CHRISTIAN FLORES analyzes the role of paradiplomacy in solving the HIV/AIDS epidemic in the Yunnan-Southeast Asian border and offers recommendations for further improvements in management.

Introduction

HIV/AIDS has become a prominent issue in China since the 1980s when the disease first entered the country. The spread of HIV/AIDS forced the central government to mobilize and act against a potential crisis that could befall upon Yunnan Province, particularly in the its border region where the epidemic has been exacerbated by drug trafficking and the flow of people. Non-traditional security issues such as HIV/AIDS management have gained wider attention from political scientists to better understand the role that paradiplomacy, or the involvement of subnational governments or organizations in the formation of foreign policy, plays in finding solutions. Appropriately, this paper attempts to answer the following question: How can paradiplomacy help solve the HIV/AIDS epidemic in the Yunnan-Southeast Asian border? To answer this question, closer attention should be placed on the way that local governments and non-government organizations (NGOs) strategize and coordinate efforts to tackle public welfare issues. Because this non-traditional security issue is not exclusive to China, this paper argues in favor of more efficient coordination between NGOs and local governments to ameliorate the HIV/AIDS epidemic. While making the case for cross-border cooperation, this paper attempts to provide recommendations for a better system of management that China may effectively implement in its border region.

Positioning Paradiplomacy: HIV/AIDS in the Yunnan-Southeast Asian Border

The study of paradiplomacy posits 11 dimensions from which to study the activities of regional governments. For example, the nationalism dimension of paradiplomacy focuses on the nationalistic aspiration of regional multinational and multilingual countries to better understand the formation of diplomacy. In the case of HIV/AIDS management in the Yunnan-Southeast Asia border region, however, the most fitting dimension from which to study this issue is the border studies dimension, which places a special emphasis on the economic, political, and social transformation within the borders of countries. The spread of HIV/AIDS in China originated in the mid-1980s along the Laotian and Burmese border shared with China, as the country opened its economy to the world. Through its liberal policies that encouraged foreign imports and the intermingling of people in the border region, the trafficking of drugs and the development of the sex industry became the vectors of HIV/AIDS in the region. This led to local governments and NGOs to become the engines behind the formulation of public health policy, extending beyond the borders by attempting to decrease transmission rates and increase public awareness. Moreover, given the movement of people within the region and the cultural connection within the Dai ethnic group in the Southwest border region of China, the border studies dimension is critical in understanding the management of HIV/AIDS.

The proximity between Yunnan Province and Southeast Asia has facilitated interaction between China and its neighbors while increasingly facilitating the flow of people.

For example, Figure 1, demonstrates the geographical closeness of Xishuangbanna, Yunnan to the Golden Triangle, a region in Southeast Asia where Laos, Thailand, and Myanmar meet. This geographic region, home to one of the largest exporters of opium to the world, has also facilitated the trafficking of drugs into China. The increasing consumption of drugs has created vectors of HIV/AIDS that have transmit the virus through risky behavior such as needle-sharing. The transactional nature of the drugs trade makes a strong case for an analysis on the basis of the border studies dimension of paradiplomacy, especially because subnational entities are required to eradicate the consumption of drugs. Thus, the spread of HIV/AIDS is not a public health concern exclusive to China. In other words, China is incapable of stopping the trafficking of drugs into the country single-handedly. Because the border studies dimension focuses on cross-border cooperation of different paradiplomatic channels such as subnational governments and NGOs, this dimension provides the best foundation for the further study of HIV/AIDS along the Yunnan-Southeast Asia border.

Moreover, with the change in human vectors and their social positions, challenges in tackling the infectious disease emerge. In the early 1980s, the local government in Yunnan attempted to prevent the spread of this infectious disease by creating policies that rigidly focused on ethnic background. For instance, the local government placed surveillance on the Dai ethnic group in Yunnan as a way of preventing the transmission of HIV/AIDS. The Dai ethnic community stretches along the southwestern border as an enclave in the countries abutting the Golden Triangle. One exemplification of this border-transcending connection within the Dai community is best illustrated by the monks who fled China after the Cultural Revolution and were welcomed by the Dai community in Myanmar and Laos. These same monks then returned to China to re-establish Buddhist institutes in Xishuangbanna. Moreover, despite the different national languages between China and its Southeast Asian neighbors, the Dai ethnic group has maintained its tradition of speaking the Dai language which may also act as a cultural connector among the Dai of different nationalities. Therefore, because of the concentration of the Dai ethnic group in the Southwestern border region and the increasing issue of drug trafficking, the local government took special precautions to enact public health along ethnic backgrounds.

