THE GOVERNANCE OF AIDS IN CHINA: ASSESSING THE

IMPACT OF GLOBAL NORMS

BY

ROWAN HAGUE

A THESIS SUBMITTED IN FULFILLMENT OF

THE REQUIREMENTS OF

DOCTOR OF PHILOSOPHY

SCHOOL OF SOCIAL SCIENCES AND INTERNATIONAL STUDIES

UNIVERSITY OF NEW SOUTH WALES, 2008

ORIGINALITY STATEMENT

‘I hereby declare that this submission is my own work and to the best of my knowledge it contains no materials previously published or written by another person, or substantial proportions of material which have been accepted for the award of any other degree or diploma at UNSW or any other educational institution, except where due acknowledgement is made in the thesis. Any contribution made to the research by others, with whom I have worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the intellectual content of this thesis is the product of my own work, except to the extent that assistance from others in the project's design and conception or in style, presentation and linguistic expression is acknowledged.’

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ABSTRACT

This thesis documents the development of the Chinese government’s response to HIV/AIDS in the context of the global AIDS regime in order to assess when, how and to what extent international AIDS norms have had an impact upon China’s governance of AIDS. Employing an applied constructivist framework, the thesis argues that the impact of global norms at the domestic level has been contingent on a) the socializing actions of norm entrepreneurs, b) the domestic political context and c) crisis. In the case of China and the impact of global AIDS norms, the central argument is that key elements of China’s domestic political context minimized the socializing affects of the global AIDS regime until the SARS crisis in 2003 led to a reappraisal of AIDS in the context of political legitimacy, at which time global AIDS norms began to have increasing salience in China. This thesis begins by identifying the evolution of a global AIDS regime before moving on to an exploration of China’s domestic political context. The thesis then documents and analyses China’s governance of AIDS from 1985 to 2007 through the use of five indicators – political commitment, legislation and policy, representation of AIDS in the media, the participation of civil society, and international engagement. The findings demonstrate that there has been a significant change between China’s pre-SARS and post-SARS AIDS governance with China acting increasingly in accordance with global norms following the SARS crisis of 2003. The thesis proposes that the SARS crisis was catalytic in that it exposed the vulnerability of the Chinese government’s claims to legitimacy, and in so doing, enabled the domestic political context to shift, allowing health, and by extension AIDS, to be reframed as a political issue. Importantly however, when the Chinese government scaled up its response to the epidemic it was able to be guided by the normative framework prescribed by the global AIDS regime.

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ACKNOWLEDGMENTS

The road to completing the PhD thesis is long and sometimes arduous. I could not have done this without my many friends and colleagues. There are too many of you to list individually, but to all of you who read drafts, came to seminars, listened to me vent and celebrated finished chapters over dinner and the occasional bottle of wine, I am very grateful.

I am especially thankful of my two supervisors, Dr. Elizabeth Thurbon and Prof. Marc Williams, for sharing their time and knowledge and for the constant reassurance that the research project was viable and valuable. Special thanks to Marc in particular for the daily catch-ups and readings of drafts in the last months - I don’t know what I would have done without you.

To my wonderful family, I am so appreciative of the love and guidance you have provided me over all these years. I know you wondered if I would ever get it done but you never wavered in your support. To my mum and dad, thank you for helping me get to where I am today.

Lastly and most importantly, my deepest love and thanks to my infinitely patient and understanding partner, Ben, without whom I would have long given up. Thank you for enduring my stress, cooking me dinners, walking our dog, listening to my ideas and fears, telling me that it was ok to have a break and always believing in me. I dedicate this thesis to you.

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TABLE OF CONTENTS

ORIGINALITY STATEMENT...... 2

COPYRIGHT AND AUTHENTICITY STATEMENTS ...... 3 ABSTRACT...... 4 ACKNOWLEDGEMENT...... 5

TABLE OF CONTENTS...... 6

LIST OF ACRONYMS AND ABBREVIATION ...... 9

NOTE ON CHINESE TERMS...... 14

CHAPTER I – INTRODUCTION: CHINA, AIDS AND GLOBAL NORMS ...... 15

1.0 INTRODUCTION ...... 15

1.1 AIDS IN CHINA...... 16

1.1.1 SCALE AND CHARACTERISTICS...... 16

1.1.2 MAJOR ACTORS IN DOMESTIC SETTING ...... 19

1.1.3 LINKS TO WIDER REGIME...... 21

1.2 CENTRAL QUESTIONS AND AIMS …………………………………………22

1.3 CONTRIBUTIONS OF THE THESIS ………………………………………….23

1.3.1 HIV/AIDS GOVERNANCE ...... 23

1.3.2 CHINA’S REGIME COMPLIANCE...... 25

1.3.3 THE IMPACT OF GLOBAL NORMS...... 26

1.4 RESEARCH STRATEGIES ...... 27

1.4.1 CONSTRUCTIVISM IN INTERNATIONAL RELATIONS ...... 27

1.4.2 APPLIED CONSTRUCTIVISM – A CONCEPTUAL FRAMEWORK ...... 33

1.4.2.1 NORM ENTREPRENEURS ...... 35

1.4.2.2 DOMESTIC POLITICAL CONTEXT...... 39

1.4.2.3 CRISIS AND UNCERTAINTY ...... 43

1.4.3 METHODS ...... 45

1.5 BOUNDARIES AND RESEARCH CHALLENGES ……………………………..47

1.6 STRUCTURE OF THE THESIS ...... 48

CHAPTER 2 – THE GLOBAL AIDS REGIME ...... 50

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2.0 INTRODUCTION ...... 50

2.1 THE GLOBAL AIDS REGIME – DEFINITIONS AND KEY FEATURES...... 53

2.2 THE PRE-REGIME PERIOD 1981-1986 ...... 55

2.3 REGIME EMERGENCE 1987-1995 ...... 59

2.3.1 NORM EMERGENCE THROUGH GRASSROOTS ACTIVISM...... 60

2.3.2 NORM EMERGENCE AT THE INTERGOVERNMENTAL LEVEL...... 67

2.4 REGIME CONSOLIDATION 1996-2007...... 75

2.4.1 CONSOLIDATION THROUGH AGENCY AND GEOGRAPHICAL

EXPANSION...... 76

2.4.2 CONSOLIDATION THROUGH ISSUE-LINKAGE AND ENSUING

ORGANIZATIONAL PROLIFERATION ...... 84

2.4.3 CONSOLIDATION THROUGH EXPANSION TO NEW ACTORS...... 93

2.5 CONCLUSION...... 97

CHAPTER 3 – CHINA’S DOMESTIC CONTEXT: POLITICAL STRUCTURE,

DISCOURSES AND INTERESTS ...... 99

3.0 INTRODUCTION ...... 99

3.1 KEY FEATURES OF THE POLITICAL SYSTEM ...... 99

3.1.1 THE PARTY AND THE STATE...... 100

3.1.2 CENTRE-LOCAL RELATIONS ...... 105

3.1.3 STATE-SOCIETY DYNAMICS ...... 109

3.2 THE NORMATIVE FRAMEWORK OF SEX: THE OFFICIAL DISCOURSE...... 114

3.3 KEY INTERESTS AND GOALS ...... 120

3.3.1 PRESERVATION OF POWER AND THE SEARCH FOR LEGITIMACY...... 121

3.3.2 ECONOMIC DEVELOPMENT...... 124

3.3.3 SOCIAL STABILITY...... 129

3.3.4 ENHANCING INTERNATIONAL STANDING ...... 130

3.4 CONCLUSION...... 135

CHAPTER 4 – PRE-SARS AIDS GOVERNANCE 1985 – 2002...... 137

4.0 INTRODUCTION ...... 137

4.1 DENIAL 1985 -1993 ...... 140

4.1.1 POLITICAL COMMITMENT ...... 141

4.1.2 LEGISLATION AND POLICY...... 144

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4.1.3 HIV/AIDS IN THE MEDIA ...... 148

4.1.4 THE ROLE OF CIVIL SOCIETY ...... 150

4.1.5 INTERNATIONAL ENGAGEMENT...... 151

4.2 LIMITED RECOGNITION 1994 – 2002...... 154

4.2.1 POLITICAL COMMITMENT ...... 154

4.2.2 LEGISLATION AND POLICY...... 160

4.2.3 HIV/AIDS IN THE MEDIA ...... 164

4.2.4 THE ROLE OF CIVIL SOCIETY ...... 166

4.2.5 INTERNATIONAL ENGAGEMENT...... 169

4.3 CONCLUSION...... 173

CHAPTER 5 – THE SARS CRISIS AND AIDS GOVERANCE ...... 175

5.0 INTRODUCTION ...... 175

5.1 CRISIS, UNCERTAINTY AND POLITICAL CONTEXT ...... 176

5.2 THE 2003 SARS CRISIS ...... 178

5.3 THREATS TO REGIME LEGITIMACY...... 182

5.3.1 WEAK HEALTH SYSTEM EXPOSED...... 183

5.3.2 INTERNAL CHALLENGES EXPOSED...... 185

5.3.3 ECONOMIC DEVELOPMENT AND SOCIAL STABILITY THREATENED...... 188

5.3.4 DAMAGE TO CHINA’S INTERNATIONAL REPUTATION...... 191

5.4 LEGITIMACY ISSUES FOR THE NEW LEADERSHIP...... 197

5.5 THE SARS CRISIS AND IMPLICATIONS FOR HIV/AIDS GOVERNANCE IN

CHINA ...... 199

5.5.1 SARS AND A NEW POLITICAL AGENDA ...... 200

5.5.2 SARS, RESOURCES DISTRIBUTION AND THE MOH...... 201

5.5.3 SARS AND OPENNESS TO NEW IDEAS ...... 202

5.6 CONCLUSION...... 204

CHAPTER 6 – CHINA’S POST-SARS AIDS GOVERNANCE – A PERIOD OF

MODEST ENGAGEMENT 2003-2007...... 205

6.0 INTRODUCTION ...... 205

6.1 POLITICAL COMMITMENT...... 205

6.2 LEGISLATION AND POLICY ...... 212

6.3 HIV/AIDS IN THE MEDIA ...... 225

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6.4 THE ROLE OF CIVIL SOCIETY ...... 230

6.5 INTERNATIONAL ENGAGEMENT...... 236

6.6 CONCLUSION...... 246

CHAPTER 7 – CONCLUSION...... 249

BIBLIOGRAPHY...... 259

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LIST OF ACRONYMS AND ABBREVIATIONS

ACT UP AIDS Coalition to Unleash Power ADAP AIDS Drug Assistance Program ADB Asian Development Bank AFC Asian Financial Crisis AIDS Acquired immune deficiency syndrome APEC Asia-Pacific Economic Cooperation ARD Antiretroviral drugs ASEAN Association of South East Asian Nations ASO AIDS service organization AusAID Australian Agency for International Development AZT Zidovudine (one of the first antiretroviral drugs) CAMP China AIDS Media Project CCDC Chinese Centre of Disease Control CCM Country coordinating mechanism CCP Chinese Communist Party CDC Centre of Disease Control (US) CECC Congressional-Executive Commission on China CHARTS China AIDS Roadmap Tactical Support China CARES China Comprehensive AIDS Response CSO Civil society organization CSW Commercial sex worker DFID Department for International Development ECOSOC Economic and Social Council FDA Food and Drug Administration FPD Former plasma donor G8 Group of 8 GBC Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria GDP Gross domestic product

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Global Fund Global Fund to fight AIDS, Tuberculosis and Malaria GHI Global Health Initiative GIPA Greater Involvement of People Living with HIV/AIDS GMHC Gay Men’s Health Crisis GONGO Government-operated non-governmental organization GPA Global Program on AIDS Health GAP Health Global Access Project HIV Human immunodeficiency virus ICASO International Council of AIDS Service Organizations IDU Intravenous drug user IGO Intergovernmental organization ILO International Labour Organization INGO International non-governmental organization IO International organization M&E Monitoring and Evaluation MDG Millennium Development Goal MOH Ministry of Health MSF Médecins Sans Frontières MSM Men who have sex with men MTCT Mother-to-child transmission NAP National AIDS program NCAIDS National Centre for AIDS/STD Prevention and Control NGO Non-governmental organization NIH National Institute of Health NPC National People’s Congress PCB Programme Coordinating Board PEPFAR President’s Emergency Plan for AIDS Relief PMA Pharmaceutical Manufacturers Association PRC People’s Republic of China

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PWA People with AIDS PLWHA People Living with HIV/AIDS RMB Renmin Bi (literally: the People’s Currency) SAR Special administrative region SARS Severe acute respiratory syndrome SCO Shanghai Cooperation Organization SCAWC State Council AIDS Working Committee SCAWCO State Council AIDS Working Committee Office STD/STI Sexually transmitted disease/infection TAC Treatment Action Campaign TCM Traditional Chinese medicine TAN Transnational advocacy network TRIPS Trade-Related Aspects of Intellectual Property Rights UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNDCP United Nations International Drug Control Programme UNDP United Nations Development Programme UNESCAP United Nations Economic and Social Commission for Asia and the Pacific UNESCO United Nations Educational, Scientific and Cultural Organization UNGA United Nations General Assembly UNGASS United Nations General Assembly Special Session on HIV/AIDS UNHCR Office of the United Nations High Commissioner for Refugees UNICEF United Nations Children’s Fund UNPF United Nations Population Fund UNSC United Nations Security Council UNTG United Nations Theme Group on HIV/AIDS USTR US Trade Representative VCT Voluntary counselling and treatment

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WEF World Economic Forum WFP United Nations World Food Programme WHA World Health Assembly WHO World Health Organization WTO World Trade Organization

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A NOTE ON CHINESE TERMS

- This thesis uses the traditional Chinese format when stating Chinese names. All Chinese names therefore have the family name first and the given name second, unless the person in question has specifically changed the order of their name.

- Because there are only a finite number of family names, some names such as Zhang are common. This makes referencing difficult. For ease of referencing therefore, where two different people with the same family name are being cited for publications for the same year, I will use their full name in the in-text citation.

- Where Chinese place names, words or phrases are used, the romanisation system of hanyu pinyin will be used and the words will be italicised. An exception to this rule will be words or names most commonly known in their Wade-Giles system equivalent such as Tsinghua (instead of Qinghua) University.

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CHAPTER 1: AIDS, CHINA AND GLOBAL NORMS

1.0 INTRODUCTION

On December 1 2003, the Chinese Premier Wen Jiabao visited sick patients at a Beijing hospital, comforting them with kind words and shaking their hands. Had it been any other day, or any other patients, Wen Jiabao’s actions could have been dismissed as another photo opportunity for the Chinese regime to show that it is kind and compassionate. However, this was World AIDS Day and the patients that Wen Jiabao was visiting and touching were AIDS patients. This was the first time since acquired immune deficiency syndrome (AIDS) appeared in China in 1985 that a top Chinese leader had been visibly engaged in AIDS advocacy and signified a major political turnaround by the government that included new funding, institutions, laws and policies and increasing international cooperation. As if this change was not interesting enough, the international praise that this shift produced represented a marked contrast to the opprobrium generated by China’s AIDS governance just several years earlier. This international praise/opprobrium suggests that there exist established expectations for the appropriate behaviour of international actors with regards to HIV1/AIDS governance, or AIDS norms.2 The existence of global AIDS norms and their impact (or lack of impact) on China’s governance of AIDS forms the central inquiry of this thesis.

This thesis thus makes the argument that there has been a noticeable evolution in China’s AIDS governance from 1985 to 2007. This will be demonstrated through an analytical framework comprised of five indicators - political commitment, legislation and policy, representation of AIDS in the media, the role of civil society, and international engagement. This thesis also argues that it is possible to identify the existence of a global AIDS regime, which has developed in tandem with the evolution of the global AIDS epidemic. Primarily declaratory in nature, the global AIDS regime’s power lies in its norms. This thesis thus employs an applied constructivist approach to examine the extent to which the regime has had an impact on China’s domestic policy. While the normative influence of the global regime on China’s

1 Human immunodeficiency virus. 2 Norms will be defined further on pages 30-31.

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governance of AIDS has varied according to a combination of both international and domestic factors, this thesis argues that the key mechanism of change was the outbreak of severe acute respiratory syndrome (SARS) in 2003 which politicised AIDS and enabled the global AIDS norms to have greater salience in China by forcing the leadership to reassess how it legitimises its monopoly of power.

In this introductory chapter I will first contextualise the research project by establishing the scale and characteristics of the AIDS epidemic in China before introducing the main actors involved at both the domestic and international levels. I will then outline the central questions, aims and the contributions of the thesis before discussing the theoretical and conceptual framework and the methodology. The chapter will conclude with an overview of the thesis structure.

1.1 AIDS IN CHINA

The purpose of this section is to introduce the issue at the centre of this thesis – HIV/AIDS in China – and the main stakeholders involved. The section will begin with an overview of the scale and the characteristics of the AIDS epidemic in China. The focus will then shift to the Chinese political actors and their involvement in the issue area. Finally, the section will seek to embed China’s national actors within the wider global AIDS regime.

1.1.1 SCALE AND CHARACTERISTICS

As of October 2007, the official estimate of people with AIDS (PWA) in China was 700,000 (range 550,000 – 850,000) with a prevalence rate of under 0.1 per cent (SCAWCO and UNTG 2007, p.4).3 This prevalence rate is obviously very low compared with some of the worst affected states (South Africa currently has a prevalence rate of 18 per cent) however the issue is not so much the current state of the epidemic but rather its potential to explode in the near future. The annual number of reported new cases of HIV/AIDS has dramatically increased in recent years (see

3 This estimate is disputed by non-governmental organizations, both domestic and international, who argue that it is too conservative and not in keeping with the number of PWA they see on the ground (for comments on previous estimates see Human Rights Watch 2003b; Rosenberg 2003; Yardley 2006).

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Chart 1.1) and recent evidence suggests that more and more people are being infected through heterosexual transmission – a worrying sign of things to come (SCAWCO and UNTG 2007, p.5). While Eberstadt’s upwards projections may yet prove excessive4 and the forecast offered by the Joint United Nations Programme on HIV/AIDS (UNAIDS) of 10 million infected by 20105 has since been admitted as unrealistic (Biggs 2006), few commentators would argue that there is room for complacency.6 Even a small increase in prevalence could be devastating given China’s enormous population (Gill and Okie 2007).

7 CHART 1.1 ANNUAL REPORTED CASES OF HIV/AIDS IN CHINA

50000

45000

40000

35000

30000

25000

20000

15000

10000

5000

0

1985- 1991 1992 1993 1990 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 A Year 2004 2005 ID 2006 S 2007 1-10

1985- 2007 1- 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 1990 10 AIDS 5 3 5 23 29 52 38 126 136 230 233 714 1028 6120 12652 7550 7909 8539 HIV/AIDS 492 216 261 274 531 1567 2649 3343 3306 4677 5201 8219 9732 21691 47606 40711 44070 39866

4 Eberstadt, a demographer, modelled the impacts of AIDS in the ‘second wave’ countries of China, Russia and India. His model forecasted a conservative 32 million upwards to 100 million cumulative new HIV cases for the period 2000 to 2025 (Eberstadt 2002). 5 UNAIDS, based on the UN Theme Group on HIV/AIDS in China’s study in 2002, warned that if the number of reported cased of HIV continued to increase by 30 per cent as it had done so since 1998, China could have more than 10 million infections and 260,000 orphans by the year 2010 (2003, p.18). 6 An exception is Hesketh (2007) who has argued that the level of resources that both international donors and the national government allocate to AIDS prevention in China is disproportionate to the level of need, especially when compared to the under-funded problem of tobacco-related disease. Hesketh’s argument is in line with a number of commentators who have critiqued the exceptionalism of HIV/AIDS in relation to other health problems. For example, see England (2008). 7 Data from SCAWCO and UNTG (2007, p.2).

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Furthermore, the country prevalence rate only calculates the number of PWA in China as a proportion of the population as a whole. This is deceptive because it obscures serious epidemics in some provinces and does not tell us much about the characteristics of AIDS in China. For example, as of 2006, intravenous drug users (IDUs) accounted for the highest number of HIV/AIDS cases in China at 44.3 per cent of the total PWA population. IDU-related HIV transmission has affected poor, border provinces where transborder drug-running is prolific. Thus, prevalence rates amongst IDUs in Xinjiang, Yunnan and Sichuan exceed 50 per cent. An issue that has gained the most international attention, former plasma donors (FPDs) living with HIV/AIDS constitute 10.7 per cent. While Henan has gained the most attention, four other provinces in central China (Hubei, Anhui, Hebei and Shanxi) have FPD populations. Another high-risk group is comprised of commercial sex workers (CSWs) and their clients, whom together account for 19.6 per cent of the total number of estimated cases. Up until now, the epidemic has been contained predominately within high-risk populations. However, there are also now worrying signs that the disease is spreading beyond the high risk groups into the general population, with 16.7 per cent of the total PWA population being comprised of partners of PWA and members of the general population. The remaining PWA are comprised of men who have sex with men (MSM) and cases of mother-to-child transmission (MTCT) that account for 7.3 per cent and 1.4 per cent respectively (MOH PRC, UNAIDS, and WHO 2006, p.1-2).

The epidemiological history of AIDS in China is usually described as one of three phases (Wu 2005, p.200-203; Shen et al. 2004, p.47-48).8 The first phase from 1985 to 1988 is described as the entry phase due to there being only 19 cases of HIV/AIDS reported– most of which were either foreigners or overseas Chinese. The second phase or the spreading phase, from 1989 to 1994, saw the emergence of an HIV/AIDS epidemic amongst IDUs in southwest Yunnan province. In the third phase, or the expansion phase from 1995 on, the number of HIV/AIDS cases has increased rapidly. This expansion is not only attributed to the spread of the disease from IDUs in

8 In chapters four and six, I also mention three different phases or periods however these relate to China’s governance of AIDS rather than to the epidemiological development of the epidemic.

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Yunnan to other high-risk groups in other provinces, but also to the infection of large populations in central China through paid blood donation.9

The main factors that have contributed to HIV/AIDS vulnerability and its expansion have been all too familiar – globalisation, poverty, inequality, sexual taboos, and denial. The reforms implemented by the Chinese government in the 1980s have had massive socio-economic ramifications. For example, the economic policies of the Deng government coupled with the one-child policy has resulted in the emergence of a wealthy, materialistic young male population and a demand for female escorts, a phenomena which has encouraged prostitution, a trap for many young women that have left their villages in search of work in the city (Beyrer 1998; Gill, Chang, and Palmer 2002; Renwick 2002; Tucker et al. 2005). Another result of the economic reforms is the ‘floating population’. This group includes millions of people who have left their rural homes in search of a decent living in urban areas and who miss out on health care and education in the process (Gil 1994, p.11; Gill, Chang, and Palmer 2002). Likewise, a mix of increased freedom of movement, unemployment and disillusionment has led to an increase in the trade in sex and narcotics and the increase of IDU populations (particularly amongst ethnic minorities) – a major contributing factor for the high prevalence of HIV/AIDS in the south- and north-western border provinces of Yunnan and Xinjiang (Beyrer 1998, p.107; Gil 1994, p.9).10

1.1.2 MAJOR ACTORS IN THE DOMESTIC SETTING

While they will be reintroduced in chapters four, five and six, it suffices here to state that the relevant domestic actors with regards to HIV/AIDS in China include central government actors, provincial government actors and non-state actors. At the central government level, there are three key institutions. The Ministry of Health (MOH) is in charge of drafting laws and regulations, plans and policies relating to public health and overseeing disease prevention and treatment. The National Centre for AIDS/STD Prevention and Control (NCAIDS) helps the MOH. The NCAIDS is part of the

9 Further discussed in chapter four. 10 For some of the many studies and reports concerning AIDS vulnerability in China see Beyrer (1998), Geyer (2003), Gil (1994), Kaufman and Jing (2002), Khoshnood and Weber (2003), Renwick (2002), Tucker et al. (2005) and UN Theme Group on AIDS (2002).

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Chinese Centre of Disease Control (CCDC),11 which is under the nominal control of the MOH.12 The agency provides the scientific research on which AIDS policies are based, as well as participating in the design, implementation and monitoring and evaluation of national AIDS programs (NCAIDS 2008). The State Council AIDS Working Committee (SCAWC) is the national AIDS committee. This multisectoral body includes representatives from 23 relevant ministries and mass organizations, as well as the vice-governors of the seven worst affected provinces (SCAWCO and UNTG 2004). Alongside these institutions, due to their ability to politicise an issue, one must also consider where the top leaders of the Chinese political regime, the members of the Chinese Communist Party (CCP) Politburo, stand on HIV/AIDS.

While this thesis primarily focuses on the outputs of the central government, local officials are also important actors in the HIV/AIDS governance in China. This is because while policy is made by the central government, it is implemented and interpreted by local officials. Consistent local-level compliance with the national AIDS plan continues to be a challenge. In some provinces, the interpretation and application of central directives by local-level officials can mean the difference between coordinated and progressive anti-AIDS action (as in Yunnan) and continued denial and repression (for example, Henan province). Therefore, in studying the impact of global AIDS norms on China’s governance of HIV/AIDS, we must take into consideration the actions of local officials and the relationship between the centre and the localities.

Aside from government actors, China also has a burgeoning community of non-state actors involved in AIDS governance. As Wu documents, China’s HIV/AIDS prevention civil society is composed of a variety of actors, ranging from individual activists, professionals, non-governmental organizations (NGOs), organizations led by PWA, rural community-based groups, to university student associations (2005, p.221). Activities engaged in by civil society range from provision of prevention, care and treatment services, to AIDS advocacy and activism.13

11 NCAIDS was established in 1998 as part of the Chinese Academy of Preventative Medicine, which was restructured and renamed as the CCDC in 2002 (NCAIDS 2008). 12 In reality there have been struggles over areas of jurisdiction (Huang 2004). 13 Centre-local and state-civil society dynamics will be discussed at length in chapter three, sections 3.1.2 and 3.1.3.

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1.1.3 LINKS TO WIDER REGIME

While the global AIDS regime will be discussed in detail in chapter two, it will suffice here to say that there are numerous stakeholders in the global policy domain of HIV/AIDS, including: UNAIDS and its Co-Sponsors (including the World Health Organization (WHO)),14 the Global Fund for AIDS, Tuberculosis and Malaria (the Global Fund hereafter), donor and recipient states, international non-governmental organizations (including those that are formed and led by PWA), the international AIDS research community and the transnational business community. Over the last two and a half decades interactions between these actors at forums such as the biannual international AIDS conferences and the United Nations General Assembly Special Sessions on HIV/AIDS (UNGASS) have produced a set of shared expectations of proper behaviour (or norms) and (weak) decision-making procedures converging around the issue of AIDS.

China has not been divorced from these proceedings. Chinese government representatives have attended international and regional meetings, and Chinese officials, scientists and non-governmental organizations have attended the international AIDS conferences. The Global Fund has awarded China four grants since 2004, the proposals for which were drafted by the Chinese country coordinating mechanism (CCM), a committee including representatives from the government, domestic and international civil society, donor states and UN agencies. As part of a slowly developing transnational advocacy network (TAN),15 domestic civil society interacts with international non-governmental organizations (INGOs). These INGOs also must work with local, provincial and central government authorities. The US, Australia and the UK have all contributed funding and expertise that has involved partnerships with central and provincial governments. The Chinese private sector has been courted by the Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria (GBC) and the World Economic Forum’s Global Health Initiative (GHI). The Chinese government has even contributed to the Global Fund, to UNAIDS and to

14 UNAIDS’ Co-Sponsors are listed in chapter two, section 2.4.2, page 84. 15 A definition of transnational advocacy network is given in section footnote 23 on page 37.

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developing countries. These frequent exchanges between domestic actors and international/transnational actors have linked China to the wider global regime.

1.2 CENTRAL QUESTIONS AND AIMS

The central problematic that this thesis addresses is China’s changing governance of HIV/AIDS vis-à-vis the global AIDS regime. Three major research questions are raised in relation to this empirical puzzle. These questions have been informed both by the research and by the constructivist school of international relations. The first research question concerns the development of the global AIDS regime. Specifically, how has the world sought to address AIDS since its surfacing in the early 1980s and what understandings have emerged and been institutionalised as a result of this response? The second question concerns the specific case of China. How has China’s AIDS governance changed from 1985 to the present? The third and most important research question of the thesis is based on the postulate that the external and internal political arenas cannot be separated. To this extent, when, how and to what degree have the global AIDS norms been internalised by China and been reflected in its governance of HIV/AIDS?

In addressing these questions, this thesis has three main aims. Firstly, this thesis aims to provide an analytical history of AIDS governance in China. This is not the first time that an attempt has been made to look at changes in China’s AIDS policies over time. However, previous studies have mainly been situated in the field of public health (see for example Wu et al. 2007) or in social policy (see for example Kaufman, Kleinman and Saich 2007). This thesis will provide an extensive and novel synthesis of both primary information and previous studies, and will trace the development of China’s AIDS governance from 1985 to 2007 through the use of five indicators: political commitment, legislation and policy, representation of AIDS in the media, the role of civil society and international engagement.

Secondly, this thesis aims to engage with constructivist scholarship by seeking to account for the way in which the global AIDS norms have had domestic impact in China. On the one hand, this involves the demonstration that a global AIDS regime exists. Following Donnelly (1986, p.602), I define a regime as ‘the norms and

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decision making procedures accepted by international actors to regulate an issue area’. Therefore, I will chart the emergence and consolidation of the global AIDS regime and will comment on its features and dynamics. On the other hand, this engagement with constructivist scholarship also involves identifying where and how the global AIDS norms have influenced the governance of AIDS in China. In other words, I aim to establish the mechanisms for the transfer/adaptation/blocking of norms in this particular case.

The third aim of the thesis is to illustrate and emphasize the particular importance of crisis as a trigger for norm transfer in the specific case of China and the global AIDS regime. Through an examination of the impact of the 2003 outbreak of SARS on domestic institutions and interests, my thesis will lend support to the idea that normative change is more likely in times of uncertainty, particularly where illiberal political regimes are concerned.

1.3 CONTRIBUTIONS OF THE THESIS

This thesis engages with three fields of inquiry: HIV/AIDS governance, China’s compliance with international regimes and the power of norms.

1.3.1 INTERNATIONAL RELATIONS AND HIV/AIDS

HIV/AIDS is one of the most important political issues that the international community faces today. Despite Boone and Batsell’s criticism that International Relations scholars had for too long proved indifferent to the implications of HIV/AIDS in world politics (2001), since 2000 there has been increased attention to the issue. Receiving the most attention has been the security implications of HIV/AIDS (Altman 2003; Barnett 2006; Barnett and Prins 2005; Bruntland 2003; Elbe 2005; Feldbaum, Lee and Patel 2006; McInnes 2006; Peterson 2002/3; Prins 2004; Renwick 2004; Singer 2002; Vieira 2006). Addressing HIV/AIDS from a global political economy perspective has produced important studies on the links between globalisation and HIV/AIDS, the socio-economic causes and consequences of HIV/AIDS, and the inequitable power relations between the developed and the developing world, particularly with regards to aid (Altman 1998, 1999; Barnett and

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Whiteside 2002; Freedman and Poku 2005; Lee and Zwi 1996; Poku 2001; Poku 2006; Poku and Cheru 2001; Poku and Whiteside 2004). The global movement for access to medicines and the struggle against the intellectual property regime has been studied in detail (Lanoszka 2003; Smith and Siplon 2006; Thomas 2002). HIV/AIDS has also provided an interesting policy area in which to study new forms of global governance and the increasing relevance of non-state actors such as NGOs, epistemic and counter-epistemic communities and the private sector (Abbott 2007; Jönsson and Söderholm 1995; Mameli 2000; Ruggie 2004; Seckinelgin 2005; Söderholm 1997; Webb 2004; Youde 2005).

This thesis does not engage directly with any of dominant themes in the literature identified above although scholarship from all three has been influential in the research design of the thesis. This thesis contributes to the International Relations literature in two ways. Firstly, it provides a constructivist account of the emergence and the consolidation of a set of norms and decision-making procedures relating to the proper governance of HIV/AIDS, or, the global AIDS regime. While much of International Relations literature on AIDS mentions the global response, including the actions of organizations such as the World Bank and UNAIDS, it is usually discussed in terms of the lack of resources, coordination and political will in the state system. The terms ‘international regime’ or ‘global regime’ are seldom used in relation to HIV/AIDS. Some scholars have argued that certain ideas and ways of thinking about and responding to AIDS have been institutionalised through international organizations (IOs), international law and processes of globalisation (Altman 1998; Lee and Zwi 1996; Mameli 2000; Renwick 2004; Youde 2005). These studies, however, all fall short of arguing the existence of a global AIDS regime. When the international AIDS regime is referred to it is generally talked about in an unproblematic way, as if it is taken for granted. For example, while Seckinelgin (2005, p.355) notes that ‘it is possible to observe that a de facto governance regime in relation to HIV/AIDS has emerged’, a satisfactory explanation of what this de facto governance regime promotes and how it emerged is not forthcoming. This thesis will contribute to this literature by arguing that it is possible to identify a global AIDS regime with a set of clearly identifiable norms and decision-making procedures. Driven by grassroots activists and intergovernmental norm entrepreneurs and institutionalised in international resolutions, declarations and organizations, the

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importance of the global AIDS regime lies in the way that it legitimises certain actors and actions and delimits others.

The second contribution of the thesis to the AIDS and International Relations literature is related to Whiteside and Poku’s (2004, p.219) comment that:

It would be enormously valuable if political scientists were to spend more time on what it is that is required to make governments take the leap of imagination that is necessary to respond to AIDS.

As already mentioned, China’s change in AIDS governance in 2003 was praised as a watershed and held up as an example of the importance of political will. To this end, understanding the reasons for this change, the degree to which change occurred and the role (if any) played by the global AIDS regime may help us to understand what is required to generate political mobilization in other cases. The thesis will also supplement the growing body of literature on state responses to HIV/AIDS (for several excellent examples see deMotts and Markowitz 2004; Osei-hwedie 2001; Parkhurst 2001).

1.3.2 CHINA’S REGIME COMPLIANCE

The second field of inquiry with which this thesis is engaged addresses the issue of China and its foreign relations, particularly China’s interaction with international regimes. This literature is concerned with questions such as: the extent to which China’s participation in international regimes is indicative of a process of learning or socialization versus instrumental adaptation (Foot 2000; Johnston 1996; Kent 1997/1998, 1999, 2002); whether the motivation to comply is externally- or internally-generated (Deng 2004; Economy 1997; Kent 2007; Lanteigne 2005; Oksenberg and Economy 1999); whether China is a revisionist or a status quo power (Johnston 2003; Wang Jianwei 2004); whether China is a responsible power (Chan 2006); and, the extent to which international and transnational non-state actors are able to have impact on China’s domestic policy (Foot 2000; Khagram 2004; Wu 2005).

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Within this field there has been extensive work on China’s interaction and compliance with the environmental, human rights, trade, and the arms control regimes (Chan 2006; Kent 2007; Lanteigne 2005). While Wu’s dissertation (2005) on the development of the Chinese HIV/AIDS prevention advocacy network includes a brief examination of the multilateral and bilateral initiatives that have increased over the last five years, there has not as yet been a comprehensive study of the development of China’s relationship and (non)compliance with the global AIDS regime - a gap that this thesis helps to fill.

1.3.3 THE IMPACT OF GLOBAL NORMS

This thesis looks at the degree to which the global AIDS norms have influenced China’s governance of AIDS. While this is a specific case, it nevertheless contributes to the wider constructivist discussion on the question of global norms16 and when and why they matter at the domestic level. The importance of normative structures in international relations has been a central focus of the constructivist approach. While the first task of constructivism was to prove that norms matter, critics noted that there was evidence that the extent to which norms mattered varied from case to case (Checkel 1998a; Kowert and Legro 1996). More empirical work into the conditions that can temper the impact of norms was needed. Thus, ‘second-phase constructivists’ have sought to illuminate when and why norms have an impact at a national level (Cortell and Davis Jnr. 2000).17

The thesis thus engages with and contributes to this literature by examining when, why and to what degree the global AIDS regime has had normative influence on China’s governance of AIDS. The thesis takes into account the varying strategies and successes of international and domestic norm entrepreneurs, the degree to which the different features of the Chinese regime – the dynamics of the political system, the official discourse on sex and elite interests - have affected China’s receptivity and the process of norm internalisation, and the central role played by crisis as a mechanism

16 Much of the literature refers to ‘international’, rather than ‘global’ norms. I prefer the term ‘global’ to take into account the plurality of actors (i.e. not simply states alone) that both influence, and are influenced by, collective expectations. 17 The constructivist approach and the importance of norms will be introduced in detail below.

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of norm transference. Furthermore, being a negotiated authoritarian state, China presents an interesting case for studying the domestic impact of global norms.

1.4 RESEARCH STRATEGIES

This thesis is informed by the constructivist approach to international politics. While I am interested in a particular sub-field of constructivism – that of international level- domestic level normative dynamics (or how and when global HIV/AIDS norms have domestic effects) – the aim of the first part of this section is to embed this sub-field within the larger constructivist research agenda. Thus, the origins of constructivism, its ontological assumptions, and epistemological and methodological varieties will be discussed. In the second and third parts of the section, I will address the conceptual framework and the methods used in this study.

1.4.1 CONSTRUCTIVISM IN INTERNATIONAL RELATIONS

To introduce the constructivist approach, one must first say what it is not. Unlike realism, liberalism or Marxism, constructivism does not represent a substantive theory of international relations. It does not make any particular claims about the content of social structures or the nature of the agents at work in social life (Finnemore and Sikkink 2001, p.393). Constructivism is instead, like rational choice, a metatheoretical approach to the study of social reality (Risse 2002, p.598), or otherwise put, it is a social theory on which theories of international politics are based (Adler 1997, p.323). Its main focus is on the role of ideas, norms, knowledge, culture and argument in politics, which International Relations theories such as neorealism and neoliberal institutionalism tend to either ignore or give little causal importance. While there are different types of constructivists according to different epistemological and methodological standpoints and the issues motivating their research, most constructivists share three core assumptions about the world: that normative structures are as important as material structures, that agents and structures are mutually constituted, and that the interests and identities of actors are socially constructed (Adler 1997; Finnemore and Sikkink 2001; Reus-Smit 2001; Risse 2002; Ruggie 1998; Wendt 1992; Wendt 1995).

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The origins of constructivism are debated. Ruggie suggests that constructivism has no antecedent, but that it was influenced by the English School which holds that the system of states is embedded in a society of states, which includes sets of values, rules, and institutions that are commonly accepted by states and which make it possible for the system of states to function (1998, p.11). Price and Reus-Smit argue convincingly that ‘the constructivist turn’ developed out of critical international theory (1998). In the 1980s, critical theorists challenged the dominant rationalist- positivist theories of international relations - neorealism and neoliberal institutionalism - in what came to be known as the Third Debate.

Despite coming to different conclusions, neorealism and neoliberal institutionalism share the same philosophical foundations. Both theories are based on rational choice theory, which sees the individual as the core unit of social life and that thus explains human action ‘on the basis of individual motivation and the causal interaction of intentional agents’ (Adler 1997, p.324). Both theories are positivist in that they assume that the world exists independent of our cognition, that it is possible to make value-free truth statements about our observations of the world, that the aim of social inquiry is to make causal statements and that we can separate ‘what is’ from ‘what ought to be’ (Marsh and Furlong 2002, p.22). The Third Debate critical theorists challenged these theories by arguing that the world does not exist independent of our cognition but is instead socially constructed, that it is therefore impossible to make objective, empirically verifiable, value-free truth statements about the world, and consequently there should be more focus on understanding how our interpretations of social phenomena affect outcomes (Price and Reus-Smit 1997, p.261).

While both the English School and critical theory provided important insights into the alternative ways in which the world and human action could be understood, they were also accused by the dominant theories of being more interested in establishing themselves contra the dominant theories rather than in developing theories that could support a vigorous research program (Finnemore and Sikkink 2001, p.391; Price and Reus-Smit 1998, p.264).18 At around the same time, there were changes afoot in world politics. The end of the cold war, the emergence of the so-called democratic

18 Smith finds this criticism erroneous given the epistemological foundations of critical theory (2000, p.386).

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peace, and the ascendancy of the global human rights regime were phenomena that neorealism and neoliberal institutionalism had failed to predict and could not adequately explain. These political puzzles, in conjunction with the challenge to provide an alternative to mainstream rationalist-positivist theories, opened a space for innovation in the field of international relations theory (Katzenstein 1996a; Price and Reus-Smit 1998; Ruggie 1998).

So what is constructivism and how does it differ from other approaches in international relations? Like critical theorists, constructivists object to the ‘unduly and unnecessarily undersocialized view of the world’ proposed by the rationalist-positivist theories (Ruggie 1998, p.2). However, unlike critical theorists who are for the most part relativists, constructivists are ‘ontological realists’- the physical world exists independent of our cognition however ‘the way in which the material world shapes and is shaped by human action and interaction depends on the dynamic normative and epistemic interpretations of the material world’ (Adler 1997, p.323). This ontology leads to the three core assumptions of constructivism.

First, while neorealism and neoliberal institutionalism tend to give primacy to material structures (such as balance of power and markets) and consider ideas as by- products that aid actors in the pursuit of their material interests (Keohane 1984, p.120- 131), constructivists argue that material structures have no meaning independent of the meaning that actors give to them. To this end constructivists argue that systems of intersubjective norms and practices are more important to study than material structures. ‘It is collective meanings that constitute the structures that organize our actions’ (Wendt 1992, p.397). For example, amity and enmity cannot be determined without intersubjective meaning. Canada and Cuba are of equal proximity to the US and have roughly the same level of material power at their disposal, and yet Canada is regarded as an ally and Cuba as an enemy. In this case, it is not sufficient to suggest that the status of amity or enmity is informed by material power. However, if we consider that the US has a common identity with Canada with both states being western democratic states whereas Cuba is a ‘rogue state’, communist and different, we get a better understanding of why Cuba’s material capabilities are perceived as more dangerous than Canada’s (Jepperson, Wendt, and Katzenstein 1996, p.34). While constructivists do not dismiss the importance of material resources, they argue

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that material power only acquires meaning through the structure of norms and practices within which it is embedded (Wendt 1995, p.73).

To this end, there has been a large emphasis on the concept of norms and their role in international relations. Early constructivists in particular, such as Wendt (1992, 1995), Finnemore (1996) and Katzenstein (1996), sought to prove that norms matter. Katzenstein (1996a, p.5) defines norms as ‘collective expectations for the proper behaviour of actors with a given identity’. Again, the word ‘collective’ implies that norms have an explicit intersubjective quality as opposed to a principled idea held by an individual. By definition, standards for behaviour cannot exist without an other to evaluate who is or is not abiding by those standards (Risse and Sikkink 1999, p.7). ‘Proper behaviour’ implies that actors ‘ought’ to behave in a certain way. Norms thus always carry a prescriptive or evaluative quality.19 ‘Actors with a given identity’ indicates that norms establish expectations about who the actors will be in a particular environment and about how these particular actors will behave (Jepperson, Wendt, and Katzenstein 1996, p.54). At times norms are standards that define behaviour for an already established identity (if you are Y, you should (or should not) do X). At other times norms operate as rules that define the identity of an actor (you should (or should not) do X if others are to recognize you as Y). Norms are thus categorized as being either ‘regulative’ or ‘constitutive’ (Katzenstein 1996, p.5; Ruggie 1998, p.22- 23).20 Constructivists thus see human action as driven by these rules of appropriate behaviour. March and Olsen (2004) call this the ‘logic of appropriateness’.

This brings us to the second assumption and a key difference between constructivism and other theories. Constructivism assumes that agents and social structures are mutually constitutive. The social environment in which we find ourselves constitutes who we are, how we understand others and how we behave. However, at the same

19 As Finnemore and Sikkink (1998, p.892) point out, this evaluative quality indicates that ‘there are no bad norms from the vantage point of those who would promote the norm’ because by definition, those promoting the norm consider the behaviour it prescribes as appropriate. For example, norms that we now hold to be abhorrent, such as racial superiority, were once considered desirable by certain actors, such as colonial powers. Therefore, although our understanding of what is ‘good’ and what is ‘bad’ may change, the goodness implicit in norms does not. 20 Finnemore and Sikkink (1998, p.891) in fact employ a further distinction between ‘regulative’, ‘prescriptive’ and ‘constitutive’ norms. However, based upon an examination of the broader literature, I suggest that the difference between ‘regulative’ and ‘prescriptive’ norms is subtle and the two terms can be used interchangeably.

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time, we can create, reproduce and change the social environment through our daily practices of interpretation, adaptation and argumentation (Risse 2002a, p.599). ‘Norms have power in, and because of, what people do’ (Keck and Sikkink 1998, p.35). The most famous example given is that of the social institution of international anarchy whereby Wendt (1992) argued that ‘anarchy is what states make of it’.21 Another example that is relevant to this thesis is the changing concept of sovereignty in international relations. Sovereignty is nothing if not a social construct – a structure of shared understanding and expectations that shape state and non-state actor’s behaviour. The core premise of the doctrine of state sovereignty as traditionally understood is that how the state behaves towards its own citizens within its own borders is none of anyone else’s business. However, as in the case of China and human rights, how a state behaves towards its own citizens is frequently of concern to other states and non-state actors. Therefore, as Keck and Sikkink (1998, p.35-37) point out, if sovereignty is a shared set of understandings about state authority that is reinforced by practices, then changes in these practices and understandings should in turn transform sovereignty.

The implication of the importance of intersubjective knowledge and mutual constitution of actors and structures is that actors’ identities and interests are not static or given as rationalism suggests but are also socially constituted. This is the third major tenet of constructivism. Norms and practices can define an identity by specifying the actions that will cause others to recognize that identity and respond to it appropriately. Consequently, identities only acquire meaning through the interaction with other actors. Actors’ identities in international relations are important as they play three necessary functions: ‘they tell you and others who you are and they tell you

21 Wendt’s famous statement was in response to the neorealist assumption that the international system, lacking a higher governing body, is naturally characterised as a competitive, self-help environment. Wendt (1992, p.399) argues that anarchy as an institution is a cognitive entity that does not exist apart from actors’ ideas about how the world works. While not denying that anarchy is presently a self-help system, Wendt argues that self-help is only ‘one of various structures of identity and interest that may exist under anarchy’. Wendt suggests that the meaning of anarchy and the distribution of power depends upon the extent to which and the manner in which one agent is identified cognitively with the other, and until recently, states have identified each other negatively. Recent trends however imply that collective meanings and identities are changing, albeit slowly. For example, some communities of states have established security regimes where the security interests of one have been superseded by the security interests of all. Therefore, Wendt (1992, p.399-400) argues that a continuum of possible anarchies exists and although very difficult to achieve, by changing the way in which they interact and identify one another, states can mitigate the self-help nature of anarchy and reconstruct it accordingly.

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who others are’ (Hopf 1998, p.175). The case of China and the norm of regime compliance is instructive. Increasingly, regime compliance and cooperation has changed what it means to be a ‘responsible’ member of international society. China’s increasing compliance with international regimes has led to fewer calls for containment and more calls for engagement, as other actors understand China’s actions as those of a ‘responsible’ state. This is of course an oversimplification – actors may have many different identities according to the different social environments in which they find themselves. ‘Constructivism instead assumes that the selves, or identities, of states are a variable; they likely depend on historical, cultural, political and social context’ (Hopf 1998, p.176). China is thus a ‘great power aspirant’, a ‘Marxist-Leninist communist state’, a ‘status quo power’, a ‘former colony’ or an ‘authoritarian regime’ according to the context in which it is operating.

While constructivists do not deny that actors act according to their interests, they argue that these interests are not given. Actors do not have fixed interests ‘that they carry around independent of social context’ (Wendt 1992, p.398). As Adler (1997) argues, national interests are not merely the collective interests of a group of people; nor, with rare exceptions, are they the interests of a single dominant individual. Instead:

National interests are intersubjective understandings about what it takes to advance power, influence, and wealth…in other words, national interests are facts whose ‘objectivity’ relies on human agreement and the collective assignment of meaning and function to physical objects (Adler 1997, p.104).

An actor’s identity accounts for its interests, and accordingly, its actions. Following this reasoning, apart from the basic interests of survival, the interests of China as an insecure, one-party regime are likely to be different from those of the US, as a western liberal democracy. Furthermore, if more than one identity is possible then it is also possible that actors can have more than one set of interests. For example, China as a ‘developing country’ is likely to have different preferences than China as a ‘great power aspirant’.

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While constructivists share the ontological assumptions that intersubjective knowledge gives material structures meaning, that agents and structures are mutually constitutive and that identities and interests are socially constructed, they do not all share the same epistemology. Typologies of constructivists abound. Price and Reus- Smit (1998, p.267-268) differentiate between post-modern and modern constructivists or what Hopf (1998, p.181-185) calls critical and conventional and what Ruggie (1998) labels post-modern and neo-classical constructivism. The majority of constructivists fall somewhere in the spectrum between post-modern and modern (or post-positivist and positivist-leaning) constructivists (Klotz and Lynch 2007). Post- modern or critical constructivists argue that meanings are always contested and inherently unstable, that the researcher can never be separated from that which is being studied, with his or her generalizations being complicit in the perpetuation of particular power relations. Therefore there is an emphasis on understanding and unmasking power relations rather than explaining action (Hopf 1998; Klotz and Lynch 2007, p.13-15; Price and Reus-Smit 1998). On the other hand, neoclassical/modern/conventional constructivists assume that while the world is always being interpreted it is possible to take social meanings, such as ‘identity’ or ‘culture’, to be stable and knowable independent of interpretive biases. Therefore, it is possible to use positivist methods to explain social phenomena (for example see Jepperson, Wendt, and Katzenstein 1996). As Finnemore and Sikkink (2001, p.395) so aptly note:

For modern constructivists, … acceptance that the world is always interpreted does not imply that all interpretations or explanations are equal; some types of explanation and evidence are more persuasive or logically and empirically plausible than others.

This thesis is most influenced by the latter school of constructivists, and particularly, by those constructivists that seek to engage with multiple levels of analysis.

1.4.2 APPLIED CONSTRUCTIVISM – A CONCEPTUAL FRAMEWORK

While the first constructivists had different foci, all sought to challenge their neorealist and neoliberal counterparts by arguing that norms mattered. Wendt (1992, 1995) disputed the inevitability of self-help as dictated by anarchy. Taking issue with

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neoliberal institutionalism’s assertions regarding international regimes as mere conduits for utility seeking by states, Finnemore (1993; 1996) argued that international organizations (IOs) could also be ‘norm teachers’, influencing state identities and interests. Katzenstein (1996) highlighted the ‘underattended’ effects of cultural-institutional context and political identity on national security, seeking to point out the limitations of the neorealist and neoliberal bias for materialism. Groundbreaking though their work was, two important critiques (Checkel 1998a; Kowert and Legro 1996) called for more research into when and how norms matter which sparked the applied constructivist research agenda. Applied constructivism thus addresses the conditionality of norms. This thesis addresses China’s changing AIDS policy and the extent to which this change can be attributed to the global AIDS regime. As such, I engage with an important constructivist problematic – that of the domestic impact of global norms.

The first stage of the inquiry was to establish the existence of a global AIDS regime. This thesis employed the concept of the norm life-cycle (Finnemore and Sikkink 1998) to analyse the emergence and consolidation of global AIDS norms. In the norm life cycle, Finnemore and Sikkink (1998, p.895) describe a three-stage process for normative change - norm emergence, norm cascade and norm internalisation. In the first stage of norm emergence, norm entrepreneurs challenge the established logic of appropriateness and attempt to convert a critical mass of states to accept the new norms. The second stage is the norm cascade. A norm cascade occurs when enough states have embraced the norm so that a tipping point is met at which stage states begin to adopt new norms even without domestic pressure for such change (1998, p.902). Finnemore and Sikkink (1998, p.902) argue that at this stage states are converted to the new norm via the mechanism of international socialization. Their argument is that states accept the norm not because they have been persuaded that it is the right thing to do but because it is the right thing to do as a member of the international community. ‘Good states’ protect the environment; ‘bad states’ do not. Therefore states emulate norm leaders for fear of becoming an outsider (1998, p.902- 903). The third stage is norm internalisation. Regardless of the reason it was adopted in the first place, the norm becomes ‘taken-for-granted’ and no longer debated (1998, p.905).

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The degree to which a global norm has domestic impact is partly dependent on the degree to which the norm is institutionalised at the international level. A norm will have more impact at the domestic level according to the degree to which it has been institutionalised in specific sets of international rules and organizations (Finnemore and Sikkink 1998, p.900; Risse 1995). This could include the codification of the norm into international law, in the rules of multilateral organizations and/or in bilateral agreements (Finnemore and Sikkink 1998, p.900). The more institutionalised a norm is in international law and organizations, the more difficult it becomes for a state to ignore. Noncompliant states are socialized into adopting the norms. Socialization, or the process of inducting actors into the norms, rules and ways of behaviour of a given community (Checkel 2005), involves diplomatic praise or opprobrium, reinforced by material benefits/costs. The degree to which the AIDS norms are institutionalised at the global level and how they came to be institutionalised is explained in chapter two.

The second task of the thesis was to examine when and how the global AIDS norms had impact on China’s governance of HIV/AIDS. Three key concepts – a) norm entrepreneurs, b) domestic political context and c) crisis - from the constructivist literature were utilised to frame the analysis

1.4.2.1 NORM ENTREPRENEURS

The process of transfer from the global to the domestic level is partially dependent on the agency of specific norm entrepreneurs. Once a norm is institutionalised at the international level, transnational and domestic norm entrepreneurs can use a variety of strategies to teach states appropriate standards of behaviour. This thesis explores both transnational and domestic activists’ attempts to influence the Chinese governance of HIV/AIDS. Having examined the role of norm entrepreneurs in the emergence and institutionalisation of global AIDS norms in chapter two, I further explore the role of intergovernmental organizations (IGOs) and transnational NGOs in promoting these norms to the Chinese government. Moreover, the thesis shows that the space for Chinese AIDS activists has been shaped by the actions of international and transnational actors.

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Since the end of the Cold War there has been an increase in attention given to the role that norm entrepreneurs are playing in changing global norms and practices (see, for example, Finnemore 1993; Haas 1992; Haas 1990; Joachim 2003; Keck and Sikkink 1998; Khagram 2004; Khagram, Riker, and Sikkink 2002; Price 1998; Risse and Sikkink 1999; Risse-Kappen 1995; True and Mintrom 2001; Wu 2005). Norm entrepreneurs are individuals, organizations or networks motivated or mandated to promote certain standards of behaviour in line with a principled idea (Finnemore and Sikkink 1998, p.898-899).

When and how do these norm entrepreneurs ‘teach’ new norms? It has been noted that the majority of norm promoting organizations do not have power in the traditional, realist sense of power in material terms (the World Bank is possibly an exception, see Finnemore 1996). For the most part, they are not able to coerce other actors, such as states, by invoking military intervention or sanctions (although they may have a hand in convincing a third party to apply sanctions). Rather, norm-promoting organizations must ‘use the power of their information, ideas, and strategies to alter the information and value contexts within which states make policies’ (Keck and Sikkink 1998, p.16).

The proselytising techniques used may depend on the type of organization they are. Epistemic communities and international organizations,22 in that they are often comprised of professionals, are able to provide expertise and credibility to state decision makers. Epistemic communities for example are able to shape policy during periods of uncertainty or crisis by their ability to provide decision-makers with expertise regarding the causes of the uncertainty and are able to disseminate new norms and understandings in the process of providing decision-makers with clear alternate policies (Haas 1992, p.15). IGOs, far from being mere conduits of states, are able to draw upon their legitimacy, their rational-legal authority, and their perceived impartiality (although this may depend on the organization) to ‘teach’ new norms to states (Finnemore and Sikkink 2001, p.401). Transnational advocacy networks or

22In their excellent discussion of the constructivist research program in International Relations and Comparative Politics, Finnemore and Sikkink (2001, p.400-402) describe norm entrepreneurs as non- state activists and discuss epistemic communities and IGOs separately. However, I would argue in that all these organizations, even international IGOs, are involved in the construction and dissemination of new global norms and therefore I include epistemic communities and international organizations as norm entrepreneurs.

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TANs23 on the other hand rely on ‘the power of the better argument’ (Risse 2000, p.28). They must persuade other actors to change their understanding of what is appropriate and they do this in a number of ways, including the collection and dissemination of information, and the use of leverage politics and accountability politics (Keck and Sikkink 1998; Price 1998). This deserves further elaboration.

Although they are important in the way that they can collect and disseminate information quickly and direct it to where it will be most effective, a lot of the power of TANs comes from the way in which they are able to package that information. This can involve framing and/or grafting. Cognitive frames, a concept borrowed from sociology and one that is much favoured by social movement theorists, ‘help to render events or occurrences meaningful and thereby function to organize experience and guide action’ (Benford and Snow 2000, p.614). This is the notion of norm resonance that ideas are more likely to be accepted if they fit in with established discourses. The aim of norm entrepreneurs therefore is to persuade target actors to embrace the new norm by using language to frame the norm in a way that the target actor will understand. The way in which a norm is framed may mean the difference between mobilization and norm rejection. Women’s and human rights networks were able to draw more attention to the issue of female circumcision by renaming the problem as female genital mutilation. By doing so they were able to distance the practice from male circumcision (which is widely accepted) and recast it in the language of bodily harm and suffering (Keck and Sikkink 1998, p.20). Grafting is a different variant of framing. Grafting involves the deliberate association of the new norm with a pre- existing norm. In an excellent study of the development of the anti-landmines norm, Price (1998, p.628) describes the process whereby the norm entrepreneurs deliberately sought to graft the chemical weapons taboo onto the issue of landmines.

As well using information strategically, norm entrepreneurs also engage in leverage politics. Advocacy networks engage in either material leverage or moral leverage. Material leverage involves a powerful ally and the linking of norm compliance to

23 Keck and Sikkink (1998, p.1,9) define transnational advocacy networks as being networks of activists, distinguishable largely by the centrality of principled ideas or values in motivating their formation. Advocacy networks can include: international and domestic nongovernmental research and advocacy organizations; local social movements: foundations; the media; churches, trade unions, consumer organizations, and intellectuals; parts of regional and international intergovernmental organizations; and parts of the executive and/or parliamentary branches of government.

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something of material value such as foreign aid or trade whereas moral leverage involves shaming where norm violation is held up to international scrutiny (Keck and Sikkink 1998, p.23). Finally norm entrepreneurs apply pressure to states by holding them accountable to their discursive positions. For example, if a state has ratified the Kyoto Protocol but has not changed its carbon emissions, norm entrepreneurs are able ‘to expose the distance between discourse and practice’ (Keck and Sikkink 1998, p.24).

Although the efforts of these norm-promoting organizations are clearly important, it is clear that their tactics do not always have the desired effects. In the case of epistemic communities for example, if ‘information is at a premium in the face of possible systemic volatility’ it is unclear how influential epistemic communities are during periods of stability (Haas 1992, p.15). Keck and Sikkink (1998, p.27) note that TANs are more likely to have success with issues that involve bodily harm or legal equality of opportunity and that the tactics they use will depend on how susceptible target states are to socializing factors. Joachim (2003) proposes that whether or not the frames advocated by non-state actors will resonate with their targets is dependent on the access they have to key actors, the allies they make and their ability to turn situations such as changing political alignments or conflict to their advantage, as well as the networks that they have at their disposal. Thus Joachim (2003, p.268) concludes that whether or not NGOs are influential is ‘contingent on the dynamic interplay of both the political opportunity structure in which they are embedded and the mobilizing structures they have at their disposal’. Busby (2007) Wu (2005) and Khagram (2004, p.21) also emphasize the opportunities and obstacles posed to norm entrepreneurs by the domestic political opportunity structure.

In the context of this thesis, we will see that norm entrepreneurs were key agents of socialization. One the one hand they were key actors in the emergence and consolidation of the global AIDS regime. This will be illustrated in chapter two. On the other hand, as discussed in chapters four and six, by promoting and providing policy advice to the Chinese government, praising/condemning certain behaviour, legitimising domestic entrepreneurs and holding the Chinese government and its donors accountable by reminding them of their international commitments, transnational norm entrepreneurs also played an important role in ‘teaching’ China

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global AIDS norms. However, the extent to which these norm entrepreneurs were able to socialize China into internalising global AIDS norms were conditioned by both the domestic political context and the SARS crisis.

1.4.2.2 DOMESTIC POLITICAL CONTEXT

In considering how and when global norms were influential on China’s governance of AIDS, this thesis also considers the critical factor of the domestic political context. There are three dimensions that I will discuss – the political structure, relevant discourse and domestic interests. Firstly, it is important to understand the political structure. Cortell and Davis Jnr. (2000, p.66) argue that domestic political structures are important because they condition access to policy-making for privileged actors in policy debates. Researchers of social movements also pay attention to domestic political structures, differentiating between ‘open’ domestic political opportunity structures such as liberal democracies as opposed to ‘closed’ domestic political opportunity structures such as authoritarian states. Domestic norm entrepreneurs are more likely to have success in open domestic opportunity structures where there is more freedom for civil society then they will have in closed opportunity structures where the state is more likely to repress opponents (Keck and Sikkink 1998; Khagram 2004; Khagram, Riker, and Sikkink 2002).

Risse-Kappen (1995) also argues that the ability of transnational actors to influence a state’s policy is reliant upon the state’s domestic structure, however he presents a more complex picture than the open and closed structures described above. Instead, three components of domestic structures can be distinguished: the structure of the political institutions (either centralized or fragmented), the structure of demand- formation in civil society (either weak or strong), and the institutions of policy networks linking state and society (either consensual or polarized). This therefore produces six distinct types of domestic structures: society-dominated, corporatist, stalemate, fragile, state-dominated and state-controlled (1995, p.20-24). The way in which a state’s domestic structure is arranged is likely to affect the access that transnational actors have to its political and social system and therefore their effectiveness. For example, state-dominated structures are difficult to obtain access to given the weakness of their civil society. However, Risse-Kappen (1995, p.26) argues

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that once access is granted, the policy impact of norm entrepreneurs is often profound due to the tight-knit nature of state-dominated structures. ‘If powerful state actors are predisposed toward their goals, they can directly influence policies’ (1995, p.26). On the other hand, states that have a more organized civil society and a more fragmented state, while being easier to access, are often more difficult to influence given the time and effort needed to form successful coalitions (1995, p.27). Busby (2007, p.254-255) agrees with Risse-Kappen, in that he argues that rather than thinking of open versus closed structures it is more useful to consider the importance of policy gatekeepers – influential actors with sufficient power to block or allow policy change. Thus individuals can be important depending on their institutional position in the political system.

I found Risse-Kappen’s state-dominated classification as an excellent starting point from which to study China’s political regime and to think about the access points for incoming norms. However, as I discuss in chapter three,24 even the state-dominated classification is too simplistic. When one considers the nature of party-state relations, centre-local relations and even state-society relations, one finds that China is better described as a ‘negotiated authoritarian’ regime.

Another dimension of the domestic political context that can help or hinder norm diffusion is the domestic discourse. The new norm is unlikely to be entering a normative vacuum. Instead it will enter a cultural landscape where it may compete with, (or be complemented by), existing norms, understandings and beliefs. ‘The domestic discourse, then, provides the context within which the international norms takes on meaning and thereby conditions its operation’ (Cortell and Davis Jnr. 2000, p.73). The more consonant with this culture the norm is, the better the fit and the more likely the incoming norm will be adopted. However, the more distant the norm is from the domestic ‘logic of appropriateness’ the more contested and possibly less domestic salient the norm will be. In the context of China’s governance of HIV/AIDS, this thesis will focus on the official discourse on sex as the most relevant discourse that has impacted upon the interpretation of incoming AIDS norms.25

24 See chapter three, section 3.1, p.99. 25 See chapter three, section 3.2, p.114.

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This may provide some explanation for why norms are not always influential. For example, Legro’s (1997) study of the adherence of the British, German and American militaries to particular warfare norms during World War II highlights the dangers of relying on global norms alone to explain behaviour. The global norms pertaining to the proper use of submarines, air power and chemical weapons, while seeming robust and durable, only restrained behaviour when they were in line with the organizational culture of the militaries concerned:

The dominant beliefs in military organizations about the appropriate ways to fight wars shaped how soldiers thought about and prepared for war, which in turn shaped the varying impact of norms on state aims (Legro 1997, p.32).

Cardenas (2004), in an interesting study into why human rights violations persist, has argued that global norms may be bypassed not only when a state’s basic interests or the interests of those who support the existing regime are threatened (to be discussed below) but also (‘and perhaps most fundamentally’) when domestic ‘rules of exception’ exist which enable the state to violate the international norm in question. These rules ‘represent a powerful and historically conditioned ‘myth’ that defines the state’s interests in a given area and holds social coalitions intact’ (Cardenas 2004, p.222). Despite the origins of these rules in self-interest, Cardenas (2004, p.223) argues that they can still exert a powerful influence once they take hold and become embedded in the domestic structures and therefore, ‘the role of standards, rules, and ideas that conflict with international human rights norms but define the targets of and rationale for state repression should not be overlooked’.

However, the concepts of organizational culture and cultural match have been accused of being unduly static, conforming to ‘the general thrust of institutionalist approaches, which have been better at explaining what is not possible in a given institutional context than what is’ (Acharya 2004, p.243). The local normative order need not be an obstacle to international norm diffusion. Neither domestic nor international normative structures are static but are constantly evolving (Cortell and Davis Jnr. 2002, p.75). As noted above, work on norm entrepreneurs has shown that global norms can be introduced into a domestic normative structure when they are framed in a way that will appeal to particular domestic understandings. ‘Since networks are

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carriers of new ideas, they must find ways to frame them to resonate or fit with the larger belief systems and real life contexts within which the debates occur’ (Keck and Sikkink 1998, p.204). Acharya (2004, p.244) explains the variance of norm diffusion by pointing to a process of localization and argues that although localization may begin with the reinterpretation and re-representation of the outside norm as described by the processes of framing and grafting, it may extend into more complex processes of reconstitution to make an outside norm congruent with a pre-existing local normative order.

