Excerpt from the Introduction for Occupational Hazards

Introduction

An Epidemic at the Margins of Governance and Governmentality

In December 2012, China's incoming president, Xi Jinping, announced a set of austerity measures that would form the basis of his trademark crusade against official corruption. He began with restrictions on the lavish banquets that are characteristic of political relations in contemporary Chinese society. Government officials and businessmen in post-Mao China have grown to rely on banquets replete with expensive alcohol, cigarettes, and food (often followed by some sort of female-centered entertainment, which can include the services of a commercial sex worker) to pave the way to success in a market economy that operates under the guise of a Leninist bureaucracy. Xi told party officials to limit themselves to “four dishes and a soup” (sige cai yige tang) when entertaining guests. He extended his reach to smoking shortly before Chinese New Year 2014, with the announcement of a policy prohibiting government officials from smoking in public and using public funds to buy cigarettes. Xi’s policies, which struck at the very heart of the informal mechanisms that have become central to party politics in China, aimed to limit corruption. But those same policies could have formed the basis of an aggressive public health campaign because they restricted officials from engaging in practices that rely on excessive eating, drinking, smoking, and even commercial sex, which all have the potential to place people at risk for the types of chronic diseases, and sexually transmitted infections, including HIV, that have been ravaging the Chinese populace for the past twenty-five years.

This book examines the unintended public health consequences of the ritual practices of yingchou that incite the lavish banquets Xi Jinping has targeted with his austerity measures. Anyone who has ever tried to accomplish anything in cooperation with a Chinese partner in China knows what yingchou is even if they have never heard the term. It is the requisite eating, drinking, smoking, and entertainment, which can include offers of commercial sex, that a Chinese host expects their guests to engage in as a means for establishing a relationship and initiating communication. Yingchou has had a huge impact on how governance is conducted in China. These behaviors have become essential for establishing and maintaining the personalistic relations, known as guanxi, that are necessary for political and economic success in post-Mao China. Avoiding these activities poses an inherent risk to success for China’s rising elite, but they are seldom recognized for their association with serious public health risks.

Standard public health paradigms frame the ritual practices related to yingchou as individual behaviors that can be changed through standard behavioral interventions. But in China, where eating, drinking, smoking, and commercial sex are part of a singular ritual practice used to develop and maintain important social and professional relationships, these are all collective behaviors that have become a “dominant discursive trend” (Rabinow 1996: 7) in governing the distribution of state-controlled resources under a plan of market reforms. China’s new market economy created a contradictory environment where state-controlled resources, normally rewarded on the basis of trust and loyalty to the state, must now be made available to private entrepreneurs who do not work for the direct benefit of the state. Yingchou is employed as an informal mechanism for demonstrating the trust, respect, and loyalty necessary for governing distribution of China’s state-controlled resources. And although these practices have helped China’s market economy grow within its Leninist political system, they have had some unintended consequences on its public health situation. Rates of chronic disease from smoking, drinking, and eating exploded following implementation of Deng Xiaoping’s economic reform measures in the 1980s (Bazzano et al. 2007, Chen et al. 2005, Cochrane et al. 2003, Gu et al. 2009, Hao et al. 2004, He et al. 2005, Lam et al. 1997, Wang et al. 2007, Yang et al. 2008). Sexually transmitted infections (STIs) also rebounded in the 1980s after their declared eradication in the 1960s (Beyrer 2003, Chen et al. 2000, Chen et al. 2007, Cohen 1996, 2000, Gil 1996). And a nascent HIV epidemic emerged in the late 1980s. This book focuses on the sexual aspect of yingchou and approaches it as a traditional masculine practice motivated by a need to find an alternative way to conduct governance, rather than simply as an individual behavior. Sex for these men, in other words, is work, and not merely a way to satisfy an individual desire. Addressing the problems that result from these sexual encounters will require examining them through a sociocultural and politico-economic lens that will reframe how we look at public health risk within this context.

