From Contaminated Blood to Inadequate Supplies
The supply of blood faces the dual challenges of both safety and sufficiency; the lack of either will endanger public health. In China in the 1990s, the chaotic plasma market triggered an HIV epidemic that led to the death of tens of thousands of people.Footnote 1 In the aftermath of this catastrophe, the authorities not only established direct control over blood administration but also adopted safer voluntary donation practices. As a result, the essential need for blood supplies should be satisfied through the active collaboration of the government and citizens.
Although blood supplies in China have been subjected to proper cleansing since the turn of this century, the problems relating to donated blood still pose real-life dangers. In recent years, surgeons have grumbled that owing to insufficient blood supplies, elective operations have been put on hold; patients have complained that they are not able to receive timely transfusions; and government officials have confessed that blood reserves are often below acceptable levels.Footnote 2 As the director of A Blood Centre put it, blood shortages (xuehuang 血荒) have “spread nationwide” and have been “occurring regularly.”Footnote 3
On the demand side, medical advances have allowed for more organ transplants, spinal operations and other invasive treatments. Recent healthcare reforms and socio-economic advances have led to an increasing clinical use of blood. Additionally, greater patient advocacy has rendered the blood shortages more visible. Nevertheless, close attention should be paid to the supply side. The current donor pool in China is seriously limited. Taking 2011 as an example, there were only nine donations per every 1,000 individuals in the population.Footnote 4 This is lower than the rates in countries such as Brazil, Russia or South Africa, and also below the bottom line suggested by the World Health Organization (WHO).Footnote 5
To identify the barriers to voluntary whole-blood donations in China's state-run campaigns,Footnote 6 I conducted fieldwork in several localities with varying characteristics. E city is known for its well-organized voluntary donations, and the blood buses parked downtown are usually full of visitors; D city is located close to E city but performs less satisfactorily regarding blood collection; F city is at the same socio-economic development level as E city, yet the blood buses there have fewer donors; B city, located close to F city, is considered mediocre in terms of blood administration. From December 2012 to June 2015, I visited these sites several times and conversed with donors and medical personnel. I also interviewed more than 20 healthcare officials in charge of blood administration, two of whom were affiliated with the National Health and Family Planning Commission (NHFPC, previously the Ministry of Health). The duration of interviews ranged from half an hour to several hours. The Appendix provides a list of the interviewees quoted in this study.
The remainder of this article proceeds as follows. The next section reviews blood collection institutions in China and elsewhere. It suggests that by examining the combination of voluntary donations and the state's monopoly over blood services, this study contributes to understanding state–society synergy, a critical “catalyst” for economic and social development.Footnote 7 The third section draws on the fieldwork and interviews to examine the absence of state–society synergy. It shows that even though citizens frequently place the blame for their reluctance to donate blood on a distrust of state-run collection agencies, political concerns prevent health officials from engaging with citizens to dispel the distrust. The fourth section analyses data from the Chinese Citizenship Survey (CCS) and finds that the effect of political trust on blood donations is statistically insignificant. The contradiction between the qualitative and quantitative data is reconciled by the fact that those who donate blood in China are not always true volunteers. Rather, they are what Richard Titmuss labels “captive voluntary donors,” that is, they are recruited by the authorities to satisfy the demand for clinical treatment.Footnote 8 Moreover, given that captive donations compromise the integrity of volunteering and may fuel unnecessary discontent, it is only within certain limits that the government resorts to this practice. Consequently, the blood shortages are manageable yet still remain serious. The final section concludes by arguing that the lack of state–society synergy to address an adequate blood supply is owing to the government's heavy involvement in this voluntary activity. At the same time, by mobilizing captive donors through work units, the government has the capacity to alleviate the nation's blood shortages that are a result of this lack of state–society synergy.