The final dimension to the domestic political context is the question of interests. Global norms are more likely to have more impact domestically if they are seen to support the interests of the political decision makers. Economy and Schreurs (1997, p.15) have argued that ‘the impact of linkages among international and domestic politics must be understood in the context of an individual state’s domestic policy structures, policy process, and traditional policy priorities’. In their study of the impact of international environmental protection norms on domestic environmental policy, they found that when the international community’s goals can be effectively linked to the goals of powerful sub-state actors, early cooperation is the result. Global norms that run contrary to the goals of the powerful sub-state actors may lead to limited cooperation (Economy and Schreurs 1997, p.8). Cardenas’ argument runs on a parallel track. Cardenas (2004, p.221) found that the presence of domestic constituencies with vested interests in violating human rights instruments remained one of the three key determinants for norm violation.

The assumption that identities and interests are socially constructed allows an explanation that incorporates not only the material interests of political actors but also their social and political interests. In a study of the changes Zimbabwe has undergone as a member of the Convention on International Trade in Endangered Species of Wild Flora and Fauna, Mofson (1997, p.164) concluded that Zimbabwe abided by the regime’s ban on ivory trading not because it believed the ban was appropriate but because violating the ban would be costly with respect to possible economic sanctions and the likelihood of being treated as an international ‘outlaw’. In this case, it was not only the fear of economic sanctions (material) but also the fear of opprobrium (social) that led to norm adherence. While noting that the material costs resulting from norm

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compliance is always one of the first considerations of domestic policy makers, Busby (2007, p.254) argues that norm compliance in the face of high material costs points to the non-material benefits of norm compliance.

In chapter three, I will argue that the Chinese elite is first and foremost interested in maintaining and legitimising the power monopoly of the CCP. To do so, three major goals are pursued – the development of the economy, the maintenance of social stability and the enhancement of China’s international standing. Incoming norms therefore are more likely to be successfully internalised if they are consistent with these interests.26

1.4.2.3 CRISIS AND UNCERTAINTY

In the context of this thesis, I argue that the SARS crisis played a key role in shifting the domestic political context and allowing global AIDS norms to gain greater salience in China. Uncertainty and crisis is often highlighted as an essential mechanism for normative change. A crisis can act as a catalyst, a ‘trigger’ (Cortell and Peterson 1999), a ‘window of opportunity’ (Kingdon 1995) or a ‘focusing event’ (Busby 2007). Proponents of change, regardless of whether they want a change of policy or a change of government, will have more success if there is uncertainty about the way that things currently are. Change is often caused by a spark, a one-off event, which triggers a process. This could be a small event such as the ratification of an international treaty, which could trigger an incremental change in a country’s rights discourse. Or it could be a larger event such as a revolution, which could trigger radical or episodic change by completely dismantling one regime to replace it with another (Cortell and Peterson 1999, p.184-185).27 While much of the institutional change and social movement literature explore changing political climates in democracies, Checkel’s (1997) study of foreign policy change in the Soviet Union is a useful insight into change in authoritarian regimes. Building on Gourevitch’s idea of an ‘open moment’, Checkel (1997, p.10) argues that ‘politics opens up, becomes more

26 See chapter three, section 3.3, p.120. 27 While there has been a lengthy debate in the institutional change literature about whether change is mainly incremental (slow and piecemeal) or mainly episodic (sudden and rare), Cortell and Peterson (1999) argue that both modes of change are possible depending on the type of event which triggers the change. I would also argue that the speed of change is also dependent on the political context.

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fluid, under conditions of crisis and uncertainty’. The chance for political change was greatest when high international uncertainty opened ‘policy windows’. ‘These windows link the international and domestic environments and motivate advocates of new ideas to promote them’ (Checkel 1997, p.124).

For those theorists advocating a model of punctuated equilibrium,28 uncertainty as provided by a crisis or shock provides the ‘punctuation’. A crisis (be it a war, depression, epidemic etc.) might elevate an issue, hitherto considered low priority, to the top of the political agenda. Although he denies that crises, disasters or other focusing events rarely carry a subject to policy agenda pre-eminence by themselves, Kingdon (1995, p.96) admits that often crises ‘reinforce some pressing perception of a problem, focus attention on a problem that was already “in the back of people’s minds”’. The uncertainty caused by crises might swing national opinion a certain way leading to dissension. This in turn can threaten the interests or even worldview of the elite and change the configuration of power within the elite, empowering some actors over others. Crises cause uncertainty about established ideas and allow new ideas to be communicated and perhaps eventually institutionalised. For example, in his work on epistemic communities, Haas (1990, p.54) mentions the importance of uncertainty in compelling concerned leaders to consult with experts who in turn encourage the adoption of new policies.

In the specific case of China and HIV/AIDS, crisis and uncertainty arrived in the form of the SARS outbreak of early 2003. As discussed in detail in chapter five, SARS undermined the government’s legitimacy. In doing so, SARS a) enabled infectious disease, particularly HIV/AIDS, to be politicised, b) mobilized new political actors and fiscal resources and c) made the Chinese government more receptive to new ideas. In this way, SARS was a major mechanism for normative change.

28 The punctuated equilibrium model is a model borrowed from biology. Traditional biological theory understood the process of evolution as being gradual or incremental. However, this theory was challenged in the 1970s when two palaeontologists, Eldredge and Gould, presented a model which represented evolution as rare, occurring only in unusual circumstances. Their most famous illustration was that of the meteor that caused the extinction of the dinosaurs but also resulted in the evolution of thousands of new species (Goertz 2003, p.133). The model has been used in comparative politics to combat incrementalism, which argues that political change occurs in a linear path of constant small alterations. Punctuated equilibrium is a non-linear model that suggests that change initially undergoes radical growth spurred on by a shock to the political system, which is followed by a period of relative stasis before its eventual decline (Baumgartner and Jones 1993; Goertz 2003, p.136).

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1.4.3 METHODS

The sources and methods used in this thesis have thus been informed by the constructivist approach and have been qualitative in nature. To examine the discursive practices occurring at the international and domestic levels, a wide array of evidence has been required, including governmental, intergovernmental and non-governmental sources. There have been significant obstacles to conducting field research in China (see section 1.5 below) and therefore this thesis has thus depended upon the large number of primary sources that are available, both on Chinese and non-Chinese websites and databases, and the use of relevant secondary sources.

Governmental evidence has thus included legal and policy statements, Chinese reports to intergovernmental organizations and applications to funding agencies, public pronouncements and debates, official statements and press releases by ministries and high-level leaders. The majority of the evidence has been produced at the central government level. This thesis has also relied on China’s print media coverage of the AIDS epidemic, specifically the Chinese government’s main English publications - the China Daily and the Beijing Review – and the news reports provided by Xinhua News Agency, the official press agency of the Chinese government. While the Factiva database has comprehensive coverage of these sources from the early 1990s, a trip to the National Library of Australia was required to access the hard copies of the China Daily from 1984 to 1994.

Intergovernmental sources of data have included official reports and speeches, proceedings of UN sessions and other multilateral or bilateral organizations and/or any resulting statements, declarations or resolutions, published minutes of the UNAIDS Program Coordinating Board (PCB), and bilateral or multilateral leaders’ statements. Non-governmental evidence has included reports, press releases and mission statements of relevant international and domestic non-governmental organizations and international press coverage. The primary sources were also supplemented by and contextualised through the use of relevant secondary sources.

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This thesis is informed by the constructivist approach. It is about norms and specifically, about the domestic impact of global norms. The research therefore involved two main empirical tasks. Firstly, Klotz and Lynch (2007, p.19) note that ‘to make assessments of the relative importance of particular meanings requires some sort of comparison, across time or space, and a baseline or metric for gauging change’. This thesis assesses China’s AIDS policy over time vis-à-vis the global AIDS norms but this of course requires that I identify the global AIDS norms against which China’s AIDS policy could be compared. Using the emergence of HIV/AIDS in 1981 as a baseline and drawing on Finnemore and Sikkink’s theory of the norm life-cycle (1998), I traced how the ideas of norm entrepreneurs (such as the American PWA movement) became institutionalised through speech acts and quasi-legislation at the global level and then reinforced or consolidated through the subsequent actions of states, IGOs and non-state actors.

The second empirical task was the analysis of China’s governance of HIV/AIDS. I developed a set of five indicators: political commitment, policy and legislation, HIV in the media, the role of civil society and international engagement. On the one hand, the development of these indicators drew on the prior efforts to measure norm institutionalisation/ salience/regime compliance and cooperation at the domestic level (see for example, Cortell and Davis Jnr. 2002; Kent 2007; Koh 1997). On the other hand, the indicators were informed by my research into the global AIDS norms and the Chinese political context (in other words, chapter two and three). While they will be discussed in more detail at the beginning of chapter four, the indicators and the sub-indicators not only illustrate a complex picture of AIDS governance, they have allowed the comparison of China’s governance over time and the comparison of China’s AIDS governance in relation to the normative prescriptions of the global AIDS regime. Therefore they have proved an important tool for the triangulation of data and for identifying key junctures.

Correlative evidence however cannot tell us why China adopted these norms. Instead, I have sought to use a limited form of narrative building. In order to reconstruct the process of change and in keeping with my theoretical framework, this has involved: analysing the domestic and international context in which Chinese decision makers were operating in order to assess changing preferences; identifying the key norm

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entrepreneurs and examining the ways in which they have tried to bring about change; and identifying any possible material or social benefits or costs China could accrue or bear by complying.

1.5 BOUNDARIES AND CHALLENGES

When beginning this research project, I had anticipated undertaking field research in China. My plan was to interview representatives of both the Chinese government and the multilateral, bilateral and non-governmental programmes on HIV/AIDS in China. Many months were spent organizing this fieldwork, contacting organizations, obtaining approval from the university’s ethics committee and securing funding. However, due to the sensitivities of the topic and the challenge of obtaining a research visa without being affiliated with a Chinese tertiary institution, it became apparent that fieldwork in China would not be possible. This changed the scope of the project and imposed new challenges, including the need to change the central questions and aims, the methods used, and of course the sources used with the project having to rely on data accessible outside of China.

I am aware that there are sources of data that I have inevitably foregone and this is to be considered a limitation of the research. It should be noted however that while this thesis attempts to address and discuss the many different dimensions of China’s governance of HIV/AIDS, a discussion which would have benefited from in-country research, the thesis has mainly addressed the question of the domestic impact of global norms and therefore has looked at the extent to which China’s national policy has developed in line with the norms promoted by the global AIDS regime. Fortunately, most major official legislative and policy documents pertaining to HIV/AIDS are available online on official websites such as the Chinese MOH, UNAIDS China or WHO China. I have also been able to triangulate information from official statements with intergovernmental and nongovernmental sources. This approach has, in the end, proved invaluable for analysing China’s approach to AIDS in the context of the global AIDS regime.

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1.6 STRUCTURE OF THE THESIS

This rest of this thesis is divided into two main parts. Part one sets up both the international and domestic context and is comprised to two chapters. Chapter two introduces the global AIDS regime. I will trace the development of the regime from the pre-regime period to a period of regime emergence to the period of consolidation. As well as identifying the evolution of a set of norms and decision-making procedures, I discuss the key drivers, features and dynamics of the regime. Chapter three then turns to the features of China’s political structure that may condition the impact of the global AIDS regime on domestic policy. The chapter will first look at the three important relationships that help define China’s political system: the party- state relationship, centre-local relations and state-society dynamics. The chapter will then look at the official discourse of sex in China before finally turning to an exploration of the Chinese government’s main interest, the preservation and the legitimation of the CCP’s monopoly on power, which is achieved via the pursuit of the goals of economic development, social stability, and international status and prestige.

Part two traces the process of China’s changing response to HIV/AIDS and its interaction with the global AIDS regime. It is comprised of three chapters. Chapter four analyses China’s pre-SARS AIDS governance from 1985 to 2002 through the use of five indicators: political commitment, legislation and policy, the representation of HIV/AIDS in the media, the role of civil society and international engagement. Two main periods are identified. From 1985 to 1993, while it participated in international meetings, both the domestic actions and the international rhetoric of the Chinese government were indicative of a state in denial. There was increased recognition of the emerging epidemic and the global AIDS regime in the period from 1994 to 2002; however the response by the Chinese government was limited due in part to the political sensitivity around the issue of tainted blood in central China. However in late 2002 and early 2003, China experienced a health crisis, the outbreak of SARS. This event, the topic of chapter five, is discussed as a catalytic trigger whose physical and psychological impact caused a lasting impression on the Chinese government by enabling the link to be made between health governance and the domestic and international legitimacy of the Chinese regime. The post-SARS AIDS

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watershed is documented and analysed in chapter six. The chapter finds that changes in several indicators provide evidence that global AIDS regime is having an impact on China’s governance of HIV/AIDS. However, there are also several ongoing challenges that suggest that several domestic factors continue to hinder norm internalisation. Chapter seven then concludes the thesis by restating the research findings in line with the aims of the thesis.

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CHAPTER 2: THE GLOBAL AIDS REGIME

2.0 INTRODUCTION

The global spread of AIDS in just over a quarter of a century has been accompanied by debate surrounding the rights of PWA, the appropriate role of the state in response to the epidemic, the role of affected communities in AIDS governance, access to treatment, and the way in which AIDS should be framed. The result of these discursive struggles, whether occurring within national contexts or in international meetings, between states, nongovernmental organizations or in the private sector, has been the development of a global AIDS regime – a structure of norms and decision- making procedures relating to AIDS governance. This chapter is not a history of the AIDS pandemic. Rather, the purpose of this chapter is to interrogate the concept of a global regime as it relates to AIDS, identify clearly definable norms and decision- making procedures, and establish the key drivers, features and dynamics of the regime. In examining the development of collective expectations about how AIDS should be understood and responded to, I am particularly interested in the implications of these expectations at the level of the state so that I might test the extent to which the Chinese government’s response to HIV/AIDS has been shaped by these norms.29

The first section of this chapter discusses the concept of an international regime. It argues that the regime concept is applicable to the contemporary governance of AIDS.30 It demonstrates that a global AIDS regime exists. The chapter provides an historical reconstruction of the emergence and consolidation of a global AIDS regime. The chapter examines the evolution of the global AIDS regime from 1981 to the present and identify three distinct periods - 1) pre-regime, 2) regime emergence, and 3) regime consolidation (see Table 2.1 for a timeline). I describe the years 1981 to 1986 as the pre-regime period in which, the disease was discovered, state responses were repressive in nature and international cooperation was minimal, with the exception of burgeoning scientific networks. With regards to regime emergence, from 1987 to 1995, I introduce the agency of norm entrepreneurs and the creation of

29 See chapters four and six. 30 It will be argued that the AIDS regime can be characterised as a declaratory regime.

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organizational energies. Norm entrepreneurs, compelled to change the logic of appropriateness of the time, emerged at both the grassroots level (the American PWA movement) and at the intergovernmental level (the Global Programme on AIDS (GPA), headed by Dr Jonathan Mann). The norm entrepreneurism at the intergovernmental level linked HIV/AIDS to human rights (instead of seeing it only in terms of public health), and led to new organizational energies (international summits, UN resolutions etc) that institutionalised a set of discursive constructions that included PWA rights, PWA and civil society involvement, universal access to evidence-based prevention and treatment programs, national leadership, multisectoral coordination and global cooperation (see Table 2.2 below).

Since 1996, I argue that the regime has undergone a period of consolidation with the strengthening of the AIDS norms occurring via several different processes. First, we have seen the AIDS norms being taken up by NGOs and civic actions who are empowered by the norms in their claims against other actors (governments/pharmaceutical companies). When these claims are won in favour of the norms, the norms are reinforced. As the AIDS norms start to empower movements in countries beyond the Northern core of activists, this can also be understood as the geographical consolidation of the regime. Second, since the 1990s, through the actions of UNAIDS, we have seen the increase in issue-linkage resulting in further mobilization of organizational energies. The linkage of AIDS to security led to the development of new frameworks and mechanisms that amounted to both a reinforcement of the global AIDS norms and the development of new decision- making procedures. Finally, we can see consolidation in the expansion of the regime to include new actors such as the private sector.

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TABLE 2.1 GLOBAL AIDS REGIME TIMELINE

1981 First AIDS cases discovered by Centre for Disease Control (CDC) in US 1982 Gay Men’s Health Crisis (GMHC) established EGIME 1983 Global monitoring of AIDS started by WHO -R Denver Principles for PWA empowerment established RE

P 1985 First international AIDS conference held in Atlanta, US

1987 GPA established, starts assisting states develop national AIDS programmes WHA adopts the Global AIDS Strategy, AIDS first disease debated in UN General Assembly (UNGA) AIDS Coalition to Unleash Power (ACT UP) established, demands PWA MERGENCE

E rights, access to treatment 1988 London Summit – human rights and coordination 1989 Montreal International AIDS Conference ‘stormed’ by ACT UP EGIME

R 1990 San Francisco International AIDS Conference is boycotted Jonathan Mann resigns from the GPA 1994 Paris AIDS Declaration – Endorsement of principle of greater involvement of PWA (GIPA) 1996 UNAIDS established Effectiveness of triple cocktail antiretroviral drugs (ARD) highlighted at Vancouver International Conference however 90 per cent of PWA in developing world will not be able to afford therapy 1998 International Guidelines on HIV/AIDS and Human Rights adopted

ONSOLIDATION Treatment Access Campaign (TAC) established C Drug companies take South African government to court for generic drugs 1999 Médecins Sans Frontières (MSF) begins campaign for access to essential EGIME medicines R 2000 Reducing HIV/AIDS become MDG 6 AIDS becomes first disease discussed by the UN Security Council 13th International AIDS Conference held in developing country, South Africa, for the first time and is scene to massive protests about the price of treatment 2001 UNGA Special Session on HIV/AIDS - Declaration of Commitment on AIDS Pharmaceutical companies v. South African government - dropped TAC v. South African government –court rules in favour of TAC Global Fund to Fight AIDS, Tuberculosis and Malaria established World Trade Organization (WTO) - Declaration on TRIPS and Public Health GBC established 2002 World Economic Forum Global Health Initiative established NGOs boycott Coca-Cola, pressures company to give ARD to employees 2003 President’s Emergency Plan for AIDS Relief (PEPFAR) established, ($15 billion) WHO announces ‘3 by 5’ campaign Clinton Foundation negotiates discounted generic ARD for developing countries 2004 ‘Three Ones’ principles introduced by UNAIDS US AIDS policies protested at the International AIDS Conference in Bangkok Clinton Foundation, UNICEF, Global Fund and World Bank announce expanded provision of generic drugs to developing countries 2005 WHO’s 3 by 5 targets not met 2006 25th anniversary of the AIDS epidemic UNGA follow-up meeting on the implementation of Declaration of Commitment on AIDS - Political Declaration on AIDS 2007 PEPFAR and Global Fund increased

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2.1 THE GLOBAL AIDS REGIME – DEFINITIONS AND KEY FEATURES

The standard definition of a regime is that offered by Krasner (1982, p.182), for whom an international regime31 is a set of ‘implicit or explicit principles, norms, rules, and decision-making procedures around which actors’ expectations converge in a given area of international relations’.32 Following Donnelly’s example (1986, p.602), I simplify this definition by incorporating ‘principles’ and ‘rules’ within the constructivist conception of ‘norms’.33 A global regime is thus a type of social institution, a ‘code of conduct’ agreed upon by actors in the global arena that can legitimise certain behaviour in a policy domain and delimit other behaviour (Rittberger 1993, p.xii). Following the above definition, a regime, made up of norms and decision-making procedures, is an ideational structure rather than an agent (i.e. it has no capacity to act). While an international organization is not synonymous with an international regime, it is difficult to talk about an international regime without referring to the organizations that may act as its agents. For example, UNAIDS is not the global AIDS regime but was instead created as an agent of the global AIDS regime. Therefore, as Keohane (1988) notes regimes can be further thought of as ‘complexes’ of norms and organizations.34 For the purpose of this study therefore, talking about the norms and decision-making procedures of the global AIDS regime necessitates the introduction of the international organizations such as UNAIDS or the Global Fund whose existence are legitimated by the regime.

31 While the terms may be used interchangeably in this chapter, I prefer the term ‘global regime’ rather than ‘international regime’ to encapsulate a plurality of actors (rather than simply state actors). 32 Krasner’s (1982, p.186) definition went on to explain the constitutive elements of the regime: Principles are beliefs of fact, causation, and rectitude. Norms are standards of behaviour defined in terms of rights and obligations. Rules are specific prescriptions or proscriptions for action. Decision-making procedures are prevailing practices for making and implementing collective choice. 33 The debate over the use of the terms ‘norms’ versus ‘rules’ is ongoing. Donnelly (1986, p.603), for example, finds that the distinction between norms and rules is rather arbitrary and argues that, in ordinary usage, rules has at least as wide a range as norms. In a discussion of constructivism, Onuf (1998, p.67-68) uses the inclusive term ‘rule’ instead of ‘norm’ and goes on to distinguish between instruction-, directive- and commitment-rules. However, in that he describes a rule as ‘a statement that tells people what we should do’ (p.59), Onuf seems to ascribe the same meaning to the term ‘rule’ that other constructivists such as Ruggie (1998), Wendt, Jepperson and Katzenstein (1996), and Finnemore and Sikkink (1998) assign to the term ‘norm’. 34 Abbott (2007) also defines international regimes more broadly as a collection of…complex political relationships among actors with common interests and understandings that bridge both the public and private spheres and the international, transnational and domestic arenas.

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This chapter is therefore concerned with the global AIDS regime or the ‘code of conduct’ agreed upon by actors in the global arena in the policy domain of AIDS governance. But how might we identify this code of conduct? According to Keohane (1993, p.28), ‘regimes can be identified by the existence of explicit rules that are referred to in an affirmative manner by [actors]’. So to what extent can we see shared ideas, patterns or similarities in the rhetoric and actions of states, sub-state actors and transntional actors? While there does not yet exist a global AIDS treaty, there does exist a substantial amount of soft law or quasi-legislation concerning AIDS governance (Mameli 2000).35 A detailed examination of UNAIDS/WHO reports and guidelines, UN resolutions and declarations, NGO press releases, speeches by world leaders and ministerial statements on the subject of AIDS governance reveals seven dominant norms for the governance of HIV/AIDS (see Table 2.2 below).

The global AIDS regime can be described principally as a declaratory regime - a regime that is normatively powerful but has limited procedural scope (Donnelly 1986, p.605).36 While the norms of the regime are not legally binding, the AIDS norms have broad rhetorical support at the global level (even if this agreement is not always reflected in norm compliance at the domestic level), with these expectations of appropriate behaviour being routinely present in actors’ justifications, recommendations and accusations. Decision-making procedures, on the other hand, relate to agreed-to practices of enforcing, implementing or promoting those collective expectations of behaviour at either the global or the national level. Empowered by an institutional bias in the international system and the control of resources, states maintain jurisdiction over decision-making procedures at both the global and the national level. Therefore, states have been able to influence the extent to which norms are promoted, implemented and enforced, with promotional activities being generally favoured over implementation and enforcement, much to the despair of activists. This will be further elaborated below.

35 For information on the advantages and disadvantages of soft law in comparison with hard law, see Abbott and Snidal (2000) and Mameli (2000). 36 It should be noted that while I use some of Donnelly’s terms and concepts, I attribute more credit to the power of norms to change behaviour than he does.

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TABLE 2.2 DOMINANT NORMS OF THE AIDS REGIME

1. AIDS programs must be embedded in a human rights framework and discrimination against PWA is unacceptable.

2. Insomuch as possible, access to prevention, treatment and care should be universally accessible.

3. AIDS programs should be evidence-based and should be monitored and evaluated.

4. National leaders should lead the way, exhibiting political will, mobilizing necessary human and financial resources, engaging in AIDS advocacy and encouraging an open policy environment.

5. National AIDS programs should be coordinated, comprehensive and multi- sectoral in nature.

6. AIDS programs and decision-making should include civil society actors, especially PWA.

7. States should support and engage with the global regime by providing transparent national epidemiological data, acting in accordance with international resolutions and agreements on AIDS, and providing appropriate resources to the global regime where applicable.

2.2 THE PRE-REGIME PERIOD 1981-1986

The pre-regime period was dominated first and foremost by a lack of knowledge about the disease, and the fear and stigma that resulted. HIV/AIDS was developing and spreading for some time before the world was aware of its existence. The discovery in the mid-1980s of the link between the human immunodeficiency virus or HIV and the syndrome AIDS suggested that one could carry the virus for years without knowing it. Increased ease of air travel, increasing migration and the transnational trade in drugs and sex are just some of the factors that allowed the

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epidemic to grow for many years (Public Broadcasting Service 2006). The disease did not come to public attention until 1981 when doctors in California and New York reported an increase of cases of both a rare form of cancer called Kaposi’s sarcoma and a type of lung infection occurring amongst young gay men. The US Centre for Disease Control (CDC) quickly surmised that they were dealing with a new disease, one that was discovered, as more cases were reported, to affect not only gay men, but also haemophiliacs, intravenous drug users, sex workers and Haitians (Grmek 1990). It was also soon discovered that the disease was not unique to the US. The first case was reported in the UK at the end of 1981, and in 1982, cases were being reported in other European countries. Similar cases were soon diagnosed in Africa amongst heterosexual communities (Preston 1986). By 1983, researchers had concluded that the disease (named AIDS in 1982) was transmitted via blood and sexual fluids.

Faced with an emerging disease, the origins, transmission and extent of which was unknown, many states resorted to traditional public health measures to contain the disease and prevent its spread. Fidler (1999, p.171) notes that the traditional public health measures used to contain cholera, the bubonic plague and the Spanish influenza were based on the philosophy that governments have obligations to contain infectious disease and protect its healthy constituents. By extension, individuals have obligations, not rights, when governments attempt to control the spread of disease. Traditional strategies employed when facing a public health emergency have therefore usually included some measure of ‘coercion, compulsion and restriction’ and a limiting of rights (Gruskin and Tarantola 2001, p.316). By 1987, 78 countries had adopted AIDS legislation, much of which was defensive and exclusionary in nature, imposing a type of cordon sanitaire around people with AIDS.37 These included compulsory testing, border restrictions, the placement of PWA under surveillance, isolation or segregation, mandatory hospitalisation, or the imposition of restrictions on behaviour and even freedom of movement (Mann, Tarantola and Netter 1992, p.544-547). For many states, as in the case of the conservative US, it was politically easier to do nothing than it was to recognise or provide assistance to certain subgroups, let alone talk publicly about sexual behaviours.

37 There were exceptions to this trend. Gordenker et al. (1995, p.38-39), for example, mention that as early as 1983, the Council of Europe addressed human rights issues in a recommendation on blood safety and in a resolution denouncing discrimination against homosexuals. This was however, as stated, an exception to the general logic of appropriateness.

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At the societal level, fear and a lack of knowledge, reinforced by a lack of strong leadership and inaction at the state level, bred AIDS stigma and discrimination. PWA became the ‘new untouchables’ (Fishlock 1985). In the US there were reports that doctors, nurses and dentists were refusing to treat AIDS patients (O'Brien 1985). In one case, ambulance officers and police would not move the body of a deceased gay man because he had died of AIDS (Engel 1986). Children with AIDS were stopped from attending school, the most famous case being that of Ryan White. Whole communities boycotted schools that let them return, even when the decision was court-enforced (Kusmer 1986). Even the mayor of New York, Edward Koch, publicly admitted that he thought children with AIDS should not go to school (Fishlock 1985). There were other reports of people with AIDS being refused housing or being fired. Around the world, rumours spread that the disease could be transmitted by kissing, sharing a glass, by shaking hands, by food served by PWA, by swimming in a pool or even by sitting in the same room with someone with AIDS (Eliason 1985; Fishlock 1985). Homophobic violence increased in the US and in Brazil (Ashford 1985; Brewer 1986). Elsewhere in the world, the early identification of AIDS in the West led to the perception of the disease as a ‘rich man’s disease’ (Lyman 1986). The early association of AIDS with ‘deviant’ behaviour led to complacency and denial, despite the emerging evidence that AIDS was heterosexually transmitted in many countries.38 The theory that AIDS came from Africa as a result of human and simian interaction resulted in a backlash in many African nations where the denial of AIDS prevalence was framed in anti-colonial or anti-apartheid language (Gordenker et al. 1995, p.31; Youde 2005 p.426).

With states going into lockdown and public panic ensuing, all eyes were on the medico-scientific community to provide answers and it was through this community that AIDS was first put on the international agenda (Jönsson and Söderholm 1995, p.462). As the disease was first identified and labelled by the US CDC, AIDS was originally studied and framed in Western biomedical terms. As mentioned in chapter one, the way in which an issue is framed can empower and mobilize particular actors. This biomedical focus mobilized medical practitioners and scientists (primarily from

38 This was certainly the case in China, see chapter four.

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the Western industrialized countries) who began to study the clinical and epidemiological characteristics of the disease, the modes of transmission, and risk behaviours, and began to develop methods of prevention, treatment and care (Lee and Zwi 1996). Early Western biomedical conceptions of AIDS would eventually be exported to other parts of the world, although not always with great success.39 Nevertheless, the search for the cause of AIDS and then the cure led to the creation of national research programmes and institutions in affected countries. Competition for funding and scientific prestige was fierce.40 The potential for the development of new, and possibly profitable, vaccines and drugs led to the involvement of the pharmaceutical industry (Jönsson and Söderholm 1995, p.462).

The necessity to share findings and collaborate in AIDS research generated the first international meetings on AIDS. These began as regional meetings, mainly organized by national CDCs. While the WHO was aware and was involved in many of these meetings, Gordenker et al. note that the WHO’s role during these early years was primarily one of monitoring the problem, not of mobilizing international coordination (1995, p.37). The first International Conference on AIDS was held in Atlanta in 1985, organized by the CDC and co-sponsored by the WHO. These, firstly annual and then biannual, conferences became an opportunity for medical professionals and scientists to exchange information and present research. Following the first international conference, the WHO established a network of collaborating research centres on AIDS and it was the representatives of these centres, backed by evidence that the disease was spreading rapidly through sub-Saharan Africa, that recommended that a global AIDS programme be established in Geneva (Gordenker et al. 1995, p.40; The Panos Institute 1987, p.48).

Therefore in the first years of the AIDS epidemic, the prevailing logic of appropriateness was to see AIDS, and by extension, people with AIDS, as a domestic health threat. The national decision-makers of states relied on the scientific

39 Altman (1999, p.565) notes, for example, that the Western biomedical paradigm emphasises certain concepts of disease, treatment, the body and sexual identities that undermine other important non- western understandings of health and healing and have therefore been sometimes met with resistance. Youde (2005) also mentions that relations between Western and African researchers have been strained due to the assumption that Western ways are the best. 40 Gordenker et al. (1995, p.37) mention, for example, the Gallo-Montagnier controversy concerning the discovery of the AIDS virus.

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community to provide a cure and in the meantime they reassured the ‘healthy’ public by developing policy and law to control AIDS or keep AIDS out, even if this meant restricting the rights of people with AIDS. Public hysteria and misperception resulted in people with AIDS being treated as social pariahs. Fear and a lack of information lead to stigma and discrimination and AIDS myths that were only reinforced by the anti-AIDS policies and legislation enacted by states. Finally, when the first examples of international cooperation emerged, they were the result of the mobilization of the medico-scientific community rather than the result of state efforts.

2.3 REGIME EMERGENCE 1987-1995

How do regimes emerge? As I have argued that the global AIDS regime is a declaratory regime, exploring regime emergence in this context involves tracing the origins of the AIDS norms and their institutionalisation at the global level. As such, this section introduces two major cases of norm entrepreneurism. Firstly, I examine the role played by the American PWA movement. Secondly, I look at the influence of Dr Jonathan Mann, the head of the Global Program on AIDS (GPA). While the American PWA movement and Mann and the GPA were not the only architects of the global normative structure, as I demonstrate in the following section, their influence was palpable.

According to the rationalist approaches, which dominated the discourse on international regimes, regimes are designed as instruments of states, perceived as the dominant units in the international system. Neorealists emphasise power-based theories (states create regimes to mitigate their sensitivities about relative gains) while neoliberal institutionalists emphasised interest-based theories (states create regimes to enhance absolute gains). Regimes in particular issue areas, such as arms control and trade, are created or imposed, often by strong states, in order to reduce certain forms of uncertainty and alter the transaction costs of cooperation by providing information and stabilizing expectations (Hasenclever, Mayer, and Rittberger 1997; Keohane 1988). I do not discount the importance of power and interests,41 nor states for that matter. As stated above, states have certainly influenced the characteristics of the

41 Although as the section on constructivism in chapter one would attest, I disagree with the material basis from which these approaches determine conceptions of ‘power’ and ‘interest’.

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global AIDS regime. However, focusing on the power or interests of states alone does not adequately capture the complexities of the AIDS regime.42 Global consensus and action on AIDS owe more to PWA activism and key individuals in intergovernmental organizations than to states. As discussed in chapter one, studies abound on the role of epistemic communities, transnational advocacy networks, transnational corporations and intergovernmental organizations in helping to define or challenge collective understandings and expectations (Finnemore and Sikkink 1998; Keck and Sikkink 1998; Klotz 1995; Price 1998). As Hauffler (1993, p.97) asserts, there is ‘no obvious reason’ why non-state actors might not create international regimes.

In the following sections, I discuss the important role played by both the American PWA movement, and Dr Jonathan Mann, the first leader of the GPA, in promoting the normative content of the global AIDS regime. While they used different methods, both the PWA movement and Mann helped to challenge the prevailing logic of appropriateness. The American PWA activists challenged, at times violently, the derogation of the human rights of PWA, exclusion of PWA from decision-making, the ambivalence of political leaders and the dominance of the biomedical frame in AIDS discourse. Likewise, Mann, as leader of the GPA, was a central architect of the global AIDS regime, espousing the importance of linking HIV/AIDS with human rights and with development, of learning from and involving affected communities, and the imperative of treating AIDS control as a global public good. The actions of the norm entrepreneurs helped to shape the political context in which international actors began to cooperate and through such international forums as the UN, international AIDS conferences and regional political bodies, the ideas they advocated came to be institutionalised.

2.3.1 NORM EMERGENCE THROUGH GRASSROOTS ACTIVISM

In many states, where the government either failed to act or could not act, communities began to respond in its place. Of these, the American PWA movement was the most organized, the most visible and arguably, the most globally influential

42 While it is certainly in states’ interests to control the spread of the AIDS epidemic, a material cost- benefit analysis will not necessarily explain why certain expectations have emerged as opposed to others. Likewise, the argument that regimes are created by an alliance of strong states is not supported in the case of the AIDS regime.

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HIV/AIDS movement in the early years of the pandemic (Bastos 1999, p.50). While aspects of the movement were unique to the political, social and cultural context in which the activists were operating, the ideas at the heart of the movement, pertaining to PWA rights, strong leadership, the necessary inclusion of PWA in HIV/AIDS governance and the right to access to treatment, have been transferable across different national contexts.

It is highly significant that HIV/AIDS was ‘the first major worldwide epidemic to occur in the modern era of human rights’ (Gruskin, Hendrik, and Tomasevski 1996, p.538), and that one of the first groups affected by the disease was the American urban gay community. Fidler (1999, p.198) notes that HIV/AIDS ‘brought the human rights revolution to bear on public health’. As already discussed above, traditional public health responses, such as compulsory testing or mandatory hospitalisation, frequently involved placing limitations or restrictions on the civil or political rights of the individual, such as the rights to liberty, security of person, freedom of movement and privacy. Viewed through the lens of the post-1945 global human rights regime such restrictions necessitated further scrutiny. Furthermore, many of these rights- limiting public health measures ‘targeted the most vulnerable populations in societies and thus constituted discrimination prohibited by international human rights law’ (Fidler 1999, p.198). The targeting of gay men in the US was a case in point.

However, the emergence of HIV/AIDS in New York and San Francisco also occurred at a time when the gay community was more empowered and more politically organized than it had ever been before. By 1981, the gay and lesbian rights movement had been in action for just over a decade. Embedded in the broader normative structure of the post-1945 global human rights regime and buoyed by the African American civil rights, the women’s and the antiwar movements of the late 1950s and 1960s, the gay and lesbian community became politically mobilized after the 1969 Stonewall Rebellion (McAdam 1996, p.32-33). By 1981, the gay and lesbian community was thus well versed in the language and politics of political activism. AIDS represented a threat not only to the lives of people in the community but also to the gains made by the rights movement itself. The association of AIDS with homosexual men led to widespread discrimination against the gay community both by the public and by the state through specific policies and by a lack of recognition

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(McQuiston 1986; Specter 1985). The PWA rights movement thus became a ‘spin- off’ movement (McAdam 1996, p.32-33) from the gay rights movement with activists able to use pre-existing networks and organizations to mobilize the community (Epstein 1996, p.10-12; Söderholm 1997, p.124).

The initial response to the AIDS epidemic was shock and denial. As more people died however, groups and organizations began to form and a movement began. In 1983, the term ‘people with AIDS’ was employed for the first time to articulate a new resistance identity, a rejection of the inevitability of death. As one group explained:

The concept was a refusal ‘of the label “victims,” which implies a defeat’ and a departure from the concept of being a permanent patient, ‘which implies passivity, helplessness, and dependence upon the care of others’ (PWA Coalition cited by Bastos 1998, p.36).

At the same meeting that the term ‘people with AIDS’ was first used, a manifesto or a ‘PWA Declaration of Independence’ was produced. The ‘Denver Principles’, as they came to be known, articulated PWA empowerment and rights and called not only for all people to support PWAs in their struggle against stigma and discrimination, but also recommended PWAs ‘be involved at every level of decision-making’ and ‘be involved in all AIDS forums with equal credibility as other participants, to share their experiences and knowledge’ (Senterfitt 1998). The Denver Principles became the cornerstone of the American PWA movement, a movement that sought to wrest control back from the medical and political establishments. These ideas were at the heart of both the community activism of the Gay Men’s Health Crisis (GMHC) and the radical activism of the AIDS Coalition to Unleash Power (ACT UP) and paved the way to the formal recognition of the principle of the Greater Involvement of People with AIDS (GIPA) by 42 countries at the 1994 Paris AIDS Summit (UNAIDS 2004a, p.183-184).

AIDS activism in the US in the 1980s can be placed on a spectrum.43 At one end of the spectrum was the provision of AIDS-related services by community-based

43 While there were many AIDS-related organizations in the US during this period, I have chosen to focus on the GMHC and ACT UP as these were the biggest and most well known of all of the organizations.

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organizations. The GMHC exemplified this approach. The GMHC was founded in 1982 because, as its chairman stated, ‘people were dying and nobody cared’ (Specter 1985). The services that the GMHC offered functioned to fill the gap left by the Reagan Administration’s unwillingness to act. The organization provided crisis counselling and homecare, undertook fundraising for PWA who could not afford insurance, funded AIDS discrimination suits and lobbied government for PWA- friendly public policy (Bastos 1999). The GMHC provided important information and rights advocacy but the organization was not overly political, despite the occasional street rally. Nevertheless, the GMHC was, and continues to be, important not only in terms of promoting PWA rights and involvement, but also in terms of providing a clear example of the indispensable role played by civil society in the absence of political commitment.

At the other end of the spectrum was the more militant style of the anarcho- democratic ACT UP, which used direct action to have more visibility and greater influence (Bastos 1999, p.42-43). The years 1987 to 1995 represented the peak period in HIV/AIDS activism in the US, partly because with the development of the HIV antibody test in 1985, more people were being tested and being diagnosed before the onset of AIDS. This meant that there was an increase in PWAs who were healthy and motivated to stay that way (Epstein 1996, p.10). Larry Kramer formed ACT UP in 1987. Kramer was one of the founders of the GMHC who had left that organization because he felt that it was not political enough. He argued that it was time for the PWA community to get angry and demand access to treatment (Larry Kramer interviewed by Public Broadcasting Service 2006). Finnemore and Sikkink (1998) note that sometimes norm entrepreneurs have to behave outside the accepted logic of appropriateness in order to contest it and provoke change. This strategy is reflected in the following explanation of how ACT UP works by an activist:

We do demonstrations, and act in such a way that the authorities (and in this case we mean government officials, researchers, politicians, the church and the law) feel is inappropriate but ultimately accomplishes our goal by bringing into focus the problems which they are unwilling or afraid to address (Greenberg 1992).

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Another activist used the term ‘impolite politics’ (Moran 1990). The formula was successful. More than 100 chapters of ACT UP soon emerged all over the world (PR Newswire 2001).

ACT UP’s main issue was the slow pace of research and the unavailability and the expense of drugs. By 1987 there was still no cure and still no effective treatment. The first antiretroviral drug, zidovudine (AZT), was originally an anti-cancer drug until scientists from the National Institute of Cancer and Burroughs Wellcome Co. (now GlaxoSmithKline) started working on it as an AIDS drug in 1985 and it was discovered thereafter that the drug could prolong the life of PWA. Under the normal Food and Drugs Administration (FDA) processes the drug would have taken years to obtain approval. However activists acquired knowledge of the efficacy of AZT and, arguing that it was inhumane to wait for approval when people were dying, demanded access to the drug even though it was still being clinically trialled (Bastos 1998).

ACT UP staged its first demonstration in March 1987, when 250 activists descended upon Wall Street to demand that Burroughs Wellcome release the new drug. In the next few years, activists ‘stormed’ the FDA headquarters and the National Institute of Health (NIH) (The Nation 2007), rallied in front of New York City Hall and District Courts demanding federal recognition and funding for services (Lambert 1989; Silberman 1987), and returned to Burroughs Wellcome to demand the reduction of the price of AZT (Patterson 1989b). These symbolic acts succeeded in bringing attention to the issue of access to treatment and produced results. Not long after the Wall Street demonstration the FDA streamlined the approval process (The Nation 2007). After ACT UP’s demonstration at the FDA, the FDA and the NIH approved the first ‘parallel track’ programme in 1989, providing wide pre-approval access to new AIDS drugs to those for whom AZT was failing to work (Bastos 1998). Because of ACT UP, Burroughs Wellcome reduced the price of AZT by twenty-five per cent (Patterson 1989a).

The organization did not limit their tactics to the US. ACT UP led one of the first protests at an international AIDS conference. As already mentioned, the first international AIDS conferences were strictly biomedical affairs. Prohibitively expensive conference fees had deterred PWA from attending. The annual conference

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was thus criticised by activists for excluding those people most affected by the outcomes of the research. Instead, as one critic declared, the conference represented ‘a chance for scientists to hobnob with their fellow wizards while dispensing wisdom and press releases to beleaguered doctors and a fawning press’ (Goldberg 1998). Sick of PWAs being represented in the abstract or as statistics on paper, ACT UP demanded PWA inclusion ‘to hold science itself accountable to PWAs’ (Goldberg 1998). In 1989 protesters met the international scientific community head on by storming the Fifth International AIDS Conference in Montreal, Canada. Opinions were divided on the appropriateness of ACT UP’s presence at the conference. Many scientists felt that the conference’s tone was changing for the worse and that science of AIDS, and rights concerns were two separate issues. Others, however, argued that there should be an overlap of science, patient concerns and public policy and that it was useful for laboratory scientists to come face to face with people with AIDS (Clark 1989). Although ACT UP had gone to Montreal to talk about treatment, the organization’s presence at the conference brought attention to the issue of the involvement of people with AIDS.

Following the Montreal Conference, ACT UP continued to use international AIDS conferences as focusing events to advance its campaign for inclusion and treatment, however in 1990 the target of protest changed. The US government had introduced an amendment to its visa and immigration laws in 1987 which, by including HIV on a list of dangerous diseases, allowed the US to turn PWA away from the borders on account of their health status. The Sixth International Conference on AIDS was to be held in San Francisco but in the year leading up to the conference, unease with the US border restrictions increased and led to many INGOs, such as the International Red Cross, and some European scientific organizations announcing that they would boycott the conference (Gordenker et al. 1995, p.113-133).44 ACT UP threatened protests. One report noted that even the official conference program, supported by the U.S. Public Health Service and the NIH, denounced the U.S. policy as ‘discriminatory, unjustified by medical knowledge regarding transmission of HIV, and counterproductive to the goal of identifying solutions to the AIDS pandemic’ (quoted in Specter and Gladwell 1990). The US government did respond to the

44 Gordenker et al. (1995, p.115) note that the boycott took many decision makers by surprise. Canada also had visa restrictions but this was not focused on at the Fifth International AIDS Conference in Montreal.

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boycott by introducing a waiver to conference attendees (Gordenker et al. 1995, p.115) but this was not enough for ACT UP.45 The conference went ahead, as did the demonstrations, resulting in clashes that led to arrests (The Independent 1990; Specter 1990). While these protests did not ultimately lead to the US government changing the border restrictions, they did shape decision-making with regards to future international AIDS conferences. Due to the pressure that was applied to the WHO and other conference organizers to uphold non-discriminatory practices, the 1992 International AIDS Conference was moved from Boston to Amsterdam. An International AIDS Conference has not been held in the US since and an effort has been made to not sponsor conferences in countries with discriminatory visa regulations.46

By the mid-1990s membership of ACT UP had waned considerably. There are many reasons for this. ACT UP’s tactics had always caused controversy but it seemed that they had started to alienate some of their supporters. Many of its leaders died. The new US administration was more open to negotiation and ACT UP became institutionalised. Most importantly, the success of the organization contributed to its demise. As PWA got better, there was less need to keep fighting (Bastos 1999; Hardy 1994). Some of its members however went on to found Treatment Action Group, an organization that continues to push the AIDS agenda, and the Health Global Access Project Coalition (Health GAP), one of the leading campaigners for increased access to treatment in the developing world (The Nation 2007; Collins 2001).47 Furthermore, the tactics used by ACT UP have been used by other PWA movements such as the Treatment Action Campaign (TAC) in South Africa.

45 Nor was it for many of the NGOs due to attend. A separate conference was organized to be held in Paris (Gordenker 1995, p.126). 46 There was controversy prior to the 2002 Barcelona International AIDS Conference when many visa applicants from developing countries were rejected. Conference organizers said that their refusals had nothing to do with whether the applicant had HIV but were due instead to a recent campaign against illegal immigration (Reuters News 2002b). However, critics pointed out that visas could only be given if the applicant had a plane ticket and medical insurance. In many developing countries medical insurance requires HIV testing and is often denied if the person is found to be HIV positive, ‘which in itself would be reason for visa denial’ (AIDS Treatment News 2002; Red2002 2002). 47 Formed in 1999, this is a group of activists, PWAs, fair trade advocates and others, dedicated to eliminating barriers to global access by lobbying governments, multilateral institutions and pharmaceutical companies. Health GAP is now a permanent member on the UNAIDS programme coordinating board (Health GAP 2008).

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It has been argued that social movements need a radical faction in order to make policy makers more amenable to cooperating with the moderate factions of the movement (Della Porta and Diani 1999, p.269). The PWA movement (the radical ACT UP versus the moderate GMHC) is perhaps a case in point. Perhaps because it has been more moderate and community service-based, the GMHC has managed to endure and has become the face of HIV/AIDS support, while ACT UP has receded (Altman 1998, p.235). Nevertheless, American PWA activism helped to challenge the prevailing logic of appropriateness, at both the domestic and international levels, by framing HIV/AIDS as an issue of human rights, and by extension, framing PWA as human beings that are entitled to treatment and participation in decisions that concern them.

2.3.2 NORM EMERGENCE AT THE INTERGOVERNMENTAL LEVEL

Another key actor in the emergence of the global AIDS regime was Dr Jonathan Mann, the first director of the GPA, the special program of the WHO that was created to address the issue. From the ‘organizational platform’ (Finnemore and Sikkink 1998, p.899) of the GPA, Mann had plenty of scope to promote certain ideas and have international influence, thus acting as an important norm entrepreneur. As stated earlier using the example of UNAIDS, it is imperative to restate that the GPA was not the regime. However, as the lead organization in charge of coordinating the global AIDS response, the GPA heavily influenced its design. Like the PWA activists, Mann helped to challenge the perception that HIV/AIDS is only a medical issue by linking the issue with human rights. The GPA leader also argued that AIDS must be thought of as a global problem that would require a global solution. Finally, Mann also advanced the norm of multisectoral cooperation and PWA involvement by experimenting in new forms of governance.

The WHO created the Special Programme on AIDS in 1986 when it became apparent that the disease was not confined to the developed world. In 1987 the fortieth World Health Assembly (WHA), via resolution WHA40.26, endorsed the establishment of the Special Programme on AIDS, which was renamed the next year as the Global Programme on AIDS (GPA), and its Global AIDS Strategy. Dr Jonathan Mann, a former CDC epidemiologist, who had been working in AIDS control in Zaire, became

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the GPA’s first director. Mann immediately began working to mobilize both international national and national political commitments to fight AIDS.

Tell us what needs to be done – not the way things are usually done. It is not ‘business as usual’ at the Global Program on AIDS and has not been since the program was founded (Mann quoted in Söderholm 1997, p.155).

As a special programme, the GPA was able to work outside the WHO’s normal bureaucratic constraints and was able to ‘borrow’ staff from other departments, ‘a procedure almost unheard of within WHO’ (The Panos Institute 1987, p.48). It was also funded by extrabudgetary contributions and operated independently of the WHO Director-General, the executive board and the WHA. Instead it answered to its own director and a management executive committee comprised of donor’s representatives (Godlee 1995; Söderholm 1997).48

Mann brought to the leadership role first-hand experience of both the scientific and the human aspects of the epidemic. Highly charismatic and hardworking, Mann gathered a large team around him and fought hard from 1987 to spread awareness of the HIV/AIDS epidemic across the globe. This was not an easy job as blame, fear and denial were endemic. Piot notes that Mann fought bureaucracies sometimes more than the virus (cited in an interview for Public Broadcasting Service 2006). As a testimony to Mann’s doggedness, within the space of several years, the GPA grew from a staff of two people and a budget of $1 million to a staff of over 200 with a budget of $109 million (Chandler 1990).

There was a lot of scope for Mann and the GPA to be normatively influential at both the global level and at the national level. The objectives of the GPA and its Global AIDS Strategy were threefold and interrelated: first, to prevent HIV infection; second, to reduce the personal and social impact of HIV infection; and third, to unify national and international efforts against the disease (Mann 1988). However, one of its main functions was to provide policy recommendations and technical assistance to states as they formulated their national AIDS programs (NAP) (Institute of Medicine 1988).

48 This did not come without its challenges. For an excellent organizational critique of the GPA, see Söderholm (1997).

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When AIDS became the first disease ever debated in the UN General Assembly (UNGA) in 1987, the resulting resolution called on member states that had not already done so to support WHO efforts and to establish national AIDS programmes in line with the Global AIDS Strategy (A/RES/42/8). By 1988 visits had been made to 145 countries, 106 short-term plans had been drawn up and 150 national AIDS committees had been established (Söderholm 1997, p.159; Sorelle 1988).

Mann believed that effective AIDS governance at both the global and the national level would require strong leadership, transparent disease reporting, evidence-based prevention and treatment programs and multisectoral cooperation. But above all, Mann believed that HIV/AIDS must first and foremost be understood as an issue of human rights. Drawing on his experience in Zaire, Mann quickly came to believe that treating AIDS as a biomedical problem alone would not be an effective strategy to stop the epidemic (Jönsson and Söderholm 1995). Instead, Mann argued that the AIDS epidemic was rooted in human rights violations (Peter Piot interviewed for Public Broadcasting Service 2006). Mann saw clearly that when states did act, their policies were typically discriminatory. The GPA therefore started to frame AIDS as a human rights issue. The GPA’s Global AIDS Strategy was historic because it was the first time that human rights were explicitly named in a public health strategy (Gruskin and Tarantola 2000, p.1). In addition to the traditional public health approach of disseminating information and teaching skills (i.e. condom use) with a view to changing behaviour, the GPA argued that not only was discrimination against PWA a violation of international human rights law but it was also counterproductive as it forced the disease underground and away from the health and social services created to help prevent HIV transmission (Mann, Tarantola, and Netter 1992, p.540; WHO 1992). Thus, the GPA developed a ‘public health rationale’ for preventing discrimination against PWA.

Garrett (1994, p.476) notes that from 1988, Mann began to frame GPA policy pronouncements on such issues as international freedom to travel,49 HIV screening of

49 Fidler (1999, p.205-206) points out that this is the most controversial issue as it relates to HIV/AIDS. While international human rights law gives the individual the freedom of movement and the freedom to leave and return to one’s own country, individuals do not have the right to enter another country. While the argument has been made that visa restrictions are discriminatory because they are based on health status, a discriminatory measure only violates international human rights law if the discrimination

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refugees, access to health care for prostitutes, and discrimination against homosexuals in the context of major instruments of human rights law. In 1988, the GPA/WHO and the government of Great Britain sponsored the first World Summit of Ministers of Health on Programmes for AIDS Prevention in London (WHO 1988a). One hundred and forty-nine countries attended. The resulting London Declaration emphasized education, free exchange of information and the need to protect human rights and dignity. ‘Discrimination against, and stigmatization of, HIV-infected people and people with AIDS and population groups undermine public health and must be avoided’ (para. 6, cited in UNAIDS 2000, p.6). Following the London Declaration the recognition that HIV/AIDS was linked with human rights was restated in multiple UN resolutions passed by the UNGA (A/RES/43/15; A/RES/44/233; A/RES/45/187), the WHA (WHA 41.24; WHA 42.33) and the Economic and Social Council (ECOSOC) (E/1990/86). In 1989, the first International Consultation on AIDS and Human Rights was convened by the UN Centre for Human Rights, in cooperation with the WHO. A resulting report proposed the need for a set of guidelines to assist policy makers formulate national HIV/AIDS strategies in line with international human rights instruments (UNAIDS 2000, p.6).50 While there is contestation over the use of condoms, or the use of traditional medicine, the idea that national AIDS programs should take due care and consideration of the rights of PWA is largely shared (if not always implemented). Thus a human rights-centred approach to AIDS came to be at the heart of the global strategy, in large part due to Mann and the GPA.

While the American AIDS activists mainly framed HIV/AIDS in terms of civil and political rights, Mann linked HIV/AIDS with social and economic rights, such as the right to health, to prevention and to advancements in science (i.e. AIDS treatment). 51Fidler (1999, p.209) notes that analysing economic, social, and cultural rights in connection with HIV/AIDS brings to the fore general political, economic and social conditions in countries and in doing so, raises the questions of resource allocation and breaches a recognized human right. ‘Given that there is no human right to enter any country freely, denial of entry on health status does not violate an established human right’. 50 A second consultation was convened in 1996 (Commission on Human Rights 1997) and produced the International Guidelines on HIV/AIDS and Human Rights (Office of the United Nations High Commissioner for Human Rights and UNAIDS 2006). 51 It is worth noting that Mann was not operating in a normative vacuum. Until 1988, the director- general of the WHO was Halfdan Mahler who was instrumental in spearheading the Health for All agenda, as formalized in the Alma Alta Declaration of 1978. This agenda enabled Mann the policy space to pursue a human rights approach.

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economic justice. Even when the GPA first started collecting data, Mann was concerned that the numbers of cases being seen were only the tip of the iceberg and that the eventual scope of the pandemic would be catastrophic. Mann was particularly mindful that the pandemic would have the most impact in the developing world. There were already signs that vulnerability to HIV/AIDS was linked to socio- economic factors such as poverty and weak health systems.

Therefore, predicting the time when treatment would be available to some and not others, Mann argued that it was not enough to think about AIDS in a national context alone but that the global pandemic required a global response.

If one permitted even conceptually the idea that it was possible to control AIDS in one part of the world without providing those control benefits to other parts of the world, that would be a prescription for long-term failure. AIDS is not a problem that can be stopped permanently in one country until it's really stopped everywhere (Mann quoted in Trafford and Okie 1987).

The WHO NAP guidelines and the Global AIDS Strategy further reinforce this idea (WHO 1988b; WHO 1992). Any global response would in part require consideration of the economic inequalities that existed between the developed and developing countries and the subsequent allocation of resources through overseas development assistance. As Mann reasoned, this was both morally right and politically prudent.

The industrialized world will certainly gain much more than it invests from global AIDS control. The alternative, as some have dared to say, is to abandon parts of the world, to abandon Africa, as if the world was not one (Mann quoted in Duerkson 1987).

While this line of argument helped to persuade donor states to provide more resources, it also helped to develop the expectation that states have a responsibility to cooperate and support the global AIDS regime. ‘All countries have a stake in global solidarity…no country can be completely safe from AIDS until every country is’ (WHO 1992, p.2).

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Due to the stigmatisation of some of the people most vulnerable to HIV, not to mention the lack of services in many developing countries, Mann also realized that, in addition to committed leadership at top levels of government, the effective governance of AIDS required the mobilization of every sector of society. Particularly important was the involvement of PWA and AIDS-related non-governmental organizations. While in the past IGO-NGO relations had been characterised by ‘sentiments of bad faith’, the GPA broke new ground by bending rules and proactively engaging with civil society actors (Söderholm 1997, p.162). Far from simply involving these organizations, Mann and the GPA actually learned from them, retained those lessons and applied them, not only in working with national governments but also to official WHO policy (Bastos 1999, p.64). By learning from and promoting proven methods of prevention and treatment, Mann and the GPA changed the nature of AIDS knowledge construction and legitimated the activities of AIDS NGOs both at the national level and at the global level. From 1988, UN resolutions recognized the role played by NGOs in combating the spread of AIDS (A/RES/43/15; A/RES/46/203; WHA42.33).

At the national level, the GPA officially recommended that states (via their NAPs) commit 15 per cent of the funds channelled through the WHO to support civil society AIDS activities and advocated NGO involvement in the policy process (Jönsson and Söderholm 1995, p.467; WHO 1988b; WHO 1992). The GPA also gave direct support in the form of ‘seed grants’, although to qualify it was required that cooperative links be established between transnational and local nongovernmental organizations and that all activities were to be conducted with the approval of the national authorities (Jönsson and Söderholm 1995, p.467).52 Apart from resource allocation, the GPA gave AIDS service organizations (ASOs) and other NGOs an opportunity to form networks and have more involvement in international decision- making (Poku 2002, p.287). For example, the International Council of AIDS Service Organizations (ICASO) was created at the first meeting of AIDS NGOs in Vienna in 1989, which was organized by the GPA.53 Importantly, ICASO has gone on to be

52 The GPA was, after all, still an intergovernmental organization. 53 Granted, this story is more complicated. For example, while ICASO was formed via the facilitating efforts of the GPA, consensus amongst the ASOs was not achieved and it was years before ICASO received legitimacy from the majority of ASOs (Söderholm 1997, p.162). However, while cooperation proved difficult, my argument is that the shared belief that cooperation and civil society involvement

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involved with the advocacy of the principle of GIPA gained consultative status within the ECOSOC in 1995, and has been a member of the governing board of UNAIDS.

Mann resigned from the GPA in 1990 and went on to Harvard where he created the AIDS Policy Coalition and continued to be influential until his untimely death in 1999. A major reason for Mann’s departure was that his innovative approach, which sometimes violated the WHO administrative protocols, put him at odds with the newly appointed head of the WHO, Hiroshi Nakajima (Söderholm 1997, p.164). Nakajima replaced Mann with Michael Merson, an administrator who would follow WHO protocol (Garrett 1994 p.481). After Mann left, the GPA began to run out of steam. This was in large part because of the loss of Mann’s leadership. For example, as a testament to this leadership, the GPA staff fell from over 200 to just four in a number of years (Public Broadcasting Service 2006). Söderholm notes that Merson put more emphasis on the priority of national-GPA relations then GPA-NGO relations. This emphasis however not only alienated NGOs but also concerned donor states, which started to withdraw funding (1997, p.166). By this time, almost all the UN agencies had AIDS-related activities in recognition of the multiple causes and effects of the AIDS epidemic. However this expanded conceptualisation of the epidemic led to rivalry between agencies and consequent budgetary inefficiencies. Eventually the major donors called for coordination. The WHA thus requested a study to be undertaken into the viability of a new UN programme (Naughton 1993). The result was the establishment of UNAIDS, which came into operation in 1996. Despite the decline of the GPA, Bastos (1998, p.67) argues that the Mann left behind an institutional legacy. ‘The structures and awareness created during the most active years of the GPA… influenced the actions and ideas of many throughout the world’.

We therefore might conceptualise the emergence of the global AIDS regime in several ways. On the one hand we have agency and norm creation. Individuals and groups of people who were not content with the way that things were decided to challenge the dominant AIDS discourse. With regards to the American PWA movement, it was about contesting the response to AIDS and PWA by the US government, by the

was essential to achieve effective AIDS governance was in itself significant, as was its inclusion within GPA decision making practices.

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medico-scientific community and by society and making it no longer appropriate for PWA to be invisible or untouchable, or excluded from decisions that involved them, or sick when drugs existed that could mitigate their illness. For Mann, it was about using his organizational platform, the GPA, to challenge the perception that AIDS was only a public health issue and to teach that it was only appropriate that both the global governance and national governance of AIDS should be human rights-based, evidence-based, should involve strong leadership, include all sectors of society and should be well-coordinated and transparent. These ideas were borrowed from broader normative structures with the obvious example being that both the PWA activists and the GPA were operating and framing AIDS as a human rights issue at a time when human rights had unprecedented salience as a global issue. Nevertheless, what was important in this case was the novelty of the linkage between human rights and AIDS. Consequently, the discursive debates and struggles between the PWA movement and the US government, between the PWA movement and the scientific community, and between the GPA, other organizations and states, led to the emergence of a set of discursive constructions or norms relating to AIDS governance.

However, regime emergence also involved the creation of new organizational energies through which the norms were institutionalised and promoted. These included a new intergovernmental organization, the GPA, which as discussed, actively worked to promote standardized ideas about AIDS prevention and control through guidelines and policy frameworks such as the Global AIDS Strategy and the Guidelines for the Development of a National AIDS Prevention and Control Programme (WHO 1988b; WHO 1992). With many states having a national AIDS program by 1992, the GPA played an important role in institutionalising AIDS norms. However, the organizational energies of the emergence period also included the proliferation of specific international meetings on AIDS such as the 1988 and 1994 world summits in London and Paris, the annual International Conferences on AIDS and the first International Consultation on AIDS and Human Rights organized by the UN Centre for Human Rights in 1989. AIDS was also included on the agenda of the UNGA, the WHA, the ECOSOC and the multiple agencies attached to the UN system. The non-binding resolutions, official declarations, reports, and statements produced by this increased politicisation also helped to affirm and institutionalise the AIDS norms.

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2.4 REGIME CONSOLIDATION 1996-2007

Since 1996 we have seen the consolidation of the global AIDS regime. Consolidation is occurring via several different processes. Firstly, returning to the concept of agency, we have seen the norms empowering new movements such as the Treatment Action Campaign (TAC) in South Africa and generating transnational advocacy networks. This is significant not only in terms of the fact that the efforts and campaigns of these movements are producing results that are increasingly in favour of the regime, but also, because the mobilization of norm entrepreneurs such as TAC represent both the geographical expansion of those norms from the ‘North’ to the ‘South’ and the further embedding of these norms as these groups and transnational networks increasingly linked AIDS to inequality and development.

Secondly, consolidation of the regime has occurred through issue-linkage and organizational proliferation. In particular, the linkage of AIDS with security and development in the late 1990s by both international organizations and some state actors led to new organizational commitments, such as the inclusion of the control of AIDS as a Millennium Development Goal (MDG), the new review procedures established at the historic UNGASS and the establishment of new sources of funding. Finally, evidence of the consolidation of the regime is seen in the inclusion of new actors, such as multinational corporations, whose behaviour is being influenced by the norms of the global AIDS regime.

As such, my discussion of the consolidation of the global AIDS regime is similar to Foot’s (2000, p.51) conceptualisation of the ‘deepening and widening’ of the global human rights regime.54 Also like Foot’s (2000, p.30, 57) discussion of the global human rights regime, I acknowledge that state compliance with the AIDS regime is far from perfect and that this problem lies within the design of the regime itself as a product of an international system where states continue to hold disproportionate

54 Foot (2000, p.29-30) notes that although the global human rights regime was established in a flurry of activity following the horrors of World War Two, it took much longer for commitment to turn to practice. Foot argues that a ‘deepening and widening’ occurred following the end of the Cold War with the creation of a new role, the UN High Commissioner of Human Rights, the emergence of new democracies and the explicit linking of human rights to criteria for the allocation of economic assistance.

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material and institutional power. Nevertheless, despite ongoing challenges, the regime’s strength is related to the way its norms have changed the terms of engagement for actors with regards to the appropriate governance of HIV/AIDS.

2.4.1 CONSOLIDATION THROUGH AGENCY AND GEOGRAPHICAL EXPANSION

This section shows how the global AIDS regime is being consolidated through the agency of norm entrepreneurs. By using the global AIDS norms to obtain leverage over other actors, new movements and organizations have in turn reinforced the norms. However, because the norms are being used by new groups in different areas of the world, consolidation can also be conceptualised in terms of the regime’s geographical expansion. To illustrate this process, I use the case of the TAC, a South African social movement, which mobilized to obtain equitable access to AIDS treatment. TAC has led a two-pronged struggle. On the one hand, the TAC has helped its government fight against the international pharmaceutical industry and the Western nations that have supported it. As such, it has played an important role in the transnational campaign for access to affordable HIV/AIDS drugs. On the other hand the TAC has fought against its own government in South Africa, where the head of state and health minister have denied the link between HIV and AIDS.

