Poverty and backwardness

So let’s talk about life expectancy in the People’s Republic of China.

There are good reasons to be skeptical of any life expectancy numbers from the China from the 1950s and 1960s. China did not have a published national census before 1982. There were national censuses of 1953 and 1964, but they were never released. They still haven’t been released.

During the Mao era, China was unconcerned with tracking its vital statistics. The Nationalists documented and published on the demographic transition on Taiwan openly, and in detail. The Communists documented little and published less.

Before 1979, China did not release its population data. There were demographic statistics from model units, but no national reports. There were isolated reports of national population, and there official numbers, somewhere, but there was no publication record.

China revealed some results from the 1953 census, but not the numbers of persons by age and sex. They didn’t reveal anything about the 1964 census. They didn’t even reveal that it had happened.

Before 1976, China did not have a national mortality survey. There were numbers from the household registration system, but there were no survey numbers. When the registration numbers were compared with survey numbers from the unpublished national censuses of 1953 and 1964 or the surveys after 1979, they did not match.

Before 1979, outsiders could not estimate the population China to within 100 million. There was simply no official record. But when Deng Xiaoping came to power, everyone cared about demography. 

The State Family Planning Commission was elevated to ministry status in 1981. After 1979, the State Education Commission established twenty-one university-affiliated population research institutes, and the Chinese Academy of Social Science stablished a Center of Population Research. There had been only one population research institution in 1978. Now there were sixty-three.

That had consequences for the study of China’s demographic history. 

After 1982, the Chinese government published vital statistics covering the entire history of the PRC. The Statistical Yearbook for 1983 included the distribution of the population by sex and age in the 1953 and 1964 surveys, and a series on births and deaths from 1950, based on the registration system.

There was one problem. The numbers weren’t reliable.

Not all the early numbers are raw numbers. They couldn’t have been. They have numbers from the Great Famine. They have numbers from the Cultural Revolution, when many villages and provinces could not track births and deaths. They must be reconstructions and estimates, at least in part.

But the deeper problem is that the early fertility and mortality numbers relied on the household registration system, and the household registration system could not reliably track births and deaths. The household registration system was established in 1954. Its coverage was incomplete in the 1950s and early 1960s, and partial after that.

We know that the registration series on births is inaccurate.  After 1979, China started conducting retrospective fertility surveys. The fertility survey reliably matched the age distribution in the census – the implied ratio was about 98% to 100%. But in almost every year between 1951 and 1980, the surveys counted more births than the registration system. 

The underregistration improved through the Cultural Revolution, but it became worse after 1974, when there was official pressure to restrict the number of births.

The mortality numbers are worse. Ansley Coale checked the difference between the total number of births between two censuses and the intercensal growth in population, with adjustments for the underreported births in the registration numbers.

The implied completeness of the registration death record was only 62% between 1953 and 1964. The registration improved, but the underlying numbers remained inaccurate. There were 57 million uncounted deaths between 1953 and 1964 and 22 million uncounted deaths between 1964 and 1982.

The registration of child deaths was worse. 

There were about 3.5 million more child deaths in 1958–59 than there were in 1957–58, but there are only 1.2 million additional registered deaths. There were 3.9 million fewer child deaths in 1962–63 than there were in 1961–62, but there were only 1.0 million fewer registered deaths. The register was only 30% complete.

The official mortality numbers are unreliable. When Judith Banister surveyed them in 1987, she said this:

In all years prior to 1973–75 the PRC’s data on crude death rates, infant mortality rates, expectation of life at birth, and causes of death were nonexistent, useless, or, at best, underestimates of actual mortality.

The 1973–75 numbers come from the Cancer Epidemiology Survey. The 1976 survey included a record of the 18 million deaths between 1973 and 1975. Those survey numbers included reasonably accurate mortality statistics. But not even that survey was reliable.

The survey was unreliable for the same reason that all other pre-1979 data was unreliable. China did not release the numbers. They released partial data, but they never released them whole. They undercounted deaths, as many as 10 to 20%. 

When Judith Banister and Kenneth Hill reviewed the numbers in 2004, against new data and new methods, they found that the survey had overstated life expectancy. Life expectancy was not 65. It was 60.

That was the good survey.

What was the life expectancy before then, before the national surveys? What was the life expectancy before the Great Famine and the Cultural Revolution? What was the life expectancy before the Communists took power?

