S223
Successful Eradication of Sexually Transmitted Diseases in the People's Republic
of China: Implications for the 21st Century
Myron S. Cohen, Gail E. Henderson, Pat Aiello,
and Heyi Zheng
Departments of Medicine and Social Medicine, University of North
Carolina, Chapel Hill
The global control of sexually transmitted diseases (STDs) represents a daunting task, and there
have been very few examples of success. The scope of the STD problem in China before the formation
of the Peoples' Republic and the effects of a governmental STD control program were reviewed. In
major cities, 10% of the population had syphilis, reaching 50% prevalence in some rural minorities.
By 1964, STDs in China were virtually eliminated through a program that destigmatized STDs,
provided an infrastructure for case finding and therapy, and eliminated prostitution. The Peoples'
Republic of China demonstrated the possibility of eliminating STDs, at least for some period of
time. Although the Chinese approach may not be ideal for Western democracies, understanding
some features of the Chinese program may help in designing a strategy for the eradication of human
immunodeficiency virus when or if treatment becomes available.
AIDS was first recognized in 1981 [1], and by the year 2000,
38 million people are expected to be infected with human
immunodeficiency virus (HI V) [2]. Remarkable resources have
been focused on the development of an HIV vaccine [3] and
antiviral therapy [4]. However, these efforts cannot be expected
to stop the spread of the disease. The World Health Organization Global Programme on AIDS and others like it [2, 5] emphasize behavioral changes, including delay of sexual intercourse in adolescents, avoidance of high-risk sex (anal
intercourse), and reliable condom use. Unfortunately, there is
no guarantee that this approach will work. Indeed, the focus
on vaccines in industrialized countries is to a large extent based
on the belief that sexually transmitted disease (STD) epidemics
cannot be controlled through education or legislation. In this
context, examination of a case involving successful prevention
and treatment of STDs may offer useful insights.
Syphilis and other STDs appear to have been virtually eradicated from the People's Republic of China in the late 1950s.
Why is description of these events excluded from discussions
of STD control (e.g., [6])? First, information about the People's
Republic of China during the 1950s and 1960s has been limited.
Most of the Chinese medical literature was not translated into
English during this time, and the Chinese medical community
was almost completely isolated from the rest of the world until
the 1980s. Second, the nature of China's propaganda machine
Presented in part: 10th international meeting of the International Society for
Sexually Transmitted Disease Research, Helsinki, 29 August-I September
1993.
Financial support: NIH (AI-31496); North Carolina Sexually Transmitted
Infection Research Center, University of North Carolina, Chapel Hill; UNCAIDS Control and Prevention Service grant.
Reprints or correspondence: Dr. Myron S. Cohen, 547 Clinical Sciences
Bldg., UNC School of Medicine, Chapel Hill, NC 27514.
The Journal of Infectious Diseases 1996; 174(Suppl 2):8223-9
© 1996 by The University of Chicago. All rights reserved.
0022-1899/96/7452-0011$01.00
and the state-controlled information system led to well-founded
concern about the validity of any data collected and reported
during this time. Last, and perhaps most important, it is gene.ally believed that the radical social and economic policies implemented in a country with a centralized socialist economy
have nothing to offer democratic, market-oriented societies [7].
Here we review what is known about the scope of the STD
epidemic in China before the rise of communism, the response
of the communist government to this problem, and the outcomes of their efforts.
STDs in China
Although syphilis may have existed in China before the
arrival of Westerners, it is generally accepted that STDs were
introduced by Portuguese traders to Guangzhou (Canton) in
the early 1500s [8]. Records from 16th century Portuguese
missionaries and traders contain accounts of women and children captured near Guangzhou to work as slaves and prostitutes
[9]. Indeed, by the time Portuguese traders began sailing between China and Japan (1551-1555), syphilis was common
enough that a hospital for such patients was established in
Japan [9].
By the early 20th century, the magnitude of the problem with
syphilis and other STDs was well-documented in the Chinese
medical literature [10] as well as records from the foreign
public health authorities and military commands in China's
coastal cities [11,12]. In 1933-1934, the Chinese Medical
Association surveyed 28 hospitals in 15 provinces, encompassing 248,722 patients [13]. Venereal disease was the fourth
most common admitting diagnosis, accounting for 6.2% of
admissions. In addition, the prevalence of venereal disease was
considerably higher in certain groups and locations in China.
