Sexually Transmitted Diseases in the Peopleʼs Republic of China in Y2K

AS OF 1999, more than 1.2 billion people live in the People's Republic of China, comprising one fifth of the world's population. Accordingly, the health of the Chinese people affects the entire species. In addition, the ancient culture of China and the dramatic actions of the communist government in the last half of the 20th century have proved fascinating to the rest of the world. Cultural and governmental forces have a critical impact on the control of sexually transmitted diseases (STDS).1 Indeed, as the Chinese people must now deal with a resurgence of STDs and a new HIV epidemic, it seems inevitable that unique and important approaches to disease prevention will be developed. We have previously reviewed the history of STDs in China.2 Sexually transmitted diseases were most likely introduced into China by Portuguese traders in port cities in the 1500s, and as in the West, these diseases flourished throughout the country. By 1950, more than 10 million Chinese had venereal diseases, and 6.2 percent of all hospital admissions were attributed to STDs. Ten percent of national minorities, 5% of Chinese city dwellers and 2-3% of Chinese rural residents had syphilis. The majority of sex workers living in urban areas had one or more STDs.2,3 The spread of STDs in China appears to have been driven by poverty, drug abuse, and rampant commercial sex work. Sexually transmitted diseases among Chinese minorities likely resulted from traditional polygamous sexual practices.2 When Mao Zedong came to power, improved health care was among his top priorities.4,5 Sexually transmitted diseases were depicted as a direct result of imperialism and Western influence.2–5 Mao attacked STDs with a massive propaganda campaign typical of his approach to many social problems.2 This campaign included mass screening and appropriate antibiotic therapy. Sex work was eliminated through draconian measures,3 including reeducation camps for sex workers and criminal penalties for their handlers. Most importantly, detection and treatment of STDs were portrayed as patriotic actions. Mao's approach was successful. Studies conducted in 19596 and 19647 documented the virtual eradication of STDs in the People's Republic of China. Western scholars were first allowed to reenter China in the mid to late 1970s. Chinese government and health officials denied the existence of STDs, and we8 and others5 used clinical observation, personal interviews, and both Chinese and Western literature to verify this claim. These methods confirmed the almost total absence of STDS in China at that time. The situation changed rapidly when China opened its doors to the West in the 1980s. Both the Chinese and Western press reported the reemergence of commercial sex work and STDs3; however, objective scholarly reports about the magnitude of the problem with STDs and HIV in China have rarely been detailed-at least in journals readily accessible to Western investigators. In the current issue of Sexually Transmitted Diseases, Chen and colleagues, representing the National Program for Surveillance of STDs, summarize STD incidence and prevalence data collected in 31 Chinese provinces over a 10-year period.9 The investigators report a dramatic increase in STDS during this time. They observed a marked increase in the incidence of syphilis relative to gonorrhea-a pattern similar to that observed in the United States.10,11 The data also reveal a growing problem with STDs in women, with increasing attribution of STD transmission to extramarital sex. The male-to-female case ratio for STDs in China decreased from 2.0 in 1989 to 1.4 in 1998, as calculated by us from the data presented. Decreasing male-to-female case ratios in the United States have been attributed to a decline in STDs in men who have sex with men, and improved detection of STDs in women.12,13 In China, it seems more likely that women are actually experiencing a dramatic increase in STDs.3 This report also emphasizes some epidemiologic features that are unique to China, where STDs are prevalent in people in older age groups than would be observed in Western countries, perhaps because sexual activity in China begins at an older age. The Chinese persist in attributing some STDs to spread through inanimate objects, referred to as “indirect spread,”9 although there is limited biological evidence to support this belief. There are several potential limitations to this study. First, the authors emphasize that many STDs are unreported. Care for STDS is delivered at many places other than public clinics within China,14 and often private sector treatment leads to underreporting. Furthermore, actual STD screening practices in the public or private sector and use of empiric antimicrobial therapy are not addressed in this article, although they undoubtedly have a powerful impact on reported rates of disease. In the past, China watchers have been cautious about the veracity of government-sponsored reports; however, several other sources corroborate the data presented in this article. The results reported by Chen et al are an extension of a Chinese study published in 1998,15 and the overlapping data in the current and previous report are identical. Similar data were also reported in a