There are official rates. The Statistical Yearbook for 1983 listed official crude death rates of 18 per thousand in 1950 and 10.8 per thousand in 1957. These numbers might have been constructed from the registration system or the census numbers.

There’s good reason to think they’re wrong.

If death numbers were underreported, death rates must have been underreported too. After Coale revised the death numbers, he made a rough correction to the death rates for understated deaths.

Coale estimated that actual death rates between 1953 and 1955 were about half what they should have been, but the gap between official and actual death rates declined as reporting improved.

Banister thought the official rates for the 1950s were understated, too. To Banister, there was simply no way that China could have achieved a death rate of 18 per thousand in 1950.

There was a plague epidemic in 1950, plus high mortality from typhus, measles, scarlet fever, and dysentery, according to scattered hints in press reports. As of 1950, China had not begun to prevent or cure tuberculosis, diphtheria, malaria, kala-azar, typhoid, poliomyelitis, or parasitic diseases. 

There was no public health system. There were no epidemic controls, no maternal and child health services, and no disease prevention system. The Chinese had only begun smallpox vaccinations in 1950. They had not eradicated it.

There were still problems in 1957. There was still typhoid, tuberculosis, diphtheria, malaria, poliomyelitis. Water, soil, and food were still contaminated. There were shortages of all kinds of pharmaceuticals and medical care. The immunizations had hardly begun. There were outbreaks of infectious disease. The heavy burden of parasitic disease was everywhere.

But the official numbers were glowing. The official death rate was 10.8 per thousand. The official life expectancy at birth was 57 years. China was still a poor and backward country, but you wouldn’t know if from the numbers. 

Banister suggests an alternative reconstruction.

The effect of Banister’s population series is to make China’s mortality transition more impressive. The pre-Communist death rate and infant mortality rate were halved by 1957, and life expectancy improved dramatically. The Great Famine led to about 30 million excess deaths, but overall mortality improved.

Banister again:

China’s progress has apparently been two or three times as fast as the norm over a very extended period. This record has been matched in only a few small nations or regions: Chile, Taiwan, and Sri Lanka are three examples that can be documented reasonably clearly. The other large developing nations, such as India, Indonesia, Bangladesh, and Brazil, have made much slower progress than China.


From our analysis of China’s 1972–76 mortality data, even when we allow for a considerable margin of error and underregistration, it is apparent that the People’s Republic of China is also a super-achiever in mortality reduction. This large nation seems to have attained a relatively advanced health status heretofore confined to developed and a few small developing countries. If our results are confirmed by more definitive health and mortality data from the Peoples’ Republic, we can conclude that the speed and the extent of China’s achievement in mortality control are unprecedented among the world’s populous developing countries.

But Banister’s conclusion here is based in part on an deflated estimate of mortality in Communist China, and an inflated estimate of mortality in Nationalist China. It’s about where Communist China started.

The title here is a quotation from Chairman Mao, from just before the Great Famine. From Alexander Pantsov’s Mao:

“[T]he 600 million people of China have one outstanding [advantage]: it is poverty and backwardness,” Mao said candidly. “At first glance this is bad, but actually it is good. Poverty arouses them to change, to action, to revolution. On a blank sheet of paper one can write the newest, most beautiful characters, one can create the newest, most beautiful pictures.”

It’s easier to make progress when the country starts from nothing. But no country is ever a blank sheet of paper.

Banister argues, on the basis of a large survey of farmers between 1929 and 1931, that life expectancy was only between 20 and 25 in 1930, crude death rates were about 41.5 per thousand, and most of the mortality reduction before 1975 was achieved under Communist rule.

There are reasons to doubt those assumptions. 

There were no national censuses during the Nationalist era, and no national registration system either, but there were surveys. There was more than one survey, too.

I can’t challenge the conclusion that the Nationalist period had high mortality. But one reason to doubt the argument that there was no substantial reduction in mortality during the Nationalist period is included in Banister’s own numbers.

Life expectancy was about 20 in 1930, at the beginning of the Nationalist period. It had improved to 40 by 1950, at the beginning of the Communist period. Infant mortality was about 300 per thousand in 1930. It had improved to 175 per thousand by 1950.

