Download Migration, STD`s and HIV/AIDS.

MIGRATION, URBANIZATION, AND THE SPREAD OF SEXUALLY TRANSMITTED
DISEASES: EMPIRICAL AND THEORETICAL OBSERVATIONS IN CHINA AND
INDONESIA
Christopher Smith
Department of Geography and Planning
University at Albany, State University of New York
Graeme Hugo
Department of Geographical & Environmental Studies
University of Adelaide, Australia
1
An Outline for the paper
A. Background
1. Averting a Full-blown HIV/AIDS Epidemic in China
2. Report of an HIV/AIDS Assessment in China
B. The Geography of HIV/AIDS in China and Indonesia
1. China
2. Indonesia
3. Some obvious similarities and differences
4. Observations
C. Theoretical Interpretations of China’s HIV/AIDS Epidemic:
1. General theoretical interpretations:
 rural-urban migration, geographic variation, population mixing, and
disease transmission;
 the ‘commodification’ of sex: an externality effect of China’s economic
reform project;
 urbanization, westernization, and culture change: China ‘catching-up’
2. specific interpretations of China’s modernization and urbanization, and its
impacts on behaviour change:
 some background:
 three sets of theoretical interpretations:
A. the dismantling of the organizational and spatial structures that helped
keep order in the Maoist city (from 1949-1978);
- this process has been accompanied by a massive rural to urban
migration, which has resulted in rapid urbanization, as well as a
marked increase in unemployment, poverty, and, for the first time
since 1949, intra-urban inequality…
- in the context of this new urban geography, both the demand for and
the supply of ‘high-risk’ activities began to emerge in the 1990s
B. a dramatic increase in the overall ‘fluidity’ of Chinese society, which has
resulted in the erosion of existing moral and behavioural boundaries;
- in spite of the many benefits associated with China’s ‘openingup,’ there are also fears about the downsides of modernity -- the
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excessive fluidity and movement that has accompanied the reform
project
- interestingly, this is something Marx predicted when he wrote
about how the ‘safe havens’ of the past evaporate or ‘melt into the
air’ when confronted with the forces of modernization (Berman,
1988).
- one of the human consequences of those forces is the emergence
of a new (or vastly increased) culture of ‘marginality,’ with more
people than ever behaving at the far reaches of what is generally
acceptable in an authoritarian society
examples of this in contemporary China include the emergence of:
 new urban youth cultures that have been challenging the
moral and sexual norms of Chinese society
 new (or revived) drug habits appearing not only in the cities
but also in the towns and villages, especially close to the
borderlands
 an entire range of sex-focussed imagery, literature,
products, and services…all available for purchase in the
marketplace
C. a new set of cultural values that have been inviting (and inciting) the
Chinese people to think of themselves differently…for example:
- people have been able, perhaps for the first time ever, to think of
themselves as actors with individual agency;
- ideas about a collective utopian future have been replaced with more
quotidian concerns for everyday life;
- the reforms increasingly stressed the importance of consumption, getting
rich, and enjoying life;
- the rigid class identities of the Maoist era have largely disintegrated
in present-day China we see a cluster of trends that can be
considered symptomatic of this new modernist ‘emptiness,’
including:
 rising crime rates
 government corruption
 marketed pornography
 the trafficking of women and girls
 drug abuse
 the spread of STDs.
C. What can be added to this from a look at the situation in Indonesia?
D. Summarizing, Interpreting, Concluding?
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1. Summarizing, thus far:
2. The state’s response to all of this? reports thus far have been contradictory….
3. Conclusions: some common themes are clearly visible in the new China:
a. the migration effect
b. a new set of structural forces that might have changed human
behaviours
c. a unique new combination in contemporary China…
4. Looking across geographies and cultures:
a. what China can learn from Indonesia
b. what Indonesia can learn from China
c. empirical observations
d. theoretical interpretations
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INTRODUCTION: HIV/AIDS IN CHINA AND INDONESIA
China is on the verge of a catastrophe that could result in unimaginable human
suffering, economic loss and social devastation (UNAIDS, 2002, p.7)
At the beginning of the twenty first century China announced a major change in its
policies toward HIV/AIDS. Until that time the government had tried resolutely to discourage the
behaviours associated with the spread of HIV and other sexually transmitted diseases (STDs). In
some cities the streets were forcibly cleared of prostitutes and drug addicts (Agence France
Presse, 2000). However, such diseases increased in incidence in the 1990s although there was a
failure to acknowledge this at an official level. By the end of the 1990s, international pressure
and the evidence that the HIV/AIDS epidemic was gaining momentum, convinced China’s
leaders that some radically new strategies were required (Becker, 2003). From a global
perspective, and in purely statistical terms, China’s HIV/AIDS problem is considered to be much
less serious than in other parts of the world. Most AIDS workers and researchers, however, point
out that what is most disturbing about the stituation in China is the speed at which the new cases
are occurring, and the geography of such occurrences. 1 The rate of increase in the number of
infected persons had been about 30% per year in the second half of the 1990s, but this appeared
to have doubled by the year 2002 (Thompson, 2003; Wu, 2003).
In Indonesia, the fourth largest nation in the world (2004 population 222,611,000), there
has been a similar experience with respect to HIV/AIDS. Although changes in its political
economy over the last decade have been quite different to those in China, they currently have
prevalence rates of 0.1 percent. Like China, there has been reluctance at official levels to
recognise that HIV is of significance and that it effects more than small numbers of marginal
groups. However, as in China, there is increasing concern because of the rapid increases in
infection notified in recent year and the knowledge that official data substantially understate the
actual rates (Ministry of Health, Republic of Indonesia, 2002, 5). Moreover, as is the case in
China, there is considerable geographical variation in levels of incidence so that in particular
parts of the country, especially some urban areas, the incidence is several times higher than the
national average (Hugo, 2001). While official notifications understate the number of infections,
1
One aspect of the geographical concern is in the realm of treatment; the medical institutions that could provide
services in the event of such an increase in prevalence are concentrated in the eastern provinces and the biggest
cities such as Beijing and Shanghai. At the present time, however, more than 70% of the patients live in China’s
rural areas (People’s Daily Online, January 24th 2003).
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between 2000 and 2004 the number increased by 166.8 percent and there is an increase in tempo
of notification.
The Chinese government now admits there may already be between 600,000 and one
million people infected with HIV (Stephenson, 2001); and the United Nations predicts that by
the year 2010 as many as 10 million people could be infected (UNAIDS, 2001). This estimate
was calculated from current conditions in China, modified by evidence from other parts of the
world where AIDS has become pandemic, especially sub-Saharan Africa, the Caribbean, and
post socialist Russia (National Intelligence Council, 2002). On the basis of these projections
UNAIDS (2002) has described HIV/AIDS as China’s ‘titanic peril,’ and although this sort of
alarmism may be a questionable strategy, evidence suggests that it has captured the attention of
China’s leaders, who are now publicly supporting a massive push in the direction of prevention
and service delivery Thompson (2004, 1) reports that the Chinese leadership which took office in
late 2002…
By late 2003, top leaders were taking a more visible role on HIV/AIDS prevention
and treatment issues – an indication that the lessons learned from SARS would
translate into an increased commitment to fighting the AIDS epidemic.
The anticipated leap forward in the epidemic during the next few years would involve the virus
spreading to an increasing number of areas and populations, resulting in the widespread
dissemination of HIV to the general population. Chinas leaders are now making plans to deal
with the potentially devastating consequences of an epidemic of these proportions, and its
consequences for individual health, community development, and overall social stability
(National Center for HIV, STD and TB Prevention, 2001). International agencies like UNAIDS
have welcomed Chinas new pro-active stance on HIV/AIDS, but there are still major concerns
about institutional and infrastructural problems that threaten to derail prevention and treatment
plans.2
The Indonesian government currently estimates that there are between 83,000 and
278,000 HIV/AIDS sufferers in Indonesia (UNIADS Secretariat, 2004) but the Indonesian
Ministry of Health (2002) has estimated the numbers vulnerable to HIV infection at between 13
No one can be quite certain, either, how strong is the leadership’s political commitment to the HIV/AIDS cause,
and there has been a history of insufficient openness when dealing with the epidemic (Yang and Smith, 2002; Gill,
2003; Center for Strategic and International Studies, 2003). It is also clear the HIV/AIDS cause will have to compete
with many other calls for resources, in light of the current problems with unemployment and poverty in China’s
cities).
2
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and 20 million people. Hence, some commentators see Indonesia to be “poised on the edge of
an Aids Explosion” (McBeth, 2004,46). The official recognition of the crisis has been slow in
coming but now appears to be accepted as a significant threat. HIV infection has been in the past
seen as being a disease of “others” by leaders – foreigners, tourists, drug users, prostitutes, gays,
etc., and not been accepted as a mainstream health issue. Even now there are many prevalent
myths regarding the disease. There are indications, however, that this may be changing. The
relatively small numbers of dedicated officials and NGOs working in this area are succeeding in
getting AIDS on the political agenda, although the resources being made available are still very
small (McBeth, 2004, 46).
The historical geography of China’s and Indonesia’s STD and HIV/AIDS epidemics
China’s STD and HIV/AIDS epidemics appear to have evolved through three phases,
each of which has had a relatively specific geographic pattern. The first of these began as early
as 1985, and was marked by geographic concentration and low overall numbers of patients. At
this point in time, most of the newly infected individuals were appearing in the coastal provinces,
and from all accounts most of them were reported to have been foreign nationals and ‘overseas’
Chinese (mainly from Hong Kong and Macau), as well as some foreigners from other parts of
the world. The official view at the time was that STDs (and then later HIV/AIDS) were
‘foreigners’ diseases -- which had come from outside China, and which could be controlled by
limiting access to potentially diseased individuals from abroad, and by rigorous testing upon
entry (Farrer, 2002).
A second phase, beginning in 1989, was also a geographically-limited epidemic, with
HIV infections clustered in China’s borderlands, particularly in Yunnan Province and Guangxi
Autonomous Region in the southwest, and in Xinjiang Autonomous Region in the far west.
During this period the majority of reported HIV infections were among intravenous drug users
(IDUs), and the spread of the virus was thought to be associated primarily with the cross-border
travel of individuals engaged in a variety of epidemiologically risky behaviours, especially the
trafficking of drugs and the sharing of infected needles. A small number of HIV infections were
being reported at this time among laborers returning from abroad, patients with other STDs, and
some female sex workers (UNAIDS, 2000).
