Minneapolis: University of Minnesota Press, 2021. xi, 194 pp. US$25.00, paper. ISBN 978-1-5179-0765-5.
In this book, Elsa L. Fan draws on her fieldwork in three different health institutions in China to explore the ways in which the health intervention of HIV testing among men who have sex with men (MSM) has impacted the lives of same-sex attracted men in China. HIV testing is the dominant HIV prevention strategy in China, and the intersection between HIV testing and the community of same-sex attracted men, as Fan argues, “reconfigured who the men were, how they understood themselves to be, and the possibilities for and limitations on who they should become” (3). In such ways, global health programs, Fan contends, have rendered the community “as commodities, as data, and as things more generally” (4), rather than subjects of care.
Fan conducted 21 months of ethnographic fieldwork in China between 2008 and 2015, as a volunteer at three different health institutions. Most of her fieldwork was spent in a US-based, grassroots foundation called the ACF (AIDS in China Fund), supported by a small group of US donors. Her participation in the work in the ACF mainly included attending its activities and travelling with the ACF to meet staff and volunteers of community-based organizations. Through the ACF, she came to know a handful of the community-based organizations and the men they served. Her access to this community through the ACF helped her examine the interconnections between HIV testing and the lives of the men. Fan also volunteered with an international organization called the Health Fund, where she came to learn about the ways in which international funding gets filtered and disseminated in different localities in China.
Based on her fieldwork at these three different health institutions, Fan presents two overarching themes underlying the global health programs. First, Fan contends that the audit regimes of global health programs have transformed HIV prevention and care into “accountability mechanisms like performance-based financing” to coalesce health outcomes with financial transparency (9). The HIV testing of the MSM community and the performance-based financing are implemented to provide a close oversight of the funding, in an effort to deliver cost-effective performance goals. As a result, community-based organizations have catered their activities to meet donors’ needs, instead of the needs of the community.
Second, Fan argues that this audit regime and HIV testing intervention have resulted in “new social formations, new identity politics, and new ways for men who desire and have sex with other men to understand themselves as MSM” (6). Global public health programs, as Fan contends, have reconfigured the ways in which same-sex attracted men perceive themselves and imagine their same-sex desires. More specifically, same-sex attracted men have come to define their HIV-risky, same-sex desires as integral to their MSM identity. The financially driven HIV testing of the MSM community, while providing rewards for both the testing and the detection of new HIV cases, has transformed the men into commodities of care, “economically coveted and could be exchanged for monetary incentives or for political capital that ensured some measure of financial stability for organizations” (16–17). In so doing, same-sex attracted men are turned into “objects to be tested and transacted as economic and political capital rather than as men in need of care and support” (17).
This book is comprised of seven chapters. The introductory chapter discusses the central themes of the book as well as the research methodology of the fieldwork. Chapter 1 explores the ways in which HIV testing has risen to be the dominant prevention tool to curb the HIV epidemic in China. This chapter delves into two major health institutions, the ACF and the Health Fund, in spelling out their different methods. While the Health Fund stresses the accountability of their funding and performance-based financing, the ACF focuses on HIV testing as an empowering tool that the MSM community can employ to take control of their health through testing and knowing their HIV status.
Chapter 2 examines the ways in which these two institutions access the MSM community for HIV testing through redefining their sexual desire as HIV risky. Because this community is a hidden population that encompasses both the heterosexual and same-sex social milieus, there is little to no perception of the risk for HIV, and hence there is little awareness of the need for HIV testing. In response, the ACF and the Health Fund employ workshops to indoctrinate in these men a new sense of self as MSM and a new perception of same-sex desires as HIV risky. This new self-recognition and new self-affirmation are prerequisites for them to be utilized as HIV testing subjects.
Chapter 3 reveals how the predominant focus on HIV testing among MSM has circumvented other forms of care, intervention, and prevention among the community. In so doing, it has transformed the MSM community into commodities of care that generate political and economic capital. Chapter 4 discusses the tension between community-based organizations and project-driven organizations, fuelled by international donors and global health programs. Community-based organizations intend to carry out the advocacy-oriented work, which is significantly compromised and thwarted by project-based organizations that emphasize HIV testing only, to control the HIV epidemic. Chapter 5 depicts the ways in which HIV-positive men wrestle with their HIV status in their everyday lives, and how such coping is indicative of their social milieus. The conclusion reiterates the underlying themes of the book.
Fan connects public health with anthropology in revealing the ways in which public health programs turn human beings into profitable commodities. This book would benefit from a critical analysis of the profound implications of the Chinese political environment on the localization of global health programs in China, as well as on the status and agenda of the advocacy-oriented organizations vs. project-based organizations. This book will be welcomed by a wide array of scholars interested in topics such as global health, HIV, and MSM in China and beyond.
Tiantian Zheng
The State University of New York, Cortland