HIV/AIDS in China - The Economic and Social Determinants

Dylan Sutherland, Jennifer Y.J. Hsu

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781136594700
• Edition: 1
• Topic: Scienze sociali
• Subtopic: Studi sull'etnia

South and East Asia may well become the epicentres of the global HIV/AIDS pandemic. More than three-quarters of a million people are now estimated to be living with HIV/AIDS in China. In 2009, AIDS had already become the leading cause of death by infectious disease. Yet, even despite China's recent economic and social progress, a number of development issues - not least the emergence of glaring inequalities - have also emerged. The expansion of the HIV/AIDS epidemic is also an important longer term development challenge.

This book analyses China's HIV/AIDS epidemic, with particular attention to the nature and impact of current economic and social changes and how these changes may be driving the epidemic. It examines aspects of income and gender inequality; rural-urban migration; commercial sex work; healthcare and civil society organizations. Health care reforms and the role of NGOs are also considered as well as general government policy. Overall, this book provides a full discussion of the most critical aspects of the current HIV/AIDS situation in China and its impact on Chinese society.

1 Understanding HIV/AIDS
epidemics

Introduction

The microbe is nothing; the terrain, everything.

(Louis Pasteur, 1822–1895)

Modern epidemiology is oriented to explaining and quantifying the bobbing of corks on the surface waters, while largely disregarding the stronger undercurrents that determine where, on average, the cluster of corks ends up along the shoreline of risk

(McMichael, 1995; taken from Decosas, 2002: 4)

What is the best way to try and understand HIV/AIDS epidemics? Should we try and understand such epidemics purely as the product of individual risky behavior and individual agency? Or, instead, as a result of the broader social and economic forces acting on groups of people, so leading entire population groups into more risky types of behavior? The first type of approach, to date, has arguably been the most dominant one used by those looking to understand the world's HIV/AIDS epidemics. The second approach, on the other hand, which considers in significant detail the types of economic and social terrain in which epidemic disease flourish, has received far less attention. Looking at what has also been referred to among other things as the “biosocial,” “structural,” “distal,” or “economic and social determinants” of disease, this approach has attempted to move beyond the subject of individual agency in its explanation of epidemic disease. Despite its neglect to date, there is now growing interest in these so-called structural determinants of disease, including those related to HIV/AIDS. The primary purpose of this book is to apply some of the ideas of this approach, with a view to further understanding China's HIV/AIDS problem from this alternative perspective. As such, this contribution to the understanding of China's HIV/AIDS epidemic takes a somewhat novel and different approach to those already made.

To explain the novel conceptual framework adopted in this book, this first chapter begins by providing a brief overview of the evolution in different approaches to understanding HIV/AIDS as an epidemic disease. First, we explain how so-called biomedical paradigms have, until recently, strongly guided understandings and conceptualizations of the HIV/AIDS epidemics. We explain why this so-called biomedical approach is now increasingly being questioned. Second, as an alternative to the predominant biomedical model, we consider and explain some of the newer, alternative ways of explaining HIV/AIDS epidemics. While embryonic and still far from perfect, these draw from the social sciences and the newly emerging discipline of social epidemiology. Third, we go on to argue that while the newer approaches to understanding HIV/AIDS epidemics are far from complete, they can provide useful alternative perspectives. This is particularly the case for a country such as China, which has undergone rapid economic and social change. These changes have profoundly affected the terrain in which epidemic disease may flourish. The speed and nature of these changes, moreover, would appear to be conducive to the further spread of HIV/AIDS.

Each of the chapters in this book goes on to identify and further investigate potential economic and social determinants of HIV/AIDS in China. This includes discussion and analysis of the impact of income and gender inequalities in China, migration, commercial sex work (CSW), public healthcare, and the role of civil society and political systems, among other things. While not exhaustive, we illustrate how further consideration of these economic and social determinants, which work predominantly at the population level, may be important drivers of the HIV/AIDS epidemic. This book also works from the basic premise that if we want to understand the fundamental causes of HIV/AIDS epidemics, we must look beyond a narrow focus of individual behavior. We must also consider the changing economic and social environment in which people live and function. By pointing to some of these deeper undercurrents and terrain in which HIV/AIDS epidemics emerge, we may also be able to create new types of policies. It is a hope that this book will also help draw attention to and discussion of these determinants.

What causes HIV/AIDS epidemics?