TAC primarily mobilized around the issue of AIDS treatment. As mentioned above the right to access to treatment was one of the main mobilizing norms of the activist organization ACT UP in the late 1980s and early 1990s. The issue however mainly referred to access to experimental drugs and the rapid approval of drugs by the FDA. Affordability was also a concern but the focus was on getting an effective drug regimen, which until 1996 proved elusive. At the 11th International AIDS Conference in Vancouver 1996, American researchers revealed that they had been working on combining drugs to stop viral replication and restore the immune system. This was called the triple cocktail as it involved the combination of three drugs. Although the drug regimen was expensive (initially about US$16,000 per year), the triple cocktail had phenomenal effects in developed countries. With the development of the triple cocktail, HIV/AIDS in developed countries changed from a death sentence to a chronic disease. Antiretroviral drugs (ARD) could be attained through health insurance or social security systems. In the US for example, thanks to earlier lobbying

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by activists and the passage of the 1990 Ryan White Comprehensive AIDS Resources Emergency Act, PWA who were either uninsured or underinsured could access the drugs through the AIDS drug assistance programmes (ADAP) which were set up in every state (Bastos 1999).55 Thus in the developed world it seemed that universal access to treatment was becoming a reality.

However, in the developing world, the situation was worsening. If there had been any sense of global solidarity in the late 1980s, the discovery of the new treatment highlighted the glaringly obvious disparities between the developed and developing worlds. Those PWA unlucky enough to live in developing countries would not be likely to benefit from the medical breakthrough and the impact of this inequality is evident in the fact that by 1996, 90 per cent of the global total of PWA lived in the developing world (Mann and Tarantola 1996, p.312). In many developing countries neither health insurance nor social security systems existed. The cost of treatment for a year could represent a year’s income (or several years’ income) for most PWA (Mann, Tarantola, and Netter 1992, p.813). AIDS was therefore still a death sentence for most.

HIV positive Zachie Achmat founded TAC in December 1998 in Cape Town, South Africa, after one of his friends, an HIV activist, died because he could not afford ARD (Power 2003). At the time South Africa was experiencing one of the fastest-growing epidemics in the world. TAC brought together AIDS organizations, churches, trade unions and the gay community to advocate human rights for PWA, particularly the right of treatment. Embedding global AIDS norms in its domestic context, the TAC drew on experience gained from the years of contesting the regime of apartheid, going so far as to frame the issue of unequal access to treatment as ‘health apartheid’ – the segregation of those who can afford health from everyone else (TAC 2000). However, TAC drew also from the experience of the precedent set by the normative influence of the American PWA movement. Furthermore, in framing AIDS as an issue of poverty and development, its objectives have been global in nature. This was articulated in its first statement:

55 It must be noted however that increasing poverty in the US has meant that more people are relying on the ADAPs and many organizations now have large waiting lists and less funding to go around (NASTAD and KFF 2006).

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The National Association of People living with AIDS/HIV… has initiated the Treatment Action Campaign to draw attention to the unnecessary suffering and AIDS-related deaths of thousands of people in Africa, Asia and South America. These human rights violations are the result of poverty and the unaffordability of HIV/AIDS treatment (TAC 1998).

As a result, TAC has also been able to link up with norm entrepreneurs such as ACT UP, Health GAP, Oxfam and Médecins sans Frontières (MSF) in order to form a transnational advocacy network for the access of essential drugs for HIV treatment.

TAC’s primary target was the international pharmaceutical industry, which was accused of charging exorbitant prices for essential medicines. ‘Denying people with HIV/AIDS access to affordable medicines in order to protect profits or intellectual property rights is tantamount to genocide’ (TAC and Health GAP Coalition 2000b). TAC started a campaign to apply moral pressure on pharmaceutical companies to lower their prices. The majority of antiretroviral drugs are produced largely in the North and many of them are under patent (Thomas 2002, p.253). Patents are time- bound monopoly rights, the protection of which is a key element of the global intellectual property rights regime as embodied in the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) to which developing countries have had to agree to in order to become members of the World Trade Organization (WTO) (Cullet 2003, p.140).56 The patented antiretroviral drugs were too expensive for the South African government to even subsidize. In order to provide all South African citizens with affordable drugs, the government had passed the Medicines Amendment Act in 1997, authorizing two practices: parallel importing, which allows importers to buy pharmaceutical drugs from the cheapest sources available abroad, regardless of whether the patent-holders give their approval; and compulsory licensing, which would allow the government to license local companies to produce cheaper versions

56 The issue of AIDS drugs and patents is complex. An argument for patents for ARD purports that pharmaceutical companies should be rewarded for the time and money put into developing antiretroviral drugs. Furthermore, this serves as an incentive to put the money into research and development in the first place. On the other hand, opponents of patents in the pharmaceutical industry argue that because these drugs are necessary to save lives, they should not be given patent protection (Cullet 2003, p.141; Spar and Bartlett 2005). Generic drugs should be made available when the drug constitutes a global public good.

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of drugs whose patents are held by foreign companies (Lanoszka 2003, p.191-192). While both practices were considered controversial under TRIPS, neither were explicitly prohibited. Furthermore, given the small profit made in Africa in proportion to those made in the developed world, it has been argued that the practices would hardly affect the international pharmaceutical companies. The pharmaceutical industry did not agree (Thomas 2002, p.254).

In 1998 a group of forty pharmaceutical companies under the banner of the Pharmaceutical Manufacturer’s Association (PMA), backed by the US Trade Representative (USTR), filed a suit against the South African government, asking the courts to overturn the law because it was in violation of the country’s obligations under TRIPS. The USTR put South Africa on its annual 301-Watch-List of countries whose protection of intellectual property is suspect and allegedly went as far as threatening South Africa with withholding aid until the law was repealed (Davis 1999; Lanoszka 2003, p.192; Power 2003). In the meantime, the South African government could not implement the law while the suit was pending. It was a classic case of ‘David versus Goliath’ – the poor versus the powerful multinationals backed by the world’s most powerful state (MSF, TAC, and Oxfam 2001) – and it was a major symbolic event. The court case allowed AIDS norms such as universal access to treatment, PWA rights and global responsibility to be brought to the foreground. As such, the court case had amazing mobilizing potential.

The TAC arranged protests against US embassies in several cities and planned a protest against the offices of the PMA (Mzolo 1999; South African Press Association 1999). The TAC was soon joined by organizations such as MSF, the newly formed Health GAP, ACT UP and Oxfam.57 Al Gore’s role in the case made its way into his presidential bid with protesters following Gore on the campaign trail and accusing him of bullying (ACT UP Philadelphia 1999; Davis 1999).58 This action caused the US to back down and state that it supported parallel imports and compulsory licensing ‘so long as they are done in a way consistent with international agreements’ (Gore quoted in Davis 1999). The Thirteenth International AIDS Conference in Durban in

57 For an overview of the expansion of the global AIDS treatment activist movement during this time from a transnational advocacy network perspective, see Smith and Siplon (2006). 58 Al Gore was the co-chairman of the US-South Africa bilateral commission, the panel which looked at trade disputes (Davis 1999).

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2000, the first of these conferences to be held in a developing country, was the defining moment. In line with the theme ‘Break the Silence’, the TAC, ACT UP and Health GAP organized direct action, including a 3000-strong march. A vitriolic ‘global manifesto’ was addressed to the South African government, the developed world, the pharmaceutical industry and UNAIDS and the scientific community in order to highlight the difference between their actions and their rhetoric (TAC and Health GAP Coalition 2000a). Meanwhile, a ‘Drop the Case’ petition was organized and was signed by 260,000 citizens and 140 organizations from 130 countries (MSF, TAC, and Oxfam 2001).

In April 2001, in what amounted to a major public relations defeat, the PMA finally withdrew their court application against the South African government. Furthermore, in November of that year, as a consequence of international movement and a push by developing countries, WTO members adopted the Declaration on the TRIPS Agreement and Public Health during its Fourth Ministerial Meeting in Doha, Qatar. The Declaration addressed the problem of inaccessibility of medicines by poor nations and affirms the rights of developing countries to protect the health of their populations (Drahos and Braithwaite 2002, p.8). ‘We agree that the TRIPS Agreement does not and should not prevent Members from taking measures to protect public heath…and to ensure access to medicines for all’ (quoted in Lanoszka 2003, p.194).59

At the same time that the TAC was battling the international patent regime and its key backers, the organization was faced with an increasingly recalcitrant government at home. In 1999, Thabo Mbeki, Nelson Mandela’s successor, began to publicly doubt that HIV was the exclusive cause of AIDS, instead suggesting in line with the American AIDS dissidents that AIDS was a ‘life-style disease’, caused by poverty and malnutrition. In 2000, Mbeki even convened a panel of both mainstream and dissident scientists to help advise him on AIDS policy in South Africa (Fassin and Schneider 2003). This questioning of the basic scientific assumptions of the

59 This was followed in August 2003 with the Members of the WTO agreeing to a mechanism with many procedures for allowing trade in compulsory-licensing medicines. This amendment was made permanent in December 2005 despite being criticised by activists as being too burdensome and unworkable in practice (Joint statement by NGOs 2005). The fact that so far no importing country has sought to make use of it has led the WHO’s Commission on Intellectual Property Rights, Innovation and Public Health to recommend that the effectiveness of the amendment be reviewed (WHO 2006, p.120).

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international AIDS epistemic community also led Mbeki to question the efficacy of antiretroviral treatment which he labelled as toxic and dangerous. This stance was supported by his new minister of health Manto Tshabalata-Msimang, nicknamed ‘Garlic Manto’, on account of her repeated assertions that AIDS can be warded off by traditional remedies such as garlic, lemon and beetroot (Wines 2007). Scholars have argued that the distrust of Western science and drugs can only be understood in the context of apartheid60 and Mbeki’s desire to find African solutions to African problems (Fassin and Schneider 2003; Youde 2005). Nevertheless, Mbeki’s stance led to widespread outrage in the international community, amongst the scientific community, civil society actors and some private actors.

The government concentrated on prevention and attempted to divert the focus on treatment by arguing that it could not afford to provide either the essential drugs or the infrastructure required to administer them. In 1998, Glaxo Wellcome offered a 75 per cent discount on its drug AZT but the government rejected the offer (Schoofs 2000). A campaign led by the TAC and MSF against Pfizer led to an agreement by the pharmaceutical company in 2000 to offer the anti-fungal drug Diflucan free to public clinics (albeit with conditions attached), but the government stalled proceedings for a year (Power 2003). With the PMA lawsuit pending, the TAC and the government stood together with a common opponent. However, when the PMA lawsuit was withdrawn, the TAC demanded the government start to make the essential drugs available. The refusal by the government to make nevirapine61 available to all pregnant women with HIV on account of the questionable safety of the drug, led the TAC to take the government to court in November 2001. The court decision was an unequivocal ruling against the government, the judge ruling that the State had an ‘ineluctable obligation’ to provide nevirapine in order to prevent mother to child transmission, or MTCT (TAC 2001). The government challenged the findings in 2002 but the appeal was overturned and a constitutional order was issued to permit the use of nevirapine ‘without delay’ (TAC 2002). Finally, in November 2003, the South African government announced the adoption and details of its Operational Plan for Comprehensive Treatment and Care for HIV and AIDS which aimed to provide at

60 It is significant for example that an epidemic provided the justification for the very first segregationist law, the beginning of apartheid, passed in 1883 (Fassin and Schneider 2003). 61 Nevirapine is an antiretroviral drug proven to be effective and economical in reducing the transmission of HIV from mothers to their babies.

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least one antiretroviral service point in every health district across the country as well as to substantially increased investment in health infrastructure and human resources, education and prevention (TAC 2003).

To conclude this section, the case of TAC and its struggle first against the PMA and then against the South African government is illustrative of several processes of regime consolidation. On the one hand, the existence of global AIDS norms empowered the movement by affecting the identity of its participants and shaping their demands, as well as providing international precedent for them. It is evident that with regards to HIV/AIDS, many actors have joined in making statements that denounce discrimination against PWA or call for strong leadership or the involvement of PWA, which in turn fail to be reflected in national HIV/AIDS responses. However, recognition of a norm, even if it is only considered an exercise in symbolic international solidarity, enables other actors to mobilize and hold norm violators (should these be states or otherwise) accountable by reminding them of appropriate standards of behaviour (Risse and Sikkink 1999, p.27-28). The existence of global norms thus empowers agents to demand certain rights or policies of their government or other actors and to enlist the support of other norm defenders abroad. In turn, through the employment of the norms and the reinterpreting and reframing of the norms to fit their domestic context, these agents serve to reinforce and further embed the norms.

TAC is a good example of the way in which the existence of global AIDS norms has provided some actors with the normative power required to generate favourable political responses, which in turn reinforce the global HIV/AIDS norms. For example, the international institutionalisation of the human right to health and access to treatment, the necessary involvement of all sectors of society and the importance of global cooperation enabled TAC to highlight the contradictions between the behaviour of the pharmaceutical companies and the challenges facing developing countries. Likewise, the norms prescribing strong national leadership and universally- accessible, evidence-based prevention and treatment programs enabled TAC to clearly draw attention to the divergence of the South African government’s position in relation to other states and even in relation to its own rhetoric. In articulating its objectives, TAC was also able to network with fellow norm defending movements.

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While the AIDS regime provides these agents with normative power over other actors, regime consolidation occurs when agents produce outcomes that further reinforce the norms of the regime. For example, in the case of TAC versus the South African government, the court’s ruling in favour of TAC was also a ruling in favour of the global AIDS norms.62

However, TAC is also illustrative of the geographical consolidation of the regime as organizations in the developing world start to employ the norms to make claims on either other actors in the developing world or actors in the developed world. This in itself represents a difference from the emergence period when the most visible and normatively influential norm entrepreneurs were mainly located in the developed world. TAC is thus an example of the geographical expansion of the AIDS regime that has occurred as the norms of the regime begin to be taken up by activists in the developing world. While this is an imperative of the reality of the pandemic as the problem of AIDS has declined in the developed world and escalated in the developing world, the reinterpretation or reframing of AIDS norms by these actors, for example by linking them to questions of inequality and poverty, has also helped to deepen the AIDS norms.

2.4.2 CONSOLIDATION THROUGH ISSUE-LINKAGE AND ENSUING ORGANIZATIONAL

PROLIFERATION

A key actor in the consolidation of the global AIDS regime has been UNAIDS, the GPA’s successor. UNAIDS attempted to strengthen the regime by a process of issue- linkage in order to generate new political commitments. Thus from the late 1990s to the early 2000s, in addition to the linking of AIDS to public health and to human rights, AIDS was increasingly linked to security and economic development. This

62 It has been noted that we often do not become aware of a logic of appropriateness until an actor violates a norm and provokes a negative response by other actors. In the case of South Africa inappropriate behaviour (state denial and the prevention of access to treatment) led to criticism and the articulation of appropriate behaviour (by TAC and diverse international actors). By helping to identify norm deviance, the South African government helped to reinforce what ‘good’ states should be doing.

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served to generate the scaling up of intergovernmental commitment and the creation of new decision-making procedures, albeit with limits and challenges. Before turning to these processes however, some introduction of UNAIDS is required.

Created by the ECOSOC in 1994 (E/1994/24), UNAIDS came into operation in 1996 and, headed by Dr Peter Piot, became the key UN agency in charge of coordinating global efforts, mandated to ‘prevent new infections, care for those already infected, and mitigate the impacts of the epidemic’ (UNAIDS 1999b).63 It prides itself as a unique organization, an agency designed to coordinate the activities of its ten Co- sponsors so that it can ‘build[s] on each member’s energies and strengths and prompt[s] them to take collective action against AIDS’ (UNAIDS 2004b, p.4). The Co-sponsors include: the UN Children’s Fund (UNICEF), the UN Development Programme (UNDP), the UN Population Fund (UNPF), the UN International Drug Control Programme (UNDCP), the UN Educational, Scientific and Cultural Organization (UNESCO), the Office of the United Nations High Commissioner for Refugees (UNHCR), the International Labour Organization (ILO) the World Food Programme (WFP), the WHO and the World Bank (UNAIDS 2005a, p.9). The Programme Coordinating Board (PCB), which governs UNAIDS, includes 22 government representatives, the UNAIDS Co-sponsors and five NGO delegates (UNAIDS 1999a). While these NGO delegates, like the representatives of the Co- sponsors, cannot vote, their inclusion on the PCB made UNAIDS the first intergovernmental organization to include representatives of the affected communities in its governing body and made the principle of GIPA a constitutive norm of the organization.

Like the GPA, UNAIDS has been both an important regime driver and a norm teacher.64 At the global level the intergovernmental organization has sought to generate political commitment and resources for AIDS. It has also served as a global resource, maintaining and disseminating verifiable and up-to-date HIV/AIDS information and helping to promote evidence-based policy via its Best Practice

63 It is worth noting that UNAIDS’ creation was not unproblematic. The dissatisfaction that resulted from the breakdown of the GPA and disagreements over the operating strategies of the new organization led to its creation being delayed for two years. 64 Vieira describes UNAIDS as a norm ‘conveyor belt’ (2006, p.22).

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Collection.65 It has also had an important role in monitoring the growth, and the trends of the pandemic and evaluating global and state responses to AIDS (Poku 2002, p.290-291; UNAIDS 2004a, 2004b, 2006a, 2007a). At the state level, UNAIDS has operated through a UN Theme Group. The main purpose of the UN Theme Group is ‘to ensure optimal joint action of UN agencies in support of an effective scaled-up country response’ (UNAIDS 2005b, p.43). As such, the Theme Group is comprised of representatives of the Co-sponsors. However, as the Theme Group is also involved in facilitating or brokering partnerships, it is also likely to include bilateral partners, NGOs, representatives from the private sector and of course, representatives of the host government. The Theme Group also advocates political commitment to a multisectoral response to AIDS, promotes national leadership and international best practice, and offers technical, financial and institutional assistance (UNAIDS 2005b, p.43; Vieira 2006).

In 2001, in order to meet the targets of the Declaration of Commitment on HIV/AIDS (discussed below), UNAIDS developed the Global Strategy Framework on HIV/AIDS – ‘a set of guiding principles and leadership commitments that together form the basis for a successful response to the epidemic’ (UNAIDS 2001, p.1). This is an updated version of the GPA’s global AIDS strategy, however, while there is an increased focus on AIDS vulnerability, much of the language is familiar. For example, the fundamental principles of the Global Strategy Framework include: the responsibility of national governments, working with civil society to provide the leadership, means and coordination for national and international efforts to respond to country and community needs; the centrality of support for the active engagement of people living with and affected by HIV/AIDS; and, the need for prevention methods, life saving treatments and the results of scientific breakthroughs to be equitably and affordably available to all (UNAIDS 2001, p.2). Therefore, the Global Strategy Framework on HIV/AIDS is a rearticulation of the norms of the global AIDS regime. The use of the framework by states in the planning of their AIDS programmes has helped to reinforce and consolidate the regime. UNAIDS has also developed the Three Ones framework to help states implement a coordinated and harmonized AIDS response. This principle involves one national AIDS coordinating authority such as an

65 For a discussion of the limitations of the ‘best practice’ approach, see Webb (2004, p.27-29).

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AIDS committee or council, one national strategic AIDS plan, and one system of monitoring and evaluation (UNAIDS 2005a, 13; 2005b, p.21).

By the time UNAIDS was established in 1996, the global AIDS regime was suffering from a lack of political mobilization. The urgency of the pandemic was retreating in the developed world due to AIDS changing from a fatal to a chronic disease while in the developing world many of the AIDS programs had collapsed through lack of funding and lack of sufficient infrastructure. Peter Piot has noted that he had three objectives when he began as head of UNAIDS. Firstly, AIDS had to be put on the political agenda of presidents and prime ministers, rather than health ministers. Secondly, in order to achieve the first objective, UNAIDS had to ‘reposition’ AIDS as an issue of economic development and security. Thirdly, UNAIDS had to mobilize resources – not only resources from donors but resources from developing countries also (Public Broadcasting Service 2006).

If we might summarise the ways in which AIDS was framed over the history of the regime, we could say that AIDS went from being a biomedical issue only in the pre- regime period to being linked with human rights in the regime emergence period. From the mid-1990s however, AIDS began to be increasingly linked with development and then security. UNAIDS’ task was helped by several factors. Firstly, as mentioned above, the late 1990s saw a rise in treatment activism, at the heart of which was a refusal to accept that PWA in the developing world should be left to die. The actions of the movement helped to keep a spotlight on HIV/AIDS as a global issue. Secondly, with the year 2000 approaching, there was a desire from within the top echelons of the UN to ‘harness the symbolic power of the Millennium to the real and urgent needs of people everywhere’ (UN Secretary-General Kofi Annan, quoted in Wren 2000). This came at the end of a period of reflection and reform in the UN and the reorienting of the system towards a focus on human security and thus the incorporation of non-traditional security issues.66 Thirdly, in the late 1990s, several Western states started to discuss the security implications of emerging infectious diseases, thus providing the discursive precedent for AIDS to be linked with security (Fidler 2004). Finally, the US presidential election was looming and it has been

66 The concept of human security was first introduced in the 1994 Human Development Report (UNDP 1994).

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suggested that the opportunity to gain gay, black and women’s votes made the Clinton Administration more amenable to the suggestion by Richard Holbrooke, the US Ambassador, that Al Gore, US Vice President and presidential candidate, bring the issue of AIDS into the Security Council (Crossette 2000).

Significantly in January 2000, the UN Security Council (UNSC) met for the first time to debate a health issue, despite arguments from Russia and China that it was an inappropriate venue for discussing an issue better dealt with by the WHO or the ECOSOC (Dow Jones International News 2000). The US Vice-President made history by being the highest-ranking official to ever preside over a Security Council meeting. The meeting focused predominantly on the impact of the epidemic in Africa which was recognised as having become an issue of international security due to its undermining of the economic, political and military establishments of states (Crossette 2000). Six months later the UNSC met again and adopted Resolution 1308, which acknowledged the risk to stability and security that the HIV pandemic could cause if left unchecked. Resolution 1308 recognized the need to incorporate HIV/AIDS prevention awareness skills and advice in aspects of training of UN peacekeeping personnel (S/RES/1308; UNSC 2001). While the UNSC’s resolution was primarily in relation to peacekeeping, the move to discuss AIDS in terms of security was symbolic.

[That] was the first time that the Security Council had debated on something that was not war and peace. That was a breakthrough because it opened so many doors, and presidents, prime ministers say ‘oh, it was debated in the Security Council; this must be a serious problem’ (quoted in Public Broadcasting Service 2006).

Whether or not HIV/AIDS is a threat to security or should be defined as such are questions beyond the scope of this chapter.67 However, the securitisation of AIDS was significant in terms of regime consolidation as it drew attention to the regime and generated a series of new organizational commitments. This proliferation of organizational energies included the expansion of the regime’s decision-making

67 The possibilities, dangers and limitations of defining AIDS as an issue of security has produced a large body of literature in International Relations in recent years (Altman 2003; Barnett 2006; Barnett and Prins 2005; Elbe 2005; Feldbaum, Lee, and Patel 2006; Garrett 2005; McInnes 2006; Peterson 2002/3; Prins 2004; Singer 2002).

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procedures through new global frameworks, such as the Millennium Declaration, the Declaration of Commitment and the Political Declaration on HIV/AIDS; and the creation of mechanisms, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria.

The Millennium Declaration

The Millennium Declaration (A/RES/55/2) was adopted in September 2000 at a summit of 197 nations, which addressed global challenges relating to peace, security, and development, including the environment, protection of vulnerable groups, human rights, HIV/AIDS and governance. The Millennium Declaration represents a global agenda that includes eight development goals with specific and measurable targets. One of the MDGs is specific to HIV – MDG 6 is to halt and reverse HIV/AIDS by 2015 – however it was acknowledged that HIV/AIDS relates or impacts upon all of the MDGs (UNAIDS 2005b, p.17-18).

UNGASS and the Declarations

The Millennium Declaration laid the groundwork for a global summit specifically on HIV/AIDS (A/RES/54/283). Therefore, in May 2001, after months of preparation and negotiation, roundtables and side-meetings, UNGASS opened in New York. The historic meeting involved 189 nations, including Heads of State, Heads of Government, Vice-Presidents, Deputy Prime-Ministers, Ministers of Health and other government officials. Just as important was the attendance of more than 2000 representatives of activist groups, service organizations, PWAs and the private sector (UN Department of Public Information 2001a). At the end of three days of debate, UNGASS produced the Declaration of Commitment on HIV/AIDS (A/RES/S-26/2). Hailed as ‘a watershed event’ (UN Department of Public Information 2001b), the Declaration of Commitment was a blueprint for waging war on AIDS and was universally accepted. With its main message being ‘Global Crisis-Global Action’, the Declaration of Commitment was intended to not only emphasize a climate of emergency but also the need for a comprehensive, multi-layered response to the pandemic.

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The Declaration of Commitment reinforced the global AIDS norms by reaffirming the centrality of human rights and PWA involvement, the importance of strong national leadership, the necessity of evidence-based prevention, treatment and care, the need for a coordinated, comprehensive and multi-faceted AIDS response and the requirement of global cooperation. However, more than a rhetorical statement, the Declaration of Commitment also introduced new decision-making procedures through the establishment of a number of clear, although non-binding, targets that were to be assessed in 2003, 2005 and 2010. In order to achieve these targets, a monitoring and evaluation framework was developed which identified a set of 19 key indicators with which progress can be measured (A/RES/S-26/2).

The weakness of the Declaration as a decision-making procedure lay in terms of the lack of enforcement and the extent to which governments have ultimate jurisdiction over anti-AIDS efforts within their borders. UNAIDS clearly states that ‘primary responsibility for implementing the Declaration of Commitment lies with Governments’ (UNAIDS Programme Coordinating Board 2002). The UN system can only ‘promote’, ‘support’ implementation, ‘monitor’ achievements and ‘endorse’ the 19 indicators (UNAIDS Programme Coordinating Board 2002). Furthermore, in order to reach consensus, the Declaration of Commitment was vulnerable to political pressure from conservative governments. Thus there is no specific mention of certain high-risk populations such as men who have sex with men, sex workers and drug users or the particular vulnerability of women. This led to mixed reactions from the nongovernmental sector (UN Department of Information 2001a).

The problems have not gone away. In 2006, a high-level meeting on AIDS took place, this time to review the progress and the implementation of the UNGASS targets. There was much optimism that private actors and states would be able to work together to build on the first declaration to increase targets and get results. However, conservative governments again hindered the negotiations and the many activists felt that the resultant Political Declaration on AIDS (A/RES/60/262) was a watered down version of the first (Smart 2006). There were some new developments such as the expansion of the definition of universal access to include not just treatment but also prevention, care and support and the recognition of the feminisation of HIV/AIDS (UN General Assembly 2006). While the failure to reach many of the targets and the

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limitations of the process have been acknowledged by leaders such as Peter Piot and the President of the UNGA, Jan Eliasson, these same leaders have argued that the declarations that we have ended up with are better than none at all. Furthermore, while states may have had the ultimate say into what went into the declarations and the extent to which the declarations can be enforced within the intergovernmental system, the targets and indicators of the declarations have provided ammunition for non-state actors. As Mameli (2000, p.217) notes, the existence of international instruments is not enough to guarantee implementation, however, these instruments do provide a focal point and a platform from which non-state actors can monitor state performance and hold governments accountable.

The Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria

The Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (‘Global Fund’ hereafter) was created in 2001 (and launched in 2002) to increase resources for the three diseases and direct them where most needed. The idea of a global fund was conceptualised by an American economist Jeffrey Sachs and was taken up by the Secretary-General Kofi Annan who used the political momentum of the Millennium to call for a ‘war chest’ to fight AIDS and other diseases linked with poverty (Public Broadcasting Service 2006). The 2001 Declaration called for the need for more AIDS-related resources, supporting:

…The establishment, on an urgent basis, of a global HIV/AIDS and health fund to finance an urgent and expanded response to the epidemic based on an integrated approach to prevention, care, support and treatment to assist Governments, inter alia, in their efforts to combat HIV/AIDS…(A/RES/S-26/2).

The Group of Eight (G8), meeting a month later, endorsed the fund and helped finance it. A Secretariat was formed in January 2002 and several months later, the first grants were approved (Copson and Salaam 2005, p.3-4).

The Global Fund is a funding instrument whose function is to ‘attract, manage and disburse resources’ (Global Fund 2008b). It is independent of the UN system. In this way it tries to remain apolitical and ‘not mired in bureaucracy’ – a common complaint

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made of the UN (Richard Feachem quoted in Public Broadcasting Service 2006). The Global Fund is an example of a public-private partnership. Its Board consists of representatives of donor and recipient governments, non-governmental organizations, the private sector and representatives of affected communities. Thus, like UNAIDS, the Global Fund has taken on an ‘ideology of multisectoral participation’ (Richard Feachem quoted in Public Broadcasting Service 2006). UNAIDS, WHO and the World Bank are also represented but they are not voting members. The Board meets twice a year and approves the grants. The Secretariat is responsible for day-to-day operations and is led by the Global Fund’s Executive Director.68

Multisectoral participation is central to the way that the Global Fund works on the ground as well. As mentioned above, the Global Fund is a financial instrument – it is not an implementing agency. Instead, national committees called country coordinating mechanisms (CCM), made up of diverse stakeholders, put together a grant proposal. Grants are given according to the level of financial resources available to a country and the burden of disease. However, successful proposals are also those that develop new, and expand on old partnerships across all sectors of society, involve affected communities, build on existing strategies, encourage transparency and accountability and aim to discourage or eliminate stigmatisation and discrimination (Global Fund 2005). When the grant is approved, the funding is given to the CCM-nominated principal recipient, which can be an NGO or a government agency, and which then implements the program under the watchful eyes of an independent auditor and a Global Fund Local Fund Agent (Copsom and Salaam 2005).

Interestingly, funding is not given all at once. Rather it is disbursed according to performance. This is to prevent fiscal irresponsibility and encourage adherence. If results are seen and independently validated, the funding continues. If not, the funding is withdrawn and reallocated (Richard Feachem quoted in Public Broadcasting Service 2006). In a way this could be considered an enforcement procedure, something that is not available to organizations such as UNAIDS. Even the grant application process is a form of enforcement as the Global Fund has the ability to encourage norm adherence (such as the implementation of multisectoral governance

68 The first Executive Director was Dr Richard Feachem. When he stepped down in 2007, Dr Michel Kazatchkine was selected as his successor.

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practices) and punish norm violation (such as not approving applications that ignore the issue of human rights for PWA).

As of January 2008, the Global Fund had approved US$10.1 billion to more than 550 grants in 136 countries. 61 per cent of these grants have gone towards HIV/AIDS related activities with the majority going towards projects in low-income countries. As of December 2007, 1,400,000 people were on ARV treatment as a result of Global Fund grants. Furthermore, a total of US$18.4 billion had been pledged and/or contributed through 2010 to the Global Fund. The majority of funding has come from states but a small but important portion has been donated by organizations and individuals (at 4 per cent). The majority of the state funding, at 68 per cent. comes from Europe (Global Fund 2008c).

The Global Fund suffers from several challenges. There have been concerns regarding the operations of CCMs and the slow dispersal of grants for example (Copson and Salaam 2005). A bigger issue is that of replenishment and sustainability. Antiretroviral treatment requires long-term adherence and this requires long-term health planning and provision of drugs. The Global Fund is inexorably dependent on states and as such is threatened by ‘donor fatigue’ (Poku 2002; Renwick 2004). Activists have been concerned about the sustainability of the Global Fund, arguing that funding rounds have not been consistent and alleging that grants have been rejected on the basis of low funds (ActionAID 2006). At replenishment meetings donor states have consistently disappointed expectations. A major obstacle is the US, which, despite being the largest contributor to the Global Fund in nominal terms, fails to contribute enough in proportional terms. The US has instead preferred to put its billions into the President’s Emergency Plan for AIDS Relief (PEPFAR).69 Furthermore, there has been criticism of the Global Fund’s disease-specific approach, which has sometimes failed to consider the inadequacies in health systems. An increase in funding is appreciated but still problematic if there is still a major problem of implementation, with many countries lacking the infrastructure to use the available

69 PEPFAR, and its successor PEPFAR II, are bilateral initiatives aimed at countering the disease in 15 countries (as opposed to the Global Fund’s 130) over five-year periods. PEPFAR had a budget of US$15 billion. PEPFAR II has a budget of US$30 billion. PEPFAR has been controversial. While it clearly provides much-needed resources. it has been criticized for its use of expensive patented drugs, the promotion of abstinence over condom use and the circumventing of governments in order to fund a few hand-picked NGOs. For more information see PEPFAR Watch (2006).

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resources promptly and effectively (Lancet Infectious Diseases 2007, p.695; Poku 2006). Nevertheless, despite its many challenges, the funding mechanism remains an important example of new organizational commitments that have been generated in the consolidation period.

Therefore, as a result of the key regime driver UNAIDS, since the 1990s we have seen the issue of AIDS, in addition to its prior constructions as a biomedical/public health issue and a human rights issue, increasingly linked with security as UNAIDS has attempted to generate increased political mobilization. The expanding linkages is one way of viewing the consolidation (or broadening if you will) of the regime. However, since 2000, we have also seen the creation of new (albeit flawed) decision- making procedures though the frameworks of the Millennium Declaration, the Declaration of Commitment and the Political Declaration on AIDS and the mechanism of the Global Fund. The proliferation of these organizational energies, not to mention the platform for action that these commitments have given norm defenders, have further strengthened the normative power of the global AIDS regime.

2.4.3 CONSOLIDATION THROUGH THE EXPANSION TO NEW ACTORS

Further evidence of the consolidation of the global AIDS regime lies in the recruitment of (and targeting of) new actors. As the global AIDS norms increasingly change the language and the behaviours available to actors, it becomes difficult to operate outside this normative framework without receiving opprobrium. To illustrate this process, I will use the case of the transnational corporate sector. Over the last decade, particularly over the last five years it has become increasingly difficult for the corporate sector to remain apathetic in the face of the global AIDS pandemic.

While states and civil society actors have been involved in the development of the global AIDS regime from the beginning, the corporate sector has been noticeably absent from these proceedings. Although the principle of involving the sector was present in resolutions and guidelines, as the head of the Global Business Coalition on AIDS, Tuberculosis and Malaria (GBC) has stated, most companies ‘have had their heads in the sand’ (quoted in d'Adesky 2003). However, Ruggie (2002; 2004) has

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noted that companies, as social actors, are not immune to society’s problems, nor are their actions free from accountability.

The recruitment of the private sector has been seen as a necessary step in the global response to HIV/AIDS. With their ability to make quick decisions, allocate resources efficiently and utilise global networks, large companies have the capacity to supplement government and intergovernmental responses to HIV/AIDS (Ruggie 2002). Small businesses can also be important in promoting non-discrimination in the workplace. As Peter Piot stated in 1997:

The hope of solving many problems lies in the development of public/private partnerships. Governments and nongovernmental organizations…cannot do it alone. We need the private sector’s help in the fight against HIV/AIDS (quoted in Bloom, Mahal and River Path Associates 2002, p.4).

Since the late 1990s, the corporate sector has had increased visibility in relation to the global AIDS regime. On the one hand, there has been a movement from within the corporate sector to act in accordance with the global AIDS regime. On the other hand, companies that have not operated in accordance with the global AIDS regime have been targeted by activists.

In the first case, there has been increasing engagement between the transnational corporate sector and other actors. We have seen for example the creation of global business alliances like the GBC and the Global Health Initiative (GHI). The GBC was established in 2001 and is currently headed by Richard Holbrooke, former US ambassador to the UN under the Clinton Administration. In the five years that it has been operating, the GBC has grown from a membership of 17 to a membership of 200 international companies. The GBC’s modus operandi is to assist companies to develop HIV/AIDS strategies, which not only alleviate the effects of the epidemic on their own workforces but also help to educate and diminish discrimination and stigma in the broader community. Companies can assess their progress with the Best Practices AIDS Standards (again promoting the norms of human rights, multisectoral cooperation and global responsibility), as developed by the GBC, and they are also encouraged to partner with governments and civil society to develop more

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comprehensive national AIDS strategies. The GBC is the private sector focal point to the GFATM and has offices in New York, Beijing, Paris, Geneva and Johannesburg (GBC 2008). Its visibility at high-level meetings such as UNGASS works to strengthen the understanding that effective HIV/AIDS governance must involve all actors in the international system.

The GHI, launched in 2002, is an initiative of the World Economic Forum (WEF), an independent international coalition with a membership of over a thousand companies and over one hundred partnerships. Like the GBC, the GHI seeks to engage businesses in public-private partnerships to tackle HIV/AIDS, tuberculosis, and malaria and build health systems. Therefore, this initiative facilitates partnerships between government actors, intergovernmental organizations, businesses and civil society actors. The WEF’s annual meetings keep global health on the agenda of some of the leading corporations in the world. Like the GBC, the GHI also works with the WHO, the ILO, UNAIDS and other relevant partners to develop and communicate corporate best practices. The GHI is also a permanent member to the private sector delegation to the GFATM (WEF 2006).

These are just two examples of the many coalitions and public-private partnerships that have proliferated in the last decade. This proliferation helps to consolidate the AIDS regime because, again, the organizations are speaking the language of the regime, with many of their underlying principles and values and subsequent actions reflecting the norms of the AIDS regime. There are very real economic or instrumental reasons for businesses to adopt HIV/AIDS policies,70 which indubitably influences decision-making. However, while activists have accused some companies of only agreeing to adopt HIV/AIDS policies as a public relations exercise, it is meaningful that the corporate sector understands that the public expects companies to be contributing in the fight against AIDS whether this is directly helping employees

70 AIDS can affect a company’s workforce incapacitating skilled workers. Recruitment and training costs increase, and in some cases, companies are obligated to pay medical bills or funeral costs. Furthermore, what is a business without customers? As people become sick, their demand for health- related goods and services may increase, but their demand for other goods and services will decrease. Finally, as can be seen in the case of Coca-Cola, inaction can lead to damage to reputation or the global brand (Bloom, Mahal, and River Path Associates 2002, p.6-13).

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or contributing to the Global Fund.71 In other words, the norms of multisectoral governance and global responsibility have shaped the way in which businesses seek to improve their reputation and their branding. In turn, the norms are strengthened and consolidated by the private sector’s actions.

However we have also seen an increase in activism targeted at large multinationals. The majority of activism has been targeted at northern pharmaceutical companies that have stood accused of putting profits before health. This activism as exemplified by the TAC and other NGOs has already been discussed in part above and by others at greater length (Lanoszka 2003; Smith and Siplon 2006; Thomas 2002). However, activists have also targeted multinational corporations with operations in areas affected by HIV/AIDS. Their argument is that if the private sector is not part of the solution, it is part of the problem.

An example is the case of Health GAP versus Coca-Cola. Coca-Cola is the largest private employer in Africa and thus well situated to become a valuable partner of UNAIDS. In 2001 at UNGASS, as part of that partnership, Coca-Cola announced that it would provide or pay for treatment for its employees living with HIV/AIDS. However, this treatment was only made available for the 1,200 direct employees of the firm’s international division in Africa and excluded the 58,000 people72 included in the wider Coca-Cola system. Health GAP and other treatment activists challenged Coca-Cola’s differential treatment policy and launched a worldwide campaign against the company in 2002. Actions included demonstrations in major American cities, product boycotting and a Global Day of Action on four different continents on October 17 2002. This pressure led to Coca-Cola promising to make treatment available to all of its employees (Health GAP 2003; Leith 2002).73 Again, as previously discussed in the section on agency, the actions of these activists against norm-violating companies helps to strengthen the AIDS norms, especially when the

71 GBC (2004) used the term ‘good corporate citizen’ in a poll that it conducted in the US in 2004. The poll demonstrated that the majority of American consumers would rather buy products from companies that they believe are ‘good corporate citizens’. 72 Health GAP put the number at 100,000 people. 73 By Coca-Cola’s own admission, the rollout of drugs has proved difficult and comprehensive coverage has not yet been achieved (Interfaith Center for Corporate Responsibility 2004). Groups such as Health GAP and ACT UP have continued to apply pressure (Health GAP 2003). However the Interfaith Center on Corporate Responsibility (2004), while noting the company’s shortcomings, has praised Coca-Cola for its actions.

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results of a campaign against a targeted company ends in that company implementing concessions in line with those norms.

This section has therefore argued that the expansion of the regime’s participants to include new actors such as the corporate sector is evidence of further consolidation of the global AIDS regime. The normative framework of the regime is sufficiently strong so as to make companies adjust their rhetoric at least and often their behaviour in line with the regime for fear of becoming the target of transnational campaigns and putting their reputations at risk. There is also evidence that in some cases, companies are implementing AIDS policies even when it is not in their interests to do so but because they consider it their responsibility to do so. For example, Ruggie (2004, p.517) notes that Heineken and DaimlerChrysler both decided to provide workplace treatment in Africa despite the costs exceeding the direct monetary benefits. ‘The evidence suggests a willingness by both firms to accept a broader social role in society, in light of the inability and in some cases unwillingness of governments to act’. This suggests that as the normative power of the regime is consolidated, it is not only influencing the behaviour of some companies but it is also changing the social meaning of what it means to be a ‘good’ company.

2.5 CONCLUSION

The aim of this chapter has not been to claim that a perfect global AIDS regime exists. It does not. There is a large literature that identifies the many complexities, challenges and the limitations of the global response to HIV/AIDS.74 This chapter has noted that in relation to enforcement and implementation, the global AIDS regime remains weak. Nevertheless, a global AIDS regime does exist and its value lies in the strength of its norms. As such, this chapter has looked at the evolution of this declaratory regime. This has seen the movement from no global response in the pre- regime period to the period of regime emergence, where the global response was shaped by norm entrepreneurs and the resulting organizational energies. Finally, in the period of regime consolidation we have seen further agency and the geographical expansion of the regime (as movements outside the North take up and reinforce the

74 For example, see the special anniversary issue of International Affairs in 2006 (volume 82, issue 2) on the challenges posed by HIV/AIDS.

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norms of the regime), the broadening of the regime through the linking of AIDS to security and the subsequent generation of new organizational commitments, and, lastly, the expansion of the regime to include new actors.

In discussing the evolution, features and dynamics of the global AIDS regime, this chapter has thus introduced the external context and the expectations against which China’s governance of AIDS will be measured. In keeping with the framework developed in chapter one, the extent to which the normative power of the regime is able to overcome the weaknesses of its decision-making procedures and influence the actions of the Chinese government, depends in large part on the domestic political opportunity structure of China (e.g. the openness of its political system, the domestic normative context and the political interests and goals of the elite). This is the subject of the next chapter.

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CHAPTER 3: CHINA’S DOMESTIC CONTEXT: POLITICAL STRUCTURE,

DISCOURSES AND INTERESTS

3.0 INTRODUCTION

Having conceptualised the evolution of the global AIDS regime, it is necessary to now turn our attention to China’s domestic context. The domestic context of a state can ‘mediate, filter, and refract’ the domestic uptake of global norms (Risse-Kappen 1995, p.25). The theoretical framework discussed in chapter one argued that the domestic context can be broken down into three dimensions – the political structure, the relevant normative context, and interests and goals. The first section of this chapter thus explores the distinctiveness of the Chinese political system by looking at three key features of the regime - the Party-state relationship, centre-local dynamics and state-society relations. The second section looks at the official discourse on sex in China. While a comprehensive account of China’s cultural makeup is beyond the scope of this chapter, the nature of, and the implications of responding to AIDS necessitates an examination of the way in which the Chinese government has publicly constructed sex and sexuality. The third section of this chapter will study the key interests and goals that motivate Chinese decision-makers. I argue that China’s decision-makers are primarily interested in preserving power. In order to do so they pursue a number of legitimating goals which include economic development, the maintenance of domestic and international stability and the improvement of China’s international standing.

3.1 KEY FEATURES OF THE POLITICAL SYSTEM

Students of domestic political structures argue that the non-uniform impact of global norms from state to state can be understood by studying how institutions shape ‘the game of politics’ (Checkel 1998b). This approach asks questions such as: Who holds the power to make decisions? Are these decisions able to be contested? Who implements policy? What role does civil society play in the political proceedings? An examination of the features of a state’s political structure can thus help us to identify points of access to decision-making or blockages which might affect the extent to

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which global norms can influence domestic governance. China’s domestic structure is best understood by looking at three key features of the regime. Thus this section will first explore the relationship between the Chinese Communist Party and the government; second, it will look at the dynamics between the centre and the provinces; and thirdly, the relationship between the state and society will be examined.

If we revisit the typologies of domestic political structures mentioned in chapter one,75 China does not fit neatly in one category.76 Given the primacy of the party over the government and of the state over society, China leans towards the ‘state-above- society’ (Checkel 1998b) or ‘state-controlled’ (Risse-Kappen 1995, p.23-24) classifications. However, in that the central government relies on the provincial and lower level governments to implement its policies, China is not as centralized as these models assume. Finally, while the Chinese political structure is more ‘closed’ than ‘open’ (Khagram, Riker, and Sikkink 2002, p.17), closer inspection reveals state- society relations are more dynamic and subject to negotiation than a straight-forward ‘closed’ classification would acknowledge.

3.1.1 THE PARTY AND THE STATE

An important feature of the People’s Republic of China (PRC) is the relationship between the CCP and the government or the state institutions. While other parties do exist in China – there are in fact eight other ‘democratic parties’, coopted though they may be (Saich 2001, p.80) –the only one that has any political authority is the CCP. Based on Marxist-Leninist principles, the CCP was created in 1921. After a long and protracted struggle against the Chinese Nationalists, the CCP came to power in 1949 and claimed authority to rule as the People’s Democratic Dictatorship, acting on behalf of the working class. With a membership of just under 70 million members (eight per cent of the adult population), the CCP is the largest ruling party in the world (Brodsgaard and Zheng 2006, p.1). Of those 70 million, only 25 per cent are cadres. China’s political elite, which Walder (2006, p.19) defines as all cadres at the

75 Chapter one, section 1.4.2.2, p.38-39. 76 In fact, Oksenberg (2002) argues that China’s current system defies encapsulation in a single short phrase.

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rank of country magistrate or above,77 is a group of roughly 500,000 people, 95 per cent of whom are members of the CCP. Of this elite, power is centralized in the twenty or so members of the Political Bureau (Politburo), its Standing Committee, the Secretary General (the top position in the party since the post of chairman was abolished in 1982) and the head of the Central Military Commission (Burns 2006, p.52). At the top of this vast and complex system is the general secretary. Under the centre, the party is represented at each territorial level of government by party committees, chosen by party congresses, and the secretariats, chosen by the committees (Saich 2001, p.81).

While it is common to conflate the CCP and the government, the party structure and the government structure are in fact two separate systems. Although the CCP is in charge, its institutions such as the National Party Congress78 and the Politburo do not comprise the ‘state’, which can be defined as the legislative, judicial, administrative, and military institutions and the people who manage these institutions (Zheng 1997, p.18). The 1954 Constitution established a number of state organs that constitute the government structure. The National People’s Congress (NPC) and its Standing Committee make up the legislature, formally empowered to make constitutional amendments, create laws and elect the President, the Vice-President and other key state positions. The judiciary, comprised of the Supreme People’s Court and the Supreme People’s Protectorate, is empowered to interpret the law. The State Council, headed by the Premier, is the executive. The various ministries (such as the MOH and government agencies under the State Council are authorised to create and implement policies in line with the laws of the NPC. The military is represented in government by the Central Military Affairs Commission (Saich 2001, p.110-140). The official head of state is the President. Under the centre, the territorial level governments are called the people’s congresses and at the lowest levels of local government these bodies are popularly elected (Zheng 1997, p.170).

77 Below the centre, there are five de facto levels of local government: the province, prefecture, county, township and village. 78 The National Party Congress, convening every five years, is theoretically the top of the party pyramid, however Saich (2001, p.85-86) notes that the function of the Congress is mainly symbolic with the Politburo in fact being the more powerful body.

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While these state institutions exist, they have served mainly to administer party policy rather than operating as a system of checks and balances. The 1982 State Constitution79 institutionalised the principle of the separation of the responsibilities of the party and those of the state, however in practice there is much overlap. At the centre, the lines between the party and the state often become blurred. The practice of ‘interlocking directorates’, or simultaneously holding both an official party post and a government post, continues to be a common practice (Brodsgaard and Zheng 2006, p.6; Zheng 1997, p.19-20). For example, the President of the PRC, Hu Jintao, is also the General Secretary of the CCP and the head of the Central Military Commission. Wu Bangguo is both a member of the Politburo Standing Committee and the chairman of the Standing Committee of the National People’s Congress. The Premier, Wen Jiabao, is also a member of the Politburo Standing Committee. Thus the CCP has penetrated deeply into the government, and to a certain extent, into the military as well.

If at the centre the overlapping of party and government posts allows for a ‘United Front’, the party-state dynamics make for a complicated structure of governance below the centre. On the one hand, there is a vertical system whereby the flow of information and command runs up and down through the system via a particular policy branch such as health. At the top of the chain is the central ministry, in this instance the MOH, which has jurisdiction over provincial, county and city departments of health. On the other hand, there is a horizontal system where at each territorial level, the party committee has authority over all government organizations within its geographic jurisdiction. Therefore the provincial party committee of Henan has authority over the Henan health sector. The vertical lines (tiao) and horizontal blocks (kuai) characterise a system which is often described as ‘fragmented authoritarianism’, a model of governance which suggests that authority below the very peak of the Chinese political system is ‘fragmented’ (Lieberthal 1992, p.8). Needless to say, this overlapping jurisdiction leads to ‘factionalism, localism and departmentalism’ (Xia 2006), as different authorities guard and negotiate their areas of jurisdiction. While the most popular argument is that the party’s interests generally

79 The 1954 Constitution ceased to operate when state institutions were dismantled during the Cultural Revolution (1966-1976). Two more constitutions were adopted in 1975 and 1978, both reflecting the politics of the time. The 1982 version is the current constitution (Saich 2001, p.110-111).

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reign over state interests, Zheng (1997, p.19) makes an interesting counter argument. He assumes that where bureaucrats have a dual status as government official and party member, ‘membership in the party has less bearing than one’s assumed responsibility and institutionally generated role on one’s political preferences’. This does seem to be more the case away from the centre. Zheng gives an example of an official who is both the provincial governor and the deputy secretary of a provincial party committee. As the head of government at the provincial level, if something goes wrong it is the governor’s fault. As deputy party secretary, if something goes wrong it is someone else’s fault. Therefore, the official will be more responsive to his government functions rather than those of the Party (p.19-20). This is not just a party- state issue, but also an issue for centre-local relations, which will be further discussed below.

While those hoping for a liberal democratic China have so far been disappointed,80 there has been significant political reform in the last two and a half decades. The CCP has had to adapt to changing times in order to survive. After the Cultural Revolution, Deng Xiaoping realized the ‘the lack of effective institutions and checks on arbitrary authority had helped bring about disasters in the Mao years’ (Zhao 2006, p.230). Despite being propelled by the consequences of the Cultural Revolution, political reform was also understood to be instrumental for the creation of popular support for the regime, the maintenance of social stability and the construction of a stable climate for foreign investment (Zheng 1997, p.162-165).81 As mentioned, the 1982 Constitution attempted to loosen the grip of the party and clarify the separation of the roles and functions of the party and the state. Thus, the CCP’s power was downplayed, mentioned only in the preamble (Saich 2001, p.110). The Constitution strengthened the legislative powers of the NPC, such as allowing the Standing Committee to formulate laws and appoint or remove central ministers when the NPC is not in session.82 There have been efforts to appoint non-party cadres to ministerial

80 On the issue of a future democratic China, there is debate over whether it is a possible or even desirable outcome. Peerenboom (2007), pointing to examples of problematic democracies in South East Asia, argues that democracy is not a cure-all. Chao and Lee (2006) examine the case of Taiwan and propose that the CCP-led state is not necessarily incompatible with democratic development. Pan (2006), on the other hand, proposes that the PRC might be better suited to a consultative rule of law regime, styled after the Singapore and Hong Kong models. 81 See section 3.3 below for more discussion on legitimacy. 82 At more than 2,900 members the NPC is too unwieldy to be able to act frequently and effectively. With only 156 members the Standing Committee is better able to come to decisions and therefore the

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positions, for example in 2007 the positions of Minister of Health and Minister of Science and Technology were given to two non-party members, Chen Zhu and Wan Gang (China Daily 2007). The legal system, in tatters following Mao’s ‘rule of man’, has been rebuilt with the CCP repeatedly declaring its intentions to move towards a ‘rule of law’ regime (Brodsgaard and Zheng 2006, p.6-7). Further reform has included efforts to introduce a civil-service system and greater transparency into an otherwise opaque system (Oksenberg 2002, p.198).

However, as Zheng (1997, p.256) notes, the CCP has wanted to ‘have its cake and eat it, too’. While it has attempted to strengthen the government, it has not wanted to relinquish its control on power. For example, while the NPC’s outcomes ‘have become less easy to predict’, it continues to be dominated by party members and the party still controls the majority of key appointments, despite the domestic media stating that China is moving towards multiparty cooperation (Brodsgaard and Zheng 2006, p.6-7; Saich 2001, p.112-115, 126-129). Politically, the party is the only avenue for advancement and few can achieve real political influence without membership (Saich 2001, p.95; Walder 2006, p.20-21). Despite the focus on institutional authority over personal authority, an emphasis on cadre accountability and constitutional amendments, the legal system is still far from constituting a ‘rule of law’ regime as understood in the West (Zhao 2006, p.244-245). Law making is directed by or at the least approved by the party and thus ‘rule by the party by law’ is the best way of describing the current system (Zou 2006, p.95). Thus it has been noted that as a general principle, with regards to the party-state relationship, ‘the CCP leads and makes policy, whereas the government implements policy’ (Mackerras, McMillen, and Watson 1998, p.10). The CCP is still very much in control (Brodsgaard and Zheng 2006, p.2; Gries and Rosen 2004, p.16; Saich 2001; Weatherly 2006, p.169).

This feature of the regime, or the continuing dominance of the CCP in decision- making, has several implications in the context of this thesis. We can hypothesise that the norms of the global AIDS regime will have more impact if they resonate with the norms and interests of the party elite because it is the elite that determines what makes it onto the political agenda. This makes the consideration of the interests of the elite strengthening of the Committee’s powers ‘greatly enhances the NPC’s legislative powers’ (Zheng 1997, p.167).

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all the more important (to be examined below). Furthermore, because of the nature of the party hierarchy, the actions and rhetoric (or inaction and silence) of high-level leaders such as members of the Politburo are politically symbolic. Therefore, we can analyse the salience of international AIDS norms by using the actions and statements of high-level leaders, in conjunction with the allocation of resources and the creation of new institutions. These elements comprise the first indicator used to study China’s AIDS governance in chapters four and six.

3.1.2 CENTRE-LOCAL RELATIONS

The second key feature of the Chinese political system that conditions the receptivity of global norms is the division of authority between the centre and local authorities.83 While later chapters will examine the relationship between the centre and the localities with regards to public health and disease prevention and control, it is important to situate this in the wider debate on the dynamics between the centre and the localities. There are many different approaches to analysing centre-provincial relations. In an overview essay Chung (1995) distinguishes among cultural, structural and procedural approaches. In this thesis my major concern is with the relative autonomy of the provinces rather than the causes of conflict. Within this debate, there is little consensus on how much discretion the localities have vis-à-vis the centre. In this section I will look at the main arguments relating to local compliance with central dictates and the key determinants in the centre-local relationship before arguing that centre-local relations are always contingent and negotiated.

In this thesis, the main focus is on national AIDS policymaking and therefore the research has primarily drawn from central government sources. There is evidence that AIDS policymaking in China is a top-down process (Zhang, Yu, and Fang 2005). Decisions regarding national AIDS policy are made by relevant ministries at the central government level and are then translated into directives that are issued to the provincial governments. From this evidence we might hypothesise that were the principles and objectives underlying the directives to change, we would see change occur throughout the system. However, the PRC has a large territory with a huge

83 In this section I use ‘local’ and ‘provincial’ interchangeably.

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population. Beyond Beijing, there are 22 provinces, five autonomous regions (Tibet, Xinjiang, Inner Mongolia, Guanxi and Ningxia) and two Special Administrative Regions (SARs) which include Hong Kong and Macau. There are also four municipalities under the control of the centre (Beijing, Shanghai, Tianjin and Chongqing). Below the provinces and autonomous regions, there is a de jure three- level administrative network of prefectures, counties and cities, and townships and districts (Saich 2001, p.141-143). Governance of AIDS in China is thus not only about the centre making decisions, but also about the extent to which provincial and lower level governments have discretion in how they chose to comply with central directives and carry out or implement those decisions. While there is a common perception of China as a monolithic, totalitarian, coherent structure with lower level officials always obeying the central government, the large body of research on centre- local relations illustrates that this is seldom the case.84 While there is agreement that the monolithic view of China is unrealistic and outdated, there is no consensus over the extent to which the centre is able to impose its views or the degree of local autonomy.

On one side of the debate, it is argued that the provinces have a large degree of autonomy and this relates to fiscal decentralization. The dynamics between the centre and its subordinate agents changed significantly in the reform era when the central government under Deng Xiaoping committed to moving China away from a command economy to a ‘socialist market economy’ (Bernstein and Lü 2003, p.2). While previously the central government had planned economic policies for the provinces and lower governments and controlled the extraction and redistribution of state revenues, part of the reform package implemented in the 1980s included the decentralization of economic management and decision-making to local governments and private enterprises. Fiscal revenue-sharing arrangements allowed local governments to retain a larger proportion of local revenue and invest it at the local level, while also giving local governments increased responsibility over the provision of public goods (Bernstein and Lü 2003, p.8).

84 Breslin (1993, p.10-40), Chung (1995) and Zheng (2007, p.1-30) offer excellent surveys of the field.

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These reforms have had implications for centre-local relations. Rich provinces such as Guangdong have become more politically influential as evidenced by the increased proportion of representation on central party organs (Saich 2001, p.144-145). While decentralization was intended to stimulate innovation and economic growth, and did so, it has meant that the centre has lost a certain degree of control over resources, and as some argue, over the scope and implementation of policies (Bernstein and Lü 2003, p.8, 10-11; Breslin 1999; Yang 1994, p.63). In the area of public health policy for example, Bloom argues that the devolution of financial responsibility has reduced the direct influence of higher levels of government (2005, p.31).85 Sargeson and Zhang (1999) have argued that for lower-level officials the market can provide material incentives far greater than those offered by the higher levels of the government and therefore some orders, from which officials do not stand to benefit, may be ignored. Or, in order to achieve the central government’s economic performance targets, other central government policies that divert funding away from economic goals may be deliberately disregarded. For example, Bernstein and Lü (2003, p.12), in their study of taxation in rural China, noted that the central government’s directives to local governments to decrease the ‘peasant’s burden’ were not complied with because the ability to extract taxes from the peasants helped the local governments to reach economic performance targets and therefore obtain promotion and bonuses.

Aside from fiscal decentralization, it is argued that the centre is always at a disadvantage due to the fact that it must rely on its subordinate agents to implement, monitor and enforce its policies. It has been argued the further one travels from the centre, the higher the level of non-compliance (Wedeman 2001, p.81). Wedeman (2001, p.81) notes that if the centre gives an order, it is passed down to the province, which must then pass it down to the county and so on. Whether an order is carried out faithfully will depend on an official’s assumptions regarding what the centre wants, the odds that non-compliance will not be detected or punished and so on. Therefore, at any level an official could misunderstand an order, attempt to implement the order and fail, or deliberately disobey the order.86 In such a system, accountability and

85 The health system will be discussed in more detail in chapter five, section 5.3.1. 86 While Wedeman (2001, p.81) acknowledges that the central government has attempted to counter and audit non-compliance in the horizontal system of territorial-based units via the vertical system of governance (the hierarchy of local bureaus of central ministries and centrally-based functional systems), he argues that this parallel system suffers from the same problems.

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transparency suffer, and information asymmetries and systemic corruption, to the disadvantage of the central government, can result.

On the other side of the debate are those who argue that the centre retains the capacity to ensure lower level compliance. Supporting their argument, they point to the political apparatus of the centre and argue that the loss of fiscal autonomy has not necessarily been paralleled by a loss in political autonomy. Huang (1996, p.315-317) argues that while there has been economic decentralization, China remains politically and bureaucratically centralized and that when the central government really wishes to implement a policy, the system accommodates this prioritisation. This ‘mobilization system’, as Oksenberg (2002, p.195) calls it, was revealed during the SARS outbreak, (which will be discussed in chapter five), when the central government showed its capacity to re-centralize power over the health sector and implement epidemic control (Schwartz and Evans 2007; Wu 2004).

The centre is said to have a number of means by which it can promote lower level government compliance with its policies, including traditional control mechanisms such as ideological campaigns and party school system training programmes, as well as new information and monitoring systems such as the cadre responsibility system (Heimer 2006; Saich 2001, p.147; Wibowo and Lye 2006). However, the most important way is through the promotion and dismissal of officials, both government and party (Huang 1996, p.315-317). The ‘one-level downward’ system means the centre appoints and removes cadres from provinces, while the provinces appoint or remove officials from the counties and so on. Saich (2001, p.146) notes this is a powerful way of rewarding and punishing officials:

One only needs to see the fawning over Jiang Zemin’s local trips or latest pronouncements by provincial party secretaries and even governors to see how powerful this can be in keeping local officials in line publicly.

While it has been argued that the ‘one-level down’ system means that the centre only has indirect control over the territorial units under the provinces and therefore non- compliance increases the further one goes from the centre, Zhang’s (1996) fieldwork

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in Pengzhe County in Jiangxi Province into county and township governments provides counter-evidence.

Chinese local government officials, like politicians in most places, are self-interested and their main interest is in furthering their political career. With political positions come material rewards (Zhang 1996, p.374).

Zhang therefore argues that despite there being undeniable conflicts of interest between the central government and the local government, local governments usually carry out the central government policies and do so because of the political incentives.

I argue that in looking at centre-local relations with regards to HIV/AIDS governance, neither a position that privileges the centre nor one that privileges the local government are suitable. Similar to the findings of Breslin (1993) and Chung (1995), my research indicates that centre-local relations is not a zero sum game and that there are too many variables that can determine how a local government choses to translate a central directive. This can therefore affect the transfer of global norms throughout the domestic political system. This feature of the political system will be returned to in relation to three of the indicators used to analyse the development of China’s AIDS governance in chapters four and six, namely, the manifestations of political commitment, the implementation of policy and legislation and the space for civil society actors.

3.1.3 STATE-SOCIETY DYNAMICS

The final feature of the Chinese political structure that has implications for the way in which global norms have domestic impact is the relationship between the party-state and society. Of particular relevance to this thesis is the extent to which Chinese civil society can act as a conduit for global AIDS norms. I argue that the reform and opening of China has led to increased individual autonomy and the impetus for civic engagement. While the party-state continues to exert considerable control over associational life by defining the rules of engagement, an ‘official’ civil society, that is increasingly internationalised, has emerged and is providing discursive space.

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Like the relationship between the CCP and the government and that between the central government and the lower levels of government, state-society dynamics have been in a state of flux since the 1980s. The economic reforms of the Deng era had important social effects, particularly the loosening of the Maoist system of control. In Maoist China, every dimension of social life was controlled by the state. Who you were, where you lived, who you loved, what you did for work or leisure, or how many children you had was defined by your unit – the collective or the jiti in the countryside or the workplace or danwei in urban China. The segmentation of society into these hierarchical, vertically-controlled structures ensured that horizontal contact between workers, students, and farmers did not occur, thus lessening the risk of the organization of opposition against the CCP (Saich 2001, p.198). Not only did the party-state control who you were, but also what you read, listened to and watched. Rather than mediating between state and society, the mass media was viewed as another arm of the state and was hence used to communicate the ideology and policies of the CCP to society (Chang and Qiu 2002, p.28-29). As such, the state tightly controlled the dissemination of information, subjecting the mass media to strict censorship and suppressing media opposition. Likewise, associational life was strictly controlled, organized through party-controlled mass organizations (Gallagher 2004, p.423). The degree of control was ‘so pervasive that it was hard to see any clear distinction between state and society; the former pervaded the latter like a nervous system pervading a body’ (White, Howell, and Shang 2003, p.274).

In the ‘reform and opening’ era, the state began to withdraw its control over the economy and certain aspects of society in order to encourage the growth of private enterprise. With the undermining of the vertical-command systems, individual autonomy has increased and the way in which people live, work, and interact with one another and the state has changed (Gallagher 2004, p.423; Saich 2001, p.203-205). While on the one hand, the economic reforms have increased standards of living, it has also brought new social problems, such as pollution and migrant issues, and heightened old ones, such as corruption and social inequity. This has led to increased dissent and open protest and the impetus to form social groups and civil society organizations (CSO) to direct complaints to the government has strengthened (White, Howell, and Shang 2003, p.274-278).

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The government has tolerated and even encouraged the emergence of new CSOs in so far as they can help the CCP reach its goals and may satisfy citizens’ desire for civil involvement.87 Recent statistics released by the Chinese government show that in 2006 there were 353,000 registered civil society organizations (Ministry of Civil Affairs 2006). However, for those who conceive of civil society as ‘a sphere of autonomous organizational space outside of and in opposition to the party-state’ (White 1993), the last three decades have been disappointing. Many of these new organizations have either been devolved from the socialist state or have been created by the state which makes them government operated NGOs (GONGOs). A smaller number have been created independently from within society by individuals and groups (Gallagher 2004, p.424). In that the state seeks to ‘capture, co-opt and control new kinds of resistance and civil action’ (Gallagher 2004, p.436), much of associational life within China is often described under the rubric of ‘state- corporatism’ (Chan 1993), ‘state-led civil society’ (Frolic 1997), ‘mother-in-law system’ (Human Rights Watch 2005) or ‘official civil society’ (Gallagher 2004). These terms are all used to describe ‘the existence of a realm between society and the state which is both constituted by both and subsumed by neither’ (Gallagher 2004, p.421).