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The third phase began in 1994, when HIV transmission began to appear in China’s
interior (Rosenthal, 2002). In some rural areas, most notably in Henan Province, contaminated
blood was circulated to both the original donors and to the recipients of blood transfusions
(Smith and Yang, 2004; BBC News Online, 2003). Blood collection centers had opened in
Henan and elsewhere in the early 1990s, encouraging peasants to donate blood and blood plasma
in return for payment (Chan, 2001). Local blood banks aggressively sought donors and many
poor peasants were happy to sell their blood, often in less than sanitary conditions. Many of the
individual donors had blood returned to them from communal vats, after the plasma had been
removed and sold to hospitals (Eckholm, 2001). It turns out that some of the pooled blood was
contaminated with HIV, which put both the donors and the recipients at risk, and in some
villages the results were disastrous, with donors being infected at rates as high as 65%.3
As tragic as the Henan blood scandal was -- and still is, in the sense that many of those
infected subsequently spread the virus to others -- from the perspective of public health policy,
by the end of the 1990s the Chinese authorities were beginning to focus more of their attention
on HIV transmissions that were occurring as a result of individual risk-taking behaviours (US
Embassy 2000). According to a UNAIDS (2000) report, the HIV infection rate among drug users
in China increased almost tenfold in a five-year period, from 0.04% in 1995, to nearly 5% in
2000; and by the end of the decade intravenous drug use was thought to account for almost 70%
of all new HIV infections in China.4
At the same time the evidence was also showing that the fastest growing rate of new HIV
infections in China was from sexual contact, much of which appeared to be linked to the
emergence of a thriving commercial sex industry in many parts of China (Wu, 2003). This
phenomenon first became evident in the late 1980s, as one of the unexpected and unintended
consequences of China’s dramatically successful economic reform project. New commercial sex
Chinese and Western media reports have focused on the so-called ‘AIDS villages’ in Henan. The official Gongren
Ribao (Workers’ Daily) newspaper, for example, reported in January 2002 that 80% of the inhabitants of Henan’s
Houyang village tested positive for HIV, 400 people had developed AIDS, and 150 had died in a twelve month
period in 2000. See “China-AIDS: Some 80 percent of Chinese Town’s Population Tests Positive for HIV,”
Financial Times, January 5, 2002. The ‘bad blood” episode, as it has become known, has been described in
numerous reports; see for example, a report prepared in 2002 by the US government’s National Intelligence Council
(ICA 2002-04) entitled: “The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China.” The full report
can be downloaded at: http://www.odci.gov/nic/.
4
Not surprisingly, the geographic distribution of such infections shows the highest rates in the region adjacent to the
so-called Golden Triangle (bordering Laos, Myanmar, and Thailand), see: http://www.usembassychina.org.cn/sandt/CDCAssessment.htm. See also the report prepared by the (US) National Intelligence Council
(2002): The Next Wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India, and China.
3
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outlets opened-up in the coastal cities and some of the provincial capitals, and sex workers
began to re-emerge on China’s streets after a hiatus of more than forty years. It is now apparent
that the sex trades have spread to the smaller cities and towns of the interior, and even to villages
in many parts of the countryside (Micollier, 2003; Hyde, 2001). One of the primary reasons for
this growth is economic, in the sense that sex is a highly marketable commodity, and as incomes
rise new outlets have emerged in multiple locations to satisfy actual and potential demnads.
More importantly, as incomes have risen in China so has inequality, and in recent years many
people have been driven toward the sex trades for purely economic reasons.
The Chinese Communist Party (CCP) successfully outlawed commercial sex work in the
early 1950s, and virtually eliminated the STDs it was associated with. The old prohibitions are
still nominally in place -- and prostitution is still a criminal activity -- but in many areas the bans
are widely ignored. According to one researcher’s estimates, China may now have anywhere
between four and six million female sex workers (Pan, 1999; 2003), a number that seems likely
to increase as the country moves further along the reform trajectory, and as its population grows
more mobile and more entrepreneurial.5 Large numbers of women have either chosen or have
been coerced by economic need to sell sexual services in a variety of locations, including
karaoke bars, massage parlors, barbershops, and hotels (Goodman, 2003).
As this brief summary indicates, in the 1990s China’s STD and HIV/AIDS problem was
restricted to specific parts of the country: the coastal provinces; the southwestern border areas;
and parts of the rural interior. This consensus of opinion was challenged in the latter part of the
decade, however, when it became evident that the epidemic was spreading both spatially and
socially -- moving into different areas and being transmitted to different groups of people. The
number of new HIV infections in 1994, for example, was double what it was in 1993; the
number in 1995 more than triple what it was in 1994; and with one exception the number of
confirmed new HIV infections in China has grown by more than 40% every year since then
(UNAIDS, 2002).6
5
Countering these trends are sporadic but sometimes very enthusiastic and serious ‘strike-hard’ campaigns designed
to clean up China’s streets. A popular location for such activites is the SEZ city at the Hong Kong border, Shenzhen.
In the late summer of 2004, for example, a multi-pronged effort was made to drive out the sex trades from one of the
city’s notorious ‘red-light’ districts: Shazui Village (see SCMP refernce???)
6 Many outsiders argue that the potential for a further and even more rapid spread of HIV in China is increased by
the overall lack of AIDS awareness and education, at least until quite recently (Holtzman, 2003). The government
counters these claims by pointing out that it has launched a number of major national, regional, and local campaigns
9
It did not take very long for researchers to realize that the potential existed for what had
been spatially discrete events to become connected, and from what was being reported in other
parts of the world, it appeared that this process could be accelerated by population mobility.
China had been experiencing a population transfer of unprecedented proportions throughout the
1990s, with perhaps as many as 120 million people – most of them from the countryside -looking for new jobs and homes in towns and cities (Smith, 1996). Because most of those
migrants have only temporary status in the cities, many of them travel back to the countryside
frequently (Solinger, 1999). The threat existed, in other words, for migration to contribute to a
rapid increase in STDs; and for the AIDS virus to gain a foothold in ‘new’ parts of China that
had hitherto recorded relatively low rates of prevalence.
In Indonesia, the spread of HIV/AIDS appears to have gone through three phases since its
initial introduction in 1987 (Utomo, personal communication). In the first phase, infection was
confined to small groups and was spread mainly by homosexual contact. In the 1990s, numbers
of notifications increased and the main method of transmission was heterosexual contact with the
commercial sex sector playing an important role. Since the late 1990s, however, there has been a
dramatic increase in notification of the disease and there has been an increasing amount of
transmission via shared needles by Intravenous Drug Users (IDUs). During the second phase of
spread there was a strong geographical concentration of HIV infection. Although official data on
infection are gross understatements, they do indicate the spatial patterning of the disease. Figure
1 shows that in 1999 the disease was especially high in:
•
The province of Irian Jaya (new Papua) where the rate was 35 times the national figure.
In this province there are a number of distinctive local behavioural and cultural elements,
which favor the spread of infection, especially the taking of multiple partners and high
incidence of patronage of sex workers (Hugo, 2001).
•
The largest number of reported cases and second highest prevalence rate is in the
megacity of Jakarta (2000 population 8,389,443). There was a strong concentration of
the disease in urban locations generally and especially in the national capital.
•
The third highest levels were in Bali, which is Indonesia’s premier tourist destination and
where there is considerable drug and sex industry activity. It has been suggested also that
against AIDS, as well as efforts to improve AIDS education and raise AIDS awareness in China; see:
http://www.china.org.cn/e-news/news823.htm.
10
there are higher levels of surveillance in this province so a greater proportion of infected
people are being detected.
•
The fourth highest incidence is in Riau. There is a well established commercial sex
industry in the area with a well established pattern of Indonesian female sex workers
serving males from Singapore.
This has been partly through the women going to
Singapore (usually undocumented) in the evenings to conduct business and then returning
to one of the islands of the archipelago the next day.
In more recent times the
entertainment industry in several of the islands near Singapore, especially Batam, has
become highly organised to serve daytripping Singaporeans (and increasingly,
Malaysians) and the sex industry is a major part of this. Batam island is the main centre
but the industry is thriving on several other islands (Hull, Sulistyaningsih and Jones,
1998).
Figure 1:
Source:
AIDS Case Rate by Province: Cumulative Cases per 100,000 People as at
31 August 1999
UNAIDS (Jakarta), 2001
4.26
1.09
1
0.02 0.18
2
4
1.00
3
0.50
5
7
0.85
0.01
6
8
0.10
0.02
1 D.I.Aceh
2 N.Sumatra
3 W.Sumatra
4 Riau
5 Jambi
6 S.Sumatra
7
8
9
10
11
12
0.07
21
0.02
18
19
0.01
24
9
0.03 0.01
11 0.1 0.03
10
0.05
12 13 14
15
Bengkulu
Lampung
DKI Jakarta
W.Java
C.Java
D.I.Yogyakarta
0.14
22
23
13
14
15
16
17
18
26
25
27
0.12
National
16
E.Java
Bali
W.Nusa Tenggara
E.Nusa Tenggara
East Timor
W. Kalimantan
17
19
20
21
22
23
24
C.Kalimantan
S.Kalimantan
E.Kalimantan
N.Sulawesi
C.Sulawesi
S.Sulawesi
25 SE.Sulawesi
26 Maluku
27 Irian Jaya
0 kms
500
The third phase of spread of HIV infection in Indonesia has involved two major
elements…
•
A spread outward from the “hot spots” identified above. For example, McBeth (2004,
46) recently wrote that it was “now invading West Kalimantan, South Sumatra, North
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Sumatra and North Sulawesi”, which it is apparent from Figure 1 are low incidence
provinces
•
A greatly increased incidence of HIV infection among IDUs around a half of whom are
estimated to be infected (McBeth, 2004, 46).7
What is apparent is that there is an important relationship between IDUs and the sex industry in
the spread of HIV with about 70 percent of IDUs in Indonesia having regular sex with
prostitutes. Cohen (2004) has shown that in Jakarta, if no IDU epidemics occurred there the
epidemic now spreading through sex workers and clients would not have caught fire. Figure 2
demonstrates how crucial this linkage is in modeling the future level of the spread of HIV
infection in Jakarta.
Figure 2:
Source:
Jakarta: Modelling Of The Incidence of HIV Infection With and Without
Intravenous Drug User Epidemics
Cohen 2004, p. 1934
Over recent years there has been increasing official recognition of the significance of the
HIV epidemic in Indonesia. This was demonstrated in a meeting on 19 January 2004 of key
national ministers and governors of the six most affected provinces in Indonesia8 with 83 percent
of all reported cases in Indonesia. This produced a declaration called the Sentani Commitment
comprising seven action points…
•
7
8
increasing condom use by 50 percent in high risk sexual activity.
