Combating HIV/AIDS in China: The Need for a Diverse Portfolio of Actors

March 17, 2008

The director of the HIV/AIDS program at Human Rights Watch, Joe Amon, wrote this highly critical, and in my view strategically narrow minded, op-ed of the Gates Foundation’s HIV/AIDS programming in China.

He asked why the Gates Foundation would choose to channel a large portion of their donations through the Central People’s Government’s Ministry of Health when this same government was detaining and imprisoning grass roots activists who are at the forefront of combating the disease. According to Human Rights Watch, “AIDS activists continue to be intimidated and detained by Chinese security forces, and those groups most vulnerable to infection – IDUs, men who have sex with men, and sex workers – are routinely harassed and abused by the police.”

Amon further argues that the types of glossy and abstract ads being published by the Ministry of Health and funded by the Gates Foundation, have been proven to be ineffective in combating HIV/AIDS. What has been shown to be effective is grass roots work among the most vulnerable groups, using clear (and graphic) materials to communicate effective preventive strategies. Yet, China continues to harass these very workers.

What would Amon have international donors do in the face of this continued harrassment? In his words, “until AIDS activists in China are allowed to speak freely, until people living with HIV are allowed to move freely, and until the government focuses its strategies on effective, rights-based interventions, [international donors] … should support other countries instead.”

While I respect the important work that Human Rights Watch is doing in making known the plight of these front line AIDS activists, unlike Amon, I think it is vital for international donors such as the Gates Foundation to continue to work closely with the Chinese Ministry of Health. To pretend that you could do otherwise in a country like China is naive at best and arrogant at worst.

While it might be true that Gates Foundation could do more to pressure the Chinese government to protect these activists, they are in a much stronger position to do so by working with the Ministry rather than by adopting a holier-than-thou attitude from outside the system. Moreover, according to the Gates Foundation, more than half of its HIV/AIDS money into China (US$30 million) is earmarked to provide grants to non-governmental organizations (NGOs) there.

To defeat this debilitating pandemic, it is critical to engage a broad-array of stake-holders — governmental, non-governmental, local and international actors, including Human Right Watch’s Amon — in order to take into account the diverse interests and needs of those affected by the disease. No one set of actors or institutions, not even the valiant Chinese activists whose lives Amon is seeking to protect, can claim a monopoly on effective strategies against the further spread of the disease in China or anywhere else. In this case, as we have learned in other human security case studies, a diverse portfolio of actors “that builds upon the capabilities of a wide range of institutional actors, and that spreads the costs and risks of intervention among them in order to maximize human security returns” (Hampson 2002: 60) is the best way forward.


29 Responses to “Combating HIV/AIDS in China: The Need for a Diverse Portfolio of Actors”

  1. Bessie Chow Says:

    First I disagree with Human Right Watch’s Mr. Amon’s call that the Gates Foundation should channel their donations to other places instead of China until Beijing stop detaining anti-Aids activists in China. I am of the same thought with Dr. Cumming that we need to rely on the support and effort of all stakeholders in the society to combat the diseases. Like most of people who have contacts with mainland officials, I am very suspicious whether the provincial government will put some of donation in their own pockets instead of launching preventative programmes. I also do not have full confiedence that local governments will really implement the polciies as suggested by the national government even of Beijing seems committed to combat HIV/AIDS. But I still insist we need to shake hands with Central People ‘s Government and include them to work in fighting against HIV/AIDS no matter how bad they are. At least, no governmetn like to see their citizens dying and the disease spreading. Also, in reality, if you want to work smoothly and make change in China, better imporve relations with the administration otherwise numerous problems will come up eventually and all your effort may be in vain. Regarding to the risks of corruption, I will suggest that the Foundation should closely montior how their donations are used or possible frequently check the accounts or progress of their sponsored programme.

    Second, I would like to point out that apart from the causes i.e. same sex sexual intercourse, grug abuseing mentioned in the UNAIDS that contribute to the spread of HIV/AIDS in China, blood selling was the major factor in China’s initial wave of AIDS and still play a large part in the tragedy. It was reported that an entire village in Central China, Hean Province become an AIDS village. Peasants there sold their blood for earning a living and the needle was contaminated with the virus. As a result, not only the man becomes HIV positive but also do his wife and newborn children. We can imagine how life will become for the wife and children in future and foresee production will nearly stop in that village. Also, we still do not know/trace whether the blood product was used and infected others. The National government has banned blood selling but there are some still illegal commercial blood centers operating with the back up of local officials. We desperately need stronger enforcement from Beijing otherwise the virus will be spread faster than we can imagine if no effective implementation or coordination of policies.

  2. Bessie Chow Says:

    Third, I want to make a general remark on the cost of treatment for AIDS or other infectious diseases. It is usually of high cost and people in developing countries cannot afford the expensive treatment. It was argued that the high price in drugs is due to patent rights as guaranteed by Trade-Related Intellectual Property Rights (TRIPS)
    For example the patent- protected antiretroviral drug “cocktail” that holds the disease in check costs about $15,000 per patient per year in the States. In India, the generic version of the drug cost only $200 because India does not need to issue patents on pharmaceuticals.

    When TRIPS takes effect in 1995, the developing countries are given 5-11 years to ensure legal compliance, after the “grace period”, what can the developing countries and their citizens cannot afford the expensive patent drug? TRIPS allowed exemptions. If the state declares that the infectious disease has become “an event of extreme urgency”, the state may get a compulsory licensing and produce the drugs without patent. On one hand I think we should protect the intellectual property. On the other hand, we have patient right at stake. Should we make reduce the price of medicine and combating disease as a higher priority than intellectual protection? If the international community has committed to fight against infectious diseases, how would state actors respond to TRIPs?

