AIDS in Pakistan: Bureaucracy, Public Goods and NGOs
by Dr Ayaz Qureshi
Palgrave Macmillan 2018, 232pp

Reviewed by: Dr Nichola Khan, University of Brighton
10 April 2018

What should the Islamic Republic’s official response to Pakistan’s increasing rates of HIV/AIDS be when homosexuality, sex work, transexualism, sex outside marriage, and injecting drug use are outlawed? How to instantiate policies and interventions that will reduce the spread of HIV/AIDS without subjecting these criminalised communities to the scrutiny and punitive measures of law enforcement? This is the conundrum with which Qureshi opens this fine-grained ethnography, the first of its kind on Pakistan.

Against the transformational backdrop of an exponential increase in injecting drug use in Pakistan that co-occurred with drug trafficking-for-arms practices in the Afghan war of the eighties, and that was followed in turn by the tripling of development aid to Pakistan in the millennium years—itself linked to the international political and aid economy of another war in Afghanistan—HIV/AIDS in Pakistan was declared a public health problem of epidemic proportions. By the millennium the World Bank predicted a doubling of HIV/AIDS prevalence every two years (41), and despite the initial deep scepticism of Pakistani government officials, succeeded in making HIV/AIDS an urgent public health priority for Pakistan. Given the spiralling prevalence of HIV/AIDS across wider South Asia, the case for urgent intervention was incontrovertibly framed.

In order to be eligible for funds, the World Bank and the IMF stipulated that the Pakistan government reorganise itself along the lines of a public-private partnership enterprise model to deliver HIV/AIDS policy. Funds would be contracted out from the international donor agencies through Pakistani government bureaucracies to NGOs. Enter the new technocracies of economic assistance, capacity building and empowerment, and their associated languages of participation, transparency, efficiency, and flexibilisation etc. These developments, rolled out on a large scale, ushered Pakistan hastily into the worlds and orthodoxies of health governance, international financial institutions, and the ideologies of expertise and strategic practice driving the global fight against HIV/AIDS.

The book documents the practice of what happens to this evolving HIV/AIDS policy response. It charts the mobility of global health policies and private sector logics as they travel and mutate through multiple fields of action and become translated into their local contexts. Qureshi rightfully distances his argument from broad-brush assumptions that donor-funded projects in developing countries are impeded by government corruption, inefficiency, a lack of capacity, and in Pakistan’s case an antiquated lumbering state bureaucracy. Rather, he skilfully illuminates the very quotidian ordinariness of Pakistani bureaucracy as it materialised HIV/AIDS policy through an imbrication of formal and informal systems that were in fact not dissimilar to the donor institutions’ own modes of operating.

The book’s arguments are built around three organising schema. First is bureaucracy, concerning the study of HIV/AIDS work at the level of government. Next is the concept of public goods, employed to question how donor policies of privatising HIV/AIDS prevention and care built the capacity for private sector organisations to dispossess people of public funds, public services, social capital, and a utopian vision of a universally beneficial society. Third is civil society which enters via the outsourcing of health to NGOs and which, the book shows, results in practices that further exclude the marginalised, cement negative attributions of ‘cultural difference’ amongst high risk groups, as well as the inability of NGOs to effectively challenge criminalisation on the grounds of sexuality, and intensify competition between NGOs for funding.

Building on his prior experience as a freelance researcher in Pakistan’s health sector, Qureshi draws from ethnographic fieldwork conducted between 2010-11 at the National AIDS Control Program (NACP) in Islamabad, at government and NGO offices and treatment facilities across urban Punjab and Karachi, and with migrant workers, transgendered hijrae, homosexuals, and HIV positive individuals in these locations. The strength of his anthropological approach is in drilling down into the micro-details, from the ‘inside’, of myriad permutations of complexity, mis-translation and interpretation that arise when the conflicting and complementary objectives of career bureaucrats, grant donors and recipients, activists, government agents, civil society advocates, consultancy firms and business profiteers etc. converge in the institutional and social life of policy practice.

