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Millions of patients: Substance abuse in China
China will be a major player on the world stage in the 21st century. Business knows well the impact of 1.3 billion customers on the world economy. China is a vast country with 22% of the world's population. But in recent years alcohol use, alcohol-related problems, and drug abuse have grown in China. HIV cases are on the rise. If the current trend continues, substance abuse will prove to have a major impact on this growing nation.
In a crowded marketplace in Gansu province, as the winds whip sand into your eyes, an old man shuffles up politely and asks, “Are you a foreigner?” “Yes, I am,” you admit. He says, “I am from the hills, up there,” and he invites you to travel to the mountains with him. Soon, you're jammed in a car with the old man, driving up rutted paths to the village. It is the home of the Dongxiang people, an ethnic minority descended from Muslim traders who rode the Silk Road. Veiled Muslim girls swarm everywhere. You meet a representative of the local government. They clasp hands and touch their hearts, in the Muslim manner. After small talk about the weather and politics, the conversation turns to business. The 78-year-old councilman says the price is $24 per gram—very cheap, with a 55% purity. “Better than Beijing or New York,” he says. Such is the drug trade in remote China.
China has a long history of drug use, with addicts who filled opium dens. When the Communists took over in 1949, they eradicated drug use in a matter of years. Opium had no place in this new state. But today, as China hurtles into the 21st century, bypassing the 20th, common people are making their own choices again. For some, the biggest lure is the greatest taboo: drugs.
Alcohol use and abuse always have been an integral part of Chinese culture. The West, though, has long held to common myths about substance use and abuse in China. Here are a few of the myths:
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Myth: Asians do not use or abuse alcohol. Reality: Asian countries, specifically Korea, Japan, and China, have the highest alcohol consumption rates worldwide. The Chinese see alcohol as a representation of happiness and auspiciousness.
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Myth: Asians have a heightened “flushing phenomenon,” an internal warning system to alert them to drunkenness. Reality: At professional dinner meetings, heavy alcohol consumption occurs, with the purpose of obtaining an edge in negotiations by getting your customer intoxicated. Drinking is socially accepted and plays a significant part in major events of daily life such as the New Year Festival, weddings, birthday celebrations, etc.
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Myth: Drug abuse does not exist in Asia. Reality: Although Asian countries have strict penalties for drug abuse, significant drug problems are present. Best estimates state that there are more than 10 million drug abusers in China, especially in southern provinces.
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Myth: Addiction treatment is available in China. Reality: There are very few beds for addiction treatment nationwide. Most drug abusers are sent to labor camps for extended periods (one to three years), and few if any treatment services are provided at these sites.
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Myth: Medical personnel in China and Nepal have been trained in addiction treatment. Reality: As in most countries, physicians in these nations receive little or no training in addictions.
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Myth: Chinese people view addiction as a disease. Reality: As in most nations, substance abuse is seen as “a bad habit” in China, to be overcome by willpower.
David J. Powell, PhD
More than 80% percent of the nation's drug addicts are under age 35, according to the Chinese government, which keeps meticulous—if questionable—statistics. Until recently, the Chinese Center for Disease Control and Prevention has focused most of its attention on tobacco use, and now seeks epidemiological data on drug and alcohol use and abuse.
In the chic clubs of Shanghai, a city of 20 million, teens now pop candy-colored Ecstasy pills. Many truck drivers use “ice” to stay awake on the ride home. But these days, the most alluring drug in China is a derivative of that ancient curse, opium. More than 70% of the nation's drug addicts use heroin, known in slang as “China White.” Nestled beside the drug kingdoms of Myanmar (Burma) and Afghanistan, China has long been a major transit route for drugs on their way to other parts of Asia and beyond. Half of the heroin from the Golden Triangle now travels through China's southern provinces of Yunnan, Guangxi, and Guangdong before reaching international seaports. Today, a new pattern is emerging: Based on Chinese government estimates, 25% of the heroin entering the country stays in the mainland for use by addicts at home, up from 10% in 2000.
International drug analysts estimate that up to 15% of heroin consumed in China is now homegrown, and that percentage is expected to rise as domestic demand continues to surge.
Alcohol consumption rates
The Chinese consume a wide range of alcoholic beverages, from distilled liquor (about 54% ethanol), to less strong liquor (32 to 44%), wine and yellow rice wine (12 to 18%) and beer (4 to 6%). China is now the second largest beer-producing country in the world. Beer accounts for 73.1% of beverage alcohol sales.