Reports appearing in the Chinese Medical Journal during the
1930s and 1940s documented very high rates of STDs among
prostitutes [14-16] in the major trading cities, and later surveys
S224
Cohen et al.
also found high rates among the minority populations living
in China's border areas. According to Hom [12], 10% of minorities, 5% of city dwellers, and 2%-3% of rural citizens had
syphilis.
Why was syphilis so widespread? Prostitution in large trading cities appears to have played a major role. During the late
19th and early 20th century, the Chinese government lost control of many coastal cities through the formation of Westerndominated treaty ports and foreign settlements [17]. Famine in
the countryside and regional wars led to refugee migration into
cities, where women were often forced into prostitution.
Shanghai was the best-known of the treaty ports, with ~ 3
million residents in the 1930s. At that time, 833,000 people
resided in the foreign settlement area of the city, with 297,000
in a separate French concession; 96.5% of these residents were
Chinese [17]. In reviews ofthe history of prostitution in Shanghai during this period, Hershatter [11, 18] points out that the
sale of sex represented the largest industry in the city. In the
1930s and 1940s, as many as 100,000 women were working
as prostitutes in Shanghai. According to Hershatter [11]:
As Shanghai became a major economic, political, and cultural
center during the first half of the 20th century, the market
in prostitutes grew and changed in nature. What had been
essentially a luxury market in courtesans became a market
primarily geared to supplying sexual services for the growing
number of unattached (though not necessarily unmarried)
commercial and working-class men of the city. The increase
in demand was apparently accompanied by a boom in supply,
fed by a burgeoning population of refugees and peasants in
distress with daughters they could not support.
There is no doubt that prostitutes represented a critical core
transmitter group [19] for the spread of STDs and that this was
recognized by Chinese and foreign authorities. Hershatter [11]
quotes from a 1939 Shanghai guidebook that offered advice
about prostitutes and warned against visiting lower class prostitutes, among whom venereal disease became distressingly common: "Her body today is wanted by Zhang, tomorrow is played
with by Li, and this goes on every day, without a night off, so
it is impossible to avoid disease."
A 1932 guidebook advises, "When the front lines where the
two armies connect are tense, ... (you can press down on the
stomach and lower regions of your opponent. If she cries out
in pain, she has venereal disease, and you must) ... immediately throw down your spear, don't begrudge the funds for the
payment of soldiers or continue to press forward the attack."
[11 ].
This was good advice. A survey of local clinics in Nanjing
(Nanking) in 1936 found that while 17.5% of 1704 general
clinic patients were positive for syphilis on Wasserman and
Khan tests, 36% of 1897 patients being seen at STD clinics
were positive [14]. Data collected in 1947 in the northern port
city, Qingdao (Tsingtao), revealed that 80.1 % of 576 prostitutes
lID 1996; 174 (Supp! 2)
and 60.5% of 95 cabaret hostesses tested positive for syphilis
[15]. A survey among 876 licensed prostitutes in Beijing, done
between 1946 and 1947, found that 89.2% had gonorrhea [16].
China has a heterogeneous population, which includes such
diverse groups as the northern nomadic Mongolians, western
Tibetans, and the Li, Zhuang, and Miao tribes of south and
southwest China. Each minority has distinct religious and medical traditions [20]. At the time of the 1949 Liberation, minorities represented 6% of the total population of China while
occupying about half of the geographic area [20]. Reliable data
on STD rates among China's national minorities before the
Liberation are not available. Surveys immediately after the
founding of the People's Republic of China in the 1950s document rates of syphilis between 10% and 50% in minorities
[21].
Hom [12] argued that the high rates of STDs among minorities were explained by "poverty, ignorance, superstition, and
oppression by feudal rulers, Han (Chinese) landlords and merchants, and marauding warlords." Hillier and Jewell [22] believed that "the fate of the minorities (showed) the all-toocommon signs of an indigenous people being decimated by the
new diseases spread by war and invasion."
