Poverty and the Spread of Bloodborne Disease in Central China

The editorial commentary by Dodd [1] provides a useful framework for understanding the epidemiological aspects of infection with HIV, hepatitis C virus (HCV), and other bloodborne pathogens in central China. However, 2 points need to be made about the larger social determinants of HIV and HCV spread in rural China, to place these epidemiological aspects in the proper context. First, central China’s HIV and HCV epidemics that began during the 1990s were and continue to be inextricably linked to poverty. Poor farmers in central China could earn more money during the 1990s by selling blood than by tilling land, and so they often supplemented their income by commercially donating plasma [2, 3]. Larger parts of rural central China were heavily affected by these bloodborne HIV and HCV epidemics, compared with urban eastern China, precisely because of the widespread poverty [4]. The HIV and HCV epidemics during the 1990s rendered infected rural farmers helpless and, thus, magnified the shortcomings of the post–Maoist era health care system, which, through decentralization and privatization, had widened the gap between health care delivery to China’s rural western poor and that to wealthier eastern urban residents [5] Second, although the scientific community reported the spread of HIV in commercial blood donors in central China as early as 1995 [3], an adequate response by central Chinese provincial officials, such as the initiation of safe blood-collection procedures and treatment for the thousands of rural farmers who were infected with HIV via an unsafe blood supply, lagged behind [6]. The Chinese government did react to these early warning signs of an unsafe blood supply by establishing regulations in 1995 to ban all unofficial collection of plasma and whole blood [7]. Along with increased financial support, such legislative measures have substantially improved China’s blood-collection system. However, insufficient political will coupled with China’s vast size and variable public health knowledge among both its citizens and its officials have hindered strict enforcement of these blood-donation laws. For example, despite a 1998 law mandating that all blood used for clinical purposes must be collected from voluntary donors [8], as of 2004, 15% of China’s blood supply still came from remunerated donors [9]. Recent national campaigns focusing on safe blood collection and HIV and HCV testing of donated blood will not immediately change the availability of safe blood products in rural areas, and it will take time for these campaigns to reach the less-developed areas of China that have higher HIV and HCV burdens [7]. With regard to patients infected with HIV, the government has taken a large step toward improving treatment by providing free antiretroviral therapy to rural and poor urban patients, but, regrettably, this program was not initiated until 2003 [10] Efforts in China in recent years to expand the base of blood donors, make HIV and HCV testing more widespread, and respond to the HIV and HCV epidemics in former plasma donors in the central region should be applauded. However, they should be weighed carefully in the context of a vast and highly variable health care system in which much of China’s rural poor stand alongside the world’s most destitute citizens in facing tremendous barriers to safe blood products We thank Roger Detels for his input