Commodities of Care: The Business of HIV Testing in China by Elsa L. Fan

Abstract

Reviewed by: Commodities of Care: The Business of HIV Testing in China by Elsa L. Fan Aaron Su Elsa L. Fan. Commodities of Care: The Business of HIV Testing in China. Minneapolis: University of Minnesota Press, 2021. 216 pp. When strategies to streamline global health resources result in narrow, magic-bullet testing solutions, what meaningful interventions and social relations are enacted or foreclosed? Resonating with contemporary debates around the limits of technical solutions for COVID-19, Elsa L. Fan's Commodities of Care explores the scaling up of HIV testing in China stimulated by global health donors through programs of performance-driven financing. From the production of the category "men who have sex with men" (MSM) to the retraction of programs that offer lasting support beyond the positive test itself, Commodities of Care deftly illustrates how new trends in global health financing simultaneously usher in new subject positions, experiences of disease, and definitions of care. In so doing, the book offers a lucid glimpse into the stories and meanings of HIV for MSM in China while never losing sight of the political economy that makes these experiences possible. Commodities of Care is the result of Fan's comparative ethnographic work across several HIV organizations in a southern Chinese city. These community-based local centers, such as Bright Love, administer sexual health services as well as events and outreach programs, yet their funding structures are ambivalently tied to heterogeneous global health donors. Some, like the Health Fund and the Global Fund, have recently pushed for performance-based financing schemes that determine payments based on quantitative measures of HIV tests administered, positive test outcomes, and other related outputs, thereby reducing care to the transactional process of "selling blood (mai xue)" (3), as one of Fan's interlocutors [End Page 715] describes it. Analyzing the consequences of this shift—e.g., the purposeful proliferation of repeated and fraudulent tests for financial gain (40), the reduction of the HIV-positive population to solely MSM (17), and the "instrumentalization of community-based organizations as technical service delivery agents rather than stewards of social change" (116)—the author illuminates the transformative effects that "audit cultures" (Strathern 2000) can wield in the making of local and global health. Having worked in the development and philanthropy industries during these "ideological shifts" (19), Fan is uniquely positioned to tell the history of global health's financial streamlining at the turn of the millennium alongside the emergence of new players like the Gates Foundation. In the introduction and Chapter 1, she ethnographically analyzes how the world of HIV testing as a singular global health solution par excellence comes together in the Chinese context. Intricately describing the promotion of performance-based financing over peer-to-peer education (26) as well as the rise of statistics like the quality-adjusted life year and disability-adjusted life year in global health discourses (36), Fan traces how these shifts appear in the narrations and material practices of her interlocutors. For example, she digs into rumors of organizations splitting performance incentives with non-MSM migrant laborers, whom they recruit to get tested for the sake of their tally. She thus reveals the concrete, local consequences of approaches like evidence-based medicine (EBM) and their dominance in public health. In Chapter 2, Fan draws on Ian Hacking's (1986) concept of "making up people"–the production of new subject positions through categories and counting practices–to show how global health's enumeration strategies led to the "making up" of MSM in China. She charts the varied negotiations over the concept of MSM in China to understand organizations' concerns about recruiting testers, noting that many MSM were perhaps in publicly heterosexual relationships. Addressing this problem of a "hidden population" and insisting that Chinese MSM could not merely be drawn out and defined in the conventional terms of identity politics, Fan illuminates how practices of self-affirmation (ziworentong) "instill in these men an acceptance of their same-sex desires and a recognition of their HIV risk as part and parcel of desires" (77). The result of this affirmation, Fan reminds us, is not just the production of new personhoods but also the manufacturing of "commodities of care" in...