China was not a blank sheet in 1950, and the reduction in mortality was not merely a Communist phenomenon. It was a Nationalist phenomenon too.

Now let’s look at some graphs. The United Nations Population Division has estimates of life expectancy for its member states dating back to the 1950s and 1960s. Here are their sources on China:

Life expectancy at birth: Based on life tables from: (a) the 1981, 1990, 2000 and 2010 censuses (adjusted for underestimation of child mortality and overestimation of old-age mortality); (b) surveys on causes of death in 1973/75 and 2004/05; © Disease Surveillance Points (DSP) system from 1991 to 2013; and (d) 1987, 1995 and 2005 population survey (1 per cent), and the annul survey on population change (1 per thousand).

They don’t have any life tables we don’t have. They don’t have any survey on the causes of death older than the 1976 Cancer Epidemiology Survey. They don’t have any more current methods. They’re using the same sources and the same methods that Banister and Coale used in the 1980s. But somehow their numbers don’t look quite right.

You’ve seen the graph, I’m sure. 

This graph is why I’m here.

The first thing I need to tell you is that this graph isn’t based on the current revision of the UN series. That shouldn’t matter. It usually doesn’t matter. But it matters here.

This is the current revision. It’s harder to miss the Great Famine in this one.

The UN doesn’t tell us the annual numbers. For reasons known only to them, they present life expectancy series as five-year averages. They tell you what life expectancy in China was in 1960. They tell you what life expectancy was in China in 1960 through 1965. That obscures some important trends. 

The UN series suggests that the first fifteen years of communist rule were a wash. The life expectancy was 43 in the first half of the 1950s and 44 in the first half of the 1960s. There’s something strange about that. 

If China really didn’t see almost any mortality reductions in the 1950s and early 1960s, it would be nearly unique. In Kenya, life expectancy was 42 in the first half of the 1950s and 48 in the first half of the 1960s. There were dramatic reductions in mortality in Congo, Sudan, Burma, and Pakistan. Not China.

But the UN series also conceals the real mortality reductions we would expect to see in the 1950s. It implies that China’s mortality reductions didn’t happen during a period of unification, land reform, and peaceful development, during the Cultural Revolution.

What surprises me here is that you don’t see the mortality improvements in the 1950s, where you would expect them, but the 1960s. You should expect to see dramatic mortality improvements during a period of peace and stability. You shouldn’t expect to see mortality improvements during a civil war.

I don’t think people should be using this graph. 

China’s reductions in mortality are a credit to a state that had immense capacity, but they reflect a state that had immense power over the lives of its people. It used its commanding power to control disease and reduce mortality. But there’s more to life than simply living.

So let’s talk about something weird. Apparently the best fit to China’s life expectancy series between 1960 and 1975 is Libya.

According to the World Bank, the two countries had similar life expectancies at birth in both 1960 and 1975. Both countries improved life expectancy at birth from about 43 years to about 63 years.

China’s 1960 numbers are depressed because of the Great Famine, but Libya’s numbers are not. That means that Libya’s improvement is not a correction from a famine, but simple reduction in mortality.

I only found this out because I was trying to see if there was any statistical effect from an intervention in 1975, but Libya matches China after 1975, too. Saudi Arabia followed a similar path.

There were substantial mortality reductions in Bahrain, Kuwait, and Qatar before the 1960s. There were substantial mortality reductions in Iraq and Syria too. I don’t think anyone takes that as a particular credit to their social system.

So whatever you might say about China, you can also say this: the Arabs did about as well as the Communists.

Keep reading

China Abandons One-Child Policy

Today, China abandoned its 35 year-old one-child policy. 

Based on the now debunked threat of overpopulation that was popularized by Stanford University scholar Paul Ehrlich, the communist government subjected the Chinese people to forced sterilizations and abortions. Many new-born babies were either killed or left to die. 

Today, the Chinese population suffers from a dangerous gender imbalance that favors boys over girls at a ratio of 117:100, and a demographic implosion that threatens future economic growth and prosperity. 

The one-child policy is a reminder of what happens when governments are allowed to interfere in deeply personal decisions of individual citizens and their families.


Today is the 27th anniversary of Tank Man’s bold act of civil disobedience against the Chinese military who just days before violently put down a democratic uprising against the Communist Party.

