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Governance and the HIV/AIDS Epidemic in Vietnam by Alfred John

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Governance and the HIV/AIDS Epidemic in Vietnam by Alfred John Governance and the HIV/AIDS Epidemic in Vietnam by Alfred John Montoya A dissertation submitted in partial satisfaction of the requirements for the degree of Doctor of Philosophy in Anthropology in the Graduate Division of the University of California, Berkeley Committee in charge: Professor Aihwa Ong, Chair Professor Paul Rabinow Professor Peter Zinoman Spring 2010 Governance and the HIV/AIDS Epidemic in Vietnam © 2010 By Alfred John Montoya For Michael A. Montoya, Elizabeth Alonzo, and Mary Theresa Alonzo. i Acknowledgements First, I‘d like to express my endless gratitude to my family, always with me, in far-flung places. To them I owe more than I can say. This work would not have been possible without the warm mentorship and strong support of my excellent advisors, Aihwa Ong, Paul Rabinow and Peter Zinoman. Their guidance and encouragement made all the difference. I would also like to acknowledge the intellectual and personal generosity of David Spener, Alan Pred, and Nancy Scheper-Hughes who contributed so much to my training and growth. Additionally, this work and I benefitted greatly from the myriad commentators and co-laborers from seminars, conference panels and writing groups. I would specifically like to extend my gratitude to those from the Fall 2004 graduate student cohort in the Department of Anthropology at UC Berkeley, particularly Amelia Moore and Shana Harris, whose friendship and company made graduate school and graduate student life a pleasure. Also, my heartfelt thanks to Emily Carpenter, my friend, through the triumphs and travails of these six years and this project that consumed them. Many thanks to the participants in the Anthropology of the Contemporary Research Collaboratory, at UC Berkeley. It was a tremendous opportunity to work alongside such generous and first-rate scholars. This work was undertaken with fellowship support from the University of California, Berkeley and the Ford Foundation, along with grants from the Department of Anthropology and the Center for Southeast Asia Studies at UC, Berkeley. Finally, I would like to acknowledge with sincere gratitude the many friends and collaborators in Vietnam and elsewhere who shared their time and talent, laughter and hope, doubt and frustration, and enthusiasm and expertise with me over the course of those many long months of fieldwork. I hope to have done them some small bit of justice here. To these people and many many others I owe whatever is thoughtful and considered in the following work. All errors in judgment, interpretation, memory, translation and the like, are, of course, my own. ii Contents Abstract …………………………………………………………………………………………...1 Introduction: Governance and the HIV/AIDS Epidemic in Contemporary Vietnam …………………………...3 Chapter Two: Mots, Choses, Ouvres: A Minor History of HIV/AIDS in Vietnam ………………...…………..20 Chapter Three: HIV/AIDS, the Problematization of Government, and the Uses of Corruption ...........................50 Chapter Four: Aid, AIDS, and USAID: Bureaucracy and Disease in the Time of Virtue ……...........................85 Chapter Five: Miettes de Mechancetes et Parcelles d’Amour…………………...…………………………….117 Conclusion: New Difficulties and the Form of the Future ………………….……………………………….138 References ……………………………………………………………………………………...152 iii Abstract Governance and the HIV/AIDS Epidemic in Vietnam Alfred John Montoya Doctor of Philosophy in Anthropology University of California, Berkeley Professor Aihwa Ong, Chair Professor Paul Rabinow Professor Peter Zinoman This dissertation concerns HIV/AIDS prevention and control in contemporary Vietnam, as an assemblage of Vietnamese Socialist governance, international NGO and US government mechanisms, and new biomedical regimes based on expert knowledges and international ―best practices.‖ It maps the emergence of HIV/AIDS in Vietnam, the rise of the complex of state practices, spaces and discourses created to deal with it, the unfortunate entanglement of this apparatus with that set against ―social evils,‖ and the rendering of HIV/AIDS a biological marker of socio-moral contagion. It examines the deadly consequences of this entanglement, the authorities‘ subsequent attempts at disentanglement following shifting epidemiological, political and economic conditions and Vietnam‘s internationally acclaimed success against SARS. It marks the new forms of exclusions and inequalities in health this generated. Broadly, I argue there was a shift from an emphasis on ―The People‖ to one on ―The Human‖ as the object at the center of this HIV/AIDS prevention and control apparatus, along with a shift from external enforcement (by authorities) to internal adherence (by oneself, to techno-scientific