Combining Voluntary Donations with the State's Monopoly on Blood Services
In a pioneering study conducted almost half a century ago, Titmuss argues that, compared with the largely commercialized blood collection system in the United States, the unpaid practices in England and Wales incurred far fewer risks of post-transfusion hepatitis.Footnote 9 This finding influenced policy practitioners around the globe, and in 1975, the World Health Assembly established the principle of “voluntary non-remunerated donation of blood” in order to collect clean blood in an ethical manner.Footnote 10
For similar safety reasons, China embraced this voluntary principle in the 1990s. As is widely known, China's under-regulated plasma-sourcing process led to tens of thousands of paid donors contracting HIV at that time.Footnote 11 In response to this tragedy, the central authorities enacted the nation's first Blood Donation Law.Footnote 12 In addition to adopting international best practices of voluntary donations, a state-run collection system was established. According to the Blood Donation Law, local governments exercise leadership in securing a safe and adequate blood supply. The health authorities, from the Ministry of Health (currently the NHFPC) to those at the county level, supervise blood centres, which are non-profit, public-service institutions responsible for collecting, processing and distributing blood within their respective jurisdictions. In general, each city can only have one blood centre. Hospitals, the Red Cross or private blood banks are not licensed to collect blood.
China is not unique in terms of combining a voluntary system of blood donation with a state-run system of blood collection. The United Kingdom and France, for example, operate in a similar manner. The WHO also calls on governments to become involved in providing blood supplies.Footnote 13 There are two main reasons why the government is expected to exercise leadership over blood donations. First, because blood is indispensable for public health and war preparations, it is imperative that the authorities commit to ensuring a sufficient supply. Second, the continual crises of blood-borne epidemics over the past several decades have called into question the ability of the marketplace to guarantee the safety of blood supplies, thus encouraging the government to take more proactive steps. More importantly, the voluntary donation system and the state-run system are not necessarily in conflict with each other. The state-run blood collection organizations have advantages, such as better funding, the capacity to reach potential donors and the ability to integrate recruitment drives seamlessly into “the general package of benefits provided by the state.”Footnote 14 The question is why, despite such advantages, does the state-run system in China fall short in terms of generating active voluntary engagement.
This empirical question has theoretical implications for state–society interactions. Instead of a zero–sum perspective, Joel Migdal and his co-authors advocate specifying the concrete encounters between state segments and societal actors and exploring the potential for mutual empowerment.Footnote 15 Peter Evans distinguishes between two types of synergy: “complementarity” and “embeddedness.” Unlike conventional wisdom that maintains that the public and private sectors perform separate functions at which they are adept, “embeddedness” implies that government officials and individual citizens can co-produce public goods and services across the public–private divide.Footnote 16
In line with this approach, China experts have stressed that the non-democratic regime is not always in conflict with societal forces. A number of scholars argue that civil society in China is not autonomous from the state, and thus they suggest that state–society relations should be analysed from a corporatist perspective.Footnote 17 Although policymaking in China is often regarded as a closed-door practice, Baogang He and Stig Thøgersen observe a set of political and administrative innovations that channel the public voice to decision makers.Footnote 18 Similarly, three recent studies explore the mechanisms that provide incentives for the government to respond to citizen demands and find that the Chinese government is relatively responsive.Footnote 19 Most relevant to this article, several scholars illustrate a trend of state–society synergy in the provision of public goods and services. Lily Tsai contends that the key to delivering social welfare in rural China is “encompassing and embedding solidary groups” that hold cadres accountable.Footnote 20 In an urban context, Jude Howell and Jessica Teets separately document the positive resonance between local governments and non-government organizations in terms of the provision of public goods.Footnote 21
The case of blood supply is particularly intriguing because synergy between the government and citizens is more a necessity than a choice. In other words, in China (and in some other countries), safety concerns not only lead to the adoption of voluntary donations but also encourage the government to take direct charge of administering blood services. By detailing the intricate interplay between government manoeuvres and citizen reactions that addresses the essential need for blood, this study offers a glimpse into the struggle to achieve state–society synergy in contemporary China.