  3. lmcinhk Says:

    Thanks Bess for such a thoughtful and informative response. FYI, I will post some good news I recently read on access to essential medicines. — LMC

  4. Kwong Kam Lun, Ivan Says:

    I also disagree with Mr. Amon of Human Rights Watch. However, I do think that his worry is understandable. Corruption is serious in China, and we really do not have confidence that the provincial governments would not swallow some of the donation given for HIV/AIDS programs. Yet, stopping all support to China is not the only choice given to him. He could, for example, direct the funds to the NGOs working in China instead of channelling through the Central People’s Government (Nonetheless I don’t know if this is possible due to the financial policies in China). Of course, running all these HIV/AIDS program in China without the Chinese government’s help is quite impossible. I am of the same view with Dr. Cummings that we need a diverse portfolio of actors to combat HIV/AIDS in China – government, non-government, civil society actors are all possible security providers.
    I would like to add some general comments to China’s current HIV/AIDS situation. Fortunately, compared to the South-Saharan Africa, China is not a badly hit region of the HIV/AIDS epidemic. Yet, with accelerated economic development in China, HIV/AIDS would be a potential obstacle to China’s economic growth. As mentioned by Bessie, the Chinese government and all civil society actors that are combating HIV/AIDS should pay attention to the major HIV/AIDS transmission cause: Blood-selling. Illegal blood selling is not only dangerous for the potential transmission of HIV/AIDS, but also to other more general health problems. I have heard that in remote villages in China a lot of people took blood-selling as their main “career”. They took special medicine that enables their bodies to “generate” more blood so that they can sell more often. All these are without the monitor of medical practitioners. Many people died because they sold too much blood and became too weak. Others died from HIV/AIDS or other infectious diseases. In my view, the single best way to tackle the problem is still education. The Chinese government should take active steps to educate people so that they can be more aware of the dangers of blood-selling, and the possible ways of transmission of HIV/AIDS. This is certainly a long battle for the Chinese government and all NGOs to fight.

  5. Annie Wong Says:

    I think Mr Amon might be going to extreme about this issue. While many human rights activists have criticised Local AIDS activists and NGOs are hampered by Chinese government’s harassment, there are lots of evidences about the efforts China’s Central Government on combating AIDS. For instance, in December 2003 Wen Jiabao and Wu Yi announced a new ‘Four Frees and One Care Policy’for comprehensive HIV/AIDS prevention and treatment: 1)Free anti-HIV drugs to AIDS patients who are rural residents or people with financial difficulties living in urban areas 2)Free voluntary counselling and testing 3)Free drugs to HIV infected pregnant women to prevent mother-to-child transmission, and HIV testing of newborn babies 4)Free schooling for children orphaned by AIDS 5)Care and economic assistance to the households of people living with HIV/AIDS. In June 2005 it was announced that a law banning discrimination against people with HIV/AIDS would come into effect by the end of the year. So China’s efforts to combating AIDS should actually be appreciated.

    Yet, going through the bureaucratic government system, what the central government orders may not be effectively carried out at provincial and local government. I wonder if those harassments and even the the attempts to prevent Gao Yaojie travelling to the United States are not the orders of China’s central government, it might be that the local government yet has not changed its mindset aligning with central government’s mindset.

    So it will be crucial for China’s central government to think about how to manage the local governments so that all the things they do, in all governmental levels, are consistent and effective to combat AIDS. And merely education is not enough, we know that sometimes, acknowledging the truth is one thing, entrenched perception is another thing. Even if by education, people will know more about AIDS, entrenched perception that HIV postive people is “bad” or “untouchable” still cause discrimination, and usually people act with perception. Just like we all know Down’s Syndrome is a genetic mutation, but some people still discrimnate against them.

    Also I have thought of one opportunity involved in applying a broader “freedom from want” interpretation of security. Can we say including issues like health threat and poverty etc helps liberizing various nations? “Securitizing” these issues and put it on an international political agenda, and with participation of different actors, it will force various nations to improve their human rights situations and refine their attitudes towards gender equality, correct ideas about sex, corruption…etc.

  6. Tisha Gopalakrishnan Says:

    Victims of HIV/AIDS in China do not live in security and in dignity. This is where there is a need of the Freedom from Want approach. I disagree with Amon’s defeatist and somewhat ethnocentric attitude. While it is necessary for the Chinese government to take further steps against discrimination, it is too idealistic to expect China to suddenly change its political scenario to tackle this problem. True, there is the problem of corruption and a lack of freedom in the institution. But, that does not necessarily qualify the need to withdraw aid completely till ‘it’s all sorted out’. The scope of security has to expand beyond the integrity of the nation. This is where the global voice should be heard, and like the case of the Ottawa Convention, an effective policy can only be designed if there is a unified team of actors. In a world of interdependency, pressure from external forces about issues that concern human security, especially issues regarding health, is crucial.
    The government has not been completely close-minded and passive. It is important to look at the progress so far. There have been many projects that have been implemented by the government. In 2003 the Chinese government launched China CARES (China Comprehensive AIDS Response), a community-based HIV treatment, care and prevention programme. China also began to produce and supply domestically made versions of AIDS drugs,78 and started an HIV/AIDS training programme for 100 doctors who care for patients at the provincial and county level.79 (there is also the “Four Frees and One Care” policy announced in December 2003, already mentioned by Annie.
    Yet, a more substantial solution to this problem to tackling HIV/AIDS and voice concerns on behalf of these vulnerable groups, would be further intervention by organizations like the Gates Foundation and other civil society actors.

    Maybe, these international organizations can have conditionalities on their contracts. It would be good to have detailed reports and budgeting to know the progress of projects. An independent monitoring system may also be organized to ensure effectiveness and transparency. This is sort of like an accept it or reject it conditional support. The government does recognize the seriousness of the AIDS problem, and therefore is likely to cooperate with this.

  7. Tim Says:

    I too think that the criticism leveled here at Joe Amon’s comments is basically fair and I agree with much of what has been said above.

    The suggestion that organisations such as the Gates Foundation should cut and run from China and take their money elsewhere does seem rather defeatist in attitude and it also ignores one fairly obvious point: that China is home to about one sixth of the world’s population. Making inroads into the percentage of people affected by HIV in China is surely a worthy enough goal to continue to pursue in the face of political hardship.

