ROCKEFELLER ARCHIVE CENTER RESEARCH REPORTS

The Ford
Foundation’s early
involvement inglobal AIDS
and grants to
Indian AIDS NGOs
by Reiko Kanazawa
University of Exeter© 2017 by Reiko Kanazawa

Note: This research report is presented here with the author’s permission, but should not be cited or quoted without
the author’s consent. Rockefeller Archive Center Research Reports Online is an ongoing publication of theRockefeller Archive Center (RAC) under the general direction of James Allen Smith, Vice President of the RAC and
Director of Research and Education. Research Reports Online is intended to foster the network of scholarship in thehistory of philanthropy and to highlight the diverse range of materials and subjects covered in the collections at the
RAC. These reports are drawn from essays submitted by researchers who have visited the Archive Center, most ofwhom have received research stipends from the Archive Center to support their research. The ideas and opinions
expressed in this report are those of the author and not of the Rockefeller Archive Center.

This PhD project is a global, national and local history of the Indian National
AIDS Control Programme (NACP) from 1986 to 2005. During my six-weekresearch trip at the Rockefeller Archive Center (RAC) in Tarrytown, New York, I
mainly examined the RAC’s holdings of the Ford Foundation’s files on AIDS in
the Human Rights and Governance Program, Ford’s grants to Indian AIDS
NGOs, as well as some material on the Rockefeller Foundation and other
American foundations. These records have contributed an essential perspective
on how Ford situated itself within the broader response of global healthorganisations and other international bureaucracies in regards to how the AIDS
epidemic in developing countries should be dealt with. They demonstrate that theFord Foundation, as an American philanthropy, had been an active voice in early
discussions of how the disease should be tackled in developing world contexts.
Most significantly, they show how Ford – as one of the first international
agencies active before 1992 – had a distinct strategy for its AIDS work in Indiaand its relationship with Indian civil society. This strategy was defined primarily
by the Foundation’s perception that issues of social development and the social
impact of AIDS were under-addressed by other international health agencies aswell as the Government of India through its National AIDS Control Organisation(NACO).

I.

“The AIDS Challenge: A Ford Foundation
Response” and Program Officer Reports:
Insiders’ Reflections on the History of theFord Foundation’s International AIDS
Strategy and Work in India

It is clear from the archival evidence that the Ford Foundation had a clear anddynamic strategy for its national and international AIDS activities vis a vis what it
perceived were changing needs in developing countries as the epidemic
progressed and the work of other international health bureaucracies,
development agencies and bilateral donors. In this first section, I present an

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overview of the Foundation’s U.S. and developing country AIDS activities
drawing from internally produced and circulated documents at various stages.
First is a 1987 Information Report prepared for the Board of Trustees titled “TheAIDS Challenge: A Ford Foundation Response.” Second is a 1998 report by
Marjorie Muecke of the Reproductive Health and Sexuality Program Office,which provides a perspective on the thematic connections between Ford’s
domestic and international AIDS work. Third is a 50th Anniversary Monographwritten in 2002 by Radhika Ramasubban and Bhanwar Singh Rishyasringa,
which focuses primarily on the AIDS NGO network in India and the shift towards
sexuality and reproductive rights. Finally, Jacob A. Gayle reviews Ford’scontributions to the global AIDS response in 2006 as the strategy was about to be
up-scaled, showing a perspective on how Ford positioned itself in a dynamic
landscape of other international AIDS actors.

1987 Why AIDS was A Problem for Developing
Countries – What Ford could Contribute
From an information paper prepared for the Board of Trustees titled “The AIDS
Challenge: A Ford Foundation Response,” we can see an early snapshot of Ford’s
intended strategy.1 In June 1987, Ford appointed a group of consultants on both
U.S. and foreign aspects of AIDS “from around the country from the fields of
medicine, public health, law, and public policy” to help identify areas of “critical,
unattended need” that Ford could become involved in. 2 The plan for Ford’s
domestic work is well defined and articulated, as it clearly lays out the
epidemiology of the crisis in various regions, the consequent social problems andthe ongoing initiatives of other organisations. In terms of developing countries,
the strategy was still somewhat vague, with the report simply stating that itstrongly believed that Ford was uniquely positioned to: “[provide] informationand logistical support in the developing countries to public health ministries and

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non-governmental organizations concerned with developing fair and effective
policies and preventive measures to contain the disease, and to share successful
strategies.”3
Chapter III, titled “AIDS in the Developing World: Potential for Foundation
Action,” shows how at this point, Ford’s understanding of AIDS in the developingworld and why it was an issue was still uncertain. Regarding the special need for
AIDS work in such a context, Ford declares that the disease “threatens a broadcross section of the population in developing nations and compounds theiralready serious public health, development, and poverty problems.”4 The reportnotes that, in contrast to the United States, the epidemic in Africa was spreadprimarily by heterosexual transmission and affected both urban and rural
populations equally. In regards to Latin America, particularly Brazil, the reportpresents more concrete evidence of the number of cases in men and women, also
noting that there was significant discrimination against those infected with HIV
and perceived risk groups such as homosexuals and sex workers. However,regarding the region of Asia, the report is the least clear, only stating that“[b]ecause of widespread intravenous drug use and prostitution associated with
tourism in some countries of the region, … public health officials fear that AIDS is‘knocking at the door’ of Asia.” Interestingly, there is no mention of the 1980s
debt crisis in developing countries, except to note that they are extremely poor.
However, Ford was adamant in this 1987 strategy report on why it needed to get
involved: “AIDS has serious consequences for most of the Foundation’s work
aimed at alleviating poverty and promoting equal justice.”5 Not only that, AIDS
was seen as a unique disease due to the “absence of preventive or curative
medicines” and the way it would compound issues in developing countries’ healthinfrastructures due to its mode of transmission (sexual, blood transfusion,needles and breastfeeding) and the existing presence of diseases of poverty, suchas tuberculosis and malnutrition. The link between AIDS, poverty andmacroeconomic development is made in a very interesting way:

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Thriving in an environment of poverty, AIDS threatens to push poor nations evendeeper into poverty. In Central Africa, it is the productive members of society
between ages twenty and fifty – particularly the educated elites – who are falling
victim to the disease. Some policy makers are seriously concerned about the
future viability of whole nations, not only in terms of net population losses but
also in terms of losing essential human capital.6
The report continues to denounce restrictive HIV testing policies forinternational travellers and immigrants in developing countries, declaring that“[h]ow societies choose to deal with the HIV infection, especially since the full
dimensions of the problem are still unknown, may be the most important issue
facing several Third World governments.”
In the next section, the report details the activities of international agencies,
focusing in particular on the World Health Organisation’s Special Programme on
AIDS (SPA) and the United States Agency for International Development(USAID). Here we learn some critical information about the SPA before it became
the Global Programme on AIDS (GPA). The goals of the SPA were to improveblood supply, prevent blood/sexual/prenatal transmission and research vaccines.
Multilateral agencies like the World Bank and UN system members were happy
for the WHO to take the lead. However, the report details that the programme
was severely understaffed and underfunded. It notes that some donors were“likely to balk at WHO’s proprietary claims to the field” and have asked the SPA
to allow UNDP and UNICEF in particular to have more of a say in programme
design. While it notes that the US did provide donor funding to the WHO, USAID
had begun a five-year contract of $28 million with a consortium of NGOs led by
Family Health International to “provide technical assistance to developing
countries in their AIDS prevention efforts.” USAID also funded $14 million for acommunications

programrun

throughtheAcademyfor

Educational

Development (AED) to provide information, education and communication (IEC)
materials.

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5

The report then turns to the landscape of international NGO work. It notes thatorganisations like the International Commission of Red Cross and Red CrescentSocieties had focused on clean blood supply, while Save the Children, whoworked on education and family planning organisations, had added HIV and STD
prevention to their health communication work. It also notes that “somewhat
belatedly,” development agencies had begun to view AIDS “not only as aninternational public health problem but also as a threat to the development
process itself.”7 Within this, the time was ripe for private U.S. philanthropies tobecome involved, noting how the Rockefeller Foundation had funded research on
sexual behaviour and heterosexual transmission of AIDS in Africa. So how was
Ford to carve out a space for itself and make an impact in this landscapeconsidering the problems in the developing world?
Ford notes its advantages and disadvantages and designs its strategy accordingly.
First, it could not draw from the financial resources and biomedical technicalexpertise necessary to become involved in vaccine and treatment research. It
notes, “[i]n any event, such work is preeminently a function of governments, andis currently being led by public institutions in the United States and France.”
Given their past experiences in health, however, where private foundations like
Ford could leave their mark was in behaviour change and educational activities.
The report notes the strengths of the Foundation being its existing relationships
with human rights activists, government policy makers and social scientificprograms at select universities in developing countries. Thus, it suggests that it
could “help support selected activities in those domains complementing – but notcontrolled by – governmental mechanisms put in place by the national AIDS
committees established by WHO.” 8 Education and behavioural change AIDS
activities could also build from Ford’s previous international work in childsurvival and reproductive health, its network of community epidemiology andmanagement in Asia, as well as its focus on human rights and connections withwomen’s organisations.

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Here we note a few tendencies of the Ford Foundation that we will continue to
see throughout the records: it stays away from hard economic as well as scientificand biomedical impact areas, focusing more on social issues like human rights,
non-discrimination, sexuality and gender. Thus, it is reasonable to infer that theFoundation understood poverty in terms of social rather than economic
development when it made the case for why it needed to be involved with AIDS indeveloping countries. Ford is also keenly protective of its autonomy and wary ofcomplete control either by multilaterals or national governments. Thus, it aligns
its expertise in work that was close to the community and potentially dealt withsensitive issues:
Free

of

constraints

thatinhibitgovernment

assistanceagenciesandnongovernment organizations dependent on government funds, the Foundation
could work flexibly and sensitively with indigenous groups on such delicate topics
as patterns of sexual behaviour and how they might be modified to prevent
AIDS.9Ford was aware of how foreign agencies were perceived in developing countries –as “European and American scientists who ‘parachute’ in to gather data on
indigenous populations but are primarily concerned with the effect of AIDS on
their own societies” – and hoped to leverage their position as a “long-established,nongovernmental institution” to bypass that. 10 Finally, the report details their
discussions with the Nairobi office on potential activities and notes that a grant
had already been made through the Rio de Janeiro office to the Brazilian
Interdisciplinary Association on AIDS. Thus, we know that before it was active inIndia, Ford had already had conversations with field offices in Africa and Latin
America.