Political Barriers to Voluntary Donations
Secret fears of fiscal transparency
When conducting fieldwork at blood donation sites, I frequently heard doubts expressed about the trustworthiness and transparency of the state-run collection agencies, especially with reference to the Guo Meimei 郭美美 incident. In June 2011, Guo, a woman in her 20s who claimed that she was the manager of the commercial branch of the Chinese Red Cross Society (Zhongguo hongshizihui shangye zongjingli 中国红十字会商业总经理), posted pictures of her extravagant lifestyle on social media. This incident led to much debate about the credibility of the Red Cross Society and fuelled popular suspicion that blood centres were selling donated blood for profit.Footnote 22
Media reports confirm the impression that questions about the trustworthiness and transparency of the blood centres alienate potential donors. For instance, after documenting the widespread suspicion that blood donors do not receive any remuneration but blood recipients are charged a high price (xianxue wuchang yongxue youchang 献血无偿 用血有偿), the Party-run Renmin ribao 人民日报 issued an appeal to rebuild trust in the blood centres as a first step to restock blood supplies.Footnote 23 Likewise, the current affairs magazine Caixin xinshiji zhoukan 财新新世纪周刊, when questioning why blood centres seldom publicize information, reported that there was a bottleneck in the state-run voluntary blood donation system.Footnote 24 Why do the blood centres refrain from disclosing information, especially fiscal information about which citizens are most concerned, to mitigate this distrust? Could this be the result of backroom deals?
During my interviews at the blood centres, some officials initially cited non-political concerns as a reason for the lack of transparency. For example, out of a respect for privacy, they could not release any information about the profile of the other party either to donors or recipients.Footnote 25 They were also unwilling to inform the hospitals how blood supplies were allocated because such revelations would result in every hospital claiming that it faced a critical shortage.Footnote 26 One official added: “blood services in other countries are not really that transparent either.”Footnote 27
As my interviews proceeded, the underlying barriers to increased transparency emerged. Several interviewees noted that they had no idea why whole blood was priced at 220 yuan per unit (200 ml). There are charges for transfusions because even though the raw material (i.e. the donated blood) is free, the collection, screening, processing, storage and distribution all involve costs. After the Blood Donation Law was promulgated, the central government set the price of whole blood at 183 yuan.Footnote 28 In 2006, the standard rate was raised to 220 yuan, which is the standard rate at the time of writing.Footnote 29 “The public criticizes us for being vampires (xixuegui 吸血鬼), but we have no control over the fees for transfusions,” a section chief grumbled.Footnote 30 In addition to the lack of access to information, frontline officials believed that they were not authorized to elaborate on the costs. One interviewee stated: “the 220 yuan fee was ratified by the central authorities in a red-headed document (hongtou wenjian 红头文件). What if we were to explain it to the masses incorrectly?”Footnote 31
Although local officials have little influence over the final prices, they should be clear about their own operating costs. My interviewees generally agreed that the overall costs were higher than the mandated price and hence the government had to subsidize the blood services; otherwise, the blood centres would be “bankrupt.”Footnote 32 They also claimed that even if they were to publicize fiscal details, citizen distrust would still remain. For instance, a section chief remarked that all their dealings were “above-board” (guangming zhengda 光明正大), and indeed, they had published this information in the local newspapers, but the readers still did not believe them.Footnote 33 Another cadre reported that nucleic acid amplification tests cost roughly 90 yuan per donation.Footnote 34 This interviewee added that if the public had been informed of this price, questions would have been raised about why the tests cost so much and whether corruption was involved.Footnote 35 From the perspective of citizens, opacity breeds distrust. But in terms of the perceptions of government officials, who may feel overwhelmed by the popular discontent, transparency does not remove existing doubts; rather, it runs the risk of inviting more trouble.