    I agree very much with Dr Cummings that ‘it is critical to engage a broad-array of stake-holders’ in order to tackle the HIV problem in China, or any other country for that matter. It is too large a problem for NGOs and other activists to tackle without the support of the broader international community and individual governments. Similarly, it would be incredibly difficult, if not impossible, for the Chinese government to make a real difference without the political and financial support of organisations like the Gates Foundation. The relative success of the International Campaign to Ban Landmines demonstrates the sort of outcomes that can be achieved when governments, international and local NGOs and grass roots activists work together and cooperate with one another. Whilst such a level cooperation between AIDS activists, international donors and the government does not currently exist – and will indeed be difficult to foster – I don’t think that this is in itself reason to give up.

    That said, I still think that there is another side to all this and that Amon’s comments are both understandable and to some extent defensible. Firstly, he is perhaps just letting off a little steam here. He has good reason to be angry about the challenges the Chinese government is creating for those who are investing time, money and effort into fighting AIDS and also good reason to express his anger and the cause of it.

    Second, isn’t he also right in a way? Human Security teaches us to focus our attention on people rather than states. And that means people everywhere – not just people in one particular country or region. So, if the efforts of activists and NGOs and the funds of international donors are being wasted in China as a result of political opposition and inneffective government campaigns, then why not redirect efforts elsewhere? To say ‘support other countries instead’ is perhaps a harsh and antagonistic way of putting it. But at the same time, there were an estimated 2.1 million deaths from AIDS in Sub-Saharan Africa in 2006, where approximately 68% of the people infected with HIV live. An official from Botswana (and I have lost the quote, I’m sorry), for example, conceded that the country is crippled by HIV so much so that it’s population is at risk of ceasing to exist if something drastic doesn’t change. Of course there are political issues in Africa that will present challenges for acitvists and donors there too…but with some countries in that region crying out for help and having such high infection rates, wouldn’t efforts be better focused there? It is not so much a case of “let’s not help China”…but rather a suggestion that given resouces are limited, if our goal is increasing the security of people as best we can with those limited resources, then it makes sense to distribute those resources and channel our efforts to the place where the problem is most prominent and where there may be greater chance of cooperation between donors, activists, NGOs and governments.

    If the question is one of how “how should we approach fighting AIDS in China?” – then I am very much in agreement that cooperation between the varies parties is essential and the best way of achieveing positive results. It is simply to hard for organisations to work effectively without the support of government in this context. But if the question is more along the lines of “given limited resources, where is the best place to allocate them?”, then perhaps Amon has a point.

  8. lmcinhk Says:

    Tisha, Ivan & Annie —

    Thanks for your insightful comments.

    To play devil’s advocate here…

    I imagine that Mr. Amon would agree with you all that China’s central government has demonstrated a clear and far-sighted commitment to combating this disease. I can’t comment on the effectiveness of the various national programs you have mentioned, but even if we assume here that these policies have been very effective, we also know that grassroots activists are still being harassed. What can be done to stop this? Isn’t it right to call upon the CPG to protect these activists?

    Mr. Amon and others argue that China’s government should put human rights first in order to effectively tackle this disease. Do you agree?

    — LMC

  9. lmcinhk Says:

    Good points, Tim.

    For those interested, you can read more about the importance of human rights to public health here:

    — LMC

  10. Winson Sau Yin Chu Says:

    Right to Liberty v Right to a Life

    Mr Amon suggested the dilemma whether to prioritize one’s right to expression/liberty over the right to a healthy life in the HIV/AIDS scenario in China. Mr Amon, with only little substantiation suggested that the right to expression/liberty of HIV/AIDS activists should trump over the right to life of HIV/AIDS patients made possible with grants from the international community. This suggestion was argued that because the freedom of expression/liberty, if granted to the HIV/AIDS workers in China, would be able to improve the HIV/AIDS situation in China.

    However, I wish to argue that this prioritization is not justified on both a pragmatic level and a normative level.

    Pragmatically, this prioritization will cause more harm to HIV/AIDS sufferers in China. In the improvement of the HIV/AIDS situation, the active involvements of national governments are important. One of the best cases of the reduction in HIV/AIDS prevalence in Uganda, which was only made possible with active government programs for education and empowerment. With account of China’s sensitivity of political and civic rights, any overt threat to cut funding if rights are not improved will be fruitless. Thus, with less money and resources provided by the international campaign, China’s HIV/AIDS program will simply be less effective than under status quo, with no substantive benefits.

    Normatively, the prioritization suggested by Amon is lacking in justification. While, in an ideal world, the two elements will not be mutually exclusive, however, in many issues of human security, the dilemma of liberty and life will often arise. In the improvement of human security, there will be many cases of having to be tolerant of the national government’s suppression of human rights in order to engage them to fix the problem at hand. If we adopt Amon’s reasoning, the international community should not engage with the government in the improvement of human security if there is also a related oppression of one’s liberty. This would simply have an absurd consequence in that it would be the promotion of isolation instead of engagement in International Relations.

    The adaptation of an engagement policy might also render the dilemma of liberty and life obsolete. In the case of China itself, the engagement with it in economic policies has also spillover into political policies. Thus, it is suggested the engagement in health policies will also lead to spillover effect into political policies.

  11. lmcinhk Says:

    Thanks Winson.

    Can you provide an example of when it would be necessary to be “tolerant of the national government’s suppression of human rights” inorder to improve human security?

    — LMC

  12. Alice Leppitt Says:

    Human Rights Watch’s Joe Amon, seems to believe that when tackling a human security issue all actors must approach the issue from the same position both in terms of politics and action. However, I agree with LMC that a diverse array of stakeholders is needed to address human security issues, including HIV/AIDS in China, as they allow for all interests and both conservative and radical viewpoints to be considered. Unlike Amon argues, these different stakeholders don’t even have to agree on any actions or goals to still be effective.

    Ideally, different viewpoints amongst stakeholders would be debated but due to an overall common goal, such as reducing the HIV/AIDS pandemic, all parties would reach consensus and cooperate beneficially with each other. As Tim discussed, this scenario was seen in the International Campaign to Ban Landmines where although some NGOs considered some governments to be too conservative, consensus and effective action was reached.