The state strictly controls associational life via four major mechanisms. The 1998 Regulations for Registration and Management of Social Organizations for example requires that every social organization have two supervising bodies: the professional business unit (generally a department of government or of the CCP) which acts as the organization’s guarantor; and, the authorizing government body (generally the local civil affairs department) which is responsible for monitoring the organization and imposing punishments if required. The second mechanism is their restricted financial autonomy. Top-down organizations, or those that have devolved from or been created by the state, generally receive some funding from the government whereas bottom-up organizations, or groups that are created within society, are expected to raise funds from society. Bottom-up organizations therefore face the issue of keeping both the authorities (in order to obtain permission to operate) and society (in order to obtain

87 Village elections (introduced in the early 1980s) could perhaps be seen in a similar light. The elections give citizens the semblance of civil participation, as well as help the state fight corruption and diffuse dissatisfaction (Saich 2001, p.177-183).

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funding) happy. The issue of registration and funding have been the major concerns of AIDS organizations (to be further discussed in chapter six). The third mechanism of control is the practice of ‘double-posting’ government or party cadres to leadership positions within social organizations. Again, this leads to the penetration of society by the state and is similar to the way in which the party has penetrated the government institutions. Finally, the ideology of the CCP constrains social organizations. The CCP remains the sole legitimate representative of the interests of the entire Chinese people and this monopoly therefore ‘reduces social organizations to a subordinate role and reduces their ability to speak for their members of their cause’ (Gallagher 2004, p.424-428).

Because of these restrictions, there are many more organizations that exist outside the sphere of state incorporation than there are within it.88 The types of organization that may find themselves outside of ‘official civil society’ can range from those that are considered threatening to the regime (such as some religious and political organizations), which may find themselves subjected to active repression, to those that deal with politically sensitive issues and whose legitimation through registration is considered an anathema to the state (such as groups that represent workers in the floating population and some HIV/AIDS groups). For many organizations, having an application for registration rejected does not represent the end of the road. Generally, as long as these organizations avoid financial misdeeds and remain non-political, the state leaves them alone (Congressional-Executive Commission on China 2005). As Ho (2001, p.905) explains however, not being registered means that an organization is not a legal entity and therefore cannot enter into contractual relations, cannot take care of the basic essentials of the employee and cannot open a bank account. These are three key factors that impede upon the effective functioning of the organization.89 Therefore, while some look to this unofficial civil society with hope for future

88 The actual number of CSOs has been estimated to be perhaps as many as three million (as of 2005). These other organizations are not considered within the official statistics due to their lack of registration (Congressional-Executive Commission on China 2005). 89 Where many bottom-up organizations hope to attract foreign funding, this may be contingent on whether or not the funds are channelled through the government or whether the source of the funding has stipulated that only registered organizations are eligible. Given the difficulties imposed by the registration process, a large number of civil society organizations register instead as ‘commercial enterprises’. However in doing so these organizations run into other issues, such as taxes registration (Congressional-Executive Commission on China 2005). For example, AIDS organizations in China that are classified as enterprises can find themselves ineligible for international grant programs such as the Global Fund.

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political change, Gallagher (2004, p.442) argues that even this civil society is one that is ‘still hampered and constricted by the state’s own activist policies in shaping, managing and co-opting social organizations’.

However, while civil society actors in China have less freedom to challenge the state than in other countries, this is not to say that they lack normative influence. Gallagher (2004, p.435-436) argues that:

To see the evolution [of social organizations] as a process either of growing autonomy or of continued dependence is to miss the way in which the constant interaction between the state and social groups can transform part of the state itself.

Registered social organizations are clearly constrained, albeit to varying degrees according to the field in which they operate, however this should not be taken to mean that these organizations are agents of the state. Saich (2001, p.174) points out that many organizations have found ways of evading controls or have tried to turn the relationship with the state to their advantage. There are many examples of instances where social organizations have had an influence on the making of and implementation of government policy. For example, Ho (2001, p.915) demonstrates that some organizations have played a positive role in the environmentalist scene precisely because of their government connections and resources. Indeed, many environmentalist organizations agree that ‘it is necessary to work from within the nexus of power in order to make a difference’. Gallagher (2004, p.435) notes that social organizations have helped put migrant and other social issues on the political agenda.

Furthermore, Chinese civil society has become increasingly internationalised and this has helped to change state-society dynamics. On the one hand, Chinese organizations are increasingly attending international and global meetings and hence becoming exposed to global norms. Saich (2001, p.174) highlights an interesting case where one GONGO, created as an offshoot of a government department in order to obtain international funding and be a member of the relevant international organization, became sensitised through its international contacts to the inadequacies of the methods of policy implementation back in China and influenced the government to

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change its approach. On the other hand, as a result of the Chinese government becoming more open to foreign aid in order to help it achieve its development goals, the number of multilateral, bilateral and non-governmental actors operating within China has increased (Zweig 2002, p.211-258). As the gatekeeper, the state was originally able to constrain this interaction, by requiring international actors organize their projects and funding via Chinese government counterpart agencies. But as Zweig’s (2002, p.258) study on the politics of overseas development assistance in China shows, constraints on donors have lessened over the last decade.90 Studies have shown that transnational actors have not just provided important financial and technical assistance to domestic civil society actors, they have also helped to disseminate global norms and legitimate and empower the activities of these actors (Wu 2005; Young 2005; Zweig 2002).

This feature of the Chinese political structure can therefore be linked to this thesis in several ways. State-society relations as they relate to AIDS governance in China are clearly linked to the fourth indicator – the role of civil society- used to examine China’s changing AIDS governance in chapters four and six. This indicator looks at the kinds of organizations that have mobilized around the issue of AIDS and the extent to which this civil society, perhaps assisted by INGOs (this links to international engagement, the fifth indicator), is able to either use AIDS norms to legitimate activities or have influence on the government’s decision-making. However, the negotiated nature of state-society relations also relates to CCP legitimacy, to be further developed below.

3.2 THE NORMATIVE FRAMEWORK OF SEX: THE OFFICIAL DISCOURSE

Incoming global norms do not enter a normative vacuum. Pre-existing normative frameworks may need to be negotiated or even countered by norm entrepreneurs. Intersubjective meanings are present in all facets of social life. Implicit in the section above, the Chinese political system is underpinned by normative guidelines relating to, for example, the authority of the CCP, the acceptable level of non-compliance by

90 According to China Development Review (2008) notes that while these laws and regulations relating to INGO-NGO partnering are incoherent and often confusing, this confusion is to be welcomed as it provides loopholes for cooperation.

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the provinces, and the role of civil society. There are also expectations relating to legitimacy, which is discussed more in the next section. This section’s focus is on the norms relating to sex. Some knowledge of the Chinese government’s construction of what is considered normal or otherwise with regards to sex is necessary for understanding the Chinese government’s governance of HIV/AIDS. The nature of AIDS transmission requires that states address issues of sex - whether pertaining to safe sex education, the provision of condoms, or programs that target sex workers or men who have sex with men - in their national AIDS programs. The way in which particular sexual practices are viewed by state and society can impact upon these programs by making some policies more politically acceptable than others, and, as a consequence, can affect the domestic impact of some AIDS norms (such as the rights of PWA). While I acknowledge that what the state dictates is not always representative of broader society practices, it is the state that makes policy and also controls the agencies that disseminate information on sex and AIDS, and therefore, in this section, the focus is on the official discourse on sex.

Like so many facets of Chinese life, what is considered normal and appropriate with regards to sex and sexuality has been dictated and institutionalised by the CCP (Dikötter 1995; Sigley 2006). While ancient texts have suggested that a range of sexual practices, from homosexuality to extramarital affairs (such as concubinage), were tolerated and even glorified in traditional China (Ruan 1994b; Zhang et al. 1999, p.583),91 the CCP’s discourse on sex has been consistently conservative. This sexual conservatism is linked with the regime’s legitimacy and identity and has been constructed as it has sought to differentiate itself from its internal and external opponents.

On the one hand, the CCP’s conservatism is based on a rejection of traditional Chinese culture and capitalism and reflects rural conservatism. During the struggle against the Guomindang, in order to seek popular support and legitimate its authority to rule on moral grounds, the CCP spoke out against the sexual decadence and moral

91 It has been argued that in ancient China, attitudes to sex were ‘open and positive’ (Ruan 1994b). Sexual practices and attitudes towards sex were influenced by Confucianism on the one hand, which emphasized the importance of sex for procreation and perpetuating the line of the family, and by Taoism on the other hand, which emphasized the achievement of harmony through sexual intercourse between woman (yin) and man (yang) (Ruan 1994a, p.117; Zhang et al. 1999, p.583).

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decay of the bourgeoisie and the wealthy landowners (Sigley 2006, p.45-46). However, the CCP’s conservatism also has its roots in the Republican era when sexuality was linked with nationalism. At a time when prostitution, venereal diseases and drug use was rampant, it was claimed by social reformers that China’s weakness as a nation, the reason that it was the ‘sick man of Asia’, was caused in part by abnormal, unconstrained, unproductive and nonprocreative sexual acts. Furthermore, the West was to blame – for taking advantage of China’s weakness and being the cause of it, by introducing sexually transmitted diseases (STDs) and encouraging prostitution (Dikötter 1997, p.73, 79; Jeffreys 2006, p.7). Therefore, upon entering power, the regulation of sex and sexuality in the PRC became part of the new regime’s agenda for nation building with the sexual morality of the CCP being contrasted with the sexual self-indulgence of imperial China and the decadent Western capitalists.

If prostitution, venereal diseases and drug addiction were identified with the old, immoral, inequitable, colonized and weak China, then it is perhaps not surprising that one of the first actions of the government of the new, virtuous, equitable, independent and strong China was to ban these practices. Less than eight weeks after the founding of the PRC, the authorities began to close down Beijing’s brothels and set the former prostitutes to work in factories (Ruan 1994b, p.504; Sigley 2006, p.46). By the 1950s, the PRC was boasting that it had successfully eliminated prostitution and STDs. The fact that this feat continues to be lauded today despite evidence to the contrary is seen by Jeffreys (2004, p.101) as evidence that the CCP’s eradication of prostitution was subsequently constructed as a sign of the political capacity of the new regime and the primacy of Chinese Marxism. Prostitution and pornography, the so-called yellow industries (yellow being symbolic of erotica in China), were not the only practices cracked down upon. Homosexuality, masturbation, premarital and extramarital sex were labelled ‘shameless’ or ‘abnormal’ (Dikötter 1995, p.181). 92 Polygamy and arranged marriages were outlawed by the 1950 Marriage Law (Sigley 2006, p.46). While not technically illegal, homosexuality was subject to administrative sanctions and was listed as a mental illness (Li 2006, p.84-85).

92 As will be seen in chapter four, early reports on AIDS in the Chinese media were coloured with references to ‘abnormal’ and ‘unhealthy’ activities such as homosexuality, prostitution and adultery.

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The new government hence institutionalised the heterosexual marital unit. Arguing against common assumptions that sex was taboo in Maoist-China, Evans (1997, p.7) notes that there was a considerable amount of materials published on sex-related issues during the early 1950s and 1960s. Nevertheless, this discourse was ‘highly selective and explicitly didactic in its distinctions between right and wrong, normal and abnormal’ and strove to regulate sexual practice ‘in support of the project of social control and economic development formulated by the new government’. The only legitimate or normal form of sexual conduct was that between husband and wife.

The Cultural Revolution is considered the nadir of sexual freedom in China. During this time, the Red Guard movement linked sex with ‘bourgeois ideology’ (Honig 2003, p.148). Class enemies were commonly accused of ‘sexual immorality’. Similarly, when someone could not be accused of class-related or political crimes, they could be accused of homosexuality instead, which would often have harsh and sometimes fatal consequences (Li 2006, p.84). Authors who wrote about romance and sex risked arrest for disseminating pornography. Kissing, sex, holding hands or even telling dirty jokes could result in public criticism and administrative sanctions. Married couples even referred to their spouses as comrades rather than husband and wife (Honig 2003). While the state is blamed for this puritanism, it has been noted that the state did not explicitly or directly repress sex during this time. Rather, it withdrew from the issue. If the official discourse on sexuality in the 1950s was one of ‘explicit advice’, the sexual discourse of the Cultural Revolution was one of ‘no advice’ (Evans 1997, p.8). By no longer publishing booklets and manuals on marriage and sex and by eliminating reference to romantic relationships in its official reports and stories for example, the state made sex taboo. Honig (2003, p.146-147) notes that the state silenced sexuality by becoming silent itself.93 The Cultural Revolution has been blamed for the inability of a whole generation to talk openly about sex, which in turn impacted upon sex education of the following generation. Sex education has suffered as leaders have ignored the issue and parents have found it difficult to talk to their children about sex (Fan 2006b).

93 As Honig convincingly highlights, this is not to say that sex and sexual experimentation did not take place during the Cultural Revolution. For some of the ‘sent-down’ youth (the urban youth who were sent to the countryside during the Cultural Revolution), the separation from family in fact afforded an opportunity to engage in sexual activity that would otherwise not have occurred (2003).

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Since the 1980s, attitudes towards sex and sexual practices have been in a state of flux, particularly amongst the urban youth. Premarital sex has increased, as has extramarital sex. Sex is more visible with the sexual content of radio shows, television, magazines, books and the Internet much greater than in the past. The sex toy industry is booming. A thriving gay and lesbian scene has emerged in major cities like Shanghai, Beijing and Guangzhou. Abortions have increased, as have instances of rape. Prostitution, pornography and the spread of STDs (including HIV/AIDS) have also made a comeback (Barboza 2007; Beech 2006; Elegant 2008; Fan 2006b; Rosenthal 1999; Watts 2005; Zhang et al. 1999).

One popular argument for the cause of these changes (and one that the Chinese government likes to use) is that the ‘opening up’ of China led to the import of liberal sexual culture through the vehicle of entertainment, news media and personal exchanges from the West (Zhang et al. 1999). Furthermore, there is a common perception that this revolution is occurring beyond the consent and control of the CCP, that it is evidence of a liberated populace shaking off the repressive policies of a puritanical government (see, for example, Beech 2006). Pan Suiming (2006, p.24-36) however suggests that China’s sexual revolution is not a straightforward product of ‘Western influences’ and argues that it is instead a consequence of the changing relationship between sex and procreation, between marriage and love, between marriage and sex, between sex and love and the attitudes of Chinese women towards sex and love. Many of these relationships have changed, albeit unintentionally, because of the government’s actions. For example, the increasing separation between sex and procreation can be read as a result of the introduction of the one-child policy in 1981. The official discourse still equates normal sex as being sex between the married heterosexual couple, but the one-child policy has meant that there has been an increased recognition in the official discourse of the importance of sexual pleasure for maintaining marital and familial harmony (Pan 2006, p.28-30; Sigley 1998, p.8). Furthermore, as mentioned above, individual autonomy has increased as the state has lessened its control of private life by lessening the power of the danwei.

The government cannot pretend that these changes in societal attitudes and practices are not occurring. However, the party-state is not consistent in its response, tending

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instead to walk a line between tolerance and repression. For example, on the one hand, homosexuality seems to be becoming more accepted. In 1997, the removal of the term ‘hooligan’ from the Chinese criminal code was also hailed as an act of de facto decriminalisation of homosexuality with ‘hooliganism’ having previously been used as a euphemism for anal sex. In 2001, homosexuality was taken off the list of mental disorders (Elegant 2008). While these have been important developments, to openly accept homosexuality has thus far been an anathema to the government who prefer the ‘Triple No’ policy – no approval, no disapproval and no promotion (Elegant 2008). Li (2006, p.92-93) points out that individuals who engage in homosexual activities continue to be subject to administrative sanctions, such as the withholding of promotions, housing allocation or bonuses, and have limited avenues for legal redress. The issue of administrative sanctions coupled with the continued emphasis by the state on marital heterosexual sex serves to maintain the ‘abnormality’ of homosexuality. Another example is the continued illegality of prostitution. After it began to reappear in China in the late 1970s, the government made prostitution illegal in 1981. Despite a number of other laws repeating the principle of the eradication of the practice, and a number of hard line anti-yellow campaigns, prostitution has increased.94 While the national rhetoric is unequivocal, at the local level there are incentives for the police and party officials to tolerate prostitution in exchange for money or sexual favours (Zhang 2006; Jeffreys 2004). It has been suggested that decriminalizing prostitution could allow the government to regulate the industry (as well as provide sex education and better control the spread of STDs). However to do so would amount to the undermining of the sexual morality that the Party has sought to maintain.

The official discourse on sex and its relation to changing societal attitudes becomes significant when examining the history of China’s governance of HIV/AIDS. In this section I have concentrated on the official discourse on sex in China in order to elucidate that which is considered ‘normal’ and ‘abnormal’ and what is allowable and what is not. The discourse on sex clearly relates to the formulation and implementation of AIDS policy and legislation. For example, how do you provide sex education when you cannot talk about sex or you do not acknowledge certain groups?

94 The number of people being investigated for involvement in prostitution activities increased from 68,091 people in 1987 to 432,000 people in 1997 (Pan Suiming quoted in Zhang 2006, p.143)

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It also relates to how HIV/AIDS is discussed by the media – again, it is difficult to talk about HIV/AIDS and methods to prevent it if it is feared that discussing condoms will encourage people to have sex before marriage. Finally, the official discourse on sex relates to civil society. On the one hand the dominant norms on sex can delimit the extent to which certain groups are able to access the political structure. It is difficult for sex workers, for example, to demand AIDS prevention when they are not supposed to exist and it is difficult for men who have sex with men to cooperate with the government when the government will not acknowledge them. However, the discomfort that the government has with anyone outside of the official discourse has also opened a space for civil society organizations as these actors act as mediators between the government and high-risk groups. This will be discussed further in chapters four and six.

3.3 KEY INTERESTS AND GOALS

Along with formal institutional structures and discourses, global norms are more likely to become salient if they are perceived to support important domestic interests (Cortell and Davis Jnr. 2000, p.77). In this section I discuss the interests of the political elite and argue that the primary motivation of the Chinese political elite is to preserve its monopoly on power. To justify and preserve this power, the CCP has sought to improve its legitimacy in both the domestic and international spheres. In order to do so, in the post-Mao era the Chinese government has pursued three major goals: the improvement of living standards through continuous economic development; the conservation of peace and stability; and, the improvement of China’s international standing. While this is not an exhaustive list,95 the political elite is more likely to be receptive to global norms when they are linked to the pursuit of these goals.

95 For example, I could have included the protection of China’s sovereignty and security and given mention to the very obvious motivating factor of Taiwan and the interest in national reunification. Deng and Wang (2004), Lampton (2001) and Nathan and Ross (1997) are just three excellent examples of the wealth of literature that covers China’s security concerns. However, in the interest of thesis relevance and brevity, the aforementioned goals must suffice.

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3.3.1 PRESERVATION OF POWER AND THE SEARCH FOR LEGITIMACY

Despite limited political reform, the political elite is intent on perpetuating party rule. Lam notes that the modern Chinese leaders do not see that there is anything intrinsically wrong with one-party authoritarian rule and ‘socialism with Chinese characteristics’ (2006, p.34-35). Self-preservation dominates elite thinking. ‘To protect socialist China and its political system’ has long been articulated as a key interest (Zheng 1999, p.115). In an excellent study of China’s compliance in four different international issue-areas, Kent (2007, p.244) notes that the ‘bottom line’ defining the limits of China’s compliance and cooperation was ‘any development that might destabilize China’s authoritarian political system, undermine its developmental goals, or threaten its autonomy’.

How does a regime preserve its power? While power may be obtained through coercive means, no state can survive for long by force alone. ‘If acceptance of commands issued by authorities is based solely or even largely on naked force, then the right to rule will be challenged’ (Alagappa 1995, p.4). Therefore, while it is important to acknowledge the very real coercive powers that the Chinese political elite has at its disposal in the form of the People’s Liberation Army and the public and state security agencies, the stability of its regime is also largely dependent on its continuing authority and relevance in the eyes of the Chinese people. In other words, central to the preservation of the CCP’s authority to rule is the issue of legitimacy. Legitimacy, and the means to achieve it, dictate which issues claim political attention.

Political legitimacy has been defined as:

The belief in the rightfulness of a state, in its authority to issue commands, so that the commands are obeyed not simply out of fear or self-interest, but because they are believed to have moral authority, because subjects believe that they ought to obey (Barker quoted in Alagappa 1995, p.2).

Weber argued that obedience can have many sources, ranging ‘all the way from simple habituation to the most purely rational calculation of advantage,’ but a reliable system of obedience normally requires the additional element of belief in legitimacy

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(quoted in Teiwes 1984, p.43). All political regimes, including authoritarian regimes, seek legitimacy. Alagappa (1995, p.4) notes that this is not purely a stratagem to perpetuate control – even the most tyrannical leaders need to believe that they are serving the national interest or fighting for a cause in order to enjoy the privileges of power.

Legitimacy is ‘contingent, dynamic and continuously defined’, an ‘interactive process between ruler and ruled’ (Alagappa 1995, p.29). Rulers use various rationales to support their legitimacy claim, which only become bases for authority when they are recognized and acknowledged as such by the ruled (Alagappa 1995, p.32). The most famous typology of legitimate authority was that offered by Weber who differentiated between: legal-rational legitimacy, based on the belief in the legality of rules of governance; charismatic legitimacy, based on the belief in the supernatural ability of an individual leader; and, traditional legitimacy, based on the belief in the sanctity of the customs of past (quoted in Teiwes 1984, p.46, 54, 58). However, it has since been argued that authority may also be claimed on the basis of ideology, performance and international support (Alagappa 1995; Rigby 1982; Teiwes 1984; Weatherley 2006).

The CCP is very aware of the question of legitimacy. Lam (2006, p.34, 38) argues that searching for the perennial mandate of heaven occupies much of the CCP elite’s time. Over the course of its rule, the CCP has deployed most (if not all) of the above- mentioned rationales in order to claim legitimacy. When the CCP first came to power in 1949, its authority was based primarily on Marxist-Leninist ideology, Mao’s charismatic leadership and the party’s role in the revolution. As the Dictatorship of the Proletariat (the People’s Democratic Dictatorship in Chinese terms), or the representative of the proletariat or the working class (the peasantry in China’s case), only the CCP was qualified to rule China because only the party understood the Marxist doctrine and only the party could lead China to its ultimate goal, the building of a communist society (Weatherley 2006, p.10). Marxist-Leninist rhetoric was supplemented with nationalist themes: the party had ended the ‘century of humiliation’ and was moving the country towards the ancient goal of prosperity and power, or fuqiang. To the extent that it was seen by its people to be progressing society towards those goals, the CCP’s rule was legitimate (Weatherley 2006; Zheng 1999).

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Goal-rational legitimacy, or the belief in the ability to accomplish goals such as communism, can be undermined when the progress towards the goal does not occur. The disastrous Great Leap Forward, a consequence of poor economic decisions, crippled the Chinese economy and led to millions dying of starvation. Likewise, Mao’s need to continue the revolution and preserve his position as the supreme leader resulted in the violence of the Cultural Revolution. While the charisma of Mao was enough to maintain the CCP’s authority, his death in 1976 broke the spell. The devastation of this period, particularly the Cultural Revolution, led to mass disillusionment with Marxism-Leninism (Weatherley 2006, p.162). While the following quote is about the impact of the Cultural Revolution on the ‘fourth generation’96 of leaders, it also reflects the disenchantment of the broader populace:

Because of the disillusionment experienced during their formative years, fourth generation leaders are, in general, ideologically less dogmatic, intellectually more sophisticated, and practically more open-minded than their predecessors. They are more concerned about issues than isms (Li 2001, p.206, emphasis added).

Therefore, by the end of the 1970s the CCP was suffering from a crisis of legitimacy.

Although, the Party could not abandon Marxism altogether – Weatherley (2006, p.165) notes that any wholesale rejection of Marxism would be tantamount to a rejection of the CCP’s claims to be the sole ruler of China - Mao’s successors have been forced to search for alternative sources of legitimacy. As mentioned in section 3.2.1, since the 1980s the regime has rebuilt a system of law and implemented other limited political reform in order to improve its legal-rational authority. However, perhaps more importantly and certainly more relevant for this thesis are the other goals that the Chinese government has explicitly pursued to underpin its legitimacy claims. The CCP has pursued economic reform and a stable, peaceful environment in order to improve the general standard of living and thus provide a performance rationale for legitimacy. However, it has also sought to improve its international standing to both meet domestic nationalist expectations (providing a basis for

96 This is the term used to describe today’s leaders and refers to the number of generations since the revolution.

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nationalist/traditional authority) and gain international legitimacy. Throughout this period, the Party’s message has been clear: only the CCP can ensure China’s glorious future. ‘Only the CCP can save China’ and ‘no CCP, no New China’ are typical slogans (Wang Fei-Ling 2004, p.26). However, in pursuing alternative means of legitimation in order to ensure its continuing relevance and its monopoly on power, the CCP has unintentionally created for itself further problems, enhancing its political insecurity. This is a recurring issue that will emerge in the following sections.

3.3.2 ECONOMIC DEVELOPMENT

Economic development has constituted a major goal of the CCP in the post-Mao period. As mentioned above, one way in which moral authority can be generated is through the ‘proper and effective use of power to promote the collective well-being of the political community’ (Alagappa 1995, p.15). Rigby (1982, p.10) argued that goal- rational legitimation is common amongst communist governments, but that the ultimate goal of a communist utopia is fairly vague and distant. Therefore, as Weatherley (2006, p.12) puts it, ruling communist parties generally set ‘more tangible and measurable targets within this utopian vision…and this allows the populace to judge for itself how successful the party has been in attaining these targets’. While Alagappa (1995, p.41) defines performance as encompassing not only economic development but also security, welfare and justice, in the case of China it is evident that the CCP has sought to secure the legitimacy of the Party through economic performance.

When Deng Xiaoping came to power in the late 1970s, the economy was in trouble. The economic blunders of the Maoist period illustrated the danger of politics in command. Mao’s Great Leap Forward (1958-1961) was the PRC’s economic nadir. Designed to help China catch up with the West within a year, this industrialization campaign, with its impossibly high grain and steel output targets, resulted in an unmitigated disaster which left tens of millions of Chinese dead and the country’s economy in decline (Watson 1998, p.22). Although the Cultural Revolution saw some growth, overall, the violence of the Cultural Revolution was disruptive to the economy. By the late 1970s, living standards in China were obviously behind those of

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the other industrializing countries in the region such as Japan, Hong Kong, Singapore and Taiwan (Foot 2000, p.63).

Deng Xiaoping was a pragmatist and saw clearly that the only way that the CCP could have a future would be by concentrating on economic development and lifting the Chinese people out of poverty, thus establishing a new basis for the right to rule. The reasoning was (and still is) that a prosperous society would be a happy and grateful society with little reason to rebel against the party. Incremental economic reform was based on five goals as articulated by Watson (1998, p.24): greater emphasis on improving consumption and living standards; greater economic efficiency; greater economic diversity in terms of ownership; acceptance of a role for the market; and, greater openness to trade and the world economy. The ‘reform and opening up’ (gaige kaifang) package therefore involved: rural decollectivisation; the setting up of special economic zones along the coast for the purpose of attracting foreign investment, increasing exports and importing high technology; decentralization of economic control in some sectors, including trade, with provincial and local governments permitted to operate under free market principles; and, the gradual elimination of state price controls on many products (Morrison 2006).

The results of the economic reform have been impressive.97 Since 1979 China’s economy has grown at an astronomical rate. From 1979 to 2005 China’s real gross domestic product (GDP) grew at an average annual rate of 9.7 per cent. With a $102 billion trade surplus in 2005, China is now the third-largest trading economy after the US and Germany. China is the largest recipient of foreign direct investment in the world, ahead of the US and India, with $60 billion flowing into the country in 2005 and, most worrying for the US, it is the second largest holder behind Japan of US Treasury bonds with $265 billion held in February 2005. China’s GDP and per capita GDP in 2005 were estimated at about $2.3 trillion and $1,700, putting China well behind the two largest economies, the US and Japan, with respect to the overall size of the economy and living standards. Nevertheless, this amounts to a 11-fold increase in the size of the economy and an eight-fold increase in per capita GDP! Looking to the future, China has been forecast to become the world’s largest exporter by 2010

97 Unless otherwise stated, the data in this paragraph is drawn from Morrison (2006).

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and the world’s largest economy by 2020. While they remain below those of the US and Japan, living standards have improved substantially since 1978. The World Bank puts the number of people lifted above the $1 a day poverty level between 1981 and 2001 to be 422 million. The average income in 1985 was $280 compared with $1700 in 2005. The adult illiteracy rate fell from 37 per cent in 1978 to less than 5 per cent in 2002 and the infant mortality rate fell from 41 per 1,000 live births in 1978 to 30 in 2002 (The World Bank 2006).

Despite China’s many economic successes however, the extent to which the CCP’s economic performance has supported its legitimacy is a matter of debate. Zheng and Lye (2005, p.194) ascribe to the view that economic development is the primary source of legitimation for the CCP, however, they argue that it is inherently unstable:

Should the economy face dramatic slowdown or if FDI were to dip suddenly due to some unforeseen circumstances, the people could readily blame the government for their economic woes. And if the people were to form the impression that the government is incapable of responding to their economic needs and welfare, the legitimacy of that government would quickly dissipate.

Wang Fei-Ling (2005, p.138) concludes that, for the CCP, using economic performance as the main source of legitimacy is likely to result in a dilemma: the more well-off (and the more educated) its public becomes, the more dissatisfied its public is likely to be with the current state of politics. Making a different argument, Shue (2004, p.29) posits that the Party, particularly the central authorities, can no longer base its legitimacy on economic performance because it can no longer claim credit for the country’s economic successes due to the increased economic responsibility given to the communities and localities and the increased role of the market. Shue (2004, p.29) points out:

This is not to say that central authorities either can or would even want to wash their hands entirely of responsibility for economic performance. …But central state responsibility for the economy has now become once-removed from what used to be called ‘the production front.

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This of course leads to contradictory behaviour. When the economy is healthy, the leadership draws attention to its role in making it so. When there is a problem, the leadership has downplayed its role and emphasised market forces or local incompetence (Weatherley 2006).

Furthermore, economic development has resulted in many other unforseen problems that threaten the legitimacy of the CCP. The disparities between the rich and poor, between urban and rural areas, between the coastal and the inland provinces are growing (Saich 2001, p.149-163; Zheng and Lye 2005, p.197-201). Income inequality has risen from 28 per cent in 1981 to 41 per cent in 2006 (The World Bank 2006). As we shall see in chapter four in our discussion of the SARS crisis and the health sector, certain policy sectors that are not profitable have suffered and the welfare system has deteriorated. Unemployment is rife. The iron rice bowl is no longer assured and job losses have accompanied the restructuring of state-owned enterprises (Weston 2004). The reforms have also encouraged the emergence of a new entrepreneurial class, with the incomes of those working for private enterprises far exceeding workers in state- owned enterprises. The CCP needs the support of this new entrepreneurial class (hence Jiang Zemin’s doctrine of the ‘Three Represents’ in 1997 which allowed entrepreneurs to become Party members) but has had to introduce new legislation to protect private property in order to keep this support, thus undermining a communist article of faith (The Economist 2007). While corruption has always existed and is not necessarily an outcome of economic development, instances of corruption have increased since the reforms despite the attempts by the centre to counter the phenomenon. In fact, the major focus of peasant discontent in recent years has been illegal land seizure by corrupt cadres and urban developers – an unintended consequence of increasing property rights (Bernstein and Lü 2003; Lü 2000; The Economist 2007; Weatherley 2006, p.144-145). Finally, the prioritisation of economic growth above all else has led to the increase of pollution and environmental degradation, which is not only impacting back on economic growth but is also affecting health standards (Economy 2004). China has 20 of the world’s 30 most polluted cities (The World Bank 2006). As mentioned in the section on state-society relations, these social problems have increasingly led to dissension and protest, threatening the Chinese government’s goal of maintaining stability, the subject of the next section.

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The language of the 11th Five-Year Plan (2006-2011) suggests that the leadership is aware of the double-edged nature of basing its legitimacy on economic development and is moving to address some of these issues and problems mentioned above. While there has been emphasis on fast rates of economic growth in the past, the new plan stresses the importance of the quality of economic development as opposed to the rate. In an effort to slow growth, the plan aims to achieve annual GDP growth of 7.5 per cent. The plan incorporates the theory of ‘scientific development’, proposed by the 16th CCP Central Committee in 2003 and enshrined in the constitution in October 2007. ‘Scientific development’ is the term being used for ‘economic growth that takes into consideration the welfare of disadvantaged sectors as well as environmental concerns’ (Lam 2005). It proposes a people-centred approach to development, one that is comprehensive, balanced and sustainable. The five-year plan therefore, whilst continuing to develop China’s ‘socialist market economy’, also states the aim of achieving the ‘five balances’, between rural and urban development, interior and coastal development, economic and social development, people and nature, and domestic and international development (The World Bank 2006). And rather than encouraging adherence to Deng Xiaoping’s famous coinage ‘to get rich is glorious’, the leadership is now encouraging the creation of a xiaokang society or ‘harmonious socialist society’ - ‘a moderately well-off society in an all-round way that benefits over one billion people’ (Information Office of the State Council 2005).

Nevertheless, while the Party has sought to put the brakes on the economy and has started to consider the need for more social development, economic development remains a political priority and will continue to be so for the foreseeable future. This was underscored by the Premier, Wen Jiabao, in his 2007 New Year speech, when he said ‘we must persevere with making economic development our central task’ in order to ‘greatly increase social wealth to lay a solid material foundation’ for the improvement of people’s lives (Xinhua News Agency 2007g). By extension, anything that threatens to impact upon or stall economic growth becomes political. As will be discussed in latter chapters, the goal of economic development has both hindered and helped the uptake of international AIDS norms at different times.

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3.3.3 SOCIAL STABILITY

By emphasising the need for peace and order China is no different from any other state. However, for the CCP, the maintenance of domestic social stability is key to ensuring its own monopoly of power. In fact, Wang Fei-Ling (2004, p.43) notes that the CCP’s political preservation is often code-named sociopolitical stability. The CCP’s focus on stability began when Deng Xiaoping came to power and argued that the CCP’s legitimacy could no longer be based on Mao’s notion of ‘war and revolution’ as this had only impoverished the nation. Instead Deng altered the party line to ‘peace and development’, a pragmatic strategy that would allow China to become powerful and in doing so affirm the CCP’s leadership credentials.

The pursuit of domestic stability is both a means to achieving legitimacy and a source of legitimacy for the CCP. It is a means to achieve legitimacy in that a stable domestic and international environment is viewed as a prerequisite for China’s economic development. However, if the CCP can no longer stake its legitimacy on the country’s economic achievements as Shue (2004, p.29) maintains, then stability becomes a major source of legitimacy.

The present regime stakes its legitimacy… not on its technical capacity to steer and to grow the economy, but on its political capacity to preserve a peaceful and stable social order under which, among other things, the economy can be expected to grow.

Weatherley (2006, p.149-150) supports Shue’s argument and has suggested that there is evidence that the Party has moved to ‘present itself in a new light as a force for stability’ and that in so doing, ‘the party seeks to play on deeply felt public fears about social and national fragmentation in China’. This strategy became particularly important after the end of the Cold War when the social upheaval in Eastern Europe led to the toppling of several communist regimes, and has been articulated in language such as ‘China can only develop well under CCP leadership’ (quoted in Wang Fei- Ling 2004, p.26). Wang Fei-Ling (2004, p.27) notes that the CCP, redefining its mission statement in 2002, now strives to be ‘the ruling party of long governance and permanent tranquillity’.

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However, in that there seems to be no limit as to what can be perceived to be destabilising activity, the pursuit of stability can lead to erratic and paranoid behaviour by the government, some of which is viewed with disdain by more liberal states. When protest occurs, the dissent is only allowed if it is isolated and able to be managed by the authorities. Full-scale protest that has the capacity to disturb the wider community is not permitted and is often dealt with in a heavy-handed manner. Human rights are often sidelined in exchange for order. The focus on stability can and does often lead to officials covering up information that is seen to be discouraging of investment and publicly disruptive. Censorship and control of information is considered critical to keeping the peace.

Even the simple bad news of national disasters, criminal cases, and epidemics are frequently suppressed and controlled in the name of sociopolitical stability, often at the expense of not only the welfare of the people but also the rationality and efficiency of governance (Wang Fei-Ling 2004, p.28).

Of course, repression and excessive information control also damages the credibility of the Party, breeds dissatisfaction and provides impetus for the destabilising forces that the party is interesting in preventing (Wang Fei-Ling 2004, p.28).

The Chinese government’s goal of maintaining stability therefore is an important factor to consider with regards to China’s governance of AIDS and the ability for international AIDS norms to penetrate at the domestic level. In particular, the pursuit of social stability at any cost both helped to cause the Henan blood crisis (see chapter four) and the 2003 SARS crisis (see chapter five), as well as providing space for change in light of these crises.

3.3.4 ENHANCING INTERNATIONAL STANDING

The third goal relating to legitimacy that the Chinese elite pursues is the improvement of its standing vis-à-vis the international community. In particular, China strives to be recognised as a ‘good citizen’ of the international community. What it takes to be a

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good citizen is a subject for academic debate,98 however according to both China’s proponents and critics alike, China’s good citizenship is to be evaluated according to the extent to which it complies with international law, cooperates with and supports international organizations and the extent to which it exercises its power responsibly (Chan 2006; Deng 2004; Gertz 2008; Johnston 2003; Kent 2007). How this translates into China’s international behaviour and its relevance to this thesis will be discussed below. But first, why does the Chinese leadership seek to improve its international standing and what does this have to do with domestic legitimacy? One argument is that it is a means to an end, that China seeks to improve its status in order to gain material benefits and help the Chinese leadership pursue its domestic goals. The Chinese leadership, beginning with Deng Xiaoping, has consistently argued that China needs a stable international environment in order to aid the development of the economy (Deng 2004, p.53; Foot 2006, p.85; Lanteigne 2005). Certainly, there are material benefits to be obtained from participation in multilateral economic institutions such as the WTO, the International Monetary Fund, the Association of South East Asian Nations (ASEAN) Plus Three process and Asia-Pacific Economic Cooperation (APEC) (Moore 2004, p.121). However, another equally important argument is that the Chinese government does in fact care about China’s international image (Chan 2006, p.203). Work on socialization and legitimacy in international relations have shown that states are concerned with where they stand vis-à-vis the international community and this contributes to their sense of self, or identity (Clark 2005; Finnemore and Sikkink 1998; Johnston 2001). The benefits of being a legitimate member of the international community include recognition, security, and the ability to shape and influence the norms and institutions of the community. In turn, international legitimacy is linked to domestic legitimacy because Chinese citizens care about how the rest of the world sees China and therefore popular support for the regime is created when it is seen to improve China’s international status (Zheng 1999).

Until Tiananmen, China had enjoyed a period of relative security with regards to its place in the world. This had begun in 1971 when the PRC finally managed to oust the Republic of China from the UN. Entry into the UN gave China access to the

98 For an excellent study on international legitimacy and changing practices of legitimacy, see Clark (2005).

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international community and afforded China recognition, legitimacy, prestige and power (Kent 2007, p.46-56). The emergence of a reform-minded Chinese leadership in the late 1970s that took a passive approach to international relations (Foot 2006, p.84) represented a sharp contrast to the resurgent Soviet Union, and China was courted by both the developed and the developing worlds. However, the Chinese government’s crackdown on protesters in Tiananmen Square in 1989 led to an international backlash (Foot 2000; Kent 2007, p.54). Meanwhile the end of the Cold War led to the fall of communism in East Europe and an increasing emphasis on democracy and human rights in international forums that were dominated by the western liberal democratic states (Foot 2000). As if this was not enough, in the mid- 1990s American international relations theoreticians and practitioners started to talk about ‘The China Threat’. The so-called ‘China Threat theory’ posited that due to ideological, economic, geo-strategic and political reasons, China’s rise would inevitably result in it seeking conflict with the US (Callahan 2005, p.705; Christensen 1996; Yee and Storey 2002). Together these factors led the Chinese leadership to reappraise China’s position in the world. While China clung to the Westphalian concept of sovereignty and promoted its five principles of peaceful coexistence, the events of the 1990s showed that the content of international legitimacy was in transition. While China was a member of the international system of sovereign states, it was still considered an outsider by the influential core community of states led by the US on account of China a) not being the right type of state and b) not conducting itself in the right way (Deng 2004, p.54-56).99

Therefore, since the mid-1990s, China has attempted to improve its international reputation. On the one hand this has included the rhetorical shift. Chinese diplomats and academics have sought to counter the ‘China threat theory’ by espousing China’s position in the world as a responsible power, as an opportunity rather than a threat (Callahan 2005, p.702; Chan 2006; Foot 2006, p.85). Beijing’s ‘new security concept’ emphasises mutual trust, peaceful dialogue and ‘win-win’ outcomes rather than continuing the zero-sum language of power politics (Deng 2004, p.62-63; Foot 2006, p.85; Paltiel 2007, p.235). Finally, in 2002, Chinese theorists began to articulate a

99 Clark explains the content of international legitimacy to include two different ‘faces’: ‘rightful membership’ or who gets to count as a member and ‘rightful conduct’ or what conduct is appropriate (2003, p.4-5).

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vision of Chinese internationalism, which has become known as the ‘peaceful rise’ foreign policy doctrine. The ‘peaceful rise’ doctrine stresses China’s intention to give priority to domestic problems of development over international expansion and promotes the transcendence of ideological differences to better improve China’s relations with other nations (Zheng 2005).100 Wang Jianwei (2004, p.160-161) notes that the increasing use of phrases such as ‘interdependence’, ‘globalisation’, ‘win-win diplomacy’, ‘cooperative security’, ‘common interest’ and ‘coordination’ – as opposed to more traditional vocabulary like ‘national sovereignty’, ‘territorial integrity’, ‘hegemony’ and ‘power politics’ – demonstrate that at least at the normative level, ‘the traditional hard-core realist paradigm…has been remoulded by something much closer to more liberal and cooperation international relations theories’.

Furthermore, in general, China’s behaviour has matched its rhetoric. For example, China has also sought to quell the fears of its neighbours by initiating and formalizing regional security (both traditional and non-traditional) and economic cooperation, emphasizing common interests and win-win outcomes. China’s relationship with the ASEAN and its involvement in the Shanghai Cooperation Organization (SCO) are good examples (Wang Jianwei 2004, p.166-184). Examples of China’s direct efforts to maintain regional stability has been the government’s decision to not devalue the Yuan during the Asian Financial Crisis (AFC) and China’s involvement in the Six Party Talks on North Korea (Foot 2006, p.85-86). Even the issue of Taiwan, the situation most likely to lead to conflict in the region, has been carefully and patiently managed by China (Chu 2004, p.246-247).101 Globally, China’s membership in multilateral institutions has increased dramatically from membership in 435 organizations in 1986 to membership in 1,325 organizations in 2000 (Chan 2006,

100 Callahan (2005) makes an interesting argument that while China exerts much time and effort in responding to the ‘China threat theory’, the purpose of this reaction is not to correct foreign misunderstandings but to generate national feeling within China. By…refuting the ‘China threat theory’ criticisms as fallacies spread by ill-intentioned foreigners, the texts assert ‘peaceful rise’ as the proper way to understand China’s emergence on the world stage. Thus in a curious way, the negatives images of the PRC that are continually circulated in Chinese texts serve to construct Chinese identity through a logic of estrangement that separates the domestic self from the foreign other (Callahan 2005, p.704). 101 While the Chinese leaders are prepared to allow the cross-straits stalemate to continue, the loss of Taiwan would be unacceptable. China’s leaders remain committed to using coercive means to prevent the loss of Taiwan even if this meant ‘sacrificing good relations with the West and the economic benefits that accrue from those relations’ (Chu 2004, p.269, 273).

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p.47). While membership is one thing, compliance with international law is another. There have been multiple studies of China’s compliance with international regimes. While China’s compliance varies across regimes and scholars disagree the extent to which compliance is motivated by instrumental reasons or by socializing forces, the common consensus is that, in general, China is now conforming more than it has in the past (Chan 2006; Economy and Oksenberg 1999; Foot 2000; Johnston 2003; Kent 2007).

The challenge for China and its elite is that it remains an illiberal regime in an increasingly liberal world. While China strives to be perceived by the world as a ‘good international citizen’ by abiding by international standards and promoting its ‘peaceful rise’, its domestic obsessions with stability, economic development and the preservation of its power often lead it to violate international law and/or undermine international regimes. A clear example is the recent crackdowns in Tibet (March/April 2008) (BBC News 2008; Yardley 2008). Therefore, in pursuit of its domestic legitimacy goals, it inadvertently has undermined its international legitimacy. However, the increased openness of China to the international community means that China’s violations become opportunities for argumentation. As mentioned in the section on civil society, as a result of China’s domestic institutionalisation of international law and acceptance of overseas development assistance there are now more international organizations involved in project implementation and monitoring within China than ever before. Therefore, China is constantly exposed to external scrutiny so that the Chinese government now finds that it must not only justify its actions to its people but also to the international community.102

How does this goal of the political elite relate to my thesis and the governance of HIV/AIDS in China? As mentioned above, it is in the pursuit of their interests and goals that the Chinese political elite is or is not receptive to global norms. Therefore, in the analysis of China’s AIDS governance, indicator five looks at China’s engagement with the global AIDS regime. However, the goal of improving China’s international status also links to indicator four (the role of civil society) because the openness generated by interdependence has enabled ties to be established between

102 Risse and Sikkink discuss argumentation and justification as a type of socialization process in their excellent study into the domestic influence of international human rights (1999).

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domestic NGOs and INGOs. Finally, China’s concern for its international reputation was a cause of the political shift that occurred in the wake of the 2003 SARS crisis.

3.4 CONCLUSION

The aim of this chapter has been to identify the main features of the Chinese domestic context that can affect the impact of global norms. Based on the framework developed in chapter one, the chapter was divided into domestic political structure, domestic norms and domestic interests and goals. With regards to the domestic political structure, I have argued that the regime continues to be characterised by its ‘authoritarian resilience’ (Brodsgaard and Zheng 2006, p.2) with the CCP continuing to maintain power and adapt to changing times. However, centre-local and state- society relations are much more dynamic and negotiated than in the past and these features of the political system can affect China’s openness to global norms. These characteristics of the Chinese political regime will be discussed in the latter chapters on China’s changing governance of AIDS primarily in relation to the indicators used to look at political commitment, policy and legislation, and the role of civil society.

I then explored the official discourse on sex as the most relevant domestic normative framework with regards to this thesis. I have discussed how the CCP’s preference for society to conform to sex within the heterosexual marital unit made some sexual practices and sexualities socially unacceptable. The impact of the official discourse on sex on AIDS governance in China and on the impact of international AIDS norms will be reflected on when looking at the indicators of policy and legislation, representation of HIV in the media, and the role of civil society. Finally, I have argued that the political elite is primarily interested in the preservation of the CCP’s monopoly on power and this leads the CCP to legitimate its rule through the pursuit of three main goals – economic development, social stability and the improvement of China’s international standing. The pursuit of these interests relate to several of the indicators, particularly international engagement and the role of civil society, and are also central to the catalytic impact of the SARS crisis.

I have now identified a) the development and the characteristics of the global AIDS regime, including a clearly identifiable set of norms, and b) the features of China’s

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domestic structure that may condition the impact of the incoming norms of the global AIDS regime. The next section of the thesis documents China’s development of AIDS governance over three chronological periods using the five indicators of political commitment, policy and legislation, the representation of AIDS in the media, the role of civil society and international engagement. The indicators are employed to analyse how and when China’s AIDS governance has changed and when, why and to what degree the global AIDS norms have influenced this governance. Chapter four focuses on the first two main chronological periods of China’s AIDS governance – the period of denial from 1985 to 1993 and the period of limited engagement from 1994 to 2002. Chapter five then examines the SARS crisis as a catalytic event that helped improve China’s receptivity to the global AIDS norms by linking AIDS to the issue of legitimacy. Chapter six then analyses China’s post-SARS AIDS governance.

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CHAPTER 4 - PRE-SARS AIDS GOVERNANCE

4.0 INTRODUCTION

Having introduced the global AIDS regime and established the domestic political structure, we turn to the development of China’s AIDS governance. I argue that it is possible to document China’s changing AIDS governance over three distinct periods: from denial (1985-1993) to limited recognition (1994-2002) to modest engagement (2003-2007). I have identified these periods through the use of a set of five core indicators – political commitment, legislation and policy, HIV in the media, the role of civil society and international engagement. These indicators qualitatively measure how China’s response to HIV/AIDS has changed and to what degree it has changed in line with the global AIDS regime. However, this thesis addresses not only the degree of change but also the cause of change. While there may be other factors that were influential in bringing about this change that are not examined here, this thesis argues that the key transmission mechanism was the SARS crisis in 2003 and the way in which it reframed AIDS in terms of political legitimacy. While the SARS crisis and its impact on the response to AIDS will be examined in chapters five and six, this chapter assesses China’s pre-SARS AIDS governance, documenting the change in AIDS governance from the period of denial to the period of limited recognition. See Table 4.1 for an illustration of the differences between the periods of denial and limited recognition.

Before continuing, it is necessary to revisit the set of indicators and their sub- indicators outlined in chapter one. It should be noted that the indicators are all interrelated – together they present a complex picture of governance. The first indicator is political commitment. Based on the normative prescriptions of the global AIDS regime and the nature of the CCP-led state, I evaluate the level of importance attributed by the Chinese government to combating AIDS by studying the rhetoric and the actions of officials. In studying AIDS in political rhetoric, I examine not only how AIDS was talked about, but also by whom and in what context. However, I also investigate whether this rhetoric was matched with the mobilization of human and fiscal resources.

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TABLE 4.1 CHINA’S GOVERNANCE OF AIDS FROM 1985 TO 2002 Indicators Denial 1985-1993 Limited Recognition 1994- 2002 Political Commitment 1) AIDS in political discourse Foreign, abnormal, not Recognized as public health ‘our’ issue issue 2) High-level advocacy None Limited, leaders remain silent 3) National AIDS Low coordination Low coordination coordination 4) Funding Minimal Inadequate 5) Political importance of Not on the agenda Political recognition limited AIDS by Henan blood crisis Legislation & Policy 1) Tenor of legislation & Defensive, exclusionary, More constructive but policy prohibitive frequently contradictory 2) Protection of rights of None Weak PWA 3) Prevention (P), treatment P - Education and testing P - Education, testing, limited (T), care (C) only condom social marketing, blood safety T - Access to TCM only T - Access to TCM only C - Minimal, high stigma C - Increased care (via increasing NGOs/INGOs) HIV in the Media 1) Dominant tone in reports Exclusionary, stigmatising, More inclusive, impersonal, on AIDS moralizing frequently alarmist 2) PWA Foreign, deviant, outsiders, More normalized but still on silent the outer 3) Openness of reporting None Minimal but increasing after Henan blood scandal The Role of Civil Society 1) Degree of mobilization Minimal, mainly research- Moderate, subject to based restrictions 2) Involvement in decision- Non-existent Minimal making 3) State response to civil No acknowledgment Limited service provision and society some advocacy accepted Political activism repressed 4) NGO-INGO ties Few Increasing International Engagement 1) International compliance/ Superficial Limited International cooperation None Marginal 2) Transparency of AIDS Minimal Minimal reporting 3) Representation at meetings Low Low 4) Openness to international Low Increased, mostly in Yunnan presence in China 5) International opinion Concerned First optimistic then highly critical

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The second indicator is legislation and policy. Domestic laws and policies, in that they are often representative of how a government regards and chooses to respond to a particular issue, are a good site from which to examine domestic compliance with global norms. Therefore, for each time period, I have sought to identify the main developments in law and policy and examine their purpose and normative content. In line with the norms outlined in chapter two, this section will pay particular attention to examining the place of human rights in legislation and policy and the extent to which prevention, treatment and care is accessible and evidence-based. However, given the nature of the Chinese political system, I also look at the extent to which centre-local relations affected implementation of these laws and policies.

The third indicator looks at HIV/AIDS in the media. In China traditional forms of media such as newspapers and television are controlled by the state and as such serve to disseminate government-approved information to both domestic and international audiences. Given that I am studying China’s compliance with the global AIDS regime, I am particularly interested in how China represents its AIDS governance to the world and therefore I have limited my media content analysis to the reports by the Xinhua News Agency, the China Daily and the Beijing Review. The media is a good site to study the emergence of new ideas and understandings as well as justifications for certain policies. Therefore, in this section I examine the dominant tone of AIDS reportage, the representation of PWA and the relative freedom of reporting in order to gauge how the government understands AIDS. The fourth indicator is the role of civil society. One of the global AIDS norms is the involvement of PWA and the essential role of civil society. As the section on state-society relations in chapter three suggested, autonomous civil society in China is constrained by the state. Therefore, this indicator looks at the degree of civil society mobilization, the extent to which non-state actors are involved in decision-making, and the state response to these actors. However, to include the transnational element, I also examine the transnational-domestic interaction.

The final indicator is that of international engagement. This indicator draws upon and adapts Kent’s distinction between compliance and cooperation. Compliance may be defined as a state’s implementation and enforcement of the norms of the international regime in question whereas cooperation in relation to international regimes is defined

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by Kent (2007, p.17) as ‘either individual actions by a state that promotes the object and purpose of a regime, and, in particular, their non-binding norms, or collective action to the same end’. Compliance has both an international and a domestic element. The first four indicators address the extent to which China has complied at the domestic level. This indicator on the one hand looks at China’s international compliance by looking at the extent to which it has met its international obligations – its attendance of meetings, the provision of data to the WHO etc. However, I am also interested in China’s level of international cooperation which can be measured in terms of: a) the quality of China’s engagement in the international arena, such as the level of meaningful representation at meetings, the level of transparency and accountability and the extent to which China does not actively undermine the regime; and, b) the extent to which China is open to international actors within its borders. This is important because one of the major norms of the global AIDS regime is that actors must cooperate. This indicator also looks at how external actors have evaluated the extent to which China’s behaviour is compliant with the global AIDS regime.

4.1 1985-1993 - DENIAL

The early period of China’s AIDS governance from the mid 1980s to the early 1990s is distinguishable by a general attitude of denial on the part of the Chinese government. It must be pointed out that China was not alone in its denial. As already discussed in chapter two, in the earliest years of the epidemic, many countries underwent a similar process of ignoring or minimising the threat of AIDS before recognizing the issue and finally engaging with it. Therefore, until the global AIDS regime and the expectations of behaviour that helped constitute it emerged in the late 1980s, China’s response to AIDS was in fact normal.

Denial can take different forms and hence it is worth explaining that in using this term I am not referring to an outright rejection of the existence of the disease within China (although there are accounts of Chinese officials doing just that) or a dismissal of the causes of AIDS (as seen in the case of AIDS denialism in South Africa). Rather, denial in the case of the Chinese government’s response to HIV/AIDS in those early years amounted to the minimization of the potential threat of the disease to ordinary, normal, responsible Han Chinese by emphasising the ‘otherness’ of AIDS– first as a

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disease that came from foreigners and then as a disease that was more likely to affect deviant or abnormal people such as intravenous drug users, prostitutes and homosexuals.

4.1.1 POLITICAL COMMITMENT

In this first period, there was minimal political commitment to understanding or combating the transmission of HIV/AIDS. Understood as a foreign disease or one that affected parts of the population that the elite deemed deviant, AIDS was an issue that had little traction among the Chinese political elite. Thus there was no high-level AIDS advocacy. While a national AIDS program and a national AIDS committee were formed in the late 1990s, coordination was low and there was minimal funding. In general then we can say that AIDS was not on the political agenda.

In the political discourse, AIDS was framed in terms of its foreign origins and its risk to people who engaged in abnormal behaviour. In other words, the prevailing attitude of the elite was ‘AIDS is not “our” problem’. However, it is important that this behaviour is understood in the context of the responses of other states at the time. By 1985, the year China diagnosed its first case of HIV/AIDS, the disease had been most visible in the West and had been particularly associated with homosexuality. The impact that AIDS would have in sub-Saharan Africa was only just coming to light. Furthermore, the first AIDS cases in China were diagnosed at a time when interaction between Chinese and foreigners were increasing due to the Chinese government’s policy of reform and opening up. As mentioned in chapter three, the Chinese government was already noticing worrying trends with regards to a reappearance of the sex industry, increasing incidence of sexually transmitted disease, issues with drug use and changing patterns of sexual behaviours.

These broader trends thus set the tone for the way in which Chinese officials understood AIDS and discussed the disease in public. In the first place, AIDS was an insidious import from abroad. Dai Zicheng, the director of the Department of Epidemic Prevention in the MOH, said on national television that ‘in Western countries, AIDS is a disease that is very hard to control’ whereas in China, ‘because of the superiority of our socialist system’ the government could take comprehensive

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measures to control it (China Central Television 1990). Another official with the Chinese Academy of Preventative Medical Science said that AIDS entered China via contaminated blood products and through casual sex with the increasing number of foreigners entering China (Wang 1988). Official reports of cases of HIV/AIDS emphasized the number of foreigners within China that had contracted the disease rather than Chinese cases. When it became apparent that not only foreigners but also Chinese were being infected, the foreign sources of the Chinese infection would be stressed. For example, reports regarding some of the first PWA, four haemophiliacs in Zhejiang Province, accentuated that they had been infected after having received blood products from the United States (Wang 1986). Even when HIV/AIDS had been contracted within China, some reports still implied that AIDS had come from abroad. Take the following case for example.

The Chinese government reported the deaths of two mainland Chinese AIDS carriers for the first time yesterday…One of the men, from the southern province of Yunnan, was an intravenous drug user…The other man, a Beijing resident, contracted AIDS via sexual contact…Dai [Zhicheng] said both men had travelled abroad (China Daily 1990).

It should be noted that this last sentence serves to imply that the men caught the disease overseas, despite Dai Zhicheng not actually saying so. While it is clear that AIDS was originally brought into the country by either foreigners or returning Chinese, too much emphasis on this point led to the common perception that AIDS was a foreigner’s disease. Thus, exclusionary laws were passed (see section 4.2.2 below), Chinese women were warned against sleeping with foreigners and all medical departments open to foreigners were required to sterilize all their medical instruments and only use syringes once (Beijing Review 1987b).

The rhetoric of the Chinese health officials during this period was also coloured by the official discourse on sex discussed in chapter three. For example, Health Minister Chen Minzhang argued that it was unlikely that AIDS would spread in China for the reason that ‘homosexuality and casual sexual relations are both against the law and contrary to Chinese morality’ (Beijing Review 1987a). Another official, Zhang Konglai, a member of the national AIDS committee, noted that in China the definition

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of ‘misbehaviour’ was different from the West. ‘In China people practice monogamy. Any sex practice beyond the couple is misbehaviour…Of course, homosexuality is more of a misbehaviour than other misbehaviours’ (Reuters News 1991). It became apparent that AIDS was spreading in China. Despite the ban on imported blood products and the restrictions on foreigners, the disease was spreading primarily amongst high risk groups that were on the social periphery - prostitutes, ethnic minorities and intravenous drug users. The fact that AIDS threatened these groups reinforced the government’s agenda of stamping out prostitution, drug use and pornography. Take Dai Zhicheng’s solution for battling AIDS for example.

An anti-pornography drive is being developed throughout the entire society. I believe that this is an effective measure for eliminating AIDS and other venereal diseases. It is imperative to firmly ban such unhealthy or criminal acts as prostitution, visiting prostitutes and using drugs...This is the radical way to eliminate the soil for growing AIDS (China Central Television 1990).

Not only did such political rhetoric reinforce the perception that responsible Han Chinese who did not ‘misbehave’ and had normal sex (heterosexual and within the marital unit) were in little danger of getting AIDS, but it also fortified societal stigma against PWA and created a major disincentive for getting tested or coming forward for help. While there were the occasional calls from the government to ‘exercise revolutionary humanism’ and care for PWA (China Central Television 1990; Xinhua News Agency 1990), these pleas were inconsistent with other rhetoric by officials, not to mention legislation and policies.

There was no high-level advocacy during this time. As a political issue, AIDS was very localised, being dealt with mainly as an issue under the jurisdiction of the MOH. As discussed in chapter three, the nature of China’s party-led regime means that expressions of commitment from the top leaders, such as the members of the Politburo elite, can be symbolically significant. Likewise a lack of movement at the top can have implications for the way an issue is understood at the lower levels of government. While there were many reports quoting health officials, there were no statements on AIDS being released by the top leaders.

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Following the emergence of large numbers of HIV/AIDS cases in Yunnan in 1989 and 1990, there was some political mobilization. A national AIDS prevention and control commission and an expert committee were formed in February 1990 to guide the work and supervise the nation-wide campaign against AIDS (China Daily 1991c). Likewise, around that time the MOH and the WHO drafted the first national AIDS program, a three year plan which was to prioritise the prevention of AIDS transmission through sex, blood and prenatal care, as well as increasing surveillance and education. In practice however coordination and funding were minimal. In 1993 the China Daily reported that the MOH had ‘issued a warning’ to the rest of government that unless ‘immediate measures were taken’, AIDS would become rampant in China in the near future (Zhu 1993b). This suggests that there was little interest in the issue in other sections of the government. The central government only spent a little over US$1 million a year (10 million RMB) over this period and this money was mainly spent on ‘mass publicity’ and surveillance and testing, both of which faced major challenges (to be discussed below, Reuters News 1993b; Zhu 1991). The efforts of the MOH to mobilize coordination and funding for AIDS prevention and control below the centre were made more difficult in an era of increasing decentralization and a consistent emphasis on economic growth. Spending money on public health took money from more profitable sectors. Without even nominal support of the top leaders, the MOH lacked power over the provinces and local funding for AIDS prevention was therefore low. In general, in terms of political importance, AIDS was not on the agenda.

4.1.2 LEGISLATION AND POLICY

The legislation and policies implemented by the Chinese government during this period reflected the perception that AIDS could be stopped at the borders or that it could be prevented by repressing and controlling ‘deviant’ behaviour. Therefore, the legislation and policy is best described as defensive, exclusionary, prohibitive, and more concerned with the rights of the healthy public than with the human rights of PWA. With such limited political commitment, the emphasis of policy was on prevention – mainly education and testing – with little options for treatment and care.

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The first laws drafted in relation to HIV/AIDS sought to defend China against AIDS. This meant excluding PWA from society by stopping them at the borders or preventing them from participating in society and prohibiting certain behaviours. The first law in regards to AIDS was passed in 1984 (becoming effective in 1985) in response to emerging international information about the transmission routes of HIV/AIDS. Therefore the 1984 Pharmaceutical Administration Law of the People’s Republic of China banned the import of all blood products. The 1986 Frontier Health and Quarantine Law of the People’s Republic of China obligated all foreigners wishing to stay in China for more than one year and Chinese nationals returning from an overseas stay of more than three months to provide a Chinese government- approved certificate of their AIDS-free status or else undergo compulsory HIV testing (Chen and Chen 1987; China Daily 1987a; China Daily 1987b; Wen 1988; Zhu 1989a). Foreign students were required to be tested for AIDS or else face losing their ‘study opportunities in China’ (Wang 1986). Foreigners found with HIV in China were escorted from the country (China Daily 1991d). This was restated and reinforced by the Certain Regulations on the Monitoring and Control of AIDS released by the MOH in 1988. The government proudly highlighted the successes of the Chinese airport quarantine stations that had detected thousands of cases of people with infectious diseases including AIDS and prevented them from entering the country, thus ‘protecting the health of the Chinese people’ (Zhu 1994). These laws reinforced the perception that HIV/AIDS was a foreign disease.

Similar to early legislation in other states, China placed greater emphasis on identifying and isolating PWA rather than on their care and treatment. The rights of the healthy public were put before the rights of PWA. For example, the Certain Regulations on the Monitoring and Control of AIDS aimed at identifying and confining HIV-infected individuals. The 1989 Law on Prevention and Control of Infectious Diseases identified HIV/AIDS as a ‘Category B infectious disease’ which required people be identified and tested, arousing public panic and fuelling discrimination (China MOH and UNTG 2003, p.38). Also, along with infectious diseases such as plague and cholera, quarantine measures were allowable for cases of HIV/AIDS (Zhu 1989a). As explained by Dai Zhicheng:

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It is imperative to observe them [positive AIDS carriers] closely so as to discover symptoms as early as possible and isolate them according to the Law on Contagious [Infectious] Diseases. This will prevent the spread of the disease in our society (China Central Television 1990).

In 1990, the government announced that job seekers would be tested for venereal disease and those found to be suffering from an STD would not able to go to work or study until they are cured. While this move was aimed at preventing and controlling STDs such as syphilis and gonorrhoea (Zhu 1990c), these rules allowed local governments leeway to include HIV/AIDS as an STD. Some provinces introduced their own regulations – Guangdong province, for example, introduced pre-marriage health examinations, restricting the right of PWA to marry, and later introduced other regulations that restricted their right to work, study and move around (China Daily 1987d; The Associated Press 1993).

Along with identifying and isolating PWA, the government sought to strengthen the legislation against IDUs and CSW in order to prevent and control AIDS. This led to the drafting and implementation of a number of laws that would impact upon the efficacy of AIDS governance in China, including the 1990 Decision of the Standing Committee of the National People’s Congress on Prohibition of Narcotic Drugs and the 1991 Decision of the Standing Committee of the National People’s Congress on Forbidding Prostitution. The penalty for using drugs or selling sex involved being sent to rehabilitation camps or ‘re-education centres’ (UNTG 2001, p.31). As one official, Dr Li Jingwu of the Department of Epidemic Prevention, stated:

We have many ways to control the problems of prostitution and homosexuality - we can lock them all up, can't we…Just let the foreign human rights groups denounce us, so long as we are preventing these people from further spreading this dangerous thing (quoted in Walker 1993).