Moreover, the interviewees at the blood centres were aware that they were deemed to be untrustworthy, but they insisted that such distrust was embedded within the negative public sentiments towards state-run agencies in general. In the words of one section chief, distrust is “not our own problem” (bushi women yijia de wenti 不是我们一家的问题) – it exists “everywhere” in social governance.Footnote 36 Another section chief responded more frankly: “The government today has limited credibility,” so to encourage donations, blood centres should “maintain as far a distance as possible from the government.”Footnote 37 In other words, since officials at the blood centres did not consider the source of public distrust to be related to their performance, they doubted that there was anything that they could do to restore their trustworthiness.
In brief, citizens blame the state-run blood centres for the lack of fiscal transparency, but interviews with insiders reveal another side of the story. Admittedly, some responses by officials may be strategic, and unless the blood centres were to publicize the complete, audited financial statements, it would be impossible to distinguish secret fears from backroom deals. Nevertheless, the foregoing analysis points to the hidden political barriers to fiscal transparency. These barriers are revisited below.
The origins of perceived infectious risks
Some Chinese people refuse to donate blood as they believe that they will contract infectious diseases by doing so.Footnote 38 From a scientific perspective, viruses cannot be transmitted through blood donation as long as sterilized, disposable equipment is used. In China today, hygienic blood donation can be generally guaranteed. What, then, are the origins of this perceived danger? And why is the Chinese government failing to correct this misunderstanding?
Fears of contracting infection during the donation process have been primarily shaped by the scandal of the blood-borne HIV epidemic on the Central Plains (zhongyuan xuehuo 中原血祸), an episode which has largely been hushed up.Footnote 39 Most Chinese people, even those working in healthcare establishments, only know that tens of thousands of poor peasants sold their blood, became infected with HIV and then died. However, a detailed investigation suggests that the increased prevalence of HIV at that time was not related to blood donated for clinical transfusions. Most infected victims gave their plasma (not whole blood) through a technique called manual plasmapheresis, which differs significantly from the common whole blood donation method.Footnote 40 Simply put, blood extracted from a donor is fractionated in a centrifugal separator. The plasma is then harvested to manufacture plasma-derived products, whereas the other components are re-injected into the donor. If medical equipment is not properly sterilized before being reused, viruses carried by one donor can be transmitted to others through the invasive re-transfusion procedure. In contrast, whole blood collection never reintroduces blood. It thus poses a minimal risk for the donor, especially when sterile and disposable equipment is used.
The deputy director of E Blood Centre wished that China Central Television would allot five minutes of airtime to explain the technical differences between whole blood donation and manual plasmapheresis so as to allay public fears. He then confessed that to be “politically minded” (jiang zhengzhi 讲政治), he should not refer to this scandal, even though the HIV outbreak in rural central China was not linked to his agency.Footnote 41 Furthermore, the public usually regards voluntary blood donation as a means to save operational costs or to promote spiritual civilization (jingshen wenming 精神文明). Yet, as noted above, the Chinese government rushed to adopt voluntary donations precisely because this method is considered to be the safest practice by international standards. With no directives from the central authorities, frontline officials consciously maintained a silence on this politically sensitive issue, although clarification on the matter would have facilitated the recruitment of donors.