and expert discourses and practices). With the shift from enforcement (a present and past-oriented mode) to adherence (a mode that moves from the present forward), the near future has now become a target of and problem for government. As new and massively increased resources for HIV/AIDS prevention and control become available new contests over jurisdiction and precedence are breaking out between sectors of this apparatus dedicated to public security and health and human services, as well as central and local health authorities. Under these conditions new life-saving and harm-reduction programs effected and protected through and under interpersonal and political arrangements often classified in the foreign and domestic press as ―corruption‖ are forcing reexamination of the ethical status of these practices. I argue that following my informants‘ stress on the ―uses‖ of corruption, rather than their naming, a more nuanced portrait of contemporary power relations and constraints emerges, one that sheds light on the transformation, in these milieu, of the emerging ethical terrain of HIV/AIDS prevention and control in Vietnam. Third, I examine PEPFAR (US President‘s Emergency Plan for AIDS Relief), investigating the friction at the meeting points between a pair of incongruous bureaucracies, their effect on local financial, facility and human resource management, and the promotion of a certain regime of accounting and audit practices. These new technologies represent a curious marriage of neoliberal rationalities and humanitarian ethics that operate by refiguring political problems in other domains as non-ideological and non-political health problems, within the framework of what I term an ―ethics of an economy of virtue.‖ Here I track the penetration of 1 neoliberal logics and calculations into the domain of humanitarian intervention. Truth games effected through the deployment of statistics, images, anecdotes and narratives collapse a broad range of meanings upon the subjected bodies of the ill, bodies and stories meant to stand in not only for those innumerable ―others like them,‖ but the exchangeable, comparable virtue of the deployer. The final chapter is a fleshing out of the framework I present in the preceding chapters, using the parallel stories of two exemplary figures; a famous and controversial Saigon social worker, and a relatively unknown young woman, a homeless heroin addict and ―graduate‖ of the Vietnamese carceral regime. These stories highlight the benefits, constraints and vulnerabilities actors working on HIV/AIDS in Vietnam within an economy of virtue face, as well as enable us to trace certain turning points in their lives against the background of the minor history of HIV/AIDS in Vietnam that I have set out. 2 Introduction Governance and the HIV/AIDS Epidemic in Contemporary Vietnam ―… et que bien poser un probleme n’est pas le supposer d’avance resolu.‖ ―… and that to state a problem clearly is not to suppose it solved in advance.‖ - A. Gide, l'Immoraliste Problem, Fieldwork and Analytic Orientation Epidemics are, perhaps, the original site and problem space of modern biotechnological intervention. Modern germ theory arose, in no small part, as a response to cholera, tuberculosis, plague and fever outbreaks in Europe and its colonies in the 19th century (Watts 1997; Rabinow 1989). Then, as now, these techno-scientific bio-technological interventions bore with them and articulated with political and ethical formations to produce novel configurations (Latour 1988; Nguyen 2009). In our contemporary of rapid intercontinental air travel, and the unfathomable interconnectivity of markets and diverse sites, globally, but particularly in the close quarters, dynamic milieu and fluid borders that make up Southeast Asia, epidemics have risen to the fore, not just as a problem of governance (Quah 2007; Poku, Whiteside, Sandkjaer 2007; Harman, Lisk 2009), but a problematization of a whole range of processes for shaping bodies and biologies (Nguyen 2009), incorporating mobile technologies and situated practices in emerging assemblages (Ong, Collier 2005), and articulating neoliberal calculations, global humanitarian ethics and local political, ethical and technological regimes (Montoya Forthcoming). This dissertation focuses on the question of governance in an epidemic, charting the problematization of disease governance in Vietnam following the first appearance of HIV/AIDS in 1990, the failure of a ―social evils‖ enforcement-based approach to HIV/AIDS, the refiguring of the epidemic and the targets of government after the 2003 SARS outbreak, and the game- altering effects of the US President‘s Emergency Plan for AIDS Relief. The central problem of this study is: ―How, under the particular economic, political and social conditions of contemporary Vietnam, is the threat of possible pandemic
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