Needless to say, this legislation had the opposite result to that intended. Those at the greatest risk of contracting AIDS were driven underground, often too afraid of the consequences of a positive AIDS test.

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The first national AIDS program, drafted in conjunction with the WHO, put an emphasis on increased prevention, in particular AIDS education and testing and surveillance. While the call for AIDS education and mass publicity remained a constant theme (as expressed in the China Daily) in this early period, efforts to implement education programmes were hampered by the conservatism of the government. Laws prohibiting the publishing of ‘obscene material’ also provided challenges for the production and display of sex education materials. Where AIDS education materials did exist, one could be forgiven for thinking that there were no Chinese people with AIDS – many of the materials had pictures of foreigners (Fu 1992). Nor was there advertising of condoms. The 1989 State Advertisement Law explicitly forbade print or broadcast advertisements promoting sex-related products, including condoms (Manchester 2003, p.3). One critic argued that the health ministry's approach to AIDS education was to tell people not to have sex, rather than how to have safe sex (Walker 1993) A survey of 1000 taxi drivers and hotel employees in Beijing in 1992 revealed that the majority of respondents knew little about AIDS, how it is spread or how it could be prevented. Many thought it was a foreigner’s disease and many thought someone with AIDS would be easily recognisable (Chandra 1993). Beginning in Beijing, several anonymous AIDS hotlines were opened in cities around China from 1992 and these provided an important public information service (Crothall 1992). However, these hotlines faced funding and political challenges. For example, the hotline in Yunnan went broke (AIDS Weekly 1994).

While there was a slight increase in testing and surveillance, the number of surveillance stations related to the size of the population was insufficient due to both a lack of human and fiscal resources. Official reports of HIV/AIDS prevalence reflected confirmed cases of HIV/AIDS rather than broader estimates taking into consideration possible cases. Also, the surveillance stations were set up to monitor only high risk groups (foreigners, IDUs, CSW) in certain provinces and therefore, the figures were distorted further. The Beijing Health and Epidemic Prevention Department, for example, announced in 1989 that it was going to expand its AIDS monitoring system so that all Chinese citizens who have daily contact with foreigners would be monitored (China Daily 1989). One WHO expert noted that the low number of cases officially disclosed contributed to public ignorance of AIDS (Godfrey 1992).

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A major issue during this period was the lack of AIDS education for health officials and medical workers. Efforts to educate these groups were haphazard, not comprehensive and had sometimes damaging implications for the treatment of PWA. Misperceptions about the disease, as well as a lack of trained staff, meant that PWA were often refused treatment. In some cases, as Human Rights Watch (2003b, p.6) has alleged, hospitals actually locked their AIDS wards and barred HIV positive persons from entering. The ignorance of health officials had implications for the effort to educate the public. For example one senior health official at the China Health Education Research Centre advised in an official paper that it was inadvisable to use condoms to prevent AIDS because ‘it is not a safe method’ and that kissing should also be considered dangerous (AIDS Weekly 1992).

4.1.3 HIV IN THE MEDIA

In the period of denial, the media, like legislation and policy, reinforced the government’s understanding of AIDS. The dominant language used or the tone of the reports on AIDS over the period could be characterised as being moralistic, exclusionary and stigmatising. PWA were talked about rather than talked to and were mainly described as outsiders – either on account of their foreignness or their deviancy.

Media coverage of HIV/AIDS throughout this period reflected the perception that it was a disease transmitted by tourists. AIDS reportage in the China Daily for the first few years, for example, emphasised the number of non-Chinese or overseas Chinese PWA (China Daily 1991b; Zhu 1989b; Zhu 1990b; Zhu 1992a; Zhu 1993b). Interviews with health officials and other professionals fuelled this understanding. In a list of ‘dos and don'ts’ published in Shanghai's Liberation Daily to mark World AIDS Day in 1991, a warning about associating with foreigners was prominent. Readers were advised to stay chaste and avoid sexual encounters outside marriage, especially with foreigners (Preston 1991). The first movies screened in 1989 about AIDS were about Chinese AIDS victims who contracted the disease from a foreign teacher (Xinhua News Agency 1989).

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Also apparent from a review of the newspapers was the sexual discourse of the Chinese government and the sentiment that the Chinese were morally superior to other peoples. One early official editorial, with regards to the foreign origins of AIDS, stated that ‘we Chinese, nurtured by our traditional culture and moral values, adopt a much more serious attitude’ (Quinn 1992). The Beijing Review (1987b) noted that ‘in socialist China the main means of spreading the virus – homosexuality, casual sex contacts and drug addiction – are opposed by both the government and public opinion’. The China Daily (1987c) argued that the key to preventing AIDS from spreading to China lay in ‘the moral and sexual education of its young people’. The lack of information on preventative measures in this period is also noticeable. While there was much reportage of cracking down on prostitution and drug use and the necessity of having a ‘healthy lifestyle’ and abstaining from having irresponsible /abnormal/unhealthy sex (i.e. abstaining from homosexual intercourse, premarital sex, extramarital affairs and drug use), there was very little mention of condoms. Again, the lack of conversation about safe sex is indicative of the government’s official discourse on sex and the fear that promoting the use of condoms and safe sex would lead to promiscuity (Manchester 2003).

Furthermore, during the period 1985 to 1993, there were no stories about PWA. Interviews were conducted with either medical experts or government officials. PWA remained invisible and silent. There was little reportage on discrimination or the stigma faced by PWA. There was also little reportage on treatment or care, again supporting the notion that PWA were outside of society. World AIDS Day, which began in 1988, did provide some opportunity for the media to serve as a proselytising tool (for example see China Daily 1991a). However, more often than not, most of the articles published on or around World AIDS Day gave much more attention to assuring the public of what the government was doing in AIDS control rather than to AIDS education. The media’s role in AIDS governance during this period must, of course, be understood in context of its use as a tool of the state. However, by acting as the state’s tool to disseminate its moral agenda, the media served to exclude, stigmatise and dehumanise PWA from society, as well as reinforce the exclusion and maintain the deviancy of those most vulnerable to infection.

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4.1.4 THE ROLE OF CIVIL SOCIETY

In many states, the national response to HIV/AIDS has been both led by and supplemented by civil society actors. In China however, civil society involvement in the governance of AIDS has been conditioned by China’s sometimes-fraught state- society relations. In the early years, there existed limited space for the mobilization of civil society outside of scientific research and there was no involvement of civil society in decision-making. While it must be assumed that the lack of mobilization was due in part to the still low prevalence of AIDS, it can also be explained by the distrust of the intentions of civil society actors by the state and the lack of acknowledgement by the state that civil society could play an essential role in China’s AIDS governance.

In the period of denial there were very few domestic NGOs operating in the field of AIDS. The NGOs that were established were generally research foundations, devolved from the state and designed to link China to the broader international AIDS epistemic community. For example, the first Chinese AIDS CSO, the Chinese Foundation for the Prevention of STD and AIDS was established in 1988 and was mandated to raise funds for research into and the prevention of AIDS, as well as to ‘observe the constitution, laws and regulations of the country’ and ‘abide by social morals to unite forces within and outside of the country’ (China AIDS Info 2006; China Daily 1988).

Foundations created to conduct scientific research were one thing, organizations intended to reach and empower vulnerable populations and PWA were another. In a context where sex work and drug use is not only illegal but framed in terms of moral deviancy, it was difficult for would-be outreach organizations to get past the odious policy of nongovernmental organization registration and official supervision. Even if they were to do so, their ability to access the affected communities was affected by their perceived closeness to the state. As one activist said, ‘if I have to work with the police, how can I work with the country's high-risk groups?’ (Schmetzer 1993).

The following example illustrates the limited space for civil society mobilization around high-risk groups and PWA in a sexually conservative regime. The first AIDS

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hotline was set up in Beijing in 1992. A project of the National Health Education Institute, the hotline was run by a group of volunteers, headed by Wan Yanhai, a known activist for gay rights (Biers 1993; Crothall 1992). Having highlighted homosexual men as a high-risk group, the volunteers used the hotline to provide support and education on AIDS. However, Wan also used the hotline to help organize support groups and an AIDS awareness conference. Shortly afterwards, the Department of Propaganda accused the hotline operators of using the AIDS issue and the hotline as a vehicle to promote the vested interests of homosexual men. ‘As far as Beijing is concerned, AIDS should be treated simply as a medical issue and not a political or civil rights issue as it has become in the West’ (Crothall 1993). The Institute’s director was subsequently sacked and Wan Yanhai was demoted, had 60 per cent of his wages cut and was later expelled. The hotline closed down for three months before becoming operational again, this time with new staff (including CCP members) that were under strict instructions not to associate with callers and to avoid promoting condoms (Schmetzer 1993).

The need to include civil society and PWA in decision-making entered the global discourse in the late 1980s and the Chinese government rhetoric reflected this norm. For example on World AIDS Day in 1992 which focused on the community, Chen Minzhang, Minister of Health, called for governments at all levels, non-governmental organizations and communities all over the country to ‘undertake commitments for AIDS prevention and control’ although what this meant was unclear (Xinhua News Agency 1992). In practice however, there was no real acknowledgement of the role of civil society, let alone PWA, either in terms of their involvement in decision-making or in the implementation of policies.

4.1.5 INTERNATIONAL ENGAGEMENT

As discussed in chapter two, the international response to HIV/AIDS began in the mid-1980s with the creation of GPA in 1986. It should be noted that there emerged from quite early on an expectation that states would and should cooperate both with the WHO and with each other on the issue of AIDS. On the surface, China complied with this global consensus. Chinese representatives attended intergovernmental meetings on AIDS such as the 1988 London Summit of World Health Ministers.

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From 1990, China hosted a number of regional seminars and conferences on AIDS (China Daily 1992b; Xinhua News Agency 1991). When Jonathan Mann came to China in 1988 to discuss the provision of technical and financial assistance to control the spread of HIV/AIDS, the Chinese government indicated its interest in cooperating with the WHO and in 1990, China worked with the WHO to draft its first national AIDS program (Beijing Review 1990). In 1992 China attended the International AIDS Conference in Amsterdam, the first time that it had sent delegates to that forum. Dai Zicheng told the attendees that China has adopted the strategy of ‘giving priority to prevention’, focusing on conducting health education and monitoring epidemic diseases (BBC Monitoring Service: Asia-Pacific 1992). Therefore, in this period, China complied with the emergent global AIDS regime in so far that it attended international meetings, provided annual epidemiological reports to the GPA/WHO and accepted GPA assistance.

However, a closer look reveals that this compliance was superficial. While the China Daily (Zhu 1990a) announced that the Chinese NAP was being designed ‘in conformity with global policies and strategies and in line with national policies and local solutions’, as demonstrated above, national policies and local solutions had far more salience than global policies and strategies. While the GPA and the Global AIDS Strategy advocated evidence-based prevention measures embedded within a human rights framework, the Chinese government enforced border restrictions, mandatory testing, isolation of PWA and the suppression of high risk groups. China’s domestic discourse and behaviour belie any reformulation of its interests in line with the norms of the regime.

Furthermore, the quality of China’s engagement with the regime was lacking. With regards to the London Summit for example, unlike most other country delegations, the Chinese delegation was not headed by the health minister or any other minister for that matter. Instead, it was headed by Dr Wang Shusheng who was the chief of the anti-epidemic station in Guangxi province (WHO 1988a, p.139). Furthermore, the Chinese government’s official discourse on sex was not only reserved for domestic consumption. ‘China’s delegate denied the existence of homosexuals, drug users, and prostitutes in his country, thus insisting that AIDS couldn’t threaten the People’s Republic’ (Garrett 1994, p.476). To this end, China’s reports on the prevalence of

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AIDS were also questionable. As mentioned, China’s domestic behaviour undermined the global AIDS regime however, China’s behaviour at the international level also undermined the regime. For example, at the London Summit, it is alleged that China’s delegate, after signing the London Declaration, openly scoffed at the GPA’s attempts to promote educative measures over restrictive measures (Garrett 1994, p.476). While China rhetorically supported international coordination, it acted unilaterally when it suited. For example, China’s efforts to keep AIDS out of the country caused furore in Hong Kong when Beijing announced in 1993 that it would impose random HIV tests on visitors to China and compulsory testing on all visitors who enter the country more than 12 times a year (Straits Times 1993). This was in response to an increase in AIDS cases in Guangdong province, an increase that was blamed on Guangdong’s opening up and the increase of visitors and investors from Hong Kong and Macau (Zheng 1993). The policy was denounced by both businessmen and medical practitioners in Hong Kong as ineffective, insensitive, inconvenient and possibly dangerous if proper safety precautions were not followed (Reuters News 1993a). The tests were only halted after a delegation from Hong Kong travelled to China to voice their concerns and it was decided cooperation on HIV/AIDS between Hong Kong and China would be increased (Agence France-Presse 1993).

By the early 1990s, international actors such as the GPA were concerned that the Chinese government did not understand the challenge that AIDS posed. Some intergovernmental organizations and nongovernmental organizations operating within China started to expand their activities to include HIV/AIDS prevention. For example, the UNDP started supporting a project on promoting multisectoral approaches to HIV/AIDS prevention in 1993 and the Ford Foundation included HIV/AIDS capacity building in its reproductive health programme launched in 1990 (China Development Brief 2002). International experts attending conferences attended by or even hosted by China expressed concern that the country’s low prevalence of AIDS made Chinese officials complacent and urged the government to do more to prevent AIDS while there was time to do so (Quinn 1992; Quinn 1993). At a meeting to mark World AIDS Day in 1992, the WHO’s representative in Beijing warned ‘for the last three years, WHO has urged that there is still time to act…that time is rapidly running out’ (Bernard Kean quoted in Agence France-Presse 1992).

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4.2 1994-2002 – LIMITED RECOGNITION

The period from the mid-1990s to the early 2000s can be called one of limited recognition. On the one hand there was a trend of increasing recognition of the seriousness of the epidemic and of the global AIDS regime. In this period then we see developments within the official discourse and political commitment, legislation and policy, some change in the reportage of AIDS, an emerging space for civil society actors, and a slight change in international engagement through the increasing openness of China to international actors. On the other hand, the emphasis must be on the word ‘limited’ because there still lacked any real recognition of the issue of HIV/AIDS by the top leaders which undermined other efforts and sent mixed messages to lower level government officials. In particular, this period must be understood in the context of the issue of contaminated blood and the practice of blood selling. The Henan blood scandal paradoxically made the issue of AIDS more pressing and more politically sensitive. This had implications for both the Chinese government’s reputation in the international community and for AIDS activists in China.

4.2.1 POLITICAL COMMITMENT

The emergence of an AIDS epidemic amongst IDUs in Yunnan and eventually amongst FPDs in central China led to AIDS being framed less as a foreign disease in this period. By the mid-1990s the MOH was starting to frame the disease as a public health issue, acknowledging that the spread of the disease was probably far wider than officials had been willing to admit. A key publication, the Guangming Daily, quoted health officials as stating that there could be as many as 100,000 people with HIV/AIDS, a figure that was much higher than the official count of 2,428 PWA (Reuters News 1995a). Chen Minzhang, the minister of health, warned that there was ‘no time to waste’ to prevent a major AIDS epidemic in China. China’s Family Planning Minister, Peng Peiyun, went so far as to insist at the opening of a conference in 1996 that ‘the government has placed AIDS prevention and control among the priorities of the Ninth Five-Year Plan and China’s Twenty-first Century Agenda’ (China MOH and UNTG 1997, p.25). One Asian Red Cross official proclaimed that

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‘China's recent recognition of the AIDS problem is one of the success stories of the world’ (Holland 1996).

The change in political discourse was accompanied by limited political mobilization. A new national AIDS committee was established, to be hosted by the State Council. The committee, made up of members from 33 ministries and agencies and chaired by a state councillor, met for the first time in October 1996 (China MOH and UNTG 1997, p.25). As discussed below, this period also saw the MOH instigate the development of guidelines relating to PWA rights and design the first long-term strategic policy framework to tackle AIDS in 1998. However, despite the establishment of a new AIDS committee, it is unclear what the committee was set up to do, other than to coordinate between different elements of the bureaucracy, which by all accounts it did not do successfully. Thompson (2004), for example, has reported that the committee only met four times after its creation and had stopped meeting by 2001. Thus national AIDS coordination remained low. At around US$1 million ($15 million RMB) per year, the central government’s annual expenditure on AIDS prevention and control was inadequate. There were also ongoing challenges with regards to the government’s unease with promoting safe sex.

Furthermore, the government’s commitment to AIDS prevention and control during this period must be seen in the context of the Henan blood scandal. This scandal has its roots in the Chinese government’s ban on the import of foreign blood supplies, implemented in the mid-1980s. This was, as mentioned above, a precautionary measure – an attempt to keep AIDS at the borders. Unfortunately, the ban on imported blood led to severe blood shortages. In China, blood is considered ‘precious and private’, and related to a person’s physical strength. Voluntary blood donation therefore was unpopular. The China Daily for example proudly noted that 1093 people gave blood for free in 1986 (Zhang 1987). While the central government tried to encourage the voluntary donating of blood and some cities such as Beijing and Shanghai made regular donations mandatory (China Daily 1992a; Zhu 1992b), most of the country’s blood supply came from blood selling schemes. In 1991, of the small population prepared to give blood (under 0.2 per cent), 77 per cent were paid to do so (Rich 1991).

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While a blood industry existed prior to 1984, the ban on the import of blood products led to an increase in the price for blood and blood products such as plasma. Given the cultural prejudice against giving blood, it is unsurprising that many of the people that resorted to selling blood did so out of financial need. It was not a hard choice to make for some. Peasants in poor areas could make more money selling blood once every fortnight than they could working the land. While the blood business was financially rewarding, more lucrative still was the extraction of plasma, a highly sought-after raw material for the production of many pharmaceutical products. Plasma became big business in the early 1990s and led to the proliferation of illegal blood brokers. Xuetou - ‘blood heads’ or ‘vampires’ - acted as middlemen, buying blood and plasma from peasants and selling to public donation centres and hospitals. A large number of these operated in Henan and surrounding provinces in central China (Mickleburgh 1996). In the case of plasma donation, farmers were able to donate blood several times a week due to a technique in which all the donated blood was pooled and the plasma extracted before the blood was re-injected back into the donors. This prevented donors from becoming anaemic but also resulted in the high risk of HIV infection (and Hepatitis C), not to mention the broader contamination of blood supplies (Human Rights Watch 2003b; Mickleburgh 1996). In many provinces, provincial and local authorities encouraged the development of the plasma industry, which they saw as beneficial to the local economy - and to themselves. Local governments motivated local people to sell blood by painting large slogans on the walls, such as ‘To Donate Blood is To Grow Wealthy’ (xian xue zhi fu), and ‘To Donate Blood is To Be Glorious’ (xian xue guang rong) (Wu 2005, p.207). Activists have alleged that many of the blood collection stations became family businesses for many local officials and further imply that while the first transmissions may have been inadvertent, local officials and businesspeople may have continued the practice despite having learnt that people were being infected with tainted blood (Human Rights Watch 2003b, p.61; Wu 2005, p.206). It was difficult to know how many people had been infected. In one village, 65 per cent of the residents tested positive. Estimates for the total number of people infected in Henan were placed as high as one million (Rosenthal 2001d).

By the late 1990s, whole villages in Henan were getting sick and people began to die. While there had been early suspicions and several scares with the blood banks and

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tainted blood products, the Chinese government’s initial reaction was to downplay the extent of the issue at both the international and domestic levels. While the risk of HIV infection among commercial plasma donors was raised in a joint publication on AIDS between the MOH and the UN Theme Group on HIV/AIDS in China (UNTG) (China MOH and UNTG 1997, p.21), neither the central nor provincial governments addressed the issue by either releasing information on the risk of HIV prevention through contaminated blood to the general public or providing any support or treatment to PWA. The central government’s official number of HIV/AIDS remained unconvincingly low. In Henan health officials denied that the province had any AIDS cases (International Market Insight Reports 2000). Domestic media coverage was restricted under the State Secrets Law of 1988, researchers were blocked from entering Henan and activists attempting to bring attention to the situation were intimidated (Rosenthal 2000b). The Chinese government only conceded that the AIDS epidemic in China had been underestimated in 2001 after sustained international media attention to the issue in 2000 and 2001 (see section 4.3.5 below).

What did the central government know, when did it know it and why was it kept a secret? The Chinese government approved of and even encouraged the blood industry in the early days. Unfortunately, the blood and plasma industry grew faster than anticipated and regulation of the industry could not keep up. Blood safety precautions such as HIV screening and sterilization were not obligatory in many locations prior to 1996. Cases of HIV/AIDS among former plasma donors began to emerge in Henan and neighbouring Anhui province in the mid-1990s. In 1993 the National Regulation of Blood Supply and Management was promulgated by the MOH and this regulation made the organization of blood donations outside of government-approved blood centres and donation centres illegal in an attempt to curb unsafe blood operations (Zhu 1993a). The 1996 Regulations on the Management of Blood Production aimed to prevent the transmission of hepatitis and HIV through plasma and blood products. The regulations stipulate the rules for the extraction of plasma (plasmapheresis), including the eligibility of plasma donors and the requirement for sites where plasma can be collected (UNTG 2001, p.31). Extensive testing of blood is required at both plasma collection sites and processing factories. This law was supported by another law approved in 1998 – the Law on Blood Donation - which stipulates that all blood

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collected for medical transfusions should be from voluntary donors, not commercial blood donations (UNTG 2001, p.31).

It should be noted that the mismanagement of blood supplies is not unique to China. Many countries dealing with HIV/AIDS, both developing and developed, have had their own problems with regards to infection via contaminated blood products.103 The way that this information comes to light and how the state in question deals with it can tell us a lot – about the way AIDS is understood and about the nature of the political system in question. While it may be the case that the provinces in question did not fully inform the central government of the extent of the problem, the legislation passed by the government to prohibit certain practices is an indication that there was some knowledge of the potential for an AIDS epidemic as a result of contaminated blood. However, the central government’s first reaction was to minimize the issue. Possible reasons for this are threefold. First, given the previous framing of AIDS as a disease of prostitutes and drug users, there was concern that disclosing AIDS cases would affect future investment in the provinces concerned. Secondly, there was the concern that admitting the extent of the problem would lead to wide-spread compensatory claims and calls for accountability. Therefore, keeping the issue quiet was a means of maintaining social stability. Thirdly, while previously the central government had been able to take the higher ground with regards to its response to AIDS, suddenly it was facing an epidemic that CCP cadres had had a hand in creating. The scandal spoke volumes about the state of the health system, the enduring culture of secrecy and the continuing practice of putting politics above people.

Facing international scrutiny, the Chinese government did finally respond. Zhang Wenkang, the health minister at the time, announced at the UNGASS in 2001 that the Chinese government was going to raise funding for AIDS prevention and control from just over US$1 million (15 million RMB) to US$12 million (100 million RMB). Furthermore, US$117 million (900 million RMB) would be spent on improving blood safety (Zhang 2001). An ‘Action Plan’ was announced – a five-year policy framework designed to support and implement the objectives of an earlier plan, the 1998

103 The blood scandals in the US, France, Canada and Japan were the biggest and most publicised (see Anderson and Davis 2007).

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Strategic Plan (see section 4.3.2 below). Media restrictions were softened and official estimates of PWA were upgraded (Chang 2001). However, Henan remained a politically sensitive topic with many officials evading questions on the topic at press conferences. For example, Zhang Wenkang told a press conference in June 2001 that the estimated number of people with HIV/AIDS was more than 600,000 (as opposed to 400,000 in December 2000) but that this increase was due to a surge in infections among drug users, the central government having cracked down on illegal blood use and thereby preventing the prevalence of AIDS among blood sellers ‘five years earlier’ (Lederer 2001). Thus, while the issue of AIDS may have received increased recognition by the MOH, the causes of one of the biggest epidemics remained politically sensitive.

Despite these developments, the Chinese government’s response was limited by the fact that the top leaders remained silent on the issue. Despite the increased openness of the government towards AIDS following UNGASS and the blood scandal, the opening address at the first national conference on HIV/AIDS was given by Zhang Wenkang, instead of by Li Lanqing, the Vice-Premier, as originally planned. This move was observed and criticized by Peter Piot, who was attending the conference and who said,

Having the health minister involved is essential, but not enough…In most countries the solution has required the support of the prime minister, the king or the president. Only then do things really start to happen’ (Rosenthal 2000a).

With so many other elements of a national response to HIV/AIDS hinging on the response of the top leaders, it followed that the silence at the top hindered the MOH’s efforts to obtain adequate funding, to coordinate with other sectors, to educate the general public and to ensure compliance by local officials.

4.2.2 LEGISLATION AND POLICY

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Reflecting the government’s recognition that the country was facing a more serious AIDS epidemic than had previously been admitted, there were a number of legal and policy developments in the period between 1994 and 2002. These developments were comparatively more constructive and progressive than the exclusionary laws of the period of denial. However, central legislation and policy was undermined by both the lack of political commitment by the top leaders and the institutional dynamics between the centre and the provinces.

There were no major national laws passed in the period of limited recognition but there were a number of important minor pieces of legislation introduced by various central government ministries. For example, in addition to several pieces of legislation relating to blood safety, in 1999 the MOH issued the Principles for Management of People Infected with HIV and AIDS (‘1999 Principles’ hereafter) which stipulated the importance of fighting discrimination and protecting the rights of PWA to study, work, receive social welfare and appropriate medical treatment, and have their personal information remain confidential. It also stipulated that PWA in prison also have the right to education and medical care, as do HIV positive migrant labourers. It also outlined the duties of PWA and noted that deliberately transmitting HIV/AIDS was punishable by law (UNTG 2001, p.33). The 1998 Principles for HIV/AIDS Education and Communication was the first truly multi-sectoral regulation, issued by nine ministries and agencies including the Department of Propaganda. The legislation provided the basic principles for the dissemination of HIV/AIDS education and communication via the mass media and other channels. Importantly, it stipulates that condom possession is not indicative of prostitution (UNTG 2001, p.32). Another development was the lifting of the ban on the advertising of condoms. The 1989 State Advertisement Law explicitly forbade print or broadcast advertisements promoting sex-related products, including condoms, for fear of promoting sexual promiscuity. In 1999 there was debate over this law when a 42-second condom announcement run by the China Central Television Channel One (CCTV-1) was cancelled by the State Administration for Industry and Commerce (China Daily 1999; Sheridan 1999; Xinhua News Agency 1999a). The issue vanished from the headlines before reappearing in 2002, when in June the NPC called on the administration to lift the

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ban. The first condom advertisements were screened on national television the next year (Coonan 2003; People's Daily 2003b).

In the period of limited recognition there were also efforts made to develop China’s AIDS policy. In 1995 the Ministry of Health issued the Suggestions on Strengthening AIDS Prevention and Control, which established the new national AIDS committee and increased AIDS funds (China MOH and the UNTG 1997). For most of the period, the focus was put on prevention, primarily through AIDS education. However, the effectiveness of prevention strategies such as AIDS education and the promotion of condoms continued to be constrained by the official discourse on sex. Education programmes during the period of limited recognition were sporadic, poorly coordinated and often short-lived. For example, in 1995, a pilot program began in Shanghai and Henan province with university students receiving a notice about AIDS when they underwent their college entrance physical check-up (Reuters News 1995b). However, the State Education Commission’s attempts at rolling out this AIDS education across the country appear to have succumbed to familiar problems. On the one hand, because of the earlier framing of the disease as one that affects people who engage in abnormal and illegal behaviour, many people were not even willing to learn about AIDS. ‘It's too embarrassing…It's not the sort of thing an upstanding citizen should show interest in’ (AIDS activist interviewed in Chandra 1995). On the other hand, many official education materials ran a fine line between educating and lecturing, due to the reluctance of the authorities to promote certain behaviour. For example, the leaflets distributed in the pilot programme to students in Shanghai in September 1995 stated that in order to prevent the spread of HIV students should ‘keep clean by abiding by moral standards and avoiding promiscuity’ (Crothall 1995).

The same problems plagued condom promotion. For example the same leaflet that urged students to avoid promiscuity mentioned that condoms could prevent HIV but that they had a failure rate of 10 per cent and therefore should not be considered as ‘a sexual safety net’. One official went so far as to stress that the information about condoms was only included for reference purposes and in ‘no way whatsoever’ advocated sex among students (Crothall 1995). Survey results in the early 2000s indicated that while most people had heard about AIDS and knew that it could be spread from person to person, only three quarters of the people surveyed were

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unaware that condoms could prevent AIDS (Brown 2002). In the early 2000s, in order to get around the discomfort of the government in promoting condoms (which were seen to promote promiscuity), the MOH reclassified the condom as a medical device rather than sexual commodity (Manchester 2003).

Towards the second half of this period, there were some major policy developments. The Chinese National Medium-and Long-Term Strategic Plan for HIV/AIDS Prevention and Control (1998-2010) (‘Strategic Plan’ hereafter) was released in 1998. The Strategic Plan called for governments at different levels to incorporate AIDS prevention and control into their local social and economic development programs. Included in the guiding principles of the Strategic Plan are the adaptation of international best practices to local situations and the prioritisation of prevention and health education. However, the plan also stated that coordination was needed between sectors and between different levels of government and stipulated that social bodies and civic organizations should be supported (State Council 1998). Thus, it is possible to see that the norms of the global AIDS regime were starting to emerge in China’s evolving AIDS policy. In response to UNGASS and as a follow-up to the Strategic Plan, the Chinese government issued the Action Plan for Reducing and Preventing the Spread of HIV/AIDS (2001-2005) (‘Action Plan’ hereafter) in June 2001. The Action Plan set a number of working objectives for 2002 and 2005. Priority was still given to prevention, with particular attention given to blood safety and AIDS education; but for the first time treatment (both traditional and western) was also noted to be critical. Another first was the inclusion of harm reduction strategies such as the implementation of condom vending machines, needle exchange and methadone maintenance (State Council 2001).

These legislative and policy developments were more constructive than the defensive and exclusionary laws produced in the period of denial and signified that there was acceptance within the government that the emerging AIDS epidemic needed to be addressed. The references to ‘international best practice’, ‘multi-sectoral coordination’, and ‘assistance to civil society’ are indicative of the increased exposure of decision-makers to global norms through international meetings and norm teachers such as UNAIDS. However, in practice, both legal and policy developments faced major challenges.

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First of all, local compliance with central dictates was hindered by the vagueness and unspecific nature of the legislation and policies and their contradiction by other laws. This resulted in local governments having a lot of autonomy in interpreting AIDS law and policy. Take the 1999 Principles for example. While this was an important piece of legislation in that it prohibited discrimination against PWA, however, there were a number of higher-weighted laws104 that contradicted the MOH’s 1999 Principles such as the 1989 Infectious Disease Law and the 1995 Law on Maternal and Infant Health Care (used and abused by officials to prevent PWA from marrying).105 The flexibility that the local governments have in interpreting this web of legislation allowed for much diversity in local AIDS law-making. Therefore, despite having national regulations stipulating the protection of the rights of PWA, a number of provinces and cities were able to pass discriminatory laws (Chang 2001). For example, Chengdu in Sichuan passed a law requiring people working in hotels, restaurants, travel agencies, public baths, swimming pools and beauty salons to be tested annually for HIV, with those testing positive required to leave their jobs (UNTG 2001, p.35).106 Likewise, while the Strategic Plan and the Action Plan introduced harm reduction strategies, there was little understanding of how such programs could be advanced in the face of strong laws prohibiting drug use.

However, there was also the issue of a lack of material political commitment. While critics noted that the Strategic and Action Plans included ambitious goals, financial resources did not support these. For example, there was little suggestion of how western treatment might be viable in the face of the prohibitively high costs of the drugs. Likewise, outside of internationally-funded pilot programs for needle-exchange and condom social marketing, there was inadequate funding (UNTG 2001; Human

104 Due to the nature of the Chinese legal system, a law by itself may not carry much power. The power of a law often depends on which legislative body it belongs to or who is promoting it. 105 The 1995 Law on Maternal and Infant Health Care was originally designed to protect mothers and to protect unborn children from diseases which can harm reproduction. For this reason, all couples must have pre-marital medical examinations and if found to have an infectious disease such as an STD or AIDS they must postpone the marriage. The law does not address the issue of couples that do not wish to reproduce, nor does it mention HIV in its list of infectious diseases. Unfortunately for PWA however, provincial and local governments have used the ambiguity of the law to refuse marriage certificates to PWA (Human Rights Watch 2003b). 106 In saying this, local level law making did not always prove discriminatory. In October 2002, Suzhou city in Jiangsu province passed a law guaranteeing patients and their families equal access to employment, education and health care, and giving PWA the right to sue for redress (Zhang 2002). This was the first law of its kind in China.

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Rights Watch 2003b). Furthermore, the lack of visible commitment from the top leaders further undermined AIDS law and policy by cementing the perception that AIDS as a public health issue was not as important as economic development and social stability.

4.2.3 HIV IN THE MEDIA

Following the other indicators, there were several changes concerning the representation of HIV in the media during the period of limited recognition as well as the continuation of several trends. In the period of limited recognition, there was a move towards a more inclusive tone of reporting rather than the exclusionary and moralising tenor of the period of denial. A major problem however was the frequent release of alarmist reports of an increased AIDS epidemic - a consequence of the government’s haphazard dissemination of AIDS cases. In keeping with this inclusive tenor, there also emerged in this period signs of a process of PWA normalization. In general however PWA remained on the outer of society.

Media discourse reflected the mood of the government. With the increased recognition of AIDS as an issue by the government, the media used less exclusionary language with some attempt made to emphasize the universality of the disease. While there were heavy media restrictions surrounding the issue of tainted blood in Henan, following the breaking of the story in the international press, some restrictions on the domestic media were lifted. In fact, the emergence of the commercial plasma donor scandal and the limited media freedom that followed allowed for the tentative inclusion of broader high-risk groups into discussions about HIV vulnerability. Articles began to mention the possibility of mother-to-child transmission, the infection of haemophiliacs and former plasma donors, heterosexual transmission and the risks for the floating population. This was a change from the perception that HIV/AIDS was a foreign or deviant’s disease. Instead anyone ‘normal’ could get AIDS.

While there were some changes in the way that AIDS and PWA were reported, many articles discussed AIDS in one of two ways. On the one hand, AIDS was often

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reported in impersonal, medicalised language. For example, there was much reportage of epidemiological data, high-risk groups, blood security and training of professionals. Otherwise, AIDS was discussed in alarmist language. ‘China is not free of the scourge of the macabre HIV/AIDS epidemic which haunts the world nowadays…Underestimating the severity of the situation will be lethal to the country’ (Xin 2001). In 2001, the UN warned the government that the media had been under- utilized in the fight against HIV/AIDS in China, and at times, had proved counteractive. ‘”Scare messages” have been broadcast and published, leading to irrational fear among the public, which is a source of discrimination against PWA’ (UNTG 2001, p.74). Headlines such as ‘China seriously plagued by AIDS epidemic’ (Xinhua News Agency 1999b), ‘War against killer virus stepped up’ (Qin 2001b) and ‘Curbing spread of macabre virus’ (Xin 2001) are cases in point. The reluctance of the government to report AIDS statistics for fear of destabilising society contributed to this alarmist reportage because it released information haphazardly and usually in response to international pressure. Both forms of reporting on AIDS served to reinforce the distance between the general public and people with AIDS. In the first case, PWA were HIV/AIDS cases (faceless, sick people) and in the second case, PWA, as carriers of the ‘killer’ or ‘macabre’ virus, were people to be feared.

Not all articles presented PWA in a negative light. Often, reportage around World AIDS Day spoke of the need for Chinese people to show respect and compassion towards people with AIDS and the need for AIDS patients to be treated ‘like people with any form of disease’ (Qin 2001a). There were lots of articles that reported the AIDS prevention activities of Beijing students (Xinhua News Agency 2000), the love and care shown to PWA by compassionate volunteers (Jin 2001), and the efforts at AIDS prevention and control undertaken by the Chinese government (Zhu 1995). There was a notable difference between media coverage of AIDS in 2000 and in 2001 and 2002, with PWA starting to be heard. In 2001, an American journalist in Beijing noted for example that PWA were interviewed on the television for the first time (Rosenthal 2001b).

However, this same journalist also noted that:

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many of the offerings this week [World AIDS Day week] seemed to be more propaganda than information. The Chinese AIDS patients featured on television news shows had generally contracted H.I.V. overseas, for example. Most ‘came out’ wearing sunglasses or with backs turned to conceal their identity (Rosenthal 2001b).

Moreover, while there was much discussion of the need for prevention and care in this new coverage, there was little discussion of what that might entail. For most of this period, there was little mention of condoms, counselling, support groups, harm reduction programmes or PWA rights. Neither was there much effort to dispel AIDS myths. There was no reportage of high-level leaders talking about AIDS.

4.2.4 THE ROLE OF CIVIL SOCIETY

The greater space for civil society actors emerged during the period of limited recognition but it was a space that was monitored and constrained by the state. Civil society actors had little involvement in decision-making. The growing AIDS epidemic coupled with increased international presence in China resulted in a moderate mobilization of nongovernmental organizations. These civil society actors could be divided into two types according to their mandate and main mode of operation. Those organizations that were mainly involved with service provision were generally accepted by the state so long as their activities were in line with the state’s agenda. On the other hand, organizations that engaged in AIDS activism- making claims upon the state on behalf of PWA – were viewed by the state as threatening and destabilizing. AIDS activism outside of the state’s sanction, such as the actions of individuals and organizations that sought to bring attention to the issue of tainted blood in Henan province, was subject to repression.

During the 1990s the global AIDS regime consolidated and promoted the central role of civil society and the principles of the greater involvement of PWA in decision making, as enshrined in the 1994 Paris AIDS Declaration, the UNAIDS governance structure and the 2001 Declaration of Commitment, for example. So while the Chinese government was a signatory to these agreements and agreed to the essential role of civil society in principle, in practice the emergence of an effective response by civil society to AIDS continued to be shaped by repressive state-society dynamics. In China Responds to AIDS it was insisted that ‘the government has paid more and more

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attention to the contributions of NGOs in AIDS prevention and control, and strongly supports their development’, before going on to publicise the achievements of the Chinese Association of STD/AIDS Prevention and Control and the Chinese Association of Preventative Medicine, two of the most prominent GONGOs in China (China MOH and UNTG in China 1997, p.38). The Strategic Plan stated that:

Governments should encourage and support social bodies and civil organization work to provide home-based care and psychological counselling service for people living with AIDS, and health education among high-risk populations. Insofar as possible, these organization should be assisted in offering support…to help HIV infected individuals and people living with AIDS so as to mitigate the prejudice against HIV infected individuals, people living with AIDS and their families (State Council 1998).

The Action Plan, on the other hand, noted as one of its ‘implementation principles’ that ‘participation from society at large must be strengthened’ but did not go into detail about the role that civil society organizations could play other than to say that charitable organization should provide social relief (State Council 2001).

Nevertheless the expansion of AIDS in China and the inability of the state to reach high-risk groups did lead to the moderate mobilization of domestic civil society actors. Of 97 NGOs, GONGOs and PWA help groups that registered the date of their establishment in the China AIDS Info directory, while only one organization was established in the period of denial, 34 were established between 1993 and 2002.107 The state considered civil society actors to be tools rather than partners. As suggested in the Strategic Plan, the government approved organizations that sought to complement the state’s anti-AIDS activities by providing education to marginalized population or care to PWA. The state continued to monitor and constrain the activities of these organizations through the use of the institutional mechanisms such as registration and government supervision of organizations (as discussed in more detail in chapter three, section 3.2.3, above). However, civil society actors were not consulted in the policy-making process at any level of government.

107 China AIDS Info is a non-commercial, non-profit website which includes an AIDS directory. As of December 2007, China AIDS Info website listed 168 organizations under the categories ‘NGOs, GONGOs and other groups’ and ‘PLWHA Support Groups’. Of these only 97 listed the years in which they were established (China AIDS Info 2007). It is these organizations that I have used as a sample.

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The mobilization of civil society was also fuelled by the increased presence of multilateral, bilateral and international nongovernmental actors in China. IGO-NGO relations were constrained by a state that acted as the gatekeeper, particularly in the early 1990s. For example, in 1994, the WHO organized a three-day symposium on the role of NGOs in promoting AIDS prevention to high-risk groups. However, one journalist noted that there was a conspicuous lack of non-governmental organizations on the guest list with the symposium instead being dominated by government officials such as the Director of the State Council Research Office, Yuan Mu, and head of the State Family Planning Commission, Peng Peiyun. In particular, ‘the controversial AIDS activist, Wan Yanhai…apparently has not been invited to the symposium’ (Crothall 1994). Nevertheless, international actors helped to legitimate the role of civil society in the governance of AIDS by actively seeking advice and consulting with organizations. For example, the UN Theme Group on AIDS in China was established in 1996 with an explicit aim of expanding partnerships in China, including with domestic NGOs (UNAIDS China 2008). Wu (2005) also suggests that, while most INGOs have generally engaged constructively with both the government and domestic civil society (a process that Wu calls ‘double mobilization’), there have been times when INGOs have gone beyond the state’s sanction to aid PWA and their advocates, such as in Henan province.

Central China was the site of much AIDS activism over this period, mobilized by the issue of the plasma donors (Chang 2002). In attempting to bring the plight of the former plasma donors to light and seek redress, however, these activists often came up against formidable political opposition in the form of the provincial and local authorities. For example, Dr Gao Yaojie, an elderly doctor living in Henan, started trying to publicize and raise funds for those infected in the late 1990s. Local authorities obstructed her activities and her house was kept under surveillance. In 2001, when Dr Gao was awarded the Jonathan Mann Award for Health and Human Rights by the Global Health Council that was to be presented to her at a ceremony in the US, Henan officials refused to issue her with a passport and argued that Gao was being used by ‘anti-Chinese forces’ (Rosenthal 2001c). Dr Wan Yanhai, a leading AIDS activist and founder of AIZHI (AIDS) Action Project also faced police harassment and threats from local government officials for visiting Henan villages.

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Wan helped to expose the blood crisis by posting information on the Internet. In August 2002, Dr. Wan was arrested after having posted on the Internet a classified health document concerning the AIDS epidemic among the former plasma donors. Dr Wan was detained by the State Security apparatus for a month for having ‘leaked state secrets’, despite the MOH having released a notice in 1999 that declassified AIDS as a state secret, not to mention the fact that the scandal had already been exposed both internationally and nationally in 2001 (Wan Yanhai 2003). International pressure led to Wan’s release (Agence France-Presse 2002; Bezlova 2002; Dow Jones International News 2002; Reuters News 2002a; Reuters News 2002b; Rosenthal 2002a; Rosenthal 2002b).

Overall therefore, the heavy-handed tactics displayed by the authorities betrayed continuing official distrust of the motives and intentions of civil society organizations. In contestation with prevailing political practice therefore the greater involvement of PWA and the leading role of civil society failed to have much salience, leading the UNTG (2001, p.71) to conclude that ‘the invaluable asset that social organizations can constitute has yet to be fully realized in the context of the Chinese AIDS epidemic’.

4.2.5 INTERNATIONAL ENGAGEMENT

China’s interaction with the global AIDS regime over this period was mixed. In general, China was relatively passive – it attended major international meetings and allowed international actors to increase their in-country presence in Yunnan Province. As discussed above, we saw limited domestic compliance in that the global AIDS norms did begin to emerge in legislation and policy. Again, however, China’s passive rhetoric was countered by its level of representation at those meetings. Moreover its domestic behaviour, particularly the lack of commitment to its people, and to the global regime by keeping the blood scandal in Henan covered up, came under heavy criticism.

China was present at all the major events in the development of the global AIDS regime. In 1994, China attended the World AIDS Summit in Paris and became one of only 42 countries to attend and sign the Paris AIDS Declaration. As mentioned in chapter two, the Paris AIDS Declaration enshrined the principles of greater

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involvement of PWA and China’s support of this statement of consensus was significant. While Chen Minzhang’s statement to the summit may have exaggerated the ‘serious efforts’ made by the Chinese government to prevent discrimination against HIV carriers and AIDS patients and to protect their human rights and dignity, he did promise that ‘relevant laws and regulations and policies suiting China's conditions will be established and improved’ (BBC Monitoring Service: Asia-Pacific 1994; Chen 1994). China was the first non-traditional donor to pledge funds for the newly created UNAIDS for the biennium 1996-1997 (China MOH and UNTG 1997, p.26) and was also a signatory to the 2000 Millennium Declaration and the 2001 Declaration of Commitment.

China also engaged the global AIDS regime by becoming increasingly open to international assistance. In 1997, UNTG worked with the Chinese MOH to produce an HIV/AIDS situation and needs assessment report. The mood of the report was sobering but hopeful. It was sobering because it noted that AIDS had the potential to become a major problem in China, but it was also hopeful because it was believed that a quick national response could prevent such an occurrence.

Given the necessary resources and expertise, it may be possible to keep the epidemic at bay in most parts of China, and to considerably reduce the negative impacts of the disease on individuals and society (China MOH and UNTG 1997, p.33).

Meanwhile over the 1990s, UNAIDS cosponsors, bilateral donors and international non-governmental organizations increased their presence in China and began to include HIV/AIDS projects in their greater development agenda. While some projects had national scope, most UN and bilateral initiatives focused on Yunnan, as the province the government had identified as having the largest number of PWA and the highest risk for spreading infection.108 The majority of INGO AIDS projects took place in Yunnan province for the reason that the provincial government was relatively open to their presence (Human Rights Watch 2003b). For example, the Australian Red Cross in conjunction with the China Red Cross Society began a peer education program for young people in Yunnan in the mid-1990s. Save the Children (UK) also

108 See China Responds to AIDS (China MOH and UNTG 1997, p.30) for details of these projects by UN agencies (such as the UNDP, UNICEF, the World Bank, UNESCO and UNFPA) and bilateral donors (such as the European Union, Australia, Norway, the Netherlands and the UK).

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started school-based peer education in Yunnan in 1996 and then implemented an integrated prevention and care project in Ruili, Yunnan in 2000 (China Development Brief 2007).

However, while China’s rhetoric both at the international level and the domestic level emphasised the need for the ‘active encouragement of international cooperation’ (State Council 1998), China’s compliance and cooperation remained marginal. If the level of official representation is symbolic of the importance China attributed to these meetings, it is meaningful that China only sent its minister of health to both the Paris Summit and UNGASS while many other countries sent their heads of state. This led the UNTG to conclude that China only saw HIV/AIDS as a medical problem rather than as a broader development issue (2001, p.34). China’s protests against AIDS being included on the agenda of UNSC in 2000 also attests to this limited perception of the disease.

However, the clearest indication that China was not yet prepared to see the global interest as being in its interests was the way in which the government handled the Henan blood scandal – its lack of transparency to both its domestic audience and the wider international community, the lack of accountability and the treatment of AIDS activists. While the risk of HIV to commercial plasma donors was recognised in China Responds to AIDS, it was seriously understated. The extent of the epidemic that was already emerging in central China had not been disclosed to the UNTG or to the WHO. The prioritisation of economic development and social stability (and the interests of the provincial elite) over human rights was so contrary to global norms that when the story of Henan became the subject of a sustained international news campaign in 2000 and 2001, the press was scathing and condemnatory. ‘Death sentence’ (Sui 2000), ‘The AIDS scandal China could not hush up’ (Gittings 2001), ‘AIDS-stricken Chinese peasants call for justice’ (Page 2001) and ‘Five dollars per life’ (The Asian Wall Street Journal 2001) were just some of the headlines. It was noted by a prominent newspaper that:

China is cruel to its own citizens in so many ways that it becomes difficult to muster a sense of outrage. But every once in a while, a story comes along that horrifies on a different level... Over the past year, another such story has been unfolding in rural

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Henan province, where thousands of peasants who sold their blood to the government are now dying of AIDS, while Beijing sticks its head in the sand (The Asian Wall Street Journal 2001).

Pressure from the international press is likely to have contributed to the Chinese government’s increased transparency and limited political mobilization in 2001. Furthermore, a similar media barrage that followed Wan Yanhai’s disappearance in August 2002 may have forced the government to consider his release (Bezlova 2002; Reuters News 2002a; Rosenthal 2002b; Spiegel 2002).

Criticism was not limited to the international press. Peter Piot, the head of UNAIDS, visited China in November 2001 in order to attend China’s first national AIDS conference. While Piot praised the increasing openness he had encountered among officials in Beijing and the government’s plans for combating AIDS, he was highly critical of the lack of education and treatment, the severe discrimination facing PWA and the failure of the top leadership to make the disease a priority. ‘There has to be public expression by the top leadership of a country that this is a top issue, that gives everyone working below them a green light,’ (Piot quoted in Rosenthal 2001a). In 2002, the UNTG updated its assessment and the result was ‘China’s Titanic Peril’, a report that was highly critical of the Chinese government’s progress in AIDS governance since 1997.

While undoubtedly some significant progress was made in the national response since that early report, much of the hope, expected commitment, and planned action forecasted in China Responds to AIDS have resulted in few outcomes and an infinitesimally small impact on the spread of the epidemic (UNTG 2001, p.7).

What was China’s response to this criticism? With regards to the UN Theme Group’s report, China’s reaction was defensive with health officials rejecting the findings of the report as one-sided and inaccurate. One official was quoted as stating that ‘the information they have is not sufficient and cannot be fully trusted’ (Ang 2002).

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4.3 CONCLUSION

This chapter has examined China’s governance of AIDS from 1985 to 2002. Using the indicators of political commitment, legislation and policy, HIV in the media, the role of civil society and international engagement, I demonstrated that it is possible to differentiate between the period 1985 to 1993 and the period 1994 to 2002. The first period is best characterised as an era of denial due to the lack of political commitment to recognising the disease as an issue for China. The result was exclusionary legislation and policies, stigmatising media discourse and no mobilization of non-state actors or civil society involvement. In terms of its international engagement in this period, other than cooperating with the GPA/WHO, China displayed little acknowledgement of the emerging global AIDS regime.

In the second period, that of limited recognition, it is possible to identify a shift in the political and media discourse with AIDS being framed as a public health issue. There were developments in law and policy and a narrow space opened for civil society actors, aided by China’s increased access to international actors. These developments signified recognition of global AIDS norms that was helped by China’s increased openness to international actors but hindered by centre-local and state-society institutional dynamics. China’s low compliance and marginal cooperation with the global AIDS regime was particularly reflected by the opaque and repressive manner in which the state handled the epidemic in central China and the continuing lack of political commitment to AIDS shown by the Chinese government.

It is possible to say that the Chinese government was aware of the existence of a global AIDS regime well before the end of 2002. Having attended and hosted global meetings and conferences on AIDS prevention and having worked with various international organizations and partners, Chinese officials had been exposed to policy recommendations and had been reminded of their international agreements and obligations. Yet, this chapter has shown that while this interaction had led to limited compliance, by the end of 2002 China was still far from behaving in line with the norms of the global AIDS regime.

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I argue that the global AIDS regime began to have more impact following the SARS crisis of 2003. While chapter six will demonstrate how China’s post-SARS AIDS governance began to move more in line with the norms of the global AIDS regime, this next chapter will examine the events of 2003. By examining how the SARS outbreak forced the Chinese leadership to frame health in terms of political legitimacy, I will show how crisis acted as a key mechanism in this narrative of normative change.

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CHAPTER 5 – THE SARS CRISIS AND AIDS GOVERNANCE

5.0 INTRODUCTION

In late 2002 and early 2003, a new disease called SARS broke out in China and created a national health emergency, as well as a global health crisis. In this chapter I argue that the SARS crisis played a crucial role in the transformation of AIDS governance in China by establishing a clear link between health governance and the domestic and international legitimacy of the Chinese regime. SARS thus served as a watershed moment in the evolution of AIDS governance in China, transforming the political context in which health policy is devised and implemented. In the pages that follow I will both review the SARS outbreak, and demonstrate the way in which the crisis created the catalyst for Chinese government to re-evaluate health and infectious disease generally, and AIDS in particular. Indeed, while other factors maybe relevant, I argue that it is impossible to understand the Chinese government’s response to AIDS from 2003 onwards without examining the role of SARS, and the ways in which the crisis politicised health by linking health with regime legitimacy.

This chapter will begin with an exploration of the role of crisis and the uncertainty it provokes as an important, and sometimes essential, circuit breaker in policy terms. A crisis can alter the political context, opening a window of opportunity in which new ideas may gain salience. After recounting the chronological narrative of the SARS outbreak, I will discuss how the crisis threatened the legitimacy of the Chinese leadership. The outbreak, or particularly the way in which the state responded to the outbreak, exposed the weakness of the Chinese health system, highlighted the internal challenges facing the Chinese government, threatened economic development and social stability and caused damage to China’s international reputation. Furthermore, the threat occurred at a time when the Chinese government was in transition, a time when the leadership was therefore at its most insecure. Therefore, the SARS crisis had both a physical and a psychological impact on China and contributed to the politicisation of AIDS.

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5.1 CRISIS, UNCERTAINTY AND POLITICAL CONTEXT

All norm entrepreneurs, regardless of issue or country, operate in a particular political context. This context is constituted by a variety of factors such as institutional and cultural structures,109 configurations of power and interaction contexts (Della Porta 1996, p.80; Kriesi 2004, p.69) which together act to provide opportunities for, or constraints against, action. As already discussed in chapter three, in China, the actions of domestic and international AIDS actors and the norms they advocate are often conditioned by the one-party system, the centre-local dynamic, state-society relations, domestic normative frameworks, particularly the official discourse on sex, and the interests of the elite. While these are the relevant domestic factors, we could also add the additional factor of the international context in order to understand the broader structure. When all is well and the political context is relatively stable, it can be difficult for new ideas to gain salience.

An injection of uncertainty as a result of a crisis however can cause this context to shift and be more receptive to new ideas and those who promote them. As discussed in chapter one,110 there are several ways in which crisis can lead to change. A crisis can cause an old issue to be seen in a new way. A crisis can also cause an organizational shift, empowering actors that previously were weak, or providing more resources where before there were few. A crisis can lead to the discrediting of previously stable ideas or policies. As old ideas are questioned, new ideas may enter the policy debate.

Many of these scenarios were witnessed during and in the aftermath of the SARS crisis. By drawing attention to the poor state of the Chinese health system and its information systems, highlighting the danger of unbalanced economic and social development, and undermining China’s international reputation, the SARS crisis forced the Chinese government to reflect upon the costs of inaction and the implications for the government’s claim to the right to rule. By politicising health, the

109 Institutional and cultural structures make up what social movement theorists call ‘political opportunity structures’ (Kriesi 2004, p.69). 110 See chapter one, section 1.4.2.3, page 42.

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SARS crisis helped to empower the health authorities and led to the recentralisation of public health. It also increased the salience of domestic and international actors advocating health reform. Most importantly, the SARS crisis allowed the HIV/AIDS epidemic to be framed in a way that engendered political will from the top levels of government.

It is important to emphasize at this point that although a crisis may open a ‘window of opportunity’ for change (Kingdon 1995; Cortell and Peterson 1999), it does not influence the extent of the change (if change occurs at all!) or which direction this change takes. Rather, the extent of change that follows a crisis or catastrophe is as Kriesi (1995, p.194) says, ‘a function of the specific political opportunity structure [or political context] at the moment the catastrophe occurs’. Likewise, its direction is determined by the way in which the crisis is perceived by both the political elite and the norm entrepreneurs, and the interaction of these groups. For example, Checkel (1997, p.124-125) notes that while there were ‘windows’ for institutional change in the Soviet Union in the 1960s and the 1980s, brought about by uncertainty in the international political climate, the change affected differed according to the extent to which the elite actively searched for new ideas, how well placed the entrepreneurs were and the extent to which the new ideas were hindered or helped by previously established interests and ideas. The extent to which AIDS governance changed and the direction of this change in the aftermath of the SARS crisis was shaped by both the international regime and the domestic political opportunity structure.

A common critique made of the concept of the ‘open moment’ or the ‘window of opportunity’ is that these theories assume inaction on behalf of norm entrepreneurs when the window is ‘closed’ (Gamson and Meyer 1996, p.280). I do not want to suggest that the AIDS entrepreneurs in China were inactive during the years preceding the SARS crisis. As already mentioned in chapter four, there was considerable effort made by advocates both inside and outside China to raise the political profile of AIDS in the pre-SARS period. For example, the Henan blood scandal was brought to light by both domestic organizations and the international press and this led to several changes in law and policy particularly in the late 1990s and early 2000s.

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It is worth noting that while there are similarities in the case of the Henan blood scandal and that of the SARS crisis, there are also significant differences. First of all, the cultural sensitivities surrounding blood donation and HIV/AIDS have meant that the situation in Henan was and has remained opaque, despite press coverage of the problem. The SARS crisis on the other hand, despite the government’s efforts, was relatively transparent. Second, whereas the blood scandal remained fairly localized, affecting Henan and the surrounding provinces, SARS was highly contagious and in a matter of weeks became a transnational problem. Third, because SARS directly threatened other countries, the outbreak stimulated international pressure of a different sort to that provoked by the Henan blood scandal. While the Henan blood scandal provoked international criticism due to the government’s lack of transparency and indifference to human rights, SARS directly affected the economy. Finally, and most importantly, unlike the SARS crisis, the Henan blood scandal did not really impact upon the political interests of the elite. Therefore, I argue that the SARS crisis was able to put infectious diseases, particularly HIV/AIDS, on the political agenda in a way that the Henan blood scandal could not. This argument will be explored further below following a brief account of the events of 2003.

5.2 THE 2003 SARS CRISIS

SARS originated in Guangdong province in China. Researchers suspect that the new coronavirus was probably exposed to humans in the exotic food markets but the first known case was retrospectively diagnosed in Foshan city, Guangdong, on November 16, 2002 (WHO 2003, p.1). When more cases of people suffering from pneumonia- like symptoms appeared in December and January, the provincial health officials surmised that they were dealing with an atypical disease. An expert team comprised of officials from both the provincial health department and the MOH was sent to the city of Zongshan to investigate. The ensuing report was sent to the provincial health bureau (and probably to the MOH as well) on January 27, 2003, but unfortunately, as the findings coincided with the Chinese New Year and because the report was labelled ‘top secret’, for three days there were no authorised provincial health officials who were authorised to read it. The provincial bureau did eventually send a bulletin to hospitals across the province. Again however, due to the Chinese New Year vacation,

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many health workers were away and the bulletin did not receive the attention it deserved (Huang 2004, p.118).

Nevertheless, the provincial authorities and the MOH were aware of the disease in January 2003 but did not report the outbreak to the WHO. The WHO (2003, p.1) heard about the outbreak via non-official sources111 in February and contacted the Chinese government for information on February 10. WHO received its first reports from the MOH on February 11. That same day, the Guangdong provincial health officials gave a press conference announcing that a disease called ‘atypical pneumonia’ had made 305 people sick, had killed five people, but was now under control (Taylor 2003).

In late February and March, outbreaks of SARS were reported in Hong Kong, Vietnam, Canada, Singapore and Thailand. In China however, a full press blackout was in place and there was little communication with the WHO (WHO 2003). No further cases of SARS were reported by China despite the fact that by March 1, the epidemic was spreading in Beijing. Beijing city authorities kept information about the epidemic not only from the public but also from the party centre because there were high-level political proceedings occurring at the time that were deemed too important to be disrupted by ‘the flu’ (Huang 2004, p.120). The WHO (2003, p.5) repeatedly offered assistance to China but the government did not take this up with the exception of the MOH which did request technical and laboratory support to clarify the cause of the Guangdong outbreak in early March. Even then, it took a week for the WHO team to be allowed access to the site of the original outbreak in Guangdong and information regarding both old and new cases was only reluctantly and infrequently released to the team by the health authorities (Altman and Bradsher 2003; Hyland 2003).

The Chinese government came under increasing domestic and international pressure. Domestically, although public discussion of the epidemic was prohibited, unofficial sources of information such as mobile phones, email and the Internet were circulating the news of the outbreak (Huang 2004, p.123). Meanwhile, as more countries reported cases and with so little known about the cause and the cure of the syndrome, global

111 Rumours of the epidemic had been spread via text messages and emails and reports noted the increased sale of vinegar, a popular Chinese method to ward off illness (Kaufman 2005).

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fear and panic rose. People were warned against all non-essential travel to East Asia. Hospitals prepared for the worst. In Chinatowns around the world there was a run on disinfectant and facemasks. Stories emerged of people who had recently travelled to Asia being sent home from school or work and of Chinese people being treated like pariahs (Chang 2003; Guelph Mercury 2003; The Independent 2003; Manning 2003; Murphy 2003; Pirani 2003). It is little wonder then that the unwillingness of the Chinese government to allow WHO officials to visit Guangdong province and the face-saving techniques of slow admission and under-reporting of SARS cases incensed the global community and led to unusual censure from the WHO, despite the Chinese government’s protestations that it was cooperating (see below for more details).

On April 3, the WHO issued a direct warning against travel to Hong Kong and Guangdong Province in China – the first time in that organization’s history that such an advisory had been issued. Beijing responded by organizing a press conference, run by the health minister Zhang Wenkang. The minister contradicted the travel warning, assuring the world that the situation was under effective control. Furthermore, he went as far as to say ‘I can responsibly tell people now it is safe to live, work and travel in China’, and implored people to reconsider cancelling their travel plans (Boden 2003; Pomfret 2003a). The government pledged to provide daily updates and a couple of days later the director of the CCDC, Li Liming, apologized to the world on behalf of the government for not having released timely information about the disease, blaming the silence on ‘poor coordination’ (Pomfret 2003b). But China had still not come clean.

The health minister’s words of assurance to the world outraged Dr Jiang Yanyong, a retired surgeon at Beijing’s 301 military hospital, who had witnessed many more cases than described by the health minister. Dr Jiang sent an email to two Chinese TV stations stating that in one hospital alone there had been 60 cases of SARS and seven deaths. When neither station followed it up, he sent the email to Time magazine who published it on its website on April 8 (Jakes 2003). The international papers picked up on the story on April 9. The China Daily tried to deflect the international fallout by implying that critics of the government were either ill-informed or ill-intentioned members of the anti-China clique (Caminis 2003; Xun 2003). Chinese diplomats

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warned the countries that sought border precautions against Chinese citizens that their relationship with China could be harmed if proper and scientific judgements were not made (Bao 2003). However the WHO soon started to pick up on the rumours and asked for permission to conduct an in-depth investigation in Beijing in addition to their investigation in Guangdong (Boden 2003). Permission was granted but in some cases, it was alleged that Chinese officials in Beijing smuggled SARS victims out of hospitals that were known to be soon visited by WHO officials (Beech, Jakes, and Yong 2003, p.23).

Dr Jiang’s testimony and the international embarrassment forced the government to act. More meetings of important state bodies such as the State Council and the Standing Committee of the CCP Politburo were held and a special task force to fight SARS was created. Importantly, the April 17 meeting of the Standing Committee called for ‘accurate, timely and honest reporting of the SARS situation’ and warned that ‘local and provincial officials would be held accountable’ (Forney 2003). On April 20 the health authorities finally revised the city’s caseload from 37 to 339. By the end of the week the number of cases had tripled to 988 (Beech 2003). In an unexpected move the health minister, Zhang Wenkang, and the mayor of Beijing, Meng Xuenong, were sacked.112 With Zhang gone, Madame Wu Yi, the Vice- Premier, became the new minister of health and the head of the new central SARS task force. Seen as an ‘iron lady’ and respected in the West, this replacement was seen as a way of restoring international trust and domestic confidence (Zheng and Lye 2004, p.63). The leaders went on a public relations drive following the revelations of April 20, releasing more information on SARS in China and working with the international community to contain the epidemic (Zheng and Lye 2004, p.67). Wu Yi even made the rare admission at the 56th World Health Assembly that at the start of the outbreak the leadership did not have adequate understanding of the gravity of the situation due to ‘defects’ and ‘no uninterrupted flow of information’. ‘All that plus

112 While this occurrence was looked upon with hope by international observers who saw it as evidence of a new development in the creation of an accountable system, Saich (2003) argues that there is evidence that this was a case of factional politics in play. Zhang was a well-known supporter of Jiang Zemin and Meng a supporter of Hu Jintao. The fact that one could not go w0ithout the other speaks to a larger power struggle between the former and current Chinese presidents. While he admits that the removal of Zhang Wenkang bolstered Hu Jintao’s political power, Bo (2007, p.225-229) argues that Hu Jintao was not playing factional politics. Instead Bo argues that both Zhang Wenkang and Meng Xuenong were let go due to their part in the cover-up.

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inefficiency of some localities and departments has made our work of SARS control somewhat passive for a period of time’ (Ministry of Foreign Affairs of the People's Republic of China 2003b).

Once the top leaders admitted the true extent of the epidemic, the party apparatus mobilized to try and contain it. SARS was declared a top government priority (Schwartz and Evans 2007, p.202). The state set up a SARS fund of US$250 million (2 billion RMB) in order to provide free treatment for rural and urban residents (Ministry of Foreign Affairs of the People's Republic of China 2003a). The dismissal of Zhang and Meng and other lower officials demonstrated that deception would no longer be tolerated and this was backed up by the introduction of new rules, which would hold officials legally accountable for any delays in reporting SARS cases. In addition, a judicial edict was introduced which made the deliberate spread of the disease punishable by 10 years in jail or even execution (Eckholm 2003). Protocols for the reporting of SARS cases to the WHO and to the general public were rolled out across the country (Schwartz and Evans 2007, p.202). Schools, movie theatres, public libraries, churches, discos and Internet bars were closed (Parry 2003). The national May Day holiday was cancelled to prevent hundreds of thousands of people travelling through the country. Tens of thousands of people were quarantined and impromptu checkpoints appeared outside villages to screen visitors. Thousands of people were mobilized to clean streets and buildings in a ‘Patriotic Health Campaign’ (BBC Monitoring Asia-Pacific 2003), a mass mobilization reminiscent of the bygone days of Maoist fervour. By June when SARS was declared contained by the WHO, China had managed an estimated 5,327 cases of SARS, of which 348 were fatal (WHO 2003).