The opening chapters develop this focus, historicising the uneasy relationship between Pakistani governments, the Islamic legal code, and public morality with the global health rationalities of the World Bank’s aim to fight and prevent AIDS in Pakistan. This aim was initially met with reticence by the post-Zia government which viewed HIV/AIDS as a Western disease arising from a shameful immorality that could be associated with the advent of democracy. These attitudes, in part a legacy of British colonial law, coupled with ‘pathologically high levels of discrimination and contempt towards sex workers, injecting drug users and transgendered hijrae’ (36) served to hinder the response and to fuel conflicts between stakeholders of both the designated World Bank’s Enhanced Program, and the UN monitored Global Fund Project.

Qureshi reveals how the subsequent emergence of targets of public-private intervention by ‘entrepreneurial governance’ produced a monopoly of policy elites that capitalised on the state’s inability to work with criminalised groups, and distorted and exaggerated narratives of ‘project success’ and public goods. Adapting David Harvey’s term, he is critical of ways marketised models of ‘transparency’ and ‘efficiency’ allowed HIV/AIDS interventions to flourish as a site for ‘accumulation by dispossession’, including corruption. He shows how conflicts resulted around the vested interests of civil servants, the World Bank, and the new NGO entrants into the health policy field. Furthermore, the practice of borrowing money for targeted private interventions that ended up with a few individuals effectively crushed the public-sector response to the HIV/AIDS epidemic. Given the money borrowed would need to be repaid by taxpayers, Qureshi argues poignantly that “we were dispossessed of before we even had it” (82).

Ch 4, 5, and 6 inspect the everyday life of NACP as a lens to analyse transformations to Pakistan’s state bureaucracy by the new funding regimes, practices, and ideologies. Specifically, the focus is on how a ‘neoliberal aid regime affects bureaucrats at a personal level’ (85), and on the opportunities afforded them to adapt the flexible charismatic procedures of the Enhanced Program for personal benefit. Drawing from his internship at the NACP in 2010, on fieldwork with high salaried civil servants seconded from other government departments, and with market-based and donor supported employees—largely public health specialists on renewable contracts—Qureshi examines the vexed question of corruption as a problem of Pakistani culture. He reveals not so much continuities between colonial and post-colonial forms of bureaucracy, as the entrepreneurial culture of a new flexible market-oriented organisation where rules were bent in the interests of short term gains. Through the anomalous image of dusty furniture, green-felted wooden desks, and stultifying government offices which produced glossy reports in the technical language of global health, he illustrates how the emergence of the new charismatic styles of management, self-promotion and appreciation, and patron-client relationships allowed officials and employees to furnish their own clientage, status, and pockets. These developments, he insists, were not ‘the inevitable product of a timeless culture of corruption in Pakistan, but produced by the entrepreneurial model of working life’ (94).

When the World Bank withdrew funding for HIV/AIDS in Pakistan in summer 2010, the story takes a shaky turn. The previous bonhomie of mutually self-serving relationships rapidly transformed into a quagmire of furious enmities, suspicions and anxieties. From his view within affected departments, Qureshi deftly shows how the flexibilisation of state bureaucracies produced an enhanced susceptibility to crisis, donor dependencies, and insecurities which undermined the continuation of HIV prevention and treatment in Pakistan.

Fortunately for the actors concerned, Pakistan eventually secured further funding from the Global Fund. The Country Coordinating Mechanism oversaw project implementation, and adapted mechanisms of ‘capacity assessment’ and participatory governance derived from the Global Fund. Here Qureshi reveals a blurring of boundaries between state and society, and the emergence of the ‘capacity’ for so-called impartial actors to serve political ends. He shows how civil society partners were included on the basis of their connections, and how the Country Coordinating Mechanism itself became dominated by a network of close associates.

The final chapters turn the focus toward civil society. First is the intensification of dynamics of conflict between the government, a Punjab-based community based organisation for people living with HIV, and their underpinning by international donor funding to NGOs. Against the backdrop of local health departments who were becoming resentful at the community organisation’s success as a conduit for distributing free antiretroviral treatments, a rapid testing programme in Jalalpur town in district Gujrat uncovered 88 HIV positive individuals out of 246 tested in the small locale (157). The discovery was met with a sensationalist media response, denialism by the local health department who were envious of the community organisation’s ability to discover what they had not, and myriad attributions of blame that included out-migration, returning drug users from abroad, and local illiteracy. Correspondingly, local people also felt angry and stigmatised by the attention accorded to this ‘immoral’ epidemic in their midst.

