Migration, Urbanization, and the Spread of Sexually Transmitted Diseases: empirical and theoretical observations in China and Indonesia

Christopher Smith

Department of Geography and Planning
University at Albany, State University of New York

Graeme Hugo

Department of Geographical & Environmental Studies

University of Adelaide, Australia

An Outline for the paper

A. Background

1. Averting a Full-blown HIV/AIDS Epidemic in China

2. Report of an HIV/AIDS Assessment in China

B. The Geography of HIV/AIDS in China and Indonesia

1. China

2. Indonesia

3. Some obvious similarities and differences

4. Observations

C. Theoretical Interpretations of China’s HIV/AIDS Epidemic:

1. General theoretical interpretations:

  • rural-urban migration, geographic variation, population mixing, and disease transmission;
  • the ‘commodification’ of sex: an externality effect of China’s economic reform project;
  • urbanization, westernization, and culture change: China ‘catching-up’

2. specific interpretations of China’s modernization and urbanization, and its impacts on behaviour change:

  • some background:
  • three sets of theoretical interpretations:

A. the dismantling of the organizational and spatial structures that helped keep order in the Maoist city (from 1949-1978);

-this process has been accompanied by a massive rural to urban migration, which has resulted in rapid urbanization, as well as a marked increase in unemployment, poverty, and, for the first time since 1949, intra-urban inequality…

-in the context of this new urban geography, both the demand for and the supply of ‘high-risk’ activities began to emerge in the 1990s

B. a dramatic increase in the overall ‘fluidity’ of Chinese society, which has resulted in the erosion of existing moral and behavioural boundaries;

- in spite of the many benefits associated with China’s ‘opening-up,’ there are also fears about the downsides of modernity -- the excessive fluidity and movement that has accompanied the reform project

- interestingly, this is something Marx predicted when he wrote about how the ‘safe havens’ of the past evaporate or ‘melt into the air’ when confronted with the forces of modernization (Berman, 1988).

- one of the human consequences of those forces is the emergence of a new (or vastly increased) culture of ‘marginality,’ with more people than ever behaving at the far reaches of what is generally acceptable in an authoritarian society

examples of this in contemporary China include the emergence of:

  • new urban youth cultures that have been challenging the moral and sexual norms of Chinese society
  • new (or revived) drug habits appearing not only in the cities but also in the towns and villages, especially close to the borderlands
  • an entire range of sex-focussed imagery, literature, products, and services…all available for purchase in the marketplace

C. a new set of cultural values that have been inviting (and inciting) the Chinese people to think of themselves differently…for example:

- people have been able, perhaps for the first time ever, to think of themselves as actors with individual agency;

- ideas about a collective utopian future have been replaced with more quotidian concerns for everyday life;

- the reforms increasingly stressed the importance of consumption, getting rich, and enjoying life;

- the rigid class identities of the Maoist era have largely disintegrated

in present-day China we see a cluster of trends that can be considered symptomatic of this new modernist ‘emptiness,’ including:

  • rising crime rates
  • government corruption
  • marketed pornography
  • the trafficking of women and girls
  • drug abuse
  • the spread of STDs.

C. What can be added to this from a look at the situation in Indonesia?

D. Summarizing, Interpreting, Concluding?

1. Summarizing, thus far:

2. The state’s response to all of this? reports thus far have been contradictory….

3. Conclusions: some common themes are clearly visible in the new China:

a. the migration effect

b. a new set of structural forces that might have changed human

behaviours

c. a unique new combination in contemporary China…

4. Looking across geographies and cultures:

  1. what China can learn from Indonesia
  2. what Indonesia can learn from China
  3. empirical observations

d. theoretical interpretations

Introduction: HIV/AIDS in China and indonesia

China is on the verge of a catastrophe that could result in unimaginable human suffering, economic loss and social devastation (UNAIDS, 2002, p.7)

At the beginning of the twenty first century China announced a major change in its policies toward HIV/AIDS. Until that time the government had tried resolutely to discourage the behaviours associated with the spread of HIV and other sexually transmitted diseases (STDs). In some cities the streets were forcibly cleared of prostitutes and drug addicts (Agence France Presse, 2000). However, such diseases increased in incidence in the 1990s although there was a failure to acknowledge this at an official level. By the end of the 1990s, international pressure and the evidence that the HIV/AIDS epidemic was gaining momentum, convinced China’s leaders that some radically new strategies were required (Becker, 2003). From a global perspective, and in purely statistical terms, China’s HIV/AIDS problem is considered to be much less serious than in other parts of the world. Most AIDS workers and researchers, however, point out that what is most disturbing about the stituation in China is the speed at which the new cases are occurring, and the geography of such occurrences.[1]The rate of increase in the number of infected persons had been about 30% per year in the second half of the 1990s, but this appeared to have doubled by the year 2002 (Thompson, 2003; Wu, 2003).