5.3 THREATS TO REGIME LEGITIMACY

The SARS crisis must be understood in terms of its threat to the political elite’s legitimacy. The threat to the political legitimacy of the regime is clearly relative. I do not suggest that the regime was about to collapse despite early comparisons of the outbreak with Chernobyl and its affects on the Soviet Union (The Economist 2003; Saich 2003). However, the outbreak did have four major consequences that had implications for the legitimacy of the regime. First, the health system was exposed as

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being the victim of the economic reforms and one of the key issues for the rural population. Secondly, the internal challenges to the authority and capacity of the central government were exposed. Thirdly, SARS impacted upon China’s economic development and threatened social stability. Finally, China’s mishandling of the disease was internationally embarrassing.

5.3.1 WEAK HEALTH SYSTEM EXPOSED

The 2003 SARS crisis exposed the poor state of the Chinese public health system. This was all the more shocking due to the fact that in 1978, ‘China’s rural, community-based primary health-care system was extolled as a model for the world’ (Kaufman 2005, p.57). A lot can happen in twenty-odd years. By the year 2000, the World Health Report ranked China number 188 out of 191 countries in terms of fairness in financial contributions to health (Kaufman 2005, p.57). The SARS outbreak put the inadequacies of the health system into sharp relief and acted as a wake-up call to the leadership.

The right to health was one of the ‘five guarantees’ promised to the people by the CCP when it came to power in 1949. This right was written into the 1954 Constitution. In order to fulfil that right the CCP established a health system that was centrally mandated and centrally funded (Schwartz and Evans 2007, p.197). The CCP recruited most private health providers into a developing public sector, gave priority to public health, particularly preventative care, and mobilized the population through ‘patriotic health campaigns’ aimed at promoting health education and providing public works (Anson and Sun 2005, p.10; Kaufman 2005, p.58; Schwartz and Evans 2007, p.197). While the Great Leap Forward and the Cultural Revolution had disastrous results in general, paradoxically, this same period represented a golden age of health in China. Two major improvements were the accessibility and affordability of health care. Accessibility was aided by an increase in medical providers. This was the age of the ‘barefoot-doctor’ –farmers who were given a short amount of training and then became their commune’s doctor (Hillier and Jewell 1983).

Another improvement was the affordability of health through the health insurance schemes (Anson and Sun 2005, p.12). By the end of the 1970s, 90 per cent of the

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population was covered by one of three schemes. The first two covered government employees and employees of state-owned enterprises and their families. Almost everyone else was covered by the rural cooperative medical scheme. The funding for the scheme came from three sources: annual small contributions of individual members of the brigades (the name of a village collective), the welfare funds of the brigades, and the public welfare funds of the commune. In return for their contribution, members of the brigade would get health-care at a reduced cost. ‘The medical cooperation scheme was thus able to guarantee access to basic health-care for almost the entire rural population’ (Anson and Sun 2005, p.43-44). ‘Health for all’ was reflected in the statistics as life expectancy increased and infant and maternal mortality rates decreased (Anson and Sun 2005, p.17).

However, the economic reforms of the 1980s saw the dismantling of the commune system and the cooperative medical scheme and as a result, ‘attention to health languished’ (UN Health Partners Group in China 2005, p.50). Like many other public services, the government decentralized public health, leaving it exposed to market forces. Therefore, the centre decreased its funding, leaving provincial and lower governments with the responsibility for the funding of service delivery. Unfortunately however, this also meant that the centre lost control over the quality of public health services (Schwartz and Evans 2007, p.198). Therefore decentralization of the public health system led to accountability, effectiveness and efficiency waning. User-pays health care increased, as did the cost of drugs, as health providers tried to make up for decreased public funding. Public health education and public works suffered (Kaufman 2005, p.58). While China’s overall health expenditure as a percentage of GDP grew in the period 1978 to 2002, the proportion of those overall costs contributed by the government decreased from 32 per cent to just 15 per cent. Individual out-of-pocket spending however rose from 36 per cent to 68 per cent. Medical insurance has also decreased, the share of overall health expenditure dropping from 47 per cent in 1980 to 27 per cent in 2002 (UN Health Partners Group in China 2005, p.39). Furthermore, this neglect of the health system affected the rural health system disproportionately to its urban counterpart. In 2002, the average level of per-capita health spending in urban areas was 3.5 times the average health spending level in rural areas. Medical insurance only covered 10 per cent of the rural population, which left many ‘exposed to the harsh reality of becoming ill without a

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way of paying for their treatment’ (UN Health Partners Group in China 2005, p.41). This led to vast contrasts in health statistics from region to region. In some poorer areas, the overall health status either stagnated or even deteriorated in the last decade (Anson and Sun 2005, p.17).

Not only did the SARS crisis expose the gaps in the public health system, but the health system also contributed to the SARS crisis. As a result of these high health- care costs to the user, many poor Chinese did not go to seek treatment until their symptoms were severe -by which time they may have already infected others (Gu 2004, p.124). Insufficient government funding coupled with a lack of accountability resulted in there being no efficient disease surveillance system, which contributed to the long delays in information. Furthermore, there is evidence that during the outbreak, medical insurance played a large part in who eventually sought treatment - poor Chinese, who did not have insurance, were reluctant to attend clinics (Gu 2004, p.124). Once the full extent of the epidemic was acknowledged, the government was able to implement the mass public health campaign method as well as policies of early identification, quarantine and free treatment, with the result being the fairly rapid containment of the coronavirus (Kaufman 2005, p.61). However one of the main fears during the SARS crisis was a possible outbreak in rural China. Given the lack of public health services and lack of wealth in much of rural China, the government would have had to face serious consequences if such an outbreak had occurred (Xu 2003, p.53).

5.3.2 INTERNAL CHALLENGES EXPOSED

The SARS crisis underscored several major flaws inherent in the Chinese political system. As these structural problems have also affected HIV/AIDS governance, they deserve further discussion. Some of the problems stemming from the centre-local relationship were discussed in chapter three. However, in the case of the SARS outbreak, the main problem was the issue of information asymmetry. Zheng and Lye (2004, p.49) explain that in China, ‘a conventional political practice is that good things can and should be exaggerated, but bad things should not receive publicity or should even be hushed up if possible’. The problem with this approach, however, is that it leads to particular information asymmetries. Lai (2004, p.79) describes the

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Chinese regime of information as having two main asymmetries. The first is the reliance of the central leadership on the information provided by local government officials. Unfortunately, as was seen in the case of the Beijing officials keeping the true extent of the epidemic from the party leaders, this reliance on lower-level officials is imperfect and gives lower-level officials the upper hand. Lai argues that lower-level officials have an incentive to distort the information in order to protect their interests.113 The second information asymmetry is one in favour of the state which keeps sensitive information away from the public. For fear of ‘public panic, social instability, economic downturns, and political consequences’, the government suppresses negative information (Lai 2004, p.77). ‘By feeding the population mainly good news, it [the Chinese state] can instil a high level of confidence in the populace’ (Lai 2004, p.80). Therefore, during the initial period of the SARS epidemic, the authorities sought to maintain social stability by not informing the public.

The second major issue revealed during the SARS crisis, and linked to the issue of information asymmetry, was the lack of accountability and transparency. The issue of local compliance with central directives has been discussed in both chapters three and four. However, the SARS crisis provided further evidence that local officials are often forced to choose between one directive and another. The covering up of information that might harm an official’s interests is common in China and this has mainly to do with the way in which the performance of Chinese bureaucrats is assessed. While decentralization has transferred the responsibility of health service provision to provincial and lower level governments, local and provincial officials are rewarded for achieving high economic development and the maintenance of social stability. These targets have therefore been pursued while other issues and other central mandates with ‘contradictory expectations’ are ignored (Schwartz and Evans 2007, p.199). While the central government may not be to blame for the long ingrained culture of bureaucratic secrecy, it must take responsibility for setting these guidelines for assessment. Officials have been assessed on the economic development of their area of jurisdiction and on how well they have maintained social stability. Promotion

113 In fact, Lai (2004) goes as far as to say that bureaucrats at each governmental level distort information because firstly they know that it would be too costly for central officials to develop alternate sources of information and secondly because even if the distortion was found out, the central government’s punishment would be lenient due to its reliance on local cadres to implement its own orders. Thus, at every level of government the information is altered to protect the messenger’s interests.

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has lain in impressing the right people and achieving high growth rates over and above set quotas (Lai 2004, p.79). This means that sectors that do not make a profit (such as health) have been under-funded and, issues that are perceived to have the capacity to slow economic growth, by scaring away investors, or to disrupt social stability are ignored or covered up (Schwartz and Evans 2007, p.199). The problem of contradictory expectations was brought to the foreground by the SARS crisis, but the same problem has hindered the reporting of cases of HIV/AIDS and certainly contributed to the Henan blood scandal.

Finally, the third challenge for the Chinese government that was exposed during the SARS outbreak was China’s lack of a coordinated bureaucracy. This is not only a problem between central and local governments, but also within a particular sector and between the civilian government and the army. Amounting to turf wars, each ministry or department jealously guards its area of jurisdiction and this ‘fragmentation’ had an impact on the flow of information (Zheng and Lye 2004, p.57). It has been noted that there are more than 12 ministries or administrations that control health in China. While this helps in terms of mobilizing resources, ‘it is difficult and costly for those bodies to formulate unified health policies’ (UN Health Partners Group in China 2005, p.28-29). In 2003 the MOH had to negotiate with other ministries and government departments before an initial response could be organized (Huang 2004, p.121). Fragmentation is not just an issue of horizontal governance but also of vertical governance. As already discussed in chapter four in relation to HIV/AIDS, the MOH was bureaucratically weak. The Ministry lacked control over provincial and local health authorities that were instead governed and funded by territorial governments. Therefore, in the case of SARS, the Guangzhou and Beijing authorities were able to override any stipulations that might have come from the MOH that were not considered in their best interests, thus hampering the government’s response to the epidemic.

These issues of information asymmetry, non-transparency and the lack of bureaucratic coordination helped cause the SARS crisis. However, they also raised questions from both domestic and international quarters about the ability of the central government to manage domestic and transnational issues. Thus, in that SARS exposed the internal pathologies of the Chinese regime, it served to threaten the legitimacy of the regime.

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5.3.3 ECONOMIC DEVELOPMENT AND SOCIAL STABILITY THREATENED

A major consequence of the SARS epidemic was the endangering of economic development goals and the disruption of social stability. As mentioned in chapter three, economic development and social stability became the government’s primary goals when Deng Xiaoping began the process of ‘opening up’ in the early 1980s, moving to base the government’s legitimacy more on its ability to increase ‘the personal wealth and living standards of the individual’ (Weatherley 2006, p.164) rather than the legacy of the revolution and Marxist ideology. As one Chinese commentator affirmed, ‘all of the legitimacy of the government is based on economic growth…if the economy has troubles, everything has troubles’ (Wu Guoguang quoted in Dorgan 2003). If economic development remains ‘the key to solving the nation’s problems’, then social stability is considered ‘the prerequisite to development’ (Huang 2004, p.119). The CCP has also focused on maintaining peace and stability domestically, not only as a prerequisite for economic development but also as another foundation for legitimacy. A key factor in maintaining peace and stability, and therefore maintaining the image of the Party as a stabilising and facilitative force, has been the quick and efficient diffusion of crises.

An immediately visible effect of the outbreak was its impact on the economy. Although only moderately impacting upon manufacturing, trade and foreign investment, the services sector (retail, tourism, hospitality and entertainment industries) was particularly hard hit (Wong, Chan, and Liang 2004, p.13-19). Consumer spending dropped as would-be consumers stayed at home for fear of catching the virus. This was particularly acute over the cancelled May holiday, traditionally a time of increased spending (Wong, Chan and Liang 2004, p.21). Tourism plummeted as both international arrivals and departures decreased. Domestic tourism ceased over the month of May. This in turn affected the hospitality and entertainment industries. A survey conducted in April (before the April 20 press conference) revealed that, compared with the revenue that had been earned in the same time period in 2002, retail stores suffered losses ranging from 10 to 50 per cent, the number of air travellers dropped by 50 per cent, hotels had lost 80 per cent of their

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guests and restaurants had lost 30 to 40 per cent of their customers (Wen et al. 2004, p.58).

Another notable economic consequence of the outbreak was the increase of government spending, linked to efforts to contain the epidemic itself, and its economic effects (ADB 2003, p.83). For example, the Chinese government constructed quarantine facilities, provided free treatment to farmers and poor urban residents who contracted the disease, and, provided income tax exemptions for medical staff. It also offered interest subsidies for the air transport and tourism sectors and temporary deductions/waivers of taxes for other SARS-affected businesses such as hotels (ADB 2003, p.89).

Overall, the crisis, although significant, did not have the devastating effect on the economy that had originally been feared due to the strength of the economy prior to the outbreak. The impact of SARS to the economy has been described as ‘moderate’. The Asian Development Bank (ADB) (2003, p.89) estimated losses of US$6.1 billion, accounting for 0.5 per cent of GDP.114 Even if the doomsday scenarios were inaccurate, for a government that has relied on its ability to maintain strong and consistent rates of economic growth as a legitimating factor the thought of what could have been was surely of concern.

Hong Kong was also affected by the SARS crisis - more so than the mainland. To quote one commentator, ‘SARS dealt a double whammy to its economy which was already mired in recession before the crisis occurred’ (Wong, Chan and Liang 2004, p.12). As Hong Kong’s GDP is highly dependent on services, the impact of SARS on Hong Kong was the worst in the world, with airlines, retailers, and the tourist industry suffering major losses. The ADB (2003, p.88) estimated Hong Kong’s total expenditure loss to be US$4.6 billion, which amounted to 2.9 per cent GDP. This too may have been a shock to the Chinese leadership given the increasing integration of the Hong Kong and Chinese economies since 1997.

114 Other estimates propose higher losses. For example, the results of the survey conducted by analysts from the China Centre for Economic Research concluded that China’s losses, amounting to as much as US$25.3 billion, or close to 2 per cent of GDP, would not be easily ignored (Wen et al. 2004, p.61).

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More significantly than the absolute numbers, the SARS crisis showed the government that that which might benefit the economy might also leave it exposed. Domestically, economic development has been uniformly pursued to the detriment of other sectors such as health. While the economy has been assisted by the funds that might have otherwise been spent on public health, it was left susceptible to the impacts of infectious disease. Internationally, increasing openness and interdependence has improved China’s economy and increased the standard of living, but it has also made the economy vulnerable to regional and international shocks. In this case, the crisis began in China itself, but some of the damage to China’s economy came from offshore. The largest losses came from the tourism and airline industries, which are both heavily dependent on foreign tourists. Despite the fact that the economic effects to the PRC did not turn out to be as serious as originally predicted, the loss of US$6.1 billion was still enough to illustrate the possible threat that a public health issue could pose to the economy.

Possibly more important than the threat to economic development was the social disruption SARS threatened to cause. Along with economic development, the Chinese government favours a policy of ‘maintaining social stability’, a policy that covers all manner of government actions from quelling protests to the control of information. For example, the Guangdong and Beijing health officials kept SARS-related information from the public in order to dispel public panic. However as one commentator, Xue Baosheng (2003), a researcher at Peking University’s School of Government Administration, critically noted, by withholding information in order to maintain ‘social stability’, the government officials had in fact given rise to that which they were trying to avoid. Voicing an opinion that many shared but dared not express, Xue wrote ‘only by actively upholding the citizens’ right to know can the government be better supervised by the public and in turn win the trust and respect of those it serves’. Another editorial in the China Daily called for the government to ‘learn from SARS to fight AIDS’ (Hua 2003). It could be argued that the dismissal of Meng Xuenong and Zheng Wenkang was as much a move to placate domestic voices of dissent, as it was a move to appease international critics.

Not only did the SARS outbreak lead to criticism of the government by scholars but the crisis also sparked civil unrest in some parts of the country. One report stated that

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the quick change by the media, from silence to sensationalist reporting on the epidemic, gave rise to public panic across the country (Cheong 2003). In some rural regions, residents took matters into their own hands setting up barricades to prevent outsiders from entering villages. Riots broke out in several regions as local residents protested against the establishment of quarantine facilities in their areas (Cheong 2003; Freedman 2005, p.175). As mentioned in chapter three, the SARS crisis struck at a nerve that goes back further than 2003. Whilst the economic reform of the 1980s originally benefited many Chinese peasants, since the early 1990s the divide between urban and rural China has widened, with development favouring urban Chinese over rural Chinese. This has resulted in the mass migration of many rural residents to the cities in search of employment and a better standard of living. As already mentioned above, the divide between rich city and poor country has been seen in the health system with only 10 per cent of peasants being covered by medical insurance. The panic of the rural communities coupled with this growing feeling of resentment towards the government led to peasants not only banding together to prevent the epidemic from entering their villages but doing so without the sanction of local government officials (Zheng and Lye 2004, p.56). Zheng and Lye (2004, p.56) suggest that these actions, while also a consequence of an inadequate understanding of SARS, were mainly a result of a lack of trust in local officials. When officials would pronounce that there were no SARS cases in a location, ‘many citizens were of the view that if the state says “no”, it must be a “yes”’ and public panic ensued.

5.3.4 DAMAGE TO CHINA’S INTERNATIONAL REPUTATION

Finally, along with exposing the paucity of the health system and the massive internal challenges, and threatening economic development and social stability, the 2003 SARS crisis damaged China’s international reputation. As first mentioned in chapter three, improving its reputation as a responsible member of the international community has played an integral part in China’s construction of self-identity over the last two decades, particularly since the 1989 Tiananmen Square crackdown. The building of an international reputation as a responsible, cooperative and rule- following state is not only conducive to the pursuit of economic growth but is also linked to China international legitimacy. This has thus involved China becoming more proactive and more supportive of international organizations such as those

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comprising the UN system. It has also involved ceding some sovereignty in order to join the WTO. The Chinese leadership has not only worked hard to improve the reputation of the country but also the reputation of the CCP. It has sought to dispel international (but particularly Western) discomfort at dealing with an authoritarian regime with a questionable record of human rights. The leadership has therefore promoted itself as peaceful and non-predatory, a good neighbour.

However, in 2003, China made a serious miscalculation - it did not disclose the outbreak of SARS to the WHO. It did not because it did not feel any need to. SARS was China’s issue – there was no need for the world to get involved. Fidler (2004, p.108) argues that China’s approach to the outbreak was in keeping with a ‘Westphalian approach’ to public health whereby health is seen as a domestic issue rather than an international matter. The state alone has supreme power over the events that transpire within its territory, including public health emergencies, and no other state or organization can assert its authority over China’s sovereignty. Therefore, rather than share information with the WHO, ASEAN or any of its other multilateral and bilateral partners, China chose to treat the SARS outbreak as a Chinese public health issue. Fidler (2004, p.108-112) points out that the Chinese government was not violating any international laws in doing so. WHO member states are only obligated to report the outbreak of diseases that are included on a list set out by the International Health Regulations and SARS was not on the list. Neither was China obligated to involve WHO in dealing with SARS. Furthermore, Fidler (2004, p.114) explains that the deliberate covering up of epidemics that might have international consequences is not new, but instead common to the Westphalian approach. States would not disclose epidemics within their borders for fear of affecting economic growth or scaring off investment. The Chinese government’s lack of cooperation, general obfuscation and even out-and-out deception was in many ways in line with a Westphalian approach to public health.

However, SARS was highly contagious. While it started in China, SARS was not China’s problem alone for long. As the transnational effects of China’s failure to control the disease began to be felt, international pressure began to mount. The international media was scathing. One prominent newspaper said:

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When one traces the illness back to the earliest known cases, it becomes clear that the Chinese government was negligent in failing to alert the rest of the world early to the unknown disease or ask for help in identifying it. …We are learning that in a mobile world, secrecy about public health in one country can quickly become everybody's problem (The Asian Wall Street Journal 2003).

Even before the entire truth was revealed, the verdict was already out - China was to blame.

In this case… the PRC's secrecy went beyond propaganda that twists the truth to something that is taking lives. If the PRC had not ordered the country's journalists not to report the spreading disease early this year, if that government had instead notified the WHO promptly of this mysterious disease, the time-consuming work of isolating the pathogen and then developing the medicine and techniques to prevent or cure would be four months farther along. Rumor-driven panic within China could have been averted. The disease likely would not have spread throughout Asia to Europe and the Americas (South China Morning Post 2003).

China’s reputation was on the line.

China has come out of this badly. There are clearly important parts of its bureaucracy that continue to operate in the familiar opaque fashion of central state authoritarianism - an image China is supposed to be shedding (The Standard 2003).

Kent (2007, p.242) points out that the SARS crisis and Beijing’s lack of transparency produced a ‘widespread realization that the modernization and globalization of China’s economy had not been accompanied by a change in attitude’. Perhaps predictably therefore, some international commentators made the leap from China’s lack of transparency in public health to investor confidence issues.

The episode is another reminder of why investors should be wary of trusting the hype over China's economy. Sure, its economy is among the strongest in the world, and its 1.3 billion-person market offers huge potential. Trouble is, China Inc. is big on spin and small on transparency… Winning the trust of investors is a key challenge for China's new government. Yet market participants should pay close attention to Beijing's handling of the SARS crisis. China wants to be a major player in the world,

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yet it won't let domestic media report on the disease. Should we trust what's said about the economy? (Peseck Jr. 2003)

Another report quoted an investment banker in Hong Kong saying ‘What this shows is that there are lot of things in China that can go wrong’ (Mitra 2003). So while one of the main reasons that Chinese officials withheld information on SARS was fear of scaring away investment, these actions paradoxically undermined the credibility of the government.

Meanwhile, the Rolling Stones cancelled their Hong Kong and Chinese mainland concerts (Asian Economic News 2003). Major airlines suspended flights to and from SARS-infected areas (Creedy and Saunders 2003). International schools closed. The World Economic Forum China Business Summit, due to take place in Shanghai, was cancelled (Business Week Online 2003). High profile political visits to China were postponed or cancelled (Associated Press Newswires 2003). The US government scaled back its diplomatic presence in the country (Anthony 2003). China’s biannual Guangzhou international trade fair, the largest of the year, went ahead but it was obvious that SARS kept many foreign delegates away (Agence France-Presse 2003b). Saich (2003) argues that these cancellations, postponements and withdrawals were a crucial factor in the leadership’s April 17 turnaround.

Also important was the consistent pressure being applied by the WHO. Armed with information gathered through informal, non-governmental sources, the WHO applied to the government to be allowed to enter the country to examine the source and the extent of the epidemic. When the Chinese government frustrated attempts to conduct proper surveillance, the WHO spoke plainly. For example, Henk Bekedam, the WHO’s representative in Beijing, made it clear that China was doing more than slowing the completion of a worldwide paper trail on the mystery ailment - it was also allowing the disease to spread (Lev 2003). As noted by Fidler, it is highly unusual for the WHO to criticize its member states because to do so can put the intergovernmental organization into a difficult position (2004, p.97). The WHO’s blunt language was therefore indicative of the gravity of the situation and the growing concern of the wider international community. The head of the WHO, Gro Harlem Brundtland, let the world know that,

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It would have been better if the Chinese government had been more open in the early stages, from November until March. We were asking questions, wanting to send in experts to help identify the source. It took too long before they felt they needed to be helpful (Brundtland quoted in Caminis 2003).

For a state that has sought to assure the world that it is a responsible member of the international community and willing and able to comply and cooperate in multilateral organizations, this very public rebuke was embarrassing.

It must have been perplexing to the new leadership to discover despite acting within its rights under international law, the Chinese government was still being portrayed in a negative fashion. Again, here Fidler (2004, p.114-126) is enlightening. He argues that the international system is no longer ruled by Westphalian norms of state sovereignty and non-intervention and this was exemplified by the case of SARS. Fidler calls this the ‘post-Westphalian’ turn in health governance. Although not obliged by international law to report the cases of SARS, all the countries affected by the virus, with the exception of China, did so (p.133). The reason that these countries did so is because there has been increasing acknowledgement that improved global surveillance of disease represents a global public good that benefits everyone (p.127). ‘States ought to report outbreaks’ is the norm and ‘”responsible” states will report outbreaks’ is thus the implication. When China did not report the SARS outbreak, it became a norm violator and an irresponsible state.

Therefore, while the Chinese government’s inaction was not illegal under international law, it was considered outrageous because it was contrary to the newly established norm. China was considered an outsider or an irresponsible state because its government had not viewed the global interest as being in its interest. Perhaps the WHO put it best:

This is the most important lesson for all nations: in a globalized, electronically connected world, attempts to conceal cases of an infectious disease, for fear of economic and social consequences, must be recognized as a short-term stop-gap measure that carries a very high price – loss of credibility in the eyes of the

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international community, escalating negative domestic economic impact, damage to health and economics of neighbouring countries, and a very real risk that outbreaks within the country’s own territory can spiral out of control (WHO 2003 quoted in Fidler 2004, p.118).

SARS began as a national public health issue but because of the government’s mismanagement of the situation, the virus ended up having global consequences. In this era of globalisation, the secrecy and non-cooperation of one state, such as China during the SARS epidemic, can threaten others. The international pressure that was brought to bear on the regime served as a reminder that the status of ‘good state’ or ‘responsible state’ comes with certain duties, and when not fulfilled, reprisal, such as an international backlash, may follow.

The mismanagement of the SARS crisis resulted in damage to China’s international reputation and represented a loss of ‘face’. An international affairs scholar, Pang Zhongying, emphasized this when he stated that, ‘the greatest damage to China caused by the SARS crisis is the loss of China’s reputation…repairing the mutual trust between China and the international community is extremely urgent’ (quoted in Saich 2003, p.19). Wen Jiabao’s speech at the special China-ASEAN summit on SARS after the government’s turnaround is evidence that the government was not unaware of the international antipathy caused by its actions. Note how the Premier seeks to reassure ASEAN leaders:

As a highly responsible government that dares to face difficulties squarely, the Chinese Government always gives top priority to the health and safety of life of the people. We have, and will continue to take resolute steps to turn around the situation (Ministry of Foreign Affairs of the People's Republic of China 2003a).

Efforts to reassure and repair can also be seen with regards to the post-April 20 turnaround in attitude towards the WHO. Lam notes that for several months the WHO inspectors were given special treatment and fairly thorough access wherever they went. The acting mayor of Beijing even said that the WHO experts could use an office next to his own in order ‘to ensure that whatever the Beijing municipality did on the medical and epidemiological fronts would fit global requirements’ (Lam 2006, p.221).

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5.4 LEGITIMACY ISSUES FOR THE NEW LEADERSHIP

While the Chinese government had faced many political challenges prior to 2003, I argue that a major reason that the SARS crisis was particularly significant, with implications for HIV/AIDS governance, is that it occurred during a period of political insecurity – the transition of leadership from Jiang Zemin to Hu Jintao. At a time when the new leadership were hoping to prove its credentials and consolidate its authority to rule, the SARS crisis exposed a regime that had failed to provide its citizens access to affordable healthcare, whose internal pathologies led to the deliberate withholding of information from its own citizens and the international community with dire consequences for its economy, society and international reputation.

The SARS crisis overlapped with the first six months of the new Chinese leadership, the transition of power from the so-called third generation, headed by Jiang Zemin, to the fourth generation as headed by Hu Jintao. Hu became the General Secretary of the CCP and President of the PRC. Wen Jiabao became the Premier, replacing Zhu Rongji as the head of the State Council. What was important about this period is that the transition was not yet complete. Jiang Zemin maintained his position as head of the military thus setting up a power struggle between Hu’s camp and Jiang’s camp. Thus this period (until Hu consolidated power in September 2004) represented the most politically vulnerable time for the new leadership. Jiang, the Party, the Chinese people and the world were all watching to see if China would thrive under Hu or stumble at the first step.

Crucially, SARS was the new leadership’s first real challenge and the way that the Chinese leaders experienced and learnt from the SARS crisis enabled a reframing of the HIV/AIDS epidemic. The SARS crisis showed the new Chinese government that its vital interests of economic development and social stability could be threatened by a non-traditional security issue (Zhang 2007, p.175).115 The first challenge to the leadership came not from Taiwan or Japan or from Russia or the USA, but from the

115 Zhang (2007, p.175) notes that the SARS epidemic ‘helped to collapse the final political and intellectual resistance to including non-military threats on the security agenda’.

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health sector. Although China had during Jiang Zemin’s leadership experienced the AFC in the late 1990s, China had come out of that situation relatively unscathed and its international reputation improved. SARS, on the other hand, caused 349 fatalities, cost China US$6.1 billion worth of economic damage and a serious loss of reputation internationally. This was not a threat that the government either expected, or was prepared for.

The Chinese government had been attempting to cultivate a new image for itself prior to the transition and the SARS crisis. As mentioned in chapter three, by the late 1990s and early 2000s, the negative repercussions of two decades of focusing on economic development rather than social development were being seen. To address this issue, in 2002 Jiang Zemin introduced the new socio-economic development goals for the first 20 years of the new century, with the aim being the establishment of a ‘xiaokang society’ - ‘a well off society in an all round way’ (Lu 2002). The term ‘xiaokang’ is Confucian in origin, and the CCP’s adoption of it flagged a realization that economic and social development must be balanced.

The plan is seen as a ‘people’s agenda’ because it aims to make measurable improvements in people’s lives. The goal is to reduce poverty by raising the level of education, health, technology, science and culture…(UN Health Partners Group in China 2005, p.3).

However, to many, Jiang’s ruling elite had been seen to represent the interests of the eastern seaboard and the growing middle class.

Before becoming President, Hu Jintao had served as the head of the Central Party School where he was in charge of the task of ‘party construction’ – a job that entailed finding ‘the formula that will enable the CCP to remain a “perennial ruling party”’ (Lam 2006, p.38). By studying political parties around the world, Hu and his advisors came to understand that the future of the CCP would depend on the extent to which it could keep in touch with the needs of the masses. The Hu-Wen leadership therefore wanted to portray itself as ‘more open, efficient and concerned about the plight of the poor’ (Saich 2003, p.24). Whereas Jiang Zemin and Zhu Rongji had spent most of their careers in the rich cities of Shanghai and Beijing, reports during the leadership

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transition emphasised that both Hu Jintao and Wen Jiabao had spent significant phases of their careers in poorer Western provinces (Saich 2003, p.24). ‘The implied message was deliberate: the new leadership would show greater concern for those who had not benefited as well from the reform program’ (Saich 2003, p.24). The SARS crisis immediately put this new image to the test and for a while, threatened to leave this new image in tatters, since the obvious losers of an uncontrolled epidemic would have been the poor. The SARS outbreak, by highlighting the weakness of the health system and the urban/rural disparities, brought the focus sharply back to the idea of ‘xiaokang society’ and how far China was from this goal.

However, while I have argued up to this point that the early response of the government to the SARS outbreak undermined its legitimacy, there is an interesting twist at the end of the story. Once the government decided to ‘come clean’ at the April 20 press conference and began to implement serious measures to control the epidemic, it was able to mobilize with surprising speed and efficiency. So impressive was this turnaround that the Hu-Wen leadership gained considerable domestic praise and even international support for having admitted wrongdoings and eventually standing up to the test of SARS (Bo 2007, p.238-240; Freedman 2005, p.175; Liu 2004, p.54). Therefore what began as a legitimacy crisis ended as a strong foundation for the new regime. It is arguable that this experience taught the new leaders that addressing issues such as health, and distrust of the government may be as important as achieving economic development as a means of preserving the CCP’s mandate to rule.

5.5 THE SARS CRISIS AND THE IMPLICATIONS FOR HIV/AIDS GOVERNANCE

In section 5.1 above, I identified three main ways in which crises can bring about political change: a crisis can cause an old issue to be seen in a new way; cause a shift in structural power, empowering actors that previously were weak or providing more resources where before there were few; and cause a shift in normative power, allowing previously stable ideas or policies to become discredited while enabling new ideas to enter the policy debate. In the case of China, I argue that the SARS crisis was so significant because it served – in all three ways – as a catalyst for change in HIV/AIDS governance. First, the SARS crisis forced the Chinese government to put

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health and infectious disease, including HIV/AIDS, on the political agenda. Second, the SARS crisis led to the increase in resources for health and disease control and the increase of political capital for the MOH. Third, the Chinese government became more open to the advice of both international and domestic policy entrepreneurs on health issues, including HIV/AIDS. For these reasons, I argue that it is impossible to understand the Chinese government’s changing response to AIDS without examining the role of SARS and the ways in which the SARS crisis politicised health, linking health policy to regime legitimacy (both domestic and international).116

5.5.1 SARS AND A NEW POLITICAL AGENDA

The SARS crisis enabled infectious disease specifically, and health more broadly, to be framed as a political issue. Despite the advocacy efforts of norm entrepreneurs and multiple evidence, such as research conducted by the World Bank and other intergovernmental organizations supporting the link between health capacity and development, and between epidemics such as AIDS and social and political instability, before 2003 the necessary political will had failed to eventuate. Henk Bekedam, head of the WHO in China, noted that prior to the SARS crisis the Hu-Wen leadership recognized that the public health system was problematic but gave the impression of being ‘not overly concerned’ (Schwartz and Evans 2007, p.200).

This changed after the SARS outbreak. By impacting upon the economy, threatening social stability and affecting China’s international reputation, the outbreak gave the Chinese government first-hand evidence of the potential political repercussions of an unimpeded health crisis. The government had already been investigating ways in which to improve its mandate – the effects of SARS brought to the forefront the link between good health governance (as well as good governance in general) and political legitimacy. Furthermore, SARS enabled norm entrepreneurs to link AIDS to China’s vital interests in a way that the Henan blood scandal could not. For example, the mobilizing potential of the SARS crisis in relation to AIDS was quickly surmised and in November 2003, Tsinghua University hosted the SARS and AIDS symposium

116 By ‘politicised’ I do not mean to suggest that in the past health in China has been apolitical. Instead, I use the term to suggest that health gained a higher level of political priority than previously. The SARS outbreak created the opportunity for health to be treated as an issue of ‘high politics’ rather than its usual delegation as an issue of ‘low politics’.

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which was attended by researchers, Chinese health officials, intergovernmental organizations and NGOs. One of the key speakers was former US president Bill Clinton who warned China that its impressive economic development could be impacted upon negatively by a growing HIV epidemic (Watts 2003, p.1636).

Therefore the SARS crisis politicised health, especially infectious disease. As Dr Rao Keqin, director of the information centre at the MOH, stated: ‘A good lesson we have learned from SARS is that we should attach the same importance to public health as we do to national defence’ (Xiong 2005, p.29). Indeed, on China’s extensive security agenda, ‘epidemics’ now comprise one of six principal categories of non-traditional security threats to China’s security environment (Zhang 2007, p.175). Since SARS, health has been explicitly understood as a means by which to attain ‘xiaokang society’ and as the central pillar of the government’s plan to build a ‘new socialist countryside’. As such it has been labelled a priority in the Eleventh Five Year Plan (2006-2010), and reinforced as such by Wen Jiabao in his address to the NPC in 2006 and by Hu Jintao in his address to the National Party Congress in 2007 (Toy 2007; Watts 2006).

5.5.2 SARS, RESOURCE DISTRIBUTION AND THE MOH

The most immediate impact of SARS (with consequences for HIV/AIDS governance) was on the infrastructure and budget of infectious disease control. The government, once spurred into action, implemented a set of emergency measures such as the creation of an emergency fund, new legislation and improvement of the health infrastructure. The government allocated US$437 million (3.5 billion RMB) for the development of a national disease control system, which included the construction of a national centre for disease control and the implementation of an internet-based, reporting system. This system allows for better coordination of information between the different levels and types of health institutions, as all cases of disease are reported in the one system, allowing for more efficiency. Other disease control facilities in other CDCs and hospitals around the country had their equipment upgraded. More broadly, there have been extra resources with regards to public health. In the Eleventh Five Year Plan (2006-2010) the government committed to ensuring that all farmers will have access to primary health care by 2010. In order to achieve this the central

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government will spend US$587 million (4.7 billion RMB) on the new Rural Cooperation Medical Scheme, planned to be fully operational by 2008. Furthermore, the government has committed more than US$2.5 billion (20 billion RMB) to upgrading hospitals and equipment (Watts 2006). It is in this context that the Chinese government has increased the resources for AIDS prevention and control work (to be discussed in chapter six).

The SARS crisis also had political repercussions. As several commentators have noted, while the outbreak revealed serious flaws in the political system, it also revealed its strength. Once the government had labelled the containment of SARS a top priority, it was able to mobilize the bureaucracy and the masses in a relatively short time. In particular, the state response to SARS was a good example of the ability of the central government to reassert authority over the sub-national levels of government and recentralise a policy sector (Schwartz and Evans 2007; Wu 2005; Zheng and Lye 2004). The outbreak resulted in the MOH gaining more political authority. Along with an increase in funding, the profile of the MOH was enhanced by the replacement of the Minister of Health Zhang Wenkang with the Vice-Premier Wu Yi. Wu Yi brought vigour, political capital and prestige to the position. As the head of the WHO has narrated, Wu Yi’s personal drive to address the issue of HIV/AIDS has been crucial. ‘Madame Wu Yi, after SARS, said “Okay I’ve done SARS, I’m ready for something else,” and she picked on AIDS’ (Henk Bekedam interviewed by Young 2006).

5.5.3 SARS AND OPENNESS TO NEW IDEAS

Perhaps most importantly, the SARS crisis, by highlighting the problems of the health system and the danger of infectious diseases to China’s vital interests, has opened a space for an open and critical conversation about the need for health reform and new policy ideas. The SARS crisis brought to the foreground the problems and concerns that the Chinese people had had previously with regards to public health but that had been obscured by the economic focus of the government. As mentioned above, this new attention to the issue has been reflected in the rhetoric and policy priorities of the central government; however, it has also been reflected in the media. For example, after SARS, there have been noticeably more articles produced by the China Daily on

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the issue of the health system and criticism is not rare. In 2005, the Development Research Centre of the State Council, an important government think-tank, released a report on the Chinese health system. Two years in the making and co-financed by the WHO and the UK Department of International Development (DFID), the report stated in no uncertain terms that the market had failed to provide fair and affordable access to public health. It has been noted that while international agencies and other researchers (including Chinese researchers) had previously published reports critical of the impact of economic reform on the health system, this was the first, comprehensive critique to be produced by a leading Chinese government policy unit. The report was critical of the user-pays system which had turned hospitals into institutions that only the rich could afford and it argued that the attempts by the government since 2003 to revive cooperative medical insurance in rural areas had been unsuccessful due to continuing problems (Project Team of the Development Research Centre of the State Council 2005).

Therefore, in the post-SARS period, we have seen the Chinese government proactively seeking information and policy advice both from domestic and international actors. This can also be linked with the Chinese government seeking to improve its international reputation by proving itself capable of addressing international concerns with its health system. China has maintained close relations with the WHO since the SARS crisis and the government’s ‘aggressive and thorough’ measures to control the avian influenza in 2005 and 2006 and resulting international cooperation was the subject of praise (Gill 2006). The Chinese government has looked to learn from other countries with high-level health officials travelling overseas to understand different health systems and policies (Armitage 2005; Powell 2005). In 2006, the Chinese government commissioned eight institutions including the WHO, McKinsey and Company, the World Bank, the Development Research Centre and several Chinese universities to draft proposals on possible health reform (Shan 2007c). The Chinese government is expected to produce a workable reform package in the near future. In 2007 a large delegation comprised of central and provincial government and hospital health officials attended a three-week intensive course in Boston at the Harvard School of Public Health in order to be able to implement these future health reforms (Harvard School of Public Health 2007). This

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new discursive space has thus allowed ideas about a range of health issues, including HIV/AIDS, to gain purchase amongst Chinese decision makers.

5.6 CONCLUSION

In conclusion, this chapter has looked at the role that crisis and uncertainty plays in spurring change. Having studied the events of 2003, I have argued that, while SARS and AIDS are very different diseases, the SARS crisis put AIDS on the Chinese political agenda. SARS did so by highlighting the weaknesses of the health system and the internal challenges to the centre’s authority, and by impacting upon economic development, social stability and China’s international reputation, thus enabling AIDS to be linked to legitimacy. This reframing of AIDS generated political attention. The outbreak also necessitated the implementation of new health infrastructure, such as the disease surveillance system and the centres for disease control, and prompted the introduction of ideas of political accountability and epidemiological transparency. It spurred the increase of resources for public health and disease control and gave more political authority to the MOH. The SARS crisis also compelled the Chinese government to search for new policy ideas and opened important channels of communication and cooperation with domestic and international actors.

The SARS crisis was a watershed in AIDS governance in China. Because of the SARS outbreak, we have witnessed a major shift in the way in which the Chinese government has chosen to respond to HIV/AIDS since 2003. The extent of this change and the degree to which AIDS governance in China has changed in line with the global AIDS regime in the post-SARS period is the subject of the following chapter.

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CHAPTER 6 – CHINA’S POST-SARS AIDS GOVERNANCE – A PERIOD OF

MODEST ENGAGEMENT 2003-2007

6.0 INTRODUCTION

Having outlined the SARS outbreak of 2003 and argued that the crisis led to the politicisation of AIDS, this chapter examines how China’s AIDS governance has developed in the post-SARS period (from July 2003 to December 2007). I argue that, compared with the periods of denial and limited recognition, the post-SARS period is best characterised as a period of modest engagement (see Table 6.1). Employing the five indicators developed in chapter one and utilised in chapter four, I assess the salience of the global AIDS norms in China. In general, all five indicators (political commitment, legislation and policy, HIV in the media, the role of civil society and international engagement) demonstrate that the Chinese government has become more receptive to the norms of the global AIDS regime. The move to behaviour in line with the expectations of the regime is most noticeable in the indicators of political commitment, legislation and policy and international engagement. However, I describe this as modest engagement due to there being a number of continuing challenges such as local non-compliance and the repression of activists which suggest that the salience of the global AIDS norms continues to be negotiated by domestic factors.

6.1 POLITICAL COMMITMENT

I argued in the previous chapter that the SARS crisis politicised AIDS and indeed, the increased level of political commitment to combating AIDS is one of the most noticeable differences between the pre-SARS and post-SARS periods of governance. As SARS enabled AIDS to be framed not only as a health issue but also as a development and security issue, in the period of modest engagement we have seen the top leaders finally become visible and involved in the national response. There have also been efforts to improve coordination and funding has greatly increased. These developments suggest that AIDS is now on the political agenda and this has also been reflected in the other indicators.

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TABLE 6.1 CHINA’S GOVERNANCE AS A CHRONOLOGICAL COMPARISON Indicators Denial 1985-1993 Limited Recognition Modest Engagement 1994-2002 2003-2007 Political Commitment 1) AIDS in political Foreign, abnormal, Recognized as public Primarily medical discourse not ‘our’ issue health issue issue, also security 2) High-level advocacy None Limited, leaders remain Leaders more visible silent & involved 3) National AIDS Low Low Medium coordination 4) Funding Minimal Inadequate Increased 5) Political importance Not on the agenda On the agenda, but On the agenda of AIDS politically sensitive Legislation & Policy 1) Tenor of legislation & Defensive, More constructive but More constructive, policy exclusionary, frequently empowering, prohibitive contradictory contradictions remain 2) Protection of rights None Weak Moderate 3) Prevention (P), P - Education and P - Education, testing, P – Education, VCT, treatment (T), care testing only limited condom social harm reduction, (C) marketing, blood safety M&E, surveillance T - Access to TCM T - Access to TCM T – TCM, ARD, only only MTCT C - Minimal, high C - Increased care (via C – Increased, but stigma increasing NGOs) stigma still exists HIV in the Media 1) Dominant tone in Exclusionary, More inclusive, Sometimes alarmist, reports on AIDS stigmatising, impersonal, frequently more educative, moralizing alarmist inclusive 2) PWA Foreign, deviant, More normalized but More visible & outsiders, silent still on the outer mainstreamed 3) Openness of reporting None Minimal but increasing More issues subject to after Henan blood debate but Henan & scandal activists still off limits The Role of Civil Society 1) Degree of Minimal, mainly Moderate, subject to Increased, subject to mobilization research-based restrictions restrictions 2) Involvement in Non-existent Minimal Increased (via Global decision-making Fund) 3) State response to civil No acknowledgment Limited service Essential role of civil society provision and some society/PWA advocacy accepted increasingly Political activism recognized by state repressed Political activism repressed 4) NGO-INGO ties Few Increasing Moderate International Engagement 1) International Limited Limited Moderate compliance/ cooperation None Marginal Increasing 2) Transparency of Minimal Minimal Improved AIDS reporting 3) Representation at Low Low Moderate meetings 4) Openness to Minimal Increased, mostly in Moderate international presence Yunnan 5) International opinion Concerned First optimistic then Cautiously optimistic, highly critical commendatory

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To return to the anecdote that opened the thesis, Wen Jiabao’s visit with AIDS patients on World AIDS Day 2003 was the strongest indication that the Chinese government had experienced a normative shift with regards to AIDS governance. Three weeks earlier, the former US president Bill Clinton had hugged a young Chinese PWA at a televised conference on SARS and AIDS at Tsinghua University (Public Broadcasting Service 2006). Being more open to international experience and norm entrepreneurs in the wake of SARS, the top leaders followed suit. The Premier visited with AIDS patients, shaking their hands and sitting with them, and in doing so became the first top level leader to be engaged in visible AIDS advocacy. The move was immediately hailed by the domestic press as a ‘bold step’ (Xinhua News Agency 2003c). Not only did the Premier’s hospital visit contribute to the fight against AIDS stigma, it was also politically symbolic. In a country where the actions of the top leaders are carefully scrutinized for their meaning, the sight of China’s second-in- command talking with and touching people with HIV/AIDS signalled to both the lower-level officials and the Chinese public, as well as to China’s external observers, that a new period of AIDS governance was underway. This is illustrated by the following quote, uttered by a health official in Beijing: ‘This is what we have all been waiting for’ (quoted by Couzin 2004).

Wen’s visit to the hospital that day represented the beginning of a new phase in political commitment whereby the top leadership was prepared to be visibly associated with the issue of HIV/AIDS. Since 2003 Wen Jiabao and Wu Yi have continued to be important visible players in China’s governance of HIV/AIDS. Both leaders have been on Time magazine’s Top 100 list (Wu Yi in 2004 and Wen Jiabao in 2006) on account of their anti-AIDS action (Beech 2004; Schell 2006). Both leaders have spent time talking and eating with AIDS orphans, have met with AIDS experts, have talked candidly about AIDS on television and in political forums and have been instrumental in mobilizing funds for research and treatment (BBC Monitoring Asia Pacific 2004; Dow Jones International News 2004b; Xinhua News Agency 2004d; Xinhua News Agency 2004e; Xinhua News Agency 2007c; Xu and Chang 2006). Likewise, both leaders have visited AIDS villages in Henan, an important acknowledgement of the former plasma donor epidemic (Xinhua News Agency 2003b; Xinhua News Agency 2005a; Xinhua News Agency 2005c). In fact, as

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if to emphasise this issue Wu Yi took time to meet with Dr Gao Yaojie (without any other officials present) while she was visiting the area. Dr Gao was one of the people to bring the Henan blood crisis to light and therefore had been targeted by the Henan authorities for years (Agence France-Presse. 2004c). The President, Hu Jintao, has also visited with PWA and has urged the Chinese people to end ‘discrimination and estrangement’ towards those suffering from AIDS (Ang 2004b; Agence France- Presse 2004b; Xinhua News Agency 2007a).

There are critics who see the Chinese leadership’s behaviour as an example of spin rather than action, who would argue that the battle against AIDS must be fought with more substance than a leader kissing AIDS orphans (Settle 2003). However, as highlighted in Table 2.2 (p.49), the global AIDS regime has long advocated that a national response to AIDS requires strong and visible political commitment, including discernable advocacy and support by high-level leaders. Televised coverage of leaders eating with and touching PWA helps break down AIDS myths and reduces stigma in a way that AIDS education pamphlets cannot. Prior to 2003, UNAIDS had long bemoaned the absence of visible high-level participation in China’s AIDS governance. Therefore, I would argue that the involvement of the top-level leaders in China’s response to HIV/AIDS is evidence of a shift in line with the global AIDS regime. Furthermore, this more recent visible advocacy has also been supported by less symbolic and more concrete actions.

One of these developments is the renewal of efforts to improve multi-sectoral coordination. The positioning of Vice-Premier Wu Yi as the Minister of Health proved critical. As mentioned in the previous chapter, the former head of the WHO in China, Henk Bekedam, credits Wu Yi as the driving force behind this post-SARS mobilization of political will (Young 2006). Unlike lower level officials, Wu Yi, as a Politburo member, had the political capital that was needed to mobilize support for increased funding, harm reduction strategies and treatment programs. Wu Yi also served as the initial director of the State Council AIDS Working Committee (SCAWC), established in 2004 to replace the largely defunct State Council Coordinating Committee for AIDS/STD Prevention (created in 1996).

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In keeping with the norm of coordinated, multisectoral governance embedded in UNAIDS’ principle of the ‘Three Ones’ (one national plan, one coordinating mechanism and one monitoring and evaluation system), the SCAWC acts as the national coordinating mechanism and is comprised of the Vice-Ministers of 23 key ministries and mass organizations (such as the Publicity Department of the Central Committee of the CCP), the ministries of education, public security etc. and the Red Cross Society of China), and the Vice-Governors of the seven provinces most affected by the epidemic (Henan, Hubei, Guangdong, Guangxi, Sichuan, Yunnan and Xinjiang). The State Council AIDS Working Committee Office (SCAWCO) is the committee’s executive body, a stand-alone office located in the Ministry of Health. The committee’s key responsibilities have been to develop the guidelines, strategies and plans for HIV/AIDS interventions; coordinate and help solve problems in the national programme for HIV/AIDS prevention, treatment, care and support; and, mobilize and promote multi-sector responses and the participation of the whole society (SCAWCO and UNTG 2004, p.9; SCAWCO and UNTG 2007, p.40).

The establishment (or reestablishment) of the SCAWC has been important in terms of creating government stakeholders with interests in the policy field of AIDS. With Wu Yi at its head, supported by Gao Qiang, who was the executive Vice-Minister of Health117 (but had important links to the Ministry of Finance), the SCAWC has had more energy and political influence than its predecessor. Following Wu Yi’s departure from the committee, Wang Longde became the head of the committee and, though not as politically important as Wu Yi, fought hard to keep up the momentum started by his predecessor.118 The Committee has produced several important documents such as the policy framework in 2004 (discussed above) and several joint assessments in conjunction with the UNTG. The SCAWC is also in charge of producing the updates for the UNGASS and annually monitors and evaluates the progress and implementation of the Strategic Plan (1998-2010) and the Action Plan (2006-2010). The SCAWC was also put in charge of developing a comprehensive M&E system when the lack of one was highlighted in the 2005 UNGASS update (SCAWCO 2005, p.19).

117 Gao Qiang took over from Wu Yi as Minister of Health in 2005 before relinquishing the post to Chen Zhu at the start of 2007. He is now serving once again as the Vice-Minister for health. 118 Wang Longde’s dedication and leadership was recently publicly acknowledged by UNAIDS (Shan 2007a).

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While the norm of coordinated, multisectoral governance has entered into China’s political jargon as evidenced in the joint assessments, the country’s political structure hinders its universal implementation. Some bureaucratic coordination and streamlining has occurred. In 2004 eleven national policy initiatives were drafted by different sectors at the central government level to support the central policy statement of that time (to be discussed below, SCAWCO and UNTG 2004) and Zhang et al. (2005, p.881) have noted that some of the offices within the MOH and the NCAIDS have streamlined their operations so that, for example, international organizations are now solely managed through the MOH’s Department of International Cooperation. However, the WHO and UNAIDS have stated that bureaucratic fragmentation, both between different sectors and between the centre and the provinces and local governments, continues to be a major problem. UNAIDS’ Joel Rehnstrom for example has said that the SCAWC has not ‘lived up to expectations’ in effective coordination (South China Morning Post 2006b).

A major criticism of the Chinese government of its pre-SARS response to HIV/AIDS was that the level of funding for the national AIDS program was a mockery and indicated a general lack of commitment despite rhetoric to the contrary. In the post- SARS period there has been a significant increase in the amount of AIDS funding allocated from the central government, as can be seen in Graph 6.1. In 2003, the central government allocated 470 million RMB (US$57.75 million) – this amounted to just under the total amount that was spent on HIV/AIDS prevention and control from 1985 to 2002. This was almost doubled in 2004 to 810 million RMB (US$101.25 million). The most recent Joint Assessment stated that the central government budgeted 944 million RMB for HIV/AIDS prevention and treatment in 2007 (US$118 million). Although the information on funding at the provincial and local level is incomplete, China has reported that local investment rose from less than 100 million RMB (US$12.25 million) in 2003 to 341.59 million RMB (US$42.7 million) in 2007 (SCAWCO and UNTG 2007b, p.11). Central and provincial funding combined comprises two thirds of China’s HIV/AIDS resources, with international contributions making up the rest. The increase in central funding reflects increased commitment to providing treatment (30.6 per cent of the funding), improving harm reduction and education (25.8 per cent) and addressing the issue of former plasma

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donors (10.8 per cent). The rest of the funding is distributed among laboratory strengthening, blood safety, voluntary testing and counselling etc. (SCAWCO and UNTG 2007, p.30).

GRAPH 6.1: CENTRAL GOVERNMENT HIV/AIDS PREVENTION AND CONTROL 119 FUNDING

1000

900

800

700

600

500

400 RMB (millions) 300

200

100

0

6 8 2 4 6 0 2 4 99 198 198 1990 1 199 199 1998 200 200 200 2006

Remarkable though the increase from 15 million RMB annual AIDS expenditure to just under a billion RMB in 7 years has been, some AIDS experts and international organizations remain concerned that it is not enough, especially given the large number of people at risk of contracting HIV. Certainly, the central government’s expenditure on AIDS when calculated as a percentage of GDP is not as remarkable.120 Sustainability is a concern with Jing Jun noting in April 2007 that there is growing AIDS fatigue.

119 This data is based on the 2003, 2004 and 2007 Joint Assessments and the 2005 Update. As such, the data for the years 1986 to 1997 is incomplete, based instead on the 2003 Joint Assessment which suggested that the total combined domestic and internationally-sourced funding for the years 1986 to 1992 came to 30 million RMB and the Ministry of Health AIDS budget for the years 1993 to 1997 totalled 55 million RMB (Chinese MOH and UNTG 2003; MOH PRC, UNAIDS, and WHO 2006; SCAWCO and UNTG 2004; SCAWCO and UNTG 2007). 120 China’s expenditure on AIDS amounts to 0.004 per cent of its GDP. By comparison, the US, albeit with a slightly higher number of PWA, budgeted 0.14 per cent of its GDP (or US$18.9 billion) for domestic AIDS expenditure in 2007 (KFF 2006).

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The government -- (and) the international community -- is not investing enough money. There was roughly 3 billion yuan ($388 million) invested last year, which is 20 kilometres (12 miles) of expressway in Beijing (quoted in Blanchard 2007).

Others argue that the issue is not so much the resources themselves but how best to make the money work. Nevertheless, the sharp increase in central funding does indicate that AIDS has moved up the political agenda of the Chinese central government and that it is prepared to support policies with fiscal resources.

As I stated in chapter 2, in fighting AIDS within their borders, state governments are expected to exhibit political leadership through its top leaders becoming visibly involved in AIDS advocacy, the mobilization of human and financial resources and enabling of a supportive policy environment. The state government is also expected to maintain well coordinated, multi-sectoral responses. Developments in the post-SARS period suggest that not only is AIDS now on the political agenda, but that the central government is increasingly internalising these norms.

6.2 LEGISLATION AND POLICY

There have been some interesting developments with regards to AIDS legislation and policy since the SARS crisis. The shift towards greater political commitment has led to a more enabling policy environment, and we have seen the development of more constructive and empowering legislation and policy than previously seen. The internalisation of several global AIDS norms has led to the moderate protection of the rights of PWA and new policies guaranteeing affordable and accessible prevention, treatment and care. Several challenges undermine these developments, the most formidable being the existence of contradictory laws and the uneven implementation of central policies by local government. However, there have been recent moves to address this issue.

Following the UNTG’s criticism of China’s legal infrastructure with regards to AIDS in 2002, the 2003 Joint Response noted that ‘the laws and regulations that play an important role are no longer applicable to the present situation and are sometimes in

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contradiction with current prevention strategies’ (Chinese MOH and UNTG 2003, p.6). In the post-SARS period of AIDS governance, efforts have hence been made to revise and streamline relevant laws such at the 2004 revision of the 1989 Law on the Prevention and Treatment of Infectious Disease (‘Disease Law’ hereafter) and to create new laws such as the 2006 Regulations on AIDS Prevention and Treatment (‘2006 Regulations’ hereafter). The passing of the latter law in January 2006 was particularly important. The creation of the issue-specific piece of legislation was hoped to ‘balance personal rights and public health care’, as articulated by the head of the China Health Law Society (Liu 2005). Lawmaking in the post SARS period has involved consultation with both Chinese and international legal advisors.

The rights of PWA have been institutionalised in several pieces of legislation. The August 2004 amendment of the Disease Law, along with updating the classification of diseases, included several important clauses with regards to AIDS governance – the first time that AIDS had been granted an independent clause in law (Dickie 2004; Ma 2004a; People's Daily 2003a). Following on from the MOH’s regulations of 1999 and several pieces of local legislation (for example, that of Jiangsu province), the amendment protects certain rights of the patient such as the right to privacy and the right to medical treatment, regardless of socio-economic background. The 2006 Regulations also set out the rights of PWA. PWA and their relatives have the right to marry, to be employed, to have access to medical treatment and to education. The 2006 Regulations prohibit discrimination against PWA and protects privacy by preventing organizations or individuals from releasing information pertaining to the personal details of PWA. PWA rights have spilled over into other debates as well. After the first PWA to marry made the news in 2002, a debate started over whether or not PWA should be allowed to marry and what obstacles made it hard for them to do so. This led to the passing of the 2003 Regulation on Marriage Registration which made premarital health checks optional instead of mandatory, as originally stipulated under the 1995 Law on Maternal and Infant Healthcare (Li 2003). Finally, in recent developments, the Ministry of Health announced that the Chinese government was considering dropping the immigration restrictions that prohibits PWA from entering the country (Reuters News 2007a).

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While the rights of PWA have thus become increasingly institutionalised and subject to protection, their internalisation has been subtly affected by pre-existing norms. The 2006 Regulations, for example, obligate PWA to inform current sexual partners and their doctor and to take measures to prevent infecting others. The deliberate infection of others is a crime, punishable by law. Likewise, while the government has noted that the immigration restrictions are under review, it has also announced that it plans to enforce mandatory testing for Chinese returning from overseas in order to make PWA aware of their status and allow them to seek assistance (The Press Trust of India 2007). Thus mandatory testing is a case of sacrificing particular rights of the PWA for both their sake and for the sake of the community. Neither the inclusion of the duties of PWA nor mandatory testing are in line with the advice promoted by UNAIDS. It has been argued that what constitutes deliberate infection is not easily detectable and that mandatory testing is discriminatory (Jürgens and Cohen 2007; UNAIDS 2002).121 However, it might also be argued that these moves could be seen as being in line with the more communitarian interpretation of human rights (albeit sometimes only rhetorically) subscribed to by the Chinese government (Peerenboom 2007, p.155- 156). Furthermore, as already discussed, the existence of law at the national level in China does not necessarily mean that the provinces or local governments will comply. A major issue with the Chinese legal system is the manner is which provinces are able to find legal loopholes to pass laws that are inconsistent with the central government’s legal framework. The extent to which the 2006 Regulations will be used to seek legal redress for PWA depends on broader issues relating to legal and political reform.122

121 The deliberate infection of others is a controversial issue because it is difficult to prove intent as opposed to reckless behaviour leading to infection or accidental infection. However, while there have been cases of people being charged for having deliberately infected others, UNAIDS (2002, p.39) argues that there should be no HIV-specific legislation: ‘Criminal and/or public health legislation should not include specific offences against the deliberate and intentional transmission of HIV but should rather apply general criminal offences to these exceptional cases’. 122 There is evidence however that the 2006 Regulations have strengthened the resolve of PWA to seek legal redress. One example is the case of Jin Wei versus the China Times, a Beijing-based newspaper. This was the first known case to be filed with regards to the new law. The defendant, the China Times, was accused of invading the privacy of two AIDS orphans. The newspaper ran a feature story on the two orphans in December 2005, using their real names and publishing their photos after having promised to keep these details private. The orphans were represented by Jin Wei, a professor at the Central Party School, who waited for the new legislation to be promulgated before filing the suit against the paper on March 1, 2006, citing Article 39 of the Regulations. Jin argued that while the news feature had been well-intentioned and sympathetic to the orphans’ plight, the newspaper’s actions had put the children at risk from AIDS discrimination (South China Morning Post. 2006a; Jia 2006). In July, the court handed down a guilty verdict and ordered the China Times to compensate the orphans (Reuters News 2006b). This was an important test of the new legislation.

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Along with the protection of the rights of PWA, recent legislation has also emphasised government commitment, accountability and multisectoral cohesiveness and cooperation. The 2006 Regulations set out the responsibilities for the different ministries and the different levels of government. Every level of government must integrate AIDS prevention and treatment into their ‘economical and social development programs’ and must strengthen anti-AIDS efforts such as establishing AIDS prevention and treatment professional teams. Both the 2004 amendment to the Disease Law and the 2006 Regulations have introduced accountability by making medical authorities and government officials legally liable for timely and transparent disease reporting. Failure to comply with the 2006 Regulations for example, the misrepresentation or covering up of epidemic data, the refusal of treatment, the public release of personal data, and the failure to take measures to test for or prevent HIV transmission are all acts that may lead to punitive measures. The 2006 Regulations also legislate for the greater accessibility and affordability of prevention, treatment and care, providing regulatory and funding guidelines for new policy developments.

As opposed to the discriminatory and exclusionary policies of the period of denial and the inadequately funded and politically supported policies of the period of limited recognition, policymaking in the post-SARS period has benefited from increased political attention to AIDS. The Chinese government’s move to support and enable ‘coordinated, multi-sector, rights-based’ AIDS policies that are founded on evidence is more in keeping with norms of the global AIDS regime.123 Since 2003, China’s policy framework has been strengthened first by the 2004 State Council Notice on Strengthening HIV/AIDS Prevention and Control (‘State Council Notice’ hereafter) and then the Five Year Action Plan for Reducing and Preventing the Spread of HIV/AIDS (2006-2010) (‘Action Plan (2006-2010)’ hereafter). The State Council Notice was the first policy document released by the SCAWC and was also significant as the first articulation of AIDS policy following the shift in commitment at the central government level. With its stated aim to improve AIDS governance, the State Council Notice addressed seven areas for improvement, including: leadership and clarification of roles and responsibilities; implementation of comprehensive

123 To enable ‘coordinated, multi-sector, rights-based, risk reduction policies’ was a stated objective of China’s Fourth Round Global Fund proposal (China CCM 2005).

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prevention (including harm reduction strategies); HIV surveillance and epidemic reporting; the provision of antiretroviral treatment; health investment; care and support for PWA; and, international cooperation (State Council 2004). The State Council Notice led the way to the 2006 Regulations and the Action Plan (2006-2010).

Following UNAIDS’ global campaign to promote the ‘Three Ones’ principle – one national planning framework, one coordinating body and one monitoring and evaluation framework – the Chinese government formulated the Action Plan (2006- 2010) to serve as the national HIV/AIDS policy framework. The plan is based on the 2004 State Council Notice and is underpinned by a number of working principles, including strong leadership by government with ‘whole society participation’. At the heart of the plan is the key objective to restrict the number of HIV infections to below 1.5 million by the year 2010. With this objective in mind, the document then sets out a number of more specific goals and indicators. For example, the Plan stipulates that by 2007, not less than 80 per cent of health workers in cities and towns and not less than 50 per cent of village health workers should be trained in HIV/AIDS prevention and treatment. This is to increase to 90 per cent and 70 per cent respectively by the end of 2010. Having established its goals, the plan then sets out the strategies to achieve them, with a heavy focus on education, scaling up intervention measures, strengthening blood management, improving the quality of HIV care services, further developing the HIV surveillance system, strengthening STD prevention and management and improving research and international cooperation in HIV prevention and treatment (State Council 2006).

In the post-SARS period, with AIDS stigma and discrimination long being cited as a major hindrance to China’s response to HIV/AIDS, there have been major efforts to scale up AIDS education. Many of these campaigns have been designed in collaboration with IGOs, INGOs and the corporate sector. There have been several important campaigns involving public service announcements (PSA) featuring Chinese celebrities. For example, a major campaign in 2005 produced in association with China AIDS Media Project (CAMP) involved a PSA featuring the basketball player, Yao Ming, playing basketball and eating dinner with HIV positive American basketball player, Magic Johnson (CAMP 2007). Most recently, in December 2007, a new campaign entitled ‘Life is Too Good’ was launched. The PSA, a joint

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collaboration by CAMP, the MOH, the UNDP and Chinese media and advertising companies, featured famous actors Jackie Chan, Pu Cunxin and Peng Liyuan endorsing condoms and safe sex (UNDP 2007). Along with broad national AIDS campaigns, there have been more targeted campaigns designed to reach women, minority groups, men who have sex with men, migrant populations, children and youth and workplaces (SCAWCO and UNTG 2007). For example, Coca Cola (China) Beverages Ltd. launched a program in 2007 to provide 100,000 sets of playing cards with AIDS, tuberculosis and malaria prevention information on them to migrant workers (Xinhua News Agency 2007d).

