Her oldest son died in August, claimed by an illness the doctor could not bring himself to name, let alone treat with his shelf of Chinese herbs and aspirin. "Blood poisoning," the mother was told. Not until days before he was gone did she hear the word for the first time: AIDS.
Now, her youngest son is dying, too, confined to bed in his brick house in the village of Gaoji. This time, Hu Ziying knows the name of the disease wasting her grown child to bone. She knows its source: the government-run hospital where her boys sold their blood. Still, she is powerless to save him. There are no AIDS drugs in northern Anhui province. None in nearly all of China, for that matter.
She could take him 600 miles to Beijing, where a special hospital can provide Western medicines. She might just as well contemplate taking him to the moon. The examination would cost more than $300. The drugs run $350 a month. She is a farmer in China's grain belt, where many households make do with $100 a year.
"There's no way," Hu said, her face buried in her weathered hands. "It's just impossible."
As the world's most populous nation takes tentative steps to confront a pandemic that its government says has already infected at least 1 million Chinese and could reach 10 million by the end of the decade, no one, save for the richest, can afford the life-prolonging drugs produced by multi- national pharmaceutical giants.
Some in the government argue that the situation is so dire that China must set aside respect for patents and other such protections and immediately produce cheaper, generic copies of the medicines. China has the right to do this under the rules of the World Trade Organization. It has threatened that course as it negotiates with drug companies for lower prices. But China's leadership is deeply torn between the competing imperatives of confronting a disease that could kill millions and respecting the norms of the global trading system on which it has staked its economic future.
Many other countries in the developing world have confronted this same choice. None has violated drug patents. India produces generic copies of Western AIDS drugs on a massive scale, but it has no patent law. Thailand, South Africa and Brazil -- which has cut its rate of AIDS-related deaths in half since 1996 -- have all wielded the threat of violating patents to force sharp reductions in price from drug companies. Drugs are far more widely available in those countries than in China.
For China, the choice is fraught with special tension. Despite two decades of market-embracing reforms, this country is still nominally Communist. That would seem to compel action free of the interests of profit-making multinational companies. Yet China has cast its lot with the forces of global commerce as the means of lifting people out of poverty. It is increasingly reliant on foreign investment. Foreign and Chinese companies alike want a system in place that reliably protects their international property.
China's government is also in a sensitive position because it is complicit in a primary cause of its AIDS epidemic: the illegal blood-collection centers that bought plasma from mostly rural Chinese in the 1990s and sold it to factories that make biomedical products such as vaccines and dubiously useful health tonics. Local government officials -- many of them in on the profits -- touted the blood-selling stations as sources of cash for poor farmers. To persuade farmers to donate frequently, the collection stations pooled the blood they collected, removed the plasma, then re-injected the rest back into donors, usually without screening. If one of those in the pool was infected with HIV, the virus that causes AIDS, virtually everyone else now had it, too.
This was the origin of the "AIDS villages" that now abound in China's countryside -- entire communities consumed by the epidemic, some with infection rates as high as 80 percent. The existence of such villages has already been widely documented in the central province of Henan. Recent interviews with government officials, Western diplomats and a network of Beijing-based activists who survey the countryside revealed a far broader problem, one that touches most of China's vast interior, including the provinces of Anhui, Jiangsu, Hebei, Shanxi, Qinghai, Sichuan, Gansu, Shandong and Hunan.
The AIDS problem in China is nowhere near as large as in the worst-hit countries of the world. In some parts of sub-Saharan Africa -- center of 70 percent of the world's cases -- 1 in 3 adults carries HIV. But Africa's experience offers caution for every country in the developing world, and particularly for China. In Africa, the epidemic can be seen in part as an outgrowth of globalization. Its spread has neatly followed the corridors of development. Truck drivers traveling great distances have been infected through liaisons with roadside prostitutes, carrying the virus home to spouses in villages.