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1998 Marjorie Muecke’s Overview of Ford’s Nationaland International Activities
Despite uncertainties in biomedical understandings surrounding the disease in
1987 when Ford first began to make grants for AIDS activities, the Foundation
was one of the most proactive organisations in addressing what it consideredneglected social aspects of the disease. A 10 September 1998 draft transition
memo report by Marjorie Muecke provides an insider perspective on the early
history of Ford’s work.11 From 1987 to 1988, the total amount of funding granted
was: $25,869,440 to U.S. activities; $18,696,171 to developing countries; and$2,280,500 worldwide. In terms of the domestic work, Muecke details how her
predecessor Cristina Cuevas at the Rights and Social Justice Program focused theFoundation’s AIDS portfolio on “developing opportunities for the formulation ofnational policy.”12 After September 1993, when Muecke came to her position as
the New York office’s Programme Officer for HIV/AIDS, she “shifted theFoundation’s approach from the content of AIDS policy to the participants (not)involved in the process of AIDS policy formation.”13 This was to reflect the factthat the disease had moved from the risk group of white middle class gay men tothegeneralpopulation,

which

would

disproportionately

affecttheunderprivileged. She states that she “proceeded to support activities that wouldchange the infrastructures of exclusion that were accelerating the spread of thevirus to women and youth, the poor, people of color, and other groups notbenefiting from HIV prevention programs.” 14 In terms of actual activities, thefocus was on (a) community-based prevention efforts as well as (b) mass media
education messages. Muecke focused the Foundation’s efforts on representing
and including diverse and less-privileged voices, particularly those of women, in
prevention and education policies. She also focused on reaching out to Black
Church leaders and leaders in the African American Muslim community to help
design appropriate health education messages and channels for treatment andcounselling. Finally, she led the national strategy to identify and combat sourcesof stigma and discrimination, particularly concerning faith-based groups’

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perceptions of homosexuality. These elements comprised what Muecke named
the “AIDS Politics of Inclusion” initiative.
In regards to developing countries, Muecke certainly defends Ford’s attention toprevention as a stance against the “current focus of HIV/AIDS at theinternational level [which] is narrowly directed at medical treatments,
pharmaceuticals and vaccine development, as evidenced by the recent
International AIDS Conference in Geneva as well as by funding streams.” 15 She
also saw the need for Ford’s presence to balance the dominance of the UnitedStates and developed countries in setting the AIDS policy, research and program
agendas. Developing countries needed to be “empowered” because domestic
policy makers would take medical advances in treatment and reduced mortality
rates as signs that the epidemic was abating and reduce international funding.
She also initiated a new approach to Ford’s worldwide AIDS work, though thestrategy here was necessarily less defined in order to be tailored to each location.
Like the “Politics of Inclusion” work in the U.S., the Foundation sought toencourage approaches that would “integrate HIV/AIDS with other dimensions ofdevelopment.” Unlike other organisations who resorted to funding highly vertical
AIDS work, Muecke saw Ford’s experience with reproductive health as an asset inunderstanding and addressing HIV/AIDS in a more comprehensive way:
Because of its leadership in the field of reproductive health, it has a critical role toplay in strengthening the linkages between HIV/AIDS, reproductive health,reproductive rights, and development.16

2002 Sexuality and Reproductive Health in India –50th Anniversary Monograph

In 2002, Ford commissioned Radhika Ramasubban and Bhanwar Singh
Rishyasringa to write a monograph titled “Sexuality and Reproductive Health

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9and Rights: Fifty Years of the Ford Foundation in India” on the occasion of Ford’s
50th Anniversary. This document provides an excellent general overview of thework in the country. India was one of first overseas sites that Ford turned its
attention to and in turn, the Foundation was one of the most active foreign
agencies in initiating responses to AIDS in the country during the early period of1986 to 1992, which was the year AIDS activities were centralized through a
National AIDS Control Organisation (NACO) and up-scaled with a substantial
World Bank grant. During this time, Ford felt that the social aspects of AIDS had
been under addressed. The disease as approached by the Indian Council ofMedical Research (ICMR), which had taken charge, was viewed as “a medical
problem of Western origin”: that India was “a monogamous society with highmoral values and incapable of succumbing to a sexually transmitted disease(STD) like AIDS in a big way.” 17 Activities emanating from the Central
Government thus focused on controlling sex workers and foreigners.
“With few leads to proceed on, but recognizing the advantage of making an earlystart in this complex and unfamiliar area of sexual behaviour,” Ford identified
public education about AIDS and the humane treatment of female sex workers as
two areas needing immediate attention.18 The Foundation’s existing Community
Epidemiology network served as the basis for NGO involvement. Saroj Pachauri,a Child Survival Program Officer, began looking for organisations Ford could
persuade to address AIDS. In this early period before 1992, Ford made grants
primarily to medical researchers at the institutions that had discovered the firstnational case and activist journalists pushing for legal protection of sex workers’
civil rights. In particular, the state of Tamil Nadu (where infection was first
discovered) was a focus location as Ford built up a small network there consistingof Christian Medical College (CMC), the local Voluntary Health Association ofIndia (VHAI) branch and the South India AIDS Action Programme (SIAAP).
Furthermore, Ford organised a consultation in Bombay bringing together the
ICMR, CMC, the Tata Institute of Social Sciences, the All-India Institute ofMedicalSciences(AIIMS),

the Nationalorganisations and NGO health activists.

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InstituteofVirology, media

1992 was a seminal year because it was when the first phase of the National AIDS
Control Programme began with a grant of $84 million from the International
Development Association (IDA) of the World Bank and resulted in “opening theflood gates to external donor funding, most notably the World Bank, and helped
legitimize the field somewhat.”19 Ford’s grantmaking took on a brisker pace as
they focused primarily on Tamil Nadu and Maharashtra, the states with thehighest prevalence levels. Despite its achievements, in 1994, Ford commissioned
an evaluation of its AIDS grantmaking in India by Ashoke Chatterjee and Dr
Kusum Sahgal. Their findings were published in a report titled “HIV/AIDS
Awareness & Control: Nineteen NGO Experiences in Delhi, Maharashtra, Tamil
Nadu.”20 This report found that there were several unsustainable trends. Fordfunded Indian AIDS NGOs put out fear-based health messages, worked inisolation and lacked mechanisms for evaluation and reflection. Around this time,
the AIDS NGO scene in the country rapidly boomed in response to foreign
donors’ interests and parallel to that came accusations of corruption and lack ofregulation.21
In light of this, the Anniversary Monograph states that Ford took a step backfrom its trailblazing strategy and initiated a more “pared down” and efficientapproach to grantmaking in 1996. In this new strategy, Ford supported a coregroup of about fifteen capable NGOs mainly in Tamil Nadu and Maharashtra but
also in the cities of Bangalore and New Delhi, which formed part of what it called“NETWORKS.” Members of NETWORKS included: CMC, the Naz Foundation
India Trust (NAZ), Nalamdana, Y.R. Gaitonde Centre for AIDS Research and
Education (YRG Care) and International Nursing Services Association India(INSA). While these organisations did receive funding from other sources, in all
their varied activities, each member focused on preventing transmission; care,counselling and support; and establishing guiding principles based on the dignityof HIV patients. The Delhi-based Naz Foundation Trust (which conducted many
coordinating and training activities for other more grassroots organisations) is aninteresting example of Ford’s tendency to designate “intermediary organizations”
in its grantmaking as a way to bring grassroots NGOs out of their isolation and in

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collaboration with each other. According to the report, many of Ford’s
NETWORKS alumni became well established and respected in the AIDS civilsociety community, with some members going on to work in national andinternational health policy. I will examine this in more detail in the third section.
Perhaps influenced by their NETWORKS members’ focus on sexuality as a keysocial issue in AIDS, Ford began to address issues of sexuality in their healthwork, changing its Reproductive Health and Population Program to a Sexuality
and Reproductive Health Program in 1994. In 1996, Geeta Misra joined the Delhi
Sexuality Program with a strong background in NGO activism and Susan
Berresford became President of the Sexuality and Reproductive Health field. As aresult of this, grantmaking began to emanate from a stance of seeing HIV/AIDS
within the framework of sexuality and sexual rights, the dignity andempowerment of women in sex work and protection against sexual violence.
Accordingly, Ford funded sex worker’s rights projects with the Sonagachi in
Calcutta and the SANGRAM in Maharashtra, as well as research on legal
protections for sex workers and their rights with a grant to the Centre for
Feminist Legal Research in Delhi.

2006 Jacob A. Gayle’s Reflections on Ford’s Global
Response to HIV/AIDS

Finally, Jacob A. Gayle, the Deputy Vice President for HIV/AIDS, reflects on
Ford’s twenty years of international AIDS work and the changing global
epidemiological scenario in 2006 to make a case for the organisation’s renewed
commitment to the global response.22 Despite 25 years of prevention and control
as well as a decade of advances in highly active antiretroviral therapy (HAART),
Gayle cites the UNAIDS statistic that there were over 40 million people livingwith HIV/AIDS around the world. The epidemic’s international epidemiological

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profile grew more and more complex as infection spread from core risk groups tothe generalized population. Furthermore, he deemed that there was a lack ofpolitical commitment and “[i]nsufficient human capacity for leadership andaction further hamper[ing] progress, despite an exponential increase in financial
resources for action.”23 Gayle clearly still sees Ford as a leader in initiating socialchange activities. By supporting key activities, issues and individuals early in theepidemic, he argues that Ford created a landscape in which healthy andconstructive dialogue about taboo issues could be discussed. Ford’s impact could
be felt most in countries like Brazil and India, who “owe much to the Foundation
for their early successes in activating community/civil society participation innational HIV efforts.”24
In light of such successes, Gayle discusses the reasoning behind why efforts
needed to be up-scaled, not just intensified: “[i]n order to have ultimate success,local initiatives need to be brought to full scale, and they need to be financiallysecure over longer time frames. Furthermore, gaps still remain at local levels andthey need to be addressed before the HIV response can be considered
comprehensive.” 25 He presents several potential initiatives Ford could pursue
during the period of 2006 to 2010, including:-

Senior decision-making and agenda-setting positions for representatives ofaid recipient countries in institutions such as the Global Fund to Fight AIDS,
Tuberculosis and Malaria, the World Bank and the US President’s Emergency
Plan for AIDS Relief (PEPFAR) to bring them “up-to-date local knowledge,
drawing on our local grantees’ experiences.”-

Harnessing the application-potential of the knowledge Ford had gatheredwith diverse local experiences by bringing them together in multi-country
mechanisms, allowing them to be implemented through agencies like
UNAIDS, WHO and the Global HIV Prevention Task Force. Gayle states:“Ford’s global voice could be crucial in ensuring that local innovations are
spread and implemented with human rights and equity in mind.”26

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There are many more initiatives proposed, all aimed at taking a more “global,”coordinated and comprehensive approach. Thus, one of the most interesting
themes that emerges from Gayle’s report is that by 2006, Ford was aware that thelandscape of global AIDS had changed. It was much less fluid than in the earlyyears and so the Foundation had to define a narrower and more focused role
against organisations operating with different areas of expertise, amounts offunding and hierarchies of governance. Not only that, but as their respective
epidemiological profiles evolved, developing countries had changing needs as
well.
However, the Foundation was well informed as to the activities and impacts of all
the global AIDS actors, as well as how some were perceived in various countries.
As narrated by Gayle, the Foundation took the stance that all organisations werebringing their talents together towards a common goal: not just preventing andmitigating the impact of the disease itself, but improving social development
overall in developing world contexts. Within this, Ford clearly had a distinct
understanding of the particular experience and expertise it brought to the tableand obviously took pride in its active if relatively smaller role. This allowed Ford
to be quite specific about where it could benefit the work of other organisationsand vice versa. For example, given their social development orientation, Ford
proposed that their grassroots work would progress more smoothly under anumbrella of authority in which the UN system would set the standards andregulations, while prominent international NGOs like Human Rights Watch with
offices around the world would monitor violations of rights. And for its own
institutional direction, Ford clearly saw the benefits of being “one of the few
foundations with an HIV portfolio that includes both US domestic andinternational grant making”: this would allow streamlining of domestic andinternational efforts into “one global program.” 27 As I detail later, this makes
Ford a unique case study for my project because it demonstrates how global AIDS
was transnational, national and local.

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II.

Gathering Information and Corresponding
with Other Organisations: How to
Understand and Mount a Strategic
Response to AIDS in Developing Countries
and India

The 1987 strategy document, the 50th Anniversary Monograph, as well as Muecke
and Gayle’s reflective reports, provide an illuminating and comprehensive, if
rather polished overview of Ford’s national and global work from 1987 to 2006.
Thus, it is important to also look into the “rougher” archival details of theinformation Ford was collecting and its correspondences with variousorganisations throughout this period. For American grant-makers like Ford who
were interested in expanding their activities internationally, understanding how
the epidemiology of the disease’s transmission differed in contexts outside theU.S. was key to their preparations in the late 1980s. Regardless of Ford’s
extensive work in India since 1952, these records show how uncertain
grantmakers were about what exactly AIDS was and what impact it would have.
They paint a more in-depth step-by-step picture of how a philanthropic
organisation like Ford confronted the advent of AIDS and framed its response.
They tell us what kinds of information and individuals Ford considered accurate
and reliable concerning the scenario of AIDS in developing countries, as well as
what issues and collaborations they dropped. While some of these were meant
more to advise the domestic programme, if aspects of them became part of theinternational and Indian programme, I have included them because I am also
considering the question of whether Ford’s understanding of the U.S. epidemic
influenced what they viewed as problems in India: i.e.: what did treatment costmean in the U.S. vs. India?