In one sample of 200 drug users in Jakarta, 90 percent were infected.
Jakarta, West Java, East Java, Bali, Riau and Papua.
12
•
reduction of harm among IDUs.
•
provision of ART to 5,000 Indonesians with HIV by the end of 2004.
•
reduction of stigmatisation.
•
establishment and empowerment of provincial and district HIV Committees.
•
development of laws and regulations conducive to HIV/AIDS prevention, care and
support programs.
•
speeding up real efforts in response to HIV/AIDS.
This agreement represents a significant shift in official attitudes toward HIV/AIDS whereby the
first time high ranking government officials emphasised and promoted the use of condoms (a
controversial issue in Indonesia9) and implemented HIV/AIDS prevention at local levels. Threemonthly meetings were instituted to monitor progress and a further six “Sentani plus” provinces
were identified.10 Later in 2004, the newly elected seventh president of Indonesia was the first to
make strong statements about the threat of HIV/AIDS and the need for action.
Migration and the broader context of HIV transmission
Most of the medical and public health experts in different parts of the world have warned
China’s leaders that without a massive focus on education and prevention, the future looks very
grim. Under such circumstances, social scientists -- particularly geographers and demographers - are eager to communicate what they know about the link between migration and the spread of
HIV/AIDS. The relationship between population mobility and the spread of infectious diseases
in general has been examined in many different contexts around the world (Massey et al, 1993;
Wilson, 1995; Prothero, 1965; 1977). Within the last two decades many of these studies have
focused on a variety of STDs in different locations, and researchers have cited increasing rates of
mobility as one of the most important factors leading to the rapid diffusion of HIV (UNDP,
2001; UNAIDS, 1998). Some of the most significant findings have come from research
conducted in Africa (Caldwell, et al., 1997; Orubuloye et.al.,1993), and, more recently, in parts
of southeast Asia (Hugo, 2001; Skeldon, 2000; Chantanavich, 2000). Because of their unique
post-migration socio-economic contexts, it is generally reported that migrant workers in
developing countries are more likely than non-migrants to take part in HIV risk-taking
9
Condom use is low in Indonesia and there is stigma associated with it due to its association with prostitution and
the well established myth that it inhibits male pleasure.
10
Central Java, North Sumatra, East and West Kalimantan, North Maluku and Maluku.
13
behaviours, and they generally report higher levels of HIV seroprevalence (Brockerhoff and
Biddlecom, 1999). Among migrant groups, two stand out as being among the most susceptible to
HIV: long-distance truck drivers, and commercial sex workers.11
In spite of the volume of empirical research documenting the role migration plays in the
spread of HIV/AIDS, theoretical work attempting to understand the social and behavioural
mechanisms underlying HIV risk-taking behaviours among migrant groups has not kept apace.
For the most part, the existing studies do not go siginificantly beyond the epidemiology/medical
geography perspective on infectious disease, which views migration simply as a vector of HIV
transmission. It is generally understood that in historical terms the spread of infectious diseases
has always been associated with population movements at varying scales. Almost by definition,
migration brings more people into close contact and creates a greater mixing of people at the
places of destination -- both of which work to provide a ready milieu for viral transmission.
Migrants bring new diseases to existing residents at the place of destination, while at the same
time they subject themselves to the diseases that may be endemic in such locations. Through the
movement of infected persons, migration also provides a vehicle to spread viruses even further
afield, to places where they were previously unknown, including the homes of the migrants
themselves. Obviously, this sequence of events is more likely to be enacted under situations of
temporary and circular migration activities, in which people move backwards and forwards
between two or more regions. It is well known that this situation is common in China (Roberts,
1977) and in Indonesia (Hugo, 1975, 1978, 1982, 2001).
This process is also important in understanding the transmission of HIV, particularly at
the aggregate level. As is the case with the diffusion of other infectious diseases, the virus that
causes AIDS tends to spread from its epicenters outward geographically along well-established
transport connections and trade routes (McCoy et al., 1996; Wallace, 1991, 1993; Wallace et al.,
1995, 1997; Wood et al., 2000). The assumption here is that migration streams -- which are
shaped primarily by the social networks of individual migrants -- will play a role in shaping the
geographic pattern of new HIV infections. From this perspective it seems likely that the
frequency, intensity, and mode of network contacts among migrants will determine the rate of
11
Studies conducted in the more developed countries of the world also highlight the vulnerability of migrant
workers to HIV, and the subsequent transmission of the virus through migrant travel (see, for example, Anderson
1992; 1996; Brummelhuis, 1997; Gras et al., 1999; Lansky et al., 2000; Organista and Organista, 1997; Wallace et
al., 1997; Wallman, 2001).
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HIV transmission in a specific location, or for a specific population group. Since needle sharing
among injecting drug users and unprotected sexual intercourse with multiple partners are the
most common mechanisms of HIV transmission globally, it is not surprising that sexual
networks and social relationships among injecting drug and the people who are workers and
clients in the sex trades, have been identified as key activities by researchers interested in
understanding the spread and transmission of HIV at the aggregate level.
At the individual level the picture becomes much more complex, because the
transmission of HIV requires more specific and intimate personal contacts than is the case for
many infectious diseases. HIV can only spread when there is intimate human contact (involving
either sexual activity or needle sharing), so a first step in understanding of the impact of
migration on the AIDS epidemic must be to identify and understand the underlying mechanisms
by which the process of migration may lead to behavioural changes that make migrants more
susceptible to particular HIV risk-taking behaviours (Weniger and Berkley, 1996).
In the context of sexual activity and drug abuse, the decision among migrants to engage
in risk-taking behaviours might be influenced by a number of activities, including: their
individual characteristics associated with (pre-migration) selectivity; their separation from a
spouse or regular sexual partner; and their (post-migration) exposure to a new social, economic,
and cultural environment in the place of destination (Brockerhoff and Biddlecom, 1999). In a
number of separate studies migrants have been identified as a sub-population whose members
are more likely than the average to engage in socially ‘deviant’ and epidemiologically ‘risky’
behaviours (Anarfi, 1992; Lukalo, 2000; Parker, 1997; Wolffers et al., 2002). In other words,
migration is acting as much more than just a transporter of the AIDS virus; it sets the stage for
broader social and behavioural changes that are thought to render migrant workers particularly
vulnerable to behaviours that put them at risk -- which in turn makes them more susceptible to
HIV infections.
Migration and disease transmission in contemporary China and Indonesia
What health officials feared most about the situation in China during the 1990s was the
possibility of HIV/AIDS spreading from what were considered to be quite localized ‘high-risk’
groups and areas -- many of which were in peripheral locations -- into the ‘mainstream’
population. As noted earlier, three localized HIV/AIDS epidemics could be identified in China:
15
approximately 68 percent of those with HIV were identified as intravenous drug users, most of
whom were in China’s southern and southwestern provinces; about 10% were infected through
heterosexual intercourse, which mostly involved commercial sex workers and their customers;
and another 10% are thought to have been infected through unsafe blood donation practices
(Rosenthal, 2002). Basing their work on research conducted in Africa and elsewhere, experts
working in China came to suspect that individuals in these relatively well-defined ‘vulnerable’
groups were having regular contact with so-called ‘bridge populations’ -- individuals and groups
that have the potential to spread HIV (Yang, 2002a; 2002b).
China’s migrant populations -- or more generally, people with transitory lifestyles or
work routines -- are assumed to represent one of the potentially most dangerous of these
‘bridging populations.’ The assumption made about migrants (in China and elsewhere) is that for
the most part they are young and poorly educated, and although they are in the sexually most
active stage of their lives, they actually have little knowledge either about STDs in general, or
about HIV specifically, and almost no access to preventive education or regular health care. Most
of China’s so-called ‘floating populations’ are young men and women who are literally adrift or
separated from their home places. In many cases they are away from home for most of the year,
living in single-sex dormitory housing, and working long hours in difficult conditions. 12 It is
assumed that under such circumstances they are easy prey for drug sellers, and that many of
them will have both the time and the money to pay for sex with local sex workers. Being far
from home, it is also generally assumed that they are less constrained by the norms of their local
(village and small town) cultures.
A recent report on HIV/AIDS in the so-called Greater Mekong Sub-region (GMS), which
includes much of southwestern China’s Yunnan Province, concluded that population mobility
has been one of the most significant factors for rapid transmission of HIV in the region. As the
author suggested, in fact:
HIV moves with people who, while on the move, pass through various risk
situations that force or encourage them to get involved in unsafe sex or drug
use…Massive population movement in the GMS has created these risk
12
Clearly the situation is different for many of the (mainly) young women who are working in factories -- all over
China -- that have regular social control and surveillance routines (see for example: Pun, 2001; 2002 – need to check
these references). In these situations, where the workers are literally ‘tied’ contractually to the factories, movement
away from the workplace is difficult.
16
environments in many places… that are continuing to fuel the epidemic (Chantavanich,
2000).
In Indonesia too, although there is a stereotype of immobility, it is apparent that there is a
high degree of mobility and the dominant form is non-permanent, circular movement which
involves many millions of workers (Hugo, 1975; 1978 and 1982).
This has several
characteristics which are important from the perspective of examining the potential spread of
HIV/AIDS….
•
migrant workers are selectively drawn from young adults, especially males.
•
movement rarely involves entire family units and these are separations from spouses
and/or parents for extended periods of up to two years.
•
they are particularly directed to places where the commercial sex industry is well
established. These include urban areas, plantations, remote construction sites, oil rigs,
mining sites, border industrial areas and forestry sites.
•
they often earn relatively large amounts of cash.
•
they often are far removed from traditional constraints on behaviour.
•
almost all commercial sex workers in Indonesia are themselves internal circular migrants.
In recent times there have been some other developments in internal population mobility
which may also have implications for the spread of HIV/AIDS. The first is the proliferation of
large factories in the Jabotabek area, and to a lesser extent in areas like Batam in Riau and
Bandung in West Java. This has involved the recruitment of many young workers, especially
women, live in dormitories, barracks and crowded boarding houses. Secondly, the onset of the
financial crisis in 1997 displaced large numbers of these urban based workers some of who
returned to their rural places of origin but many others who moved into the informal sector and
also swelled the numbers working in the informal part of the commercial sex industry (Hugo,
2001). A third development has been the displacements of more than 1.3 million Indonesians by
the outbreak of violence in several outer island locations after 1998. Many of these IDPs
(Internally Displaced Persons) have been accommodated in “temporary” camps. These places
have a history in Africa of fostering the extent and spread of HIV infection.