Ever since I learned about Tank Man in high school I’ve idolized him. He’s been my computer desktop background for years, and I even bought a canvas of the photo and have it hanging on my wall in my apartment.

We have no idea who he is or the fate he met for standing against a massive column of tanks, but I think if we all wish to see a free society in our life time we should be prepared to obstruct, even with our own bodies, the gross injustices perpetrated by the state.

I also really enjoy the symbolism of him holding grocery bags. It shows the dichotomy between voluntary cooperation in the marketplace and the brutal violence of state power and authority.

I’ve included the lesser-known wide angle shot so you can get a real feeling for just how profound his actions were.

Be like Tank Man.


September 9th 1976: Chairman Mao dies

On this day in 1976, the Chinese Communist leader Mao Zedong died just after midnight at the age of 82. Born in 1893 into a Chinese farming family, the young Mao quickly developed an interest in Marxist and Communist ideology. After World War Two, a civil war broke out in China between the ruling nationalists led by Chiang Kai-shek and the communists he had tried to purge. Despite having the support of many Western nations like the United States, Chiang Kai-shek was defeated and Mao, who had led the communists, was victorious. On October 1st 1949 Mao proclaimed the founding of the People’s Republic of China. Mao then ruled the country as Chairman of the Communist Party, and under his rule any opposition to the communist regime was ruthlessly suppressed. Millions died under his rule, some from his disastrous policies like the ‘Great Leap Forward’ of 1958 which tried to rapidly transform China from an agrarian to industrial economy and triggered a deadly famine. Millions more died under his ruthless persecution, especially after the 'Cultural Revolution’ of 1966 which aimed to purge counter-revolutionary forces in Chinese society. Overall Mao’s rule is believed to have caused the deaths of 40 to 70 million people. In his last years Mao worked to ease tensions with Western powers and met with US President Nixon in China in 1972. Mao Zedong died in 1976 following a period of deteriorating health; his body lay in state at the Great Hall of the People for ten days and his embalmed body remains on display in his mausoleum in Beijing.

Celebrating the "Unknown Rebel”

26 years ago today, the whole world watched as a lone Chinese hero stood in front of an advancing column of tanks, refusing to stand down in the face of authoritarianism. 

On the 26th Anniversary of Tiananmen Square, we’re reflecting on the importance of individual liberty while reading old catoinstitute​ articles on the bone-chilling act of valiant defiance at Tiananmen Square.

“China has made substantial economic progress, but the ghosts of Tiananmen are restless and will continue to be so until the Goddess of Liberty is restored,” writes James A. Dorn in this  #ThrowbackThursday Cato@Liberty post from the 20th Anniversary.

"Because the Communist Party departed from orthodoxy and allowed a greater degree of economic freedom, 680 million Chinese fled poverty between 1980 and 2010 and the rate of extreme poverty fell from 84% to 10% during the same period. However…China is still ruled by a regime that represses freedoms of the individual,” wrote Gabriela Calderon de Burgos on Cato’s Spanish language blog, Libremente, in honor of the 25th anniversary last year.

Imagine a world in which the Chinese government (and all others!) had respected its peoples’ rights of assembly and free speech. It might have looked something like this…..

Saturday & Sunday at MoMA Film: An elderly man recalls Mao’s China in the documentary Mr. Zhang Believes, screening as part of our annual Doc Fortnight festival. 

[Chi (Mr. Zhang Believes). 2015. China. Directed by Qiu Jiongjiong. Shown: Cai Yifan as Zhang as a child. Courtesy of All Ways Pictures]

Is broad and clean
And you can’t tell
Where the dead have been
And you can’t tell
What happened then
And you can’t speak
Of Tianamen.

You must not speak.
You must not think.
You must not dip
Your brush in ink.
You must not say
What happened then,
What happened there.
What happened there
In Tiananmen.

The cruel men
Are old and deaf
Ready to kill
But short of breath
And they will die
Like other men
And they’ll lie in state
In Tianamen.

They lie in state.
They lie in style.
Another lie’s
Thrown on the pile,
Thrown on the pile
By the cruel men
To cleanse the blood
From Tianamen.

Truth is a secret.
Keep it dark.
Keep it dark.
In our heart of hearts.
Keep it dark
Till you know when
Truth may return
To Tiananmen.

Is broad and clean
And you can’t tell
Where the dead have been
And you can’t tell
When they’ll come again.
They’ll come again
To Tiananmen.

