Anthropology of East Europe Review 33(2) Fall 2015 96 Blind Spot: How Neoliberalism Infiltrated Global Health. By Salmaan Keshavjee. Oakland: University of California Press, 2014. xxxviii. 240.pp. Notes. Bibliography. Index. $29.95, paperback. Jennifer J. Carroll, Division of Infectious Diseases, The Miriam Hospital, Providence, Rhode Island Salmaan Keshavjee’s Blind Spot is an attempt to chart the effects of global development efforts on local communities at the world’s economic peripheries. Based on his experience as a health officer for the Aga Khan Foundation (AKF), a non-governmental organization (NGO) in eastern Tajikistan, Keshavjee provides first-hand knowledge of the results reaped by healthcare development efforts and the economic regulations that accompany them. Keshavjee argues that neoliberal financial and managerial schemes play a defining role in global health today and are transmitted worldwide through NGOs and their largely quantitative metrics of program evaluation, such as patient adherence, rates of referral, and overall cost efficiency. The end result, according to Keshavjee, is the growing specter of “neoliberal programmatic blindness,” or “blind spots,” wherein “the original aims of projects…get lost or ignored” (15). In other words, the humanitarian goals of development efforts become lost in the flurry of attentions paid to neoliberal modes of governance. The first of Blind Spot’s four sections provides historical context for the Badakhshan region of Tajikistan, where the ethnographic portions of this book take place. Keshavjee provides a sound review of the Soviet health care system, relying heavily on the work of medical historian Mark Field, who has arguably produced more first hand accounts and analyses of the Soviet medical system than anyone, to outline the ideological underpinnings of Soviet medicine. This is followed by a discussion of public health in Tajikistan after independence. Keshavjee presents AKF as a paradigmatic example of the NGOs, which flourished in post-Soviet Tajikistan, bringing with them the financial support—and exigencies—of global development institutions. The second section offers a closer look at healthcare reform efforts in Badakhshan, where hospitals are grossly underfunded and most of the population lives in deep poverty. During Keshavjee’s tenure at AKF, the organization established a revolving drug fund in Badakhshan to create a self-sustaining pharmacy network, a project that Keshavjee argues was designed specifically to cater to the economic mission of the United States Agency for International Development (USAID), the fund’s primary donor. The fund itself would be sustained by charging patients twice or even three-times the market value of pharmaceutical drugs, ignoring the fact that residents’ reported willingness to pay for drugs “meant little in the face of being completely unable to pay” (p.81). This project, Keshavjee claimed, reflected the tendency to blame negative health outcomes on individual ignorance and apathy (i.e. unwillingness to pay), rather than the structural barriers (i.e. inability to pay) faced by the region’s population. Anthropology of East Europe Review 33(2) Fall 2015 97 The third and fourth sections of the book offer the most intimate look at the neoliberal ideologies that made a revolving drug fund in Tajikistan’s poorest region. In Chapter 6, Keshavjee provides a concise yet cogent history of neoliberal economics, grounding the birth of this economic philosophy squarely in Western European and North American efforts to weaken the appeal of communism to developing nations. In particular, it was thought that if neoliberal infrastructures could be successfully developed in economically vulnerable nations, Soviet influence would be unable to follow. In Chapter 7, Keshavjee traces the footpath of these ideologies from powerful international agencies like the International Monetary Fund (IMF) and the World Bank through funding requirements and recipient NGOs to the local communities where they work. The fourth and final section argues that neoliberal reforms shift the cost of healthcare from government institutions to local communities based on the premise that these patients should be transformed from recipients of healthcare to consumers of healthcare services. These programs are enacted despite existing data, cited in the book, which indicate that access to healthcare plummets following their implementation. Nevertheless, such reforms proliferate where neoliberal thinking “overrides both qualitative and quantitative data” (p.135), because neoliberalism, itself, is hegemonic. It proliferates not because it works, but because it is accepted as ‘common sense.’ While Keshavjee’s purpose in authoring Blind Spot is abundantly clear, the book leaves a number of questions unanswered. For example, how do the perspectives of the individual actors who work for global financial institutions (like the IMF or even USAID) inform their efforts in places like the Badakhshan? Ethnographic research conducted among the global health elite (such as that of Paul Geissler and James Pfeiffer) indicates that the ideological balancing act these individuals perform is much more complex and nuanced than the lock-step mental subjugation to neoliberal logics that Blind Spot seems to imply. To this end, the book fails to address the complexity of neoliberalism as a practice in a satisfactory way. A discussion of the current anthropological literature on global health in Eastern Europe and Central Asia is also noticeably absent from this text. Erin Koch’s ethnography of tuberculosis control in Georgia, Michelle Rivkin-Fish’s analysis of the World Health Organization’s (WHO) involvement in women’s reproductive health in Russia, Jonathan Stillo’s critiques of the work of the Global Fund in Romania, and Michelle Parson’s deconstruction of epidemiological trends in Russia all come immediately to mind as works that could have added significant depth to Keshavjee’s analysis if they were brought into the conversation. Consequently, it is also difficult to discern what lessons the reader can take away from Blind Spot about the Central Asian region. Though he introduces the text on page 13 as an ethnography, the sparseness of ethnographic data and the complete absence of discussion about Keshavjee’s research methods and protocol raises questions about how ethnographic this analysis really is. In the end, Blind Spot fails to provide a new perspective on global health in the post-Soviet sphere due to the sheer scarcity of organized ethnographic analysis. Tajikistan appears predominantly as a foil against which Keshavjee articulates inconsistencies that exist Anthropology of East Europe Review 33(2) Fall 2015 98 between the aims and the methods of neoliberal healthcare reforms, not as a unique locale with a generative culture. Nevertheless, Keshavjee’s Blind Spot is a cogent and readable account of the institutionalization of neoliberalism and transmission of that ideology through healthcare reform efforts. Chapters 6 and 7, in particular, offer an extraordinarily concise and well-written account of the history of the IMF that simply begs to be taught in either undergraduate classrooms or graduate seminars. This book would serve as a wonderful introduction to the complex realities of global disease burden, international monetary policy, structural adjustment programs, and global health. The writing style is smooth and engaging, and Keshavjee excels at rendering these complex ideas extremely intelligible. Scholars and students, alike, who wish to enter into contemporary conversations on medical anthropology and global health will find themselves well-served by adding this book to their arsenal.