Indonesia is also one of the world’s largest suppliers of international labour migrants
(Hugo, 2003). This movement shares many of the characteristics of internal circular migrants
17
although the length of separation from family is generally longer. The main characteristics,
which could increase this vulnerability, are as follows…
•
most OCWs move without their families and may be separated from family and friends at
their destination usually for a period of around 2 years.
•
women are a major element in the migration and in fact dominate in the official migration.
The women are predominantly employed as household domestic workers which can and
does expose many to the threat of exploitation.
•
There is a significant movement of Indonesian women to work in the commercial sex
industry in Malaysia (Jones, 1996).
•
there is increasing evidence of trafficking of women from Indonesia to elsewhere in
Southeast Asia (Jones, 2000).
•
the OCWs are overwhelmingly of rural origin with limited skills.
•
there is little official support for OCWs once they are in a foreign country.
•
perhaps more than a half of OCWs are not legally resident in their destination country
which exposes them to the risk of exploitation.
•
there is a thriving commercial sex industry in many of the destinations of OCWs.
•
the OCWs often have disposable cash income.
Reviewing some of the empirical evidence: China
It is now generally accepted that STD infection is likely to be a result of having
unprotected casual sex, the majority of which is provided commercially in China. Yang (2004)
has reviewed a large number of studies conducted in different parts of the country. In many
instances these studies have reported higher STD prevalence rates among temporary migrants
than among other population groups, which suggests that migrants are more likely to have had
multiple sexual partners, and to have engaged in casual or commercial sex. Significantly, the
majority of commercial sex workers in China are also migrants, and most of them are young and
have relatively little formal education. As we have seen in studies conducted elsewhere in Africa
and Asia, female sex workers tend to be highly mobile, as are many of their clients, which
implies a potentially widespread pattern of STDs across space (Hugo, 2001). Female sex workers
are doubly-exposed to HIV infection: as risk-takers themselves; and also as victims of the risktaking sexual behaviours of others. Because of the well-known correlation between the incidence
18
of STDs and the (later) transmission of HIV, the migration connection is considered to be
crucial in this context.
From the data collected in studies of HIV risk-taking behaviour it appears that temporary
migrants in China are also more likely than non-migrants to be users of illegal drugs (Qiao et.al.,
2001). A study conducted in Beijing, for example, showed that almost 50% of the clients in an
involuntary drug treatment center were temporary migrants; and the likelihood of drug use
among this population was significantly greater than it was among the permanent residents of the
city (Zu et al, 2001). The same study also made it clear that a significant percentage of those
infected with HIV were temporary migrants. Data from a survey conducted in a southwestern
province by Yang and his colleagues also show that temporary migrants are over-represented in
the STD and HIV statistics. Migrants made up only 1.8% of the total pool of respondents
(representing 2.5% of the working age population) in 2000; but they accounted for 13.0% of the
known drug users, and 14.4% of injecting drug users (Yang, 2002a; 2002b).
A correlation analysis using this survey data showed that the total drug use index and the
injecting drug use index were both positively correlated with the volume of temporary migration
in the province.13 The correlations were stronger for injecting drug use than the total drug use
index, and both sets of correlations seemed to get stronger over time (from 1996 to 2000).
Although the results of such an aggregated study certainly should not be taken as definitive,
13 The data used in the analysis come from a community survey conducted in southwestern China by Xiushi Yang
and his collaborators in China (see Yang, 2002a; 2002b; 2004). The survey is part of an ongoing project on the link
between migration, HIV risk-taking behaviour, and HIV/AIDS, funded by the National Institute on Drug Abuse. The
survey covered an entire province in the region and used a special questionnaire to compile annual information from
1996 to 2000 on a wide range of socioeconomic indicators, as well as on STDs, HIV, drug users, and detained sex
workers. For annual cases of HIV and STDs, data were collected at the county level and based on sentinel
surveillance data (for HIV), and clinical records (for STDs) from the Provincial Department of Health. All other data
were recorded at the township level in rural and town/district level in urban places. Because the two main indicators
of primary interest to this paper -- reported cases of HIV and STDs -- are measured at the county level, this paper
uses counties as the unit of analysis, and defines ‘community’ as a county or an independent city. Accordingly, all
social, demographic, and economic indicators at the township (rural) and town/district (urban) level are aggregated
to the county level for the analysis. To take advantage of the five-year data series, the original data are transformed
into ‘county-years.’ Each ‘county-year’ record contains county- and year-specific information on HIV, STDs, and
other socioeconomic indicators. The sum of all county-year records constitutes the sample for the analysis reported
in this paper. For the sensitive information about drug use (and also commercial sex and STD/HIV/AIDS prevalence
rates, see later), the raw data were converted into indices, to protect individual communities from being identifiable.
Specifically, the total number of drug addicts, the number of injecting drug users, the number of detained
commercial sex workers, and the number of confirmed HIV infections were regrouped into intervals, and numeric
indices were created to represent the intervals in ascending order. The index for total drug addicts ranges from 0 to
34, while those of injecting drug users, detained commercial sex workers, and the number of confirmed HIV cases
range from 0 to 31, 0 to 19, and 0 to 9, respectively.
19
Yang has suggested, with some reservations, that temporary migrants are more likely than their
permanent counterparts to use illicit drugs and to inject drugs.
The same data also pointed to a correlation between temporary migration and the
prevalence of commercial sex activities, using both the number of detained commercial sex
workers, and the number of entertainment establishments as indicators (Smith and Yang, 2004 –
reference needed). It is widely recognized that entertainment establishments such as bars,
karaoke parlors, and barbershops often provide -- or are closely associated with the availability
of -- commercial sex services, and Yang’s results suggested, at least at the aggregate level, that
the presence of temporary migrants, both as customers and as service providers, is positively
associated with commercial sex activity.
Although the analysis reported by Yang and his colleagues is based on secondary
sources, and their conclusions are far from being conclusive, the evidence points to a relationship
between temporary migration and the behaviours that carry a high risk for contracting STDs,
including HIV. It is important to stress that from an analysis of this type we can not say with any
certainty why temporary migrants are more likely to engage in STD/HIV risk-taking behaviours,
other than that their demographic profiles predispose them to such behaviours: their youth; their
living away from home; their concentration in the informal sectors of the urban economy; and
their residence in makeshift migrant communities. From what we have learned through history
about the transmission of infectious diseases, as well more specifically from observing recent
HIV/AIDS epidemics in other parts of the world, it is reasonable to hypothesize that in
contemporary China all of these characteristics, working in a variety of ways, are speeding-up
the transmission of STDs and HIV.
To take this suggestion a step further, in a recent paper Smith and Yang (2004) have set
out some dimensions of a theoretical interpretation of the relationship between migration and
risky behaviour that involves considering four sets of potentially causal variables. The theoretical
framework of this interpretation draws upon concepts from two major sociological perspectives:
‘social isolation’ theory, and ‘social control’ theory; and from two sets of geographical
observations: one pertaining to the individual socio-economic characteristics and pre-migration
selectivity factors among migrants; the other focusing on the sorts of places migrants are most
likely to congregate in. The relationships between and among these different sets of factors are
illustrated schematically in Figure 3.
20
Figure 3:
Source:
Theoretical Framework for the Study of Temporary Migration and
STD/HIV/AIDS Risk Taking Behaviour
Smith and Yang, 2002
Reviewing some of the empirical evidence: Indonesia
Despite the characteristics of Indonesian circular migration outlined earlier, there is no
direct evidence to suggest that circular migrants in Indonesia have a higher rate of HIV infection
than non migrants. This is because migrant workers have not been included among the sites for
sentinel surveillance activities and the collection of data on HIV infection. We also must
emphasize the inappropriateness of assuming migrants per se have a greater vulnerability to HIV
infection. The evidence is that many are placed in contexts where they are at higher risk of
infection than if they would have remained in their home areas. Circular mobility is occurring
on a massive scale in Indonesia. In Java few rural households are not influenced by it. There is
a concern not just because of the high level of individual labour mobility in Indonesia but the
nature of that mobility and the extent that it puts movers in destination situations that are
potentially high risk areas. There are also few data to suggest that Indonesian OCWs have a
higher rate of HIV infection than non migrants at the destination or origin. While it is illegal in
Indonesia to insist that workers be compulsorily tested for HIV before or after migration (Asian
Migration News, 1-15, December 2002) in fact many destination countries and employers do
21
insist on pre-departure testing and periodic testing while they are in the destination (e.g.
Singapore) although no data are available regarding them. One set of data released relates to
Brunei which compulsorily HIV tests incoming Indonesian OCWs and of 33,865 tested only one
was HIV positive (Parida, 2000). It should be noted in passing that Indonesia has an extremely
high rate of premature return among its official overseas workers (Hugo, 2003). It is not known
which proportion of these returnees are people who have been found HIV positive. While the
bulk of Indonesian CSW international labour migration is to Malaysia it does occur to other
areas. In 2003 (Asian Migration News, 16-31, May 2003) it was reported that 100 Indonesian
migrant workers working as prostitutes in several cities in Saudi Arabia had been arrested and
were being deported. Another report (Asian Migration News, 16-30, June 2003) was that 1,500
young Indonesian women were trapped in the sex business in Abu Dabi after being tricked into
moving there with the promise of well paying jobs as factory workers or domestic workers.
As is the case in China, just as the nexus between IDUs and the Sex Industry has been
important in the increasing incidence of HIV infection, this is also the case with respect to
another nexus – that between the commercial sex industry and population mobility. As in China,
there has been a massive increase in individual mobility in Indonesia much of it involving
circular migration and the separation of families (Hugo, 2002). There are several elements in the
relationship between population mobility, the commercial sex industry and the spread of HIV.
•
Almost all Commercial Sex Workers (CSWs) in Indonesia are themselves circular
migrants. They do not practice their business in their home communities.
•
Mobile groups are among the heaviest users of the services of the commercial sex
industry. Results of behavioural surveillance surveys in several Indonesian towns show
that more than half of highly mobile males bought sexual services in the past year
(Ministry of Health, Republic of Indonesia, 2002, 11).
•
The Indonesian commercial sex industry is concentrated in areas where there are large
numbers of circular migrants – in cities, border crossing points, remote clusters of
employment in construction, mining, plantations, etc., at tourist destinations, along
transport routes and in transport centers and ports.
