This book is a collection of essays addressing varied historical and ethnographic contexts of health governance in Pakistan, governance in the sense of state control as well as control exercised by communities and kin groups. The essays share a focus on the intertwining of the carceral with care, and therefore draw out patients and caregivers’ scepticism as they respond to ill health and pursue and evade health protections and treatment. Ambitiously, the book does this by moving across varied health domains that are usually studied separately. Khan connects infectious disease responses in Pakistan with mental health provision, seeing in both an element of “carceral violence through the exclusion of the patient from the wider population” (p.38) but then in later chapters, the book opens up to the category of chronic illness more broadly, chronicity being “a framework to theoretically capture the longstanding histories of kinship disorders, experience of political violence and state brutality” (p.170). Coloniality, poverty and health are keywords in the book’s title. Khan addresses a lengthy historical panorama, enabling him to draw out colonial legacies and inheritances in the present and enfold the evolving neo-colonial geopolitics of development assistance to Pakistan as a poor country. Poverty also features in terms of the material conditions in which Khan’s interlocutors live and which constrain their health-seeking practices in manifold ways.

Chapters 1 and 2 are historical. Chapter 1 is a review of mostly secondary historical literature on the carcerality of colonial medicine and public health. It examines how colonial medicine and public health differentiated within populations in racialised and classed ways, protecting the colonisers’ enclaves while allocating few resources to indigenous health protection and meting out punitive forms of care based on the class background of patients. Khan focusses on the asylum as definitive for healthcare in colonial India, but also canvasses historical research showing how “asylum-like” care came to “extend into communities where disobedience to public health reform becomes punishable by law” (p.40), as with the 1897 Epidemic Diseases Act and the 1898 Leprosy Act. The end of the chapter returns to mental illness and explores how it “provided a site to express the political conditions of colonialism and the displacement from the family that accompanied it” (p.50). Where other scholars have turned to Manto’s lunatics asylum for inspiration here, Khan offers an interesting reading of a fresh historical primary source: psychiatrist Ibraheem Khalil Sheikh’s novel Ibrat Kada, written in Sindhi, published shortly after Partition and dramatising the experiences of his patients. Khan reads Sheikh’s agenda as a psychiatrist as broadly de-carceral, diagnosing his patients differently than the colonial state’s designation of madness and normalising their seemingly pathological symptoms as a product of the very same colonial state; accepting superstitious symptoms as echoes of violence from the patient’s past; and playing into the patient’s realities and viewing them as ibrat, exemplary but at the same time horrific, capturing both the “psychic costs of post-colonial violence” as well as “the inability to fully escape from the clutches of fate” (p.50).

In chapter 1 we glimpse Sheikh negotiating within constraining bureaucratic structures, while chapter 2 canvasses in more detail the bureaucratic formations of public health in Pakistan shortly after independence, focussing on historical primary sources related to American health assistance in the 1950s/60s. Khan explores an archive of the writings of Fred Soper, an American epidemiologist who strove to make health a central agenda in US politics towards South Asia during the Cold War. The chapter details Soper’s efforts to establish a Cholera Research Lab in East Pakistan. Soper wanted the Lab to be an international scientific institute devoted to the study of the clinical epidemiology of cholera. However, his research interest in cholera came into conflict with American geopolitical interests in the Indo-Pacific related to the surveillance of diseases that could disrupt transnational trade networks. Recalling Chapter 1 on the enclavist nature of colonial public health, as well as the contours of colonial medical attributions of germ-carrying native bodies and medically pathological geographies, Khan shows how American geopolitical perspectives on the Lab reproduced colonial-era paranoias about the inherently diseased character of South Asian geographies and racialised bodies. While Khan depicts Soper as a supporter of multilateralism, he also explores Soper’s grumbles in his diaries about the bureaucratic cultures of the Pakistani military and governing elite, their observance of Ramazan fasting recalling for Soper an indigence again betraying colonial discursive roots; Soper’s archive sees public health knowledge as white, flowing from the Americans to the Pakistanis. Reproducing the logic of containment and arguing that disease was tied to geography rather than socio-economic conditions, Soper would often express his frustrations at the creation of a basic healthcare infrastructure and continue to insist on the importance of mass immunisations as a means of treating disease in its permanent foci.

The first ethnographic chapters examine the implications of the bureaucratisation of public health for ordinary life. Chapter 3 returns to the treatment of mental illness through isolation in the asylum, examining interviews with former psychiatric patients, family members, police and other legal actors, and scrutiny of case files. As in colonial times, the treatment of mental illness in Pakistan today is shaped by constructions of criminality. We see law enforcement agencies surveying communities but also providing care. In the wake of the Safia Bano decision of 2016, which prevented the mentally ill from death sentencing, the line between surveillance and care depends on legal decision-making concerning the genuineness of the illness. While this legal reform is seemingly progressive, it has also had the effect of creating lengthy delays to care, snarling up cases in red tape and paperwork, as the genuineness of a patient-prisoner’s claims to being mentally ill is adjudicated amid pervasive assumptions about malingering, lying and fraud, which Khan sees as exerting symbolic violence upon the sick. Sometimes, recalling cases in Ibraheem Khalil Sheikh’s Ibrat Kada, patients refuse to view themselves as sick, invoking reasons for their crimes corresponding to beliefs about jinns and magic. The severity of the cases canvassed in the chapter leads Khan to also explore family members’ negotiations around imprisonment. Sometimes families’ capacities to care are exhausted and they become uncaring, handing the patient over to the criminal justice system; but they struggle to have the patient admitted, and have to pay bribes to do so.