    However, as with Human Rights Watch and the Gates Foundation in China, sometimes conservative and radical viewpoints cannot agree or work together. This does not have to result in less effective outcomes. In fact, forcing cooperation may not always lead to ‘building’ benefits and ‘spreading risks’, sometimes it may result in compromises, weaker outcomes and watering down. In the China example, I believe that the independent work of both Human Rights Watch and the Gates Foundation is very important. Human Rights Watch should continue their radical position criticising the governments human rights record and voicing the concerns of marginalised, grassroots AIDS activists and victims. I see their radical voice as opening up political space for more conservative NGOs such as the Gates Foundation to act effectively. Human Rights Watch is bringing attention to the issue and therefore pressuring the Central Government to act. Whilst the Central Government won’t work with Human Rights Watch, they will be more willing to cooperate with the Gates Foundation. Perhaps the positive actions the Central Government has already taken (as discussed by Annie and Tisha), are not simply a result of cooperation with conservative organisations, such as the Gates Foundation, but also pressure from radical voices, such as Human Rights Watch?

    Amon needs to realise that not all stakeholders can agree or work together, however there independent actions can still be complementary.

    Just shortly and on a different issue, I think that Amon’s call for international donors to look to other countries is entirely unproductive in tackling the HIV/AIDs pandemic and uncomplimentary to a human security approach. Amon is basing his call on the actions of the Central Government and its Human Rights record. A human security approach, which focuses on the individual, would see the questionable record of the central government as all the more reason to act in China and help to empower and educate individuals whilst treating and preventing the disease. The more alternative actors in China, the more pressure there is for the government to act and act in such a way that benefits the most. If left unchecked, the government may not address certain areas or victim groups and at worst corruption may lead to no action occurring.

    When tackling issues such as HIV/AIDS the interests and concerns of individuals must always be paramount, especially when governments may not be capable or willing to address them.

  13. Sannie Says:

    I agree with Tim and LMC’s comments that the Chinese government cannot be excluded in the efforts to combat HIV in China.

    1. First, we learnt from the lesson of the landmines that inclusion of as many actors as possible is crucial to the success of human security efforts. I think this concept is clear to all of us.

    Compared to the European counterparts, I dare say that the co-operation with Chinese government is more critical. We cannot forget that the Chinese government possesses the most resources. Moreover, due to the lack of a separation of power, the central government controls every level of the government, representing the judicial, legislative and executive branch of the government. We cannot hope to have laws about HIV passed and have them implemented without the support of the government. The government is some one you surely do not want to exclude.

    For example, education cannot be done without the help of the government. I would like to stress the importance of education by mentioning that 17% of Chinese citizens had never heard of HIV/AIDS, and 77% did not know that HIV transmission could be prevented by using condoms (Stenson J. (2003) “China Survey finds 1 in 6 haven’t heard of AIDS”, Reuters Health, January 3 ). I do not see that how Human Rights Watch can come up with a feasible work plan to the NGOs that effective education to the population can be achieved without help from the Chinese government, where they have absolute censorship over the television programmes and the education programmes.

    2. The second point is that, we are already witnessing the change of attitude of the government towards HIV to become more receptive and non-discriminatory. In World AIDS Day 2003, Wen Jiabao was the first Chinese premier to shake hands with an HIV-positive person. (Dickie M. (2003) “Handshake seals shift in China AIDS approach”, Financial Times, December 2 ). We surely have to allow more time for China to adopt a change of attitude in the realization of the importance of including AIDS activists.

    Moreover, we have to give room for policy incoordination and contradictions between different government departments. There may be resistance of local level government to the state guidelines, and this may explain some events of discrimination of violations of rights of HIV activists like arbitrary detention, harassment and intimidation.

    3. *** The third and most important point is that, I do not think that human securities issues should be messed and linked with human rights issue. Of course I agree that non-prosecution of those HIV activists is important in combating HIV, and human rights of assembly, freedom of speech and freedom of movement should be respected in any case. My point is that, if we do not separate human security efforts from other sensitive issues, such as human rights in China, “human security” may have the danger of degrading as a tool to achieve political goals. And the call of Anon to the international community of excluding China in their assistance is an example: the fundings to halt HIV is a weapon to force China to respect human rights.

    Moreover, the attack of Human Rights Watch is , as said “strategically narrow”. Human Rights Watch accuses the Chinese government of having along history of prosecuting and repressing activists by cancelling public meetings and singling out individuals. My interpretation is that, many other public meetings and individuals are singled out and prosecuted, obstructed and thrown into prison, like Fa Lun Gong. This is the way Chinese government deals with potential groups of powers in general, but Human Rights Watch present the case as if China is adopting this attitude only towards the HIV activists. Putting things back into the bigger picture, I think that human rights in China is an issue too complex to be dealt with in a short period, and it is too long a period for HIV positive people and potential HIV positive people to wait until every right is respected.

  14. Eugenia Chan Says:

    I truly understand Mr. Amon’s concerns over human rights in China. In order to better combat HIV/ AIDS in China, one must summon support from a wide array of actors. Those human rights activitists who are detainied by the Chinese Government play pivotal roles in delivering frontline services against the disease.

    Mr. Amon is also right in pinpointing the Government’s misgivings in harrassment of those HIV/ AIDS patients. HIV-related discrimination presents major obstacles to effective prevention and treatment (“HIV, Human Rights and Law). The burden is on the Chinese Government to improve human rights of those patients.

    However, I disagree with Mr. Amon that donations should be withdrawn from the Chinese Government. As Dr. Cummings suggested, an effective human security campaign requires a collaborative action of a wide range of actors, government or non-government, local or international as seen from the success of banning AP landmines. Since different actors have different strenghts and different roles and interests, they can complement with each other in help those innocent patients.

    Human rights abuse is a common feature in most HIV/ AIDS stricken countries. Following Mr. Amon’s logic, no donations should be channeled through the national governments in those countries. Is it a desirable outcome for international anti-HIV/AIDS campaign?