22
The potential for the spread of HIV infection through the strong interaction between migrant
workers and the commercial sex sector is demonstrated in Figure 4. The infection can readily be
passed from customers to CSW or vice versa. However as the diagram shows both CSW and
customer then have a substantial capacity to spread the infection. Firstly, both can take it back to
their home area and pass it on presumably to their partners. However a strong feature of
mobility of internal migrant workers and CSWs in Indonesia is that they don’t tend to always go
back to the same destination to work. The existence of established circuits of circular migration
among CSWs occurs not only within Indonesia but also in international sex worker migrations
(Brockett, 1996). Hence there are multiple diffusion effects as both CSW and customer become
agents of diffusion.
Figure 4:
Model of Potential Spread of HIV/AIDS in Indonesia Through The
Commercial Sex Industry
New Workplace
New Workplace
CSW
Customer
Home Area
Home Area
spread of HIV infection
A Cautionary Remark: Migrants as Scapegoats?
As intriguing as both the theoretical and the empirical parts of this work are, it is
important to stress that the vast majority of migrants -- in China, Indonesia, and elsewhere -manage to steer well clear of all ‘risky’ behaviours, and do not contract or spread diseases of any
type. In fact as a number of recent studies have pointed out, there is nothing about being a
migrant, per se, that is associated with a higher risk of contracting the HIV virus (Skeldon,
23
2000). It is much more likely, in fact, that some of the specific localities in which migrants tend
to congregate have become the source of the services and/or facilities associated with ‘risky’
behaviours: including local drug suppliers, sex workers on the streets or in brothels, and
entertainment places such as bars and lounges.
It is also worth noting here the dangers of falling into the trap of making scapegoats of
migrants, by ‘blaming’ them for many of the things that are going wrong today. This pertains
especially to contemporary China, which has been experiencing a rural to urban population shift
of monumental proportions (Zhang, 2001). 14 It is generally assumed that the demographic
characteristics of migrants predispose them to many other social and health problems, including
crime, that are threatening to upset the social order in China, and are becoming a major concern
to the leaders in Beijing.15 Although it may be reasonable to assume that migrants might
be responsible for some of these problems, or perhaps for making such problems worse, it would
be unwise -- and unjustifiable -- to focus only on migrants and their behaviours in the analysis of
social problems.
In the realm of sexual activity in China, for example, and specifically STDs, this was
brought home dramatically with the publication of recent sex survey data. One national survey
reported that the main clients of sex workers are middle class men under 35 years old (Pan,
2001). Although migrants are now being linked with the spread of STDs, this survey reported
that officials and businessmen in urban areas are ten times more likely to pay for sex than
physical laborers in China’s cities, and twenty-two times more likely in rural areas (Kaufman
and Jun, 2002). This reinforces the findings published by Parish (2003) and his colleagues in
their nationwide study of a specific sexually-transmitted disease, chlamydia. Parish reported that
This willingness to attribute ‘blame’ to the migrants surfaced again in response to the SARS outbreak in the
Spring and Summer months of 2003. There were reports that migrants who returned to their homes were among the
first to be quarantined if there was any suspicion of contact with, or proximity to, anyone who had the virus
(Kaufman, 2003).
15
Policy makers and people-on-the-street certainly seem to have concluded that the sudden appearance of so many
transient people must be associated with the increase in crime rates of all kinds, for example, especially in China’s
cities (Liu, Zhang and Messner, 2001). In addition, the vast numbers of new migrants in many of China’s cities has
reintroduced a significant element of intra-urban inequality -- in terms of both income and access to services -- that
has not been seen in China since before the Communist takeover in 1949 (Kahn and Riskin, 2001; Knight and Song,
1999; Knight et.al., 1999). In the presence of such rising inequality, there is a growing concern about social disorder
in China, and a deep-seated fear that the situation will get out of control. Perhaps the most dangerous trend, from the
perspective of the regime leaders at least, is the problem of urban unemployment. Urban labor markets are being
flooded with laid-off workers, as the massive state-owned enterprises are restructured, downsized, and privatized.
Such workers now have to compete with the influx of migrants, many of whom are willing to work for lower wages
and in adverse conditions.
14
24
“the chlamydial epidemic is concentrated in commercial sex networks, with socially active men
who earn a high income and transmit these infections to their wives and other steady sex
partners.” Although it seems likely that many of the sex workers in question are migrants, their
customers, who are clearly not migrants, are also running a considerable risk of spreading the
disease.
If we want to understand where Chinas’ HIV epidemic may be heading next, it may be
appropriate, therefore, to look beyond the rural areas and the periphery, and at other population
groups in addition to migrants. In demographic terms, it is in China’s cities where most of the
recent population growth has been recorded, and some extraordinary transformations have been
underway now for nearly two decades. Although there is still little direct evidence to support
such a hypothesis, it could well be in the cities where the most significant and potentially the
most lethal changes in epidemiological risky behaviour will occur in the near future. This
discussion will focus on the situation in contemporary China, but in the following/final section of
the Chapter an attempt is made to put these observations into a wider context, using the case of
Indonesia for specific comparisons and contrasts.
In Indonesia too it is apparent that it is in urban areas where much epidemiological risky
behaviour is concentrated.
Hugo (2001) has recognised the following ecological areas in
Indonesia where both HIV rates are elevated and there are concentrations of migrant workers and
the commercial sex sector.
•
Ports and other important transshipments points and transport hubs as well as along major
transport routes.
•
Major urban centres, especially fast growing cities.
•
Major constructions sites, especially those in more remote areas.
•
Border areas.
•
Other areas where large numbers of contract workers are employed – plantations, forestry
enterprises, mines, oil extraction areas, remote factories and processing plants, etc.
It is apparent though it is urban areas where the bulk of risky behaviour involving the
commercial sex sector and reuse of needles by IDUs occurs in Indonesia.
URBANIZATION AND RISK-TAKING BEHAVIOUR IN CHINA
25
Over the last two decades China has been the most rapidly developing and the most
rapidly urbanizing nation in the world (Solinger and Chan, 2002). The economic reforms of
Deng Xiaoping’s modernization project transformed China dramatically, and within two decades
most of the institutions and the infrastructure of Maoist socialism were altered almost beyond
recognition. China’s rapid urbanization has been the subject of much new research, conducted by
both domestic and foreign scholars (see, for examples, Li and Tang, 2000; Ma, 2002; Ma and
Wu, 2004; Logan, 2002), but to date very little research emphasis has been directed toward the
human outcomes of China’s extraordinarily rapid urbanization It has been in the cities of China
where the impacts of economic reform and the process of ‘opening-up’ have been most evident,
and where there has been the most impact on human activity. What we are suggesting here is the
notion that such radical changes have been -- and will increasingly continue to be -accompanied by epidemiologically high-risk new behaviour patterns.
For the purpose of clarity, and in what should best be regarded as an exploratory exercise,
we attempt to link three overlapping dimensions of China’s urbanization to new risk-taking
behaviours among city dwellers: firstly, the dismantling of the organizational and spatial
structures that helped to maintain social control in Chinese society, especially its cities, during
the Maoist era (from 1949-1978); secondly, the increase in the overall ‘fluidity’ of Chinese
society, some of which has been expressed in geographical terms (e.g. migration) but which has
also resulted in the erosion of some of the behavioural boundaries of China’s recent past; and
thirdly a new set of cultural values that have been allowing the Chinese to think of themselves,
perhaps for the first time ever, as actors with individual agency. It is hypothesized that these
overlapping forces -- which are geographical, socio-economic, and cultural in nature -- are
interwoven with and thoroughly implicated in the emergence of new behaviours and lifestyles in
urban China.16
Urban restructuring and the demise of the socialist ‘golden age’
16
It is important to re-emphasize here that this is merely a hypothesis at this stage, but the author, along with a
number of collaborating China scholars, is currently developing a survey instrument that can be used to assess some
of the fundamental cultural changes that are taking place in a sample of China’s cities. For a theoretical introduction
to this project, see, for example, Smith, 2003.
26
During the Maoist era (1949-1976) China’s cities achieved what now looks like a rather
unlikely blend of high social stability matched by low prosperity. Through a combination of
political manipulation and social/spatial engineering, China’s leaders managed to create a new
urban society that some scholars have described as the ‘golden age’ of Chinese socialism (Whyte
and Parish, 1984; Solinger, 2000). In the cities, remarkably few instances of social disorder were
visible: mobility was highly constrained, unemployment was virtually nonexistent, and crime
and other social problems were almost unheard of. No one was wealthy, but neither was anyone
visibly destitute, and intra-urban inequality was probably as low as it has ever been measured
anywhere in the world.17 The household registration system (the hukou) restricted peasant entry
into the cities, and controlled unwanted migration out of the countryside. By limiting the
competition from rural migrants, the state virtually guaranteed city dwellers access to jobs and
their attendant state benefits. The workers -- and usually their entire families -- were covered by
national labor insurance, which provided pensions, medical care, and maternity leave.
The outcome of the near-total state control over society in Maoist China was a highly
homogenous urban society, in which almost all urban dwellers had the same (low) salaries, and
spent virtually the same as everyone else, in the same threadbare shops. Outsiders were partly
fascinated -- and partly repulsed -- by what they saw as the dull conformity of urban life in
Mao’s China (Kirkby, 1985). There was no advertising (other than political propoganda), no
trading, no personal services being offered, and virtually no commercial activity on the streets.
The cities were peaceful and safe, and ‘deviant’ or ‘high-risk’ behaviour of any sort was rare
(Liu, Zhang and Messner, 2001). According to the Party-line, this was one of the major benefits
of socialist egalitarianism; but it is also evident that at the local level the state kept a close eye on
everyone, and was more than willing to use force to weed out any wayward individuals and
behaviours.
In the economic realm, within a relatively short period of time (after 1949), the smallfactory nature of the pre-revolutionary Chinese city -- where jobs were insecure, mobility was
the norm, and welfare benefits were nonexistent -- was almost totally eradicated. In the new era
the workforce was under tight control. Individuals were tied to work-units they could not leave:
the net effect was that the cities were essentially peasant-free for about two decades. The
17
At the start of the 1980s, the average household in China spent less than 5% of its total budget on housing,
utilities, transport, education, and medical care combined; in the United States the equivalent figure would have
been closer to 50% or 60%; see Smith (2000).
27
‘invisible walls’ that kept the peasants out of the cities were enforced by rigid registration
checks, food rationing, and governmentally assigned jobs and housing -- which were unavailable
to the peasants in the countryside (Chan, 1994).