Chapter 4 looks at the exclusionary politics of Pakistan’s public health protections during the COVID-19 pandemic, as experienced in low-income settings in Lahore and Karachi. Recalling Fred Soper’s prioritisation of mass immunisations rather than the setting up of basic healthcare in Chapter 2, the chapter explores how low-income families understood the risks of COVID infection as inseparable from chronic conditions of poverty in their lives. Whereas rich Pakistanis could practise social distancing effectively, with their middle-class nuclear families the model for public health messaging, in low-income families, maintaining a livelihood and material sharing between kin meant that they could not practice isolation in the ways demanded by the state. Recalling the colonial logics of differentiation discussed in chapter 1, Khan shows how discourses about Christian minorities as unhygienic, or of Afghan refugees as mobile and untrustworthy led to greater levels of stigmatisation and militarised surveillance. Khan depicts treatment centres as places where preferential care was meted out to the wealthy and well-connected and where, in the absence of such privileges, patients received “poor-quality care that could further deteriorate health conditions” (p.120).

Where chapter 4 highlighted the particular ramifications of punitive public health approaches for minority groups, chapter 5 looks in more detail at Afghan refugee communities in the slums of Lahore, beginning a focus on displacement and migration within the book which I would have appreciated having seen set up a bit more clearly in the introduction and framing. Khan’s Afghan interlocutors struggle with addiction and depletion of their health amid the chronic shortages in their lives. As the policing of their addiction is shaped by experiences of policing terrorism in the wake of the war on terror, Khan’s interlocutors describe excessive surveillance, harassment and suspicion, forceful incarceration and also physical violence from the state (including a ‘Shoot to kill’ policy at the border for entering without authorisation), further exacerbating health injustice. Fear of the authorities inhibits health-seeking; Afghan refugees read a lack of care into any forms of health protection extended by the state, seeing “the care provided by the state as inherently selfish in nature” (p.129), with COVID-19 and polio vaccines feared to be means of killing them off. When they do seek medical care, recalling chapter 3 about files, red tape, paperwork and assumptions of malingering, “the category of patient-hood was not given… but had to be proven through medical evidence in the presence of language barriers”, Khan’s interlocutors “carry[ing] their diagnostic tests and tests from other cities and countries to make their suffering legible” (p.135). Recalling again Sheikh’s Ibrat Kada, addiction becomes legible as a means of numbing the self, a product of their social suffering; to which Khan’s interlocutors respond via self-medication and familial carceral care.

Chapter 6 looks at Pakistani migrants in the US and departs from most chapters’ focus on fear of state authority, though it does also mention Khan’s interlocutors’ intense awareness of migration regulations, Legal Permanent Residence, Green Cards and citizenship. Rather, the chapter cements the thread through the book around the lethality of care in families, the unkindness of family and how chronic disorder derives from kinship disorder in the context of needy transnational families marked by patriarchy: “the combination of material scarcity and disease in which flows of resources venerate violence in kin groups” (p.169). In this chapter Khan uses the concept of chronicity to demonstrate “blurring lines between mental and physical as well as infectious and chronic diseases” (p.149). He shows how illness in transnational kin groups raises moral questions about whether the sick person has been “treated rightly” (p.154) – these are accusations and counter-accusations that flow back-and-forth between Pakistan and the US. In analysing how illness experiences are interwoven with family politics, Khan highlights patriarchy and gender inequality.

The book’s title, with its reference to discretionary medicine, attempts to encapsulate the main insight about the arbitrariness, even cruelty, of healthcare in Pakistan in a context where the health system is weak and overloaded. In the introduction, Khan emphasises bureaucratic violence, health providers’ lack of accountability, transparency and inequity as they respond differentially to patients in accordance with whether the patient can pay a bribe, whether the patient looks like one deserving of attention and whether the patient has any ties of connection and influence. This becomes a picture of care as discretionary. Here Khan seeks to speak back to Foucauldian biopolitics and the pervasive application of this concept, parochialising Foucauldian biopolitics to the stronger and more comprehensive welfare apparatus developed by European states and therefore not straightforwardly applicable to a setting like Pakistan. Here Khan charts similar territory as Akhil Gupta (2012) does in Red Tape, where he writes of how the Indian developmental project looks little like the rationalised European disciplinary society but is rather a process “shot through with contingency and barely controlled chaos”; the state perpetrates violence in the very act of maintaining healthy populations; Gupta also sees his project as explaining an arbitrariness which is “not itself arbitrary; rather it is systematically produced by the very mechanisms that ameliorate social suffering” (cited on p.15). Khan departs from Gupta in important respects, in that he does not start with the assumption that the state is benevolent but rather with the assumption that “penalty and care are both entangled in the bureaucratic management of populations” (p.15). In the conclusion, Khan returns to his conceptual offering around discretionary medicine, making clear that when health care becomes bureaucratised to the extent that it is no longer caring, it is also a de-socialised medicine, failing to respond to the structural causes of poor health. Amid a medical anthropology that often feels overdetermined by Foucault, and amid the pressing real-world health injustices Khan canvasses in Pakistan but also, familiar to other South Asian settings and beyond, this is an important project.

References:
Gupta, A. (2012). Red tape. Bureaucracy, Structural Violence, and Poverty in India. Durham: Duke University Press

© Bloomsbury Pakistan 2025