James Fenton - Hong Kong, 15 June 1989

Bonnie Wright visits Chengdu, learns how to play mahjong, and hangs out with a panda!

Last week, Bonnie Wright was invited to visit Chengdu, in the People’s Republic of China. Check out all the photos from her visit right here!
Longread of the Day: The AIDS Granny In Exile

In the ‘90s, a gynecologist named Gao Yaojie exposed the horrifying cause of an AIDS epidemic in rural China and the ensuing cover-up and became an enemy of the state. Now 85, s…

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Macey Foronda / BuzzFeed

The enormous brick fortress in West Harlem was built in the mid-1970s as a visionary housing project, a new model for an affordable, self-contained urban community. Today, on a balmy September afternoon, it is a low-income housing compound lined with security cameras, guards, and triple-locked doors. A few drunks shouting at nobody in particular linger outside. Pound for pound, though, the most dangerous person living here may just be a diminutive 85-year-old Chinese grandmother dressed in a stylish purple sweater set with black leopard spots sent by her daughter in Canada.

This is not a slum. Neither is it where you would expect to find an internationally known human-rights warrior living out her golden years. In her one-bedroom apartment, Dr. Gao Yaojie — known to many as “the AIDS Granny” — moves with great difficulty through her tidy clutter and stacks of belongings. In the small kitchen, she stirs a pot of rice and bean porridge, one of the few things she can digest. She lost most of her stomach in surgery after a suicide attempt four decades ago and suffered multiple beatings during the Cultural Revolution.

A large bed where Gao’s live-in caretaker sleeps overwhelms the living room. In Gao’s bedroom, two twin beds are piled with stacks of books, photos and quilts. Her desk is heaped with papers, medications, and yet more books. Gao’s computer is always on, often clutched to her chest as she lies working in bed.

“I left China with one thing in each hand,” Gao says to me in Chinese. “A blood-pressure cuff to monitor my high blood pressure and a USB stick with more than a thousand pictures of AIDS victims.”

Before she agreed to meet me at all, she set rules via email: There would be no discussion of China’s politics, the Communist Party’s future, or the myriad issues that concern other dissidents. These are inexorably tied to her own life, but Gao does not want to be known as a multipurpose Chinese dissident. A lifetime of looking over her shoulder for danger has left her wary. She never learned English.

“I seldom see anyone,” she says. “Many people from China are very complicated. I don’t know what kind of intentions they have. I see them as cheating to get food, drinks, and money. They don’t really do any meaningful work.”

Gao believes she is watched here, just as she was in China for so many years. Given China’s well-documented pattern of stifling critical voices abroad, it’s impossible to rule out that someone is monitoring or harassing her, even in Harlem.

Money is tight. She had a fellowship through Columbia University for her first year in the U.S. Now she gets by on private donations that cover roughly $35,000 a year in expenses, the largest of those being her rent at Riverside. She has a few teeth left and can’t afford dental work.

She spends her days in bed, sleeping, writing, researching online, and obsessively analyzing what she witnessed in China in a lifetime that bridged tremendous tumult. For hours, she clicks away on her keyboard, emailing contacts back home for information and putting final touches on her newest book. She learned to use a computer at age 69.

This will be Gao’s 27th book and the ninth to chronicle China’s AIDS epidemic, a public health catastrophe that decimated entire villages and put her on the government’s enemy list. “You wouldn’t understand the earlier books, they were too technical,” she says, flashing a near-toothless grin.

“Although I am by myself, appearing to be lonely, I am actually very busy,” she says. “I am turning 86 soon and will be gone, but I will leave these things to the future generations.”

Her unplanned journey from Henan province to Harlem began 17 years ago, six months after she retired as a gynecologist and professor at the Henan Chinese Medicine University hospital in Zhengzhou. She went from being a retired grandmother to China’s first and most famous AIDS activist, and became such a thorn in the side of the regime that she eventually fled to New York for safety, away from her family and everyone she knows.

She turns to her computer and pulls up a photo of a gravely ill woman with an incision up her abdomen. Gao did not set out to become a dissident.

“I didn’t do this because I wanted to become involved in politics,” she says. “I just saw that the AIDS patients were so miserable. They were so miserable.”

