A review of Opportunistic Infections: The Governance of HIV/AIDS in China, by Elsa Fan.
In her dissertation, Elsa Fan explores a contemporary health crisis in China – the HIV epidemic among men who have sex with men (MSM). Balancing multiple identities as a volunteer, consultant, policy maker and ethnographer working with leading institutions in the HIV/AIDS sector in China, Fan’s positionality grants her access into the very places where members of community-based organizations (CBOs) confront the rollout of HIV rapid testing (HRT) technologies. Fan’s ethnographic expedition in Beijing, Taiyuan and Hainan reveals how recent community-based testing programs operate as sites of subjectification, where ethical subjects are fashioned and, through unequal relations of obligation, are governed. Amid shifting funding allocations and inflamed identity politics, new citizenship conditions are born around HIV testing: MSM can achieve a sense of belonging in China, but only if they realize their responsibility in the progression of the HIV epidemic.
In Chapter 2, Fan asks why policy makers target MSM populations when heterosexual transmission accounts for the majority of new infections in China. Fan reveals how MSM sexualities figure in the imaginaries of policy makers. The local sexual identity term, tongzhi, comes to represent an uncontainable ambiguity in the “general population” that threatens an orderly response; many tongzhi do not assume a homosexual identity and may have sex with women as well as with men. These undifferentiated, “bridging” sexualities trouble policy makers because they evade classification and defy enumeration. Policy makers envision HRT programs, led by CBOs, as providing the means by which these men can be identified and encouraged to “come out”, in the name of health protection. By fostering tongzhi identities through HRT programs, CBOs enact a modernizing project that rescues ambiguity from a state of unknowing and backwardness. Here, Fan builds on Tom Boellstorff’s discussion of the genealogical shift in the term MSM from a behavioural category to an identity (“But Do Not Identify As Gay: A Proleptic Genealogy of the MSM Category”, Cultural Anthropology 26/2, 2011, pp. 287-312). However, Fan moves beyond Boellstorff by also demonstrating how CBO deployments of MSM identities animate a commodification process that reconfigures “MSM into consumers who not only want [health] services but are willing to pay for them” (p. 65). Testing programs, Fan insists, manufacture the desires of MSM to be free and healthy citizens, having already set the conditions of their fulfilment.
In the third chapter, Fan draws upon Michel Foucault’s notion of governmentality to demonstrate the powerful role CBOs play in the art of surveillance, accomplishing more than merely reaching “hidden” MSM (Graham Burchell et al., eds., The Foucault Effect: Studies in Governmentality, London, 1991, pp. 87-104). CBOs have become instrumental in “reconfiguring these populations into communities through which they can be tested voluntarily” (p. 76). As new forms of belonging and responsibility become organized around testing, HRT programs mobilize “biosocial communities” (Paul Rabinow, “Artificiality and Enlightenment: From Sociobiology to Biosociality”, in Mario Biagioli, ed., The Science Studies Reader, London, 1999, pp. 407-416). However, as Fan illustrates, RHT programs also create new moral divisions between those who test positive or negative. Inadvertently, the promotion of HRT gives rise to shame, unleashing accusations upon those suspected of being HIV infected, even in the supposed safe spaces of CBO training workshops. The eventual move toward including HIV positive volunteers in CBOs helps to create communities of positive people; confessional practices build rapport between positive volunteers and clients. Fan argues that the formation of these biosocial communities reflect the extension of state power over populations of MSM, which goes deeper into the social fabric than ever would be possible for the Chinese Centres for Disease Control and Prevention.
Chapter 4 portrays the thorny terrain of CBO politics that unfurled in the wake of the election of the main oversight committee for the Global Fund in 2009. Rivalling factions of AIDS activists struggle to secure their interests in the face of an uncertain funding future. Controversy ensues around CBO authenticity. The redeployment of tongzhi identities and origin stories of CBOs’ beginnings invoke boundaries between real and fake CBOs. Temporality is crucial in these contestations—is the CBO merely set up to accept Global Health Foundation funding, or does it have a longer history that predates this project? Can CBOs be traced back to tongzhi communities? “Place” also features prominently in these discursive formations with respect to what it means to be “in” or “from” the community. And CBOs and individuals viewed as capitalizing on the epidemic or their HIV status are accused of “eating AIDS rice”, echoing Sandra Hyde’s earlier discussion of rice metaphors and sexual modernities in China (Eating Spring Rice: The Cultural Politics of AIDS in Southwest China, Berkeley, 2007, pp. 33-34).
In Chapter 5, Fan examines the ethical orientations that shape the subjectivities of MSM, combining Foucault’s “technologies of the self” (in Paul Rabinow, ed., Ethics Subjectivity and Truth, New York, 1997, pp. 223-251) with James Laidlaw’s notion of confessional penance (“For an Anthropology of Ethics and Freedom”, Journal for the Royal Anthropological Institute 8/2, 2002, pp. 311-332). Through this lens, men’s subjectivities are viewed as emerging along an ethical trajectory that simultaneously affirms sexual pleasure and renounces unethical sexual practices. Here, testing acts as the vehicle through which these ethical orientations arrive; only when MSM act responsibly through getting tested can they ‘truly’ embrace their sexual pleasures. The production of these ethical subjectivities exemplifies a mode of governmentality that ‘liberates’ these men while also limiting the very ways they can enjoy particular pleasures and freedoms.
In conclusion, Fan reminds the reader that she is less preoccupied with evaluating the performance of the RHT project and is more concerned with the way “institutional and global values [are] reinscribed through these interventions” (p. 175). HIV testing as an intervention responds more to market logics than to the actual needs of MSM. Fan argues that these logics, while attending to MSM, elide a wider concern for the lives of other people, including female sex workers and injection drug users.
In Designs for an Anthropology of the Contemporary, James Faubion laments that the field of gay and lesbian studies has yet to fully realize “its promise of being the next great force of undoing of humanist essentialism” in anthropology (Durham, 2008, p. 34). I would add that the broader relevance of queer studies in medical anthropology, in its interrogations of the treatment of difference, has yet to take centre stage. Fan makes an impressive leap forward in realizing these possibilities in her dissertation, displayed in the diverse genres of literature she effectively engages in conjunction with medical anthropology: science studies, gender and queer studies, and the anthropology of development, humanitarianism, and neoliberalism. Particularly noteworthy is her contribution to medical anthropological studies of citizenship; her work raises critical questions around how we conceptualize contemporary social movements and their complex entanglements in techno-bureaucratic regimes. Furthermore, Fan’s attentiveness to an analysis of capitalism (vis-à-vis notions of bio-value, commodification, and neoliberalism), steadies the reader’s focus on why her theorizing matters—we learn how market logics come to replace public health exigencies and how well-intended practices in health development can unexpectedly produce and embed powerful new forms of social inequality in the lives of those who may already be socially disenfranchised.
Centre for Global Public Health, Department of Community Health Sciences
University of Manitoba
Extended fieldwork, ethnographic fieldnotes (based on extensive participant observation conducted during workshops, program and policy meetings in Beijing, Taiyuan and Hainan), and on-going informal interactions and discussions with key informants, policy makers and workshop participants.
University of California, Irvine. 2012. 209 pp. Primary Advisor: Tom Boellstorff.
Image: Photograph by Elsa Fan.