In addition to the imprint of the blood-borne HIV epidemic, scandals not related to blood have given rise to doubts about the safety of donating blood. When doing fieldwork on a blood bus, I met a young man who was afraid of infection. After the nurse unpacked a new kit in front of him and emphasized that every item in the kit had been sterilized and was disposable, and thus could not transmit any viruses, he queried: “But how can you guarantee that every device is virus-free? You see, even Sanlu milk powder once received an award as a Product Exempt from National Quality Inspection (guojia mianjian chanpin 国家免检产品)!”Footnote 42 In a similar vein, many non-donors asserted that blood centres were degenerate, citing examples such as corrupt cadres, fabricated statistics and under-regulated foodstuffs. As a result, health authorities constantly expressed their grievances about scandals in other policy areas, about media exposure of these incidents, and about the corresponding popular discontent. These “invisible hands” (kanbujian de shou 看不见的手) greatly undermine the trustworthiness of the state-run blood collection agencies.Footnote 43
Missing leaders in donation campaigns
Kathleen Erwin and colleagues observed that even when would-be donors in Shanghai expressed confidence about the sanitary conditions of blood collection, they were still reluctant to donate owing to the taboo about giving blood in Chinese medicine and traditional culture.Footnote 44 Taiwan shares a similar cultural background but has had great success in attracting blood donations. In 2012, the donation rate in Taiwan was twice as high as the rate in high-income countries.Footnote 45 The officials and nurses I met commonly attributed the success of the donation drives in Taiwan to the role-model effect created by elected leader Ma Ying-jeou 马英九, who had donated blood more than 180 times. As the director of A Blood Centre commented, “What about our leaders? If they were to take the lead in donation campaigns, I am certain that others would follow!”Footnote 46
These complaints by officials reflected the concerns of citizens: if donating blood does not have a negative impact on health, why are the political leaders not setting an example by doing so? As the fieldwork progressed, I learnt that several high-level cadres, including former president Hu Jintao 胡锦涛, the fourth-ranked member of the-then Politburo Standing Committee, Yu Zhengsheng 俞正声, and the retired health minister, Chen Zhu 陈竺, among others, had all donated blood. Other than occasional media reports, information about their donations seldom appeared on the blood centres’ websites, on bulletin boards displayed near the blood buses or in publicity brochures. This begs the question of why Hu Jintao and his fellow donors were not depicted as models.
One explanation was provided by the director of A Blood Centre, who, with a sense of irony, complained that political leaders in China had never led the way. This cadre stressed that as a “subordinate,” he was not authorized to use a photo of Hu Jintao giving blood as promotional material to solicit donors. Moreover, because the photo had been taken three decades earlier when Hu served as a provincial Party boss, he said: “Who knows whether there are any problems with this picture? We dare not use it.”Footnote 47 Although the NHFPC never explicitly granted permission to use this photo for publicity, it did not deny permission either. Given the above analysis on the price tag fixed by the central authorities and the technical origins of the HIV-contaminated blood, about which the top leaders remained silent, this again suggests that politically minded officials often wait for explicit directives. Only then can they take steps without worrying about being censured by their superiors.
Other health officials pointed out in interviews that political leaders shunned publicity for fear that citizens, especially netizens, might think that they were merely “posing for blood donations” (zhuang yangzi 装样子).Footnote 48 When I first heard about this, it struck me as rather strange. But actually it followed logic similar to that in the preceding discussion: officials may be challenged by citizens regardless of how they justify the operating costs or make promises about the safety of giving blood. To avoid any trouble, these officials prefer to dodge direct encounters with citizens as much as possible. After all, there are few formal institutions in China which require officials to respond to citizen inquiries.
To recapitulate, blood collection in China seems stuck in a “catch-22” situation. It is unfair to disproportionately blame the citizens for not donating blood, because their “unscientific” fears do not necessarily originate from scientific ignorance. Rather, their fears are related to politics. It may also not be warranted to place too much blame on the official side. Against the backdrop of public distrust and ambiguities emanating from the central authorities, it is difficult for officials to make substantial progress in this regard. Admittedly, the position of each side is reasonable. Yet, ultimately, the absence of synergy between the government and citizens has led to serious blood shortages throughout the country.
Captive Voluntary Donations as a Partial Remedy
Revisiting the trust account
Although citizens and officials disagree about whether citizen distrust results from backroom deals or from secret fears, they generally acknowledge that it is a major deterrent to donating blood. But does trust really matter? This section utilizes the CCS to evaluate the effect of trust. The survey was conducted by the Research Center for Contemporary China at Peking University in 2008. Based on a stratified, multistage, probability proportional-to-size design and spatial sampling techniques, a representative pool of 4,004 respondents was selected from 73 county-level units scattered among 25 provinces.Footnote 49 To my knowledge, the CCS is the only nationwide probabilistic survey that includes blood donations within China.
