The risk of success: cultural determinants of chronic disease and sexually transmitted infections among urban Chinese men

Abstract

During the 1950s and 1960s, the People's Republic of China successfully waged a series of public health campaigns to control the infectious diseases that were ravaging them as a nation. This included a campaign that targeted the social roots of sexually transmitted infections (STIs). China is now facing a new disease profile that includes emerging epidemics of chronic disease as well as reemerging epidemics of STIs. Many of these diseases are strongly associated with gender and occupation, suggesting need for a critical model of health literacy that recognizes the role of social risk in promoting risky behaviors rather than focusing on a simple model that disseminates knowledge about biomedical risk. Such a model is useful for explaining why people armed with knowledge about biomedical risk continue to engage in risky behaviors. This article focuses on the social risks that wealthy Chinese businessmen and government officials negotiate on a daily basis. It highlights the concept of guanxi that is so central to building relationships in China and explains the traditional process of yingchou used to establish and maintain relationships among this cadre of men who depend on one another for political and economic success. This process, which has become pervasive in China's era of market reform, requires men to engage in frequent practices of smoking, drinking, eating and female-centered entertainment that are contributing both to their success and to their increasing vulnerability to chronic disease and STIs. The paper concludes by offering some alternative approaches to addressing this emerging disease pattern among this particular segment of China's population.

INTRODUCTION

Several decades after the People's Republic of China mounted successful public health campaigns to control rates of infectious disease, including sexually transmitted infections (STIs), the country is now experiencing a rapid transition in its disease profile that includes newly emerging epidemics of chronic disease as well as reemerging epidemics of STIs. Successful response to this transition will require new health education programs that increase health literacy around these emerging diseases. Rather than relying on a functional model of health literacy that promotes behavior change through simple dissemination of scientific knowledge about risk, it is important to develop a critical model of health literacy that helps people challenge the social risks caused by traditional requirements and expectations in society (Wang, 2000; Hirsch et al., 2009). The concept of risk typically used to inform functional health literacy models assumes that scientific knowledge about a disease prompts people to make rational decisions that help avert any type of biomedical risk (Lupton, 1999). This scientific approach, which neglects the many social and cultural models that ultimately determine exposure to certain biomedical threats, often fails to affect behavior change. A model of social risk assumes that no behavior is irrational and that people engage in behaviors that ‘generally make sense in a particular social and cultural context’ (Hirsch et al., 2009). Looking at disease through a perspective of social risk is useful for understanding why people armed with knowledge about biomedical risk continue to engage in risky behaviors.

Data about the newly emerging conditions of chronic disease and STIs in China highlight a strong association with gender and occupation clustered particularly around working-age men; an association perhaps best exemplified by smoking. Sixty percent of Chinese men smoke as opposed to 5% of Chinese women, and men between the ages of 35 and 44 are most likely to smoke. When one takes account of China's 320 million adult smokers as compared with the rest of the world, one out of every three smokers world wide is a Chinese man (Gu et al., 2004). In fact, men account for 80% of deaths attributable to smoking in China (Gu et al., 2009). Disproportionate consumption of alcohol among working-age men also affects men's vulnerability to a variety of diseases including stroke, the leading cause of death in China (Bazzano et al., 2007; Zhang et al., 2008). Moreover, while official statistics demonstrate that STIs affect women more than men, it is suspected that rates are actually higher among men who are more likely to seek methods of self-treatment that help avoid contact with a medical practitioner or surveillance mechanism. Many women actually contract STIs from their husbands or male partners who earn high incomes and frequently socialize and travel for work (Parish et al., 2003; Chen et al., 2007; Wu et al., 2007).

These gender and occupationally biased statistics are not surprising given the necessity for businessmen and government officials to engage in traditional practices of smoking, eating, drinking and casual sex to achieve political and economic success in China (Uretsky, 2008). While many studies recognize that behaviors associated with risk for chronic disease and STIs are deeply entrenched in distinctive Chinese characteristics associated with male practices (Liu et al., 1998; Cochrane et al., 2003; He et al., 2005; Bazzano et al., 2007; Chen et al., 2007; Yang et al., 2008; Zhang et al., 2008), there has been no research to date that links these risky behaviors to their cultural significance.

