Abstract
AIDS in Pakistan ties global trends in HIV/AIDS control to granular analysis of the politics of HIV/AIDS programme implementation in Pakistan. In particular, it focuses on the complex relationships between global donors, national and local governments, non-governmental organizations (NGOs) and community-based organizations (CBOs).
Qureshi carried out extensive participant observation and interviews inside health bureaucracies—an important methodological move that gives the book its explanatory power. He carried out ethnographic fieldwork mostly at the Government of Pakistan’s National AIDS Control Program (NACP) in Islamabad and also made visits to CBOs, donor organizations and Anti-Retroviral Therapy (ART) and counselling centres. The book’s rich description of the messy relationships between these actors is its strength. There are detailed analyses of the hierarchical relationships and jockeying for power and money between World Bank, CBO and government officials. There is attention on how global guidelines are used (and misused) by local actors, as well as on rich ethnographic material about complex topics like corruption.
AIDS in Pakistan is a useful contribution to a small but growing subfield within medical anthropology focusing on the social organization, power relations and politics of health policy and systems. This literature takes policymakers and health staff as points of ethnographic entry. This work has a long history within medical anthropology, with some classic work that still reads well today (Foster, 1987; Justice, 1986). Also, there continues a small but illuminating stream of ethnographies in this vein, including a focus on the interactions between international donors, governments and NGOs (Closser, 2010; Oni-Orisan, 2016; Pfeiffer, 2003; Schuller, 2012; Smith, 2003; Smith-Nonini, 1998; Storeng, 2014; Storeng et al., 2018).
In addition to adding to the literature on health policymaking, AIDS in Pakistan provides useful contributions to the anthropological literature on HIV/AIDS control. This literature is extensive, with many influential and important ethnographies, most of them focusing on sub-Saharan Africa (Fassin, 2007; Kalofonos, 2010; Nguyen, 2010; Rosenthal, 2017). Qureshi’s book adds something new to this literature in its focus on a South Asian country where HIV/AIDS is not a leading cause of morbidity and mortality. In Pakistan, as AIDS in Pakistan shows, decisions to fund control of HIV/AIDS rather than other, more prevalent health conditions were controversial.
Several chapters in this book stand out in offering particularly useful ethnographic insights. Chapter 2 describes how AIDS—not a priority for many Pakistani public health experts or politicians—was pushed as a priority by international donors. Some Pakistani leaders were not enthusiastic about HIV/AIDS programmes because of the political volatility of discussing a sexually transmitted disease in the Pakistani context. However, many Pakistani public health experts’ reservations about prioritizing AIDS came from very reasonable epidemiological observations. They were more concerned about other epidemics, such as hepatitis B and C, which affect approximately 15 million people in Pakistan. In the context of very limited funding for control of other infectious diseases, they felt that AIDS, with a prevalence of a fraction of 1 per cent in Pakistan, should not be a primary focus of funding and control activities.
Yet as Qureshi describes in Chapter 2, pressure and money from international donors overrode these concerns. Under World Bank pressure, HIV/AIDS went from being a disease neglected for political reasons in Pakistan to being a top priority. As part of this process, Qureshi shows, the World Bank sidelined the Ministry of Health and favoured NGOs and CBOs in its funding processes, ostensibly because of the lack of support of political leaders for HIV/AIDS control. The complex effects of this neoliberalization of services are a focus throughout this book.
Another particularly informative section of this book is found in Chapters 7 and 8, which describe the personal stories and power struggles between CBOs, and between CBOs and the government, all competing for international HIV/AIDS funding. This section includes the fascinating personal histories of the leaders of two of Pakistan’s most influential HIV/AIDS CBOs; both came from underprivileged backgrounds, and after contracting HIV navigated through very complex and difficult social territory to become leaders in the provision of HIV/AIDS treatment in the country. A strength of his analysis, however, is that Qureshi does not leave the story there: in addition to what is impressive about these people, he also explores what is complex—including allegations that one of them has been embezzling money. Also, Qureshi points out that these activists’ personal narratives of embodying suffering have become buffed and ready for consumption by international donors: it is through these narratives that they establish themselves as legitimate leaders of HIV/AIDS CBOs. Ultimately, however, these CBO leaders had to present not only a compelling narrative but also had to ‘show numbers’ of AIDS patients who they had served. Their authority was contested: these chapters contain a fascinating description of the conflict between CBOs and local government. Qureshi delves in these chapters into the complex terrain of money, donor demands and competition that characterizes the aid landscape, in helpful ethnographic detail.
At points, AIDS in Pakistan reads like a dissertation, with a proliferation of theories and cites. It would be difficult to use in an undergraduate classroom. But its fine-grained ethnography of interactions between different actors will be of use to those interested in the contours of South Asian bureaucracy, particularly in how it interacts with donor money and demands.
In concluding this book, Qureshi grapples seriously with the outcomes of internationally funded HIV/AIDS programming in Pakistan. Drawing on a World Bank finding that Pakistan’s HIV/AIDS programme was ‘moderately unsatisfactory’, Qureshi asks whether in reality things might not be even worse and adds that ‘the policy of public–private partnership deprived the Pakistani people of an evolving, sustainable public response to the epidemic’ (p. 200). Given the compelling ethnographic material in this book, it is hard to disagree with this statement. As Qureshi points out, relying on CBOs resulted in a ‘quagmire of problems’ (p. 204)—from mismanagement to fraud. It is not at all clear that CBOs were doing a better job of providing HIV/AIDS care than the government would have done—and the policy of funding them rather than the government diverted much-needed money away from a deeply underfunded health system. Yet this begs the question: would there have been much of an HIV/AIDS response at all absent international funding, given the lack of interest in the topic at political levels? Or, if funding had been given to the government, would that have been much better? As Qureshi notes, his book ‘has not provided compelling arguments about the capacities of Pakistan’s public health system to take on the HIV/AIDS epidemic either’.
What, then, to do? Qureshi reviews several options. He lands on the proposal, promoted by anthropologist James Pfeiffer, that an ‘NGO Code of Conduct’ would ensure that funding for NGOs does not divert needed resources from cash-starved government health systems (Pfeiffer et al., 2014). Qureshi notes, ‘These kinds of principles deserve an experiment’ (p. 206). After reading his detailed argument, I agree.