All this began to change dramatically after the reforms were underway in the early 1980s,
and within two decades most of the partitions and boundaries that had been assembled during the
Maoist era had been dismantled (Solinger, 2000). At this time China began to urbanize very
rapidly, both as result of a massive population transfers from the rural areas to the cities, and as a
result of the deliberate upgrading of lower order places into higher order places (Lin, 2002). 18
Market forces have effectively worked to reshape the landscapes of China’s cities, while at the
same time restructuring the lives of the workers. What had once been the norm -- having a
permanent, relatively well-paid and secure state-sector job -- is now very much of a luxury. In
fact, by the end of the 1990s unemployment was probably the most serious problem in China’s
cities, with at least 13 million laid off in 1997 alone, and several million more in subsequent
years (Solinger, 2002). Wages in the state sector slipped down to (and even below) the level of
those outside it; and with job security sacrificed to competition, fears about the rise of a new
urban underclass population began to become a reality (Parish and Chen, 1996). By the end of
the 1990s it was becoming clear to observers from home and abroad that the social problems that
had effectively been eradicated from the Maoist city had returned to plague the cities of Deng
Xiaoping and his successors.
Unlike the cities of the socialist era, China’s cities today look as if they are prosperous; but
this outward appearance is actually obscuring the phenomenon of rising intra-urban inequality,
extensive pockets of poverty, and more than a few signs of social instability (Pei, 2001).
Behavioural norms were changing rapidly at either end of the social spectrum: the new rich were
starting to consume and behave in ways they had never even dreamed about just ten years earlier;
while at the other end increasingly large numbers of city dwellers were facing a desperate struggle
just to make ends meet (Conachy, 2001; Schauble, 2002; Forney, 2003; Chan, 2003). It is within
these new dimensions of China’s urban social geography that we might look for signs of what the
Although there are many debates about exactly how best to calculate what percentage of China’s population is
‘urban’ as opposed to ‘rural,’ the statistics show that the proportion has increased from roughly 10-12% in the early
1950s, to about 20-25% by the mid-1980s, then almost doubling by the year 2000 (Zhang and Zhao, 1998). In
official circles it is estimated that urbanization could continue to increase at this steep rate over the next few
decades, eventually reaching 50%, with some estimates as high as 75% (People’s Daily Online, 2002).
18
28
Party leaders were starting to refer to in the 1990s as ‘deviant’ behaviours (Dutton, 1992; 1998),
and, in the terminology used in this Chapter, ‘high-risk’ activities.
The new urban mobility and the erosion of behavioural boundaries
In addition to the process of internal migration that has been reshaping China’s urban
landscapes, one of the recurring themes in debates about the modernization project in China
involves the idea of movement or mobility, as expressed in the Chinese term liu. An important
dimension of modern behaviour, especially among the young, involves the preference for being
constantly on the move, or literally ‘mobile.’19 The Norwegian sociologist Borge Bakken (2000)
has argued that there is a connection between movement, deviance, and danger in the modern
city, as indicated by the emergence of a new breed of urban anti-heroes: the liumang (roughly
translated as ‘hooligans’).20 As Bakken points out, the Chinese character liu -- meaning ‘to flow’
-- carries with it the negative connotation of a person who is not tied down spatially, and whose
character is brought into question as a result of his (actual and assumed) lack of stability. The
character mang has been used to describe people who come from ‘outside the boundaries,’ ‘from
the wilderness,’ or, more likely these days, ‘from the countryside.’ Combining these two
characters into liumang, we have a word to describe a person who appears to be unreliable in
some way, and not to be trusted: which is certainly the way many city residents think about
migrant or ‘floating’ populations (Buruma, 2001).
Although many Chinese today are enjoying the benefits of positive change and the new
possibilities associated with China’s ‘opening-up,’ there are also fears about the downsides of
modernity -- the excessive fluidity and movement that has accompanied the reform project. This
is something Marx had in mind when he described the tendency for the “safe havens” of the past
tend to evaporate or “melt into the air” when confronted with the forces of modernization
(Berman, 1988).
19
The Chinese expression liulang, for example, implies roaming around and a proclivity for the vagrant life, which
is a recurrent theme in Chinese popular music; and liudong is associated with the new ‘floating’ populations, which
can now be seen everywhere in urban China. The Chinese word dong means or implies movement, but it also
denotes change and alteration. Like liu, dong represents both hope and danger (Bakken, 2000), and it is perhaps
more than a coincidence that the demonstrations leading up to the final crackdown in Tiananmen Square, in June
1989, were described by many -- and officially, by Deng Xiaoping and his cohort -- as dongluan, ‘turmoil’ or
‘disturbance.’
20
Liumang is the word used to describe the perennially popular ‘hooligan’ literature associated with Wang Shuo and
other writers, where layabouts and minor hoodlums are often the (anti-) heroes of the day (Barme, 1999; J. Wang
1996).
29
In behavioural terms one of the major outcomes of such forces is the emergence of a new
(or vastly increased) culture of ‘marginality:’ with more people than ever before involved in
pursuits that only a few years earlier had been sharply proscribed. Examples of this in
contemporary China include the new urban youth cultures that have been challenging the
behavioural and sexual norms of Chinese society; the new (or revived) drug habits appearing in
some of China’s cities; and the emergence of an entire range of sex-focused literature, products,
and services -- including imagery and real-life activities -- that are available for purchase in the
marketplace (Farrer, 2002) As one recent observer has remarked: “Chinese urbanites today are
bombarded with a global popular culture and consumer economy that places sex at the center of
just about everything” (Farquhar, 2002, p. 247).
A visit to China today, especially to the breathtakingly transformed cities along the east
coast, and to the new Special Economic Zone cities -- which, like Shenzhen, Zhuhai, Xiamen,
and Haikou, barely existed three decades ago -- will confirm Farquhar’s suggestion that sex and
sexuality are now very much in evidence everywhere. With the state no longer in charge of
everything the people read -- and more importantly, no longer deciding who writes and who
publishes -- books and magazines with a strong sexual content are for sale everywhere (Smith,
2003). Explicit descriptions of sexual activity are now commonplace in erotic and romantic
novels; and harder-core reading is and viewing is relatively easy to attain for those who know
where to look, as well as on the Internet.21 There is also a great deal of interest these days in
what is referred to in China as ‘sexology’ (the ‘scientific study of sexual behaviour), both from
the consumer point of view and as a new field of academic enquiry, and this has spawned a
proliferation of sex manuals and related publications (Bakken, 2000; Dikkoter, 1998).22
The marketplace is clearly at the root of most of these new developments, and in China’s
cities there are now opportunities to buy virtually anything: lurid pictures are for sale in
magazines, as posters and calendars, and in books. New lines of fashionable clothing, cosmetics,
and personal care products intended to accentuate (male and female) sexuality are now
ubiquitous. Sex-oriented shops in most of the big cities are now selling birth control supplies,
condoms, herbal aphrodisiacs, skimpy leather clothing, and all manner of sex toys and aids.
21
Recent SCMP story on the huge trade in pornographic CD’s and DVD’s in China…see???
It is not uncommon to find domestic medical sexology texts for sale in bookstores today (see Liu, et al, 1997), as
well as translations of foreign classics like the Kinsey report, a host of new versions of erotic stories from China’s
past, and a brisk trade in volumes devoted to a new branch of medical science dealing purely with male sexuality,
called nanke (‘men’s medicine,’ see Farquhar, 2002).
22
30
Chinese films now routinely feature explicit sex scenes, and, although visually much tamer,
Chinese television advertising is now thoroughly suffused with sexual imagery designed to sell
products of all types.
It is difficult to interpret the significance of these developments, and to analyze their
impact on the sexual behaviour of the urban Chinese. Judith Farquhar (2002) suggests that China
has become obsessed with sex as a topic to talk about, to look at, and to take part in. The most
important aspect of all of this new sexual emphasis, she argues, is the sharp break it represents
with the past. Prior to the economic reform period (pre-1978), sex -- its depiction and even its
mention -- was largely taboo in China. Sex was considered at that time to be purely functional:
adults were expected to reproduce for the revolution; as Farquhar puts it “model mothers were
rewarded for building socialism by giving birth to many children” (p. 215).
The rules were changed soon after Deng Xiaoping came to power, with the widespread
application of the ‘one-child’ policy in China’s cities, but sex, either as an activity or as a
recreational and entertainment topic remained largely off-limits. By the end of the 1980s, this
had begun to change, however, with sexuality emerging as a part of life quite separate from
either reproduction or obligations to the state.23 In the new millennium it is evident that sex has
now become a freestanding topic in its own right, and one reason for this -- Farquhar suggests -is that for the modern Chinese citizen sex is considered to be part of the new order. The
pervasiveness of sex and sexual imagery, and the seemingly endless fascination with the topic, is
not (just, or even mainly) because sex is fun, Farquhar claims, but because it represents
modernity and cosmopolitanism for the Chinese (see also, Schein, 2001).24
It is possible to interpret the obsession with sex, and the new tolerance level for sexual
activity, as factors that have contributed to the significant increase in commercial sex in China,
which in turn have resulted in greater levels of exposure to epidemiological high-risk behaviours.
The dilemma for the Party-state -- which is totally committed to the forward march of progress in
23
With all of the new officially-sanctioned and scientific research being conducted on sexual activity in China
(Bakken, 2000), it is apparent that the topic of sex in China is still essentially an official, if not a state project -- but
one that is also entirely consistent with the market economics and consumption-oriented capitalism of the
modernization project (Liu et.al. 1997).
24
This is also the case in China’s small towns and in the countryside, where sexual imagery -- including calendars
with scantily-clad women featured each month…the sort of thing that most women in the West find offensive -- has
come to represent a kind of ‘rural development modern,’ in which sexy pictures figure as ‘condensed signifiers’
linking their users to what Farquhar calls “a new and ambitious imaginary” (p. 217).
31
economic terms -- is how to balance the economic benefits associated with sex and the sex
trades, with its more negative (and dangerous) side effects.
A more sanguine interpretation of these new developments is to see them as one
dimension of a society-wide shift from Maoist asceticism to the middle-class enjoyment of a
wide array of capitalist ‘luxuries.’ This shift can be witnessed as the satisfaction of all sorts of
new ‘appetites,’ none of which were realizable in the Maoist era (Farquhar, 2002). In the mid1970s it would have been totally unacceptable to introduce the topic of individual appetites, or
their indulgence, into public discourse in China. By comparison, in what Farquhar calls the
‘roaring nineties,’ evidence of the satisfaction of personal ‘appetites’ -- including appetites for
sex -- was being extravagantly displayed in a wide array of public places in China’s cities. The
Communist Party continues to urge the people to consider doing public service, to maintain high
standards of morality, and to pursue selfless behaviours, but this only serves to highlight the
disparity between what was acceptable behaviour in the past and what is commonplace today.