First-hand reports revealed negative attitudes held by majority Han Chinese. A Chinese writer who visited the Miao tribe
(in southern Guizhou province) in the 1920s illustrates the view
that minority groups were lower-class beings [20]: "The Miao
retain their old customs tenaciously.... In their social structure, they still have conditions which make them appear like
a relic of primeval times."
In addition, several different tribal groups in the south were
reported to exhibit a relaxed attitude toward sexual relations.
A Western visitor to the Miao tribe in the first decade of
the 20th century described these free sexual relations [20]:
"Morally, most of them are below, and some of them are
immeasurably below, the Chinese
, There are no decent
The Ta-hua Miao were,
women among the Ta-hua Miao
and in some cases still are, so bad that they could hardly be
worse. This is describing their moral condition in very few
words, but they are quite enough."
The Chinese oppressed these minorities, demanding heavy
tributes, exploiting minority workers who had come to Chinese
cities, and often enslaving minority women.
Eradication of STDs in China: Medicine Is Politics
The charismatic leadership that brought Mao Zedong to
power was based on grass-roots politics developed over 2 decades of guerrilla warfare in the countryside. Mao rejected the
Russian model of revolution based on the urban proletariat.
Instead, in remote rural territories governed by communist
forces, local leaders encouraged the masses to develop their
own solutions to social problems [23].
Improved health care was a clear-cut priority of communist
programs, intimately related to social and economic develop-
JID 1996; 174 (Suppl 2)
Eradication of STDs in China
ment. According to Mao, disease was produced by an unhealthy
society [12, 24, 25]. In pre-Revolutionary China, the average
life expectancy for a man was 32 years [22]. Western imperialism was held accountable for China's underdevelopment and
the poor health of its people.
In 1950, Mao articulated his guiding principles for health
care in the new China [24]: Health care must be directed at
the masses of laboring people (rather than the wealthy or welleducated); traditional and Western medicine must be unified
(this was essential since the resources required for Western
style medicine were not available); prevention of disease must
be emphasized (ultimately leading to focus on communicable
diseases); and mass campaigns should be used to achieve these
health care goals.
Methods for Mass Campaigns
One of Mao's most innovative revolutionary strategies was
his use of a military campaign style to solve social, economic,
and political problems. First, advance troops would be assigned
to get the feel of a situation and identify local leaders. These
leaders were encouraged to define their own problems and to
define the causes of these problems through the communist
ritual of "speaking bitterness" (i.e., telling stories of bitter life
under the old landlord system, dramatized in "The Yellow
Earth" [26]). Approaches were modified based on the needs
of different groups in the population. Mobilization depended
on the use of plays, songs, and group meetings for propaganda
[26]. Every citizen was a soldier, benefiting from the results
of a successful campaign. Solutions were tested in small sample
areas before implementation in wider regions.
The Campaign against STDs
Plans to eradicate STOs in China began in 1950 [12]. In
1954, these efforts were coordinated under the direction of the
Central Research Institute of Dermatology and Venereology.
To evaluate this campaign, we relied on a variety of data
sources and methodologies. These included personal interviews
with Li Hongjiong (Professor Emeritus, Department of Dermatology and Venereology, Peking Union Medical College) and
George Hatem (a North Carolina physician who lived and
worked in China and played a key role in this campaign [25]);
first-hand reports and observations written during and after the
eradication campaign; translation of all Chinese articles related
to this campaign available in the Library of Congress, Bethesda,
Maryland; and discussions in 1979 and 1980 with Chinese
physicians working in the infectious diseases department of a
tertiary care hospital in Wuhan, a city in central China [27].
In addition, one of us (Z.H.) trained and worked in the Department of Dermatology and Venereology, Peking Union Medical
College, from 1985 to 1990.
The campaign against STOs had four basic features, which
included training of paraprofessional and public health person-
S225
nel and mass screening with treatment, propaganda, and complete elimination of prostitution.