The perceived vectors of HIV/AIDS and the populations affected by this infectious disease has transformed over the years. In fact, the rates of HIV/AIDS have been rapidly increasing among men who have sex with men (MSM).  This change brings about a challenge that requires a multifaceted method address the transmission of HIV/AIDS in the Yunnan-South Asian border. Unfortunately, on this front, the central government has failed to effectively solve the increasing problem brought about by HIV/AIDS. Despite providing free antiretroviral treatment for HIV/AIDS patients since 2016, the central government continues to face difficulties in curbing the rapidly increasing transmission rates among the MSM group. In fact, when one looks at the province as a whole, the MSM group has maintained steady transmission rates, therefore making this group the most at risk. Hence, the transformation in vectors of HIV/AIDS demonstrates the importance of using the border studies dimension in studying the management of the infectious disease in Southwestern China.

While the study of paradiplomacy has eleven dimensions from which the topic of HIV/AIDS management in the Yunnan-Southeast Asia border, the border studies dimension best accounts for 1) the movement of people along this border and 2) the transformation of viral vectors.

The Local Government and NGO Nexus

Effective management of the HIV/AIDS epidemic in the Yunnan-Southeast Asian border is complicated by drug trafficking and the change in the populations afflicted by the disease. Drug trafficking has become prevalent along the Chinese border region that touches Laos and Myanmar. In 2005, the number of officially registered drug users in China reached about 1.1 million, and by 2013, that figure rose to about 2.5 million^,. The rapid uptick in demand for drugs has increased the drug supply flowing into China through its Southeast Asian border. Heightened drug consumption has sustained a high prevalence rate between 20%-29%, among intravenous drug users (IDU) in Yunnan from 2001-2010. Furthermore, the MSM population has become a larger vector for the transmission of the disease. The prevalence of HIV among the MSM group was about 9.42%-11.78% between the years 2008-2010. Altogether, the high rates of IDU and MSM transmissions demonstrate that HIV/AIDS is still a prevalent issue in Yunnan, despite governmental and non-governmental organizations (NGO) efforts to manage the disease.

To tackle the worsening HIV/AIDS epidemic, local governments must undertake a model of governance that allows for improved cooperation with NGOs. Although the 2017 Foreign-NGO Law provided local governments with managerial power over these organizations, the Yunnan government can implement a system of performance-based collaboration as an effective mechanism to better fight HIV/AIDS transmissions. A performance-based collaboration is defined as an initiative in which governments provide NGOs with economic and administrative resources if these organizations are deemed able to create a positive impact on the local population. This collaboration system has been implemented by the cities of Shanghai and Ningbo to improve elderly care. In the case of Ningbo, the local government purchased services from the Starlight Nursing Association (SNA) to meet the demand of a growing elderly population. The effective expansion of elderly care achieved by SNA was met with increased resources and assistance from the Ningbo government. This same system can be implemented by local governments along the Yunnan-Southeast Asian border region to increase their localized efforts aimed at decreasing HIV/AIDS transmissions. For example, the Xishuangbanna local government can work with organizations such as Home of the Buddha’s Light, which have historically pushed forward initiatives that include public outreach campaigns to raise awareness and counseling services for patients of HIV. Successful performance by NGOs such as Home of the Buddha’s Light may allow these organizations to provide even medical services. Although Buddhist monks and nuns currently do not receive medical training from public health professionals, the system of performance-based collaboration has the potential to increase the access to treatments that reduce transmissions if monks and nuns had the qualifications to administer antiretroviral or preventative drugs. Because these organizations can effectively localize efforts, i.e. religion-based events, aimed at the predominantly Buddhist regions along the border, NGOs may very well have a larger impact than local government efforts. For example, official testing centers lack the cultural and religious awareness of the population they serve. Therefore, a successful coordination between NGOs and the local government in the border regions of Yunnan Province can potentially help better manage the issue of HIV/AIDS along the Yunnan-Southeast Asian border.