In Indonesia, the fourth largest nation in the world (2004 population 222,611,000), there has been a similar experience with respect to HIV/AIDS. Although changes in its political economy over the last decade have been quite different to those in China, they currently have prevalence rates of 0.1 percent. Like China, there has been reluctance at official levels to recognise that HIV is of significance and that it effects more than small numbers of marginal groups. However, as in China, there is increasing concern because of the rapid increases in infection notified in recent year and the knowledge that official data substantially understate the actual rates (Ministry of Health, Republic of Indonesia, 2002, 5). Moreover, as is the case in China, there is considerable geographical variation in levels of incidence so that in particular parts of the country, especially some urban areas, the incidence is several times higher than the national average (Hugo, 2001). While official notifications understate the number of infections, between 2000 and 2004 the number increased by 166.8 percent and there is an increase in tempo of notification.

The Chinese government now admits there may already be between 600,000 and one million people infected with HIV (Stephenson, 2001); and the United Nations predicts that by the year 2010 as many as 10 million people could be infected (UNAIDS, 2001). This estimate was calculated from current conditions in China, modified by evidence from other parts of the world where AIDS has become pandemic, especially sub-Saharan Africa, the Caribbean, and post socialist Russia (National Intelligence Council, 2002). On the basis of these projections UNAIDS (2002) has described HIV/AIDS as China’s ‘titanic peril,’ and although this sort of alarmism may be a questionable strategy, evidence suggests that it has captured the attention of China’s leaders, who are now publicly supporting a massive push in the direction of prevention and service delivery Thompson (2004, 1) reports that the Chinese leadership which took office in late 2002…

By late 2003, top leaders were taking a more visible role on HIV/AIDS prevention and treatment issues – an indication that the lessons learned from SARS would translate into an increased commitment to fighting the AIDS epidemic.

The anticipated leap forward in the epidemic during the next few years would involve the virus spreading to an increasing number of areas and populations, resulting in the widespread dissemination of HIV to the general population. Chinas leaders are now making plans to deal with the potentially devastating consequences of an epidemic of these proportions, and its consequences for individual health, community development, and overall social stability (National Center for HIV, STD and TB Prevention, 2001). International agencies like UNAIDS have welcomed Chinas new pro-active stance on HIV/AIDS, but there are still major concerns about institutional and infrastructural problems that threaten to derail prevention and treatment plans.[2]

The Indonesian government currently estimates that there are between 83,000 and 278,000 HIV/AIDS sufferers in Indonesia (UNIADS Secretariat, 2004) but the Indonesian Ministry of Health (2002) has estimated the numbers vulnerable to HIV infection at between 13 and 20 million people. Hence, some commentators see Indonesia to be “poised on the edge of an Aids Explosion” (McBeth, 2004,46). The official recognition of the crisis has been slow in coming but now appears to be accepted as a significant threat. HIV infection has been in the past seen as being a disease of “others” by leaders – foreigners, tourists, drug users, prostitutes, gays, etc., and not been accepted as a mainstream health issue. Even now there are many prevalent myths regarding the disease. There are indications, however, that this may be changing. The relatively small numbers of dedicated officials and NGOs working in this area are succeeding in getting AIDS on the political agenda, although the resources being made available are still very small (McBeth, 2004, 46).

The historical geography of China’s and Indonesia’s STD and HIV/AIDS epidemics

China’s STD and HIV/AIDS epidemics appear to have evolved through three phases, each of which has had a relatively specific geographic pattern. The first of these began as early as 1985, and was marked by geographic concentration and low overall numbers of patients. At this point in time, most of the newly infected individuals were appearing in the coastal provinces, and from all accounts most of them were reported to have been foreign nationals and ‘overseas’ Chinese (mainly from Hong Kong and Macau), as well as some foreigners from other parts of the world. The official view at the time was that STDs (and then later HIV/AIDS) were ‘foreigners’ diseases -- which had come from outside China, and which could be controlled by limiting access to potentially diseased individuals from abroad, and by rigorous testing upon entry (Farrer, 2002).

A second phase, beginning in 1989, was also a geographically-limited epidemic, with HIV infections clustered in China’s borderlands, particularly in Yunnan Province and Guangxi Autonomous Region in the southwest, and in Xinjiang Autonomous Region in the far west. During this period the majority of reported HIV infections were among intravenous drug users (IDUs), and the spread of the virus was thought to be associated primarily with the cross-border travel of individuals engaged in a variety of epidemiologically risky behaviours, especially the trafficking of drugs and the sharing of infected needles. A small number of HIV infections were being reported at this time among laborers returning from abroad, patients with other STDs, and some female sex workers (UNAIDS, 2000).