Training of personnel. Personnel to undertake the battle
against STOs did not exist, and the program to incorporate
local-level folk and traditional practitioners into the health care
system had not been implemented. To solve this problem, the
new government recruited thousands of public health workers,
who received a few months of training in the syndromic recognition and treatment of venereal diseases. Laboratory diagnostics were primarily limited to microscopy and simplified serologic testing for syphilis. Treatment focused primarily on the
use of penicillin and some adjunctive herbal medicines (dihuang and yinzi) designed to prevent or treat allergic reactions
[8]. Use of public health workers in this way was quite controversial in the 1950s. The Ministry of Public Health in China
was dominated by Western-trained physicians [28], and there
was concern that such health workers would lack the requisite
education and skills needed to carry out these tasks. On the
other hand, this approach reflected the antielitist, antiprofessional attitude of many in the communist party leadership,
particularly Mao, and the use of paramedics became a strategy
in the long-term plan to extend basic-level preventive health
care services to every county in China [29].
Mass screening. In some locations (e.g., former treaty ports
such as Shanghai and Canton), mass screening for syphilis was
done, and all infected subjects were treated [8, 30]. In most
areas of the country, local public health workers conducted
surveys consisting of questions believed relevant to assess risk
(figure 1). These included questions related to signs or symptoms consistent with syphilis or to exposure to syphilis. Affirmative answers led to testing and treatment. Recruitment of
the population to the survey was a priority. The Chinese bureaucracy had considerable experience in identification and location
of tax-paying citizens. Relying on this characteristic of Chinese
political culture, Mao's government had established a highly
articulated administrative system and an even more powerful
parallel political structure that were able to reach down to the
lowest levels of village and neighborhood life [31]. Hu et a1.
[8] described mass screening in Anhui Province. In 1958,
1,275,600 people in five counties were tested for syphilis, and
3.8% were positive. Only 1 new case was found in 1960-1963
by screening 1,354,13 8 additional subjects.
Propaganda. One of the purposes of mass propaganda efforts for the STD campaign was to maximize the probability
of obtaining truthful answers to survey screening questions.
Like other campaigns in China, the campaign to eradicate STOs
included aggressive use of the mass media, mandatory educational meetings, and incorporation of political messages into
entertainment events [26]. For example, in villages throughout
China, one-act plays were used to explain the STO control
program [12]. Perhaps the most important feature of the STO
campaign propaganda was its targeting of disease-rather than
the patient-as the enemy. For STOs, the culprit was identified
as Western civilization and capitalism. These diseases were
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Cohen et al.
The Eight Questions -
Have you had
1.
Sex outside of marriage or with a prostitute?
2.
Three divorces or two or more marriages?
3.
Parents or a spouse with syphilis?
4.
No children after 3 years of marriage, spontaneous
abortions, or stillbirths?
5.
Genital ulcers, non-itching skin eruptions?
6.
A deformed nose or tongue?
7.
A history of syphilis or treatment for syphilis?
8.
Employment as a soldier or prostitute or in a service trade
(barber, hotelier, restaurateur)?
Figure 1.
Chinese mass screening survey.
not believed to be a problem inherent to Chinese society. They
had been delivered and spread through Western contamination
and the forces of imperialism [12, 25]. Elimination of STDs
was, therefore, patriotic.
Eradication ofprostitution. The eradication of prostitution
was the most unique aspect of the Chinese STD control program, and the most controversial from a Western perspective.
Hom [12] claimed that most brothels were closed down within
weeks of the Liberation by the "direct action of the masses."
This seems unlikely, given the entrenched nature and economic
value of prostitution.
In reviews of prostitution in Shanghai [11, 18], Hershatter
described a more lengthy, organized program, in which the
authorities prepared facilities for the reeducation of prostitutes
and conscripted reluctant teachers and social workers for 3
weeks' training on the reeducation of these women. On 25
November 1952, 324 brothels in Shanghai were closed, brothel
owners were arrested, and prostitutes were transported to the
Women's Labor Training Institute. The women were incarcerated and committed to a reform program. First, they received
therapy for STDs. Second, they were given general education
with emphasis on literacy, intended to convince them that the
reason for their prior behavior lay in the economic subjugation
and exploitation of the old society. Third, the women were not
allowed to leave the compound or visit with former associates
but could see relatives with permission.
By physically separating them from the brothel owners (who,
contrary to public opinion, often functioned as parental figures
for the young girls), the program intended to replace these
bonds with loyalty to the new regime. Last, the women were
forced to engage in productive labor, such as making towels
and socks. Most women were released from the facility in
1953, generally to the custody of their families in the city or
the countryside. Factory jobs or other forms of labor were
lID 1996; 174 (Suppl 2)
arranged before release. In some cases the staff helped arrange
marriages.
