In looking at the outcomes of China’s policies and strategies to eliminate the spread of HIV and hepatitis through blood donation, we do not intend to suggest that these effects were always deliberate on the part of officials within the health bureaus. Nevertheless, the public health outcomes were effective. We explore several here.
The effort to increase voluntary donation and eliminate blood selling as a way of stemming transmission of TTIs effectively convinced many Shanghainese that the element of risk in blood donation was swiftly contained. Public health campaigns used television commercials, movies, billboard advertisements, and leaflets within the work unit explaining how donating blood was “glorious.” Celebrities were depicted donating blood to show the public not only how safe it was but how good it made one feel to be part of a national movement.
The more important technique used by the Health Bureau in its media campaign however, was its subtle shift in identifying who and what were “risky” about blood donation. By acknowledging the experience of the desperately poor and rural “blood sellers” at the hands of unscrupulous, illegal commercial buyers -- as opposed to the unhygienic practices -- the government was able to deflect popular concerns about whether the state apparatus was in fact what should be feared. Urban Chinese already view rural inhabitants as uneducated, backward, and culturally unlike them. That the blood sellers were from rural areas made the problem seem a distant one that was unlikely to touch them. Moreover, criminalizing blood selling allowed for a popular understanding that giving blood in other ways—ie., through voluntary donations-- would NOT be risky because it was regulated and a public service (not for private monetary gain). Along the way, blood selling came to be portrayed as an occurrence that was confined in time and place. Television coverage of the contaminated blood crisis was effective in creating a popular understanding that the spread of HIV through blood donation was limited to rural poor communities and to a very small region of China. Listen to this 42 year old woman from Shanghai talk about the scope and boundaries of the emerging epidemic caused by blood donation:
I know [about AIDS and blood donation] from TV about the AIDS village in Henan province, where they are poor and short of medical facilities. Some people organized villagers to sell blood for money. I saw it on TV, and the village is dirty as hell. They are so ignorant and irresponsible for their own lives. People are dying everyday according to the TV report. Though recently we have heard less about it. This rarely happens in big cities like Shanghai where it is safer and has proper protections. #5 F24
In some cases, the emerging epidemic was not seen as national in scope, but rather limited to a single village, or even a single individual:
I heard on TV about AIDS [and blood donation]. It happened in a village. A villager was infected with AIDS and demeaned by other residents because it is hard to tell if he had done something bad or was infected through the blood he received. According to the TV coverage, he was given vigilant scrutiny by local residents. The disease is not easily transmitted, but AIDS infection was found in him after he donated blood. #27 M34
By containing media coverage from the outset, and framing the disclosure limited in time and place, the impact of the crisis on public perception about the safety of blood donation was effectively controlled. By 2006, we found that Shanghainese were largely convinced that the epidemic had been contained and in any case was limited from the outset. Although a few expressed concern about receiving transfusions, for the most part they reported that they were not afraid of contamination from donating blood -- an idea that was for them coupled with the assumption that urban hospitals and donation centers would be cleaner, safer and more modern than those in rural areas.
I have seen that from TV and newspapers. These events are more often in backward areas, I have not heard that happened in Shanghai. #43 M 57 There is a village in Henan where most residents sold blood for a living at unofficial places and were all infected with AIDS. In TV news, a pregnant woman received blood transfusion when she delivered and her baby was infected. There are quite a few similar cases… They gave blood through unofficial channels. I believe such incidents would not happen in official hospitals. #31 F34
Despite successfully minimizing public concern for risk of infection from donation, public health campaigns still had to overcome widespread popular sentiment that donating blood was in and of itself deleterious to one’s health. This cultural assumption was in place long before HIV, or even blood donation, existed in China. Hence, it is important to put blood donation in the historical context of China’s efforts to augment donations in general, and then to recognize what the effort to outlaw “selling blood” accomplished in regards to overcoming this more deeply-held fear.
Worldwide, demand for blood for transfusion and other surgical or medical procedures grew after World War II. As medical techniques became more advanced, the need for blood also grew, and an increasing pace over time. China experienced a similar increase in demand, that grew slowly at first, and then increased more rapidly in the 1970s, spiking more dramatically in the 1980s with the combination of economic expansion and a growing population. Thus, for most of the Maoist era (1949–1976), China was able to meet its demand for blood by relying on a mandatory donation system managed by the state-run communes, work units and universities. Each unit was assigned its quota, and donations were minimally compensated. Since quotas were an integral part of the planned economy – in this case, “planned donations” – they were very much a part of the everyday landscape of Chinese socialism.
