current issue > summer 2010 contents

Face to Face: An Interview with Joan Kaufman

East Meets West

Lisa Leslie Henderson writer
Brian Smith photographer

Adorned with a striking necklace from one of her favorite artists in Beijing, Joan Kaufman settles in with a cup of coffee to reflect on her career in international health policy. A self-acclaimed China wonk, Kaufman’s home is filled with Chinese art and antiques: carved cabinets, rosewood wall hangings, and porcelain bowls. Having returned stateside from China over a decade ago to raise her family in Wellesley, Kaufman continues to circle the globe with a suitcase, identifying and addressing emerging issues and opportunities, and educating current and future world leaders about international health issues.

Kaufman moves seamlessly between academics and the public and non-profit sectors. She’s taught at the Heller School for Social Policy and Management at Brandeis, at the Kennedy School of Government, and at Harvard School of Public Health. She’s worked for the Ford Foundation, the United Nations Population Fund, and served on advisory committees for the World Health Organization and the National Institutes of Health. An expert in health and social policy, reproductive health, gender equity, and HIV/AIDS, Kaufman has published extensively and has the ear of the Chinese government.

WWM: What first ignited your interest in public health and in health policy in China specifically?

Kaufman: My interest in China came first. I became completely hooked on everything Chinese after taking a summer course at Columbia on Chinese art, taught by a curator at the Metropolitan Museum. I ended up focusing my undergraduate degree, and a subsequent Masters, in Chinese Studies. My thesis examined the Chinese family planning program, which led me to a second Masters degree in public health.  From there I spent four years on the ground in China, working with the United Nations’ Population Fund (UNFPA).

WWM: You were one of the first western public health specialists to be invited into China as part of the reforms introduced by Deng Xiaoping. What were you brought in to do?

Kaufman: This was a very interesting time in Chinese history. Deng Xiaoping has just returned to power following the Cultural Revolution. He was convinced that population control was key to China’s bid for modernization and invited the UNFPA into China to develop a core of expertise in the reproductive health field. We had probably 20 projects going on at the time including undertaking China’s first scientific census and building technical expertise in terms of demography, clinical trial know-how, and manufacturing of modern contraceptives.

WWM: What was the public’s reaction to the One-Child Population Policy?

Kaufman: The One-Child policy really built upon an earlier program—the Later, Longer, Fewer campaign—which encouraged couples in urban areas to limit themselves to two children and those in rural areas to limit themselves to three. The One-Child policy called upon party members to further limit themselves to having one child. The policy wasn’t very popular anywhere, nor well implemented in the rural areas where most people followed a policy of having two children with adequate spacing, especially if the first child was a girl.

WWM: Is it time for the policy to be overturned?

Kaufman: Yes, the policy is not necessary and is, in fact, the cause of considerable other problems. I have been active in a project that I initiated when I was with the Ford Foundation in China that has been looking at fertility rates across China for some time and the negative consequences of the one child policy. The country has changed so much in terms of fertility intentions and desires, and an awareness of the economic tradeoffs of additional children, that we don’t think there would be a massive resurgence in births if the policy were revoked. Maybe a short term up-tick.

There are, however, long-term, unintended consequences of the One-Child policy that will be very difficult to manage. The country’s sex ratio and age ratios are quite distorted. The skewed ratio of more boys to girls will play out for decades in terms of the marriage market and a dearth of girls in society in general. There are not going to be enough young working people to support an elderly population given that life expectancy is so high. China is already entering into below replacement fertility in urban areas, so even though the overall population will continue to grow for a while, once it starts to decrease, it will decrease dramatically and with huge distortion.

WWM: You were actively engaged in health issues in the early days of the AIDS epidemic. What was China’s response?

Kaufman: The first AIDS case was diagnosed in 1985. It was considered a so-called “foreigner’s epidemic”—imported from the vices of the west. I was living in the US at the time, getting a doctorate at Harvard’s School of Public Health, and was part of the AIDS and Reproductive Health Network, which was working on AIDS projects in Africa, Latin America, and Asia. The dynamics of the emerging epidemic in China were clear to me and I advocated for an aggressive prevention program by the Chinese government. When I moved back to China to work with the Ford Foundation in 1996, I devoted a large portion of my grant portfolio to mobilizing the government’s AIDS response. I was able to fund some important behavioral research studies, build up a non-governmental advocacy community, work with government health officials, and bring the researchers, advocates, and government officials together to coordinate our efforts.

WWM: Was there much of a non-governmental health community in China at the time?

