Elsa L. Fan. Commodities of Care: The Business of HIV Testing in China. Minneapolis: University of Minnesota Press, 2021. 216 pp. $25.00 (e-book), ISBN 978-1-4529-6121-7; $100.00 (cloth), ISBN 978-1-5179-0764-8; $25.00 (paper), ISBN 978-1-5179-0765-5.
Reviewed by Elise Li Zheng (Georgia Institute of Technology)
Published on H-Sci-Med-Tech (May, 2022)
Commissioned by Penelope K. Hardy (University of Wisconsin-La Crosse)
In the book Commodities of Care, Elsa L. Fan details how HIV rapid-testing technology, which has been widely deployed by health funds and nongovernmental organizations (NGOs) targeting the MSM (men who have sex with men) community, has transformed the landscape of HIV care into a performance and market-oriented regime, making (homosexual) bodies into social/political capital (hence the “commodities of care”). The monograph is based on the author’s prior engagement with HIV-related philanthropical work in mainland China. Her acquaintance with various levels of personnel in the system (NGO staff, local officials, community workers, and patients) adds depth and nuance to the ethnographical material and articulates succinctly the social and economic logic of HIV care in China’s MSM communities.
The book mainly focuses on two critical aspects of how commodities are made through the cost-effectiveness structure of HIV care delivery among MSM. The first is how the performance-based health programs and their governing techniques have (re)shaped the way prevention and control are administered. In chapters 1 and 3, Fan details the economic logic behind the distribution of testing services among various communities and the ways the audit regimes and languages of value have reconfigured the landscapes of HIV prevention and care. Global donors and local centers for disease control (CDC) in China have adopted a performance-based financing structure that calls for scale and standardization, allowing accounting and accountability measures to be established so that local organizations and their operations can be incentivized and closely monitored. Rapid testing targeting MSM suits this logic and structure, as it produces performance goals. Small organizations, which largely depend on the donors and Chinese CDCs’ social service contracts, translate the outreach and testing efforts into a value-production process to secure funds and “long-term sustainability” (p. 50). However, during the actual operation, other vital aspects in HIV care (such as treatment and prevention) and other groups are downplayed or even neglected. As Fan criticizes in the book, the current structure is “a very narrow purview of what mattered, and left little room, or funding, to explore alternative methods of prevention and care for MSM” (p. 10).
The second aspect, shown in chapter 2, is the making of MSM, through testing and community outreach, as an identity and selfhood of those who are deemed “at risk.” The term was originally an epidemiological instrument and focused only on sexual behavior rather than sexuality for “neutral” HIV surveillance. Nevertheless, this category has been reinvented and reimagined with a Chinese context for the purpose of test initiatives. It transfers the target population (some of whom are “hidden” in heterosexual relationships because of traditional social values) as subjects of governance by creating a new form of selfhood (ziworentong) and self-responsibilities—the “empowerment” of the target population (p. 51). MSM identity is created by defining and finding out who is “at risk” to test, and hence it is deeply entangled with the financial initiatives of testing as outsourced social service from funding sources and authorities to NGOs and local communities. Fan argues that this process transformed MSM into commodities of care “that accrue political and economic value,” which is transacted between the stakeholders (p. 23).
From a science and technology studies (STS) point of view, Fan’s work demonstrates the critical entanglement of the material and the social—how a certain technology is shaped by and shapes social relationships. When it comes to finding out if someone has a certain disease, “testing” is initially material yet also socially constructed with this material. Testing can differ from diagnosis; in diagnosis, medical professionals make claims based on various sources of information, and the practice is embedded in the authority of medicine and performed through physician-patient interactions. Testing, however, is usually seen as more technical. It is to reflect the existence of certain pathogens, and the results are simple. The technical parts do not get much attention in this book. However, testing can play a pivotal role as not only a technical tool but also a “sociotechnical system” that entangles various social forces to render the patients visible and as subjects of governance and that directs resources and shapes identities in the care and prevention business.
Chapters 4 and 5 extend the discussion into the communities and individuals themselves. With scholarly engagement with biopolitics and bio-citizenship, Fan touches on the power issues between selfhood and governmentality in HIV prevention and care. However, this part seems to be a weaker aspect of the book and connects less with the testing technology. How does the technology signify self-control and channel responsibilities into the way they live their lives? What is the link between individual identity and epidemiological knowledge production? China is seen by the field of medical sociology/anthropology (and some STS) as an ambivalent case of neoliberal health (e.g., psychotherapy); is the making of MSM selfhood part of the neoliberal health regime, and what is its implication in the context of China’s political regime? Fan rarely mentions or addresses this “elephant in the room,” the political sensitivity of homosexuality and social advocacy under an authoritarian government in China. The latter part of the book could perhaps have been better organized around the theoretical and empirical connections with Chinese politics, which are hard to obscure in contemporary China studies.
Overall, this book offers a strong argument on how testing technology’s social and economic logic could shape the care and prevention of HIV in China. It shows the intricate relationship between technology and its social production. More nuanced and deeper political discussions can be addressed in future research. The socio-material approach can inspire future study of the current COVID-19 pandemic, for example, how polymerase chain reaction (PCR) tests became a vital component in shaping the landscape of the pandemic and public health responses. The production, financial structure, distributing strategies, and performance behind COVID-19 tests should not be ignored.
. Annemarie Jutel, “Sociology of Diagnosis: A Preliminary Review,” Sociology of Health & Illness 31, no. 2 (2009): 278-99.
. Li Zhang, Anxious China: Inner Revolution and Politics of Psychotherapy (Oakland: University of California Press, 2020).
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Elise Li Zheng. Review of Fan, Elsa L., Commodities of Care: The Business of HIV Testing in China.
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