This article seeks to explain the historic origins and contemporary significance of the risky behaviors practiced by many working-age Chinese men and in particular highlight the contribution a model of social risk can make to understanding emerging patterns of chronic disease and STIs in China. It focuses on a traditional socialization practice known as yingchou that helps establish and maintain professional ties of success in China. As the article explains, establishment of a market-oriented economy in 1978 spawned a new class of business entrepreneurs driven by the pursuit of economic success. The maintenance of a traditional socialist bureaucracy that still controls the resources, permits and allowances necessary for entrepreneurial success requires businessmen to procure resources from government officials who are prohibited from engaging in monetary exchange. This has engendered a unique system of patron-clientelism, enabled by a return to traditional relationships structured around the concept of guanxi, which is dependent on feelings of trust and mutual exchange. Establishing and maintaining guanxi often relies on the social rituals of yingchou that requires men to participate in activities of smoking, feasting, drinking and female-centered entertainment that is often coupled with commercial sex.

Taking such an approach not only helps illustrate the important contribution social risk makes to risky behavioral practices, but also allows for a more syndemic approach to examining China's emerging disease profile. The term syndemic implies a situation where a singular set of social conditions can create vulnerability to a cluster of diseases. Looking at disease from a syndemic perspective creates a more holistic analysis focussed on environments and agents of risk rather than the linear association between individual behaviors and discrete diseases prioritized by the biomedical model. Such an approach can open up useful social avenues for addressing the confluence of a variety of diseases (Singer and Clair, 2003).

METHODS

This paper is based on 18 months of ethnographic research, conducted between 2003 and 2006, that examined the potential impact of sexual practices among wealthy urban Chinese businessmen and government officials on the country's burgeoning HIV epidemic (Uretsky, 2007). Research was conducted in an area with both an active cross-border trade industry and a mature HIV epidemic. This method of research allowed examination of men's ‘lived experiences’, which offered an important perspective on understanding motivations for their sexual practices. The study revealed that the same networking ritual (yingchou) that governs the sexual practices of wealthy businessmen and government officials also promotes heavy patterns of smoking, drinking and indulgent eating. Most men in the study considered themselves at greater risk for chronic disease than for HIV, but also expressed a lack of agency to control behaviors related to both because of the necessity to engage in frequent networking practices as a means of success. These results are not meant to be generalizable across an entire population, but rather, are an in-depth look at a discrete population that offers explanation for the strong statistical significance between gender, occupation, chronic disease and STIs in China. The results and discussion presented here are useful for informing necessary research and programming going forward.

Snowball sampling was used to recruit people from across local society into the study. Sampling began with businessmen and government officials. Several key informants who had experience in both business and government offered introductions to other men who fit the study criteria. All men included in the study were engaged in either business or government jobs, all had networks that tied them to both occupational categories, and they ranged in age from 26 to 45. The inclusion of women highlights an assumption that gender and gender-related practices are relational (Connell, 1995; Guttmann, 1997). Women were recruited through separate processes of snowball sampling and included married women working in government and business as well as women engaged in the commercial sex industry (both managers and workers). Women ranged in age from 20 to 40. The study also included local health officials, medical personnel and employees of international HIV/AIDS prevention and intervention projects. This broad sampling frame allowed for triangulation of data and construction of a comprehensive model of the local politico-economic and socio-cultural factors that affect male sexual practices. A total of 37 men and women from the community participated in the study in addition to 15 officials and international agency employees. Written consent is difficult to obtain in China, especially in the case of sensitive studies. As a result, all study participants agreed to inclusion after completing a process of oral consent that was part of a study protocol approved by ethical review boards in both the USA and China.

Data were collected through participant observation and a series of semi-structured and unstructured in-depth interviews. Participant observation is a useful tool for understanding how natural habitats influence behaviors and practices and allows the researcher to understand the difference between what people say they do and what they actually do (Bernard, 2006). Participant observation was conducted in all locations where urban Chinese men work, live and pursue entertainment including offices, homes, restaurants, karaoke and disco clubs, massage parlors, saunas and hair salons. In-depth interviews were all conducted in private spaces often determined by the research participant to accommodate time restrictions. These included participants’ offices, homes, private rooms in restaurants and entertainment establishments and Buddhist temples. One participant even requested to be interviewed in his car. All interviews were conducted, transcribed and translated by the author who is fluent in mandarin Chinese. Men and women alike were equally receptive to the author, a woman, whose gender did not restrict access to information or locations. Due to the sensitive nature of the topic, most interviews were recorded in the form of notes, although some participants did permit use of tape recorders. Different interview guides were used to direct the semi-structured interviews with varying segments of the sampling frame but all focussed on collecting data around a basic set of themes that included the daily pressures and expectations of businessmen and government officials, the definition of a Chinese man, family relations and the roles and responsibilities of a man in the home, the uses of entertainment, and knowledge and attitudes toward HIV/AIDS.