Our conceptualization of what causes disease and poor health has evolved in a number of long cycles, spanning the past two centuries of medical thought. Today, this conceptualization is going through another important cycle of change, particularly as regards epidemic disease. As such, before undertaking an investigation of a specific epidemic disease, such as HIV/AIDS, in a specific country such as China, it is important to understand how different approaches to understanding disease have evolved. In particular, biomedical explanations have to date largely dominated the academic understanding of HIV/AIDS. Many now argue, however, that this particular approach is proving inadequate. HIV/AIDS epidemics in many, if not most, regions continue to grow. At the same time, what is considered as a rather narrow range of “technological” solutions has also been applied to combating the epidemics. It is argued by some that traditional epidemiological accounts are “inadequate to the task of understanding public health issues as they apply to HIV/AIDS” (Barnett and Whiteside, 2006: 77). This raises the question of how biomedical views, so influential in understanding disease, have evolved. Also, why are they now considered inadequate to understanding the HIV/AIDS epidemics by some?

When thinking about HIV/AIDS, there is tendency to automatically think of it as a phenomena related to risky individual behavior – unprotected sex or intravenous drug use (IDU), for example – and in turn as a problem of individual agency.¹ Arguably, this is because of the strong influence of epidemiology and the medical sciences in our conceptualization of HIV/AIDS. A popular definition of “epidemiology” considers it as the study of why any individual becomes ill at any particular time. Despite this current day focus on the individual in our understanding of disease, there has also been recognition of the role that broader social and economic conditions play in disease generation in earlier periods of history. Rudolf Virchow, for example, a nineteenth century founder of social medicine, noted over a 100 years ago that the medical sciences were inextricably and essentially linked to the social sciences. Clearly, the way in which disease and health has been conceptualized has evolved over time. In fact, according to expert epidemiologists, it is argued that three distinct models, corresponding to different eras, are identifiable (Susser and Susser, 1996). These include the miasmatic era, followed by infectious disease epidemiology, and the highly influential paradigm known as the germ theory. Finally, an era of chronic disease epidemiology, accompanied by what has become known as the black box paradigm, is thought to have emerged (ibid.).

Miasma

According to epidemiologists, the miasmatic era may have started as early as the seventeenth century. It emerged as a result of the quantitative analysis of the social distribution of mortality that was possible with the recording for the first time of statistics that showed the kinds of people that were dying and the reasons for their deaths. The miasma model also grew out of the increasing concern for public health and the noticeable differences in health across society that was emerging. Agricultural and subsequent industrial revolutions had led to rapid changes in the way people lived. By the nineteenth century, rapid industrialization and urbanization created difficult living conditions in urban areas. These trends, incidentally, are not unlike those seen in China today. They led to high mortality rates and growing concerns about public health. The concept of miasma, therefore, emerged around this time. It was used as a framework to try and explain the newly acquired health information about the nineteenth-century city slums (in both Europe and also the United States).

A key feature of the miasmatic theory is that it did not have any specific scientific proof of causality between disease and the environment. Today, therefore, it would be considered a very simplistic model and conceptualization of disease generation. Instead, it made a rather common sense connection between high mortality rates and the accompanying poor economic and social conditions (such as water supplies, sewage and sanitation, and housing conditions). At this time, the biomechanics of organisms were not well understood. As such, miasmatic theorists went on to hypothesize that it was simply the unhealthy environmental conditions that gave off “foul emanations” or “bad air” that caused disease and high mortality (Susser and Susser, 1996: 669). As with the current day focus on social and economic determinants of health, therefore, it attributed disease and ill-health to the underlying “terrain” – both physical and social – that people inhabited. For most of the nineteenth century, this miasmatic theory was the dominant model used to explain disease. Although there was little hard science supporting the miasmatic approach, the actual policy implications of the model were straightforward and actually effective. Advocates suggested common sense policies aimed at improving the environmental factors that they believed caused disease. Thus they suggested enclosed drainage and sewage, the building of public baths as well as better housing, and rubbish collection.² Broader social and economic forces were also identified as having a strong bearing on health. They also recognized the two-way relationship between miasma and poverty and poverty and miasma. In this sense, the early followers of miasma adopted a broad “socially connected” approach to understanding disease (Susser and Susser, 1996). Even if their theory of disease was vague and unscientific, insofar as the exact mechanism whereby disease emerged was not really described or understood, the actual policies based on its inductive reasoning were successful.

