotic political bureaucracy, it is not enough for concerned international health organizations to call for accountability, transparency, and the rule of law. Clearly the aforementioned are essential conditions for an effective response to the challenge of HIV and other emerging epidemics, but if these conditions are to develop, the international community must provide encouragement and concrete support to the competent, compassionate, and committed Chinese public health workers and nascent AIDS activists who are already working toward a best practices HIV/AIDS program for China.

China’s government is not the first, nor will it be the last, to deny its AIDS crisis until the very last moment. (The word “AIDS” never publicly passed former US President Ronald Reagan’s lips during his presidency. South African President Thabo Mbeki still appears unconvinced that HIV causes AIDS.) Fortunately, governments are not the whole story. No country in the world has fashioned a strong HIV/AIDS policy without leadership from the health care sector and social pressure from non-governmental organizations. There is evidence that both are present in China today.

They may have received an unsolicited and tragic boost from the SARS virus, whose ease of transmission, short incubation period, and relatively high death rate have combined with the forces of globalization to rapidly undermine the Chinese government’s knee-jerk stance of secrecy and denial in domestic health affairs. It is too soon to predict what lies ahead, but the potential impact of SARS on China’s AIDS epidemic should alarm the bureaucrats and even get them moving. Large numbers of peasants with advanced HIV disease and without access to even rudimentary health care will succumb rapidly to an agent as virulent as the SARS virus when it arrives. Should this tragedy occur, it will play out in full view, with the rest of the world watching anxiously.