Kaufman: The whole idea of an NGO [non-governmental organization] is not well received in China, especially at the local level, where such organizations are often viewed as anti-government, not non-governmental. But on the AIDS issue, and on some other issues like the environment, there is a growing appreciation for the important role that these organizations play both in service delivery and in advocacy. I am seeing more cooperation between the local Centers for Disease Control in China and NGOs, especially when the centers are trying to reach some of the most affected and highly stigmatized populations—like drug users or gay men. The presence of NGOs is growing, but it is still thin.

WWM: Among which subpopulations did HIV first surface in China?

Kaufman: Seventy percent of the early cases involved injecting drug users who shared needles. China was a major transshipment route in the heroin trade in the Golden Triangle in Southeast Asia. Very early on we made a case for harm reduction programs, which include clean needle programs and drug replacement programs—like methadone—to try to decrease the HIV infection rate among the injecting drug user population.

Of course at that point in China there was the feeling that these people were social garbage and that they deserved to die because of their own behaviors. Further, the government had the mistaken belief that the epidemic would stay contained within the injecting drug user population. One of the first things we did was to bring in the “Asian evidence,” people from Thailand and Vietnam, to show the efficacy of harm reduction programs and the evidence that epidemics never stay contained within any one population. I am happy to say that, today, China has a very aggressive harm reduction program for injecting drug users as part of their AIDS prevention program.

WWM: What was the turning point, when AIDS prevention became more accepted?

Kaufman: By 2002, the epidemic became more widespread—over one million Chinese were reportedly infected at the time with estimates of ten million by 2010 (the estimates were subsequently reduced to 650,000 and now is 750,000)—and the infection had spread to include female commercial sex workers, homosexual men, and paid blood donors and their families.

Many people were quite critical of the Chinese government’s handling of a widespread outbreak in Central China that involved blood donation. There is a long history of paid blood donation in China. Traditional cultural reservations about giving blood have impeded the development of a voluntary blood donation system. In this instance, blood collection centers in central China were following unhygienic procedures and many, many people became infected. In Henan province alone, over 60 percent of the adult population in some villages became infected; vertical transmission spread the disease to spouses and offspring and, over time, a major orphan problem emerged. The Chinese government suppressed news of this epidemic and to this day no one has really taken responsibility for it.

But it was a turning point for China with re­spect to HIV/AIDS. It changed the face of AIDS in China—these were innocent victims—and the public became more sympathetic. It also forced the government to develop a best-practices response, including launching a free AIDS treatment program.

WWM: What is a best-practices response?

Kaufman: Best practices are interventions that have been proven over and over to reduce HIV transmission. But to be successful, you also have to create an “enabling environment,” a multi-sectoral approach. In order to convince people to come forward for AIDS testing, you have to have enforceable laws and policies that protect them from losing their jobs. You need collaboration between the Public Security Bureau (police), the health department, and NGOs that may be working with drug users so that they are not arrested when they come to a syringe and needle exchange site. In the larger scheme, you have to work on gender equity so that women have more power in their marriages. Most of the global AIDS dollars go to health ministries not to multi-sector initiatives, however.

WWM: You have lived in China and speak Mandarin, but what is your secret, how have you been able to be so effective in the inner circles within China?

Kaufman: I am a collaborator and have been interested and involved in China for a very, very long time. I enjoy a trusted status in China, having built many relationships in the government working with the UN as a funder through the Ford Foundation, and conducting academic research with Chinese colleagues. Even on controversial topics like the AIDS epidemic, my goal is to help China, not to further any personal agenda.

WWM: You are the China Team Leader for The International AIDS Vaccine Initiative. Are we even close to developing an effective vaccine?

Kaufman: No, but it takes decades to develop vaccines. From an evolutionary biology perspective, this is a very challenging virus. The investment we have made in developing the vaccine to date has already led to an enormous amount of scientific knowledge and has demonstrated that a vaccine is possible. Will we have a vaccine commercially available within the next decade? I am not sure. I personally believe that given the complex human behavior that needs to be changed for really effective prevention, having a vaccine is going to be the easiest way to avoid future infections. A vaccine that protects women or young girls, without them having to demand condom use, is important.

WWM: While HIV/AIDS remains at the cornerstone of the Obama Administration’s 2010 budget, it also represents a broader definition of global health, including preventable and tropical diseases, malnutrition, and the health needs of mothers and children. What do you think of this policy shift?

Kaufman: When I teach my global health policy course, I agree with the Obama Admin­istration. The lion’s share of funding has gone to HIV/AIDS, and there are other unattended problems, like maternal mortality or malaria, that need to be addressed. When I teach my AIDS policy class, however, I argue that, although we have made very real progress, we must not get complacent. Four hundred people continue to become HIV-infected every day. For every two people put on treatment, five new HIV infections occur. There are just not enough health care dollars out there.