A 2001 World Health Organization survey estimated annual alcohol consumption in China to be 4.5 liters per adult (ages 15 and older). This is an increase from a level of 1.03 liters in 1970. Although China's annual alcohol consumption rates remain well below European rates (8.6 liters), these statistics may be affected by the number of rural poor residents in China. With their ability to purchase alcohol being limited, home brewing and illicit alcohol production and sales are made more appealing.
It is important to examine trends in China over time. Beer consumption (in million tons) has gone from 6.92 in 1990 to 22.89 in 2001. Spirits and wine consumption have stayed relatively stable during this timeframe. While it is useful to look at drinking-related harm, such as medical complications related to alcohol use and abuse, social indicators, etc., this unfortunately has not been studied systematically in China. But with rapid social and economic change, it is fair to assume that there will be a steady increase in alcohol-related health and social problems.
12-Step and other treatment
There are very few centers for treatment of alcohol and drug abuse in China. In a country this vast, there remain only a few hospitals offering treatment. Doctors seem reluctant to diagnose alcohol and drug abuse, seeing it either as a sign of character defect or a bad habit. A social stigma remains a major barrier to recognition of the disease. Hence, hospitals treat primarily late-stage alcoholism, and almost exclusively in men. Women are rarely treated for alcohol problems, given a more intense stigma surrounding use in women.
A key step in addressing substance abuse issues in China was to begin 12-Step programs. AA has long existed in China in the English-speaking, expatriate communities. In the mid-1990s a Korean-speaking AA group began north of the border of China and North Korea. The first Chinese-language AA meetings began in Beijing in 2000. Since then, AA meetings in English and Mandarin are held daily in Beijing and an increasing number of other cities. It is roughly estimated that there are 60 AA members in Beijing. Big Books and AA pamphlets have been translated into simplified Chinese and are readily available in several cities.
Al-Anon meetings also have begun in several cities, although Al-Anon members find it difficult to sustain meetings with the turnover of the expatriate community from which sponsors are drawn. NA has begun in Shanghai and Beijing, although it is difficult for a drug addict to attend meetings given the legal consequences of “being public” with one's drug abuse.
The Municipal Mandatory Rehabilitation Center in the sand-swept, northwestern city of Yinchuan houses 200 addicts/inmates who have been through the cycle: addiction, arrest, detox, rearrest. There are 695 similar mandatory centers in China, and in 2005 they “treated” 216,000 addicts. An additional 56,000 repeat offenders were sent without trial to “detoxification-through-labor” camps. In these grim places, inmates toil for 16 hours a day making products such as stuffed animals, Christmas ornaments, and paper valentines. HIV abounds in the centers; the government estimates that 69% of Chinese AIDS patients are heroin users. There is an abundance of heroin inside the rehab centers.
The central government admits that 90% of Chinese addicts relapse once they leave the centers. The question can be raised as to whether these individuals ever got clean in the first place. Even in rehab centers where drugs are less abundant, officials make little effort to address the physiological and psychological needs of a heroin-addicted brain. Addicts are treated as criminals. With drug addiction soaring nationwide, the Chinese government has sought alternatives to the state-run detox centers. Expensive and unorthodox remedies alike have flooded the market.
There is light at the end of the tunnel, though. In 2007, nearly 150 addiction professionals will be trained and credentialed by the newly formed China Association of Addiction Professionals. A faculty of 40 addiction experts from throughout the world will provide this training in Beijing, Shanghai, and Kunming (southern China, Yunnan Province). In March and April courses will be offered to 150 participants from throughout China on the 12 core functions of addiction counseling.
The first program for children of alcohol- and drug-abusing parents will begin at Beijing Medical University, with the assistance of Jerry Moe of the Betty Ford Center and Zhang Qiuling of BMU. Epidemiological research into the prevalence and incidence of alcohol and drug abuse will begin at BMU's National Institute of Drug Dependence and the Chinese Center for Disease Control and Prevention, in cooperation with the Pacific Institute on Research and Evaluation. Discussions are under way to open a freestanding treatment center outside of Beijing, staffed by Chinese medical personnel and recovering addicts and alcoholics, modeled on programs such as Hazelden and High Watch Farm in the United States.
China likely will become the major player on the world stage in this century. How it deals with its growing alcohol and drug abuse problems will be a significant factor in how its growing role plays out.
David J. Powell, PhD, is President of the International Center for Health Concerns, Inc. He is a global consultant who has advised more than 70 nations on treatment delivery systems and manpower development. He helped to establish Alcoholics Anonymous and Narcotics Anonymous in China. Powell wrote on trends in the addiction counseling profession in the March 2005 issue. His e-mail address is djpowell2@yahoo.com.