While a performance-based approach has its merits in creating an effective system of collaboration between local governments and NGOs, the issue of HIV/AIDS requires local governments to act as facilitators, not managers, in the performance-based collaboration system. In other words, by increasing available to NGOs such as funding, professional legal networks, and even offices with the appropriate facilities, local governments can incentivize these organizations to accomplish their goal of lowering transmission rates. At the same time, these organizations should also be provided with a degree of autonomy to properly do their jobs. Local governments, acting as facilitators, can help coordinate the organizations that enter the performance-based system and encourage smaller organizations that have a more specific outreach to join the system. With regards to HIV/AIDS, local governments face the challenge of institutional stigmatization which deters patients and at-risk groups from seeking or accessing treatment; this can be ameliorated through the efforts of smaller NGOs. Shanghai Leyi, which cooperates with the Center of Disease Control to prevent hospitals from discriminating against male sex workers, has successfully helped these workers access healthcare and legal counseling. The success of Shanghai Leyi lies in its dissociation from the local government which allows the organization to help sex workers overcome institutional stigmatization. However, Shanghai Leyi has not officially been registered as an NGO and, because of the recent Foreign-NGO Law of 2017, may face difficulties in fully implementing its work since large amounts of funding come from foreign entities. Therefore, the role of local governments as facilitators in the performance-based collaborative system is imperative for NGOs like Shanghai Leyi. In the case of the Yunnan-Southeast Asian border region, local governments can help facilitate the job of religious leaders and peer-to-peer workers which have played an important role in battling HIV/AIDS. Feng et al. studies the impact of medical professional training on a Buddhist organization and women’s peer-to-peer group in Xishuangbanna Prefecture. Their training included knowledge on HIV/AIDS and discrimination of patients with HIV, as well as proper condom use. While the Buddhist organizations scored higher in sharing their knowledge of HIV/AIDS after the training, nevertheless, the women’s group scored higher in the promotion of condom use within the community. By helping smaller civic organizations or groups enter the performance-based collaboration system, local governments can help NGOs implement programs that reach out better to the MSM and IDU populations.

Lastly, the local governments along the Yunnan-Southeast Asian border region can lower transmission rates by promoting cross-border cooperation between NGOs. Zhang et al. demonstrates the Health Poverty Action (HPA) was successful in lowering the rates of in the border region as a whole by implementing a cross-border cooperative relationship with the local Burmese health sector. Through effective management of the program implementation, building trust and cooperation among, and maintaining respect for the local culture as well as encouraging sustainable development, HPA and the local Burmese health sector were able to decrease the cases of malaria entering Yunnan province by 94.5% between 2008-2014. At the same time, the rates of the malaria parasite found in people along the China-Myanmar border region was reduced to less than 5% from about 20%. The promotion of cross-border cooperation along the Yunnan-Southeast Asian border to reduce HIV/AIDS transmissions can be undertaken by an NGO with extensive program management experience like HPA. With increased diagnosis stations, clinics, needle-exchange stations, outreach teams, and treatment centers managed by NGOs under the performance-based collaboration scheme, cross-border cooperation may prove to be effective. Thus, cross-border cooperation between local governments and NGOs in the border region have the potential to address the high rates of HIV/AIDS transmission among IDU and MSM groups.

All in all, the empirical evidence demonstrates that the alternative model of combating the high transmission rates of HIV/AIDS among IDU and MSM populations in the Yunnan-Southeast Asian border region has the potential to be successful. The local government should implement a performance-based system to incentivize NGOs to cooperate with the government while carrying out their work. Moreover, the local governments should serve as facilitators for NGOs joining the performance system while providing these organizations with sufficient autonomy. Lastly, the government should encourage cross-border cooperation modeled after the HPA approach to combat malaria, which has proven to be successful. 

Conclusion

The problem of HIV/AIDS has become of increasing concern to China, specifically along the border regions where drug trafficking, the sex industry, and regular movement of people have created many complications for managing the epidemic. While political scientists attempt to provide various approaches with regards to how to best tackle the issue, this paper places forth an alternate method of managing the infectious disease. The paradiplomatic approach proposed in this paper aims empirically demonstrates how the local government-NGO nexus may very well prove to be successful in the efforts to tackle HIV/AIDS along China’s Yunnan-Southeast Asia border by empirically demonstrating how this method may be successful. The empirical evidence demonstrates that local governments have options to mitigate and better manage the infectious disease. Future researchers should closely follow the development of NGOs in China’s border regions and the change of local politics, as this may affect the way that these organizations approach the management of HIV/AIDS. More importantly, future studies may be able to provide a more quantitative approach to studying the effectiveness of paradiplomacy in the formation of more effective methods of management. This may be useful in better understanding the degree to which certain variables affect the formation of policy to tackle infectious diseases such as HIV/AIDS.

Christian Flores can be contacted at christiandavidflores1@outlook.com.