Urban culture change and the individualization of life in the new China
Going hand-in-hand with urban and socio-economic change is a remarkable cultural
change in urban China, involving what amounts to the definition of a new concept of the
individual (Tang, 2000; Croll, 1994; Smith, 2003). In the Maoist era (from 1949 to 1976) the
notion of selfhood was drawn clearly by socialist dogma, and for the most part it was a highly
regimented concept. An individual subject’s identity was fixed by orienting him/herself toward
an external order. The moralizing models that Chinese people were exhorted to identify with, and
which were represented almost universally in the art and literature of the time, embodied such
concepts as altruism, self-sacrifice, clean and healthy living, and everyday heroism (Donald,
2000; Gilley, 2001).
Social responsibilities and class status consigned the citizens of the revolutionary society
into thoroughly immutable group identities, which existed along a simple continuum: from the
‘red’ (the good) at one end, to the ‘black’ (the bad) at the other end. In real terms this meant the
truly poor peasants were at the ‘good’ end of the class spectrum, and the thoroughly
reprehensible rich landlords were at the other end (Blecher, 1997). Mao Zedong warned his
followers that even with the utmost of zeal it would not be possible to obliterate the ‘bad’ classes
easily; he made it clear in fact that the revolution had only just begun with the Communist
32
victory over the Nationalists in 1949, and that the struggle would most likely continue for
several decades, until all members of such classes were eliminated or neutralized.
In spite of its excesses, including the huge amount of death and destruction it was
responsible for, some China scholars have argued that this version of communism provided the
Chinese with an appealing ‘story’ that many of them were able to live with at the time. It
imparted a structure of belief and an orientation to life that had an elegant simplicity, and an
entire generation was actively convinced (or became passively resigned to accept) that it was not
just the best, but the only way for them to live. Most observers have now concluded that in
conceptual and emotional terms, Chinese communism in the Maoist era was effectively a ‘closed
box,’ and that the people had virtually no opportunities -- and would rarely try to -- question the
way events were interpreted by the Party/state.25
It is now evident that (post-1978) most of the principles associated with Maoist-style
communism have been discarded: ideas about a collective utopian future were replaced with a
quotidian concern with everyday life; while at the same time the economic reforms increasingly
stressed the importance of consumption, getting rich, and the endless expansion of markets. The
rigid class identities of Mao’s time also disintegrated, both informally as a result of the new
economic and geographic freedoms, and formally, as an edict of the regime.
To justify its existence in such circumstances, the Party-state began to redefine its
hegemonic project as a determined attack on China’s poverty and backwardness, which was to
be achieved primarily by stimulating rapid economic growth. This new project -- initially
referred to as Deng Xiaoping’s ‘Four Modernizations’ -- has generally been popular with most
people, mainly because of the material benefits it has brought them. More significantly, in the
context of behaviour change, the new project was also welcomed as a significant shift from an
almost blind allegiance to external power, to a situation in which it looked as if individual
freedom could be attained and autonomous self-expression achieved -- both of which can be
interpreted as truly modern (and, previously, exclusively Western) accomplishments (Perry and
Selden, 2000).
25
The Maoist hegemonic project did not so much try to change what the people thought, as the way they thought
(Blecher, 1997), which it did by making the language of class and class conflict dominate all aspects of everyday
social and cultural life. This represented the socialist version of modernity; very different from the capitalist version
of modernity, in that it rarely encouraged subjects to be pre-occupied with the self. It was extremely rare to find any
discourse, spoken or written, in which there was a conscious awareness of the complexities and contradictions
associated with the self. In modern thought and literature, the individual subject is generally free to construct his/her
own meanings from an infinite range of possibilities (Elvin, 1997).
33
In spite of the liberalizations, the new trends have not been uniformly heralded as
beneficial for China. Some cultural critics have suggested that in spite of the material
advancements, the contemporary era has involved a transition from the ‘noble’ vision of utopian
socialism, to one that has only the “baseness’ of the self” at its core (Zhang, 1997). Some of the
critiques of the new era suggest that a high price is now being paid for this transition, in the sense
that the self, and the search for it are in some way ‘superficial’ and even ‘shameful’ activities. As
one Chinese cultural critic has indicated, one of the significant ‘costs’ associated with life in
contemporary China is “the loss of frameworks in which to situate oneself.” For some Chinese,
he argues, this has resulted in a loss of orientation, associated with “a modern sense of
meaninglessness, lack of purpose, and emptiness” (E.Y.J. Wang, 1996, pp. 39-40).
It is from this perspective, perhaps, that we can begin to interpret some of the currently
widespread phenomenon of cynicism, alienation, and thoroughly self-serving behaviour that is
being reported as almost omnipresent in contemporary China (Zha, 1995; 1997). This sentiment,
originally expressed in literary and artistic circles (Wang 1996), is now shared by many China
scholars in the social sciences, both Chinese and foreign. Political scientist Marc Blecher (1997),
for example, has observed that the: “profound uprooting of cultural moorings provided by shared
values, commitments and identity” makes it appropriate to speak about “a cultural crisis in
contemporary China” (p. 213). One dimension of that crisis -- if we combine these trends with
the headlong rush toward consumption in China’s cities -- is the relentless drive to serve oneself
exclusively by sampling all possible forms of entertainment and excitement, including some
behaviours that involve a high degree of risk.26
We do not have to go far in present-day China to find a cluster of trends that can be
considered symptomatic of these new self-serving tendencies, including rising crime rates,
government corruption, marketed pornography, the trafficking of women and girls, drug abuse,
and commercial sex. In its attempts to come to terms with such new developments, the Partystate has become almost morbidly obsessed with the idea that it must try to maintain control, if
China is to stay on the desired trajectory for its modernization drive (Perry, 2002). The state is
frantically trying to use its own authority to influence not only Chinese minds, but also to
produce healthier and more upstanding Chinese bodies. Standing in the way of such a goal,
however, are ‘waves’ of unhealthy and immoral practices: interpreted by the leadership as
26
Arguably, this is clearly a goal that is related to the modernist pre-occupation with individuality (Barme, 1999).
34
washing-up from the shores of foreign countries; but which in reality -- as we shall see in the
next section of this Chapter -- might also be conceived as part of a Party-state project.27
During the first years of the STD/HIV epidemic in China, many medical experts still
argued that the vast majority of the threat to public health was coming from beyond China’s
borders: an idea that was fuelled by popular prejudice, as well as publicly-stated (official)
pronouncements. Foreign residents and Chinese citizens who traveled abroad or who had regular
contact with foreigners, including employees of joint-venture firms and hotels, were (and still
are) tested for HIV. The official language used in media pronouncements (particularly in the
editorials of state-controlled outlets) about HIV/STDs identified a clear notion of foreign
nationals as a dreaded ‘other’ group. As Evans (1997) suggested at the time:
Discussions about sexually transmitted diseases serve to reinforce a range of
binary assumptions about differences between good and evil, Chinese and foreign,
and arguably between male and female. The enemy appears as…the
foreigner…Maintaining a distance from the suspect foreigner represents a barrier
against contamination” (pp. 163-4).
More recently, it has become apparent that at least as much attention should be paid to
the domestic dimensions of STDs. Some scholars have been arguing that one consequence of the
reforms, in addition to the increased ‘marketability’ of sex, has been the abandonment of most
forms of sexual inhibition in China. The proliferation of sexually explicit novels, some of the
most prominent of which have been written by women, is just one example of this trend. 28 In her
recent book about Shanghai, Pamela Yatsko (2001) describes another manifestation of the new
freedom in sexual expression: an entirely new urban landscape of ‘nightlife’ that includes a
vibrant bar and karaoke scene, open prostitution in the clubs and on the streets, and easily
The Party/state’s efforts to counter such trends have run into three interrelated dilemmas. In the first place, it is the
state’s own modernization project that has produced all of these negative trends, although not wittingly, and it can
hardly now turn back the clock. Secondly, an essential part of the reform project involves the application of neoliberal principals to state governance, with the result that the Chinese state has visibly withdrawn itself from many
areas of economic and social life, effectively creating more ‘space’ between state and society. Understandably, the
regime is now experiencing resistance to its efforts to re-insert its presence into that space on issues of morality and
social behaviour. Thirdly, and perhaps most significantly, within the last two decades the regime has lost almost all
of its moral authority, primarily because of the widespread corruption that has been unearthed within its own ranks
(Pei, 1998a; 1998b; Perry, 1999; Kwong, 1997).
28
As the Chinese government has discovered, banning such books simply serves to increase their popularity, as in
the case of Zhou Wei-Hua’s Shanghai Baby (2001).
27
35
available drugs -- none of which was in evidence in Shanghai even ten years earlier. The reasons
for these new developments are not difficult to find, Yatsko claims:
Market-oriented reforms have weakened old systems for controlling lives. Now
residents socialize more, they job-hop, they travel frequently…it is easier…for
people to meet and conduct clandestine trysts…The state is no longer able to exert
the same control on people...because it no longer satisfies citizens’ every material
need (pp. 208-209).
It is also apparent that in many situations the state is now reluctant to clamp down too
tightly on the various components of the sex trades, primarily because they are consistent with
the commercial spirit of the reforms (Hyde, 2001). Commercial sex outlets continue to flourish
in large and small towns all over China (Pan, 2001), and one reason for this is state complicity.
In her book about Shanghai, for example, Yatsko (2001) suggests that many government
officials consider prostitution and other elements of the sex trades are necessary to develop their
local economies.29
The situation in Indonesia
Like China, Indonesia has experienced rapid urbanisation over recent decades. While in
both nations there are difficulties in establishing the level of urbanisation, the proportion of
Indonesians living in urban areas has increased from 17.3 percent in 1971 to _____ percent
currently. Like China, this has been associated with substantial social and economic change.
However, there have been significant differences between the two nations in the nature and
progress of this change. While the Suharto regime (1966-98) greatly restricted the rights of
Indonesians, the country did not experience the high degree of control that China experienced.
There was little control over internal migration and the lack of institutional constraints meant that
urbanisation was more rapid in Indonesia than China in the 1970s and 1980s. Since 1998,
Indonesia has been experiencing a substantial political change involving democratisation and an
attempt to devolve power and investment within the country. Hence, there has been an increase
in personal freedoms although the change has not been as dramatic as that in China. While
China and Indonesia have similar levels of average income, the trajectory has differed in recent
29
Yatsko (2001) writes about a saying that she claims is often heard in China today: fanrong changsheng, which has
two meanings, depending on which Chinese character one selects to depict the sound ‘chang;’ it can either mean:
‘thriving and prosperous’ or: ‘thriving and prostitution’ (p. 195).