    Second, state action is required in effectively combatting HIV/AIDS. Withdrawing donations from the Government would undermine efforts in combatting the disease.

    The Chinese Government has set combatting against HIV/AIDS one of its top policy priorities in the Five Year Plan in March 2006. China Comprehensive AIDS Response (China CARES), which assists 127 high-prevalence counties in providing care and support to people living with HIV/AIDS; the “Four Free and One Care” policy (see panel); and the formation of a State Council AIDS Working Committee responsible for the development of a comprehensive policy framework. All these require investment of large amount of money.

    As mentioned above, HIV related discrimination is a main obstacle. Although supervision from NGO can help to reveal the situation, state action in setting up laws or enforcement against this form of discrimination is much required. Also, discrimination against homosexual is another main obstacle. Same-sex sex is one of the major causes of tranmission in China. We should call for more state action in eliminating thise discrimination. Withdrawing aid from the Government would only exacerbate the situation.

    Also, as Bessie suggested, blood selling is another major cause of infection. This is especially prevalent in western villages as the people there are poor and are forced to sell their blood under financial pressure. The process is often not monitored by medical practitioners and the injection needles they use are reused without sterilization. As a result, those villagers become highly vulnerable to the disease.

    Large amount of funds is required to strenghthen enforcement of the hygiene standards in running the state-run blood selling campaigns. Also, the state should consider wholly abolishing this blood trade. If donations are no longer channelled through the Chinese Government, state action in combatting such practice would be undermined.

    Another major cause of HIV/ AIDS is unsafe prostitution which call for state action in better regulation of the sex trade. State action is also deeply required in delivery of medicine, strenghthening quality of health care, etc. No action of any NGO would be successful without support of adequate state action.

    Of course international organization should request the Government to stop the harrassment, it is no use rejecting working with the Govenment and help outside the system. Given the important role of the Government, if aids are withdrawn, then it will be only the HIV patients and innocent civilians that suffer.

  15. Annie Wong Says:

    After reading Human Rights Watch’s report “Restrictions on AIDS Activists in China” in June 2005(, I wonder if China’s central government is trying to centralize its authority and be the sole actor dealing with HIV/AIDS issue. While China’s central government has been very active implementing various national programs to combat AIDS, demonstrating its determination and concern over combating AIDS, on the other hand, according to the Human Rights Watch, China’s central government has left in place lots of bureaucratic obstacles making NGOs hard to be established. Human Rights Watch has commented “Chinese NGOs face three key problems: a restrictive system of registration, a requirement that government agencies administer and police their daily work, and a requirement that funding be routed through government agencies, creating opportunities for corruption”. So that means, China acknowledges the need for NGOs in dealing with HIV/AIDS, yet it needs NGOs under its control, in other words, GONGOs.

    While Human Rights Watch would comment this restrictive system will eventually limit the growth and development of NGOs in China, I would say that China’s policy to limit the growth and activity of local NGOs by requiring new NGOs to obtain a government sponsor before they can register is understandable.

    In HIV/AIDS case in China, we can see that this is not just a health problem, but is related to different domestic problems: human rights, poverty, corruption, education, illegal business operations…etc. which China might see all these as domestic issues that it do not want others (meaning the foreigners) to interfere. This actually reflects a challenge to “Freedom from want” approach in Human security. For issues like poverty, inequality, health threat and environmental issues, they are usually very closely related to domestic problems, to deal with these issues on a level that involves global players: NGOs (not GONGOs), international organizations and various governments, local governments might be reluctant to allow other players to get involved. What if we looked back to history, if it’s not Martin Luther King, Jr leading the American civil rights movements, that ended racial segregation and discrimination in the States, but China at that time, criticized and urged the States to treat their black community better, giving them lives with dignity, maybe the States won’t allow the international community to step in deal with this domestic issue with international cooperation.

  16. Eugenia Chan Says:

    I would also love to discuss the TRIPS Agreement with you all as Bessie has mentioned it.

    Protection of IPRs became a hotly debated issue in the earlier 1980s since technological innovation was blooming. The United States, Japan and the European Union pushed for international protection of IPRs to be added to the agenda of the Uruguay Round of GATT. Finally, the Trade Related Aspects of Intellectual Property Rights (TRIPS) Agreement as part of the global trade agreement was signed in 1994.

    TRIPS serves to protect IPR that encourages technological innovations and facilitates technology transfer from the developed North to the underdeveloped poor.

    However, many NGOs have attacked the TRIPS as an obstacle to access to health care medicine for many patients in the developing world. Before TRIPS, developing countries can produced mimicked AIDS medicine and sell them at a much cheaper price to those HIV/AIDS patients in the third world. However, after TRIPS took effect, those patients have to pay a much higher price for medicine. For example, the average annual income of South African people was less than US$3000 in 1995, while the HIV/AIDs drugs cost US$12000.

    In fact, compulsory licensing is allowed under article 31 of the TRIPs agreement that member governments are given authority to grant a license to a party to produce the patented product without the consent of the patent holder. However, compulsory licensing is subject to certain restrictions set out in article 31. Developed countries are required to make efforts to obtain authorization from the right holder before issuing a compulsory license unless there is a “national emergency” or “other circumstances of extreme urgency”. Article 31 also set out that compulsory licensing must be authorized predominantly for the supply of the domestic market of member authorizing such use. Developing countries criticized that member countries without local manufacturing capacities would not be able to make us of compulsory licensing since they cannot issue licenses to manufactures based in another member state.

    Parallel importing was also challenged by developed countries. It allows developing countries to take advantage of the common practice of differential pricing of drugs across different countries. Article 6 allows member countries to import pharmaceutical products from other countries only if the exclusive right is exhausted, meaning that a patent holder ceases to have exclusive rights to sell or dispose of the patented good once the patented product has been placed in the market for sale. However, the article does not stipulate whether the exhaustion of IPRs must be incorporated into national legislation. In 1997, the Pharmaceutical Manufactures’ Association of South Africa together with 39 translational pharmaceutical industries filed a lawsuit against South Africa Government alleging the amendment of Medicines Act to authorize parallel importing and compulsory licensing violated the TRIPs Agreement.