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Beyond Biomedical: Involving the Social Sciences with
the SSRC
From the early years, the Foundation did indeed seem to be particularlycommitted to issues outside the biomedical and scientific, gathering knowledge
regarding social issues of anti-discrimination and human rights aspects. In 1987,
Ford received a letter from the Social Science Research Council (SSRC), a New
York-based non-profit organisation, about “initiat[ing] a conversation” for Ford
support of a project on the “social consequences of the AIDS pandemic.”28 The
SSRC often turned to private foundations rather than the American government,“whose support seemed more appropriate for the natural sciences,” and I thinkthat tendency is well demonstrated here. 29 In the face of uncertainty about avaccine cure for the disease, the basis for the project was to understand and toproject the “social, cultural, economic, and political consequences” of the AIDS
epidemic. The SSRC makes a strong case for the need for perspectives from social
scientific disciplines: “we are fixed on no idea other than on the necessity for asafeguard against a piecemeal approach in which information rarely crosses
disciplinary lines or transcends a focus on a specified problem or issue.” 30 Afterappointing a steering committee from professionals in the natural, medical andsocial sciences, the SSRC intended to begin three rather ambitious research
projects. The first one would forecast the social consequences of the AIDS
epidemic, “drawing on demographic and economic projections, epidemiologicalforecasts, historical analysis, and social theories.” The second one would develop
social science policy capabilities to advise national governments and other “social
institutions” to cope with the epidemic. The third one would “study theconsequences of the epidemic outside the advanced industrial societies of theWest in Brazil and Africa in particular.” To do this, they proposed “foster[ing]indigenous research in the affected societies in partnership with social scientists
working on related problems in the U.S. and Western Europe.”31 The letter statesthat they had already done much work on a national scale but were looking toform a global network of research institutions. It is not clear if Ford did make a

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grant to them for this project. However, from Ford’s strategy for AIDS prevention
in developing countries, it would seem that the philosophy of the SSRC and thework they proposed deeply resonated with them. Almost a year later, the Council
had a more clearly defined strategy and had already begun their work. They got
back in touch with Shepard Forman, Director of the Human Rights andGovernance Program, on 12 August 1988 to invite him to a meeting they would
hold on 17 October in New York.32

Cost and the Problem of AIDS in the Developing World

It is clear from the copies of articles present in the Office Files of Shepard
Forman of the Human Rights and Governance Program that the cost of AIDS interms of their domestic and potential international programme was indeed aconcern. A handwritten note saying “[i]n case you are interested” is sent from
Denise Silver to Forman on 11 December 1987 with a copy of Jane E. Sisk’s “The
Cost of AIDS: A Review of the Estimates” published in Health Affairs in summer
1987.33 There are also copies of John K. Iglehart’s “Financing the Struggle Against
AIDS,” a Journal of the American Medical Association piece titled “TheEconomic Impact of the First 10,000 Cases of Acquired Immunodeficiency
Syndrome in the United States,” a 1987 Overseas Development Council piececalled “AIDS and Poverty in the Developing World” and a piece by Daniel Fox
called “The Cost of AIDS from Conjecture to Research.” These articles mostly
focus on the U.S., examining the hospital and treatment costs HIV patients would
have once their disease progressed and the consequent financial burden on thehealth care and insurance systems.
There is no comment by Ford about these articles in the archival records that I
have found, so we do not really know how they factored into the strategy.
However, their presence in the archives raises a few questions concerning how

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exactly Ford understood the problem of AIDS in a developing world context andhow it conceptualized the need for particular types of action. Since the Alma Ata
Declaration of 1978, a key discussion among multilateral health and development
agencies as well as national governments concerned how developing countries
should organise their health infrastructures given a context of limited resources.
Alma Ata vs. Selective Primary Care was essentially a debate about how health,particularly infectious diseases, should fit within an economic development
framework. This debate is thus also at the crux of critiques public healthprofessionals in India have about their national AIDS programme: if cost given
the resource-poor context was such an issue, why was the programme itself so
expensive to run and so vertically oriented? The presence of these articles raises
critical questions. Given the earlier epidemic in the U.S. and the fact that Ford
was an American philanthropy active in domestic AIDS grantmaking quite earlyon, did information about macroeconomic cost of AIDS in relation to GDP seep
into their understanding of what AIDS would cost developing countries? Or (andI hope to investigate this history in the future), was Ford’s understanding of why
AIDS was devastating in India drawn from their past grantmaking relationships
with Indian economists and social scientists who were commissioned to come up
with more India-specific measurements of poverty in the early 1970s? In regards
to themes and theories in history of international health, this raises the questionof scale in historicizing the global AIDS response: how does a grassroots strategy
fit into an understanding of top-down public health within a macroeconomic
framework? As we will continue to see, Ford rarely engaged with national
economic issues as part of the reasoning for their international health work.

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Lincoln C. Chen and the Harvard School of Public
HealthAs early as 1987, Ford was also gathering data from health experts in university
research institutions. In a 3 March 1987 letter titled “Implications of AIDS for
Ford Foundation Programming” to Ford Officer Oscar Harkavy from Lincoln C.
Chen, Takemi Professor of International Health at Harvard University’s School of
Public Health, Chen describes two studies by Harvard scholars on theimplications of the epidemic in developing world contexts: one by Joe Potter andMike Stoto of the Department of Population Sciences on the demographic impact
of AIDS in Central African countries and another by David Hunter of the
Department of Epidemiology “examin[ing] AIDS from many perspectives,
including policy issues.” 34 Chen’s assessment was that despite “scientificuncertainty,” the AIDS epidemic in Africa and the United States would continue
to expand. If Ford was to pursue a program on AIDS nationally andinternationally, a sound public health strategy was essential. He encouraged Fordto draw from “historical and comparative experience…[g]enerating scientificallysound information and encouraging sober dialogue on these issues” in designing
its approach.
The way Chen positions how the AIDS crisis would be a devastating problem indeveloping countries is interesting. In addition to what is usually cited by policy
literature at this time about the uncertainty of vaccination and drug treatment, heargues that AIDS was likely to become a major cause of death in Africa,“particularly among young adults.” This is similar to the macroeconomic
argument made about AIDS and population control by the World Bank in the1993 World Development Report, linking how devastating a disease would be to
the GDP of a resource-poor nation due to how many it would debilitate in theeconomically productive age group of 15 to 40. 35 For Ford’s influence indeveloping countries, Chen had the following advice: “[T[he major issue for an
Americanphilanthropyisinternational

healthinterdependence.” 36 By

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interdependence, Chen likely referred to the idea that health resources, just likediseases, could traverse national boundaries in an era of increasing transnational
movement and connections.37
Chen further elaborates on the impact AIDS would have domestically: that “fearinduced” responses that violated ethical and legal codes do not work. He went on
to identify the Foundation’s child survival and reproductive health programme as
the best jumping off point for dealing with AIDS from a “health interdependence”
framework:
For any developing country, the issue naturally will be commensurate attention
to other health problems (diarrhea, vaccine preventive infections, malnutrition,other sexually-transmitted diseases). Development of a health infrastructure will
ensure that control and treatment for AIDS (when technologies are developed asthey surely will be) can be made available at affordable costs to people.
Investments today, therefore, in oral rehydration and vaccination programs thatbuilds sustained capacity in LDC [least developed countries] are essential both on
their own right but also to gain LDC cooperation today and to assist with their
AIDS program in the longer-run. No other funding actors are pursuing these linesof potential program development.38
Most significantly, Chen’s advice strikes a contrast to Ford’s later involvement insocial and human rights issues at a very grassroots level. His recommendations
are far more “top-down” and well versed in debates about macroeconomic costsof disease interventions and their impact on the general health infrastructure,
ongoing between WHO, World Bank and other international actors since Alma
Ata in 1978. Indeed, the two articles he includes with his letter lean towards morestatistically and technically rigorous prevention work than the activities Fordlater pursued with the Indian NGOs. In particular, one question that arises here
is whether Ford’s understanding of how devastating the epidemic would be inIndia (which could “still be saved” since Asia had a “later” epidemic) came fromDavid Hunter’s piece, which makes epidemiological projections about spread and20

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impact of AIDS in various African countries. In any case, it is not clear whether
Chen felt his advice was specifically tailored to the position of a private American
philanthropy like Ford among multilateral and bilateral international health anddevelopment agencies. Since the concept of a “multi-sectoral” response was new
to global health interventions at the time that AIDS became a crisis, it isreasonable to assume no one was quite sure exactly how each actor with influence
and resources at different levels could contribute to the global AIDS response.

AIDS in India

In 1987, less than a year after the first cases of HIV/AIDS were discovered in
Tamil Nadu and Maharashtra states, Ford was gathering information on India’s
epidemiological profile in preparation for their grant strategy in the country. A 21
July 1987 inter-office memorandum from Marge Koblinsky to Bill Carmichael,
John Gerhart, Shepard Forman and Oscar Harkavy attaches a copy of a 17
January 1987 Lancet article by Jacob John of Christian Medical College Vellore
titled “Prevalence of HIV Infection in Risk Groups in Tamil Nadu, India.” 39 The
reason for asking for John and his colleagues at Christian Medical College was
because Ford was already funding a Community Epidemiology grant there. From
this, Ford understood that AIDS was primarily spread through prostitutes, “agroup that obviously sets the stage for possible dissemination throughheterosexual spread.”

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Gathering Experts: The Ford AIDS Consultative GroupA handwritten note from Shepard Forman to Steve Marks on 28 January,
probably in 1987 or earlier, reveals that Ford was looking for expertise on the“international legal and human rights dimensions of the AIDS Problem,”preferably without “a lot of calling around…w/ one or 2 discreet inquiries.”40 In
March 1987, they were still searching for potential consultants, considering
people such as Brooke Schoepf, a medical anthropologist and independent
consultant who worked on the spread of AIDS in Zaire.41
By June 1987, a letter from John D. Gerhart to Richard Horovitz and William
Saint indicates that the Ford AIDS Consultative Group had been formed leading
up to the December Board meeting (for which “The AIDS Challenge: A Ford
Foundation Response” had been prepared) with Robert (Bob) Stein ofEnvironmental Mediation International as lead coordinator. 42 Stein and June
Osborn of the University of Michigan School of Public Health would addressinternational issues.43 Stein would also cover legal and rights aspects, as Osborn
would also be in charge of overall health policy. John Marshall formerly with the
National Center for Health Services Research would cover the aspects of cost anddelivery and care. Jane Delgado of the National Coalition of Hispanic Health andHuman Services Organization would cover education and health communication.
Mychelle Farmer of the Adolescent Sexually Transmitted Diseases Clinic at
University of Maryland Hospital would cover AIDS and teens. Richard Merritt of
the Intergovernmental Health Policy Project and Richard Dunne of Gay Men’s
Health Crisis would address agenda building. Michael Seltzer, an independent
consultant of the Foundation Center who authored “Meeting the Challenge:
Foundation Responses to Acquired Immune Deficiency Syndrome,” would also
support by leading his own consultancy on the non-profit sector, mapping
funding strategies for the expanding health crisis.44 In a 5 June 1987 letter toForman, Seltzer says “The addition of Ford to the small, but rapidly growing, list