The large amount of qualitative data from the original research project was recorded as typed field notes and interview transcripts. Data were filed and categorized into an indexed system that developed during the course of the research. A method of ‘grounded theory’ (Bernard, 2006) was used to analyze the data. This involved a process of textual analysis used to understand both popular and official discourse about dominant patterns of masculinity and male sexual culture. Common themes that emerged during the research process were categorized together as were common responses to interview questions. This initial coding exercise was used to relate certain events to each other through a process of ‘textual interrogation’ (Dowsett, 1996). The process of ‘thick description’ used to guide analysis helped to preserve and explain local meanings and cultural practices conveyed during the research process (Asad, 1986). This led to emergence of the dominant theme of yingchou, which ultimately opened up investigation into concerns about chronic disease.

RESULTS

The unofficial structure of a ‘typical’ workday

Officially, the men observed in this study worked Monday through Friday from 8:00 a.m. till 6:00 p.m. with a 3 h break from 11:30 a.m. to 2:30 p.m. for lunch and siesta (xiuxi). Most men in the study, however, did not return home until they completed the many unofficial duties related to their work roles, which often ended as late as 2:00 a.m. In addition, the typical workweek observed was not delineated by weekday versus weekend and loyalty to work and the Communist Party often had to supersede loyalty to one's family.

Many participants often began their workday hosting a guest for breakfast. Guests were typically out-of-towners who were either evaluating work of the local officials or seeking to develop new official relationships for tourism and trade. Alternatively, local businessmen interested in developing new business opportunities, often hosted local officials who could enable their success. Breakfast was followed by trips to the field to view and inspect a local site of either business or government operations. This provided evidence of the host's capacity to carry out either their official duties or their intended business venture. True success, however, was dependent upon establishing a trusting relationship with one's guest. This involved continued demonstration of respect throughout the day and their professional relationship. As a result, hosts typically invited their guests to a luncheon banquet at 11:30 a.m., which included various local delicacies and requisite strong alcohol used to demonstrate mutual respect through a ritual hierarchical model of exchanging formal toasts. Lunch was usually followed by a brief siesta (xiuxi) and then official work-related duties continued from 2:30 until 5:30. The host always invited his guests to dinner in the evening for another banquet that consisted of more local delicacies and strong alcohol. After dinner hosts typically invited their guests out for entertainment, which could include massage, foot reflexology, hair washing or a trip to a local disco and karaoke club; often followed by a midnight meal. Entertainment could be coupled with sexual services from a service girl in the establishment. Alternatively, the guest could be offered services from a brothel-based sex worker who was discretely solicited to his hotel room. Finally, cigarettes were constantly exchanged between host and guest throughout the day, again as a means of initiating and maintaining communication and respect. This typical day of hosting and entertaining could define 6 or even 7 days of the workweek for local officials and entrepreneurs in this study.

The pressures to conform

While many men were reluctant to participate in frequent practices of yingchou, they also expressed a lack of agency to resist. These men constantly recounted the influence that yingchou activities have on their success because government officials are more likely to instill the trust needed to procure resources in people who can demonstrate personal and Party loyalties exemplified by participation in the collective activities of eating, smoking, drinking and female-centered entertainment. This pressure places burdens on a man's health and personal life. As one Party employee recounted, ‘When your boss calls, you have no choice but to drop everything and go for the evening'. Government workers said participation was necessary for strengthening and maintaining relations with their superiors and limiting any potential career threats. These expected loyalties to the Party created a dilemma for many men who desired to fulfill the traditional ideal of Chinese masculinity, which requires a man to prioritize responsibility to his family.

Local bureaucrats felt equally as compelled to yingchou with their superiors as a way of pleasing the men who determine their future promotions. As one mid-level official recounted:

If you want to be an official and advance up the ladder, you must have personal relations. You cannot advance without these personal relations. And where do personal relations come from? You have to invite them out to eat, for a massage, shoot the breeze, solicit prostitutes for them and they'll see that you're useful. … Slowly if you give them the impression that you can do these things, you will gradually advance in rank.