My focus on the sexual practices inherent to yingchou stemmed from an interest in China’s HIV epidemic. When I arrived in China in the summer of 2002 to explore possible topics for research on the HIV epidemic, one-third of the patients under treatment for HIV/AIDS in Beijing at the time were homosexual men.¹ Many people in the international community of HIV/AIDS experts thought this might represent a turning point in China’s epidemic to make it mimic the early epidemic in the United States. I later learned that even though one-third of the people who sought treatment for HIV/AIDS in China at the time were gay men, there were scores of other men around the country who were at risk for infection but not willing to come forward, whether for testing or treatment. At the time, a national AIDS hotline was flooded with calls from businessmen and government officials who had visited female commercial sex workers and subsequently learned about the potential risk incurred through such behavior. Many of these men exhibited what one prominent Chinese AIDS researcher later called “AIDS Panic” (Cao 2004). Afraid they could have contracted HIV, these men frantically called the hotline to ask the attendant if she could diagnose them over the phone, since approaching their local anti-epidemic station² would be politically risky if they were suspected of illegal behavior, or worse yet found to be HIV-positive. This of course was not possible; they would need an HIV test to determine their serologic status.³

The men who called this hotline were not alone. Nationally, men who travel and engage in business entertaining (yingchou) fuel China’s burgeoning commercial sex industry, placing them at higher risk for sexually transmitted infections, including HIV, than any other class of men in China (Parish et al. 2003, Parish and Pan 2004). Despite these statistics, the epidemiologic paradigms that govern HIV prevention and intervention strategies in China neglect these men in their efforts. The global HIV narrative is dominated by epidemiologic paradigms that associate risk for infection with individually motivated behaviors. But the narrative becomes much more complex when forces outside an individual’s control compel them into such behavior. In this book, I show that China’s HIV epidemic is not solely the result of epidemiologic transmission patterns but one that fundamentally occurs at the intersection of everyday practices of governance, which are often informal, and the contrasting mode of self-censoring that many men simultaneously exhibit to support the type of government rationality or governmentality (Foucault 1991) that helps to sustain party legitimacy and traditional masculine performance. This has resulted in a standard set of competing discourses that daily pose serious risks to the men involved in governing China because even though they are unofficially obligated to eat, drink, smoke, and solicit commercial sex as a way of achieving political and economic success, they must simultaneously cover up any evidence of such behavior to uphold the moral principles of their official duties and the party that supports their livelihood. This type of juxtaposition, caused by the competing discourses between informal governance and formal governmentality in post-Mao China, has become even more acute under Xi Jinping’s anti-corruption campaign. Large restaurants and entertainment venues previously supported by government patrons have closed down, and sales of luxury brands of alcohol have plummeted.⁴ But government officials find alternative ways to fulfill their unofficial needs, widening the gap between governance and governmentality that has shaped the HIV epidemic in China. So, while this is a book that highlights the HIV epidemic in China, it is not about HIV/AIDS per se. HIV in this book acts rather as a lens to understand the significant impact that everyday practices of informal governance, founded in elite masculine tradition, can have on the lives of those who engage in its processes. It answers questions about HIV in China that can inform public health practice around the epidemic, but it also explains the masculine processes that drive the political bargaining that has characterized party politics in the post-Mao era. This cultural analysis, which sits at the nexus of public policy and public health, will also contribute to our knowledge and understanding of global health by offering valuable insights into the mechanisms that are responsible for both the emergence and the resolution of global pandemics in China.

I begin with the story of a government official who engaged in yingchou as a way to build his own career to demonstrate the unintended consequences everyday practices of governance can have on individual lives and public health in China.

Turning AIDS on Its Head

When I first met Wang Yantao in 2003, he had already been diagnosed with AIDS and his wife also knew she was HIV-positive as a result of having sex with her husband. Wang lived in an area made infamous by its many injection drug users, commercial sex workers, and the HIV epidemic, but neither he nor his wife fit the profile of someone typically perceived as “at risk” for infection. Neither had ever injected drugs, and she had never sold sex. In fact, they were middle-class people who both worked in stable, secure government jobs. Wang was young and quickly climbing up the local ladder of officialdom. They had a young daughter who was pretty and cunning, and they had also just built a new house. Such success did not come easily though. Wang had to work hard to reach the point where he could build such a nice house at such a young age. Work in this case often came in the form of the many nights he spent away from home attending banquets with colleagues and superiors, drinking and smoking heavily with them, and accompanying them to the local karaoke and disco clubs where they could eat, drink, sing, and dance in the company of a female hostess who could also provide sexual services for an extra fee. Wang sometimes made it home after a long night of entertainment but other times woke up the following morning next to a young woman he had never met before.