Chinese communication presented at a meeting of international donor organizations in 1998.16 In addition, a Lexus-Nexus search revealed 32 articles published in the English news media since 1980 that documented the STD and HIV epidemics in the People's Republic of China. Finally, further corroborative data from China were reported at the 10th Meeting of the International Society for STD Research in July of 1999.17 How do we explain the reemergence of STDs in China? Historian Gail Hershatter addresses this problem in her remarkable book, Dangerous Pleasures, which describes the history of commercial sex work in China and its reemergence throughout China in the 1980s.3 According to Hershatter, between 1981 and 1991 more than 580,000 sex workers were detained by the government, and in 1991 alone 104,000 were detained. In discussing the rise of commercial sex work, Hershatter describes social forces that favor the spread of STDs, which include increased cultural focus on personal wealth and consumer goods, unhappy marriages that might favor extramarital affairs, younger age for sexual liaisons, wider availability of pornography, and sexual messages in the mass media. Critical to the prominence of these social forces has been the loosening of government control over population movement. During the Maoist era, before the economic reforms, rural-to-urban migration was prohibited, and urban residents were assigned by the government to work in danwei-work units that controlled housing, food rations and other welfare provisions.8 The reforms of the past 20 years have allowed Chinese people self-employment, free movement, and considerably reduced governmental control. Movement of the rural citizens in particular has resulted in a migrant labor population estimated at more than 100 million people.18 Emphasis on personal wealth, travel, and freedom of movement not possible in the prereform era of strict governmental control unleash social forces important to the spread of STDs, and further reduce the ability of the government to intervene. The reemergence of STDs in China has grave implications. Given China's successful implementation of family-planning policies, which have led to older age at first pregnancy, the reproductive consequences of STDs are likely to be devastating for many families. In addition, STDS can be expected to amplify transmission of HIV.19 Although the first cases of HIV were seen in foreigners visiting China, or returning “Overseas Chinese,” the infection has appeared in intravenous drug users in southern China and most recently in many provinces through sexual contact. It has been estimated that as many as 10,000,000 Chinese will acquire HIV by 2010 in the absence of effective prevention.16,20 Based on its previous public health programs, the Chinese government's response to the STD epidemic has been predictable. A national campaign focused around “The Six Vices” was launched in 19893; the six vices included commercial sex work, pornography, trafficking women and children, using and dealing narcotics, gambling, and profiting from superstition. However, unlike the patriotic public health campaigns that successfully eradicated STDs in the 1950s, this campaign appears to have had little impact on the epidemic. Criminal penalties for commercial sex work were instituted, and some sex workers have been assigned to reeducation camps. There is little evidence, however, that these penalties have had the desired effect. In the 1950s, there was no possibility that the sex workers would go back to their former lifestyle, given the severity of the penalties and extent of government surveillance3; indeed, many women undertook “arranged marriages” during the course of their reeducation. However, this approach is no longer effective. Indeed, some women appear to share useful information while incarcerated and return to commercial sex work when released.3 Unfortunately, it seems unlikely that the tactics used so successfully in the 1950s can be expected to work again. However, China is clearly intent on developing new resources and policies to reduce transmission of HIV and classical STDs. The very publication of accurate data related to the incidence of STDs9,15–17 and HIV16,20 represents a monumental change in approach from the traditional use of propaganda, which downplayed reports of trends that revealed ineffective governmental policies. Such acknowledgement has helped to foster and direct international support for STD and HIV prevention, including extensive support from many international donor agencies and the US National Institutes of Health. These resources are directed at biological and behavioral interventions that have shown great promise in other parts of the world,1 and have focused vaccine development. Inspired by these efforts, the broadest possible response has already been embraced by the Chinese government16; however, given the energy and ingenuity of Chinese scientists, public health and healthcare professionals, and the commitment of the government, novel programs and success are to be expected. Just as we in the West learned important lessons from the remarkable STD control program the Chinese used in the 1950s, it seems likely that we will learn critical lessons from interventions launched in the 21st century.