In Western societies, attempts to deal with STDs through
control of prostitution have generally failed [32]. In China,
however, the campaign to eliminate prostitution was not isolated from events taking place in the rest of society. Rather,
this campaign was part of a new political and economic system
that had the power and will to enforce such prohibition. Furthermore, revolutionary Chinese ideology was strongly committed
to improving the status of women. Before 1950, women had
virtually no rights; they belonged to their fathers or their husbands. The Marriage Law of 1950 gave women legal and property rights [33]. Bride sale and dowry became illegal, and
women gained the right to divorce. Gradually during the 1950s,
women's school attendance and participation in the labor force
became the new norms of Chinese society. While absolute sex
equality was never achieved and urban women benefitted more
than those in rural areas, these changes were important in the
lives of Chinese women [34].
This, in combination with a puritanical political ideology
that forbade the commodification of female sexuality, created
an environment that was not supportive of the reemergence of
commercial sex work. In fact, during the Maoist era (1949~
1976), the only mention of a problem with prostitution in
English-language materials was at the height of the famine of
1958-1960 in Shanghai, when the disastrous policies of the
Great Leap Forward resulted in >20~30 million deaths nationwide [35].
Results of the Campaign to Eradicate STDs
A series of articles published in China between 1959 and
1964 [8, 25, 30, 36, 37] documented the success of the campaign to eradicate STDs. Between 1960 and 1964, the prevalence of syphilis (based on serologic testing) in > 700,000 hospitalized patients hospitalized in seven cities throughout China
was 0.54% (table 1); only 26 new cases of syphilis (0.004%)
were discovered. At the Beijing Medical College, 10.1% of
outpatients had syphilis in 1950, while 0.05% were positive in
1963 [37]. In 1964, the Chinese stopped screening inpatients
and pregnant women for syphilis [37]. Of course, it is always
possible that these results represent an exaggeration resulting
from governmental pressure. However, according to our discussions with physicians in Wuhan in 1979 and 1980 [27], it
appeared that physicians encountered virtually no STDs in clinical practice. It wasn't until the early 1980s, when Westerners
were allowed to visit China in large numbers, that STDs began
to be seen again. This account is consistent with the personal
experiences of one of us (Z.H.).
Reemergence of STDs in China
A national study of STDs between 1987 and 1990 at 16
urban surveillance sites in China monitoring four major
lID 1996; 174 (Suppl 2)
Eradication of STDs in China
Table 1. Patients in seven cities after eradication campaign in
China [8].
City
Beijing
Shanghai
Tianjin
Shenyang
Wuhan
Chongchin
Lanzhou
Total
No. of
hospitals
3
1
5
3
4
2
6
24
No. of
dermatology
patients
206,362
114,499
126,028
105,963
112,843
46,302
60,696
772,693
No. (%) with
syphilis
1195
517
912
164
732
194
476
4190
(0.58)
(0.45)
(0.72)
(0.16)
(0.65)
(0.42)
(0.78)
(0.54)
No. (%) with
primary syphilis
7 (0.0034)
o
o
1 (0.0009)
16 (0.014)
1 (0.002)
1 (0.0017)
26 (0.004)
STDs (syphilis, gonorrhea, nongonococcal urethritis, and
condyloma acuminatum) demonstrate that the incidence of
STDs is increasing sharply [38]. In a recent study from
Guangzhou (Canton) between 1986 and 1989 [39], 14,513
patients with STDs were recognized, with 5905 cases in
women. Gonorrhea was the most common STD; there were
only 14 cases of syphilis. The male-to-female ratio for STDs
was 1.5:1, and the incidence of STDs in women grew faster
than in men. In 1993, the Chinese People's Daily Newspaper
(1 December 1993) reported that 830,000 Chinese had had
STDs since 1980, as determined on the basis of government
reports. Both prostitution and promiscuity are held responsible for this epidemic.
In addition, physicians appear to lack training for treatment
and counseling of patients with STDs. Case finding is difficult
because of limited resources and lack of public cooperation,
and therefore official government reports are likely to underestimate the true incidence rates. The attitude of the public (and
impotency of the government) can be linked to economic reform and far greater freedom of movement and individual autonomy than in the days of Mao. While the government does
not seem to have the strength or the will to deal with STDs as
in the past, a recent press release reported the incarceration of
200,000 prostitutes and requirement that they submit to 6
months of moral education [40].