Overall, 10.8 per cent of the respondents reported donating blood. This figure is higher than the donor rate provided by the NHFPC because, for the denominator, the CCS sampled respondents between the ages of 18 and 70, whereas the NHFPC used the entire population. In addition, for the numerator, the CCS asked if the respondents had previously donated blood, whereas the NHFPC recorded the number of donations collected during the previous calendar year.Footnote 50
Drawing on the above analysis of the qualitative evidence, trust in state-run blood centres in particular, and trust in political agencies in general, was expected to be a determinant of donations. To tap its magnitude, this study used a battery of trust items in eight major political agencies as a proxy for two considerations.Footnote 51 First, blood centres are quasi-government branches and are subordinate to the healthcare authorities, thus most citizens regard blood centres to be government agencies. Second, distrust of blood centres, as elaborated upon above, is embedded in negative sentiments towards the political system. It is hypothesized that, all else being equal, respondents with higher political trust are more likely to donate blood.
To make the estimation more accurate, this study took several factors into account. First, blood donations are an important indicator of civic engagement, which has a “tight reciprocal” yet “quite asymmetric” association with social trust.Footnote 52 Using the standard survey item, “Generally speaking, would you say that most people can be trusted or that you need to be very careful in dealing with people?” as the gauge, social trust was included in the model. Second, Bruce Dickson reports that Chinese Communist Party (CCP) members have a higher propensity for pro-social activities, including but not limited to donating blood, because the CCP “actively mobilizes its members to behave in these ways.”Footnote 53 Similarly, an article on charitable-giving finds that where such mobilization takes place is also a consideration. Those working in the state apparatus (i.e. government agencies, public service institutions or state-owned enterprises) more frequently donated blood, whereas those working in non-state-owned sectors contributed more money.Footnote 54 Given the potential effect of mobilization, this analysis incorporated CCP membership and the type of work unit. Third, standard demographic and socio-economic features, including age, gender, educational level, hukou 户口 status and household-income level, were also included as control variables. The descriptive statistics are presented in Table 1.Footnote 55
Table 1: Descriptive Statistics of the Variables
Notes:
The number of observations is 4,004. Missing values are imputed. Survey design effects (stratum, sampling units and individual weights) are controlled.
Unexpected results
Table 2 displays the binary logistic regression outputs. Surprisingly, political trust is not statistically associated with the likelihood of donating blood, holding the other variables constant. This result is robust when employing other trust measurements and specifying different models. If no controls are included, the effect of political trust is negative. Moreover, the effect of social trust is marginal. Since distrust is expected to be an important obstacle to voluntary donations, how should the unexpected result be interpreted?
Table 2: The Effect of Political Trust on Blood Donations
Notes:
Cell entries are logit coefficients, with standard errors in parentheses. †: p < .1, *: p < .05, **: p < .01, ***: p < .001. The number of observations is 4,004. Missing values are imputed. Survey design effects (stratum, sampling units and individual weights) are controlled.
This study suggests that the key to understanding this mismatch lies in captive voluntary donors, i.e. those “in positions of restraint and subordinate authority who are called upon, required or expected to donate.”Footnote 56 Local governments in China sometimes impose donation quotas on work units, which further mobilize their members to engage in this “political task.”Footnote 57 Although captive donors are urged, not coerced, to donate, their motives differ from those who are involved in genuine volunteering.Footnote 58 For instance, they may believe that by refusing to donate they will give their superiors a negative impression; they may give blood because of peer pressure from colleagues; or work units may induce them to give blood with the promise of such tangible benefits as bonuses or paid leave as tokens of support.Footnote 59 It is very likely that political trust and social trust have little impact on blood donations because neither affect captive voluntary donors as much as they affect purely voluntary donors.
The effects of CCP membership and work units also support the captive voluntary donation argument. Highly consistent with Dickson's findings, CCP membership turns out to be a powerful predictor of blood donations.Footnote 60 Meanwhile, those attached to a work unit are more likely to donate blood, all else being equal. The differences between the state sector and the non-state-owned sector are not large, probably because all work units, regardless of their nature, are mobilized to organize blood drives.