    The legal action on South Africa stirred up widespread criticism of the TRIPs Agreement by the developing countries, non-governmental organizations and human rights activists. The controversy led to the Doha Declaration on the TRIPs Agreement and Public Health. The Declaration affirms that the TRIPs Agreement should be interpreted and implemented so as to protect public health and promote access to medicines.

    However, the issue of whether developing countries without pharmaceutical industry and manufacturing capacities can import generic drugs produced under a compulsory licence in other countries was unresolved in the Doha Declaration. The Council for TRIPs was instructed to find an expeditious solution to this problem before the end of 2002. Unfortunately, the WTO was unable to come to an agreement by the end of 2002. Criticism of the WTO finally pressed developed and developing countries to reach a consensus on the issue. Under the agreement, all least developed countries can issue a compulsory license for the supply of a developing country.

    As seen from above, under immense international pressure, implementation of TRIPS is still a bit inclined to guarantee access to medicine. However, while the definition of “emergency” remains unresolved, there still exists risks that one day access to HIV/ AIDS or other life-saving medicine might be affected.

  17. Jeni Cheung Says:

    I agree with most of others’ comments that Amon’s stategy to shift the fund out of China is unpractical and useless in solving the issue of HIV in China.

    By shifting out, it means that you have given up the needed, it means a backward step. Also, I believe that there are more organizations which are willing to provide funds for combating HIVs as long as the public is aware of the issue.

    As Sannie noted, the problem of corruption in China is very complex and the prosecution of activists is not unique in this issue.

    However, I do think the China government is well aware of the potential problems HIV may bring and it has been devoting resources to improve the situation.

    As discussed in the past few weeks, a strong leadership and state cooperation with NGOs are very important. Since China is in a very favorable position to become a leader in solving human security problems, it would serve as a good opportunity to cooperate with the Gates Foundation to bring success to the issue, fully utilizing the resources coming in, allocating as much as possible on fighting AIDs. Perhaps what Amon is doing, as mentioned by Tim, is pressuring the China government and generating public opinion to urge it to take more actions, i.e. generating political will.

    In addition, I do not think that attacking China based on its past human rights abuse record is a very good path towards solution. It reminds me of the U.S. critizising China’s record while in fact, the U.S. is not much better than China. I prefer positive compaigning, not condemning the opposition. And more importantly, the government is one vital actor in obtaining success, as discussed in the AP mine case study. Therefore I think the reasons for maintaining good relationship with the government outweigh negative compaigning.

  18. Richard Uy Says:

    I guess the issue here is basically how to work the system: from the outside or from the inside.

    This issue above touches primarily on principles and values and whether we are prepared to uphold those and stand tall or prepare to bend and just go with whatever flow is required of us.

    Some would argue that the ends justifies the means thereby working from within, acceding to the Mainland government’s rules is the best method as it assures we be able to treat the HIV/AIDS victims better. This however means that even if we do not agree on all points civilised… a few good points should suffice.

    On the other hand we have the working from the outside whereby we get to say we are doing what the world expects of us, we do not agree with your methods and until you change your attitude, we will not help. This attitude is very much all high and mighty yet it preserves what it means to be human and to have principles and values. These things which cannot and should not be corrupted just to justify an end goal.

    The argument therefore ends up with is the price of being stiff-nosed worth it if HIV/AIDS victims do not receive proper care? or turned the other way, is it really what we want, setting precedence with China that the world bends to its twisted wishes?

    I preferably would go with staying holier-than-thou to be honest. We cannot be bullied by daydreaming governments and bend to their obviously corrupted wishes. Humankind moves in one direction and that it together, providing for the needs of the disadvantaged and needy. I feel it is time to stop thinking in terms of them and us… just promote the world’s view and current feelings on how to treat people.

    The last thing we want is setting precedence with China on how the world may try to interact with the Mainland (which is through sacrificed means).

    Short term, we may lose a few people in the world because they cannot receive proper attention for their plights. Long term, and think long term as in more than 5 generations really…, that we may be able to break how each country deals with each other and create a more united thinking world. As we only have one world really.. we cannot keep on thinking in terms of them and us.

  19. Zheng Weiwei Says:

    As Mr. Amon’s words, to cooperate with the Chinese official institutions is a challenge. But it is still the most effective and safe way to work in the land of China. So it is still necessary for the international organizations to push and motivate the central government and the local government of the severely afflicted provinces like Henan to face the difficult and dangerous situations while try to figure out some solutions.
    For China, there are always some ‘official’ dilemmas to face, for the authoritarian political system, the huge population, the developing gap, etc. It is very hard to find the right balance point in some severe issues with large impacts. As said by the Deputy Minister of Health Yin Dakui in a 2001 statement, leaders “are worried that, once the problem is revealed, it will harm their social and economic development.” When, subsequently, the Pandora’s Box of Henan’s AIDS outbreak was opened, concern about stability shifted to fear for the political survival of the province’s Communist Party leadership. It is true that in such a Confucian society with a negative judgment over HIV issue – so-called a dirty disease, it is hard for the whole society to face the disease and morally accept the whole issue calmly. But it is not a right and long-term solution for the government to keep the population in a dangerous situation knowing nothing about HIV/AIDS.
    Besides, in my personal experience as a Chinese, it is not an easy thing to get some knowledge of AIDS/HIV until years ago that the newspapers, televisions started to tell what is HIV/AIDS, what we should avoid and what is unnecessary panic. As my acknowledge from documentaries, e.g. “Better to Live on” by Chen Weijun , the poor country-side like towns in Henan suffered more, especially from the unsafe ‘blood dealing’. It was a hard issue that the Chinese people were even kept without the right to know the HIV/AIDS issue. The severe consequence was already led to and now the government realized and takes a more positive attitude towards the disease.
    HIV/AIDS is not a health problem only covering a single country but already becomes globalized. The Chinese government’s attitude should have changed earlier and taken prevention and propaganda vis-à-vis the disease. Meanwhile the international groups also need a more positive attitude to push the government and cooperate with the nations for the severe health and security problems. They can push and change. If the international groups just give up, the battle will be in a harsh circumstance.
    Laurie Garrett, “HIV and National Security: Where are the Links?” Council on Foreign Relations: 2005, accessed February 2, 2006
    See also in Christopher Bodeen, “AP Interview: Chinese AIDS Activist, Once Labeled Subversive, Rises to Prominence,” Associated Press, March 31, 2004; Elizabeth Rosenthal, “China now Facing an AIDS Epidemic, A Top Aide Admits,” New York Times, August 24, 2001; Jonathan Watts, “Hidden from the World, a Village Dies of AIDS while China Refuses to Face a Growing Crisis,” The Guardian, October 25, 2003. 63
    Hao Si Bu Ru Lai Huo Zhe (Better to Live on), Chen Weijun, [Jinan] : Qi Lu dian zi yin xiang chu ban she ; [Zhongguo] : Xian xiang gong zuo shi du li fa xing, [2002?]