During the Cultural Revolution, my work unit was organized to give blood regularly. The work unit was Food Shop of North Station. We got 50 Yuan annually, donating blood once every two or three months. We donated quite frequently over a period of a year. We were organized to go traveling afterward for four to six days. The money was for compensation but the holiday was to replenish health…. I managed the manufacturing, and I was the assistant of the workshop director. The workers went to donate blood based on the job number, but we could not tell them just to donate blood. We went first, [but] I was not qualified… The factory prepared the tonics and money to pay the workers. We Ningbo people steam red dates, red beans, and walnuts [to replenish]. We cook soybean curd with a little steamed food [nutritional tonics]. The blood station gave a bottle of milk and two cakes. At the time nothing was compensated. Honestly, we had high morality. #1 M57
Nevertheless this same fifty-seven year old man goes on to say:
Nothing was compensated for us except for 300 RMB. We went to donate blood voluntarily, and we did not care about the money… [but] even if you gave 300 RMB, people would not donate blood. But 300 RMB was not a little amount in the 1980s. Workers from textile mills were rich then. They did not think much of 300 RMB, but they thought 200 cc of blood was more valuable. [He also took three days rest paid vacation.] #1 M57
This reference to compensation provides an interesting foreshadowing to practices under the current planned donation system. They point not so much to a break with the past, or creation of an entirely new means of encouraging donation today, but rather to the continuity and familiar infrastructure onto which current practices have been laid. What is perhaps “new” then is the fiction around unpaid donation that has arisen as a result of adopting international standards of blood collection and banking to make public health work in China.
Since the 1980s, with China’s burgeoning economic growth, both the capacity and the demand for more advanced medical treatments – and the blood they require –grew. The system of compulsory donation through state-run unit continued during this era, but supply no longer met growing demand. It was in this context that commercial blood donation began to flourish. The dismantling of the communes and centrally planned economy, and the underdeveloped private enterprise taxation system, meant the central government no longer had the resources to fully fund public health. Provincial health bureaus and other public and private entities saw an opportunity to raise capital by purchasing blood locally (and cheaply) and selling it to urban hospitals (or pharmaceutical companies) where demand was high. While uncompensated donation at the work units grew only slowly, purchased blood (from the countryside) escalated.
This system continued into the 1990s, until the crisis of contaminated blood – first discovered in 1995 – forced the government to reorganize blood donation and compensation systems, specifically re-emphasizing “planned giving” as its primary public health strategy for ensuring an adequate blood supply. Recognizing the need to respond to new economic realities, work units began increasing remuneration to those workers who agreed to donate on behalf of the work unit. Compensation from the work unit was not seen as the same as blood selling for two reasons: 1) workers were asked to voluntarily participate to meet the quota, and compensation was offered as an expression of caring and appreciation for the willing donation of one’s valuable essence (in press); and 2) the “profit” motive associated with selling blood to the urban public hospitals was removed. Although hospitals still had to pay for blood, the payment was to cover legitimate costs of screening, testing, and storage of blood, not for profit. Likewise, compensation to the donor was not motivated by personal profit (as in selling one’s blood), but by the willingness to contribute to the public good. Thus, by the mid- to late-1990s, receiving compensation for one’s donation was not only a legitimate practice, but one that was seen as furthering the adoption of modern blood procurement practices.
Compensations provided by work units to those who donate could be quite generous. Some work units gave donors up to 20% or 50% of their monthly salary in pay and a week or two of paid vacation, or a trip to a resort. In other work units, the standard was for money and a few days off, but no paid vacations.
As in other work units, donors at our danwei were given subsidy and a few days off. The subsidy was 1500 yuan ($200) and one week vacation. #21 F23
The vacation was kind of incentive. It was given and allowed by the work unit and had nothing to do with the blood center. It was not payment. It was a kind of encouragement. It is usually referred to as a fund for nutrition because in the first day or two, donors need to take some supplements.