China has, until recently, been largely insulated from the epidemic by its relative isolation. But as the country engages the outside, it opens up places where the virus can filter in along with everything else.
In a recent report, the United Nations described AIDS in China as "a titanic peril," one that places the country "on the verge of a catastrophe that could result in unimaginable human suffering, economic loss and social devastation." Experts say China, along with India, is likely to eventually be home to the largest population of AIDS sufferers in the world.
'We're in Denial'
In the village of Gaoji, home to about 800 people, at least 20 percent of the population participated in the selling of blood, Hu Ziying figures, many of them several times a week. How many became infected with HIV is not known.
Hu, 66, said her six sons made their living growing corn, wheat and sweet potatoes. Their land supplied enough to eat, but they lacked cash, and they increasingly needed it to pay for daily necessities.
"They didn't have any money to send their children to school," Hu said during an interview in Fuyang, a small city about 35 miles from the village. "They didn't have money to send them to the doctor."
Then they discovered an easy way to get some. They could bicycle to the county hospital in the town of Lingquan, four miles away. They could submit to a quick poke of a needle, wait for a vial to fill with 400 milliliters of their blood, receive some pooled blood in return and then bike home with 50 renminbi in their pockets -- about $6.
Qi Baobiao, Hu's oldest son, was 41 when he died. The county hospital said nothing about AIDS after testing his blood. It was not unusual. Local doctors rarely inform patients they have AIDS, instead employing euphemistic diagnoses.
"They tell them they have 'fever disease' or 'strange disease' or 'blood poisoning,' " said Li Dan, a Beijing-based activist who visited Gaoji twice in mid-September. "No one wants to admit there is an AIDS problem because then no one will buy the village's crops or marry their women. The local officials just want these people to die. If these people die, then they figure the problem will just go away."
In the past six months, six people in the village have died, according to Li.
The roots of the epidemic now interfere with efforts to stop it. Local officials fear that even acknowledging the problem amounts to an admission of complicity in its spread. This has deprived the central government of reliable data. Prevention programs are nonexistent in many areas, stymied by enduring social taboos about discussing sex and by shame over the ubiquity of prostitution and illegal drugs in a country that supposedly stamped out such vices decades ago. According to the government, about 6 million people work as prostitutes in China. Western governments say the real number is probably 20 million. While data are scarce, most experts think condoms are used in commercial sex less than one-third of the time.
"The government hasn't paid attention to this disease," said Xu Keyi, a medical doctor with years of experience at the Centers for Disease Control and Prevention in the United States who supervises the Beijing Clinical Research Center for AIDS. "We're in denial."
Recently, however, AIDS has been elevated as an issue by China's establishment. On Saturday, on the eve of World AIDS Day, the English-language China Daily endorsed the U.N. report as "the harshest assessment and sternest warning ever given," adding that the epidemic has become "a delicate social issue that needs joint efforts from all sectors of society."
In recent days, a team of Chinese AIDS experts released a study asserting that rapid action by the government could spare 10 million people by 2010 and avert a major epidemic. "Right now there still exists a chance to prevent and control the broad spread of AIDS in China," declared the study, released to coincide with World AIDS Day. "It also may be the last chance."
On Monday, state media reported that the government will soon lift a ban on condom advertising. Beijing is mobilizing teams of college students to hand out free condoms.
But even as China's leaders begin to grapple with the problem, the situation in the countryside seems far removed, colored by fear and ignorance.
In China's largest cities, where people do know something about AIDS and some doctors know how to treat it, most are still helpless. The patients simply cannot afford the medicine.
"It's very painful to tell people you can do nothing for them," said Li Taisheng, director of the AIDS Center for Diagnosis & Treatment at Beijing Union Medical College Hospital, one of the few such institutions in the country. "I'm a doctor and I know how to treat these people, but I don't have the drugs, and the patients can't pay."
