Xiongqiao village in China's Henan province is the most depressing place I have been in my life. The local authorities had made it off limits to foreigners so we had to meet our local guides, a farmer and his wife, under cover of darkness in the middle of the countryside. Even then they whispered to me to keep quiet in case someone overheard and informed the authorities. Apart from squelching feet, the only sound was a chorus of frogs and the crackle of firewood. The blaze was part of a funeral ceremony—the tenth in the tiny community that year; they had all died of HIV/AIDS. Many others seemed certain to follow: the farmer's wife was infected, so was his mother, his aunt, his cousin, his cousin's wife, their neighbour, and possibly many of the children. They had contracted the disease because they were poor and had sold blood—one donation earned more than a week's labour on the fields. Their small, dark house had literally been built with blood money. That was back in the mid 1990s, before they had heard of HIV, while their government was still declaring it a foreign disease.
I came away deeply disturbed, wondering how many others were in the same situation. Local non-governmental organisations (NGOs) said there were many villages with infection rates of more than 50%. Conceivably, millions had the disease and there was a high possibility that it was still being spread through tainted blood transfusions, childbirth, and the sexual activity of a mobile population.
I still don't know the truth, despite the sea change in China's attitude towards AIDS. Beijing has acknowledged it has a big problem, promised free tests and antiretroviral drugs, and launched a much improved public education campaign. But Henan has resisted the call for it to come clean, and the health services in many of the poorer provinces are so badly underfunded that they are unable to collect accurate data on infections.
The lack of knowledge about the scale, origin, and direction of HIV infections is arguably the biggest problem facing most countries in Asia. It is a challenge that Susan Hunter attempts to address in AIDS in Asia: a Continent in Peril, which looks at how the world's most populous continent is being affected by one of the world's deadliest diseases.
This ambitious endeavour is one that Hunter seems well qualified to undertake. A New York-based independent consultant to UNAIDS, UNICEF, and USAID, she won plaudits for her previous book on AIDS in Africa, Black Death. This follow-up, however, is more political, less scientific. That difference might have been no bad thing—there is certainly plenty to be passionate about—but Hunter's polemics are undermined by a shortage of relevant fieldwork and a lack of reliable data.
Hunter's approach is evident in a quote she cites by Paul Farmer, who states that ill health inevitably derives from lack of power, which in turn originates from the violation of human rights. Arguing that the most disenfranchised people are consequently the most vulnerable to HIV, Hunter provides some fascinating, horrifying, and heart-rending details about the spread of the disease among sex workers, drug users, prisoners, ethnic minorities, women, and children, many of whom are traded like farm animals.
Ignorance seems widespread; in India, for example, we learn that two-thirds of people surveyed as recently as 2003 had never heard of HIV/AIDS or any other sexually transmitted disease. In southeast Asia, only 13% of young women could identify two ways to protect themselves from the disease. Central and local governments tend to dodge the issue because it is so difficult for them—for cultural or religious reasons—to broach the subject of sex.
Discrimination is another key factor. We read that in 1996, 95% of India's blood supply was considered risky, but a caste-type system for donations is now in place, which—as one local journalist notes—means “reputable blood banks now advertise blood that is guaranteed not to come from the dregs of society”. Hunter also suggests that China is using HIV/AIDS to commit genocide on its minorities, while the ethnic groups among the hill tribes of Laos are in danger of being wiped out by AIDS.
Unfortunately, what ought to be a powerful argument for positive social intervention fails to convince, because of Hunter's selective use of statistics and quotations. Each chapter starts with a tragic first-person tale by a different victim, but the impact of this is undermined because they are “composites” of the many people who told Hunter their stories.
Reliable statistics are notoriously hard to come by, but instead of recognising the wide range of possibilities, Hunter tends to pick the most sensational number with little explanation why. She declares, for example, that there are 1 million infected people in Henan, which she calls the only province with an “accurate” estimate. Such a high figure is plausible, but even NGOs on the ground admit it is pure guesswork. The Chinese government says Henan's victims are more likely to be in the tens of thousands, which is also closer to estimate by WHO. Similarly, on a regional level, Hunter devotes much more space to the worst possible scenario for HIV/AIDS in Asia—that envisaged by Nicholas Eberstadt, who holds the Henry Wendt Chair in Political Economy. A foreign policy analyst rather than an epidemiologist, Eberstadt has predicted 400 million cases in China, India, and Russia by 2025. The more boring official statistics, which suggest there are only 11·3 million cases today in Asia, are, says Hunter, seen as an underestimate by “most experts”.
This book never adequately explains why this giant continent with six in ten of the world's people still has only one in four of recorded HIV cases, despite its notoriously large drug and sex trades and the fact that two thirds of the world's poor inhabit the region. There are two main possibilities: either there is a giant cover-up, or Asia is doing something right. Hunter never seriously considers the latter. The picture of Asia that she paints is one of corruption, crime, inefficiency, religious dogma, political oppression, and imperial exploitation. “The colonial powers”, she insists,”broke the backs of their Asian subject states”. But it is hard to equate this with the same continent that has such rapid economic growth and high levels of literacy in many of its countries.
Perhaps the reason is that Asia is just too big for generalisations. Although it is possible to chastise many countries in the region for weak government action on AIDS, others like Malaysia, Thailand, and North Korea have used ruthless methods that—painful though it is for a liberal to consider—may have helped to control infection rates. Japan and North Korea, which do not fit comfortably into Hunter's concept of Asian victimhood, do not even merit one reference in the book's index.
The big problem of HIV/AIDS in Asia is that there is a lack of solid information on which to make policy decisions. This book does not change that. Indeed, it bodes ill for the future that such a thin study has been so heartily endorsed by senior figures in international AIDS organisations, such as Peter Piot, Executive Director of UNAIDS. Surely, Asia deserves something better.