Other demographic and socio-economic characteristics generally match the typical donor profile. Those who are younger, male, better educated and from urban areas, and those whose families are wealthier, have a higher propensity to donate blood.
Assigning donation quotas within limits
The results from the CCS data indicate that all variables, except for political trust and social trust, have an effect on blood donations. These unexpected results are very likely owing to the fact that donating blood in China is sometimes not a spontaneous act but rather one mobilized by the authorities.
The adoption of captive donations also explains why, despite widespread suspicion about giving blood, China seldom suffers from life-threatening blood shortages. Many health officials whom I interviewed remarked that the reliance on quota assignment was useful in terms of striking a balance between supply and demand, especially when weather conditions were poor.Footnote 61 Some captive donors reported that compared with rolling up their sleeves on blood buses downtown, they felt that blood drives organized by their work units were safer and more convenient.Footnote 62 Several scholars have also been supportive of the effectiveness of work unit-based captive donations. Even though they are not in line with international standards for voluntary donations, captive donations exemplify how the Chinese government tailors its measures “in ways that are locally informed, and that make sense in a cultural context” in an effort to make public health function.Footnote 63
Nonetheless, the donation quotas generally do not exceed 10 per cent of the overall population of the work unit. Given their positive effects, why does the government not set quotas higher in order to completely meet the demand for clinical blood? When answering this question, interviewees presented two lines of reasoning. First, even though captive donations boost blood supplies when a purely voluntary approach fails to meet demand, they are still a distorted form of volunteering. In a city without donation quotas, a health officer fiercely argued that although the difference between captive donations and voluntary donations “appeared to be slight,” it “would lead to a huge loss” (chazhi haoli miuyi qianli 差之毫厘 谬以千里), since captive donations compromise the integrity of volunteering and, in the long run, the benefits offered by work units may crowd out genuine volunteers.Footnote 64 Some officials whose agencies heavily depend upon captive donors also supported this position. The Party secretary of C Blood Centre, for instance, conceded that captive donations “obstructed voluntary donations.” At the same time, he stated that this practice should “neither be promoted nor be denied” (bu xuanchuan bu fouding 不宣传 不否定) – after all, “you have to choose the lesser of the two evils.”Footnote 65
Finally, although the government has the capacity to mobilize captive donors through work units, it is aware that an excessive reliance on this approach burdens work units, and may result in discontent and even resistance to this political task. A section chief remarked that work units were requested only to “make a small contribution” (yisi yisi 意思意思); if too many quotas were imposed, “the game would be over” (dajia dou meidewan le 大家都没得玩了).Footnote 66 Therefore, captive voluntary donations are merely a partial remedy that is used sparingly, and although the blood shortages are manageable, they remain serious.
Conclusions and Implications for State–Society Synergy
The blood-borne HIV disaster of the 1990s condemned tens of thousands of Chinese to an early death and prompted the government to combine voluntary blood donations with state-led management of the blood supply system. However, efforts to guarantee safety do not always ensure adequate supplies. The ongoing nationwide blood shortages still pose a threat to public health.
Public distrust of the state-run collection agencies is often cited as a reason for the lack of volunteer blood donors. Interviews with officials, however, reveal the political concerns that prevent the healthcare authorities from dispelling such distrust. Based on an analysis of non-transparent fees, perceived risks and the lack of any visible leadership, this article argues that distrust of the blood collection agencies is embedded in popular discontent with the overall political system and should be examined as a reciprocal issue. Evans underscores the crucial role of a network of trust that “bind[s] state and civil society together.”Footnote 67 Unlike the optimism found in some previous studies,Footnote 68 the findings in this study imply that the stock of social capital in China that bridges the public–private divide is dwindling. Consequently, there is a lack of cooperation on the part of both officials and citizens when it comes to addressing the life-or-death need for blood donations. Such synergistic relations are further strained by bureaucratic institutions. The three cases examined converge to illustrate that politically minded officials may avoid taking positive actions, especially if their superiors do not send out clear signals.
