Securing Blood: PEPFAR and Neoliberal War


On January 28, 2003 President George W. Bush delivered his third State of the Union Address focusing on global security. In its name, he both defended the U.S. War on Terror invasion of Iraq through lies about weapons of mass destruction, and introduced the President’s Emergency Plan for AIDS Relief (PEPFAR)[1] — a new program that pledged 15 billion dollars over five years in the largest financial commitment of a single country toward a single disease. Since 2003, both the War on Terror and PEPFAR have been expanded and further intertwined by President Barack Obama, demanding critical scrutiny. I argue here that despite their seemingly disparate realms of military force and medical relief, the War on Terror and PEPFAR both embody the logic of security: harnessing biopolitical discourses of life and humanitarianism to legitimate the expansion of neoliberal military and economic policy benefiting U.S. empire.

Sex, Blood, & Security Logics
PEPFAR targets the sexual transmission of HIV/AIDS by funding abstinence-only and monogamy-centric public health education.[2] It also requires funds-seeking organizations to develop an anti-prostitution policy that ensures PEPFAR funding will not be used to “promote, support, or advocate the legalization or practice of prostitution.”[3] Importantly, the policy must apply to the entire organization, not just its PEPFAR-funded campaigns.[4] Organizations needing funds have been forced to choose between receiving aid and teaching harm reduction strategies for sex workers.[5] In this way, PEPFAR reflects what Gayle Rubin calls the “hierarchy of sexual value” dividing “good sex” from “bad sex” in which “good sex” (which PEPFAR aligns with health and security) is reserved for sex that is “heterosexual, marital, monogamous, reproductive, and non-commercial.”[6] Other forms of sex are positioned as threats not only to individuals’ health but also to global security.
In addition to promoting abstinence-only programs and anti-sex worker practices, PEPFAR aims to protect what it calls “blood security” through promoting “quality assurance for collecting, testing, [and] storage of blood” and the “rational use of blood and blood products.”[7] The commodity-focused discourse of “quality assurance” and “rational use” reflects a neoliberal biopolitics that links blood to sex and race via security. This policy reflects intense racial, sexual, gender, and national violences as “bad blood” and “bad sex” are mapped onto racialized bodies in the Global South that are positioned as security threats to the U.S. and contemporary geopolitics. PEPFAR then seeks to manage the circulation of “bad blood/sex” in the name of protecting U.S. economic and political interests.
Security’s rise as a military-medical framework infuses neoliberal capitalist ideologies into global health and blood policy. As Michel Foucault explains it, security (as opposed to sovereign power) focuses not on prohibition but on allowing, monitoring, and tracking circulations.[8] The goal of security is not to prohibit circulation (whether the circulation of bodies, disease, or capital) but to manage the risks of circulation and nullify potential harm to the system. In global health and blood policy, security logics are coupled with the rise the rise of militarized humanitarianism, where categories such as “peacekeeping” and “human security” mobilize mass movements of troops and weapons to “protect basic human rights” in various locations across the globe. PEPFAR is part of this militarized humanitarianism, as it embodies what Didier Fassin and Mariela Pandolfi call a replacement of political and legal justifications for militarized interventions with affective and humanitarian ones that are then imagined to be beyond political and legal authority.[9]
Blood’s Circulation
Blood is an apt site for analyzing how security logics work in our contemporary military and medical cultures — and PEPFAR more specifically — because of its unique material and metaphoric relationship to circulation. Racial, gender, sexual, and national ideologies shape what blood is imagined to transport, and conversely, these ideologies move through the world stuck to blood narratives, policies, and practices. Currently, development organizations such as the World Bank and WHO define a national blood banking system that conforms to western standards of rationality as a key marker of development, as does PEPFAR.[10] This policy of aligning proper blood management with “development” and “progress,” taps into centuries-old associations between blood and racially gendered civilizationalist narratives. Given a technological and development-based spin however, the emphasis on a rational and economically sustainable blood banking system fits well into neoliberal logics that harness the supposedly race- and gender-neutral language of efficiency and security to justify militarized aid projects (including PEPFAR) that have explicitly racialized and gendered effects.[11]
Disease as (In)Security: For Whom?
PEPFAR’s medico-military framework is an outcome of the securitization of HIV/AIDS that began in 2000 when Vice President Al Gore launched a campaign to bring the pandemic under the purview of the United Nations Security Council[12] because it was “a global aggressor that must be defeated”[13] through a “sacred crusade.”[14] Gore insisted that it was the duty of the U.N. and the international community to “wage and win a great and peaceful war of our time — the war against AIDS.”[15] Gore claimed that the U.N. and individual countries such as the United States must wage war not because HIV/AIDS had already killed millions of disproportionately poor, queer, non-white, and transgender people (many of whom were already rendered vulnerable due to their citizenship status, race, incarceration record, and homelessness) but because it was a threat to “democracy,” “economic reforms, opened markets, privatized enterprises, [and] stabilized currency.”[16] Gore explicitly militarizes medicine and medicalizes war, and does so in the service of expanding global neoliberal capitalism. Despite Gore’s language of “wars” and “winning” though, as part of recent “humanitarian wars” and their shifting deployments of sovereignty and security, the 21st century “war on AIDS” is better understood as a global security operation performed in the service of national interests. In other words, what shapes these health practices is a desire to track, regulate, and manage the circulation of disease at the level of populations so as to maximize the circulations of capital, commodities, ideas, bodies that are beneficial to the current world order and specifically to U.S. imperial projects.