While the move to increase AIDS awareness has been important, one of the more dramatic developments in the post-SARS period has been the government’s endorsement and provision of harm reduction policies, such as needle exchange programs, methadone maintenance therapy, and the social marketing of condoms. While harm reduction strategies in China were not unheard of prior to 2003,124 the first Joint Assessment report noted that the breadth and scope of the harm reduction programmes remained ‘inadequate’ due to lack of ‘a supportive environment and relevant policies’ (Chinese MOH and UNTG 2003, p.33). Methadone maintenance therapy had not been piloted at all prior to 2004. In 2004 however, harm reduction strategies were endorsed by the government in the State Council Notice as a necessary tool in the fight against AIDS, a move that led to their inclusion in a Round 4 Global Fund grant proposal that targeted high risk groups (China CCM 2005). Increased leadership and funding have therefore enabled an ambitious scaling-up of needle exchange programs and methadone maintenance therapy.

With regards to needle exchange, while there were 91 needle and syringe exchange sites in operation by the end of 2005 (MOH PRC, UNAIDS, and WHO 2006), this number had been substantially increased to 729 by the end of 2006 and there are plans to expand this number to 1400 by the end of 2008 (WHO 2005; Wu et al. 2007, p.681). Likewise, there were 128 methadone clinics by the end of 2005 (MOH PRC, UNAIDS, and WHO 2006). This number had risen to 397 by the end of October 2007

124 Needle social marketing (rather than the more controversial term of needle exchange) was advocated by the State Council in 2001 and pilot programs were established in Yunnan in 1999 and in Guangxi and Guangdong in 2002 (Chinese MOH and UNTG 2003, p.26; Wu et al. 2007, p.682). Likewise, there were several 100% condom use programs conducted in several key areas.

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and there are plans to increase the number to 1500 by 2008 (Gill and Okie 2007; SCAWCO and UNTG 2007a, p.21; WHO 2005). In relation to condoms, the 2006 Regulations stipulated that every entertainment site must offer access to condoms and a number of promotion campaigns have been launched around the country, particularly targeting CSW (SCAWCO and UNTG 2007).

Prior to 2003, treatment and care remained vague concepts in the government’s AIDS policy plans. While some PWA had access to traditional Chinese medicine (TCM), few people could either access or afford ARD. Likewise, there were few options of assistance for PWA. However, as already discussed, the SARS crisis exposed the danger of inaccessible and unaffordable health services. In December 2003, the Chinese government announced the introduction of the ‘Four Frees and One Care’ policy (Chinese MOH and UNTG 2003). The policy guarantees free ARD to rural PWA or people with financial difficulties living in rural areas, free voluntary counselling and treatment (VCT), free drugs to HIV infected pregnant women to prevent mother-to-child transmission, and HIV testing of newborn babies, free schooling for children orphaned by AIDS, and, care and economic assistance to the households of people living with HIV/AIDS (SCAWCO and UNTG 2004, p.9). This policy was further legislated in the 2006 Regulations. The legislation also ensures the provision of free or low cost drugs to rural and urban PWA with financial difficulties to combat opportunistic infection (State Council 2006). This policy came about after the Chinese government licensed two domestic manufacturers to produce generic drugs and it waived tariffs on imported drugs.125

When the policy was first announced there was concern that the provinces would be expected to fund this policy mandated by the centre, in which case poorer provinces would be at a disadvantage (Thompson 2004). Two subsequent policy documents were issued. The Measures for Management of Drug Treatment of HIV/AIDS and Common Opportunistic Infections at No/Reduced Charge (the ‘Measures’ hereafter) were jointly issued by the MOH and the Ministry of Finance. Article 3 of the

125 This was legislated by the Ministry of Finance and the State Administration of Taxation in the 2002 Notice of the Ministry of Finance and the State Administration of Taxation on Exempting Imported Anti-AIDS Drugs from Taxes and the 2003 Notice of the Ministry of Finance and the State Administration of Taxation on Exempting Value-Added Taxes from Anti-AIDS Drugs.

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‘Measures’ stipulates that the central government assumes the cost of providing free treatment to AIDS patients in high prevalence areas, free drugs for the prevention of mother to child transmission and reagents for infant testing whereas local governments are responsible for all other costs including those for treating opportunistic infections and eliminating barriers to accessing treatment. The ‘Measures’ were accompanied by the Opinions Concerning the Management of HIV Antiviral Treatment, jointly issued by the MOH and the State Administration of Traditional Medicine, which delineated the responsibilities for the management and implementation of the program at all levels of government with the MOH in charge of overall management and supervision (Zhang et al. 2005, p.878).

As of October 2007, a cumulative number of 39,298 people aged 15 and above had commenced treatment with 31,849 people currently receiving ARD (SCAWCO and UNTG 2007, p.24). However the total number of people currently receiving ARD is only 25 per cent of the population that needs antiretroviral treatment and the dropout rate is high (at least 8 per cent) due to side effects, drug resistance, difficulty with adherence and progression of the disease. The scaling up of the ‘four frees program’ therefore faces major challenges with regards to the overall ‘unhealthy’ state of the health system and technical issues relating to implementation, human capacity and access.126 Nevertheless, the Chinese government is nothing if not ambitious - the Action Plan (2006-2010) includes a target of treating ‘not less than’ 80 per cent of AIDS patients with antiretroviral drugs or traditional Chinese medicine by 2010 (State Council 2006).

The Chinese government has also sought to specifically address the issue of the former plasma donors. In 2003, based on a successful pilot program situated in Shangcai County, Henan, the Chinese government launched the ‘China Comprehensive AIDS Response’ or ‘China CARES’, an extensive community-based HIV treatment, care and prevention program. This program, ‘the first major initiative to directly address the needs of families and communities affected by HIV’, was initially set up in five central and northeastern provinces (including Henan) and later expanded to two more thanks to a grant from the Global Fund. The program was

126 This is discussed constructively in Zhang et al. (2005, p.880-881).

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established to initiate treatment with domestically-produced antiretroviral drugs and provide health care and education, mother to child transmission prevention and voluntary counselling and testing (Chinese MOH and UNTG 2003, p.27). 25,000 of the population receiving ARD have done so via the China CARES program (Zhang et al. 2005).

Finally, with states expected to provide transparent data to UNAIDS, formulate evidence-based AIDS programs and monitor and evaluate these programs, it is significant that since 2003 the Chinese government has worked on improving the quality of its epidemiological data by enhancing surveillance and testing, and establishing a M&E framework. The need to strengthen HIV/AIDS surveillance and standardize epidemic reporting was included in the 2004 State Council Notice, legislated for in the 2006 Regulations and included in the Action Plan (2006-2010). The number of national sentinel sites has increased from 158 at the end of 2002 to 393 at the end of 2006. More significantly, the number of provincial sites has increased from ‘several’ in late 2002 to nearly 500 at the end of 2006 (MOH PRC, UNAIDS, and WHO 2006, p.8; SCAWCO and UNTG 2007, p.28). By the end of 2005 there were 2850 clinics offering free voluntary counselling and testing services, and laboratory screening has improved (SCAWCO 2005, p.3).

There have also been developments with regards to epidemic reporting with two major information management systems being established - the Comprehensive Response Management Information System and the Traditional Chinese Medicine on AIDS Treatment Database and Analysis System. After the SARS crisis highlighted the issue of outdated, inadequate information systems, there was a push to move from a paper-based system, where paper reports had to pass through a hierarchy of officials, to a nationwide web-based system where information has been able to be collected and passed on instantly to superiors via the Internet (MOH PRC, UNAIDS, and WHO 2006, p.3). In that the information is used for policy advocacy and program planning, the updating of surveillance systems is evidence of the increasing salience of the norm of evidence-based programs (SCAWCO and UNTG 2007, p.28).127

127 As a consequence of the improvements made to the surveillance system, in 2005, China revised its estimate of HIV/AIDS cases downwards from 840,000 (the 2003 estimate) to 650,000. According to the 2005 Update on the HIV/AIDS Epidemic and Response by China, the revision is the outcome of

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Finally, in line with the Three Ones principle, the Chinese government has established the China AIDS Monitoring and Evaluation Protocol, formed a national M&E expert team and provided training to strengthen capacity at various levels of government (SCAWCO and UNTG 2007, p.29). This it has done in line with UNAIDS guidelines and with UN technical assistance.

While the Chinese government has increasingly institutionalised global AIDS norms in AIDS legislation and policies, once again, implementation is hindered by the Chinese government’s moral agenda and the dynamics of negotiated authoritarianism such as bureaucratic fragmentation, the controversial issue of civil society, and issues of centre-local autonomy. While access to services such as HIV testing or needle exchange has certainly increased, the number of people actually using the services is well underneath the targeted number. In some cases, this is because of the remaining hardline approach to drug use and sex work. For example, just two paragraphs after it legitimates the use of harm reduction strategies, the 2004 State Council Notice states that ‘public security bureaus are required to severely crack down on illegal activities such as sex work, drug trafficking, and drug abuse’ (State Council 2004). The hardline approach therefore continues to contradict and undermine China’s harm reduction strategies and treatment programs. Furthermore, policy implementation is hindered by the continuing inadequacies of multisectoral coordination. Again, this can be illustrated with regards to the harm reduction strategies where condom campaigns targeting CSW are undermined by the police who until very recently have used condoms as evidence of prostitution (Xinhua News Agency 2007e). One critic has

improved methodology and a wider range of data. For example, while the 2003 estimate used ‘limited’ data from 194 national sentinel surveillance sites, the 2005 estimate used ‘more complete and representative’ data from 329 sentinel surveillance sites (MOH PRC, UNAIDS and WHO 2006, p.3). The biggest surprise was the revision of the number of former plasma donors living with HIV/AIDS - only 55,000 instead of the 2003 estimate of 199,000! This estimate was disputed by NGOs who for the most part were sceptical of the new findings. Despite these concerns, this estimate and the methods used to obtain it were supported and endorsed by UNAIDS and WHO (Yardley 2006). It should be noted that while the overall number of HIV/AIDS cases has been revised downwards, both UNAIDS, the Chinese MOH and the WHO noted that there was no room for complacency. Joel Rehnstrom for example noted that, although the new numbers provided a better picture of the epidemic, ‘there is still a long way to go’ (Yardley 2006) and has since warned that the number of estimated PWA is less concerning than the number that was not in the report - the number of people at risk of contracting AIDS, estimated to be between 30 and 50 million (South China Morning Post 2006b). Wang Longde pointed out that almost 200 new infections a day is a major concern and does not indicate that the situation is improving. Henk Bekedam stated that the figures regarding new infections reveal that the situation is more serious than first thought, although he did go on to say that the previous forecast of 10 million PWA by 2010 was unrealistic (Biggs 2006).

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noted that while cross-sectoral cooperation is mentioned in the 2006 Regulations, the law does not offer any explicit mechanism for the integration of the activities of the 20 departments that are currently engaged in AIDS prevention (Kwok 2006). As will be further discussed in section 6.4 below, many of the policies require civil society involvement in order to be effective and reach targeted populations. However, the 2006 Regulations are vague on the subject, preferring only to mention the need for ‘whole society’ to participate in supporting the government’s efforts.

The main issue facing the effective implementation of AIDS law and policy however is the issue of centre-local autonomy. The central government, international organizations and some nongovernmental organizations have repeatedly stated that non-compliance by local officials has been and continues to be a key challenge to China’s response to HIV/AIDS. China’s 2005 UNGASS update for example stated:

Some local leaders do not understand enough about HIV/AIDS prevention, treatment and care work, and mechanisms to support multisectoral participation in HIV/AIDS prevention, treatment and care remain incomplete. At the city and county levels, these problems are especially pronounced (SCAWCO 2005, p.15).

In December 2004, Wu Zunyou, director of the Division of Health Education and Behavioural Intervention in China’s CDC, was quoted as saying that some local leaders were completely unaware of the state’s medium- and long-term plans on HIV/AIDS prevention and control (Xinhua News Agency 2004a). In 2006 a survey of more than 3000 local government officials was conducted to evaluate their level of AIDS awareness. It was found that 60 per cent of those surveyed had little awareness of AIDS prevention and control (Xinhua News Agency 2006c). As already discussed in chapter 3, section 3.2.2, there is a certain amount of bargaining and adaptation that occurs between what the centre dictates and how the local governments choose to implement those orders. Local government HIV policy has therefore often reflected a calculation of where the issue stands in terms of the central government’s list of priorities combined with local interests.

While there is now less doubt with regards to the central government’s position on AIDS prevention, local governments still adapt national law and policies to local

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conditions. This explains some of the variation in HIV policy from province to province. Take Henan for example. There are many officials who were directly involved in the blood selling schemes and therefore have an interest in keeping PWA court cases, activism and claims on the state to a minimum (Human Rights Watch 2005). Likewise, on the subject of crackdowns on AIDS activists at the local level, Adam Li, the Director of the Mangrove Support Group in Beijing, has said:

They [county heads and village officials] are wondering: 'How will this reflect on my political record to have these groups doing their thing?' and 'What if they petition the central government? Could I lose my job?' And that's when they send in the local cops to stop these groups and to control them (quoted in Oleson 2006).

So while the national government has promised, via the Four Frees and One Care and the Chinese CARES program, to provide medical aid to PWA and assistance for AIDS orphans, the Henan response remains uneven and in some cases hostile to grass-roots organizations that have tried to take advantage of the new policies. There have also been stories of crackdowns and cover-ups occurring prior to ministerial visits (BBC Monitoring Asia-Pacific 2005b; Human Rights Watch 2005).

The issue of non-compliance with central government policies is not the fault of the local government officials alone. For example, in 2004 Henk Bekedam of WHO stated that, while the central government had made firm political commitments to deal with AIDS, the message could have been ‘better passed to the provincial and county level for more effective implementation’ (Woo 2004). Despite the efforts made to discourage local officials from choosing between HIV prevention and economic development, as well as developments with regards to encouraging accountability and making disinformation or the deliberate covering up of epidemics punishable by law, cadre performance and promotion is not based on the level of investment in HIV prevention. The concern is that there has continued to be mixed messages transmitted from high level government downwards with regards to the prioritisation of economic growth over social development.

While these institutional dynamics have impacted upon the salience of the global AIDS norms, there have been measures undertaken to address the issues of non-

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compliance and legal ambiguities. The central government has engaged in a major campaign to educate local officials on HIV policy and knowledge. Thanks to a pioneering lecturer named Jin Wei, once-controversial AIDS lectures are now regularly given at the Central Party School, the top training centre for the middle and top-ranking party officials, and have served as a model for the introduction of HIV education into the curricula of provincial and municipal party schools (Wang 2007). The SCAWCO has also organised training programs designed to brief officials on the 2006 Regulations and the Action Plan (2006-2010) and in June 2006 broadcast a presentation to 100,00 officials. This was followed by an HIV Policy Advocacy Group travelling around the country. As stipulated in the Action Plan (2006-2010), the goal was to deliver speeches to 90 per cent of local officials above county-level by the end of 2007 (Xinhua News Agency 2006a; State Council 2006; SCAWCO and UNTG 2007b).

A large part of this process of education has been to frame AIDS in the context of economic costs in order to prevent local officials under-reporting AIDS cases for fear of hindering economic development within their jurisdiction. There is acknowledgement by the central government that there remains confusion over the place of AIDS prevention in the hierarchy of policy issues. For example, in April 2004 Vice Health Minister Wang Longde said:

Despite high awareness of the central government, some local officials still cannot understand the threat of AIDS…Some may worry that publicizing the AIDS epidemic will affect the local investment environment and economic growth, and others may think AIDS is still no threat to them (Xinhua News Agency 2004b).

When he met with Margaret Chan, the newly elected WHO chief, Premier Wen Jiabao acknowledged, ‘in the past, many of our officials only knew of GDP and not of the CDC’ (quoted in Xinhua's China Economic Information Service 2006). Therefore, the central government has tried to emphasize that HIV/AIDS prevention and control can help officials achieve their goals.

HIV/AIDS prevention and control is linked to economic development, social stability, and national security and prosperity…In order to respond to and contain

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HIV/AIDS in China, local governments must: realize the importance and urgent need for prevention and control; integrate HIV/AIDS into the routine government agenda as an important item; strengthen the leadership, streamline and coordinate efforts; and urgently and effectively respond and contain HIV/AIDS, which is a priority linked to the interest and benefit of China and its people (State Council 2004).

The key AIDS reference manual for decision makers, ‘A Leadership Textbook on AIDS Prevention Policies’, edited by Jin Wei, has a section on the impact that AIDS could have on economic growth (Ma and Lin 2006). In 2005, when he was invited to talk at the Central Party School AIDS lecture series, Peter Piot (2005) framed AIDS as ‘an exceptional threat to progress’ and argued that there ‘is simply no precedent in history for an epidemic with such damaging and long-lasting effects on social and economic development, or on the capacity of states to maintain stability’.

The issue of centre-local coordination, particularly the education and capacity building at the local levels, is also a central component of two recent multilateral projects. The first is the ‘China AIDS Roadmap Tactical Support (CHARTS)’ program. This project, launched in 2005, is designed to improve China’s capacity to respond to HIV/AIDS and is jointly funded by the Chinese government, UNAIDS, Australia, the UK and Norway (AusAID 2007). A central element of the project is the training and empowerment of local officials. In the three years since its launch, the project has had some positive results (Wang 2007; Xiong 2008). The second project is being coordinated by the UNDP and the Chinese legislature and is designed to ‘strengthen a harmonious legal environment for a successful coordinated response to HIV/AIDS in China’. The project will focus on legislation at the local level (Xinhua News Agency 2007b).

6.3 HIV IN THE MEDIA

In the post-SARS period, the media coverage of HIV/AIDS has reflected the political negotiation between domestic norms and structures and incoming global norms. The dominant tone of AIDS reporting has moved towards being more educative and inclusive, although alarmist and moralistic reports still make an appearance. While the media still finds it difficult to abandon overly moral language when talking about

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IDU, CSW and MSM, PWA are much more visible and mainstreamed in media articles. Finally, while certain topics such as the Henan blood scandal and repression of activists are not reported on, we have seen more freedom on the reporting on local governments and their compliance with the central government.

The post-SARS politicisation of AIDS is mirrored in the media. Most noticeably, there has simply been more coverage of the issue. As Graph 6.2 shows, the incidence of articles that concern HIV/AIDS and China as reported by the China Daily and the Xinhua News Agency has increased. The increase in reporting is a product of the loosening of state restrictions of AIDS-related issues and is a reflection of the government’s efforts to publicise its new commitment to combating AIDS to both domestic and international audiences. Thus we see the most number of AIDS-related articles in 2004, the year of the most substantive policy developments. It is also noticeable that there has been an increase in the number of articles that have included statements from high-level leaders (other than the Minister of Health).

In conducting content analysis on these articles, several trends emerge. First, the media is struggling to find the right tone to use in the reportage of AIDS-related issues. On the one hand there has been implicit recognition that the media can be used as an important tool in prevention. Therefore, in the post-SARS period there has been a noticeable increase in advocacy and AIDS awareness. There is a real transformative or educational quality to many of the articles and there has been a perceptible increase in mention of the rights of PWA to marry, procure employment, to human dignity, and so on (Chen 2004; Meng 2004; Sun 2005; Xinhua News Agency 2003). Articles highlighting the damage inflicted by stigma and discrimination and the need for Chinese society to have compassion and not exclude PWA have also increased (see, for example, Xinhua News Agency 2003a; Zhou and Jinhui 2004).

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GRAPH 6.2 CHINA AND HIV ARTICLES IN CHINESE MEDIA (BASED ON FACTIVA SEARCH)128

160

140

120

100

80

60 Number of articles

40

20

0 1998 1999 2000 2001 2002 2003 2004 2005 2006

On the other hand, the media finds it difficult to balance AIDS advocacy and inclusion with the government’s moral agenda. In trying to be more open about the disease and discussing risk behaviours and intervention measures, some articles demonstrate the sexual morality of the government, whether it is in relation to the ‘unhealthy sexual behaviour’ of MSM or in warning of the danger of AIDS spreading from high-risk groups to ‘normal’ people. Take the article discussed below for example. The journalist discusses the efforts of a local government in Northeast China to give CSW AIDS education and the dilemma thus facing the police. While the journalist argues for the education of CSW, their description of the ‘evil industry’ clearly reflects the official discourse on sex.

It is true that no action of prostitution should be tolerated… Cracking down on prostitution is certainly one of the major measures to check the spread of AIDS in addition to remedying corroded social ethics… it is an undeniable fact that the vice

128 This graph is based on rough quantitative research conducted using the Factiva database. The research was undertaken using articles with the key words ‘HIV’ and ‘China’ in their headline and/or leading paragraph, using China Daily and Xinhua News Agency as the sources. It is meant as an indication only.

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cannot be eradicated in the foreseeable future. Since this is so, we cannot count solely on police moves to check the prostitution-related spread of HIV/AIDS. Other moves have to be taken simultaneously. Awareness education for CSWs is such a move (Liu Shinan 2006).

The challenge of alarmist language also still remains. Increases in AIDS cases generally make the headlines and AIDS is often described as ‘the fatal disease’ or ‘the deadly disease’ or ‘deadly affliction’.129

In the post-SARS period, PWA have been increasingly visible and mainstreamed. As PWA and civil society involvement and PWA rights have entered the public discourse, PWA voices have increasingly been heard with many more interviews with and features on PWA and AIDS NGOs being published. For example, there were several articles published on NGOs and individuals during the time of the International AIDS Conference in Bangkok, including Song Peifei (who became famous after former president Bill Clinton hugged him on national TV in 2003), Li Xiang of the Mangrove Support Group, Wan Yanhai (controversially mentioned), Chung To of the Chi Heng Foundation and ‘Xiaoyu’ of ‘Home of Love’ (Lin 2006; Ma 2004). This enhanced visibility has applied even to highly stigmatised groups. Despite the challenges of language, there have never been so many articles dedicated to issues once felt inappropriate for a domestic and international audience such as the provision of condoms to truckdrivers and the floating population or projects aimed at teaching safe sex to MSM, CSW and IDUs. One journalist for the China Daily, Lin Gu, spent ten days in Yunnan, sitting in on training workshops with IDU, CSW, PWA and MSM and helping hand out condoms in gay bars. ‘What struck me most during this recent visit was that AIDS has lent a human face to these once-invisible social groups’ (Lin 2006). When an issue to do with HIV/AIDS is reported, nowadays the opinion of a PWA is often sought in addition to those of health officials. For example, one report on the contradictions between the law and harm reduction policies not only

129 This is an issue that has been recognised and efforts have been made to address it. In April 2004 China’s first symposium on news coverage on AIDS took place at Tsinghua University. Yang Zhengquan of the China Foundation for Human Rights Development argued that the news coverage on HIV/AIDS was still ‘narrow and shallow’ and that the media should help promote more knowledge on AIDS prevention and keep the people aware of the development of AIDS while avoiding social panic (Xinhua News Agency 2004c). In 2006 the Central Department of Publicity held workshops on accurate and balanced HIV/AIDS reporting (Xinhua News Agency 2006). For a detailed study on HIV/AIDS- related social panics by local Chinese media, see Jing (2006).

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quoted a local bureaucrat but also sought comments from a voluntary AIDS prevention worker and a PWA (Xinhua News Agency 2005b). There has also been much positive coverage of famous actors and sportsmen, such as Jackie Chan and Yao Ming, being involved in PWA advocacy.

There are still some subjects that remain off limits. While the media is allowed to talk about the FPDs and how they became infected, the articles are always portrayed as if the issue is now in the past, a problem that people are moving on from due to the good policies of the provincial government. This is visible in headlines such as: ‘Henan provides lesson in fight against AIDS’ (Xiao 2004); ‘Henan province boosting help to HIV/AIDS victims’ (Di 2004); and, ‘Henan gets it right in war against HIV/AIDS’ (Zhang 2005). Predictably, there is no media coverage of ongoing claims on the state by PWA or the detention of AIDS activists. For example, the awarding of Dr Gao Yaojie by Vital Voices was reported but Gao’s criticism of both the central and the Henan government’s treatment of PWA and activists was not (Xinhua News Agency 2007f).

Nevertheless, the lessening of restrictions on the media has enabled mild criticism of the government to appear. For example:

… The government should have taken a more positive attitude to deal with this problem. Until very recently, the government had largely adopted a passive posture to the burgeoning epidemic, failing to tackle the problem head-on in the early stages. The government's low-profile approach resulted in much of society being inadequately informed about this lethal affliction (Zheng 2004).

The media has also started to serve as a watchdog for the central government by reporting on provincial developments that are not in line with the central laws and policies. For example, a recent article debated the issue of mandatory testing. The article pointed out the discrepancy between the recent moves by several provinces to enforce HIV testing for certain high risk groups and the 2006 Regulations that prohibits mandatory testing before talking the opinions of experts and activists who were for and against the prevention measure (Shan 2007d). Likewise, there has been an increase in articles lauding the role of NGOs and deploring the actions of local

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governments that do not support their efforts to promote AIDS prevention (Shan 2007b; Wen 2007b; Xiong 2007). Again, this does not seem to have extended to Henan.

6.4 THE ROLE OF CIVIL SOCIETY

In the post-SARS period of AIDS governance, the norm of civil society and PWA involvement has become more salient in political discourse, however in practice civil society actors continue to have to negotiate their role vis-à-vis the state. The mobilization of civil society actors has increased as a result of the new policies and the new openness engendered by the political shift, despite limited opportunities for civil society involvement in decision-making. The state also continues to differentiate between organizations that it perceives as working with the state by providing service provision and promoting non-discrimination, and those that it perceives are working against the state by pursuing social justice and rights for PWA. However, in turn China’s increasing openness to international actors and the NGO-INGO ties that are emerging are serving to temper the state’s ability to repress activists. Therefore, despite the ongoing challenges, the space for civil society is widening.

Since the SARS crisis, there has been an increase in the mobilization of civil society actors operating in the area of AIDS governance (Human Rights Watch 2005; Wu 2005). For example, 62 of the 97 organizations listed in the China AIDS Info directory were established in the post-SARS period (China AIDS Info 2007). The majority of these organizations are GONGOs but, as mentioned in chapter three, even these organizations can be engines for new policy ideas. For example, many local CDCs have established AIDS Care Centres and AIDS Patient Associations, which often have PWA on staff (Wu 2005, p.222). There have been signs that registered independent voluntary organizations and unregistered NGOs are also on the increase (Global Fund Observer 2007; Wu 2005, p.222). These civil society organizations are playing an important role in advocacy and service provision.

This mobilization has been spurred in part because the central government has increasingly talked about the role of civil society in AIDS prevention and control. In 2004 on the eve of the 15th International AIDS Conference in Bangkok, the Premier

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called for ‘the participation of the whole society’ in the fight against AIDS (Wen Jiabao 2004). While this was not very explicit, Wang Longde went on to say at the conference that, ‘we must unite all forces of the entire society, especially from the non-governmental organizations (NGOs), if we want victory in containing AIDS...many NGOs have very rich experience and insight’ (quoted in Xu 2004). At the heart of the government’s growing acceptance of NGOs is the recognition that the success of the government’s new harm reduction programs relies on reaching high- risk groups, something that the government finds difficult given its commitment to crack down on drug use and prostitution. As Wang Longde said again in 2005 at the joint summit on business and AIDS:

We've understood deeply that in HIV/AIDS prevention there are certain things that the government is not able to do…People like drug addicts, sex workers and homosexuals are reluctant to talk to government workers. Therefore, we must encourage NGOs to participate in the work (Pottinger 2005).

The full use of NGO contributions and the removal of barriers that hinder their participation were listed in China’s 2005 progress report as key measures to achieve its UNGASS objectives (SCAWCO 2005). Likewise, China’s future priorities, as stated in a speech by Wang Longde to the UN High-Level Meeting on HIV/AIDS in June 2006, included giving ‘full play to the role of non-governmental organizations’ (People's Republic of China Mission to the United Nations 2006). At the XVI International AIDS Conference in Toronto in 2006, Zhang Weiqing, Minister of the National Population and Family Planning Commission, talked about the need for NGO involvement in condom distribution and health education (National Population and Family Planning Commission of China 2006). In line with the growing strength of the norm, in the most recent Joint Assessment, special attention was given to the government’s advocacy and support of civil society participation and, for the first time in any major official document since China signed the 1994 Paris Declaration, the principle of GIPA was mentioned. ‘By participating in project design, implementation and monitoring, the initiatives and commitment of community-based and PLHIV groups continue to be strengthened which reflects the GIPA principle’ (SCAWCO and UNTG 2007, p.15).

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To a certain extent, the rhetoric of the central government has been institutionalised in some of more important policy documents and legislation. In 2004, the State Council Notice stipulated a role for civil society in prevention and care.

Civil society and mass organizations such as the Labor Union, Youth League, and Women’s Federation etc., are required to actively conduct HIV prevention education… It is required [by local governments] to further support the role of civil society organizations such as the Red Cross, and provide care and support to people living with HIV/AIDS (State Council Notice 2004).

As mentioned above, there was also mention (albeit limited) in the 2006 Regulations of the need for ‘relevant organizations and individuals’ to carry out education and so on with high-risk groups. The Action Plan 2006-2010 calls for relevant departments to ‘actively encourage social associations, civil foundations and civil institutions, and individuals’ to help with AIDS prevention, treatment and care (State Council 2006). In the most recent Joint Assessment, it was recommended that the relevant laws and regulations (regarding registration for example) be revised to allow a better environment for civil society involvement (SCAWCO and UNTG 2007).

Along with the government’s acknowledgement of their essential role in AIDS governance, civil society actors have also been aided by the increased number of IOs and INGOs operating in China. Many international donors emphasise the importance of partnership with domestic civil society actors. For example, the Bill and Melinda Gates Foundation just recently launched a $50 million HIV/AIDS prevention campaign in China, of which $30 million will be used to provide grants to local, national and international NGOs (Bill and Melinda Gates Foundation 2007). Civil society partners are not only sought after in terms of implementing programs, but they are also consulted with in the design of the programs. These transnational links are important because while civil society has had an important role to play in programme implementation, its role in national policy-making remains limited. As Human Rights Watch notes, ‘the government still does not view NGOs as a resource from which it can draw expertise and insight into positive policies and laws to combat AIDS’ (2005, p.51).

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The Global Fund has also provided an important opportunity for the involvement and legitimation of unregistered grassroots organizations. For example, the Global Fund requires that China’s CCM include civil society participation. CCM representatives play a crucial role in determining priorities and preparing proposals for funding. While the NGO and PWA seats on the CCM were originally given to GONGOs, this trend was challenged in 2006 by a group of registered and unregistered grassroots organizations who argued that the way in which the CCM representatives were elected was not in keeping with the norms of the Global Fund. As a result of this challenge, while NGO representatives to the CCM must be legally registered, unregistered grassroots organizations are able to take part in electing the representative.130 Furthermore, China’s proposal to the Global Fund’s sixth round of grant applications was entitled ‘Mobilizing Civil Society to Scale Up HIV/AIDS Control Efforts in China’ and was designed to ‘strengthen capacity of NGOs and improve their ability in partnership with government agencies’ as well as to continue to reach vulnerable populations and fill the gaps in the national treatment and care program. To this end at least 70 per cent of the US$14 million was to be allocated to civil society activities (CCM 2006). More than 80 legally registered and unregistered NGOs, GONGOs and academic institutions were consulted in the drafting of the proposal and only one person on the 14-person writing team was from a government department, making the process one of the most consultative and participatory yet seen in China (Global Fund Observer 2007; Hsu 2007).131

130 The election process was criticised by Wan Yanhai and his NGO as being non-transparent, unequal and ‘full of double standards’ (Dickie 2006). At the crux of the affair was the issue of registration with Wan Yanhai and other organizations alleging that only legally registered organizations were included in the election process. A separate protest election was organized and a petition was circulated which called upon the Chinese government and the Global Fund to respect the principles of the Fund (Dickie 2006). The result was a review of the electoral proceedings relating to the elections of the NGO sector and the PWA sectors. The review was led by UNAIDS which in turned commissioned Bernard Rivers and Qiu Renzhong to undertake it. Rivers and Qiu (2006) found that the NGO election process was sufficiently ‘transparent, documented and developed within the sector’ for the election to be regarded as valid. This said, they did note that there was a low number of participating organizations and gave a number of reasons for this including weaknesses in one clause in the CCM’s terms of reference, which led to organizations being incorrectly informed that only registered organizations could participate in the vote. The review stated that although only legally registered NGOs can be elected as CCM members, organizations do not have to be registered to take part in the sector group and vote (Rivers and Qiu 2006). 131 Unfortunately, the excitement generated by this development has been shortlived with the implementation of this grant thus far not having gone as planned. The Global Fund Observer (2007) has reported that in the bid to get the grant money, the organizations that the grant was supposed to help mobilize have been sidelined in favour of GONGOs with strong ties with the government.

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While the space for civil society is expanding, the Chinese government still controls the space. The Chinese government continues to vet civil society activity and control organizations through its registration process132 and still favours those organizations that complement the state agenda rather than those that are critical of the state. As already discussed in chapter three, Chinese government has a more corporatist notion of civil society. NGOs should complement and supplement the state, not challenge or ‘check and balance’ the state. Joel Rehnstrom of UNAIDS has noted that most of the time activists get into trouble when they assert patients' rights, seek compensation or highlight inadequacies in the government's response (Oleson 2006). This is because the Chinese government sees these actions as socially destabilizing and therefore threatening. Therefore, the repression of AIDS activists is not explained solely in terms of political interests (as, say, in Henan province) but also in terms of the Chinese government’s broader understanding of the relationship between the state and civil society actors. Human Rights Watch (2005, p.52) notes that, ‘the government’s lingering suspicion about the role of non-governmental groups seems to trump the public health imperative of working with civil society’. In a report on AIDS activism in China, Human Rights Watch (2005, p.2) highlighted three areas of human rights concerns other than the issue of registration, including: the censorship of websites that provide AIDS information to MSM; the harassment of activists working with IDUs and CSW; and, most particularly, the detention and harassment by local authorities in Henan province of AIDS activists that help orphans, speak to the media, or demand access to ARD.

Therefore, once again, Henan has been the battleground where activists have tested the limits of official tolerance as legal redress is sought for the FPDs. For example, in June 2003, five HIV-positive residents of Xiongqiao went to Zhengzhou city to present a petition to the provincial government about the poor standard of health

132 In a promising development, in May 2007 Xinhua News Agency reported the completion of research by the Sichuan provincial government’s Legislative Affairs Office into NGOs and their role in AIDS prevention. The research report concluded that the current registration requirements and the limitations on donating hindered NGO effectiveness. Liu Xiao of the Legislative Affairs Office said that two major improvements could be made, relating to NGOs. First, national lawmakers could set up new NGO laws to clarify their legal status, duties and legitimate rights. Secondly, the government should improve feedback mechanisms for suggestions from the NGOs with regards to HIV/AIDS policy, along with creating a simpler administrative process for registration. The article finished by stating that the Sichuan provincial government was drafting new regulations to deal with the issue (Wen 2007a).

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services in their village. Several days later, Xiongqiao was raided by hundreds of police and ‘thugs’ who smashed windows, beat up residents and arrested 13 farmers, including PWA (Human Rights Watch 2003a; Sui 2003). In July 2004, two PWA were detained in order to stop them from travelling to Beijing to petition the national health department on why they had not yet received the treatment to which they were entitled. Two other farmers were arrested for leading other villagers in breaking into a hospital and taking equipment in protest after a local court refused to investigate the source of their infection (Ang 2004a). Hu Jia, an outspoken critic of the Chinese government and its response to HIV/AIDS in Henan, was held for a week in 2004, for 126 days in 2005 and for 41 days in 2006 (Reuters News 2006a). In November 2006, several days prior to a 6-day conference on ‘Blood safety, AIDS and legal human rights’ of which Wan Yanhai was the chief organizer, Wan was detained by men claiming to be from the Beijing Public Security Bureau. While he was only detained for three days, Wan was forced to cancel the conference (Agence France-Presse 2004a; Agence France-Presse 2006a; Fan 2006a). Finally, in February 2007, Dr Gao Yaojie was placed under house arrest after she applied for a visa in order to attend the Vital Voices Global Partnership awards ceremony in the US (Dow Jones International News 2007).

While the government continues to repress AIDS activists, nevertheless its recognition and acceptance of global AIDS norms at both the domestic and international levels has provided ammunition for external observers. For example, after the crackdown on Xiongqiao Village in 2003, Human Rights Watch called on China’s State Council to investigate the matter and one representative said,

The deepening cover-up in Henan province stands in stark contrast to Beijing's calls for international cooperation and its pledges of openness about public health (Human Rights Watch 2003a).

In this way, external observers are able to remind the Chinese government of its rhetoric and hold it accountable. Furthermore, the eyes of the world are well and truly on Henan province and every time that an activist goes missing it is quickly reported in the international news. Groups like Amnesty International, Human Rights Watch and ACT UP waste no time in registering their protest (ACT UP 2006; Agence

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France-Presse 2003a; Amnesty International Asia Pacific 2004; Harmsen 2003; Toy 2006), as do representatives of UN agencies and bilateral donors (Barrett 2007; Dow Jones International News 2006; Reuters News 2006a; Reuters News 2007b).

This too is changing aspects of China’s response to AIDS activists. China’s treatment of these activists is tempered. For example, in Wen Yanhai’s case, he was only kept for three days as opposed to a month in 2002 (Agence France-Presse 2006a). Gao Yaojie was not only released from house arrest relatively quickly but she was even granted permission to travel to the US. This had not happened in the past. Despite international protest in 2001 when she was refused a passport to travel to the US to accept the Jonathan Mann Award and in 2003 when Gao was prevented from travelling to the Philippines to receive the Ramon Magsaysay Award for Public Service, the authorities were not moved. However, in 2007 despite the loss of face, the government let her go. This fact did not escape Gao who stated in an interview several days after her release, ‘I think it's a sign of the progress our society has made…Ten years ago this could not have happened’ (Oleson 2007). Activists may be empowered to continue their claims on the state if it is clear that the powers of the state to respond are being tempered by the international censure.

6.5 INTERNATIONAL ENGAGEMENT

It has previously been demonstrated that one major consequence of the SARS crisis was the tarnishing of China’s international reputation as a responsible power. Since the SARS crisis, we can say that China’s international compliance has deepened and it has started to cooperate with the global AIDS regime. While its level of representation at international meetings has not improved, China has been more politically proactive at the global and regional levels in terms of proposing health cooperation. Furthermore, it has matched its rhetoric with domestic behaviour and it has also become more open to international actors, actively seeking assistance in order to achieve its UNGASS objectives and fulfil its international monitoring and evaluation obligations. Therefore, while China still has its critics, the general response has been cautiously optimistic and frequently commendatory.

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The HIV/AIDS High-Level Meeting of the UN General Assembly held in September 2003 was the first review of the 2001 Declaration of Commitment and the first high profile meeting relating to HIV/AIDS since the SARS crisis. While China only sent Gao Qiang, the Executive Vice Minister of Health, the speech that he gave was novel in several ways. First of all, in addition to the mandatory reference to ‘the Chinese government’, Gao Qiang specifically mentioned both Hu Jintao and Wen Jiabao and their concern about HIV/AIDS. This was the first time in an international forum that a Chinese top leader had been mentioned by name in relation to HIV/AIDS. Second, along with stating the ‘comprehensive measures’ being undertaken by the Chinese government to prevent HIV/AIDS, Gao Qiang admitted that ‘in some areas, HIV/AIDS prevention and treatment had not been adequately attended and funded’ and that therefore, ‘HIV/AIDS has not been effectively controlled’. He then admitted that China had about 840,000 HIV/AIDS infections (People's Republic of China Mission to the United Nations 2003). This is possibly as close to a mea culpa as the Chinese government gets and represented a different tone of rhetoric than that of Zhang Wenkang who represented China at UNGASS two years earlier.

Finally, Gao Qiang outlined what has since been referred to by UNAIDS as the ‘five commitments’ (UNAIDS 2006b). First of all, government responsibility would be strengthened and accountability increased. Second, Gao stated that the government was committed to providing free treatment for PWA with financial difficulties. Third, Gao promised that the Chinese government would improve the laws and regulations and intensify behavioural interventions. The fourth commitment was to protect the ‘legitimate rights of HIV/AIDS patients’ by opposing social discrimination and providing care and economic aid to PWA. And fifth and finally, the Chinese government promised to be more active in international cooperation, welcoming financial and technical support, and ready to be active in the global fight against HIV/AIDS and ‘fulfil its responsibilities and obligations’ (People's Republic of China Mission to the United Nations 2003). Once again, with the exception of multisectoral cooperation and the involvement of PWA, the ‘five commitments’ reflect the key norms of the global AIDS regime and is a strong example of the Chinese government espousing regime rhetoric. However, while in the past the Chinese government has often agreed to norms in rhetoric at the international level while doing otherwise at

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the domestic level, as mentioned above, in the post-SARS period this rhetoric has been supplemented by action.

Along with its domestic commitments, China’s international behaviour is also supporting its rhetoric. For example, China has not just supported but has also introduced proposals for international health cooperation, reflecting a more proactive approach than that taken in the pre-SARS period. For example, in October 2003, Wang Guangya, the Permanent Representative of China to the UN, presented a draft resolution called ‘Enhancing Capacity Building in Global Public Health’. Wang explained that the resolution had been drafted in view of the sixth MDG and noted that:

…Only by enhancing the capacity of the international community to combat HIV/AIDS, malaria and other infectious diseases and boosting national capacity building in public health can there be a solid basis for development and prosperity in all countries (UNGA 2003).

The resulting General Assembly resolution A/RES/58/3 ironically urged member states to further integrate public health into their national economic and social development strategies, and to increase investment in improving country health systems.

China’s attempt to become more proactive in this policy field has been particularly noticeable at the regional level. For example, in April 2004, the first ASEAN + 3 Health Ministers Meeting took place in Malaysia. The Co-Chairs’ statement noted that China had expressed interest in developing proposals for activities on communicable diseases (HIV/AIDS, disease surveillance), traditional medicine/complementary and alternative medicine and capacity building (ASEAN 2004). A week later, the United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP) met in Shanghai to discuss multilateralism, regional cooperation and ‘emerging social issues’. The resulting resolution, the ‘Shanghai Declaration’, amongst other things, called for the coordination of a:

More effective and comprehensive response to HIV/AIDS…in the region by

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prioritizing effective strategies against them in national development planning, committing sufficient resources, mobilizing the private sector and civil society, enhancing sustained and comprehensive intervention and strengthening regional cooperation in establishing preventive measures and increasing the availability of affordable quality drugs (UNESCAP 60/1).

The session also adopted a China-initiated call for action to enhance regional capacity building in health (UNESCAP 61/12; Shao and Yong 2004). Later that same year, China, joined by Thailand and the Philippines, put HIV/AIDS on the agenda of the 2004 APEC Ministerial Meeting in Santiago, Chile, with a proposal called ‘Fighting Against AIDS in APEC’ in which AIDS is articulated as being a ‘threat to the global economy and society as a whole’ (APEC 2004b). The initiative was endorsed at the subsequent Economic Leaders’ Meeting in the ‘Santiago Declaration’: ‘We pledge our collective political commitment to combat the further spread of the AIDS pandemic’ (APEC 2004a). In 2006 China hosted the APEC Symposium on Emerging Infectious Diseases (APEC 2006).133

The Chinese government has also been more open to international presence in China in order to improve its response to HIV/AIDS. At the 2004 International AIDS Conference in Bangkok, Wang Longde made a surprising plea for assistance.

At present China is still facing challenges and difficulties in the fight against AIDS…We would like to strengthen our collaboration and cooperation with all countries and international organizations, and we welcome assistance and support from multilateral as well as bilateral organizations (Dow Jones International News 2004a).

The international community obliged. Major bilateral and multilateral donors (see Table 6.1) have contributed to the training of officials and other capacity building programs, prevention and treatment programs, and research projects. For example, the CHARTS program has worked to strengthen leadership and coordination of HIV responses at the national level, to increase capacity at the provincial level and below, and to mobilize resources and information exchange (AusAID 2007). UNAIDS and

133 While HIV/AIDS has been on the agenda in many of these forums, it is interesting that it has not made it on to the agenda of the Shanghai Cooperation Organization, the China-led multilateral organization that includes China, Russia, Kazakhstan, Kyrgyzstan, Tajikstan and Uzbekistan, despite some cooperation on health.

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its co-sponsors have been instrumental in providing technical and policy advice and assistance with program implementation (see UNAIDS 2007b).

TABLE 6.2 TOP FIVE SOURCES OF INTERNATIONAL ASSISTANCE Main donors Timeframe Funding Main projects ($US/mil) Global Fund to 2003-2008 $179 See Table 6.3 below Fight AIDS, Tuberculosis and Malaria UK134 2000-2006 $58 HIV/AIDS Prevention and Care Project 2006-2010 $68 (via the (Yunnan and Sichuan) Global China AIDS Roadmap Tactical Support Fund) (CHARTS) Bill and Melinda 2007-2011 $50 Research, treatment and prevention Gates Foundation135

US136 2002-2008 $35 Comprehensive International Program of Research on AIDS President’s Emergency Plan Australia137 2002-2009 $33 Xinjiang HIV/AIDS Prevention and Care Project Tibet Health Sector Support Program CHARTS

The SCAWC has worked with UNAIDS and the UNTG to improve monitoring and surveillance and produce joint responses and UNGASS updates (Chinese MOH and UNTG 2003; MOH PRC, UNAIDS and WHO 2006; SCAWCO 2005; SCAWCO and UNTG 2004; SCAWCO and UNTG 2007). In some cases, UN technical advice has been adopted without local consultation – such is the perceived importance of

134 DFID (2006). 135 Bill and Melinda Gates Foundation (2007). 136 US assistance to China is based on a Memorandum of Understanding on cooperation in the field of HIV/AIDS, first signed in 2002 and renewed in 2007 (US DHHS 2007; Xinhua News Agency 2005d). 137 Information on Australia’s assistance to China can be found on the AusAIDS website at http://www.ausaid.gov.au/country/country.cfm?CountryID=36&Region=EastAsia.

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international cooperation (Zhang, Yu and Fang 2005).138

As suggested above, the Chinese government has also been more open to an increased INGO presence in the post-SARS period. Some of the INGOs already working in China found that they were more positively received and were able to expand their programs. For example, as one Ford Foundation program officer notes, ‘China is so much more open than before – there’s a great opportunity post-SARS to do something…many local governments welcome foreign aid to help them deal with [the] HIV/AIDS epidemic’ (Funders Concerned About AIDS 2005). This new openness has also attracted new INGOs with significant funds such as the Clinton Foundation and the Bill and Melinda Gates Foundation.

In addition to being open to intergovernmental and international nongovernmental organizations, China also proactively courted the GBC and individual multinational corporations in order to better involve the private sector in the fight against HIV/AIDS. Pre-2003, AIDS was not being discussed by the Chinese private sector. Since 2003 however the Chinese government has been more interested in cooperating with global efforts to engage the private sector. In late November 2003, the Chinese government, along with Harvard University, the WEF and UNAIDS, hosted the first meeting of business, government and civil society to discuss the role of partnerships to combat HIV/AIDS in China. It was at this meeting that Peter Piot argued that the lack of strong statements from high-level leaders had made it easy for business leaders (and local officials) to ignore the issue. AIDS had not been on ‘the radar screens of Chinese firms’ because they were ‘waiting for the government to send a strong signal’ (quoted in York 2003). The strong signal was sent when in July 2004 the Vice Minister, Wang Longde, invited the GBC to help with China’s national AIDS response. The outcome was the formation of the China Business and AIDS working group. This was followed in March 2005 by a Joint Summit on Business and HIV/AIDS in Beijing, hosted by the GBC and the MOH. The Summit drew together 450 senior representatives from Chinese and foreign governments, multinational corporations and the media in order to discuss ways in which the private sector can

138 Zhang, Yu and Fang (2005) quite rightly see this lack of grassroots consultation as being problematic however to my mind, it demonstrates an eagerness by the Chinese government to be seen as compliant by the international community.

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partner the government to advance China’s national HIV/AIDS strategy for prevention and control (Canadian NewsWire 2005). During the summit Madame Wu Yi urged domestic and international businesses to help their employees get tested and treated (Kahn 2005).

Therefore, the encouragement from such a high-level official was seen by those in the GBC as an important mobilizing tool. Indeed, only two months after the summit, the GBC announced that 26 Chinese and multinational corporations had made definite commitments to fight HIV/AIDS in the workplace and in the wider community, including an agreement between Merck Sharp Dome and the Ministry of Health worth $30 million (Canadian NewsWire 2005). The Chinese government also gave the GBC permission to set up an office in Beijing, which was opened in November 2005 (BBC Monitoring Asia Pacific 2005). While the GBC works in China with the government’s permission but mainly works with businesses alone, the China Health Alliance, developed by the GHI and launched in December 2006, claims to be the first private- public partnership for public health. It involves the Chinese government, select companies, select international organizations and NGOs and is designed to educate, test, treat and support Chinese company employees, especially migrant workers at risk of tuberculosis and HIV/AIDS. The Alliance’s first project is targeting five million migrant workers in Guangdong Province and will eventually expand into more provinces (Liu 2006).

While China clearly benefits from these transnational ties in that China receives material assistance to help the government in its fight against HIV/AIDS, as already discussed China has not been unaffected by the increased interaction with the global AIDS regime. A responsible member of the AIDS regime must be prepared to shoulder the costs that accompany the benefits. In the case of China, the costs of cooperation have included having to change certain behaviours and procedures in order to act in accordance with international expectations for appropriate AIDS governance. In other words, China, in exchange for the assistance, is expected to be working towards achieving its UNGASS objectives and therefore must prove that its institutions and policies incorporate PWA rights, civil society involvement, evidence- based prevention and treatment based on best practices and so on. We have already seen how China’s domestic governance is suggestive of the greater internalisation of

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global AIDS norms. The post-SARS transnational linkages are serving to continue and reinforce this internalisation of norms.

China’s relationship with the Global Fund is a good example of this normative ‘conveyor belt’. The Global Fund is China’s most important and largest source of external assistance. China has so far obtained grants from Rounds 3, 4, 5 and 6 of the Global Fund. The grants have helped finance a variety of programs including: the treatment and care of former plasma donors in Henan and six other provinces; the scaling-up of harm reduction, treatment and support programs amongst poor and vulnerable populations in seven provinces, including Yunnan and Xinjiang; the prevention of HIV/AIDS in seven provinces that currently have low prevalence but are considered to be at high risk; and, the promotion of civil society involvement (China CCM 2004, 2005, 2006a, 2006b). The total amount of assistance thus far granted is $176 million (see Table 6.3 for more details on grant agreements and actual disbursements).

However, China had an inauspicious start in its relationship with the Global Fund. The core founding principles of the Global Fund are human rights, the greater involvement of PWA and civil society, and transparency of information – principles that the Chinese government has not always found it easy to comply with. China’s first two applications to the Global Fund were rejected. One ground for rejection was alleged to have been ‘China’s penchant for secrecy and its largely unreliable statistics’ (The New York Times 2002). For example, Chen notes that one of the first proposals did not name the specific provinces that would receive funding (2003, p.54). The Global Fund also found that the composition of China’s Country Coordinating Mechanism, the body in charge of grant proposals and the overseeing of project implementation, was not sufficiently broad, involving little NGO participation (Young and Qian 2006). The then head of UNAIDS in China, Michel Sidibe, said, ‘The Country Coordinating Mechanism should not just be an artificial thing, put in place in order to access the Fund…it should be a permanent sustainable coordinating model’ (quoted in Chen 2003, p.54).

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139 TABLE 6.3: CHINA’S HIV/AIDS GLOBAL FUND PORTFOLIO Round Title Principal Recipient Total Funding Request Approved Maximum Disbursed (as of January 2008) 3 China CARES (China The Chinese Centre $97,888,170.00 Comprehensive AIDS RESponse) for Disease Control - A Community-Based HIV and Prevention $97,888,170.00 Treatment, Care and Prevention Program in Central China $58,869,018.00

4 Reducing HIV transmission The Chinese Centre $63,742,277.00 among and from vulnerable for Disease Control groups and alleviating its impact and Prevention $63,742,277.00 in seven provinces in China $23,936,918.00 5 Preventing a New Wave of HIV The Chinese Centre $28,902,074.00 Infections in China for Disease Control and Prevention $12,544,128.00

$11,080,295.00

6 Mobilizing Civil Society to Scale The Chinese Centre $14,395,715.00 Up HIV/AIDS Control Efforts in for Disease Control China and Prevention $5,812,875.00

$1,791,961.00

As mentioned in section 6.4 above, the Global Fund has thus helped to change state- society relations and forced the Chinese government to include some element of civil society in AIDS decision-making. There is also evidence to suggest that China’s second proposal failed in part because of China’s repression of AIDS activist Wan Yanhai. The Global Fund was able to use China’s pending application as leverage to obtain Wan’s release. The Chinese health officials were allegedly warned that the funding would not be approved if Wan remained in detention and shortly afterwards Wan was let go. An insider was quoted as saying, ‘They really want – they really need – the money from the Global Fund…there was just too much at risk’ (quoted in Rosenthal 2002b). In the end, however, Wan’s detention and ongoing issues with the CCM, led to the rejection of the Round 2 application (Chen 2003, p.54). Therefore in order to be granted funding, China has had to become more transparent, the CCM has

139 See the Global Fund to Fight AIDS (2008a).

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come to include representatives of government ministries, international donors and NGOs, and proposals have had to be in line with global norms.

In turn, China’s shift in both international rhetoric and behaviour, backed up by the changes in its domestic governance of AIDS, has been (for the most part) positively received by the international community. With regards to the visible efforts of the Chinese leaders for example, Peter Piot has said:

The leadership in China is completely changing now in terms of how it deals with AIDS…at the central level, now I feel very comfortable that they want to take it on. A thousand treatment centres are being established…These things a few years ago would have been unthinkable. So there’s progress (Peter Piot interviewed by Public Broadcasting Service 2006).

Likewise, Trevor Neilson, the executive director of the GBC, commended Vice Premier and Minister of Health Wu Yi, Vice Minister Wang Longde and the entire Chinese government for having made AIDS a top priority. ‘Their leadership is extraordinary’ (quoted in PR Newswire 2004).

There is optimism with regards to the legislative and policy developments since SARS. Joel Rehnstrom, the head of UNAIDS in China, said of the introduction of the 2006 Regulations that the move was ‘encouraging’ and that with regards to a response to AIDS, ‘a good policy and regulatory environment is very important… and we're seeing the pieces falling into place’ (quoted in Oon 2006). Another HIV/AIDS Technical Officer with the China WHO office said:

Five years ago I would have said that China is 10 years behind other countries and not taking full advantage of lessons learned in other parts of the world; now I would have to say China is becoming one of the leaders in the global HIV response. Over the coming years, the world will probably learn a lot from the various programmes that China is now launching to combat its HIV epidemic (Katharine Poundstone, quoted in Parry 2006).

And an article in Lancet described China’s move towards evidence-based policies as a ‘vigorous response’ after ‘a slow start’ and has suggested that China’s experience

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‘could be informative to other countries’ (Wu et al. 2007, p.688). In general, there is satisfaction with regards to China’s transparency and AIDS surveillance with Peter Ghys, the manager of epidemic and impact monitoring at UNAIDS, stating that ‘not only is more data available but the analysis of that data has also improved and has allowed us to come to an estimate that we are quite comfortable with’ (Agence France-Presse 2006b).

This is not to say that China does not still have its critics. Human rights groups and AIDS activists continue to lambast the Chinese government for its alleged mistreatment of PWA, high risk groups and activists and its inability to hold the Henan government accountable for the blood scandal. These same groups also criticise UNAIDS and the Global Fund for tacitly supporting these violations of global AIDS norms by the Chinese government (Human Rights Watch 2007). Overall however, INGOs, IGOs and bilateral partners have praised the government’s recent achievements and, while recognizing the considerable challenges that remain, are cautiously optimistic about the future (Funders Concerned About AIDS 2005; UNAIDS 2007b, p.2).

6.6 CONCLUSION

In summary, we can conclude that China’s governance of AIDS in the post-SARS period reflects a modest engagement with the global AIDS regime. It is modest in that there remain sizeable issues to overcome, particularly in light of local level compliance, PWA rights and the role of civil society. However, via the employment of the five indicators of political commitment, legislation and policy, HIV in the media, the role of civil society and international engagement I have demonstrated that global AIDS norms have gained salience in China and are increasingly having an impact on the Chinese government’s domestic and international behaviour.

In the post-SARS period, the most dramatic difference has been seen in relation to the Chinese government’s commitment to the prevention and control of HIV/AIDS. The top leaders moved from a position of invisibility and indifference to visible AIDS advocacy. The national AIDS committee went from being defunct and forgotten to

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being headed by a Politburo member with the will to mobilize a multisectoral response and increase fiscal resources to levels that dwarfed previous AIDS budgets. This change in commitment had important flow-on effects in terms of the regulatory and policy environment with laws and policies in the post-SARS period becoming more inclusive and empowering. There is now a greater legal basis from which PWA can pursue rights claims, greater transparency and accountability, and there is greater access to prevention, treatment and care. Although there continue to be major challenges with regards to bureaucratic fragmentation, legal ambiguity and local non- compliance, these issues have been acknowledged and are beginning to be addressed.

I have argued that there has also been an increase in media attention to HIV/AIDS in the post-SARS period, as evidenced by the higher incidence of AIDS-related articles. However, the media has struggled to find a balance between fully embracing the norms of the global AIDS regime and the moral agenda of the government. While more and more articles use educative and inclusive language, there continues to be a tendency to alarm and to condemn certain behaviours that lie outside the state’s official discourse on sex. In saying this, PWA have become increasingly visible, and although Henan province and certain AIDS activists remain off-limits, there has also emerged increased debate relating to contradictory laws and policies, the role of civil society and local compliance with central policies. While there have not been dramatic changes with regards to the role of civil society, I have argued that the space for civil society has widened as the norm of civil society involvement has been internalised in both policy and legislation and in political discourse. While the state continues to control the space through institutional means and repressive tactics, the increased access that the state has given to international actors and the transnational ties between INGO/IO-NGOs that have emerged have in turn impacted upon the dynamics between the state and civil society actors.

Finally, I have demonstrated that China has started to engage more fully with the global AIDS regime. China has increasingly complied with the global AIDS regime by meeting its reporting obligations and by changing its domestic behaviour in line with global expectations. While the level of China’s representation at international meetings has not improved, the Chinese government has begun to proactively engage with the regime by actively promoting global and regional health cooperation,

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requesting international financial and technical assistance and accepting the costs of this assistance in terms of increased exposure to international monitoring and criticism. In turn, the international response to China’s post-SARS governance of AIDS has generally been positive.

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CHAPTER 7 - CONCLUSION

This thesis has adopted a constructivist approach to examine the development of China’s governance of AIDS in the context of the global AIDS regime. It has particularly focused on the international/domestic problematic and has assessed the actors, structural factors and uncertainty that have conditioned the extent to which global AIDS norms have had an impact upon China’s governance of AIDS. While this thesis has provided insights into more general literature on the local effects of global norms, it has also shed light on the question of China’s susceptibility/resistance to socialization.

This thesis began with three main aims. Firstly, this thesis sought to provide an analytical history of AIDS governance in China. Secondly, the thesis aimed to engage with constructivist scholarship by: a) demonstrating that a global AIDS regime exists, documenting its emergence and consolidation and interrogating its features and dynamics; and, b) identifying the main obstacles/mechanisms that either hinder or help the transfer of the norms of the global AIDS regime to China. The third aim of the thesis, which is related to the second, was to illustrate and emphasize the particular importance of crisis as a normative catalyst in the specific case of China and the global AIDS regime. This conclusion will address the main findings of the thesis in relation to these aims.

Analytical history of AIDS governance

My research has mapped out in extensive detail the way in which China’s governance of AIDS has evolved in the twenty-two years since the first case was diagnosed in China. As stated in chapter one, this is not the first history of the Chinese government’s response to HIV/AIDS. Nevertheless, while my thesis has drawn on similar sources of information as previous studies, this analytical history is different from other accounts in that it is informed by International Relations scholarship rather than public health or social theory. Employing a constructivist approach led me to ask different questions, to use novel analytical methods and to subsequently produce a different interpretation for sometimes-similar findings. In examining the Chinese governance of HIV/AIDS from 1985 to 2007 I developed a set of five indicators:

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political commitment, policy and legislation, HIV in the media, the role of civil society and international engagement. These indicators were the analytical tools that I used to both chronologically compare China’s AIDS governance and measure China’s internalisation of global AIDS norms. The thesis has demonstrated that China’s governance of AIDS has been divided into three main periods.

Not unlike other accounts,140 I have described the early period of AIDS governance, from 1985 when the first case of AIDS was diagnosed to 1993, as China’s period of denial. During this period, China’s domestic response to AIDS was exclusionary and discriminatory and often shaped by the government’s sexual conservatism. As reflected in ministerial statements and the media, the Chinese government talked about AIDS as a problem that lay outside of ‘normal’ Chinese society. The disease was only a danger to foreigners (and those who had improper relations with foreigners) and deviants (anyone having sexual relations outside the heterosexual marital unit and intravenous drug users). By extension PWA were deviant. As such, while a national AIDS program was drawn up and a national AIDS committee established, the central government gave little time or resources to AIDS prevention other than to produce laws and policies to either prevent AIDS from entering the country, via the banning of blood imports and visa restrictions, or keep PWA and high-risk groups out of society, via mandatory testing, restrictions on schooling and employment and the prohibition of drug use and prostitution. At the international level, China was party to the fledgling global response to HIV/AIDS (and the subsequent emerging norms) but often denied outright that China had the types of problems that could lead to AIDS vulnerability.

The second period of AIDS governance, from 1994 to 2002, I have described as the period of limited recognition. During this period China increased its engagement with the global AIDS regime, enhancing both its rhetoric in international forums and allowing a greater transnational presence within China itself. Increased consultation with UNAIDS led to several new AIDS policy statements that promoted policies in line with best practices and the protection of the rights of PWA was included in regulations produced by the Ministry of Health. However, while AIDS was

140 See, for example, Wu (2005) and Wang (2007).

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increasingly addressed by the Ministry of Health, national leadership was missing. The top leaders remained silent, the MOH held little political influence with the lower level governments. AIDS policies were undermined by the lack of resources and contradictory legislation. There was limited coordination between sectors and the space for civil society was restricted to service provision. The lower levels of government, due to the lack of visible top-level leadership, still understood AIDS as something to be hidden or ignored and this had severe outcomes in central China. The international attention brought to the man-made AIDS epidemic in Henan province in 2000 and the repression of AIDS activists, followed by the report on China’s response to HIV/AIDS in 2001 by the UN Theme Group on HIV/AIDS, amounted to international opprobrium being heaped on the Chinese government for: being indifferent to the rights of PWA; not providing adequate access to prevention, treatment and care; having deficient monitoring and evaluation systems; lacking national leadership and political commitment; having an uncoordinated national AIDS program; suppressing civil society involvement; and, not acting in accordance with the international agreements that China was party to. In other words, China was held to normative account by the global AIDS regime.

I have described the post-SARS period of AIDS governance (from 2003 to 2007) as a period of modest engagement and have argued that it is possible to demonstrate a normative shift in line with the global AIDS regime that occurred following the SARS crisis. This shift has been most noticeable with regards to the indicators of political commitment, policy and legislation and international engagement. In the period of modest engagement we have not only seen the top leaders visibly involved in AIDS advocacy and supporting the national AIDS program, new political energies have helped relaunch the national AIDS committee with comparatively more influence than previously and led to the dramatic increase in the central government’s financial contributions. New legislative and policy developments have reflected this new political commitment, including: the provision of new, and scaling up of existing, prevention, treatment and care programs; and the institutionalisation of multisectoral coordination, local official accountability and transparency, and the rights (and duties) of PWA. China has also enhanced its compliance and cooperation with the global AIDS regime by specifically articulating and justifying its behaviour in line with the global AIDS regime, by strengthening surveillance and monitoring and evaluation

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systems in order to meet international reporting standards, by requesting financial and technical assistance and by accepting the costs of this assistance.

This is not to say that there are not continuing problems. While there has been a noticeable increase in AIDS reportage and more inclusion of PWA voices, the media continues to struggle to find the right tone when talking about AIDS (i.e. how to talk about AIDS prevention activities without sacrificing the moral agenda of the Chinese government). The issue of bureaucratic fragmentation, both between different sectors and between central and local governments, continues to impact upon coordination and implementation of AIDS programs and the subsequent universal uptake of norms. Furthermore, the norm of civil society/PWA involvement continues to lack salience in a regime where AIDS activists are seen as a source of social instability. While these issues and what they tell us about the transmission of norms in China will be reflected on below, this thesis has demonstrated that China’s AIDS governance in the post- SARS period reflects the internalisation of global AIDS norms.