The fieldwork research shows how government involvement precludes volunteering; on the other hand, the survey analysis offers some relevant but different insights by indicating that the effect of political trust on blood donations is statistically insignificant. This article argues that such a mismatch between the qualitative and quantitative data can be reconciled if one takes into consideration the fact that a sizeable proportion of blood donors in China are subject to pressure from the authorities.Footnote 69 Although distrust limits voluntary donations, under captive circumstances such distrust becomes less important. Captive donations can boost blood supplies when a purely voluntary approach does not satisfy clinical needs.Footnote 70 Nevertheless, captive donations also come at a cost because they compromise the integrity of volunteering and, more importantly, they may fuel unnecessary discontent. As such, although the government has the capacity to alleviate blood shortages by assigning donation quotas to work units, it also places limits on these quotas. Ultimately, the intricate interplay between government manoeuvres and citizen reactions has led to blood shortages that are serious yet manageable.
In sum, the qualitative and quantitative evidence presented in this article is set in juxtaposition rather than being complementary.Footnote 71 By comparing the fieldwork and survey data, this study on the one hand illuminates the political barriers to effective cooperation between state and society when addressing blood shortages. On the other hand, it suggests that one way to partially remedy blood shortages, ironically, involves the government's further mobilization of captive donors. Taken together, this analytical strategy produces a refined understanding about the struggle to achieve state–society synergy in contemporary China. It remains to be seen whether this pattern has altered with the recent strengthening of the state's power and the growing alienation among officials.
Acknowledgements
For helpful comments, I would like to thank Yongshun Cai, Lianjiang Li, Tim Pringle, Yuhua Wang and two anonymous reviewers. I am also grateful to the Research Center for Contemporary China at Peking University for sharing the Chinese Citizenship Survey data. Generous financial support was provided by the Research Grants Council of Hong Kong (CUHK14613815), the Chinese University of Hong Kong and the Harvard-Yenching Institute.
Biographical note
Yue Guan is a postdoctoral researcher in the department of East Asian Studies, the University of Vienna. Her research interests include political participation and volunteering, political trust and local governments in China. She received a PhD in government and public administration from the Chinese University of Hong Kong.
Appendix
Interviewee 1, administrator in a hospital in B city, June 2012.
Interviewee 2, section chief of A Blood Centre, December 2012.
Interviewee 3, director of A Blood Centre, December 2012.
Interviewee 4, section chief of B Blood Centre, December 2012.
Interviewee 5, section chief of A Blood Centre, December 2012.
Interviewee 6, section chief of C Blood Centre, May 2013.
Interviewee 7, section chief of A Blood Centre, August 2013.
Interviewee 8, official of D Blood Centre, September 2013.
Interviewee 9, official of D Blood Centre, November 2013.
Interviewee 10, deputy director of E Blood Centre, December 2013.
Interviewee 11, deputy section chief of E Blood Centre, December 2013.
Interviewee 12, official responsible for organizing blood drives in a public-service institution in B city, December 2013.
Interviewee 13, section chief of B Blood Centre, December 2013.
Interviewee 14 (the same person as interviewee 3), director of A Blood Centre, December 2013.
Interviewee 15, director of B Blood Centre, December 2013.
Interviewee 16, official responsible for organizing blood drives in a sub-district administrative office in F city, June 2013.
Interviewee 17, director of the Blood Donation Office in F city, June 2014.
Interviewee 18, section chief of F Blood Centre, June 2014.
Interviewee 19, NHFPC official, June 2014.
Interviewee 20, director of D Blood Centre, August 2014.
Interviewee 21, retired director of E Blood Centre, September 2014.
Interviewee 22, retired NHFPC official, November 2014.
Interviewee 23, director of C Blood Centre, November 2014.
Interviewee 24 (the same person as interviewee 23), director of C Blood Centre, June 2015.
Interviewee 25, Party secretary of C Blood Centre, June 2015.