36
years. While prosperity has increased exponentially in China, in Indonesia the Asian economic
crisis of 1997 saw a plummet in national wealth which has not fully been recovered.
One important demographic feature which China and Indonesia share is that the nations
have had over the last decade or so their largest ever youth and young adult generation in history
and indeed the largest (at least relatively) they will ever have (Hugo, 2005).30 Not only are they
a large part of the national population, they are the final generation to grow up in an era of full
education, of massive penetration of mass media and subject to the forces of globalisation.
There is a new youth culture in a new era of consumption. Moreover, they are disproportionately
represented in urban areas where these forces are of their strongest. This is due to the high rate
of youth selectivity in the high levels of migration to cities over the last two decades.
While there has not been the dramatic shift in policy which China has experienced and
rapid socio-economic change has been occurring over a longer period, there are similarities in
that there have been dramatic changes in social behaviour, especially among the youth and
young adult population and it is most strongly concentrated in urban areas.
One of the features of the demographic behaviour of contemporary Asian youth which
has been identified by commentators (Xenos and Kabamalan, 1998; et al. 2001; Westley and
Choe, 2002; Gubhaju, 2002) is increasing level of risk behaviour among them compared to
previous generations. One important area is in sexual risk taking (Westley and Choe, 2002, 61)
although Asia differs significantly from Sub Saharan Africa in the incidence of premarital sex.
Gubhaju (2002, 104-5) has shown that pre marital sex is clearly on the rise in Asia despite strong
traditional norms opposing it in many nations.
Moreover, the risky sexual behaviours of
adolescents are compounded by a widespread sexual double standard, which accepts, or even
encourages, promiscuity among men but strictly restricts women’s sexual behaviour. Figure 5
presents data drawn from national surveys indicating the proportion of women in their early 20s
who had sex by the time they were 18. While early marriage is a factor, it is apparent that pre
marital sex is of significance in Indonesia and elsewhere in Asia and levels of sexual risk taking
is on the increase (Westley and Choe, 2002, 61).
30
They are the last generation of births born under a high fertility regime.
37
Figure 5:
Source:
Percent of women aged 20-24 who had sex by age 18, selected Asian
countries
Haub and Huong 2003
120
Percent
100
80
60
40
20
ia
Ca
m
bo
d
La
os
ne
i
M
ya
nm
ar
Ph
ilip
pi
ne
s
In
do
ne
sia
Th
ai
la
nd
Br
u
Si
ng
ap
or
e
M
al
ay
sia
Vi
et
Na
m
0
Country
In Indonesia not a great deal is known about the sexual behaviour of youth, but Figure 6
shows rates of sexual intercourse among high school students in three cities. It is apparent rates
are much higher among males than females. Figure 7 shows that the peak incidence of HIV
infection in Indonesia is in the 20s age group and there are significant numbers in the 15-19 age
group. It is important to point out that there is low use of condoms among sexually active youth
in Indonesia (Hugo, 2001).
Figure 6:
Source
Indonesian cities: sexual intercourse among high school students, 1997
Kaldor et al. 2000
38
Figure 7:
Source:
Indonesia: age structure of the population reported with HIV infection,
November 2000
Directorate General CDC and EH Ministry of Health, Republic of Indonesia, 2001
350
300
Number
250
200
150
100
50
0
0-4
5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60+
Age
As indicated earlier, in recent time in Indonesia it is the increasing number of IDUs who
are causing particular concern in the spread of HIV/AIDS. It has been reported (Vatikiots and
Crispin, 2004, 36) that in 2002 there were around 160,000 intravenous drug users in Jakarta, 55
percent were sharing needles and half were infected by HIV. The rapidly increasing use of drugs
in Indonesian cities is an established fact and it is clearly associated with rapid social and
economic changes similar to those described earlier for China.
In Indonesia the evolving HIV epidemic must be seen to some extent as a continuation of
long standing trends in the spread of HIV in which urban areas, the commercial sex industry and
population mobility have played important roles.
However, it also undoubtedly has been
influenced by the profound social and economic changes sweeping the nation. This has seen the
erosion of increased individuality, traditional values, the decline in the influence of the family
and shifting attitudes toward sexual relationships. This is overlain with a well established
commercial sex sector and double standards with significant use of CSWs by Indonesian married
men. Women are often in an unequal relationship with men in respect to sexual activity and
there is a strong antipathy among men to the use of condoms. Hence, the crisis needs to be seen
as being driven by a mix of long standing cultural, gender and historical forces as well as the
impact of rapid social and economic change.
39
CONCLUSIONS AND IMPLICATIONS FOR FUTURE RESEARCH
It is not especially helpful for researchers to conclude, from a purely statistical
perspective, that China’s (and Indonesia’s) HIV/AIDS situation is still a fairly small-scale
problem, in international terms. In the first place, it is the rate of increase (the new incidences) of
the disease that is significant, rather than the overall numbers (the prevalence), and the evidence
points to a rapid worsening of China’s situation in recent years; and secondly, any loss of life to
a preventable disease is lamentable in an era associated with such a wealth of new medical
knowledge. There is no doubt that China is facing a serious problem with STDs and HIV/AIDS,
and it is a welcome sign that its leaders have now begun to focus some significant effort in the
realm of prevention and treatment.
This Chapter has focused on China’s STD and HIV/AIDS epidemic, and has tried to look
for contrasts and comparisons with the current situation in Indonesia. The major theme of the
Chapter is concerned with the circumstances under which China’s previously unconnected
outbreaks of HIV/AIDS might become connected, with the disease spreading to parts of the
country not already significantly afflicted. One of the most obvious answers to this question,
based in part on the work that has already been reported from Indonesia and other countries in
the region, involves the role of migration in the transmission and spread of HIV/AIDS in China.
One of the unintended consequences of China’s reform project was the creation -- beginning in
the mid-1980s -- of an enormous opportunity divide between the rural and the urban sectors,
which has produced one of the largest population movements in the history of the world.
It is apparent from empirical studies conducted in both developing and developed
countries that migration helps to spread the HIV/AIDS epidemic, and as has been suggested in
this paper, there is some evidence pointing in that direction in China as well. In addition to the
increased exposure to HIV at their places of destination, many of China’s migrants -- too many
to be counted accurately -- travel back and forth to their homes, often several times a year,
running the risk of taking with them any diseases they may have picked-up along the way, and
spreading them to their partners. Some empirical support is offered to support this hypothesis,
although it is far from being a water-tight argument, and there are reasons to think that
demographic change does not tell us the whole story about HIV/AIDS in contemporary China.
At the same time as this mass migration was taking place, for example, an entirely new
set of structural forces was emerging in China, any or all of which might have influenced human
40
behaviours, and not only among migrants. It is the links between these new forces and the rising
prevalence of risky behaviours associated with the transmission of STDs and HIV, which we
now need to be exploring.
The major theme of this Chapter, therefore, has been focused on where we ought to be
looking for future growth areas of STDs in China, and, fuelled by the evidence that they seem to
be spreading most rapidly among the middle class sectors of Chinese society, there are good
reasons to look beyond the migrant groups for answers. This Chapter has explored some of the
reasons why it is appropriate to look at China’s cities as the potential breeding grounds for rising
rates of prevalence of STDs and HIV/AIDS. Although there is hardly any substantive data
currently available to support such an argument, intuition and common sense point in a number
of overlapping directions.
The Chapter attempts to frame China’s HIV/AIDS dilemma in the context of the sociogeographic transformation that have accompanied the reform project in the urban realm. What
we are seeing in urban China during the contemporary era is the emerging and expanding
polarization of Chinese society. At one end of the spectrum we find the new urban poor, and the
increasing marginality of some major sections of urban society. This has been accompanied by
the simultaneous emergence of a sizeable middle-class, made up of individuals who have
prospered during the reforms. Among this group, which also includes many of the wealthy
‘overseas Chinese’ investors from Hong Kong, Taiwan and Singapore, surplus capital is now
available to be pumped into a new street- and club-level world of entertainment, consisting of
establishments and activities catering to all of the new ‘appetites’ that are being generated in the
post-socialist consumption milieu in China’s exploding cities (Farquhar, 2002).
The work-force for such establishments comes from the rural and urban poor at the
bottom end of the social ladder; while the nouveau riche at the other end are both the customers
and the investors. The stage has been set for a wholly new array of behaviours; some of which
are no doubt harmless, but others might involve risks associated with alcohol, drugs, and sex. In
these newly dangerous times, this could prove to be a deadly combination for a small but
growing number of participants. Migration has played and will continue to play a part in this
process, in the sense that rural women on the move are the sex workers in many of the new
establishments; while rural men now living in the cities are among the purveyors of sex and
drugs on the streets. As we have seen in this Chapter, there is evidence pointing in this direction
41
in China, as well as in Indonesia. In both cases, however, migration is only one of many
variables that have interwoven to produce totally new sets of potential risk factors.
In a series of very complex ways, all of which still need to be theorized and analyzed
carefully, the changes associated with China’s transition could be contributing to a situation in
which there is more risk-taking behaviour occurring in the cities. Migration probably has an
important role to play in this process, but many other forces are also operating, and it is prudent,
therefore, to focus research attention in other directions, especially as many of the migrants
appear to be settling into their new lives in the cities, and are not likely to return permanently to
the countryside anytime soon (A. Chan, 2001).
Some of the common themes that are clearly visible in urban China include: the
emergence of increasingly individualized, self-serving, and potentially damaging behaviours; the
rapid erosion of existing barriers to and controls over such behaviours; and a thoroughgoing
transformation of everyday life, that has left many people concerned primarily with the
satisfaction of their own ‘appetites.’ The bottom-line in China today is that some people are now
rich enough to try out everything, some of which will necessarily involve risky behaviour; while
at the opposite extreme, others are poor enough to have to risk almost anything to make ends
meet. In epidemiological terms the danger is that these two sets of risk takers are now beginning
to interact with each other on a daily basis in the vast marketplaces that China’s flourishing cities
have become.
42
REFERENCES
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Anarfi J K. (1992) “Sexual networking in selected communities in Ghana and the sexual
behaviour of Ghanaian female migrants in Abidjan, Cote d”Ivoire”, in Sexual Behaviour
and Networking: Anthropological and Socio-cultural Studies on the Transmission of HIV
(Ed. T Dyson).
Anderson R M (1992) “The transmission dynamics of sexually transmitted diseases: the
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