A constructivist approach to the global AIDS regime

This thesis has also demonstrated that a global AIDS regime exists that helps to regulate how international actors think about and govern HIV/AIDS. I have shown that due to the relative lack of enforcement and implementation procedures, the global regime is primarily a declaratory regime. The global AIDS regime’s value therefore lies in its norms which I identified as including: human rights-embedded programs and non-discrimination; universal access to prevention, treatment and care; evidence- based AIDS programs that are monitored and evaluated; national leadership; multisectoral coordination; civil society and PWA involvement in decision-making; and, transparent and constructive engagement with the global community. These norms are institutionalised in a body of quasi-legislation or soft law, such as the 2001 Declaration of Commitment on HIV/AIDS and the 2006 Political Declaration on AIDS. The norms are also embedded within the governance structures and operating principles of international organizations, such as UNAIDS, public-private partnerships, such as the Global Fund and the Global Health Initiative, and particular bilateral and multilateral aid projects, such as the CHARTS project in China (see chapter two).

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Drawing on Finnemore and Sikkink’s theory of the norm life-cycle, this thesis traced the evolution of the global AIDS norms and identified three main periods. In the pre- regime period, from 1981 when the disease was first identified to 1986, a global response was slow to eventuate with individual states responding to AIDS with often- discriminatory public health measures. The first instances of international cooperation took place between scientific exchanges. However, I have shown that in the period of regime emergence, from 1987 to 1995, the normative underpinnings of the developing global response was shaped by the agency of norm entrepreneurs, such as the American PWA movement, which challenged the logic of appropriateness at the grassroots level and then promoted this activism transnationally; and, Dr Jonathan Mann, who from his platform of the GPA, was able to impart his experience and beliefs around the world and influence global AIDS policy. In particular, the creation of the GPA was an example of the new organizational energies that existed in the emergence period, which also included the first intergovernmental summits on AIDS in London and in Paris. The norms were increasingly institutionalised both at the global level, in a variety of resolutions, declarations and guidelines, and at the national level via the creation of national AIDS programs based on the Global AIDS Policy promoted by the GPA.

I demonstrated that the global AIDS regime has undergone a period of consolidation from 1996 to 2007. The widening and deepening of the regime was illustrated through three examples. Firstly, I employed the case of TAC to show how agency continues to play an important role. Individuals/organizations/groups that were previously invisible or marginalized are empowered by the global AIDS regime in their struggles. As activists gain victories in support of the global AIDS norms (as in the case of TAC versus the South African government, for example), the norms are strengthened. Furthermore, the increase of activism in new areas of the world has represented a geographical expansion of the AIDS norms. Secondly, the expansion of the regime can be seen in issue-linkage, such as the linking of AIDS to development and to security, and the subsequent generation of new organizational commitments, such as the creation of UNAIDS, the Global Fund and a multitude of global frameworks such as the Declaration of Commitment on AIDS. Thirdly and finally, we have witnessed the expansion of the regime to encompass new actors such as the

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private sector. The more these new actors start to change their rhetoric and behaviour to reflect the norms prescribed by the global AIDS regime, the more they reinforce the logic of appropriateness.

Transmission and internalisation of norms

While this thesis has aimed to document the history of China’s governance of HIV/AIDS and the evolution of the global AIDS regime, the primary concern of the thesis has been to evaluate the specific influence of the global AIDS regime on China’s governance of HIV/AIDS. Drawing on applied constructivist concepts, I looked at three factors – norm entrepreneurs, domestic political context and crisis - that have conditioned the transmission and internalisation of the global AIDS norms in China.

I provided evidence that transnational norm entrepreneurs, including IGOs, INGOs and bilateral partners and public-private partnerships (such as the Global Fund) have played an important role in transmitting the global AIDS norms to the Chinese government. They have done so in various ways according to their mode d’emploi. IGOs such as the GPA and UNAIDS, having more access to central decision-makers than other entrepreneurs, have provided guidelines and policy advice that has contributed to the design of the Chinese national AIDS program. Bilateral partners and the Global Fund have been normatively influential in their linkage of global AIDS norms to financial and technical assistance. INGOs have been able to both strategically target government and grassroots civil society. Indeed, the activities of transnational norm entrepreneurs have been particularly influential in widening the space for domestic norm entrepreneurs by legitimising their existence and involvement in AIDS governance in China and by publicizing repression of these actors by the state. Furthermore, through the socializing processes of praise/opprobrium and by persistently reminding the Chinese government of its promises or commitments vis-à-vis the global AIDS regime, norm entrepreneurs have tried to hold the Chinese government to normative account.

However, I established that the degree to which norm entrepreneurs have been successful in transferring the global AIDS norms to the Chinese government has been

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in large part dependent on the domestic political context. In this thesis I articulated three main elements of the domestic political context. First, the domestic political structure has affected the impact of the norm entrepreneurs and the universal internalisation of incoming norms. I demonstrated that China’s domestic political structure is best characterised as a negotiated authoritarian regime. Three key features of the regime have at times impacted on the degree to which global AIDS norms have been internalised – the party-state relationship, the centre-local relationship and the state-society relationship. In keeping with Risse-Kappen’s (1995) ‘state-dominated’ political structure, the nature of the CCP-led state has meant that norm entrepreneurs have had more influence when the CCP elite has been predisposed to their ideas (and vice versa). However, unlike the state-dominated political structure, the internalisation of norms at the level of the central government does not necessarily mean that the story is over. For example, it was difficult for the Ministry of Health officials to enforce local compliance with its regulations when the top elite was silent on the matter of AIDS prevention. However, even when the SARS crisis led to the CCP elite politicising AIDS and the more meaningful institutionalisation of global AIDS norms at the national level, the nature of the centre-local relationship has meant that universal internalisation at the provincial levels of government and/or below has remained a challenge. Likewise, in other states new norms have been adopted and promoted by non-state actors. In China the state is still distrustful of autonomous civil society and this has also impacted on the salience of the norm of civil society involvement and the greater involvement of PWA.

The second important element of the domestic political structure that has conditioned the receptivity of the Chinese government to global AIDS norms has been the official discourse on sex. I argued that the Chinese government has promoted a conservative understanding of sex. Its construction of sex workers and homosexuals as deviant and abnormal hindered the internalisation of human rights-embedded AIDS programs and anti-discrimination and evidence-based prevention policies, particularly in the periods of denial and limited recognition. The official discourse on sex has also influenced the way in which AIDS has been reported on and the visibility of PWA in the media and has also had mixed consequences for the space for domestic norm entrepreneurs. In this regard it is significant that while the Chinese government still engages in conservative rhetoric, in recent years societal attitudes to sex have changed and this

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has led to the increasing tolerance of homosexuality and sex outside of marriage by the Chinese government. While it has not been the direct focus of the thesis, it is possible that these changes have contributed to the receptivity of the Chinese government to global AIDS norms.

Finally, the third important element of the political structure that has affected the domestic salience of the global AIDS norms has been the extent to which the incoming norms have resonated with the interests of the political elite. I argued in this thesis that the primary concern of the political elite is the maintenance of its monopoly of power. However, in order to legitimise this monopoly, the CCP pursues three main goals – economic development, social stability and the improvement of China’s international standing. These goals have at time blocked certain norms – for example, PWA rights and the involvement of civil society have not always proved as salient as the maintenance of social stability – and at times assisted their internalisation, especially when linked with China’s desire to be understood as a responsible member of the international community.

Crisis as a catalyst

While the actions of norm entrepreneurs and small shifts in the domestic political structure can account for the incremental change that occurred in the period of limited recognition, this thesis has demonstrated that the main trigger that enabled the transfer of global AIDS norms to the Chinese government was the SARS crisis. As discussed in chapter five, in this particular case, crisis provided the conditions needed that made the Chinese government more receptive to the global AIDS norms. The SARS crisis had four consequences. Firstly, it exposed an under-funded, inequitable and inefficient health system. Secondly, it uncovered the internal pathologies of the Chinese political regime such as the opacity of information, the lack of compliance and accountability at the lower levels of government and the lack of overall coordination. Thirdly, the SARS crisis slowed the country’s economic development and threatened social stability. Finally, the way in which the Chinese government initially responded to the outbreak had implications for China’s international standing as other states, intergovernmental organizations and private actors responded with anger and frustration, and doubted the veracity of China’s data. As argued in chapter

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three, the CCP has justified its rule of China to both international and domestic audiences by emphasising its ability to ensure health, fight corruption and cover-ups, increase living standards, maintain stability and be a good international citizen. However, the SARS revealed the disparity between this image and reality and was therefore a threat to the legitimacy of the Chinese political regime.

Consequently, in the aftermath of the SARS crisis, the domestic political context shifted. First, in that it had to be seen to be responding to the outbreak, the Chinese government was forced to put health and infectious disease, including HIV/AIDS, on the political agenda. Second, the SARS crisis led to an increase in resources for health and disease control and the increase of political power for the MOH. Third, the SARS crisis led to increased access to Chinese decision makers with the Chinese government becoming more open to the advice of both international and domestic policy entrepreneurs on health issues, including HIV/AIDS. Indeed norm entrepreneurs were able to use the experience and political momentum caused by SARS to frame HIV/AIDS in a way that generated political attention. For these reasons, I argue that the SARS crisis was a catalyst that created the conditions for the transmission of norms from the global AIDS regime to China.

On a final note, it might well be pointed out that in this particular case China’s behaviour does not exhibit norm-driven behaviour, but that instead its shift in AIDS governance, as a response to the threat to its interests, represents an example of instrumental adaptation. I would respond to this argument in several ways. Firstly, this thesis cannot, and indeed did not set out to, provide a definitive answer as to whether China has changed its governance only as a result of instrumental reasons or because the government realised it was the ‘right’ thing to do. Secondly, it is important to emphasize that while the SARS crisis opened the window of opportunity by threatening the Chinese government’s interests and therefore allowing the political context to shift, the SARS crisis did not determine the direction that the government took. Instead, the Chinese government’s rhetoric and behaviour regarding AIDS governance since the SARS crisis, such as the visible and meaningful involvement of the top leaders in AIDS advocacy, the legal institutionalisation of the protection of the rights of PWA, multisectoral coordination and official accountability and transparency, the increased provision of evidence-based prevention, treatment and

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care, the changing discourse in the media with regards to AIDS and PWA, the improvement of surveillance and monitoring and evaluation systems and the growing recognition of the importance of civil society, have reflected the greater internalisation of the norms of the global AIDS regime. It is for this reason that the existence of a global AIDS regime is significant and deserving of scholarly attention. Finally, even if the Chinese government only became more receptive of the global AIDS norms when its interests were threatened, the extent to which the Chinese government has changed both its rhetoric and behaviour and become engaged in the politics of articulation and justification at both the international and domestic level suggests a continuing process of norm internalisation.

This thesis has therefore shown through a focus on the Chinese government's policies towards AIDS that a global AIDS regime exists and that while it lacks enforcement procedures, it has, nevertheless, had an influence on China’s governance of HIV/AIDS through the vehicle of its norms. The thesis has demonstrated that the mechanism by which, and the degree to which, China has changed its governance of HIV/AIDS has been contingent on the actions of norm entrepreneurs, the shifting features of the Chinese political structure and the mechanism of crisis.

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CHINESE PRESS

Publications Consulted Beijing Review 1986-2007, accessed via University of New South Wales library and Factiva database. China Daily 1984-2007, accessed via the National Library of Australia and Factiva database. Xinhua News Agency 1989-2007, accessed via Factiva database.

Articles Cited In-Text Bao Daozu. 2003. “Government – All SARS Cases Reported”. China Daily. April 11. Beijing Review. 1987a. “AIDS: Will it Spread to China?” 30 (32):7. Beijing Review. 1987b. “China Makes Efforts to Prevent AIDS”. 30 (39):32-33. Beijing Review. 1990. “China Drafts Plan to Combat AIDS”. 33 (14):9. Chen Hong. 2004. “HIV/AIDS Battle Front is Human Rights Priority”. China Daily, April 20. Chen Weimin, and Chen Zhisong. 1987. “New Border Health Law”. China Daily, April 9. China Central Television. 1990. “Health Officials on Measure to Control the Spread of AIDS”. [Cited July 2004]. Available at: http://www.casy.org/Chindoc/chencctv_90.htm China Daily. 1987a. “Beijing Tightens Border Health Rules”. April 23. China Daily. 1987b. “China AIDS Victim Dies”. June 29. China Daily. 1987c. “Education can Stop AIDS”. July 23. China Daily. 1987d. “Health Exam”. February 13. China Daily. 1988. “AIDS Research gets Funding Support”. May 28. China Daily. 1989. “Beijing Steps up AIDS Check”. November 4. China Daily. 1990. “China Reports on First AIDS Deaths”. October 19. China Daily. 1991a. “Basic Facts Help World Fight to Prevent AIDS”. November 28. China Daily. 1991b. “China Seen Alert and Active on World AIDS Day”. December 2 China Daily. 1991c. “China Spares no Effort in Fighting Spread of AIDS”. July 24. China Daily. 1991d. “HIV Case”. April 9. China Daily. 1992a. “Beijing Adopts Law on Blood Donation”. February 17.

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China Daily. 1992b. “Regional Seminar on AIDS Opens in Kunming”. September 24. China Daily. 1999. “Condom Spot: Ad or Education?” December 10. China Daily. 2007. “Job More Important Than the Person Doing It”. August 2. Couzin, Odilon. 2004. “China can Lead New Fight in War on AIDS”. China Daily, May 18. Di Fang. 2004. “Henan Province Boosting Help to HIV/AIDS Victims”. China Daily, March 3. Hua Hua. 2003. “Learn from SARS to Fight AIDS”. China Daily, June 11. Jia Hepeng. 2006. “AIDS Orphans' Privacy is Subject of Court Battle”. China Daily, May 10. Jin Baicheng. 2001. “Doctor of Love and Compassion”. China Daily, November 12. Li Wuzhou. 2003. “A Revolution in Marriage Lines”. China Today, November. [Cited May 5 2006]. Available at: http://www.chinatoday.com.cn/English/e2003/e200311/p12.htm Lin Gu. 2006. “Pay Attention to the Neglected”. China Daily, August 12. Liu Li. 2005. “Legislation Key to Epidemic Control”. China Daily, September 7. Liu Li. 2006. “Top Firms Join Fight Against AIDS”. China Daily, December 9. Liu Shinan. 2006. “AIDS Needs a Wider Perspective”. China Daily, October 18. Lu Xueli. 2002. “Blueprint for an Overall Xiaokang Society in China”. China Daily, December 3. Ma Guihua. 2004b. “NGOs Active in China's Fight against AIDS”. China Daily, July 20. Meng Na. 2004. “China Strives to Eliminate Discrimination Against HIV/AIDS Patients”. Xinhua News Agency, April 5. People's Daily. 2003a. “China Amends Anti-Epidemic Law after SARS Outbreak”. June 17. People's Daily. 2003b. “Government Approved Condom Ads Aired for First Time in China”. November 28. Qin Chuan. 2001a. “Protection of Victims' Rights Stressed”. China Daily, November 19 Qin Chuan. 2001b. “War Against Killer Virus Stepped Up”. China Daily December 3. Shan Juan. 2007a. “AIDS Control Needs Help of All: Minister”. China Daily, July 18.

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Shan Juan. 2007b. “Fight for the Distressed Fraught with Frustrations”. China Daily, August 8. Shan Juan. 2007c. “Health Reform Plan Hindered by Debate”. China Daily, October 31. Shan Juan. 2007d. “Talk Back: Debate over Forced HIV Tests Rages On”. China Daily, August 8. Shao Yongwei, and Yong Zhang. 2004. “Asia Pacific Joins Hands in Epidemic Fight”. China Daily, April 29. Sun, Shangwu. 2005. “New rules to combat AIDS spread”. China Daily, October 28. Wang Gangyi. 1986. “China Requires Tests for AIDS”. China Daily, December 20. Wang Gangyi. 1988. “China Steps up Anti-AIDS Measures”. China Daily, January 29. Wang Jiaquan. 2007. “China's battle against AIDS: engaging every official in the cause”. Xinhua News Agency, November 27. Wen Chihua. 2007a. “Legal Reform Urged for More Play of NGOs in China’s Fight Against HIV”. Xinhua News Agency, May 1. Wen Chihua. 2007b. “The Good Fight”. China Daily, June 7. Wen Jia. 1988. “Regulations to Keep Out AIDS Virus”. China Daily, January 15. Wu Yiqing. 2007. “Breaking the Stigma”. Beijing Review, March 8. Xiao Jiao. 2004. “Henan Provides Lesson in Fight Against AIDS”. China Daily, February 18. Xin Zhiming. 2001. “Curbing Spread of Macabre Virus”. China Daily, June 27. Xinhua News Agency. 1989. “‘Controversial' AIDS’ Film Fills Cinemas”. March 31. Xinhua News Agency. 1990. “AIDS Cases Found”. October 20. Xinhua News Agency. 1991. “International AIDS Forum on AIDS Prevention”. March 10. Xinhua News Agency. 1992. “China has 969 Reported Cases of AIDS Infection”. December 2 Xinhua News Agency. 1999a. “Ads for Condoms Aired to Prevent Unwanted Pregnancy and HIV/AIDS”. November 29. Xinhua News Agency. 1999b. “China Seriously Plagued by AIDS Disease”. December 1 Xinhua News Agency. 2000. “Chinese Pay Close Attention to AIDS Prevention”. December 1

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Xinhua News Agency. 2003a. “Chinese HIV Carriers Fight Social Stigma”. November 30. Xinhua News Agency. 2003b. “Chinese Vice-Premier Visits AIDS-Hit Village”. December 23. Xinhua News Agency. 2003c. “Shaking Hands with HIV/AIDS Victims, Wen Marks a Milestone for China”. December 1. Xinhua News Agency. 2004a. “China Popularizes HIV/AIDS Knowledge Among Local Officials”. December 1. Xinhua News Agency. 2004b. “Chinese Health Official Urges to Enhance Awareness, Investment in AIDS Combat”. April 8. Xinhua News Agency. 2004c. “Chinese Human Rights Group Appeals to Media to Improve AIDS Coverage”. April 17. Xinhua News Agency. 2004d. “Chinese Premier Outlines Strategy on AIDS Prevention and Control”. July 9. Xinhua News Agency. 2004e. “Chinese Premier Visits HIV/AIDS Expert”. June 15. Xinhua News Agency. 2005a. “AIDS-Hit Villagers Cherish Premier's New Year Greetings”. February 12. Xinhua News Agency. 2005b. “Cops in Clash over Condoms”. June 13. Xinhua News Agency. 2005c. “Round-up: Chinese Leaders Spend Spring Festival with the Disadvantaged”. February 9. Xinhua News Agency. 2005d. “US Official Calls for Further Anti-AIDS Cooperation with China”. June 7. Xinhua News Agency. 2006a. “China to Promote AIDS Awareness Among Local Officials”. June 28. Xinhua News Agency. 2006b. “China Trains Publicity Officials on HIV/AIDS Reporting”. December 25. Xinhua News Agency. 2006c. “Three Fifths of Officials Show Little Knowledge of AIDS: Survey”. October 12. Xinhua News Agency. 2007a. “China Focus: President Hu Tells HIV Carriers, Communities Not to be Daunted by Disease”. December 1. Xinhua News Agency. 2007b. “China, UNDP Work to Improve AIDS Law-Making”. December 1. Xinhua News Agency. 2007c. “Chinese Premier Revisits AIDS-Suffering Central China Villages”. December 1.

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Xinhua News Agency. 2007d. “Coca Cola gives Chinese Migrant Workers AIDS Awareness Playing Cards”. May 24. Xinhua News Agency. 2007e. “Condoms No Longer Evidence of Prostitution in China”. November 30. Xinhua News Agency. 2007f. “Four Chinese Women Honoured with Human Rights Award in U.S.” March 16. Xinhua News Agency. 2007g. “Chinese Premier Underlines Importance of Further Economic Development in New Year Speech”. February 16. Xinhua's China Economic Information Service. 2006. “Feature: AIDS Prevention Lecture in Party Schools, China's New Approach to Fight AIDS”. 2006. November 30. Xiong Lei. 2007. “NGOs Finally Accepted as Valuable Partners”. China Daily, April 13. Xiong Lei. 2008. “Charting the Battle Against HIV/AIDS”. China Daily, January 29. Xu Binglan. 2004. “Campaign on AIDS Awareness”. China Daily, July 13. Xu Lingui, and Chang Ailing. 2006. “In China, Red Ribbon Flies from Zhongnanhai to Streets on World AIDS Day”. Xinhua News Agency, December 1. Xue Baosheng. 2003. “Valuable Lesson for Government to Learn”. China Daily, June 6. Xun Feng. 2003. “Enmity Greater Threat Than Illness.” China Daily, April 9. Zhang Feng. 2002. “New Rules to Control Disease”. China Daily, October 16. Zhang Feng. 2005. "Henan Gets it Right in War on HIV/AIDS”. China Daily, November 4. Zhang Tingting. 1987. “Blood Donors Get New Incentives”. China Daily, April 20. Zheng Caizhong. 1993. “AIDS Peril Warning in Guangdong Province”. China Daily, February 23. Zheng Lifei. 2004. “War on AIDS Needs More Ammunition”. China Daily, July 15. Zhou Yan, and Guo Jinhui. 2004. “AIDS-Hit Villagers Celebrate Chinese New Year with Tears and Hope”. Xinhua News Agency, January 20. Zhu Baoxia. 1989a. “New Health Rules for Sino Travellers”. China Daily, November 6. Zhu Baoxia. 1989b. “One More AIDS Case Disclosed in Beijing”. China Daily, December 2.

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Zhu Baoxia. 1990a. “China Plans to Check the Spread of AIDS”. China Daily, March 2. Zhu Baoxia. 1990b. “Outdoor Activities Highlight AIDS Day”. China Daily, December 3. Zhu Baoxia. 1990c. “VD Tests for New Job Seekers”. China Daily, December 14. Zhu Baoxia. 1991. “AIDS Fight to Get $800,000 in Grants”. China Daily, March 16. Zhu Baoxia. 1992a. “AIDS Day Awards Handed Out in Beijing”. China Daily, December 2. Zhu Baoxia. 1992b. “Donations of Blood Mandatory”. China Daily, April 21. Zhu Baoxia. 1993a. “Crackdown Set to Curb Illegal Trade in Blood’. China Daily, April 13. Zhu Baoxia. 1993b. “State is Urged to Fight AIDS in China”. China Daily, December 2. Zhu Baoxia. 1994. “Thousands of Disease Carriers Detected”. China Daily, January 13. Zhu Baoxia. 1995. “Drive to Sting Deadly Virus”. China Daily, December 2.

268

INTERGOVERNMENTAL DOCUMENTS (REPORTS, GUIDELINES, STATEMENTS)

Asia Pacific Economic Cooperation (APEC). 2004a. 'One Community, One Future': Santiago Declaration. (Leaders’ Declaration). 12th APEC Economic Leaders' Meeting. November 20-21 2004. Santiago de Chile. [Cited January 2 2008]. Available at: http://www.apec.org/apec/leaders__declarations/2004.html Asia Pacific Economic Cooperation (APEC) (Submitted by Thailand, China, and Philippines). 2004b. Fighting Against AIDS in APEC (Agenda Item VI.2). Santiago, Chile: Asia-Pacific Economic Cooperation. Asia Pacific Economic Cooperation (APEC). 2006. Report on the APEC Symposium on Emerging Infectious Diseases (submitted by China). Health Task Force Meeting, September 14-15, Da Nang, Vietnam. Association of South East Asian Nations (ASEAN). 2004. Co-Chairs' Statement - First ASEAN +3 Health Ministers Meeting. April 23. Penang, Malaysia. [Cited June 4 2007]. Available at: http://www.aseansec.org/16091.htm Asian Development Bank (ADB). 2003. Assessing the Impact and Cost of SARS in Developing Asia. In Asian Development Outlook 2003 Update. [Cited January 2004]. Available at: http://www.adb.org/Documents/Books/ADO/2003/update/ado2003update.pdf Australian Government Overseas Aid Program (AusAID). 2007. China HIV/AIDS Roadmap Tactical Support Project. [cited January 18 2008]. Available at: http://www.ausaid.gov.au/china/projects/charts.cfm Commission on Human Rights. 1997. E/CN.4/1997/37. Second International Consultation on HIV/AIDS and Human Rights. January 20. Congressional-Executive Commission on China (CECC). 2005. Chinese Civil Society Organizations. [Cited October 23 2007]. Available at: http://www.cecc.gov/pages/virtualAcad/rol/ngosumm.php Department for International Development, UK (DFID). 2006. "China steps up fight against AIDS with UK support". Press Release. August 15. [Cited June 2 2007]. Available at: http://www.dfid.gov.uk/news/files/pressreleases/china- fight-aids.asp The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). 2005. Revised Guidelines on the Purpose, Structure and Composition of Country Coordinating Mechanisms and Requirements for Grant Eligibility. [Cited June

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2006]. Available at: http://www.theglobalfund.org/pdf/5_pp_guidelines_ccm_4_en.pdf The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). 2008a. China and the Global Fund: Portfolio of Grants. 2008. [Cited January 17 2008]. Available at: http://www.theglobalfund.org/programs/Portfolio.aspx?countryid=CHN&lang =en The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). 2008b. How the Global Fund Works. 2008. [Cited March 1 2008]. Available at: http://www.theglobalfund.org/en/about/how/ The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). 2008c. Monthly Progress Update – 31 January 2008. [Cited March 1 2008]. Available at: http://www.theglobalfund.org/en/files/publications/basics/progress_update/pro gressupdate.pd Joint United Nations Programme on HIV/AIDS (UNAIDS). 1999a. Modus Operandi of the Programme Coordinating Board of the Joint United Nations Programme on HIV/AIDS (UNAIDS). June. [Cited February 29 2008]. Available at: http://data.unaids.org/Governance/PCB01/mojune99rev_en.pdf Joint United Nations Programme on HIV/AIDS (UNAIDS). 1999b. UNAIDS Partnership: Working Together on HIV/AIDS. Geneva: UNAIDS. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2000. HIV and AIDS- related stigmatization, discrimination and denial: forms, contexts and determinants. Geneva: UNAIDS. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2001. Global Strategy Framework on HIV/AIDS. Geneva: UNAIDS. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2002. Criminal Law, Public Health and HIV Transmission: A Policy Options Paper. Geneva: UNAIDS. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2003. AIDS Epidemic Update. Geneva: UNAIDS. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2004a. 2004 Report on the Global AIDS Epidemic. Geneva: UNAIDS.

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Joint United Nations Programme on HIV/AIDS (UNAIDS). 2004b. A Joint Response to HIV/AIDS. Geneva: UNAIDS Joint United Nations Programme on HIV/AIDS (UNAIDS). 2005a. From Advocacy to Action: A Progress Report on UNAIDS at Country Level. Geneva: UNAIDS. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2005b. Resource Guide for UN Theme Groups on HIV/AIDS. Geneva: UNAIDS Joint United Nations Programme on HIV/AIDS (UNAIDS). 2006a. 2006 Report on the Global AIDS Epidemic. Geneva: UNAIDS. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2006b. Strengthening and sustaining leadership and political commitment to the response to HIV epidemic in China. Geneva: UNAIDS. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2007a. AIDS Epidemic Update. Geneva: UNAIDS and WHO Joint United Nations Programme on HIV/AIDS (UNAIDS). 2007b. The Power of Partnership: United Nations Support to China’s Response to AIDS. UNAIDS: Beijing. Joint United Nations Programme on HIV/AIDS (UNAIDS) China. 2008. “UN Theme Group on AIDS in China”. [Cited April 14 2008]. Available at: http://www.unaids.org.cn/UNAIDS%20IN%20ENGLISH/About%20UNAID S6.htm Joint United Nations Programme on HIV/AIDS (UNAIDS) Programme Coordinating Board (2002) Promotion and Implementation of the Declaration of Commitment Adopted by the United Nations General Assembly Special Session on HIV/AIDS (UNGASS). Report for PCB 12th Meeting Geneva 29- 31 May 2002. [Cited June 2007]. Available at: http://data.unaids.org/Governance/PCB03/PCB_12_02_03_en.pdf?preview=tr ue Office of the United Nations High Commissioner for Human Rights and the Joint United Nations Programme on HIV/AIDS (UNAIDS). 2006. International Guidelines on HIV/AIDS and Human Rights. Geneva. Piot, Peter. 2005. “AIDS - One of the biggest challenges to society”. Speech given to CCP Central Party School. June 15. UNAIDS. [Cited June 2007]. Available

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at: http://data.unaids.org/Media/Speeches02/SP_Piot_ChinaPS_15Jun05_en.pdf United Nations (UN) Department of Public Information. 2001a. “Press Conference by AIDS Service Organizations”. June 27. United Nations (UN) Department of Public Information. 2001b. “UN Special Session on HIV/AIDS Seeks to Spur Massive Global Response to Crisis”. Press Release AIDS/20/PI/1359. June 20. United Nations Development Programme (UNDP). 1994. Human Development Report. New York, Oxford: Oxford University Press. United Nations Development Programme (UNDP). 2004. “‘Life is Too Good’: Jackie Chan, Pu Cunxin and Peng Liyuan featured in an ambitious AIDS awareness campaign in China”. Press Release. December 6. [Cited April 2 2008]. Available at: http://www.undp.org.cn/modules.php?op=modload&name=News&file=article &sid=4230 United Nations General Assembly (UNGA). 2003. A/58/PV.43. 43rd Plenary Meeting. October 27. United Nations General Assembly (UNGA). 2006. 2006 High-Level Meeting on AIDS - Closing Remarks by Assembly President Jan Eliasson. June 2. United Nations Security Council (UNSC). 2001. Press Release. SC/6992. January 19. United Nations Theme Group on HIV/AIDS in China (UNTG). 2001. HIV/AIDS: China's Titanic Peril. Geneva: UNAIDS. United States Department of Health and Human Services (DHHS). 2007. "Agreement between the United States and the People's Republic of China on HIV/AIDS Cooperation". December 17. The World Bank. 2006. China. The World Bank Group, September. [cited November 2 2007]. Available at: http://go.worldbank.org/81COGHVX80 World Health Organization (WHO). 1988a. AIDS Prevention and Control: Invited Presentations and Papers. World Summit of Ministers of Health on Programmes for AIDS Prevention. London. World Health Organization (WHO). 1988b. Guidelines for the Development of a National AIDS Prevention and Control Programme, WHO AIDS Series 1. Geneva World Health Organization.

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World Health Organization (WHO). 1992. The Global AIDS Strategy, WHO AIDS Series 11. Geneva: World Health Organization. World Health Organization (WHO). 2003. Update 95 – SARS: Chronology of a Serial Killer. July 4. [Cited November 2005]. Available at: http://www.who.int/csr/don/2003_07_04/en/index.html. World Health Organization (WHO). 2005. China (Country Profile). Geneva: World Health Organization. World Health Organization (WHO). 2006. Public Health Innovation and Intellectual Property Rights: Report of the Commission on Intellectual Property Rights, Innovation and Public Health. Geneva: World Health Organization.

273

RESOLUTIONS

UNITED NATIONS ECONOMIC AND SOCIAL COUNCIL E/1990/86. 1990. Prevention and control of acquired immunodeficiency syndrome (AIDS). E/1994/24. 1994. Joint and co-sponsored United Nations programme on the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS).

UNITED NATIONS GENERAL ASSEMBLY A/RES/42/8. 1987. Prevention and Control of Acquired Immunodeficiency Syndrome (AIDS). October 26. A/RES/43/15. 1988. Prevention and Control of Acquired Immunodeficiency Syndrome (AIDS). October 27. A/RES/44/233. 1989. Prevention and Control of Acquired Immunodeficiency Syndrome (AIDS). December 22. A/RES/45/187. 1990. Prevention and Control of Acquired Immunodeficiency Syndrome (AIDS). December 21. A/RES/46/203. 1991. Prevention and Control of Acquired Immunodeficiency Syndrome (AIDS). December 20. A/RES/54/283. 2000. Review of the Problem of Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome in All its Aspects. September 5. A/RES/55/2. 2000. Millennium Declaration. September 8. A/RES/S-26/2. 2001. Declaration of Commitment on HIV/AIDS. June 27. A/RES/58/3. 2003. Enhancing Capacity-Building in Global Public Health. November 17. A/RES/60/262. 2006. Political Declaration on HIV/AIDS. June 2.

UNITED NATIONS SECURITY COUNCIL S/RES/1308. 2000. On the Responsibility of the Security Council on the Maintenance of International Peace and Security: HIV/AIDS and International Peacekeeping Operations. July 17.

UNITED NATIONS ECONOMIC AND SOCIAL COMMISSION FOR ASIA AND THE PACIFIC

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60/1. 2004. Shanghai Declaration. 61/12. 2005. Regional call for action to enhance capacity-building in public health.

WORLD HEALTH ASSEMBLY WHA40.26. 1987. Global Strategy for the Prevention and Control of AIDS. May 15. WHA41.24. 1988. Avoidance of discrimination in relation to HIV-infected people and people with AIDS. May 13. WHA42.33. 1989. Global Strategy for the Prevention and Control of AIDS. May 19. WHA42.34. 1989. Nongovernmental Organizations and the Global Strategy for the Prevention and Control of AIDS. May 19.

275

NON-GOVERNMENTAL DOCUMENTS

AIDS Coalition to Unleash Power (ACT UP). 2006. Protests at Chinese Consulates 2006 [cited May 28 2007]. Available at: http://www.actupny.org/reports/china_3_06.html. AIDS Coalition to Unleash Power (ACT UP) Philadelphia. 1999. "Al Gore's 'Apartheid 2000' Campaign Comes to Philadelphia". ACT UP Philadelphia Press Release, June 23 [cited January 5 2007]. Available at: http://www.globaltreatmentaccess.org/content/press_releases/sa_med_act.htm ActionAid. 2006. "3…2…1…Gone? Failure to Call Global Fund Round 6 Risks the Whole 2010 AIDS Treatment Target". April 1. [Cited June 2006]. Available at: http://www.actionaid.org/wps/content/documents/233_1_321gone_hiv_global fund.pdf Amnesty International Asia Pacific. 2004. "Demonstration for arrested HIV/AIDS activists in front of Chinese embassy". Asia Pacific Link. (8) [cited November 2 2007]. Available at: http://asiapacific.amnesty.org/apro/aproweb.nsf/pages/issue08 Anderson, Evan and Davis, Sarah. 2007. AIDS Blood Scandals: What China can Learn from the World’s Mistakes. Asia Catalyst. September. [Cited March 21 2008]. Available at: http://www.asiacatalyst.org/AIDS_blood_scandals_rpt_0907.pdf Bill and Melinda Gates Foundation. 2007. ‘Major Commitment to Expand HIV Prevention in China’. Press Release. November 14. [Cited March 29 2008] Available at: http://www.gatesfoundation.org/GlobalHealth/Pri_Diseases/HIVAIDS/Annou ncements/Announce-071114.htm China AIDS Info. 2006. 2006/2007 China HIV/AIDS Directory. Beijing. [Cited February 15 2008]. Available at: http://www.china- aids.org/2006_directory.pdf The China AIDS Media Project (CAMP). 2007. Press Packet. [Cited April 2 2008]. Available at: http://chinaaidsmedia.com/documents/2007_07_CAMP_PK.pdf China Development Brief. 2002. “HIV/AIDS Project Digest”. June 1. [Cited March 19 2008]. Available at: http://www.chinadevelopmentbrief.com/node/163

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China Development Brief. 2007. Directory of International NGOs (DINGO). [Cited August 2007]. Available at: http://www.chinadevelopmentbrief.com/dingo/ China Development Brief. 2008. Frequently Asked Questions on Registering an International NGO in China. [Cited April 16 2007]. Available at: http://www.chinadevelopmentbrief.com/node/296 Funders Concerned About AIDS. 2005. Interview with Eve Weng-Jing Lee, Ford Foundation Program Officer. November. [Cited March 30 2008]. Available at: http://www.fcaaids.org/publications/documents/FCAAInterviewwithEVELEE Nov2005.pdf Global Business Coalition on AIDS, Tuberculosis and Malaria (GBC). 2004. GBC National Interview Schedule [cited October 24 2006]. Available at: http://www.kintera.org/atf/cf/{4AF0E874-E9A0-4D86- BA2896C3BC31180A}/Survey%20Results%202005.pdf Global Business Coalition on AIDS, Tuberculosis and Malaria (GBC). 2008. “GBC History”. [Cited April 15 2008]. Available at: http://www.gbcimpact.org/live/about/history.php Global Fund Observer. 2007. “China Changes Course on Using NGOs as Grant Implementers”. September 30. Greenberg, Jon. 1992. ACT UP Explained. ACT UP. [Cited October 17 2006]. Available at: http://www.actupny.org/documents/greenbergAU.html Harvard School of Public Health. 2007. Senior Health Executives From China Visit Harvard School of Public Health for Leadership Training. July 19. [Cited November 2007]. Available at: http://www.hsph.harvard.edu/news/press-releases/2007- releases/press07192007.html Health Global Access Project (Health GAP). 2003. Coke's AIDS in Africa Program: Fizzles in 6 Months (letter to Coca-Cola CEO). Progressive Newswire. [Cited October 23 2006]. Available at: http://www.commondreams.org/news2003/0326-11.htm Health Global Access Project (Health GAP). 2008. “About Health GAP (Global Access Project)”. [Cited April 14 2008]. Available at http://www.healthgap.org/hgap/about.html The Henry J. Kaiser Family Foundation (KFF). 2006. HIV/AIDS Policy Fact Sheet: U.S. Federal Funding for HIV/AIDS: The FY 2007 Budget Request. February.

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[Cited March 27 2008]. Available at: http://www.kff.org/hivaids/upload/7029- 03.pdf Human Rights Watch. 2003a. “China: Police Violence Against HIV-Positive Protestors Escalates”. July 9. Human Rights Watch. 2003b. Locked Doors: The Human Rights of People Living with HIV/AIDS in China. 15 (7). Human Rights Watch. 2005. Restrictions on AIDS Activists in China. 17 (5). Human Rights Watch. 2007. Letter to Peter Piot, Executive Director of the Joint United Nations Programme on HIV/AIDS. September 27. [Cited April 1 2008]. Available at: http://hrw.org/english/docs/2007/09/27/china16962.htm Interfaith Center for Corporate Responsibility. 2004. Press Release - Letter to Chairman and CEO of Coca-Cola. [Cited October 24 2006]. Available at: http://www.iccr.org/news/press_releases/pdf%20files/cokeletter100704.PDF Joint statement by NGOs on TRIPS and Public Health. 2005. “WTO Members Should Reject Bad Deal on Medicines”. December 3. [Cited March 1 2008]. Available at: http://www.cptech.org/ip/wto/p6/ngos12032005.html Jürgens, Ralf, and Cohen, Jonathan. 2007. Human Rights and HIV/AIDS: Now More than Ever. New York: Open Society Institute. Manchester, Tim. 2003. Condom Quality in China: Improving quality to help fight AIDS. Bath, United Kingdom: Futures Group. [Cited March 3 2005]. Available at: http://www.futuresgroup.com/Documents/FGECONDOM.pdf Médecins Sans Frontières (MSF), Treatment Action Campaign (TAC), and Oxfam. 2001. “Drug Companies in South Africa Capitulate Under Barrage of Public Pressure”. Joint Press Release. April 19. [Cited February 15 2008]. Available at: http://lists.essential.org/pipermail/pharm-policy/2001-April/000944.html National Alliance of State & Territorial AIDS Directors (NASTAD) and the Henry J. Kaiser Family Foundation (KFF). 2006. National ADAP Monitoring Project Annual Report. Washington, D.C. President’s Emergency Plan For AIDS Relief (PEPFAR) Watch. 2006. “The Issues”. [Cited March 1 2008]. Available at http://www.pepfarwatch.org/index.php?option=com_content&task=view&id= 73&Itemid=90

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Red2002. 2002. "People registered in the International AIDS Conference are unable to participate because their visas were denied". Press Release, July 7. Rivers, Bernard, and Qiu Renzong. 2006. Review of China CCM Elections. July 27. [Cited June 2007]. Available at: http://211.167.248.3/ccm/ccm_review_en.doc Smart, Theo. 2006. “Final Declaration of Commitment on HIV/AIDS Adopted - Disagreement Over Strengths and Weaknesses Persist”. AIDSMap. June 5. [Cited September 2007]. Available at: http://www.aidsmap.com/en/news/23430F64-73AC-4AF1-9D13- C3EDC8A72251.asp Treatment Action Campaign (TAC). 1998 10 December 1998 - Day of Action [Cited October 23 2006]. Available at: http://www.tac.org.za/treat.html. Treatment Action Campaign (TAC). 2000. Open Letter to Members of the National Assembly and the National Council of Provinces on the Opening of Parliament [Cited October 22 2006]. Available at: http://www.tac.org.za/documents/nl20000204.txt. Treatment Action Campaign (TAC). 2001. TAC, Children’s Right Centre and Dr. Haroon Saloojee win court battle against government! December 14. [Cited February 29 2008]. Available at: http://www.cptech.org/ip/health/sa/tac12142001.html Treatment Action Campaign (TAC). 2002. Contempt of constitutional court order: Complaint Against the MEC for Health Mpumalanga: Request for an urgent investigation (letter to Human Rights Commission). December 2. [Cited Febraury 29 2008]. Available at: http://www.tac.org.za/news_2002.html Treatment Action Campaign (TAC). 2003. TAC welcomes cabinet adoption of treatment plan. November 29. [Cited February 29 2008]. Available at: http://www.tac.org.za/newsletter/2003/ns20_11_2003.htm Treatment Action Campaign (TAC), and Health Global Access Project (GAP) Coalition. 2000a. Global Manifesto to Save 34 Million Lives July 9 [Cited October 22 2006]. Available at: http://www.tac.org.za/Documents/Statements/memo.htm. Treatment Action Campaign (TAC), and Health Global Access Project (GAP) Coalition. 2000b. Global March for HIV/AIDS Treatment - The International AIDS Conference 9 July 2000 [cited 20 October 2006]. Available at: http://www.tac.org.za/Documents/Statements/globcall.pdf.

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Wan Yanhai. 2003. Statement Presented to the Congressional-Executive Committee on China Congressional-Executive Committee on China (CECC), October 20 2003. [cited February 24 2005]. Available at: http://www.cecc.gov/pages/roundtables/102003/yanhai.php. World Economic Forum (WEF). 2006. Global Health Initiative. [Cited November 3 2007]. Available at: http://www.weforum.org/en/initiatives/globalhealth/index.htm. Young, Nick. 2006. “You Cannot Fix the System in Three or Four years”. China Development Brief. November. Young, Nick, and Qian, Tina. 2006. “Governance Spat Plagues Coordinating Board of Global Fund, Divides NGOs”. China Development Brief. May 31.

280

INTERNATIONAL PRESS ARTICLES

Publications Consulted Full search of Factiva Database from 1981 to 2007 conducted.

Articles Cited In-Text Agence France-Presse. 1992. “Time Running Out for China to Fight AIDS”. December 1. Agence France-Presse. 1993. “Hong Kong, China to Meet Twice a Year to Combat AIDS”. February 24. Agence France-Presse. 2002. “Protest in New York Against Detention of Chinese AIDS Activist”. September 19. Agence France-Presse. 2003a. “Amnesty International urges China to come clean on AIDS epidemic”. July 12. Agence France-Presse. 2003b. “Attendance at China’s Largest Trade Fair Substantially Down Due to SARS”. April 15. Agence France-Presse. 2004a. “Another AIDS Activist Goes Missing in China”. August 9. Agence France-Presse. 2004b. “China President Shakes Hands with AIDS Patient, Vows End to Discrimination”. November 30. Agence France-Presse. 2004c. “Top Chinese Leader Met with Country's Most Famous AIDS Activist". February 18. Agence France-Presse. 2006a. “China AIDS Activist Released from Custody in Beijing”. November 27. Agence France-Presse. 2006b. “China Emerging from Shadows of AIDS Pandemic”. May 30. AIDS Treatment News. 2002. “Barcelona: Visa Barriers May Disrupt Conference”. Issue 381. AIDS Weekly. 1992. “Nation Marks World AIDS Day with Misinformation”. December 8. AIDS Weekly. 1994. “AIDS Hotline Goes Broke”. February 14 Altman, Lawrence, and Bradsher, Keith. 2003. “China BARS WHO Experts from Origin Site of Illness”. New York Times, 26 March.

281

Ang, Audra. 2002. “China Rejects UN Report on Looming AIDS Epidemic”. San Diego Union-Tribute, June 29. Ang, Audra. 2004a. “2 Chinese Villagers Arrested in AIDS March”. Associated Press Newswires, August 1. Ang, Audra. 2004b. “Chinese President on TV With AIDS Patients”. Associated Press Newswires, December 1. Anthony, Ted. 2003. “China Plays Coy on SARS”. Hobart Mercury, 1 April. Armitage, Catherine. 2005. “China Looks Our Way for Healthcare Solutions”. The Australian, September 19. Ashford, Moyra. 1985. “Brazil Heads the World's AIDS League”. The Sunday Times, August 25. Asian Economic News. 2003. “Rolling Stones Cancel China Tour, Citing Pneumonia Fear”. April 7. The Asian Wall Street Journal. 2001. “Five Dollars Per Life”. June 1. The Asian Wall Street Journal. 2003. “China Endangers World Health”. 18 March. The Associated Press. 1993. “South China Restricts AIDS Carriers in School, Work, Marriage”. July 27. Associated Press Newswires. 2003. “China: Blair Prime Minister Blair Postpones Trip”. 1 April. Barboza, David. 2007. “A People's Sexual Revolution in China”. International Herald Tribune, March 4. Barrett, Devlin. 2007. “China Allows AIDS Activist to Visit U.S.” Associated Press Newswires, February 17. BBC Monitoring Service: Asia-Pacific. 1992. “Chinese Official Briefs International Meeting on AIDS”. July 30 BBC Monitoring Service: Asia-Pacific. 1994. “China's Public Health Minister on AIDS Prevention, Control”. December 7. BBC Monitoring Asia-Pacific. 2003. “Chinese Politburo Member Promotes 'Patriotic Health Campaign' Against SARS”. April 25. BBC Monitoring Asia-Pacific. 2004. “Chinese Premier Urges Officials to Prioritize AIDS Prevention”. December 1. BBC Monitoring Asia-Pacific. 2005. “China's Wu Yi Invites Private Sector to Join HIV/AIDS Campaign”. March 19.

282

BBC Monitoring Asia-Pacific. 2005. “Chinese Welfare Worker says Local Governments Fail to Help AIDS Orphans”. January 5. BBC News. 2008. “China Defends Tibetan Crackdown”. April 12. Beech, Hannah. 2003. “How Bad is it?” Time (online edition), April 13. Beech, Hannah. 2004. “Wu Yi” Time, April 26. Beech, Hannah. 2006. “Sex, Please, We're Young and Chinese”. Time, January 15. Beech, Hannah, Jakes, Susan and Huang Yong. 2003. “Hiding the Patients”. Time, (23). April 28. Bezlova, Antoaneta. 2002. “China: Activist's Arrest Shows Divergence on Fighting HIV/AIDS”. Inter Press Service, September 3 Biers, Dan. 1993. “China's First AIDS Hot Line Faces Uphill Battle”. The Associated Press, February 27. Biggs, Cassie. 2006. “China Revises Down HIV/AIDS Cases”. Associated Press Newswires, January 25. Blanchard, Ben. 2007. “China not Investing Enough to Fight AIDS – Experts”. Reuters News, April 6. Boden, Christopher. 2003. “China's Health Minister: The Country is Safe”. Associated Press Newswires, 3 April Brewer, Steven. 1986. “Homosexuals Say They're Threatened By ‘Gay Bashing’”. The Associated Press, January 18. Brown, David. 2002. “Survey Finds China’s AIDS Awareness is Lacking”. The Washington Post. July 9. Business Week Online. 2003. “Editorial: SARS May Force Change on China”. April 23. Canadian NewsWire. 2005. “26 Companies of the Global Business Coalition on HIV/AIDS (GBC) Announce Immediate Commitments to Fight AIDS in China”. May 18. Chandler, David. 1990. “Leader of Global Fight Against AIDS Resigns”. The Boston Globe, March 17. Chandra, Rajiv. 1993. “China: Talking About Sex to Fight AIDS”. Inter Press Service Global Information Network, March 9 Chandra, Rajiv. 1995. “AIDS-China: Beijing Bids to ‘Repair House Before it Rains’”. Inter Press Service, December 1

283

Chang, Irene. 2003. “Fear of SARS, Fear of Strangers”. The New York Times. May 21. Chang, Leslie. 2001. “AIDS Panic in China Leads to Draconian Measures”. The Wall Street Journal, March 23. Chang, Leslie. 2002. “New Breed of Activist Braves China's AIDS Crisis”. The Wall Street Journal, April 2. Cheong, Ching. 2003. “Threat to China's Social Stability”. Straits Times, May 6. Clark, Cheryl. 1989. “Scientists Vow boycott Over AIDS Uproar”. The San Diego Union-Tribute, June 11. Collins, Huntly. 2001. “AIDS Activists Turn Abroad”. The Seattle Times, March 8. Coonan, Clifford. 2003. “First Condom Ads on TV Signal Attitude Change”. South China Morning Post, December 7. Creedy, Steve, and Saunders, Megan. 2003. “Fighting Disease Risks”. The Australian, April 4. Crossette, Barbara. 2000. “Gore Presides Over Rare Security Council Debate on AIDS”. The New York Times, January 11. Crothall, Geoffrey. 1992. “AIDS Hotline Service Extended”. South China Morning Post, December 28. Crothall, Geoffrey. 1993. “Health Official's Sacking Signals Beijing's Attitude to Homosexual Rights”. South China Morning Post, August 15. Crothall, Geoffrey. 1994. “National Meeting to Focus on AIDS”. South China Morning Post, May 31. Crothall, Geoffrey. 1995. “Schools Resist AIDS Scheme”. South China Morning Post, November 6. Davis, Bob. 1999. “Gore Hopes New AIDS Pact Will Help Shake Protesters”. The Wall Street Journal, August 12. Dickie, Murie. 2006. “UNAIDS Steps in to Resolve Global Fund Poll Dispute”. Financial Times, June 12. Dickie, Murie. 2004. “AIDS, SARS Play Role in Revision of Diseases Law”. Financial Times, August 30. Dorgan, M. 2003. “SARS Costs China $30 Billion - Tally is Still Growing”. KRTBN Knight Ridder Tribune Business News, May 1. Dow Jones International News. 2000. “UN Calls AIDS Threat to Peace, Not Just Health, in Africa”. January 10.

284

Dow Jones International News. 2002. “China AIDS Activist Freed After Official Probe”. September 20. Dow Jones International News. 2004a. “China Appeals For Help In Fighting Emerging AIDS Epidemic”. July 13. Dow Jones International News. 2004b. “China's Premier Appeals For Public To Help In AIDS Fight”. July 10. Dow Jones International News. 2006. “UN Agency Appeals TO China Over Missing AIDS Activist”. March 1. Dow Jones International News. 2007. “China Police Block AIDS Activist From Visiting US, Friend Says”. February 7. Duerkson, Susan. 1987. “World Health Experts Urge Global Unity to Fight AIDS”. The San Diego Union-Tribune, June 3. Eckholm, Erik. 2003. “China Applies Criminal Statute to SARS”. International Herald Tribune, May 17. The Economist. 2003. “China’s Chernobyl”. March 26. 367(8321): 9-10. The Economist. 2007. “Governing China: Caught Between Right and Left, Town and Country”. March 10. 382(8519): 23-25. Elegant, Simon. 2008. “The Love that Dares to Speak its Name – Discreetly”. Time. January 13. Eliason, Marcus. 1985. “Britain Swept by AIDS Panic”. The Associated Press, February 25. Engel, Margaret. 1986. “Rescuers Balk At Moving Body Of AIDS Victim”. The Washington Post, February 6 Fan, Maureen. 2006a. “AIDS Activist Is Detained On Eve of Meeting in China”. The Washington Post, November 26. Fan, Maureen. 2006b. “In China, Delicately Testing the Taboo on Talking About Sex”. The Washington Post September 11. Fishlock, Trevor. 1985. “Letter from New York: City in Fear of the New Untouchables”. The Times, September 5. Forney, Matthew. 2003. “Silent For Too Long”. Time (online edition), April 21. Fu, Charlene L. 1992. “Prudery, Other Problems Hamper AIDS Prevention”. The Associated Press, January 13. Gertz, Bill. 2008. “Hayden takes China to task”. The Washington Times. March 13. Geulph Mercury. 2003. “Fear and Panic the Worst of SARS”. April 8.

285

Gittings, David. 2001. “The AIDS Scandal China Could Not Hush Up”. The Guardian, June 11. Gittings, John. 2003. “China Steps Up to a Global Threat”. YaleGlobal, December 5. Godfrey, Deirdre. 1992. “China: AIDS Threat Hangs Over World's Most Populous Nation”. Inter Press Service Global Information Network. Goldberg, Ron. 1998. “Conference Call: When PWAs First Sat at the High Table”. POZ Magazine, July. Hardy, Terri. 1994. “Movement Intensity Drops Off AIDS Groups Lament Waning Membership”. Los Angeles Daily News, Feburuary 28. Harmsen, Peter. 2003. “US Scholars Pressure China to Review Way it Deals with AIDS”. Agence France-Presse, August 5. Hesketh, Therese. 2007. “HIV/AIDS in China: the numbers problem”. The Lancet 369 (9562):621. Holland, Laurie. 1996. “China's New Focus on AIDS Hailed as Turning Point in Global Prevention”. Agence France-Presse, May 7. Hyland, Anne. 2003. “WHO Blasts China Over Lack of Data on Virus”. Australian Financial Review, 26 March. The Independent. 1990. “AIDS Protesters Arrested”. June 21. The Independent. 2003. “The SARS Outbreak: Fear and Panic in Chinatown Where Businesses Face Contrasting Fortunes”. April 25. International Market Insight Reports. 2000. “China - Henan Rural Country - No AIDS Here”. May 16. Jakes, Sarah. 2003. “Beijing's SARS Attack”. Time (online edition), April 8. Kahn, Joseph. 2005. “China Asks Help on AIDS, Minister Urges Businesses to Join Fight”. The New York Times, March 19. Kusmer, Ken. 1986. “Teen-Age AIDS Victim Returns To School After Lengthy Court Battle”. The Associated Press, April 10. Kwok, Kristine. 2006. “New guidelines step up the battle against HIV/AIDS”. South China Morning Post, February 13. Lambert, Bruce. 1989. “3,000 Assailing Policy on AIDS Ring City Hall”. The New York Times, March 29. The Lancet Infectious Diseases. 2007. “The Global Fund: Growing Pains”. November. 17(11): 695

286

Lederer, Edith M. 2001. “Minister: 600,000 in China Have AIDS”. AP Online, June 26. Leith, Scott. 2002. “Coke Boosts AIDS Attack”. Atlanta Journal-Constitution, September 27. Lev, Michael A. 2003. “World Health Organization Needs More Operation from China over Deadly Virus”. KRTBN Knight-Ridder Tribune Business News, 22 March. Lyman, Rick. 1986. “U.N. Unveils Costly Plan in War on AIDS”. The Record, November 21. Ma Guihua. 2004. “China Revises Law on Infectious Diseases”. The Lancet Infectious Diseases 4 (11):652. Ma Guihua, and Gu Lin. 2006. “Slowly, Transforming the Party Line on AIDS”. Asiafrica, February 19. Manning, Anita. 2003. “Living in Fear of SARS”. USA Today. April 7. McQuiston, John T. 1986. “City Finds Rise in Complaints of Bias Against Homosexuals”. The New York Times, March 8. Mickleburgh, Rod. 1996. “Vampire Shops”. The Globe and Mail, September 21. Mitra, Sabyasachi. 2003. “China's Slow SARS Handling Exposes Investment Risks”. Reuters News, 9 April. Moran, Thomas. 1990. “AIDS Activists Plan More ‘Impolite Politics’”. The Record, January 30. Murphy, Dean E. 2003. “In U.S., Fear is Spreading Faster than SARS”. The New York Times. April 16. Mzolo, Bhungani. 1999. “Aids Drugs Protests”. All Africa, July 7. The Nation. 2007. “ACT UP at 20”. March 22. Naughton, Philippe. 1993. “WHO to Review Global AIDS Strategy”. Reuters News, 14 May. The New York Times. 2002. “China's Looming Catastrophe”. September 16. O'Brien, Kathleen. 1985. “At Work, Fear is Contagious”. The Record, November 22. Oleson, Alexa. 2006. “China's Grass-Roots AIDS Groups, Once Nonexistent, Now Fight to Survive”. Associated Press Newswires, May 31. Oleson, Alexa. 2007. “Chinese AIDS Activist says Outside Pressure Helped Lift Travel Ban Against Her”. Associated Press Newswires, February 22.

287

Oon, Clarissa. 2006. “Beijing puts into law policy guidelines to combat AIDS". Straits Times, February 13. Page, Jeremy. 2001. “AIDS-Stricken Chinese Peasants Call for Justice”. Reuters News, May 31. Parry, Martin. 2003. “China Speeds Up Campaign to Halt SARS”. Agence France- Presse, April 23. Parry, Jane. 2006. China's pragmatic approach to AIDS. Bulletin of the World Health Organization 84 (4):261-262. Patterson, Dennis. 1989a. “Company Announces Price Reduction of AIDS Drug”. The Associated Press, September 18. Patterson, Dennis. 1989b. “Officers Tear Down Wall to Remove AIDS Protestors At Burroughs Wellcome”. The Associated Press, April 25. Peseck Jr., William. 2003. “China's Troubling SARS Silence”. National Post, 1 April. Pirani, Clara. 2003. “The Fear of SARS”. The Australian. April 5. Pomfret, John. 2003a. “China Says Disease Is in Check; Health Minister Encourages Tourism Despite WHO Advisory”. The Washington Post, 4 April. Pomfret, John. 2003b. “Official Says China Erred on Oubreak; Rare Apology Cites ‘Poor Coordination’”. The Washington Post, 5 April. Pottinger, Matt. 2005. “China Enlists Companies, NGOs in AIDS Fight”. The Wall Street Journal, March 21. Powell, Alvin. 2005. “Health Care Reform in China Discussed”. Harvard University Gazette, September 8. Power, Samantha. 2003. “The AIDS rebel”. The New Yorker, May 14. PR Newswire. 2001. “AIDS at 20: Can this Man Find a Vaccine?”. June 4. PR Newswire. 2004. “Global Business Coalition on HIV/AIDS Announces New China Business And AIDS Working Group Beijing”. July 6. Preston, Yvonne. 1986. “AIDS Deaths in Africa Could Rise to a Million, Report Says”. Sydney Morning Herald, November 27. Preston, Yvonne. 1991. “China Sees AIDS as Foreign”. The Age, November 30 The Press Trust of India. 2007. “Chinese Returning from Abroad after 1 Year to be Tested for HIV”. December 1. Quinn, Andrew. 1992. “China Slowly Comes to Grip with Menace of AIDS”. October 4.

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Quinn, Andrew. 1993. “AIDS Spiral Raises Rights Issues in China”. Reuters News, November 23. Reuters News. 1991. “True Extent of AIDS in China Still a Mystery, Doctors Say”. March 15. Reuters News. 1993a. “Amid Uproar, China Halts AIDS Testing of Visitors”. February 23. Reuters News. 1993b. “China to Increase AIDS Spending”. November 16. Reuters News. 1995a. “As Threat Grows, China Launches Anti-AIDS Drive”. October 28. Reuters News. 1995b. “Chinese Students Study Programme Against AIDS”. September 16. Reuters News. 2002a. “Rights Group Say AIDS Activist Detained by China”. August 28. Reuters News. 2002b. “Spain faces visa storm at AIDS conference”. July 8. Reuters News. 2002c. “U.S. Asks China About AIDS Activist”. August 31. Reuters News. 2006a. “China AIDS Chief Knows Nothing of Missing Activist”. March 22. Reuters News. 2006b. “China Court Punishes Paper for AIDS Report”. July 17. Reuters News. 2007a. “China Enforces HIV Tests for Returning Nationals”. December 6. Reuters News. 2007b. “China says Not Aware of Travel Ban on AIDS Doctor”. February 6. Rich, Vera. 1991. “China: Living By Blood”. The Lancet 338 (8765):501. Rosenberg, Tina. 2003. “Seed Interview: Wan Yanhai”. Seed Magazine. January/February. Rosenthal, Elisabeth. 1999. “Seriously, China Learning Sex Is Fun”. The New York Times, April 11. Rosenthal, Elisabeth. 2000a. “In Rural China, a Steep Price of Poverty: Dying of AIDS”. The New York Times, October 28. Rosenthal, Elisabeth. 2000b. “Scientists Warn of Inaction As AIDS Spreads in China”. The New York Times, August 2. Rosenthal, Elisabeth. 2001a. “AIDS Crusader's International Award Wins Scowls in China”. The New York Times, May 31.

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Rosenthal, Elisabeth. 2001b. “China Now Facing an AIDS Epidemic, a Top Aide Admits”. The New York Times, August 24. Rosenthal, Elisabeth. 2001c. “China Seems Uncertain About Dealing Openly With AIDS”. The New York Times, November 14 Rosenthal, Elisabeth. 2001d. “Suddenly, AIDS Makes the News in China”. The New York Times, December 4. Rosenthal, Elisabeth. 2002a. “China Frees AIDS Activist After Month of Outcry”. The New York Times, September 21. Rosenthal, Elisabeth. 2002b. “China's Top AIDS Activist Missing; Arrest Is Suspected”. The New York Times, August 29. Ruggie, John. 2002. “Managing Corporate Social Responsibility”. Financial Times, October 25. Schell, Orville. 2006. “Wen Jiabao”. Time, April 30. Schmetzer, Uli. 1993. “Fear, Ignorance Behind China's Rise in AIDS”. The Seattle Times, December 14 Schoofs, Mark. 2000. "Giving it Away". The Body, April 4. Senterfitt, Walt. 1998. “The Denver Principles: The Original Mainfesto of the PWA Self-Empowerment Movement”. Being Alive, 01 May. Settle, Edmund. 2003. “A Photo Call is Not a Cure”. South China Morning Post, December 4. Sheridan, Michael. 1999. “Prudery Halts China's Battle Against AIDS”. The Sunday Times, December 5 Silberman, Steven. 1987. “32 Arrested at N.Y.C. AIDS Sit-In”. The Record, July 1. Sorelle, Ruth. 1988. “Worldwide Cooperation Hailed”. Houston Chronicle, June 13. Sorelle, Ruth. 1992. “Conferees Urge Full Use of All Resources to Fight AIDS”. Houston Chronicle, July 26. South China Morning Post. 2003. “Coming Clean”. 11 April. South China Morning Post. 2006a. “Beijing Daily Sued for Identifying AIDS Orphan”. March 7. South China Morning Post. 2006b. “UN says AIDS Panel Needs to Lift Game as Number at Risk Rises”. June 24. South African Press Association. 1999. “Protest Against High Drug Prices Planned”. September 11.

290

Specter, Michael. 1985. “Gay Groups Mobilize Against AIDS Communities Fight for U.S. Funds, Battle Erosion of Civil Rights”. The Washington Post, August 2. Specter, Michael. 1990. “Letter from the AIDS Conference”. The Washington Post, June 23. Specter, Michael, and Malcolm Gladwell. 1990. “Activists Take to Streets at AIDS Conference”. The Washington Post, June 20. Spiegel, Mickey. 2002. “By Choking Information, China Worsens AIDS Crisis”. International Herald Tribune, September 14. The Standard. 2003. “China's Silence a Worry”. 29 March. The Straits Times. 1993. “Beijing Makes Tests Compulsory for all Frequent Visitors”. January 30 Sui, Cindy. 2000. “Death Sentence”. Townsville Bulletin, December 9 Sui, Cindy. 2003. “Hundreds of Police Storm ‘AIDS Village’ in China, Arrest 13 Farmers”. Agence France-Presse, July 3. Taylor, Chris. 2003. “The Chinese Plague”. The Age, May 5. Toy, Mary-Anne. 2006. “Plea for Missing Chinese AIDS Activist”. The Age, March 23. Toy, Mary-Anne. 2007. “Party Too Corrupt, Hu Tells Congress”. Sydney Morning Herald, October 16. Trafford, Abigail, and Okie, Susan. 1987. “The Uphill Battle Against AIDS Worldwide”. The Washington Post, August 25. Walker, Tony. 1993. “China in Bid to Tackle its AIDS Problem”. Financial Times, April 6. Watts, Jonathan. 2003. “HIV could Blunt Progress in China, Clinton Warns”. The Lancet. 362 (9396):1636 Watts, Jonathan. 2005. “Sex is China's Latest Boom Industry”. The Guardian, June 25. Watts, Jonathan. 2006. “China's Rural Health Reforms Tackle Entrenched Inequalities”. The Lancet. 367 (9522):1564-1565. Wines, Michael. 2007. “Taking On Apartheid, Then a Nation's Stance on AIDS”. The New York Times, September 8. Woo, Eva. 2004. “WHO warns Aids; prevention failing at the local level”. South China Morning Post, September 16.

291

Wren, Christopher S. 2000. “Annan Says All Nations Must Cooperate to Solve Problems Like War and Poverty”. The New York Times, September 14. Wu Zunyou, Sullivan, Sheena G., Wang Yu, Rotheram-Borus, Mary Jane, and Detels, Roger. 2007. “Evolution of China's response to HIV/AIDS”. Lancet 369 (9562):679-690. Xia Ming. 2006. “China Rises Companion: Political Governance”. The New York Times. Xiong Lei. 2005. “How SARS Could Save a Nation”. NewStatesman, January 1. Yardley, Jim. 2006. “New Estimate in China Finds Fewer AIDS Cases”. The New York Times, 26 January. Yardley, Jim. 2008. “Chinese Nationalism Fuels Tibet Crackdown”. The New York Times, March 31. York, Geoffrey. 2003. “Epidemic Threatens to Devastate China's Economy”. The Globe and Mail, November 6.

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