  20. Sandeep Says:

    this problem that Amon seems to conjure up seems to be one of the classic engagement v isolation. China has its problems, we’re in a position to help micro scale, but that might perpetuate the “problem” in macro scale, what do we do?

    The Gates foundation has been criticized in the past for having a sort of monopoly in some areas of research of killer disease(link below), but hidden in the criticism is the belief that some efforts are better than none.

    Taking specifically the situation of ppl with AIDS/HIV-infected in China, it seems ludicrous to suggest that by not giving the central ministry any help would suddenly alter the CCP’s direction or invoke a sudden change in the politics of China. Rather, engaging them and building up a rapport with them and trusting that they will, in the long term, see what the world sees as an effective solution seems to be more advantageous to all parties involved.

  21. Hui Hiu Ning,Rebecca Says:

    I agree with Dr. Cummings that there are strong practical reasons for China to engage a broad array of stakeholders, particularly international actors, to tackle the HIV/AIDS problem.

    First, it helps curb political manipulation. By political manipulation, I am more inclined to focus on the manipulation of information by local governments in concealing the HIV/AIDS spread. The cause of such manipulation is due to the inherent problelmatic relationship between the Central People’s Government and the local governments of China. Local governments are often reticent about the seriousness of the problems they encounter in the provinces for the sake of their vested interests, whereas the CPG, in facing a plethora of governing issues in China and in reliance on the local governments for information, often suffers from deficiency of information to make sound response. I think in recent years, the CPG has shown some improvement in adopting a more open approach to the HIV/AIDS pandemic, it is more now of the local governments being a major obstacle in tackling the problem.Therefore, local NGOs and other international actors do play an important role in monitoring the the local governments.

    Second, NGOs play a crucial role in educating the citizens about HIV/AIDS, such as on how to have safe sex. The Ministry of Health attributed 37% of the reported cases to drug abuse, and 28% to unsafe sex. However, there are almost no approved networks or organisations to support gay men (being one of the high-risk groups), and this has a highly negative impact on HIV/AIDS prevention among gay men (, 2008). Therefore, I believe overseas NGOs will take advantage of their knowledge and experience in contributing to the preventions of HIV/AIDS in China. Also, they bear an important role in exerting pressure upon the Chinese government and other states to put effort in stopping the epidemic. One successful example is the exposure of the AIDS pandemic in Henan province mainly due to illegal blood transfusion on the AIDS day in 2000. The impeccable world attention received forced China to take a much more active role in combating HIV/AIDS problem in China.

    Referring back to Amon’s remarks, I personally disagree with his position. However, his remarks raised an interesting concern regarding the dilemma of some international NGOs and donors involved like in the present case. I appreciate Amon’s genuine concerns with the plight of the activists, however, this sounds like a threat not only to China but also to other countries where human rights protection is under severe criticism which are in need of international assistance.

    In my opinion, whether a country will grant rights and freedoms to its people is a much much more onerous and complex issue and should be treated as a separate human security agenda. In fact, practically speaking, most countries currently suffering from HIV/AIDS pandemic also have poor human rights record.If, applying the same logic, does it mean that none of them should receive donation and help from the world unless they guarantee human right protections to its people? Such rationale is appalling as it seems to put all the blame on individual regime and will never ever play a possitive role in contributing to human security development.

  22. Winson Sau Yin Chu Says:

    In response to Dr. Cummings’ post about when it is necessary to be “tolerant of the national government’s suppression of human rights” in order to promote human security, I believe that it is in the nature of the human security paradigm to prioritize the security of the individuals over the actions of the states.

    I would like to argue that the novelty in human security is that it would wish to seek aside the traditional concerns of state security and simply focus on the betterment of the security of individuals. The defects of the old traditional model based on state security has led to limited aid and help towards the security of individuals because there has been too much focus on the political and ideological dispute between different countries. Thus, recognizing that there is no universally accepted notion of human rights, liberty or democracy, I wish to suggest that we must forgo these political and ideological differences and concentrate on the improvement of the security of the individual.

  23. Pretty Chan Says:

    In combatting HIV in China, the effort of Chinese Government is undoubtedly important. However, I believe Chinese Government is also following the global trend in making a concertive effort to combat HIV as possible. There’re many reasons behind this, first, the international pressure to make a cooperative effort is an important element. As China has become a member of WTO, her performance in the international arena, in all aspects, including human security measures are concerns of other states, but just the economic improvement.

    Second, we could see the change of mode of governance in China. Although one-party rule is still dominant, President Hu Jintao emphasizes his concern to people’s livelihood. His effort in comforting the soldiers rescuing in snow storm, and his cabinet in visiting village families, these are all showing the Chinese government’s emphasis on human security concerns.

    Therefore, I am optimistic about Chinese government’s effort in human security, and combating HIV in the future.