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China Photos / Getty Images

In April 1996, Gao, then 69, was called from retirement to consult on a difficult case. A 42-year-old woman, Ms. Ba, had had ovarian surgery and was not getting better: Her stomach was bloated, she had a high fever and strange lesions on her skin. She grew sicker and her doctors were stumped. After finding no routine infection or illness, Gao demanded an AIDS test for the young mother.

Gao knew from her work that AIDS had entered Henan, the heartland Chinese province. Yet her colleagues scoffed: How could a simple farmer have AIDS? China had only a handful of confirmed cases. The government said AIDS was a disease of foreigners, spread through illicit drugs and promiscuous sex.

Gao insisted on a test. The results came back; Ms. Ba had AIDS. Her husband and children tested negative, which puzzled the doctors further. The patient was not a drug addict nor a prostitute, so Gao began to investigate. She determined the source was a government blood bank — Ms. Ba’s post-surgical blood transfusion infected her with HIV. “I realized the seriousness of the problem,” Gao later wrote. “If the blood in the blood bank carried the AIDS virus, then these victims would not be a small number.”

With no treatment available, Ms. Ba died within two weeks. Her husband, Gao remembers, spread a cot on the ground in front of her tomb and slept there for weeks in mourning.

Witnessing his grief launched Gao on a relentless campaign. She began investigating AIDS in Zhengzhou and nearby villages, conducting blood tests, compiling data, and trying to educate farmers about the risks carried by blood donations and transfusions.

Over months and years, her research into the epidemic took her across much of rural China. What she found astounded her: villages with infection rates of 20, 30, 40% or more; whole communities of AIDS orphans, zero treatment options, and little awareness of what was sickening and killing a generation of farmers. Worse, the population did not know how the disease spread. The numbers of how many were infected and died remain secret, the officially released data almost universally believed to be far too low.

Gao had finally found the cause. “Even now, the government is lying, saying AIDS was transmitted because of drug use,” she says. “The government officials were very good at lying.”

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An illegal plasma station in Shangdong, 2004 courtesy of Gao Yajoie

The breadbasket of China, Henan is cut by the Yellow River and its seasonal, devastating floods. Through generations of extreme poverty, it developed a reputation as a place where people lie, cheat, and steal. In reality, rural Henan is not unlike Middle America, with its sweeping, open pastures, peaceful landscapes, and hardworking people. But among the poor agrarian landscape, dark and deadly ideas for amassing wealth germinate. In the early 1990s, emerging from several decades of manmade and natural disasters, floods, and famine, its best resource was people, nearly 100 million living in a China operating under the notion that “to get rich is glorious.”

Among the cruelest of these schemes was the “plasma economy,” a government-backed campaign from 1991–1995 that encouraged farmers to sell their blood. Fearing the international AIDS epidemic and viewing its own citizens as disease-free, China banned imports of foreign blood products in 1985, just as disease experts began to understand HIV and AIDS were transmitted through blood.

Modern medicine requires blood, and importantly, blood plasma, which makes albumin, an injection vital after surgery and for trauma victims. It is also used in medications for hemophilia and immune system disorders. And plasma is a big-money business — and a deeply controversial one — worldwide. Giving plasma is more time-consuming and painful than donating blood, so fewer people contribute for free, and it attracts people who need quick money: In the 1990s, inmates in United States prisons were pulled into a plasma donation schemes; today, Mexican citizens cross into the United States to border town plasma collection stations.

Though the donors of Henan got a pittance for their blood, middlemen grew relatively wealthy on what was believed to be a pure, untainted plasma supply. Plasma traders worked to convince Chinese people traditionally opposed to giving blood — thought to be the essence of life — to sell it. Villages were festooned with red sloganeering banners: “Stick out an arm, show a vein, open your hand and make a fist, 50 kuai” (at the time, about $6), “If you want a comfortable standard of living, go sell your plasma,” and “To give plasma is an honor.”

Local officials in some places went on television, telling farmers that selling plasma would maintain healthy blood pressure. (It doesn’t.) Traders pressured families, especially women. Since females bleed every month, the cracked reasoning went, they could spare a few pints for extra income.