Wang Yantao’s HIV status is certainly not surprising to anyone familiar with even the most basic epidemiology of HIV/AIDS. After all, he displayed the classic risk profile of a man who engages in repeated unprotected sex with commercial sex workers. He could have used a condom to protect himself, his wife, and his other sexual partners, but he didn’t know he was putting himself or others at risk for a deadly virus. In fact, he had little knowledge about HIV or AIDS before he was diagnosed with the full-blown disease. There were very few HIV prevention messages and programs at the time in the remote area of China where he lived. Those that did exist were mostly targeted at the young women who sold sex to Wang and his colleagues. Sex workers, considered at high risk for HIV infection, are more common targets for HIV prevention programs looking to have a large measurable impact on the epidemic. Wang, who such programs consider a “client of a sex worker,” may not have responded to standard public health messages anyway, for his repeated visits to commercial sex workers were not prompted by the individual behavioral patterns that public health programs typically target, but rather by his quest for the professional success that allowed him to build his house. From his perspective, Wang was engaging yingchou, which had become an unofficially required duty of his work as a rising government official. Not doing so would have threatened his political status. Any public health model used to prevent Wang from infecting himself or his sexual partners would have aimed at helping him avert some sort of biological risk. But Wang was much more concerned about averting the social risks (Hirsch et al. 2010) he could have incurred by not engaging in these behaviors. To him, he was not infected simply because he had unprotected sex with a sex worker but because he was seeking the success that lies at the nexus of masculinity, male sexual culture, and governance in China. The response for a man like this must also consider the role that local socially, culturally, and politically constructed meanings play in promoting the behaviors related to a disease like HIV (Parker 1991, Vance 1991), rather than simply following epidemiologic pathways of causation.

It may seem odd to begin a book on HIV/AIDS—an epidemic so rigidly defined by global discourses of risk, vulnerability, and stigma caused by inequalities of wealth, gender, race, and sexuality (Carrillo 2002, Gutmann 2007, Padilla 2007, Parker 1999, Farmer 1992)—with the story of a man like Wang Yantao, who has access to power and privilege. Men like Wang are considered to be among the arbiters of power and wealth. Theories of structural violence attribute HIV infections to the actions of such men but do not include them among the narratives of a disease that has been painted as the purview of marginalized groups of injection drug users, female commercial sex workers, and men who have sex with men. But these very same men shape and control the institutional and social structures that foster inequalities and create the vulnerabilities we so desperately want to address. Including them in the narrative is an important piece of transforming our inquiries about HIV/AIDS into an effective tool for designing public policy by offering explanations behind the processes implicit in distributing power (Parker and Aggleton 2002, Courtenay 2000).

Notes

1. There was only one hospital ward in China (the one in Beijing) that accepted and treated HIV-positive people on an in-patient basis at the time.

2. This term (fangyi zhan in Chinese) was adopted from the old Soviet system of health. Anti-epidemic stations were responsible for monitoring disease in China. The Chinese government has now adopted the model and name of the Centers for Disease Control (CDC) from the United States.

3. It is difficult to assess the impact of the HIV epidemic on this class of men because the government does not keep statistics on infections within this sector of the population. Doing so would reveal the weaknesses of the state. In 2012, however, the Chinese CDC did announce that men over the age of fifty are now accounting for the fastest rise in new cases of HIV (Shan 2012). The cause is not known, but it could be related to retiring men who spent their careers engaging in yingchou practices and soliciting commercial sex.

4. Global sales of Remy Martin fell by 17 percent following Xi Jinping’s announcement of his austerity measures.