  24. XuDuo,Audrey Says:

    AIDS is a dire threat to human security, it not only undermines the socio-economic development but also the secure and healthy life of those affected people.
    The experts from the prophylaxis medical and science offices in China predicted that if the AIDS problem was still being unsolved, the number of the infection patients in 2010 will reach 10,000,000. However, if effective solution has been done, the number will be not more than 1500,000.
    The minister of the Ministry of Public Health said that if the AIDS infection situation in China cannot be controlled, China will become the next India, America or Africa. The governments in China had been called upon to recognize their obligations to provide sufficient health care protection against these threats.
    Due to the news during these years, AIDS in China also result in some other social problems, the social conflicts and the AIDS is mixed, AIDS and insecurity exist together and influenced by each other. The regions with more affected people have more social problems since those people are always being discriminated and either feel depress or angry about the society, it’s an important cause lead them to do some illegal activities. The high rate of suicide of affected people also influenced the stability of the society.

    “Freedom from Want” in human security concept focuses on creating opportunities for people to live a life in security and dignity. The safety of people and nations from violence is also a main concern in it. Traditional practice of national security does not treat human diseases as a human threat to human security. However, since AIDS is an infectious and the situation of AIDS has become more and more serious and cannot be neglected, it is forcefully being included into the scope of security

    After reading the article, I think that the idea of Mr. Amon about turning the donations to other places instead of China until the anti-AIDS activity there stops is understandable but not rational enough. The cost of treatment for AIDS is too high for people in developing countries to afford. The donations help is very important to China to control AIDS. Once the situation of AIDS become worse in China, the disease may be spread to other places, it will not only become a disaster in China but also a disaster all around the world. However, when looking at the serious corruption problem in China, the Foundation can strengthen the power of supervisor during the program process. It may possibly contribute to decrease the possibility of corruption.

    Along with it, the government has set up many projects on combating AIDS. The attitude of the discrimination is also changing gradually through the media and education although the government still needs to take further steps to against discrimination. For example, the society still treats the male homosexual intercourse as one of the most important cause of AIDS, however, the fact is not as some people think, the reason why the gay men are more easily to get AIDS is not due to the way they having sex but their sexual life with great confusion. The reason for it somehow due to the mental pressure that result from the discrimination of the society.

    Focusing on people but not government closely meets the essence of human security. However, running AIDS program in China without the cooperation of Chinese government is impossible since the government holds the majority of resources and the highest control power. Along with it, we need a diverse rage of actors, includes the government, to combat human security problems. Cooperation between governments, non-governments and other all possible providers will be very effective when all of them are focusing a project which will bring benefits to them all as we learnt from the landmines case.

  25. Ana Wisbeck Says:

    After reading so many insightful comments, it made me realize that in the international arena, there’s a place and the need for all kinds of actors and their subsequent opinions.

  26. Ana Wisbeck Says:

    After reading so many insightful comments, it made me realize that in the international arena, there’s a place and the need for all kinds of actors and their subsequent opinions.
    Even though we all seem to agree that Mr. Amon call for an “embargo” in China because of its unfair practices towards some health workers is unpractical and in fact a step back from the precendent progressses made, I do believe that his comments do play a role in this process.
    How can we tackle the Chinese goverment persecution of workers? Outside states have very few leverage to deal with this and as we discussed simply checking out is not up for discussion. In fact, we may need some extremists like Mr. Amon to put some sort of external pressure. Of course, this only works if we assume that no one is going to follow his advice. The idea is not so much to threaten, but to send out the message to the chinese government that it’s not ok to act in this way.
    In conclusion, we need extremists, we need grass-root workers risking their safety, we need outside government, pharmacutical labs, we need everyone to contribute by playing different roles.

  27. ana Wisbeck Says:

    Apologies for the repetition above.
    I would also like to respond to the accusations that AIDS cannot be combated by subtle campaing ads on tv. Of course simpply putting ads on tv will not help, but at the same time exposing an entire population to graphic detailed information doesn’t seem like the solution as well.
    judging by the strong responses we got here in Hong Kong for the sex photo scandal, i would say that in asia the population is (at least in public) extremely conservative. I think it would be fair to say that in mainland china, they would even be more conservative due to governmental repression in the past.
    due to this cultural reason, I think that the campaings are not such a bad idea aftre all. Thay may not be very informative, but they give out the message that the government considers this issue a serious one and is willing to go beyond its comfort zone to address. It comes to show that the government cares and not jsut to inform.
    If this campaing is backed by more informative campaigns in a smaller scale for targetted groups it could be effective.

  28. Sannie Au yeung Says:

    I would like to reply to Richard´s comments.
    I agree with you that China is a country which is full of internal problems especially in human rights issues, which obviously, as said, is what the world finds it hard to tolerate. However, when we adopt the working from the outside approach, and show China what the world expects of it, I am afraid that China would take it another way. To the Chinese government, I dare say that what we speak of ¨the world¨ is no more than ¨foreigners ignorant of condition of the country of China” to them. Of course I agree that pressing issues such as human rights issue in China should be dealt with, but wouldn´t it be more effective if we adopt a more friendly approach that is based on cooperation and discussions? What I mean is that by co-operation with the government ( cooperation not in the sense of bending to every wish of the government), and the building of trusts, we can bring the issues of human rights and human security to the attention of China.
    Moreover, I still think it is not a good idea to mix human security issues up with political affairs. From the lesson of the water crises, the success of the Indus Agreement was based on the separation of politically sensitive issues from the mere technical and practical water issues. By the same token , issues like fundamental rights can be dealt with separately with problems such as AIDS. Anyway, the Chinese government is not very interested in outside help on this issue, as commented by our classmates. Non-provision of funds is not a major loss for them.

  29. Joe Amon Says:

    Perhaps this thread is dead, but I would like to point out that the original post is inaccurate.

    The post says:

    What would Amon have international donors do in the face of this continued harrassment? In his words, “until AIDS activists in China are allowed to speak freely, until people living with HIV are allowed to move freely, and until the government focuses its strategies on effective, rights-based interventions, [international donors] … should support other countries instead.”

    In fact the quote – which is from an entirely different source than the op-ed on the Gates Foundation – says NOT that Gates or that all international donors should support other countries but that the Global Fund should hold its meetings in other countries.

    It is disapointing that the students in this class did not apparently go back to the source of the information and discover this mischaracterization of my remarks.

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