The pressures to engage in these behaviors do not end once a relationship is established. The trust embedded in the relationship must be maintained through repeated frequent yingchou. Several men revealed that government contracts are often granted and sustained on the basis of trusting partnerships established and maintained in karaoke clubs and massage parlors. This is equally true for the state-owned and private companies vying for government contracts in this era of market competition. Such positions can increase a man's chances for professional success but weigh heavily on his family.

Only one man interviewed chose to resist the pressures of success that were dependent on building relationships with local officials. This man had been a small local businessman and was offered an entry-level position in a local township government. While the position would have increased his social status, he chose not to accept it because of the implications on his personal life and health. He was unwilling to sacrifice his family life for his career and success.

Unmet concerns of chronic disease

The men and women interviewed in this study often expressed concern over their own health and the health of their husbands but were unsure how to address these concerns and felt as if they lacked the means to prevent chronic disease. One of the first women interviewed for the project immediately identified her husband, a 36-year-old mid-level tax official, as a good candidate for a project that looked at concerns related to men's health. She said he was not healthy at all because of all the drinking he was required to do for work and suffered from high blood pressure, high cholesterol and chronic fatigue. Many wives and children of local officials expressed similar concerns. One woman interviewed during the project was married to a man who worked as an aide to a top-level provincial official. People in these positions often consume alcohol in place of their bosses. Her husband had suddenly been admitted to the hospital at the time of the interview with a diagnosis of end-stage liver disease, which she associated with his long career.

Many men try to counteract the effects of their professional requirements through alternative therapies rather than proven biomedical treatments such as large doses of herbal therapies marketed to protect the liver. Such potions are popular health protective materials (boajian pin) in China. Still, two other men elected a hospital-based treatment that claimed to literally strip their blood of cholesterol. The procedure withdrew their blood and separated out white fatty deposits before reinfusing it back into their bodies. This was used as an antidote to the indulgent eating required for their entrepreneurial success.

DISCUSSION

Reward and loyalty under a Leninist system

Ubiquitous scenes of urban Chinese men collectively engaging in activities of smoking, eating, drinking and female-centered entertainment are often attributed to increasing access to wealth and Western attitudes that have accompanied rapid economic growth (Chen et al., 2000; Cochrane et al., 2003; Gu et al., 2004; Bazzano et al., 2007; Chen et al., 2007). Further analysis indicates that such practices are perhaps associated with economic growth but more likely caused by the masculine practices necessary for achieving success in China's market economy.

Much of this is related to the growth of a market economy under the umbrella of a Chinese Leninist state. The redistributive economy characteristic of state socialism allocates state-controlled resources to workers on the basis of objective measures such as work output and demonstrated loyalty to the Communist Party (Walder, 1986). In contrast, a market mechanism promotes private resource ownership and exchange facilitated through money, which is not allowable under the guise of a socialist state. The result is a hybrid type of economy that honors the ideals of redistribution and allows market growth through a traditional form of reciprocity based on trust and cooperation.

Networking in Chinese society

Development of a true market economy in China is difficult because the mechanisms are often curtailed by a system of state socialism that can only support a redistributive economy. Turning to a traditional system that has historically relied on relationships of trust for exchange, however, has helped to create an intermediate position where both the market and the state can coexist. These relationships, known as guanxi, legitimate a process of exchange that is also founded on loyalty.

The Chinese term guanxi implies a close sense of reciprocity between two people related through a kin or kin-like institutional bond (Yang, 1994). Traditional guanxi relationships adhered to patterns of hierarchy dictated by Confucian ideology. Today guanxi relationships rely on networks of relatives, classmates, old friends, army buddies and common ancestral home. These innate relationships are imbued with a strong sense of human sentiment that forms an everlasting bond between two people who can turn to each other for favors and assistance. Relying on this traditional system of social relations helps government officials structure a non-monetary system for rewarding resources that subverts redistributive regulations of the ruling state ideology.

Building guanxi relationships

While guanxi-based relationships offer the type of trust and loyalty needed to facilitate exchange in China, most government officials and businessmen who negotiate exchange of state-controlled resources do not share the requisite bonds for guanxi. Such bonds can be built through the practices of yingchou that have traditionally been used to facilitate trust and communication between upper class Chinese men. Many studies have examined and analyzed the concept of guanxi (Bian, 1994; Yang, 1994; Kipnis, 1997; Wank, 1999; Yan, 1996), which is central to Chinese culture, but none has discussed the concept of yingchou, which provides a mechanism for establishing guanxi.