A second case study of a community-based organisation for HIV positive people raises the question of biological citizenship based on HIV status, the politicisation of civil society through media campaigns, the use of figureheads to further awareness, and the intensification of competition between NGOs culminating in accusations of corruption and the misuse of donor money. The analysis of these examples strengthen the book’s argument about dispossession through elucidating ways discourses of empowerment and civil society were appropriated to advance the personal agendas of a few individuals, and camouflaged a host of inequalities, power struggles, and vested interests.

Qureshi’s conclusion for the effectiveness of the public-private partnership model of delivering global health policy in Pakistan, and for the intersecting material, cultural and utopian public goods it promised, is pessimistic. While the World Bank’s ‘moderately unsatisfactory’ verdict on Pakistan (198) led to its eventual withdrawal of funds, the dynamic changes ensuing from the scaling up of the HIV/AIDS response in Pakistan to the state bureaucracy, the keeping of public goods, and in civil society ultimately resulted in a sharp rise in prevalence rates between 2005-2017 that point to a ‘considerably more damning’ (199) scenario. Failures in both the public and private sectors combined with the individual profiteering and corruption consolidated the dispossession of some of Pakistan’s most marginalized communities. Despite these failings, Qureshi calls for a radical transformation and strengthening of the public sector.

This ethnography has valuable insights for practitioners and academics, and it raises interesting comparisons for the rise and demise of other global health or development initiatives in Pakistan. The connections Qureshi raises between the NACP, and more static or traditional sectors of the state bureaucracy, and the broader impact of these dynamic transformations as they ebb and flow through the culture of other bureaucratic sectors in Pakistan warrant future attention. Their relevance for understanding other HIV/AIDS bureaucracies across the world is also pertinent, and addressed in the concluding chapter. Certainly, other global health initiatives in Pakistan illuminate the soundness of the deep suspicion of foreign interference. For example, the 2011 case of the CIA’s use of a polio vaccination programme in the ‘Af-Pak’ border regions to conduct counter-terrorism espionage demonstrates precisely how such suspicion may be understandable.

Ideas of foreign interference and domination also underpin the AIDS denialism in South Africa that Didier Fassin writes about in When Bodies Remember. AIDS denialism in South Africa is likewise intimately entwined with state politics and policies, and fortified by a national history of white dominance which historically blamed lethal infections on apartheid rulers who ingrained black inequality and poverty. For Fassin, Aids denialism represents both a resistance and a revivalist strand of black nationalism that seeks to heal the wounds of racist rule in post-apartheid society. In Pakistan by contrast, Qureshi shows us a more cynical adoption of AIDS ‘orthodoxy’ by a convolution of actors in urgent competition with one another. This is both characteristic of the marketization of global health, but also arguably of resourceful ways Pakistanis have secured their livelihoods and futures against the backdrop of the state’s failures to provide adequate healthcare, education, welfare, and justice to all its citizens equally. In this sense, his conclusion—which would also require a systemic response to nepotism, clientelism, and corruption—may be idealistic, but it may also be propitious.

The book’s focus on the criminalisation of immorality and putatively aberrant sexual practices also speaks more widely to a longstanding but growing public intolerance of the endemic structural, institutional and sexual violence experienced by women, girls, and non-heteronormative individuals; to rapes that go unpunished by the judicial system; to punitive rapes and killings ordered by tribal councils; to the notorious Hudood Ordinance law, and to the stubborn persistence of ‘honour’ as an powerful modality for controlling women’s freedom and bodies. Outside of Pakistan it bears on political and policy responses to the uncovering of child sex grooming in Britain by Pakistani gangs, on sexual attacks on European women by Muslim migrants, and on the growing prevalence of HIV amongst Pakistani migrants in Europe. Qureshi’s book will have wider resonance for studies of sexuality, law, public health, government, development, democracy and societal change in the Islamic Republic, and it deserves to be read widely.