Even those who say China should disregard drug patents acknowledge that the country needs far more than pills to address the epidemic. Blood-testing facilities are in limited supply. Only a few dozen doctors in all of China are skilled in treating AIDS. Rudimentary health care is beyond the reach of millions of Chinese peasants because a once-socialized system now requires payments for virtually everything.
Still, some officials within China's Ministry of Health have privately advocated that, as a start, the government immediately license the generic production of the complete spectrum of AIDS drugs. So far they have been outweighed by their counterparts in other agencies, particularly within the Foreign Affairs and Foreign Trade ministries, according to government and industry sources.
Only a few AIDS drugs are protected by patents that are valid in China, but dozens of others are covered by government pledges of protection. Pharmaceutical giants, and U.S. and European officials lobbying on their behalf, have successfully convinced China's leaders that abrogating these promises would hurt the country's reputation among investors and undermine its commitment to free trade only months after it entered the WTO.
"They're a lot more interested in policing intellectual property than in tackling the AIDS problem," said Stan Abrams, a patent lawyer at the firm Lehman, Lee & Xu in Beijing. "They have been dealing with IP complaints a lot longer. For the government's image abroad, it's still a better issue for them."
Others say the government's priorities show that China's leadership simply does not grasp the magnitude of the threat.
"Some departments in our government understand, but they don't have power," said Wan Yanhai, China's leading AIDS activist, who was arrested in September and imprisoned for almost a month on charges of revealing state secrets after he posted a government document on the Internet that showed that Henan province officials knew about their AIDS troubles far earlier than previously disclosed. "Some have the power, but they don't understand."
'We Have a Crisis'
Government officials angrily reject such characterizations, maintaining that they are fully committed to using the most effective means of delivering affordable drugs to AIDS patients as quickly as possible.
"We're not afraid of making drug companies mad," Han Mengjie, assistant director of the National Center for AIDS, which is affiliated with the Ministry of Health, said during a recent interview in Beijing. "We know we have a crisis. We urgently want to be able to provide the cheapest possible drugs."
In recent months, China has licensed substantially cheaper, generic copies of four Western AIDS drugs for domestic production, none of them protected by patents or official agreements. The government is soon expected to approve production of a fifth drug, a copy of Viramune, produced by the German firm Boehringer Ingelheim GmbH, which has encouraged China to go ahead. The drug will complete the pieces for the first domestically produced "cocktail" of generics that can be used to treat AIDS patients. It will sell for about $400 a year, according to the companies involved.
That is still far more than most patients can pay. China has applied for subsidies from the Global Fund to Fight AIDS, Tuberculosis and Malaria, an international source of grants. China also is negotiating with a trio of pharmaceutical giants -- GlaxoSmithKline PLC of Britain, Merck & Co. of Whitehouse Station, N.J., and Bristol-Myers Squibb Co. of New York -- for reductions in the prices of their wares. The government has already secured two price reductions from Western pharmaceutical companies in recent months, dropping the original $10,000 annual cost of AIDS treatment by more than half. Another price drop is expected in coming weeks.
"We have already assured them there will be appropriate reductions in price," said William Stockley, China general manager for Glaxo in Shanghai. "We're close to the endgame."
The pharmaceutical giants assert that the debate over whether to break their patents is driven by a false assumption that such a course would amount to the most aggressive means of treating patients. For one, the company already making a drug can get it to patients more quickly than one just launching production, they say. And given the complexities of treatment -- the dangers of side effects, the likelihood of drug resistance building up -- China would do far better to work with the originators of drugs to devise a comprehensive plan rather than going it alone.
"We've already got a factory," Stockley said. "The full A to Z of running an AIDS program is our daily work. We're ready to fly."
Nevertheless, some proponents of breaking the patents say that in working with the drug industry, China's leaders are making a calculation based more on economic expediency than on compassion.
"The feeling is that these are a bunch of farmers and it's not worth hurting China's reputation as a place to do business to save them," said Li, the AIDS activist in Beijing who has surveyed rural villages ravaged by the disease. "It's a simple cost-benefit analysis."