(Interviewer: Is the economic compensation standard high? I have heard that some work unit give 2000–3000 RMB.)
2nd Woman: So much? Our work unit only gives us 1000.
1st Woman: No work unit can give 2000–3000 RMB.
3rd Woman: The economic compensation is different in different units.
1st Woman: It is different, for the work unit has different profit. The country should unify this economic compensation, and it shouldn’t be given by the work unit. Work unit with good income, with abundant source, and work unit with poor income, the country should consider this.
2nd Woman: After blood donation, the work unit will send people to visit you, and they can not accompany you for long. This is the fact.
(Interviewer: Then should the country set the compensation standard? And according to the standard, how much do you think is proper for Shanghai?)
1st Woman: For Shanghai, I think it should be 2000–3000.
2nd Woman: It should be 2000–3000.
(Note: the average annual salary for this group was 46,000 Yuan) #49 F40
As noted above, the outlawing of commercial blood donation centers did not eliminate the practice of compensating donors for their blood. Rather, it occurred in the context of a set of social structures and cultural practices already in place, and was made possible by the clever distinction made between compensation from the work unit and “blood selling.” Blood selling had become identified as a public health disaster while providing compensation via the work unit was perceived as underpinning a voluntary and and safe procurement system – quite antithetical to the coercion of poverty that compelled blood selling by rural peasants.
We found that Shanghai donors were clear on the distinction between blood selling and work unit compensation, even though both amounted to monetary compensation for donating one’s blood.
I don’t think it is payment [when asked about work unit compensations]. It is a humane way of showing care and friendship from leaders and colleagues. The kindness, which is more important than the gifts [or money], makes people happy to realize blood donation is glorious. #5 F24
Similar sentiments were expressed by a 46-year-old woman and her 49-year-old husband:
(Husband): Blood donation is public interest oriented and a kind of contribution, totally different from selling blood. Unpaid blood donation reflects the a person’s high morality. Selling blood for money is to survive poor living conditions.
(Wife): Selling blood is the last choice for poor people.
(Husband): It is an obligation for those employees in work units, who are allocated with a quota for blood donors who are compensated. We donated blood as a social contribution, not for money or fame. #24 F46 M49
A 42-year-old woman who worked as a household cleaner told us:
It is not payment. It is encouragement for this highly conscientious deed. A woman who had the same cleaning job as me once asked if donors were paid. I said “No. They would not do it then. If not for the certificate [showing it was not paid], it would be misunderstood as selling blood.” In my hometown, blood donation refers to selling blood. They don’t have the notion of blood donation not for payment. The payment from work units is more symbolic. It is not money-oriented as is blood selling. #26 F42
Part of the reason the public was able to distinguish between “bad” kinds of paid donation and “good” compensated donation was that the public health campaign created a media discourse that used celebrities to endorse the idea that giving blood was to be celebrated:
I had seen some ads on TV. Chen Rong (a popular star) donated blood, and there was the slogan, “A drop of blood may ignite hope.” #41 M 20
Q: Did you hear about blood donation through media?
3rd Man: Yes; in broadcast and TV
4th Man: On internet. There are advertisements with famous stars, like Yao Ming, Sun Li and Xu Rongzhen, and all of them participate in these advertisements.
3rd Man: Chen Rong also did. She donated blood herself, and told people the benefits, so it was convincing.