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of foundations acting against AIDS is very heartening…Given the Foundation’s
international scope, its longstanding concern for minorities and their civil rights,
and its resources, the Foundation is in a position to make a unique contribution.”
Other individuals served as resource consultants, such as King Holmes of the
Harborview Medical Center in Seattle who researched AIDS in Kenya.45
The agenda at this stage was still quite open as the Consultative Group had theirfirst meeting on 2 June 1987 in Washington D.C.46 Stein in his coordinating roleencourages the consultants in an update letter to “get in touch with one anotherand share potential contacts, existing material, and use one another’s expertise to
the common good.”47 He asks that they “scope out the issues to be addressed,then identify what other work is now ongoing or is proposed and who is doing it,
and… devise a program based on the above which will give the Foundation an
opportunity to provide useful support to institutions in the areas described.”48
However, what was certain was the overall guiding principle: that “AIDS is adisease which is working significant and long term changes to society.”
Gerhart’s Comments on Developing Country Strategy
By September 1987, the consultants’ recommendations for Ford’s AIDS agenda
were mostly in place and a few individual grants had already been made.
Domestic priorities included: quality of life and care issues, legal issues andshaping public agendas.49 The goals for the national-level work appear to be wellarticulated and extremely detailed here as they were in “The AIDS Challenge”
Information Report presented to the Board that December. However, the sections
on the international and developing country strategies were apparently evensparser than they were in the final Report to the Board. John D. Gerhart’s indepth comments in a 14 September 1987 letter to Forman on the paucity of therecommendations for Ford’s international work shows us a crucial moment inwhich we see the Foundation conceptualising why it needed to be active indeveloping countries. First, Gerhart starts by saying that “[the consultants’report] would benefit from a little more description of the extent and implications

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of the epidemic, such as are contained in the Panos paper.”50 The Panos Institute,a London-based journalism/think tank/non-governmental organisation, had
authored an influential report titled “AIDS in the Third World” in 1986 on theimplications of AIDS in developing countries. Chapter 5 titled “Africa: AIDS andthe Shrinking Development Dollar” in particular talks about how AIDS will
impact the national economies of African countries, which is probably what he
was referring to.51 Gerhart goes on to say:
It would be helpful to give some description about why AIDS is going to be much
more devastating in the developing countries (poorer general health, poorer
health care, many more opportunistic diseases, untested blood supplies,
penchant for reuse of needles in inoculations, etc.). It does make the important
point that health expenditures are lower per capita than even the costs of a blood
test, but it could make this stronger: emphasis must be put on prevention
because it is simply impossible to cover the costs of care.52
Simply saying that developing countries allocated less of their GDP on publichealth and that they were poorer was not enough. He asked that they be more
specific and detailed about the biomedical and epidemiological particulars of
AIDS, noting that King Holmes, their Kenya expert, had commented verbally inconversation with them on the issue of the threat of communicable diseases suchas tuberculosis after the immune system was disabled, compounding the healthcrisis. Gerhart states that the Foundation needed to better understand how AIDS
wasaproblemindeveloping

countries

bothepidemiologicallyandmacroeconomically to formulate a more appropriate strategy that demonstrated
their “comparative advantage.” He offers some preliminary thoughts:
I see little benefit in our taking on issues of international testing requirements,
visas, etc. since, as the report points out, this has little effect on transmission, andalso has the high visibility, is contentious, involves diplomatic feelings, etc. I
would think we would have little to offer on that score. Likewise, I think it isexpensive and pretentious for us to take a leading role in coordinating either

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donors or government agencies since we are a minor actor and not wellestablished in the health field. We have no capacity whatsoever to develop aninternational health services corps, or an international data base, nor are we anappropriate agency to do these functions.53
Gerhart goes on to discuss whether Ford’s U.S. work carried any policy relevancefor their developing country programme, which he concludes by saying that thecontexts were simply too different: developing countries did not have theconcepts of job security, health insurance, testing policies, all of which were key
strategic areas of Ford’s more detailed American AIDS activities. Therefore,
Gerhart recommends that they pursue behavioural research, information andeducation, prevention and targeting of high-risk populations. In his opinion,
Ford’s comparative strengths in this field were that first, as a non-governmentalorganisation, they were “less vulnerable to political sensibilities,” and second,
they could make use of the strong linkages with social science researchcommunities. He concludes by reiterating: “I do not believe we should get heavily
involved in the care and cost of care issues, since this is unlikely to have any real
impact on the ultimate spread or effects of the disease in the poorest countries.” 54Thus, through Gerhart’s comments, we can see the process behind how Ford
determined its capacity for impact accordingly for developing countries.
Furthermore, this letter shows that at least one Ford official felt that theirdeveloping country AIDS programme had to be completely divorced from their
U.S. activities.

Discussions with the WHO from 1987 to 1988
Potential Collaboration
On 7 August 1987, there is an inter-office memo from Shepard Forman to various
program directors about his meetings with WHO officials: Jonathan Mann, SPA
Director, and Axel Mundigo, social science researcher with the Human

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Reproduction Program (HRP).55 The purpose of the meeting was to exchange
information about their respective organisations’ activities and for Ford to getcomments from Mann and Mundigo concerning their upcoming strategy.
Mundigo, previously with Ford as a sociologist and demographer, was speaking
with Forman about the inclusion of AIDS-related research on sexual behaviour in
the WHO’s HRP. In terms of Ford’s capabilities, Mundigo had said that theiradvantages were their involvement in rights and policy issues. He gave Forman a
few examples of quarantine and the isolation of HIV infected people, advisingthat “the Foundation should carve out a special and highly visible effort thatstresses rights and ethics.” 56 Mann was also supportive of Ford focusing on
human rights and protections as well as the wellbeing of people living with AIDS.
This is not surprising given that Mann was developing a philosophy of thecompatibility of human rights and global public health through his leadership of
the GPA until 1990 and later in establishing the Francois-Xavier Bagnoud Centerfor Health and Human Rights at Harvard Public Health in 1993.57
However, according to Shepard, Mann also saw a “larger and morecomprehensive role for the Foundation.” He describes Mann thus: “He is a highly
articulate and knowledgeable advocate on the subject and welcomes theFoundation’s involvement.” Here we see how Ford might have situated itself as
support for the core national program directed by the WHO:
Mann urged us to concentrate our efforts in areas not being covered by others or
to seek ways to complement activities already underway. For example, he began
by noting that WHO is already coordinating the exchange of educational
materials between countries and the provision of technical information tonational AIDS commissions. The Foundation could, however, play a role infunding evaluators of educational efforts and surveys on societal attitudes andresponses to AIDS that would be extremely useful in developing national
programs.58

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More specifically, Mann suggested that Ford could support four main areas:
education, technical assistance, rights issues and health care delivery. In
education, Mann was concerned that media materials were being prepared butthat messages were not reaching people, particularly homosexual males in poor
urban settings in developing countries. He suggested that Ford could help fundgay men’s organisations in the industrialized world to reach these communities.
In terms of health care delivery, he advised that Ford identify organisations that
could assist in delivering humane care. He was also keen on the idea of
unemployed people living with AIDS receiving training as professional
caregivers.
The most interesting section concerned Ford’s capabilities in human rights.
Mann felt Ford could be most impactful by focusing on rights because “1) no one
else is doing it and 2) relative success or failure of our efforts to combat AIDS will
depend on prevailing social attitudes and how we deal with the afflicted.”59 Mann
was keen to avoid “authoritarian approaches” to the AIDS crisis, which would
isolate the HIV-infected and people with AIDS (PWA). Thus, he urged Ford tofund a series of studies on attitudes to AIDS of various sections of society in about
twenty countries, including information on legal codes, national policies and how
HIV infected and PWA were treated. “Are they rejected by their families? Firedfrom their jobs? Kept from school?” This would “provide the context fordeveloping a productive atmosphere for working with the disease.” 60
Furthermore, the WHO was also concerned with HIV screening and restrictions
on international travel and potential human rights abuses, suggesting that Ford
keep tabs on legal developments concerning this area.
In another interesting section, Mann said the Ford Foundation could potentiallycontribute towards technical information but in terms of small donations, notthrough any activity. Mann told Shepard that the WHO was collaborating with
the World Bank to generate information about health care costs and did not
believe there was need for Ford involvement, although “some funds from Ford orother private donors might hasten the results.”61 The main thing for developing

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countries was to make a context-appropriate model for understanding health coston a per capita care basis. This would be supplemented by continuous
improvements in surveillance and reporting systems, improving the quality of
epidemiological data. Mann told Shepard that “[s]imply predicting aggregate
costs generates the wrong kind of response and is not useful in any case.” 62 He
relates that the WHO had begun a project led by James Chin, a social scientist, toundertake a “Surveillance, Forecasting and Impact Assessment.” This was meant
to develop a set of scenarios that could be used for African and Asian countries,
as researchers in Copenhagen had already been working on a model for Europe.63
Rather than forecasting on a sector-by-sector basis (how HIV impacted theeducation sector, industry, etc.), there was need for consensus on national rates
of mortality, morbidity and transmission. Shepard then told Mann about thework the SSRC was proposing to do and said he “reacted with interest.” Mannrequested a meeting with those working on this project to coordinate andimprove efforts because he felt the WHO was “the proper organization to do this(governments aren’t suspicious of them and want the data they can provide).”64
There is a theme emerging here on the differences between what is appropriate
for a multilateral and what is appropriate for a private foundation to do.
Decision to remain autonomous
On 13 October 1987, there is an interoffice memorandum from Forman to“Distribution” on the WHO’s coordination of global and national AIDS activities.
He describes his meeting with Terry Mooney, an official seconded to the WHOfrom the Canadian Ministry of Foreign Affairs who was discussing with potential
donors leading up to the WHO’s fourth Meeting of Participating Parties to takeplace on 12 to 13 November 1987.65 Shepard expresses his discomfort with the
WHO taking the role of lead international coordinator of all governmental,
intergovernmental and civil society work. We can also see the origins of why Ford
turned to make links with civil society. He describes the WHO’s intention toformally establish its leadership and coordinating role by creating a global
commission on AIDS and a Commission of Participating Parties. Furthermore,

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the WHO would establish National AIDS Control Programmes with the healthdepartments of national governments, who would set the agenda for research andaction on their respective national AIDS crises, “with the expectation that all
external funding would be directed through them.” We also find a copy of a draft
proposal for the WHO SPA Joint Management Structure, as well as the plan for
Comprehensive Coordination of Global and National AIDS Activities in this grantfile, which states that: “All governmental, intergovernmental and nongovernmental efforts, whether scientific, technical or financial, must be
consistent with and supportive of WHO’s Global Strategy on AIDS as approved by
the World Health Assembly.”66 While Mooney was keen for Ford to sit on theCommittee of Participating Parties, Shepard apparently told him outright: “apolicy that limited grantmaking to agencies and activities approved by an official
body such as a National AIDS Control Programme would run counter to theFoundation’s general policy of independence in grantmaking.” 67 Besides its
philosophy on autonomy, it would be interesting to find out precisely what it wasthat Ford disliked so much about working on core programmes with national
governments.
What we do know, on the other hand, is exactly how one Ford official felt aboutcollaboration with the WHO. On 23 October 1987, there is an interofficememorandum from Oscar Harkavy to Forman about his 13 October letter. 68
Harkavy expresses his strong feelings against the WHO’s complete ownership of
the global AIDS response: “I became increasingly irritated as I read the WHO
document. It claims complete control for WHO over all international AIDS
activities, as is WHO’s posture on all health matters.” 69 He gives some pastexamples, in which diarrheal disease research centres of developing countries
such as Bangladesh “fought valiantly” to avoid being overwhelmed by the WHO“despite the latter’s determined effort to take it over.” He notes that WHO
leadership in the Human Reproduction Program also resulted in bad relations
between European and American donors. The only program in disease control
that managed to avoid “complete domination” was the Tropical Disease Research(TDR) Programme in which the WHO shared formal sponsorship with the WorldRAC RESEARCH REPORTS

29

Bank and the UNDP. “In sum,” he ends, “the WHO document is a heavy-handed
bid for absolute control of all AIDS work. Based on experience with other WHO
efforts, we should collaborate on the ground, but maintain our own independenceof operation.”70
Contact again for a database
As Ford’s approach on rights and social issues solidified about a year later, they
were again in contact with the WHO about a comprehensive database on rights
work by international organisations in the developing world. On 12 August 1988,
there is an interoffice memorandum between Steve Linick and Bill Carmichael,
Shepard Forman and John Gerhart about Ford making a possible grant to theWHO’s Global Programme on AIDS (GPA).71 As always keen to “avoid duplicative
grantmaking,” Ford was looking for information about other international donors
working on AIDS in developing countries. Linick had contacted Roy Widdus andManuel Carballo, programme coordinators of the WHO’s GPA, requesting
information about the human rights aspects of the disease, who replied that there
could be information in their headquarters but that it would be in a “rather
unsystematic fashion.” Linick answered mentioning the possibility of Fordmaking a small grant to help generate the data, to which Widdus repliedsuggesting a joint WHO/Ford effort in “obtaining the necessary information.”
What came out of this potential collaboration is not clear from the records. Thus,
these early correspondences with the WHO show how Ford considered working
as support for the core program but found the WHO’s desire for proprietary
management too stifling. However, it is reasonable to assume that Ford took
some inspiration from the WHO officials in their international strategy for AIDS,in particular Mann and his affinity for human rights.

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Summary

While the history of global AIDS has often been told as one of institutional
responses, these records show that it was also one of individuals and their areasof expertise operating within institutional cultures. Furthermore, they show how
when corresponding with the WHO or discussing the central programmeemanating from the World Bank’s lending, Ford presented an institutional face ofa smaller American philanthropy that styled itself as an expert on grassrootshumanrightsandsocialdevelopment

issues.

While

some

of

these

correspondences give us a good understanding of where Ford fit amonginternational

healthorganisations,development

agenciesandnational

governments, others remind us of a smaller national-level circle of influence that
the Foundation operated in. In the early years of around 1986 to 1988, private
American philanthropies were starting to identify the areas of the domestic AIDS
crisis they would each address. Within this environment, Ford was unique forpushing both a domestic and an international strategy. Whether it managed thissuccessfully is not a question to investigate here, but tracing the activities of Ford
presents a fascinating case study of precisely how the history of global AIDS isinternational, national and local. Part of global AIDS is the history of one
American philanthropy with equally substantial domestic and international
programmes that had to present one face to its philanthropic colleagues andanother to international health bureaucracies. And as we explore Ford’s
relationship with Indian civil society in the next section, we will see how they
believed social issues relating to AIDS were best solved by the NGO-sector due totheir proximity, understanding and influence with local and sometimes
marginalized communities.

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III. Looking into the Grant Files

In this section, I examine in depth several case studies of the Ford Foundation’s
grants to Indian AIDS NGOs. Because of the sheer volume of the number ofgrants and materials within them, I will mainly focus on the early years andsignificant members of NETWORKS, for which I mainly draw from therecommendations/requests for grant action sections. I also used as backgroundmaterial AIDS and Civil Society: India’s Learning Curve by Radhika Ramsubban(who was a co-author of Ford’s 50th Anniversary Monograph I mentioned earlier)and Bhanwar Rishyasringa. They examine six of the most prominent Ford funded
NGOs in their 2005 publication.72

1990-1993 Earliest Grants: CMC and IHO

The first grants were made in 1990 to Christian Medical College Vellore (CMC)
and the Indian Health Organisation (IHO) in Bombay. As I mentioned earlier,Ford was already supporting the institution through an existing epidemiology
program and got their initial understanding of the AIDS epidemic from Jacob
John, as evidenced by the presence of his Lancet article in Forman’s files. These
grants were made from the Population Program of the Developing Country
Programs Division led by Officer Saroj Pachauri. Ford’s early strategy with these
two were to support “innovating experimental education, communication andtraining programs for AIDS.” 73 CMC was to build an AIDS Reference andResource Centre and IHO was to establish an Indian AIDS Foundation in
Bombay. In the précis for this initial series of grants, Ford sets a global context:

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The AIDS pandemic has created a new agenda of public health concerns
worldwide that requires a complex and unprecedented range of institutionalinnovations. It has brought with it an affirmation of the interdependence between
countries and the need for addressing problems through joint action bybiomedical and social scientists.74
It goes on to state that the brunt of the impact in the developing world was in theregions of Africa and Latin America and that “India and other Asian countries
have, therefore, a unique opportunity to face this challenge at an early stage whenthe magnitude of the problems is still manageable.”75 Furthermore, the advantage
was that Asian countries could learn from all other regions that faced an earlier
epidemic – the only obstacle was denial that AIDS was an issue. This confirms
what we learned from the 1987 strategy, that organisations seeking to work in
India, which is designated part of the Asia region and “late to the epidemic,” 76
could still be saved with heavy emphasis on prevention. Furthermore, there is thesuggestion that their epidemiological profile would be similar to Africa and Latin
America. The précis firmly establishes that AIDS was not just a health issue: “italso impacts on issues of human rights, governance and public policy, education,social services and the quality of life.”
It notes the sero-surveillance focused activities emanating from the Governmentof India (GOI) to reflect the issue of infected blood from donors in the major
cities of Madras (now Chennai) and Bombay. In October 1985, the Indian Councilof Medical Research (ICMR) established an AIDS Task Force and built up a
network of clinical and sero-surveillance to gather epidemiological data, which
had since expanded to include the collaboration of state health services. ICMR
with support from the WHO also established a Central AIDS Unit to coordinate
supplies, quality control and evaluation. The précis states that in addition tothese activities, there was a pressing need for the Indian AIDS prevention
program to include education and awareness campaigns. This was why the New
Delhi office was making its first grants to these organisations for these activities,building on Ford’s existing research and service programs on STDs and women’s

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reproductive health in rural and tribal women in Maharashtra and urban slum
women.
Ford chose IHO due to its advocacy, education and counselling work on behalf of
prostitutes, drug addicts and hijras (transvestites) in the red-light districts andcity slums of Bombay as well as rural and tribal areas in Maharashtra andneighbouring states. It also pioneered AIDS awareness and education throughmass media and seminars even before the first national case was discovered. Its
director Dr I.S. Gilada was a member of ICMR’s AIDS Task Force and worked at
J.J. Hospital, an institution in Bombay that provided AIDS and STD treatment
and control services. The IHO was to establish an Indian AIDS Foundation,
which would disseminate information on AIDS through a variety of print media
and television channels; put together education and training programs; andprovide community-level education, counselling and care programs throughmobile clinics in the red-light districts of Bombay.
CMC, home to a highly-respected Virology Department, was not just a node in thenation’s epidemiological surveillance system and one of the four ICMR
designated National AIDS Virus Reference Centres. It also a Ford grant recipient
for the establishment of an Epidemiology Resource Centre, as mentioned in thefirst section. I found Ford’s reasoning for why they wanted to work with thisinstitution interesting:
It combines technical competence with missionary zeal to serve the poor and thedisadvantaged and, through its outreach programs, makes great efforts to provide
health care to those who do not have access to hospital facilities. Its Community
Health and Development (CHAD), Rural Unit for Health and Social Affairs(RUHSA) and other outreach efforts, provide excellent examples of how research
can effectively be translated into relevant program strategies for addressing thehealth needs of the poor.77
Why the focus on poverty as part of health?78 While this is not the place to fully
investigate this question, I would like to mention that one critique of global

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health and disease control programs is that they do not work because they fail toaddress underlying questions of systematic poverty. While this may not be acounterexample per se, it is key to consider how Ford conceptualized their workin health while acknowledging the context of poverty.
It is also interesting that this new AIDS centre that the CMC would build was tofocus on psychological assessment and counselling of HIV positive people andpeople with AIDS. It had three main objectives: first was to construct a databaseon psycho-social aspects of AIDS and to distribute this information through a
newsletter; second was to develop programmes for training health workers andnon-health professionals like social workers and teachers to help those with HIV
and AIDS cope with psycho-social problems; and finally, it was to organize aforum to discuss policy by bringing together activists, researchers and otherprofessionals to “develop specific recommendations and guidelines fordissemination to Indian audiences.”79 Thus, Ford’s first foray into AIDS work in
India took the form of grants to two organisations that were already active innational AIDS work. They were both also key nodal centres in national
epidemiological information-gathering with experience in treatment andcounselling. The content of the work was surprisingly courageous and forward
thinking, as activities such as psychological counselling presumes people are
already infected with HIV and require not just treatment but also psychologicalcare. This initial group of grants to these two organisations can be viewed as Ford
“dipping its toes” and exploring the possibilities of the work it could do.

1991-1995 Group 2

The next generation of grants were made in two main groups. One set comprisedof three organisations starting in 1991 for a period of 2 to 3 years, which wereInternational Nursing Services Association of India (INSA), Population Services

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35

International (PSI) and Voluntary Health Association of India (VHAI). Anotherset of five between 1 and 5 years comprised of grants to five groups, which were
the Trust for the Rights of the Underprivileged in Society Today, PREPARE India
Rural Reconstruction and Disaster Response Service, All India Institute ofMedical Sciences (AIIMS), South India AIDS Action Programme (SIAAP) andSevadham Trust. Ford conceptualized its role thus:
Additional support for AIDS programs could be critical to stimulating interest
among NGOs and state governments in India. Such support would prepare thegroundwork urgently needed to develop local expertise and attract donor funds.
At this time, when other donors have yet to gear up support for AIDS work andwhen the state governments, NGOs and researchers have little on-the-groundexperience with the multiple dimensions of the problem, the Foundation could
make a significant contribution.80
During this period, Ford was convinced that behaviour change activities shouldtake precedence as the major element in prevention and Tamil Nadu andMaharashtra would be the regional focus as high prevalence states. The
recommendation for grant/FAP action in the précis states that “[a]t the heart ofprevention is persuading people to change risky sexual behavior” and cites thereasons why government efforts have been unsuccessful so far in controlling the
spread of HIV is because of the “difficulty in bringing about behavioural changes
in sexual relationships.” 81 Ford’s solution to this was to work withnongovernmental organisations because of their proximity to the community andtheir understanding of local culture. In fact, NGO-led behaviour change activities
with high-risk groups should be a key element in prevention: “As AIDS
prevention and control measures require the active participation of communities,
NGO involvement is being increasingly sought by governments and donors in thefight against the spread of HIV/AIDS.”82

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1994 Mid-point Assessment: Chatterjee and Sahgal on“HIV/AIDS Awareness & Control: Nineteen NGO
Experiences in Delhi, Maharashtra, Tamil Nadu”
As mentioned in the overview, in 1994, Ford commissioned Dr Kusum Sahgal(Professor at the Maulana Azad Medical College in New Delhi) and Ashoke
Chatterjee (Senior Faculty at the National Institute of Design in Ahmedabad) to
conduct a survey of nineteen grantees of the Foundation in the cities of Delhi,
Pune, Vellore, Bombay, Nasik and Madras/Chennai. Here I will draw out a few
interesting points that were not evident about the report in Ramasubban andRishyasringa’s Anniversary Monograph. The survey reportedly was an
assessment

of

the

quality

of

the

IEC

(information,

educationandcommunication) materials that these organisations had produced, taking into
account “how unique are the social, cultural and economic environments within
which HIV/AIDS activities are conducted.”83 Despite citing numerous areas inwhich improvement was needed, in many places it acknowledges that theseorganisations were working in an uncertain and unstable terrain, faced with
opposition from those who resent AIDS work as a “megabuck bandwagon, withlucrative appeal which attracts opportunism and masks other urgent needs.”
There was no manual for how to do HIV/AIDS intervention, which made theseNGOs’ work particularly difficult in the “absence of a coherent and sustained
support system.”84 It commended these organisations’ choice to “enter a service
in which complexity, frustration and disappointment is guaranteed.” Thus, theirfirst challenge was to “build a stamina for perseverance and suffering capable ofbeing tested at every turn.”85 Sahgal and Chatterjee’s survey offers the following:
The consultants have been impressed by the sincerity of purpose which has
marked each one of their encounters, and the quality of human fortitude which isthe badge of so many persons serving and affected by the HIV/AIDS crisis. In thelong term, this is perhaps the most important resource India has toward meetingan uncertain HIV/AIDS future. The significant of the quality of this human

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resource goes well beyond one sector. It is a commitment to a holistic, integrated
understanding of health, environment and empowerment. It would seem of theutmost importance that this unity of purpose be actively nourished as well asshared. A band of some 20 grantees may appear of little significance as a number,
yet each one of them is ideally placed as a catalyst and as a role model. Theirdemonstration can be significant, and is certainly the most important
contribution the Ford Foundation has made, and can continue to make, in whatmust be the most difficult challenge India’s health systems have faced since
Independence.86“Intermediary” NGOs in NETWORKS: Case study of
The Naz Foundation
As mentioned in the overview, Ford changed its strategy in 1996 to be more
efficient, focused and selective in its grantmaking, after a wave of corrupt NGOsdue to the immense amount of AIDS funding made available. It also wanted tobring its AIDS work under a reproductive health approach. At this stage, Ford’s
understanding of India’s epidemiological profile was that it would become the“epicentre of the global HIV/AIDS epidemic,” citing a UNDP study in which it
was predicted that the country would have 4 million recorded cases of HIV/AIDS
by the end of the century.87 Thus, the HIV threat was particularly serious “asIndia struggles to cope with the heavy burdens of poverty and ill-health.”88 The
epidemic had now spread to the general population and without a cure, the mostimportant activities should focus on prevention and within that, the promotion ofsafe sexual behaviours. However, prevention was difficult in India because (i) the
epidemic had not progressed far enough in the country for Indians to witness ona wide-scale the suffering due to progression of HIV infection to AIDS and (ii)discussion about sexuality and sexual behaviours in the country was taboo. While
this is not the place to investigate this here, one issue Indian public health38

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professionals have critiqued over the years is the overestimation by global healthagencies of the country’s prevalence rates.89 It is interesting here in 1996 that
Ford based its prevention activities based on such statistics, that India wasessentially sitting under an “explosive” volcano. The question is, as Ford went
further into ground-level grassroots activism, whose statistics informed theirunderstanding of the “need” for their kind of work?
That year, Ford made a set of four grants to what it called “intermediary” or“support” organisations, which meant they would train other more local
grassroots organisations in carrying out their AIDS activities. These nodal
organisations were meant to “play pivotal roles in the critical areas of training,technical assistance, research and documentation, information sharing anddissemination, and organisational capacity building.” 90 They were the Naz
Foundation (India) Trust based in New Delhi, the Y.R. Gaitonde Medical,
Educational and Research Foundation in Madras, International Nursing Services
Association of Bangalore and Counselling and Allied Services for AIDS in
Bombay. Of these, I am particularly interested in the Naz Foundation as myfieldwork is based in Delhi. Founded and led by Anjali Gopalan in 1994, the Trust
would continue to be a reliable node in Ford’s network of AIDS NGOs. The
Foundation has become well known in India and internationally for its activism
in protecting gay, lesbian and transgender rights in a country where
homosexuality is still illegal.91
In the proposal for the first grant Ford received from the Naz dated 12 December
1995, we can see exactly how the organisation positioned itself in relation to thecentral national programme.92 In the opening section titled “An Urgent Need,” wecan see that the Naz was also struggling with imprecise figures emanating fromvarious sources about the national prevalence rates:
The Global Program on AIDS (WHO), Harvard AIDS Institute, the Indian
Government and various non-governmental agencies give figures that range fromseveral hundred thousand to several million infected persons. What can safely be

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39

said is that unless effective steps are taken quickly, the battle against HIV
transmission in India will be lost.93
What is interesting in the above text is that I have yet to come across a case where
Ford acknowledged the disagreements over epidemiological calculation methods
for national prevalence rates. Yet the Naz as its grant recipient was aware of thisdebate, likely due to its members regularly tracking this information in literature
produced by multiple multilateral agencies (WHO, UNDP, etc.) and perhaps also
influenced by critiques of Indian public health professionals. This raises thetheme in historicizing global AIDS of: whose statistics informed where need andwhat kind of need is perceived? It also raises a question concerning a grantmakerand recipient’s relationship: who was the expert here?
The Naz’s proposal goes on to detail six reasons why behaviour-changed focused
prevention strategies had not been effective so far, the most significant for myproject being that first, most programmes did not address the taboo issue of
sexuality and second, that the people carrying out these activities see HIV as“happening to someone ‘out there’,” misunderstanding the “sexual and drugusing reality of our society.” The few organisations committed to enacting “multilevel” attitude change were of “a new breed” and had not had enough time toestablish the roots that would allow them to be effective.94
Given this scenario, the Naz believes the catalyst for scaling up prevention would
have to come from voluntary organisations themselves as they “play a significant
role in promoting human development.” It sets the current scene for NGO
activity in the country, stating that it was only after the Seventh Five Year Plan
that the government began to acknowledge the crucial role that civil society
played. NGOs in all shapes and forms – “from the grassroots level to the highest
levels of policy formulation…[w]hatever may be the interaction with thegovernment, whether collaborative or confrontational” – can make a vital
contribution:

40

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The role and involvement of NGOs as a catalyst for changes in attitude andbehavioural patterns is a vital factor for the success of national programs.
Because of their in depth communication with the community, NGOs havegreater credibility and encourage a more participatory approach which is
conducive to a change in attitudes and behaviour.
In addition to being an instigator of change, the Naz positions itself as one who
could be a mentor and coordinator for other more grassroots NGOs in a moredeliberately systematic and institutionalized voluntary sector. “Intermediary” or“support” NGOs, in contrast to grassroots NGOs, had two main advantages.
Employing staff who were well versed in national and international development
issues, they would be able to understand “the full spectrum of service
organisations.” They also facilitated connections between other voluntaryorganisations, governments, funding bodies and research institutions. The Naz
proposed that it serve as an intermediary NGO. It would take four “nodal
agencies” in various districts under its wing, training them in issues such as “TheExperiences of Positive People in India” and “Sensitivity to High Risk Groups”
and supporting them as they carried out their activities.

IV. The Rockefeller Foundation and the Debt
for Development Coalition: American
Philanthropies and the Debt Crisis?
Finally, while my main focus at the Rockefeller Archive Center for this research
trip was primarily the Ford Foundation due to their vested interest in Indian civilsociety, the Rockefeller Foundation was also active in global AIDS. It is wellknown that the Foundation led the way in forming global public-private
partnerships for vaccine research such as the International AIDS Vaccine
Initiative (IAVI) through the initiative of Seth Berkley, then researcher with theRockefeller’s Health Sciences Division.95 This is another important piece of the

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41

history of global AIDS, in which a private American foundation initiated a uniquemodel for international public-private collaboration in vaccine research in the
1990s. This is because many other foundations, Ford being a prime example,
were more interested in social issues rather than bio-medically focused vaccine
research (interestingly, both sides claim that these are under-addressed aspects)
and few successfully reached out to collaborate with national governments,
multilaterals and for-profit pharmaceutical companies. This raises somequestions about the precedents for American philanthropies active later in global
AID like the Gates Foundation and the Clinton Foundation.
In addition to this, the Rockefeller Foundation worked with the Ford Foundation,
the International Development Research Centre and the John Merck Fund tocreate the AIDS and Reproductive Health Network in 1988.96 I also confirmed as
was stated in the 1987 “The AIDS Challenge” that the Foundation funded
research on behavioural aspects of transmission in African and Latin Americancountries and was a key actor in funding the research that constructed the“epidemiological profile of AIDS” in developing countries. Though I have notinvestigated these earlier activities in systematic detail, I do know that theRockefeller Foundation supported social scientific research on sexual risk
behaviour in Costa Rica in 1991. In a series of correspondences between
Leonardo Mata, Professor at the Institute for Investigations in Health (INSA) and
Dr. Scott Halstead, Director of the Rockefeller Health Sciences Division, Matamakes the case for the prevention-policy relevance of his research which
proposed to study knowledge, attitude and practices in regards to humansexuality in Costa Rica at a national level, using an innovative “anonymous
ballot” system to interview people who were not comfortable with talking about
sensitive topics.97
Furthermore, I also came across a very unusual Rockefeller Foundation grant toan NGO called the Debt for Development Coalition, which provides a fascinating
insight into the context of American philanthropies’ understandings of how AIDS
activities should be funded in the context of the balance of payments crisis of the42

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1980s to 1990s. The Debt for Development Coalition, Inc. was established in1988 as a tax exempt, 501(c)(3) not-for-profit organisation and received the
majority of its funding from the United States Agency for International
Development (USAID). To put it in simple terms, its objective was to help NGOs
conduct a “debt-for-development swap” in which the debts of developing
countries could be turned into economic development opportunities using“innovative exchanges of debt” – what it called “Swaps Against AIDS.” 98 The
angle was that purchasing such debt would free up critical funds for Third World
governments to invest in AIDS prevention. Interestingly, the officer questioning
whether this organisation’s proposal was in line with the Foundation’s strategy
does admit it was a rather complex set of financial transactions.
This is interesting because one issue in the critical secondary literature is that
AIDS programmes in developing countries (vertical, un-integrated with publichealth infrastructure, overfunded) are an extension of Selective Primary Care andare thus (a) vehicles for prescribing neoliberal ideologies in health and (b)ineffective in a context ravaged by structural adjustment policies. 99 This isbecause the central National AIDS Control Programme (NACP) is primarily
funded by the World Bank, a multilateral development agency who is also thelargest lender in health.100 The World Bank was closely tracking the data on thebalance of payments crisis since the 1980s and corresponding with GOI officials,
other regional development agencies like the Asian Development Bank (ADB)
and members of the Aid India Consortium. Thus, it is a reasonable conjecturethat their intimate involvement in the 1991 Indian debt crisis and formal
liberalisation of the economy was at least a factor in determining the shape of thecore National AIDS Control Programme, since at least in the case of India, theBank provided the majority of funding conditional upon certain agreements inregards to the programme design.101
So how did these two American philanthropies’ understandings of the debt crisis
influence their strategy on what kinds of AIDS work needed to be done in thedeveloping world? This is essentially a question of (a) where the Ford and

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43

Rockefeller Foundations each saw their capabilities in developing countries and(b) their general approaches to how problems should be solved: as top-down or
ground-up? grassroots or macroeconomic solutions? From this snapshot of thearchival records, we see them taking very different tactics. It would seem that theRockefeller Foundation was at least aware of the idea that AIDS prevention had
to be seen in the context of the debt crisis. While it did not have the influence inmacroeconomic policy making circles that multilateral agencies like the WorldBank had, through an American non-profit with USAID funding like Debt forDevelopment, it indirectly addressed AIDS as an issue of freeing up funding fromdebt repayments. To them, this was one way to solve the AIDS problem in thespecific context of a developing country.
On the other hand, with Ford I have seen little to no mention or engagement with
the Indian macroeconomic scenario and how it impacted AIDS, other than to saythat India was a developing country with diminishing resources. However,
poverty was clearly an issue Ford was intimately familiar with. They funded two
Indian economists to research measurements of poverty in the country in theearly 1970s. Furthermore, Ford once was privy to high-level policy discussions inIndia, as the first Ford representative in India, Douglas Ensminger, enjoyed aclose relationship with Jawaharlaal Nehru and the Planning Commission. Thishistory needs to be investigated in more detail, but it suggests that by the time
AIDS became a crisis, Ford had become an organisation that preferred to keep
things small and work ground-up, identifying a need that fit with the work they
had already been doing in the country and going from there. Rather thanpresenting themselves as authorities on matters of health as the Rockefeller
Foundation’s International Health Division (IHD) and later the WHO did, it was
keen to work with non-state actors, civil society and grassroots organisations
close to the local community, building up a small system that supplemented thenational programme, even avoiding contact with the Central Government.
Without making generalizations, it would seem the Ford Foundation on thewhole tended to see health as part of social development. Thus, working on social
issues – which were conceptualized around a core concept of poverty –44

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surrounding a particular disease would result in improvements in health. This
theme needs to be teased out better, but for me, this case of the Rockefeller
Foundation and the Debt for Development Coalition in contrast to Ford’s workadds more depth in historicizing global AIDS. It introduces more themes we haveto consider: multilateral vs. national government vs. private philanthropy,
grantmaking vs. health project lending, social vs. biomedical, top-down vs.
ground-up health, health as a result of or as a catalyst for development, and social
development vs. macroeconomic development.

V.

Conclusions and Implications of Findings
for Project

When I initially wrote my proposal detailing why Ford’s grants to Indian AIDS
NGOs at the Rockefeller Archive Center (RAC) were important for my project, myinterests were more India-focused. I stated that I wanted to understand how
these NGOs presented their need for Ford funding. Given the national context ofthe health sector reforms of the 1990s, the privatization and NGO-isation of
public health and the vertical orientation of the Indian National AIDS Control
Programme (NACP), how did these NGOs make a case for the importance of theirwork to a foreign grantmaker? After researching the records at the RAC, I have amuch more nuanced understanding of how involved Ford was in, not justsupporting, but also initiating and directing the Indian NGO sector’s AIDS
activities through their grantmaking. Given their early involvement before the1992 scale-up, this has significant implications concerning how the discourse
surrounding the epidemic’s impact in the country developed. It also goes some
way to explain the critique that Indian public health professional have had ofboth the NACP and civil society “AIDS-wallas” work – that it is divorced from thereality of the health sector reforms and un-integrated with the existing healthinfrastructure. While taking into account the initiative and agency of these NGOs

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before Ford got involved, this raises the question of: to what extent did theFoundation’s social development orientation establish the discursive framework
within which India’s AIDS NGOs situated their activities, especially considering
they were one of the first international agencies active in India until 1992?
These records also showed that Ford had a distinct strategy and rationale for whysocial development issues should be strongly promoted in the civil society sector:
partly due to practical issues (like resources, existing portfolio, work others were
doing and not wanting to work with national governments), but also due to agenuine belief in promoting socially progressive programs and organisations.
This is evident from the kinds of organisations and people they were talking to.
While this information needs to be balanced with interviews and archival data inIndia, this was a key finding. It also raises more questions: if Ford was active inAfrican (Kenya) and Latin American (Brazil) countries before India, given their(and everyone else’s) lack of experience with AIDS, did they export their findingsin these locations to India? Or did they build more from their expertise andunderstandings of Indian society due to their long relationship since 1952, and if
so, how? Furthermore, how exactly did the Ford-supported NGOs exist alongside
the NACP and the National AIDS Control Organisation (NACO) after 1992 and at
various stages of the programme’s phases? This is pertinent as the NACP
increasingly decentralized at the behest of the Bank to reflect the fact that health
was a state matter in India and there were significant efforts from within NACO
tomainstream

AIDS

with

the

healthinfrastructure

and

other

disease/reproductive health programs.
In addition to this, I have found a wealth of archival information about the Ford
Foundation’s contributions to the global AIDS response. It has shown how
uncertain and fluid this terrain was in the early years. The complete ownership of
the global response by the WHO with its Special and then Global Programme on
AIDS (SPA and GPA) was contested by representatives of developing countries
and private philanthropies like Ford. As those in the UN and Bretton Woods
systems responded to such critiques and built up collaborative responses (first46

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WHO and UNDP, then WHO and World Bank and finally UNAIDS in 1996), Ford
forged its own path. This has opened up many areas of contextual knowledge thatmy project could build upon as it is clear to me that this slice of Ford’s AIDS
activities in India is part of many other narratives that need to be historicized.
One area is the history of American philanthropies’ involvement in global health,in which much of the critical secondary literature focuses on organisations suchas the Bill and Melinda Gates Foundation or the Clinton Foundation who wereactive later in the global epidemic.102 Less is known of the activities of this earlier
generation of foundations, barring Jennifer Brier’s research on Ford’s
relationship with Brazilian AIDS NGOs. 103 Did the Ford and Rockefeller
Foundations set (or re-set) the precedent for how a private US philanthropy
could be involved in a global epidemic response in the late 20th century?
Another related area is a balanced understanding rich in archival evidence of how
the concepts of multisectorality, a united “global response” and AIDS as morethan a biomedical issue came about. The Ford and Rockefeller Foundations arepart of a larger group of global and regional actors involving multilateralinternational organisations such as the WHO and the World Bank, new initiatives
like UNAIDS and the Global Fund, bilateral donors like PEPFAR, USAID and thedevelopment agencies of other nations, particularly those in northern Europe. In
the literature these organisations produce, they present themselves as part of one
global “team effort,” bringing their various talents to the same table andreinforcing each other’s positions. Collaboration and coordination to avoid
overlap is a key theme in the history of the global AIDS response particularly inthe early years. Within this, Ford’s social development orientation as a part of
AIDS prevention strikes a significant contrast to the “magic bullet” disease
control programmes of the 1950s and 1960s – and yet they did not address
macroeconomic issues or engage with the question of health as part of economic
development, despite their understanding of poverty and its connections tohealth in India. So how did this approach to addressing a global epidemic – byeveryone at all levels and from all sides – develop and what was it a response to?
And exactly how collaborative was it?

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47

My findings from the archival research have been presented chronologically andaccording to source type rather than organised under themes. This is because I
did not want to flatten the “dimensionality” of the sources and their rich potential
for historical analysis. As a historian of global health, I often work with officiallypublished policy literature of health organisations and development agencies andthese records (on a contemporary topic no less) provided a refreshing andgrounded perspective on the unfolding of an unprecedented global epidemic. In
some cases, I found full copies of policy documents, research publications andnews articles, which signalled when they were consulted and significant in policy
circles. In the grant records, I found follow-up reports containing documents
such as instructions for games with local teenagers that were used in healtheducation activities, showing a glimpse of the day-to-day workings of an Indian
AIDS NGO in the 1990s. By allowing me to trace the narrative of one organisationconsistently, these records have provided me with traction and focus in mycurrent research questions but also raised a multitude of new ones. In sum, therich primary sources of the Ford Foundation held at the Rockefeller Archive
Center – from the reflective internal accounts, the handwritten notes, thecorrespondences, the supporting documents in follow-up reports submitted by
grant recipients and the rougher “footprints” of articles and reports gathered –reveal critical insights into the process behind the global AIDS response and how
it played out in India from the viewpoint of one American philanthropy.

VI. Endnotes

1 “The AIDS Challenge: A Ford Foundation Response”, 1987, Original – AIDS Report, Box

11: Series II AIDS Background Files, FA717, Human Rights and Governance Program,
Office Files of Shepard Forman, Ford Foundation records, Rockefeller Archive Center.
2 Ibid., p. i.
3 Ibid., p. iii.
4 Ibid., p. 4.

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5 I will discuss the Ford AIDS Consultative Group more in the second section. Ibid., p. 35.
6 Ibid., p. 37.
7 This perhaps refers to the collaboration between the WHO and the World Bank in AIDS

around this time or the Bank’s lending to national AIDS programmes and other smaller
AIDS activities before India in 1992. Ibid., p. 39.
8 Ibid., p. 40.
9 Ibid., p. 40.
10 Ibid., p. 41.
11 Marjorie Muecke’s transition memo on HIV/AIDS “What we’ve been doing about
HIV/AIDS for the past decade”, Reports 015017, Box 752, Catalogued Reports 1394917726, FA739F, Ford Foundation records, Rockefeller Archive Center.
12 Ibid., p. 2.
13 Ibid., p. 3.
14 Ibid., p. 3.
15 Ibid., p. 15.
16 Ibid., p. 18. For more information on exactly how Ford felt about an integrating
HIV/AIDS and STDs into existing family planning and reproductive health programmes,
an inter-office memorandum on the Fourth International Conference on AIDS in Asiaand the Pacific held in Manila, Philippines from 25-29 October 1997 is particularly
illuminating. Ford was clearly optimistic about implementing the 1994 Cairo Programmeof Action. Memoranda on Fourth International Conference on AIDS in Asia and thePacific, Manila, October 25-29, 1997, Reports 013852, Box 737, Catalogued Reports
11775-13948, FA739E, Ford Foundation records, Rockefeller Archive Center.
17 Radhika Ramasubban and Bhanwar Singh Rishyasringa, Report 016626: “Sexuality andReproductive Health and Rights: Fifty Years of the Ford Foundation in India”, Box 853,
Catalogued Reports 13949-17726, FA739F, Ford Foundation records, Rockefeller Archive
Center, p. 82.
18 Ibid., p. 82.
19 Ibid., p. 83.
20 Ashoke Chatterjee and Dr. Kusum Sahgal, Reports 012767: “HIV/AIDS Awareness &Control: Nineteen NGO Experiences in Delhi, Maharashtra, Tamil Nadu”, 1994,
Catalogued Reports 11775-13948, FA739E, Ford Foundation records, Rockefeller Archive
Center.
21 Radhika Ramasubban and Bhanwar Singh Rishyasringa, Report 016626: “Sexuality andReproductive Health and Rights: Fifty Years of the Ford Foundation in India”, p. 85. Also,
Devaki Nambiar, “HIV-Related Stigma and NGO-isation in India: an historico-empiricalanalysis”, Sociology of Health & Illness 34:5 (2012), pp. 714-729. Kavita Misra, “Politicomoral Transactions in Indian AIDS Service: Confidentiality, Rights and New Modalities
of Governance”, Anthropological Quarterly 79:1 (Winter 2006), p. 40.
22 Jacob A. Gayle, “Early Thoughts about the Ford Foundation and the Global Response
to HIV/AIDS”, 25-26 January 2006, Reports 016850, Box 867, Catalogued Reports
13949-17726, FA739E, Ford Foundation records, Rockefeller Archive Center.
23 Ibid., p. 2.
24 Ibid., p. 3.
25 Ibid., p. 4.
26 Ibid., p. 5.
27 Ibid., p. 10.
28 Frederic Wakeman to Shepard Forman, 22 September 1987, Box 8 Series II: AIDS
Background Files, FA717, Office Files of Shepard Forman Human Rights and Governance
Program, Ford Foundation records, Rockefeller Archive Center.

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49

29 <http://rockarch.org/collections/nonrockorgs/ssrc.php>. (Accessed 27 February2017).
30 Ibid.
31 Ibid.
32 Frederic E. Wakeman Jr. to Shepard Forman, 12 August 1988, Box 8 Series II: AIDS
Background Files, FA717, Office Files of Shepard Forman Human Rights and Governance
Program, Ford Foundation records, Rockefeller Archive Center.
33 Denise Silver to Shepard Forman, “The Cost of AIDS: A Review of the Estimates”, inBox 8 Series II: AIDS Background Files, FA717, Office Files of Shepard Forman Human
Rights and Governance Program, Ford Foundation records, Rockefeller Archive Center.
Original article citation: Jane E. Sisk, “The Costs of AIDS: A Review of the Estimates”,
Health Affairs 6:2 (Summer 1987), pp. 5-21.
34 Lincoln C. Chen to Oscar Harkavy, 3 March 1987, Reports 012371: Implications of
AIDS for Ford Foundation programming, Box 610, Reports 11775-13948, FA739E, Ford
Foundation records, Rockefeller Archive Center.
35 The World Bank made the reverse argument as well, about how much a country could
save by investing in prevention. It praises India in particular for adhering to the Bank’s
advice for a well-designed AIDS programme: “If the transmission rate could be slowed to
one every five years, that number could be reduced to only four infected persons in 2000
for every one today. The corresponding reduction in medical costs, after discounting at 3
per cent a year, amounts to $750 by 2000 for each currently HIV-positive person inIndia, for a total saving of $750 million.” World Bank (1993), World Development Report
1993: Investing in Health, New York, p. 20.
36 Ibid.
37 Ulyssess B. Panisset, International Health Statecraft: Foreign Policy and Public
Health in Peru’s Cholera Epidemic (University Press of America, 2000), pp. 74-75. Julio
Frenk and Fernando Chacon, “International Health in Transition”, Asia Pacific Journalof Public Health 5:2 (1991), pp. 170-175.
38 Ibid.
39 Marge Koblinsky to Bill Carmichael, John Gerhart, Shep Forman, Oscar Harkavy, 21
July 1987, Series II: AIDS Background – AIDS in India, Box 8, FA717, Ford Foundation
records, Rockefeller Archive Center.
40 Handwritten Note, Shep to Steve Marks, 28 January, Series II: AIDS Background –AIDS in India, Box 8, FA717, Ford Foundation records, Rockefeller Archive Center.
41 Shepard Forman to Susan Berresford, “AIDS Consultancy”, 16 March 1987, Series II:
AIDS Background – AIDS in India, Box 10, FA717, Ford Foundation records, Rockefeller
Archive Center.
42 John D. Gerhart to Richard A. Horovitz and William S. Saint, “AIDS Consultative
Group”, 6 June 1987, Series II: AIDS Background – AIDS in India, Box 10, FA717, Ford
Foundation records, Rockefeller Archive Center.
43 Shep Forman/Marge Koblinsky to Representatives, 8 June 1987, “AIDS Consultative
Group”.
44 Seltzer also founded Funders Concerned about Acquired Immune Deficiency
Syndrome. Michael Seltzer to Shepard Forman, 5 June 1987, Series II: AIDS Background– AIDS in India, Box 10, FA717, Ford Foundation records, Rockefeller Archive Center.
45 Susan V. Berresford to POICs/Deputy POICs, 18 June 1987, Series II: AIDS
Background – AIDS in India, Box 10, FA717, Ford Foundation records, Rockefeller
Archive Center.