The germ theory

Miasma, although quite effective in the public policy realm, lost appeal as an approach to understanding disease owing to revolutionary discoveries in microbiology that took place during the second half of the twentieth century. These developments led to the identification of the actual germs that caused disease. As early as 1840, Jakob Henle came to the conclusion that disease was actually caused by microorganisms, not simply the miasma found in polluted environments. Around two decades later, Louis Pasteur went on to demonstrate that living organisms were responsible for an epidemic affecting silkworms. After this, a flow of further scientific evidence emerged backing up these ideas, and far greater understanding of human diseases followed. In 1882, for example, Robert Koch established that a specific mycobacterium caused the deadly killer, tuberculosis (TB). Similar breakthroughs were also made with other diseases such as anthrax and leprosy. The growing isolation of particular organisms, now identified as the ultimate “cause” of disease, led to a growing concentration of scientists on the exact biomedical and physical understanding of disease. As time passed, the broader environmental reasons that miasmatic theory had earlier concentrated on were increasingly overlooked. These revolutionary scientific discoveries therefore led in turn to a new paradigm within medicine, known today as the germ theory of disease. This transition from the rather vague miasmatic understandings of disease to specific causal theories has been highly important for the way in which we conceptualize disease today. The germ theory, however, is also characterized by its “narrow laboratory perspective of a specific cause model – namely, single agents relating one to one to specific diseases” (Susser and Susser, 1996: 670). It looked to specify which particular agents were responsible for disease, establish how transmission occurred, and then to limit transmissions by vaccines, as well as isolating those infected and treat the disease. The concentration on the social dynamics of disease that the miasma theory called for, by comparison, was quickly replaced by “a focus on control of infectious agents” (ibid.). In the battle of competing paradigms, the supporters of the traditional philosophy of public health based around the miasma paradigm soon lost their influence in the medical hierarchy. They were also “disparaged in ways that in many places continue in the present” (ibid.). Thus the search for other causes of disease – those in the environment in particular, looking beyond the “microbe” – slowed down considerably. Today, the legacy of the germ theory for our understanding of HIV/AIDS epidemics, particularly its emphasis on the individual as host of disease, remains influential.

Interestingly, and also of importance, this revolution in the early part of the twentieth century also precipitated great changes in how the study of medicine and public health was organized. In 1916, for example, the United States undertook important reforms. Medicine concerned with the general population and that with individual health was separated. Schools of public health were split from schools of clinical medicine. This new demarcation between individual and public health, it is argued, had a further deep effect on how disease was conceptualized, reinforcing the general trend (Barnett and Whiteside, 2006: 77). Epidemiologists, as a result, were left to fill the vacuum between the fields of individual and public health. These epidemiologists became “part medical practitioners, part statisticians and part public health experts” (ibid.). It is argued that in attempting to cover such a wide field epidemiologists “were bound to fall between all possible stools” (ibid.).

The black box

By the beginning of World War II, germ theory lost some of its appeal and a third stage and new paradigm again started to emerge. By this time many infectious diseases, for example, typhoid and diphtheria, had been identified and treatments were developed. Communicable diseases no longer constituted the main threats to public health in the developed world (although this was not the case for the developing world). Scientists and policy makers, moreover, did not expect the reemergence of communicable diseases that we have seen today such as HIV/AIDS and TB. Instead, chronic diseases, including heart disease and cancer, started to become the major health concerns. Changing lifestyles and aging populations were also among the reasons driving the emergence of new types of chronic disease. Models explaining chronic disease, therefore, would again have to focus more upon the social and physical environments in which the chronic diseases were evolving. The particular paradigm adopted during the Chronic Disease era has been called the black box paradigm or the risk factor paradigm.

The modern “risk factor paradigm” composes of “studies that relate exposures to disease outcomes inform public health interventions to reduce individual risk for disease” (Schwartz, Susser and Susser, 1999: 19). This model, interestingly, did not dwell upon the need to understand the exact causal mechanisms (hence our lack of understanding of the “deeper undercurrents” in the modern era). Indeed, the pathogenesis of disease was not essential to the black box paradigm (in which the inner processes, the “black box” are not observable). Early studies looked at the relationships between lung cancer and heart disease and looked for associated risk factors among individuals. Based on this method, these studies established smoking and cholesterol as risk factors for these conditions. Use of increasingly larger data sets allowed for comprehensive statistical analyses leading to the identification of risk factors. These studies, moreover, related exposures to disease to outcomes to inform public health interventions to “reduce individual risk for disease” (Schwartz, Susser and Susser, 1999: 19). Crucially, then, there remained an emphasis on the individual, as in the earlier germ theory approach.