The third phase began in 1994, when HIV transmission began to appear in China’s interior (Rosenthal, 2002). In some rural areas, most notably in Henan Province, contaminated blood was circulated to both the original donors and to the recipients of blood transfusions (Smith and Yang, 2004; BBC News Online, 2003). Blood collection centers had opened in Henan and elsewhere in the early 1990s, encouraging peasants to donate blood and blood plasma in return for payment (Chan, 2001). Local blood banks aggressively sought donors and many poor peasants were happy to sell their blood, often in less than sanitary conditions. Many of the individual donors had blood returned to them from communal vats, after the plasma had been removed and sold to hospitals (Eckholm, 2001). It turns out that some of the pooled blood was contaminated with HIV, which put both the donors and the recipients at risk, and in some villages the results were disastrous, with donors being infected at rates as high as 65%.[3]

As tragic as the Henan blood scandal was -- and still is, in the sense that many of those infected subsequently spread the virus to others -- from the perspective of public health policy, by the end of the 1990s the Chinese authorities were beginning to focus more of their attention on HIV transmissions that were occurring as a result of individual risk-taking behaviours (US Embassy 2000). According to a UNAIDS (2000) report, the HIV infection rate among drug users in China increased almost tenfold in a five-year period, from 0.04% in 1995, to nearly 5% in 2000; and by the end of the decade intravenous drug use was thought to account for almost 70% of all new HIV infections in China.[4]

At the same time the evidence was also showing that the fastest growing rate of new HIV infections in China was from sexual contact, much of which appeared to be linked to the emergence of a thriving commercial sex industry in many parts of China (Wu, 2003). This phenomenon first became evident in the late 1980s, as one of the unexpected and unintended consequences of China’s dramatically successful economic reform project. New commercial sex outlets opened-up in the coastal cities and some of the provincial capitals, and sex workers began to re-emerge on China’s streets after a hiatus of more than forty years. It is now apparent that the sex trades have spread to the smaller cities and towns of the interior, and even to villages in many parts of the countryside (Micollier, 2003; Hyde, 2001). One of the primary reasons for this growth is economic, in the sense that sex is a highly marketable commodity, and as incomes rise new outlets have emerged in multiple locations to satisfy actual and potential demnads. More importantly, as incomes have risen in China so has inequality, and in recent years many people have been driven toward the sex trades for purely economic reasons.

The Chinese Communist Party (CCP) successfully outlawed commercial sex work in the early 1950s, and virtually eliminated the STDs it was associated with. The old prohibitions are still nominally in place -- and prostitution is still a criminal activity -- but in many areas the bans are widely ignored. According to one researcher’s estimates, China may now have anywhere between four and six million female sex workers (Pan, 1999; 2003), a number that seems likely to increase as the country moves further along the reform trajectory, and as its population grows more mobile and more entrepreneurial.[5] Large numbers of women have either chosen or have been coerced by economic need to sell sexual services in a variety of locations, including karaoke bars, massage parlors, barbershops, and hotels (Goodman, 2003).

As this brief summary indicates, in the 1990s China’s STD and HIV/AIDS problem was restricted to specific parts of the country: the coastal provinces; the southwestern border areas; and parts of the rural interior. This consensus of opinion was challenged in the latter part of the decade, however, when it became evident that the epidemic was spreading both spatially and socially -- moving into different areas and being transmitted to different groups of people. The number of new HIV infections in 1994, for example, was double what it was in 1993; the number in 1995 more than triple what it was in 1994; and with one exception the number of confirmed new HIV infections in China has grown by more than 40% every year since then (UNAIDS, 2002).[6]

It did not take very long for researchers to realize that the potential existed for what had been spatially discrete events to become connected, and from what was being reported in other parts of the world, it appeared that this process could be accelerated by population mobility. China had been experiencing a population transfer of unprecedented proportions throughout the 1990s, with perhaps as many as 120 million people – most of them from the countryside -- looking for new jobs and homes in towns and cities (Smith, 1996). Because most of those migrants have only temporary status in the cities, many of them travel back to the countryside frequently (Solinger, 1999). The threat existed, in other words, for migration to contribute to a rapid increase in STDs; and for the AIDS virus to gain a foothold in ‘new’ parts of China that had hitherto recorded relatively low rates of prevalence.

In Indonesia, the spread of HIV/AIDS appears to have gone through three phases since its initial introduction in 1987 (Utomo, personal communication). In the first phase, infection was confined to small groups and was spread mainly by homosexual contact. In the 1990s, numbers of notifications increased and the main method of transmission was heterosexual contact with the commercial sex sector playing an important role. Since the late 1990s, however, there has been a dramatic increase in notification of the disease and there has been an increasing amount of transmission via shared needles by Intravenous Drug Users (IDUs). During the second phase of spread there was a strong geographical concentration of HIV infection. Although official data on infection are gross understatements, they do indicate the spatial patterning of the disease. Figure 1 shows that in 1999 the disease was especially high in: