Public Health, Global Surveillance, and the “Emerging Disease” Worldview: A Postcolonial Appraisal of PEPFAR

Abstract

Drawing upon a postcolonial lens, this project looks at how meanings of HIV/AIDS are discursively constructed within the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), which was launched in 2003 under the presidency of George W. Bush and has been heralded as the largest global public health intervention program in history. Building on existing literature that theorizes the interrelationships of public health and national security, global surveillance, and transnational hegemony, the postcolonial theoretical standpoint interrogates how such meanings are constructed within PEPFAR. A postcolonial deconstruction of the 2009 PEPFAR report to the Congress revealed three meanings of HIV/AIDS that were discursively constructed in such policy documents: (a) the “Third World” as a site of intervention, (b) U.S. altruism as “lifting” the burden of the soul, and (c) AIDS, economics, and security. The themes put forth the linkages among the symbolic representations in neocolonial configurations and the politics of material disparities across the globe, thus issuing a call for the creation of participatory and dialogic spaces for engaging subaltern voices that are typically treated as targets of policy and intervention discourses.

Notes

¹Globalization is defined here as the complex interflow of people, commodities, and services across dispersed spaces that are woven into interconnected webs through ever-intensifying networks, time–space compression, technological innovations, and economic policies (Giddens, 1990).

²Harvey (1989, 2005) defines neoliberalism as a political economic intervention at the global level that pushes the agenda of free market economy through the pursuit of trade liberalization, privatization of resources, and the minimization of tariffs and trade-related barriers. Neoliberalism therefore embodies the principle of on one hand, minimizing state-level interventions in the operation of transnational corporations, and on the other hand, ensuring the military-police function of the state in securing spaces for the operation of transnational corporations (TNCs).

³Neocolonialism, interchangeably used here with neoimperialism, refers to contemporary forms of colonialism that are played out through the economic exploitation of subaltern sectors by the consolidation of power in the hands of global transnational hegemony. Neocolonialism on one hand is spatially situated as specific countries in the global North exert their power on the global South through their hegemonic influence on international financial institutions (IFIs) such as the World Bank (WB) and the International Monetary Fund (IMF); on the other hand, it is globally distributed and fragmented, as transnational hegemony enacts its power and control across global spaces.

⁴The emerging disease framework is the global consolidation of the capacity to monitor diseases and develop solutions on the basis of articulations of problems of global security and economic rationality that threaten global capitalist interests. The emerging disease framework is an important tool in the hands of neocolonialism as it creates greater surveillance capacities for transnational capital and brings greater amounts of global spaces under the auspices of transnational hegemony by linking health, geosecurity, and corporate profiteering (King, 2002). We discuss the “emerging disease framework” in greater detail in our section “Public Health and Globalization.”

⁵Transnational capitalist hegemony refers to the configuration of dominant global actors including transnational corporations, nation-states, global organizations such as the UN and the World Bank, and local elites that work hand-in-hand to optimize the profits of the political economic power structures in a global landscape (Harvey, 2005).

⁶The term “medicalization” refers to the fact that Western understanding of health is inexorably intertwined with the practice of professional medicine. Lupton argues that cultural understandings of health are a product of ideological processes; and that in the West, the close association of health and medicine can be linked to a need for social control of the mechanized body under late capitalism (Lupton, 1995).

⁷Here we refer to Zoller's analysis of global health policies understood in the backdrop of “globalization” (2008, p. 391) or “a polysemic term that may be used to refer to growing interplay between multiple cultures, homogenization of cultures due to the growth of international media, and the growth of particular trade and economic relationships.”

⁸As Brown and Bell (2008, p. 1571) mention, the introduction of the “Global Strategy on diet, physical activity and health” was heralded by the director-general of the WHO as a “landmark achievement in global public health policy.”

⁹A more detailed explication of King's (2002) conception of the “emerging disease worldview” is provided later in this article.

¹⁰For more detail on “high technology” epidemiology vis-à-vis SARS and HIV/AIDS, see Galloway and Thacker (2007)

¹¹Throughout his piece, King uses the term “postcolonial public health ideology” to describe post 1990 policies. He uses of the term “postcolonial” as a temporal reference. To avoid confusion with our notion of “postcolonial health communication” as a transformative perspective that seeks to disrupt contemporary Western public health approaches, we steer clear of King's term “postcolonial public health” in our essay.

¹²The history of U.S. immigration laws vis-à-vis HIV/AIDS has been defined by an attitude of insularity. Since 1987, AIDS has been on the list of “Communicable disease[s] of public health significance,” a list published by Department of Health and Human Services that bans immigration and travel to the United States by foreigners infected with AIDS. It is only as recently as 2009 that this ban has been lifted. According to a CDC fact sheet, “the Department of Health and Human Services (HHS) and Centers for Disease Control and Prevention (CDC) published a final rule that removed HIV infection from the list of diseases that can keep people who are not U.S. citizens from entering the United States” (HHS/CDC, 2009).

¹³An online version of this document is available at http://www.pepfar.gov/documents/organization/113827.pdf

¹⁴For the next three sections, all subsequent quotes are from the research artifact: the PEPFAR document, unless otherwise indicated.

¹⁵U.S. Central Command (CENTCOM).

¹⁶U.S Southern Command (SOUTHCOM).

¹⁷U.S Military HIV Research Program (MHRP).

¹⁸U.S. Africa Command (AFRICOM).

¹⁹For specific instances of culture-centered narratives that pave the way for positive transformative spaces among sex workers in Kolkata, India, see Basu and Dutta (2009) and Basu (2011). The authors can also be contacted for information about culture-centered approaches in the context of HIV/AIDS.