HIV disease appears to be rare in China at present. Only
1106 HIV -positive persons had been identified as of May
1993, including 14 with AIDS [41]. HIV disease has been
concentrated in the southern border province of Yunnan,
where intravenous drug use has been a problem [41]. While
China has formulated AIDS prevention policies [42,43], the
Chinese people are being led to believe that HIV is a disease
of foreigners, and there is little public STD education [4245]. The rise of STDs and the likely spread of AIDS in
China today clearly demonstrates that while it is possible to
eradicate STDs, public policies alone do not lead to permanent behavioral change. Indeed, Ko [45] has argued that
sexual repression in China, as a legacy of Mao Zedong's
S227
era, may help facilitate the spread of STDs, perhaps in part
as a backlash to these policies.
Conclusions
STDs continue to plague humans. Understanding and controlling the transmission of STDs is critical. Development of
vaccines is time-consuming and has, to date, proved impossible
for STD pathogens transmitted in ejaculate [46]. In addition,
effective antimicrobial therapy for STD pathogens (as is available for gonorrhea, Chlamydia infection, syphilis, and others)
has not led to control of these diseases [6, 32]. It is essential
that we focus on the behavioral and societal aspects of STDs
if we are to implement a successful HIV control program [47].
Two perspectives on STD behavioral control have arisen [2,
47]. In one paradigm, the individual is responsible for his or
her own behavior and is expected to recognize the effects and
consequences of his or her actions. Smokers should stop smoking, fat people should stop overeating, and sexual abstinence
or monogamy is the only sure way to avoid AIDS and other
STDs. However, interventions dependent on individual change
in sexual behaviors are only now being systematically studied
[47], and long-term results are not generally available.
The alternative approach to STD control is a public health
focus on governmental interventions at the societal as well as
the individual level. The STD campaign in China was almost
entirely governmental and left few personal options. Mass
screening for syphilis was mandated and made good sense
given the sensitivity and specificity of the tests available, the
prevalence of the disease, the efficacy oftherapy, and the ability
of the government to enforce cooperation.
We believe that, despite historical, political, and economic
differences, the experience in China with syphilis has three
important messages for the prevention of AIDS and other STDs
today. First, public health campaigns can have a dramatic impact on STDs. This observation correlates with the now popular
idea that information and education, generation of appropriate
social service resources, and identification of a social support
network can help prevent the spread of AIDS [2]. Second, the
achievements of the Chinese campaign resulted in large part
from improvements in the status of women. The Marriage Law
and the elimination of prostitution were essential to STD control. It has now become clear that HIV cannot be controlled
without dealing with prostitution and concomitantly providing
women with other means of support [48]. In reality, the global
response to AIDS uses at least some of the principles of the
Chinese campaign, although with less obvious success.
Third, and most controversial, control of STDs in China
appeared to result from (and may have required) curtailment
of the rights and privacy of many individuals. Given the magnitude of the syphilis epidemic in China, the health consequences
of this disease, and the success of the campaign (viewed 43
years later), it is possible to understand the rationale for some
of the draconian measures used. However, it is also important
5228
Cohen et a!.
to realize that the Chinese campaign was organized to destigmatize prostitutes and people with STDs. In addition, the treatment provided for STDs was a positive, sometimes life-saving
benefit of the campaign. The situation with HIV disease is, of
course, different. Curative therapy for HIV disease is not available and patients with HIV infection are often badly stigmatized.
Ironically, given the widespread negative assumptions about
the Chinese government, we believe that their response to syphilis deserves serious reexamination by the world health community. Building a public health infrastructure capable of identifying patients with syphilis, formulating a rationale for global
mass screening strategy, and creating an environment in which
patients can be identified and treated (the Chinese achievement)
are ingredients essential to a campaign to eradicate HIV disease
when or if curative therapy becomes available.
Acknowledgments
We thank Allen Brandt, Holli Hamilton, Keith Wailoo, Desmond Runyan, and King Holmes for helpful comments.
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