Yingchou has been used as a means of social intercourse since the Song dynasty (960–1279). The feasting and drinking that form the basis of yingchou practices are reminiscent of hierarchical rituals that traditionally defined social discourse in China. The alcohol and food that structure these practices are never consumed individually but rather used as a shared social experience to demonstrate mutual respect. Each person in turn around a table must toast the others individually and collectively as a group. The communication is initiated and sustained through a constant exchange of cigarettes; a practice that has transformed yellowed teeth into an emblem of professional success in China (Wank, 2000). It also continues into the realm of female-centered entertainment that has traditionally been used to strengthen bonds of trust between elite Chinese men (Hershatter, 1997). These traditional rituals impart a type of respect used to demonstrate loyalty toward Party officials.

The importance of yingchou to building the guanxi that facilitates operation of a market economy under a Leninist system has turned the requisite smoking, drinking, eating, and sex into an unofficial part of a man's work. This is acceptable in a system where an institutional framework associated with a person's role rather than specific activities serves to define work (Uretsky, 2008). Prevention efforts to reduce these behaviors should thus consider their ‘occupational’ roles (Popp, 2001) as well as their health effects.

CONCLUSION

Addressing the formidable challenges posed by China's new disease burden must begin with understanding the structures that promote risk associated with these diseases. Research has shown that the newly emerging patterns of disease in China are disproportionately affecting working-age men. Many, however, are not engaging in these behaviors on an individual level. The alcohol, food, cigarettes and sex associated with disease are used as important commodities of exchange that play a valuable role in political and economic success. Prevention among this sector of society is thus dependent on recognizing that such behaviors are not simply individual pathologies but rather collective practices conducted within a specific context. Risk in this context is viewed in terms of career and success and not purely disease exposure. To refuse the cigarette or refuse the drink can be tantamount to insult and disrespect that can threaten success. Thus, for many men, the short-term economic and political benefits of engaging in yingchou practices far outweigh the long-term risks incurred through smoking, drinking or unprotected sex.

The biomedical model that examines diseases as discrete problems that have definite etiologies does not allow us to take the social, cultural, political and economic influences on a person's lifestyle into account when evaluating their risk for disease. In the coming years, many Chinese men suffering from tobacco-related illnesses will find their way to a thoracic surgeon and men suffering from alcohol-related illnesses may consult a liver specialist, while those affected by STIs and perhaps HIV/AIDS may find solace in various courses of antibiotics and anti-retroviral therapies. But while these illnesses all require distinct biomedical treatments, clues into their causes can often be found within a singular cultural and politico-economic phenomenon linked to the unofficial work requirements that ensure success for many of China's urban businessmen and officials.

These results have broad implications for the public health interventions necessary for stemming China's emerging epidemics of chronic disease and STIs. Given how entrenched networking practices are to forming relationships in China, it is impractical to suggest that public health interventions focus on changing men's drinking, smoking, eating and sexual behaviors in the short-term. There are areas, however, where public health can act as an advocate for gaining better understanding of the dynamics that support these behaviors. To begin with, research on chronic disease in China must adapt its measures to the local situation. Targeting the specific demographic discussed in this article will also require developing new workplace interventions that redefine work and the workplace. Additionally, it is important to develop interventions that can target people at the collective level where they engage in risky behaviors rather than educating them at the individual level.

A more realistic approach to preventing chronic disease and STIs among this demographic of men will take advantage of addressing their dilemma of competing loyalties. While loyalty to the Party is paramount to professional success, masculinity in China is defined by a man's responsibility to his family. Engaging in risky sexual behavior potentially threatens the health of their wives and engaging in behavior related to chronic disease can place undue financial and psychological strain on the family. Involving men in programs structured around responsibility to their families may have a much larger impact than promoting a type of health literacy that focuses on biomedical risk. Changing a culture of professional networking with a millennium of history is a daunting task. Giving men the agency to control their behavior in a way that takes advantage of their masculine responsibilities rather than undermining them, however, is a good approach to creating a new form of health literacy that takes into account the social challenges and social risk they face on a daily basis.

FUNDING

The data used to inform this article was collected through a project funded by a National Institutes of Health Ruth Kirschstein National Research Service Award for Individual Predoctoral Fellows [F31MHo69075].