4th Man: Public advertisements advocate for all people to help, because the blood bank is in need, all types of blood are needed. #60 64M, 33M
Our interviewees repeated the sentiments they had garnered from public health campaign slogans that portrayed voluntary donation as glorious and patriotic:
Donors should take the opportunity to “spread love.” #9 F48
It is glorious to give blood as we donated blood to save lives. # 22 F22
Voluntary blood donation became seen as a “glorious” and “patriotic” gesture that was safe to the body, despite deep seated sentiments that it could harm one’s health. In the end, we found many donors who were compelled to give, and did so, sometimes simply as an act of individual patriotism rather than as a response to a work unit demand. However, in many of these cases, we found that donors still worried about the possibility that their donation would have residual ill-health effects. That is, the idea of donating blood became embedded in a larger set of sentiments about personal sacrifice to the larger society, to the nation, even at the expense of one’s own personal health. In a response to a question regarding where she learned about blood donation, a 24-year-old woman told us:
From TV commercials and news reports of insufficient blood supply of certain types of blood. The public was called to donate…. Many people think it harms health, but if it harms the body, there shouldn’t be so many blood donors. Some of them even donate annually. Giving blood was a taboo for my mother’s generation. I am influenced by TV and commercials, which are successful in promoting [it]. Actually blood donation is so simple to finish at once. It is far less complicated than marrow donation, which requires many steps and procedures. All we need is an incentive or compulsive measure. No extra compensation is necessary except a favorable policy for usage after donation. #29 F24
In another vein, a 31-year-old man reported:
Previously, I thought blood donation was harmful to health. There are many negative opinions about this, such as that it is harmful to yuan qi. I felt confused and that it was irrelevant to me. The public had no contact with information about it. Seniors usually think blood donation affects health in the long run. According to them, the side effects include dizziness, tiredness which influences daily work. Especially it causes male sterility, which I feared the most. Later more information has been made available on the media. More friends and colleagues devoted themselves to this public deed. The notions changed gradually. Blood donation became acceptable to more and more people, including the fact that it is harmless to health and even good. Also understanding the fact that the human body can restore itself after proper rest, made it appropriate to think that blood donation is absolutely good to your health and harmless. As for my own understanding, I don’t believe blood donation has no influence on health. But it is recoverable, controllable, and temporary. (emphasis added) #16 M31
Interestingly, this donor went on to explain how he was so motivated to give blood for the sake of his society that he donated on his own at a blood mobile one day while walking by the department store with a friend. He explained that he was “caught by the ‘patriotism bug’ and wanted to make a donation to feel ‘glorious.’” He then explained that his work unit organized blood drives and paid large compensation: two weeks vacation and 2,000–3,000 Yuan He did not donate when this was offered because he felt that the health risk must be high if the reward was so great. He felt the payment to donors should enable them to buy nutritious tonics after donating. At his van, he was only given cookies, mineral water and an umbrella.
Continuing, we found that this donor exemplified some of the ambivalence surrounding compensation versus no-compensation for blood donation, and it points to a delicate balance the work units must strike: Offering enough compensation to express appreciation for the individual’s sacrifice and contribution, without instilling either coercion or a sense of fear among potential donors. Although this man begins by noting that uncompensated donation is the best kind of donation, he reveals that in the end, he would have wanted compensation in order to ensure his long-term health. He said that he donated without any need for compensation and when he went home he “didn’t dare tell his parents.” In fact he played badminton with a friend and went to swim, but on the third day he got a fever of over 38C. The febricide he took for his fever did not work at all. He was scared. He had to tell his parents under their questioning before going to the hospital for his fever (for an infusion). After three days of fluid infusions, his fever went down. He felt confused and was unsure if it was caused by the blood donation or if it was that he was overexcited and lacked proper rest after donating. He would be more conservative next time, he said, making sure to rest for 3–4 days after donating.
The idea of packaging donation as rewarding in and of itself caught on to some degree. A few donors considered the voluntary uncompensated donation to be the ideal for contemporary China. And indeed, the public media and blood center continue to emphasize that this is the ideal type, which should eventually replace even compensated donation through the work unit. But among donors, the ideal donation remains one that is compensated by the work unit. The idea that the donor has sacrificed for the social good was accompanied by the idea that society, by way of the work unit, should care for the donor. Compensated blood donation is thus distinguished from “blood selling” and understood as the best, most productive and effective way to ensure donations among the public. It also attended to cultural fears about the potential harm to one’s health for donating. It did not eliminate such fears so much as answer them by rewarding the donor with ample resources to replenish his or her health and, more importantly, to be acknowledged as a person who sacrificed their health for their nation.
Making compensation a reward for glorious service to one’s country distinguishes it from blood selling. Blood selling was represented as a societal failure, in the sense that it made visible the desperately poor citizens for whom the state had failed to adequately care. In contrast, compensated donations represented the success of both socialism and post-socialist reforms: they reinforced the idea that the social system worked to take care of its patriotic citizens. Remuneration by the work unit was seen as a way for the work unit to reward the donor, take care of him or her, and acknowledge the large sacrifice made on behalf of the donor for the good of society.