Like other human security aid projects, PEPFAR aims to regulate circulation — particularly the circulation of bodies, disease, blood, and logics across national borders. It is housed in the U.S. Department of State, and its planning documents reflect a military logic characteristic of U.S. military policy during the War on Terror under both the Bush and Obama administrations. President Obama reauthorized and expanded the program in 2008, further linking it to military practices and concerns: “The U.S. global health investment is an important component of the national security ‘smart power’ strategy, where the power of America’s development tools…can build the capacity of government institutions and reduce the risk of conflict before it gathers strength.”[17] PEPFAR, as a cornerstone of U.S. global health and blood policy, is thus positioned as a tool of national and global security, figured as both preventative and curative, and imagined to be capable of protecting the U.S. body politic and national interests from foreign threats. These threats are simultaneously medical, military, and economic ones as microbes, forms of governance other than the liberal nation-state, and cultural practices (including commercial, queer, non-monogamous, or otherwise “bad sex”) are imagined as attacking not just the places in which they reside but the U.S. and the global order. Always futural (“reduce the risk…before it gathers strength”), the threat of “bad blood” and “bad sex” looms on the horizon, poised for attack.
In these ways, PEPFAR reflects deep-seated and pernicious sexual, racial, gender, and national ideologies. If blood is life in the cultural imaginary, it is always simultaneously death, and it is the intertwining of these metaphors that renders it always potentially lucrative and always potentially suspect. The security apparatus is designed to manage precisely this unease, monitoring and controlling blood’s flows across borders, bodies, and boundaries. But of course this project is never complete, as blood’s fluidity renders it forever slippery, and blood has always escaped the regulation apparatuses designed to capture it. As PEPFAR demonstrates, the security apparatus links medicine and militarisms through frameworks of global health, humanitarianism, and biopolitics. Those of us who take seriously our work as critical cultural scholars and activists, committed to transnational feminist, queer, anti-racist, anti-capitalist, and disability rights movements, have the opportunity to reframe the issues of wellness, HIV/AIDS, and safety not in the service of national or even global “security” (with their attendant violences, including neoliberal war) but instead in the service of global social justice.
Campbell, David. The Visual Economies of HIV/AIDS. 2008. http://www.david- Accessed 14 December 2012.
Center for Health and Gender Equity and Center for Human Rights and Humanitarian Law.
“Human Trafficking, HIV/AIDS, and the Sex Sector.” October 2010.
Duggan, Lisa. The Twilight of Equality?: Neoliberalism, Cultural Politics, and the Attack on 
Democracy. Boston: Beacon Press, 2003.
Fassin, Didier, and Mariela Pandolfi. “Introduction: Military and Humanitarian Government in
the Age of Intervention.” Contemporary States of Emergency: The Politics of Military and Humanitarian Interventions. New York: Zone Books, 2010. 9-25.
Foucault, Michel. Security, Territory, Population: Lectures at the Collège de France, 1977-78.
Ed. Michel Senellart. Trans. Graham Burchell. New York: Picador, 2009.
PEPFAR. “Partnership Framework Document to Support Implementation of the Malawi
National HIV and AIDS Response between the Government of the United States of America and the Government of the Republic of Malawi.” May 2009. Accessed 20 March 2011.
_____. “PEPFAR’s Five-Year Strategy.” December 2009. Accessed 11 November 2010.
Rubin, Gayle. “Thinking Sex: Notes for a Radical Theory of the Politics of Sexuality.” The 
Lesbian and Gay Studies Reader. Eds. Henry Abelove, Michèle Aina Barale, and David Halperin. New York: Routledge, 1993. 3-44.
Simpson, Bob. ” ‘Please Give a Drop of Blood’: Blood Donation, Conflict and the Haemato-
Global Assemblage in Contemporary Sri Lanka.” Body and Society 15 (2009): 101-122.
“Text of President Bush’s 2003 State of the Union Address.” Washington Post. 28 January 2003.
United Nations. Security Council. 55th Session. The Situation in Africa: The Impact of AIDS on Peace and Security in Africa. Hearing. 10 January 2000.
United States Congress. H.R. 1298 (108th): United States Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act of 2003. Accessed 14 December 2012.
United States Congress. H.R. 5501 (110th): United States Leadership Against HIV/AIDS,
Tuberculosis, and Malaria Act of 2008. Accessed 14 December 2012.
The White House, Office of the Press Secretary. “Statement by the President on Global Health Initiative.” 5 May 2009.
President-on-Global-Health-Initiative/. Accessed 20 March 2011.
World Health Assembly. “Utilization and Supply of Human Blood and Blood Products.” 29 May 1975. Accessed 14 December 2012.


  • [1] “Text of President Bush’s 2003 State of the Union Address.”
  • [2] The original 2003 policy required that 33% of all PEPFAR funds received by an organization be used to promote abstinence (United States Congress. United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003). The 2008 reauthorization bill changed this, instead requiring organizations to file a report with Congress “if less than half of prevention funds go to abstinence, delay of sexual debut, monogamy, fidelity and partner reduction in any host country with a generalized epidemic” (United States Congress. United States Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2008).
  • [3] Center for Health and Gender Equity and Center for Human Rights and Humanitarian Law 15.
  • [4] Ibid. 19.
  • [5] Ibid. 15-16.
  • [6] Rubin 13.
  • [7] PEPFAR. “Partnership Framework Document.”
  • [8] Foucault 65.
  • [9] Fassin and Pandolfi 12.
  • [10] Simpson 105.
  • [11] For more on how racial, sexual, and gender ideologies are constitutive foundations of neoliberalism, see Lisa Duggan’s Twilight of Equality.
  • [12] Campbell 1.
  • [13] United Nations 5.
  • [14] United Nations 7.
  • [15] United Nations 7.
  • [16] United Nations 5.
  • [17] The White House, Office of the Press Secretary.

cathy hannabach