Though some villages were spared, often thanks to foresight of skeptical local leaders, Henan’s poorest places, especially those with bad farmland, jumped into the blood trade with gusto. Henan officially had around 200 licensed blood and plasma collection stations; it had thousands of illegal ones. Collection stations were overwhelmed. Needles were reused time and again, as were medical tubes and bags. Sometimes, stations sped up the process by pooling blood, unknowingly re-injecting people with HIV-tainted red blood cells.

The system became a perfect delivery vehicle for HIV. Thousands upon thousands of the farmers who sold plasma to supplement meager earnings left with a viral bomb that developed into AIDS. In the years before education and life-extending antiretroviral drugs, it was a death sentence.

As Gao made her discoveries, another doctor, Wang Shuping, was finding the epidemic further south in Henan. Both tried to get provincial health officials to act, to warn people about the risk of AIDS via blood donations and transfusions, and to shut down the system. Both say their bosses and government officials told them to keep quiet.

For several years, Gao, Wang, and other doctors spoke out, but the scandal was hushed up. When people started getting sick and dying en masse, the epidemic became harder to hide.

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Gao giving a lecture about AIDS in Henan province. courtesy of Gao Yajoie

As soon as she began making her discoveries, Gao started giving public lectures, printing AIDS education pamphlets for villagers, and speaking to the press. Still, local officials managed to keep the news contained for a few years.

By 1999, some brave Chinese investigative reporters started writing about the plasma economy and AIDS epidemic. In 2000, international media seized on the story, and Gao became a favorite media subject, seemingly unafraid, always willing to provide detailed statics and talk about what she had found in the hidden epidemic.

Gao and the other doctors finally convinced China to ban plasma-for-cash programs and shut down unlicensed blood collection centers, but the damage was already done to thousands infected with HIV and hepatitis. (And despite the reforms, smaller illegal plasma operations still continued to pop up in rural villages.) This was not without pushback: Gao was threatened, blocked from speaking, had her own photos of AIDS victims confiscated, and believes her phone was tapped for years. Then there were the young men who followed her everywhere, forcing her to sneak out to do her work in rural areas under cover of night.

Gao continued to work to educate rural people about the disease and push for legal rights for victims. She inspired dozens of young volunteers, like the activist Hu Jia, to travel to Henan to donate money, food, and clothing over the years. But as the government tightened its controls and increased threats, volunteers stopped going. Gao, targeted more than most, kept sneaking in. She traveled undercover, visiting families and orphans and passing out her pamphlets.

Her charity embarrassed local officials who weren’t doing the job, and several became enraged. In one particular AIDS village, Gao learned the mayor had put a 500 yuan ($82) bounty on her head. Any villager who caught her in town and told police would get the huge sum. In all the years she visited, donated, and brought journalists in to investigate, Gao says, “they didn’t even try to catch me, they didn’t want to turn me in.”

Gao focused her attention, and her own family’s bank account, on the AIDS orphans, chastising the government to admit what had happened and make reparations. For that she became a target, as did those who accepted her gifts. Local officials wanted credit for helping AIDS victims, though according to her, most did very little.

“I gave them money,” she says, nodding toward a photo of a young woman. “She sold blood at age 16 and died at 22. I gave her 100 kuai ($16). If you gave them money and other things, they had to say it came from the government; they would have to thank the Communist Party.”

China has never provided a full accounting of the infection rate and death toll from the plasma disaster in Henan and surrounding provinces. Low estimates say 50,000 people contracted the virus through selling blood; many more sources put the number at at least 1 million. Another million may have contracted HIV through transfusions of the contaminated blood. Gao believes as many as 10 million people might have been infected, but she is alone in that high estimate.

China recently acknowledged AIDS is its leading cause of death among infectious diseases. In 2011, a joint U.N.–Chinese government report estimated 780,000 people in China are living with HIV, just 6.6% of them infected via the plasma trade, in Henan and three surrounding provinces. The real numbers are subject to debate and almost certainly higher, say global health experts. That figure also includes China’s original, larger AIDS epidemic that entered from Burma into Yunnan province along the drug trade route in 1989, about which the government has been much more open. There is no way to trace how many of China’s acknowledged AIDS cases are linked to the Henan plasma disaster. This is not an accident.

“You understand the situation?” Gao asks. “One thing is lying and the other is cheating. Fraud. From top to bottom, you cannot believe in government officials at any level. Cheating, lying, and fraud are what they do.”

To read the full article, click the link at the top of this post.