Reductionism has been an important part of modern scientific techniques. According to a growing number of critics, however, this has at times led to an atomization of the problem when it comes to the understanding of disease. While reductionism may benefit our comprehension of the actual physical properties of diseases, it does not necessarily help in understanding epidemic disease, which by definition involves the interaction of large numbers of people in specific social and economic environments. As noted, epidemiology as an academic discipline in general seeks to understand why any individual may contract a disease at any particular time.³ As such it may explain why individuals become ill, but it does not explain why particular groups or sections of population are more likely to contract diseases, or even why some countries are more likely to have higher HIV/AIDS prevalence than others. When we consider HIV/AIDS epidemics as social processes, however, rather purely than the product of individuals and their actions, a different etiological question emerges: “why do some populations have much AIDS, while it is rare in others?” (Decosas, 2002: 3). This new approach has led some to believe that the present era of epidemiology is coming to an end. Instead of focusing risk factors at the individual level, we are now being urged to recognize “causal pathways at the societal level” (Susser and Susser, 1996: 668). This has led to the blossoming of new approaches to understanding health, which is enshrined in the approaches of social epidemiology and appreciation of the social determinants of health. Indeed, such is the appeal of this new approach that various organizations have been established to promote it (such as the WHO's Commission on the Social Determinants of Health) and academics are spending increasing time and effort further exploring the subject.

Alternative approaches

Dissatisfaction with the current conceptualization of HIV/AIDS and the associated policies, those that focus purely on individual agency, has led to a backlash among a variety of different groups, including academics, policy makers, and those working on the ground. Critics from among social and medical sciences, for example, argue that there are many difficulties with the current approaches. Some have argued that both context and historical perspective are missing in our understanding of the epidemics (Stillwaggon, 2006). Others have accused current approaches of suffering from “disciplinary blindness,” in which alternative viewpoints are blocked and excluded from discussion (Craddock, 2004). Some echo this, pointing to the weakness of applying a “rigidly disciplined approach” to what is essentially a highly complex social phenomenon (Farmer, 1999: 15). Farmer (1999) goes further, arguing individual academic disciplines have done their best to establish their own niches in the search for greater research funding, to effectively monopolize this research area. Behind many of these criticisms, however, lies the fundamental observation that the conception of disease is driven purely by medical science, rather than “expanding into broader social science analyses required for more comprehensive understanding of an epidemic” (Barnett and Whiteside, 2006: 77). Given these problems, many now argue that there is greater need for what may be termed a “biosocial” understanding of disease, one that incorporates both the biological and social (Farmer, 1999). Of course, the rush to provide new insights into the social and economic determinants of health raises a number of fundamental questions. What, for example, does this new approach actually consists of? How can it be put into operation to yield new and improved understandings on the world's HIV/AIDS epidemics? Is it really of any scientific value?

We can get some idea of the new approaches to understanding HIV/AIDS epidemics in the growing literature that has emerged looking at how the broader social and economic conditions that may drive HIV/AIDS epidemics (see, e.g., Barnett and Whiteside, 2006; Farmer, 1999; Kalipeni et al., 2004; Stillwaggon, 2006). These works have taken on titles such as the “ecology of poverty” (Stillwaggon, 2006), the “social ecology” of HIV/AIDS (Decosas, 2002), emphasizing the broader historical and socioeconomic context in which epidemic disease may emerge. In attacking what they see as the disciplinary blindness of previous work, they have also explicitly committed ...

Table of contents

• Front Cover
• HIV/AIDS in China – The Economic and Social Determinants
• Routledge Contemporary China Series
• Title Page
• Copyright
• Contents
• List of illustrations
• Preface
• List of abbreviations
• 1 Understanding HIV/AIDS epidemics
• 2 Economic and social determinants of HIV/AIDS
• 3 Inequality and HIV/AIDS epidemics
• 4 Commercial sex work
• 5 Migration
• 6 Healthcare
• 7 The role of civil society organizations
• Conclusion
• Notes
• Bibliography
• Index