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46 Notes of First Meeting of Ford Foundation Consultants on AIDS Policy, Series II: AIDS

Background – AIDS in India, Box 10, FA717, Ford Foundation records, Rockefeller
Archive Center, p. 1.
47 Bob Stein to Ford Foundation AIDS Consultants, “Update”, 10 June 1987, Series II:
AIDS Background – AIDS in India, Box 10, FA717, Ford Foundation records, Rockefeller
Archive Center.
48 Ibid., p. 2.
49 Shepard Forman to Susan V. Berresford and William D. Carmichael, “AIDS”, 10
September 1987, Series II: AIDS Background – AIDS in India, Box 10, FA717, Ford
Foundation records, Rockefeller Archive Center.
50 John D. Gerhart to Shepard Forman, “AIDS Consultants Report”, 14 September 1987,
Series II: AIDS Background – AIDS in India, Box 10, FA717, Ford Foundation records,
Rockefeller Archive Center, p. 1.
51 “These young men and women in their twenties and thirties are the breadwinners oftoday and tomorrow. They support the young and the old – and the nation’s economy.” It
is not clear what projection model this analysis is based on. We know that the Bank wascollaborating with the WHO early on to predict loss in GDP due to AIDS for developing
countries (Mead Over, “The Macroeconomic Impact of AIDS in Sub-Saharan Africa”,
1992), so it will be interesting to investigate whose data the Panos used. Panos Institute,“AIDS in the Third World”, (London, 1986), p. 40. In terms of understanding AIDS
through cultural theory and discourse analysis of “AIDS in developing countries”
representations in newsprint, Paula Treichler’s work is interesting. Paul Treichler, “AIDS
and HIV Infection in the Third World: A First World Chronicle”, in Elizabeth Fee andDaniel M. Fox, AIDS: The Making of a Chronic Disease (California, 1992).
52 Ibid., p. 1.
53 Ibid., p. 2.
54 Ibid., p. 2.
55 Shepard Forman to AIDS Files, 7 August 1987, “Meetings at the World HealthOrganisation – Geneva”, Box 10 Series II: AIDS Background Files, Human Rights andGovernance Program, Office Files of Shepard Forman, FA717, Ford Foundation records,
Rockefeller Archive Center, p. 1.
56 Ibid., p. 2.
57 Elizabeth Fee and Manon Parry, ‘Jonathan Mann, HIV/AIDS, and Human Rights’,Journal of Public Health Policy 29:1 (April 2008), pp. 54 – 71. Jonathan Mann, ‘Human
Rights and the New Public Health’, Health and Human Rights 1:3 (1995), pp. 229 – 233.
58 Shepard Forman to AIDS Files, 7 August 1987, “Meetings at the World HealthOrganisation – Geneva”, p. 2.
59 Ibid., p. 4.
60 Ibid., p. 4.
61 Ibid., p. 3.
62 Ibid., p. 3.
63 He mentioned that USAID was also working on a model for developing contexts. Ibid.,
p. 3.
64 Ibid., p. 4.
65 Shepard Forman to Distribution, 13 October 1987, “WHO’s Coordination of Global &National AIDS Activities”, Box 10 Series II: AIDS Background Files, Human Rights andGovernance Program, Office Files of Shepard Forman, FA717, Ford Foundation records,
Rockefeller Archive Center, p. 1.
66 WANG DOC 4951F, WHO Special Programme on AIDS Comprehensive Coordinationof Global and National AIDS Activities, Box 10 Series II: AIDS Background Files, Human

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51

Rights and Governance Program, Office Files of Shepard Forman, FA717, Ford
Foundation records, Rockefeller Archive Center, p. 1.
67 Shepard Forman to Distribution, 13 October 1987, “WHO’s Coordination of Global &National AIDS Activities”, p. 1-2.
68 Oscar Harkavy to Shepard Forman, 23 October 1987, “WHO’s Coordination of Global &National AIDS Activities”, Box 10 Series II: AIDS Background Files, Human Rights andGovernance Program, Office Files of Shepard Forman, FA717, Ford Foundation records,
Rockefeller Archive Center.
69 Ibid.
70 Ibid.
71 Steve Linick to Bill Carmichael, Shep Forman and John Gerhart, 12 August 1988,“Possible Grant to WHO Global Program on AIDS”, Box 10 Series II: AIDS Background
Files, Human Rights and Governance Program, Office Files of Shepard Forman, FA717,
Ford Foundation records, Rockefeller Archive Center.
72 Radhika Ramasubban and Bhanwar Rishyasringa, AIDS and Civil Society: India’s
Learning Curve (New Delhi, 2005).
73 Indian Health Organisation Grant No. 08903026, 23 May 1990 to 31 March 1994,
Series: Ford Foundation Grants – H to K, Reel 7024, FA732D, Ford Foundation records,
Rockefeller Archive Center.
74 Recommendation for Grant/FAP Action. Indian Health Organisation Grant No.
08903026, 23 May 1990 to 31 March 1994, Series: Ford Foundation Grants – H to K,
Reel 7024, FA732D, Ford Foundation records, Rockefeller Archive Center, p. 3.
75 Ibid., p. 3.
76 See also Cindy Patton, Globalizing AIDS (Minnesota, 2002).
77 Recommendation for Grant/FAP Action. Indian Health Organisation Grant No.
08903026, 23 May 1990 to 31 March 1994, Series: Ford Foundation Grants – H to K,
Reel 7024, FA732D, Ford Foundation records, Rockefeller Archive Center, p. 5.
78 Ford funded research in India in the early 1970s on a new field called “poverty studies”.
VM Dandekar and Nilakantha Rath, “Poverty in India – I: Dimensions and Trends” and“II: Policies and Programmes”, Economic and Political Weekly 6:1 and 2 (January 1971),
pp. 25-27+29-48; pp. 106-146.
79 Recommendation for Grant/FAP Action. Indian Health Organisation Grant No.
08903026, 23 May 1990 to 31 March 1994, Series: Ford Foundation Grants – H to K,
Reel 7024, FA732D, Ford Foundation records, Rockefeller Archive Center, p. 6.
80 Recommendation for Grant/FAP Action. International Nursing Services Association ofIndia No. 09100835, 13 August 1991 to 31 August 1996, Series: Ford Foundation Grants –H to K, Reel 7054, FA732D, Ford Foundation records, Rockefeller Archive Center, p. 4.
81 Recommendation for Grant/FAP Action. Sevadham Trust No. 09201359, 9 December
1992 to 9 December 1995, Series: Ford Foundation Grants – S to Thel, Reel 7206,
FA732G, Ford Foundation records, Rockefeller Archive Center, p. 3.
82 Ibid., p. 3.
83 Ashoke Chatterjee and Dr. Kusum Sahgal, Reports 012767: “HIV/AIDS Awareness &Control: Nineteen NGO Experiences in Delhi, Maharashtra, Tamil Nadu”, p. 3, 10.
84 Ibid., p. 12.
85 Ibid., p. 12.
86 Ibid., p. 12.
87 Recommendation for Grant/FAP Action, Naz Foundation No. 09600517, 19 June 1996
to June 1999, Series: Ford Foundation Grants – U to Z, Reel 8354, FA732E, Ford
Foundation records, Rockefeller Archive Center, p. 3.
88 Ibid., p. 3.

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89 The National AIDS Control Organisation (NACO), as well as Indian health statisticiansand epidemiologists challenged UNAIDS estimates (what they called “decontextualized
numbers”) of their national epidemic starting in 2001 and throughout the 2000s. Ritu
Priya, “AIDS in Perspective: Between Exaggeration and Denial – Revisiting the
Epidemiology of HIV Infection’, in Ritu Priya and Shalini Mehta (eds.), Dialogue on
AIDS: Perspectives for the Indian Context (New Delhi, 2008), p. 29. Lalit Dandona,
Vemu Lakshmi, G Anil Kumar, Rakhi Dandona, ‘Is the HIV burden in India being
overestimated?’, BMC Public Health 6:308 (December 2006). In fact, in 2007,
UNAIDS/WHO state in their 2007 “AIDS Epidemic Update” that they had revised theircalculation methods primarily due to Indian health statisticians’ challenge.
UNAIDS/WHO, ‘AIDS Epidemic Update’, Geneva (December 2007), p. 3.
90 Recommendation for Grant/FAP Action, Naz Foundation No. 09600517, 19 June 1996
to June 1999, Series: Ford Foundation Grants – U to Z, Reel 8354, FA732E, Ford
Foundation records, Rockefeller Archive Center, p. 4.
91 However, my project’s focus is not on gender and sexuality in global HIV/AIDS, as thisis much better handled by medical anthropologists well versed in gender theory, as wellas ethnographic research methods. Ford’s New Delhi Program Officer Geetanjali Misra
has published work on this, as have Suparna Bhaskaran’s 2004 Made in India:
Decolonizations, Queer Sexualities, Trans/National Projects, Stacey Leigh Pigg’s 2005
Sex in Development: Science, Sexuality, and Morality in Global Perspective and finally,
Lawrence Cohen and others in a University of Chicago roundtable discussion titled“Sexual Identity in India”. <http://www.ssa.uchicago.edu/sexual-identity-india-session1-part-1>.
92 Capacity Building on HIV/AIDS of Intermediary Organisations Project Proposal, theNaz Project 12 December, 1995. Naz Foundation No. 09600517, 19 June 1996 to June
1999, Series: Ford Foundation Grants – U to Z, Reel 8354, FA732E, Ford Foundation
records, Rockefeller Archive Center.
93 Ibid.
94 Ibid.
95 “15 Minutes with Seth Berkley President and CEO of International AIDS Vaccine
Initiative”, Stanford Social Innovation Review (Winter 2004).
<https://ssir.org/articles/entry/15_minutes_with_seth_berkley>. (Accessed 24
February 2017).
96 Berkley also published his findings on the epidemiological profile of HIV/AIDS indeveloping countries in the early 1990s, such as: Seth Berkley, “AIDS in the Developing
World: An Epidemiologic Overview”, Clinical Infectious Diseases 17:2 Controversies in
the Management of Infections in Immunocompromised Patients (Nov. 1993), pp. S329 –S336. Seth Berkley, “AIDS in the Global Village: Why US Physicians Should Care about
HIV Outside the United States”, Journal of the American Medical Association 268:23(December 1992), pp. 3368-3369.
97 Leonardo Mata to Scott Halstead, June 1991, Box R3030, RG 1.20-1.23, FA471,
Subgroup 1.23: Rockefeller Foundation records (A97), Rockefeller Archive Center.
98 The Debt for Development Coalition, Inc., “Swaps Against AIDS: A New Initiative toIncrease Funding for AIDS Prevention and Control”, Box R3030, RG 1.20-1.23, FA471,
Subgroup 1.23: Rockefeller Foundation records (A97), Rockefeller Archive Center.
99 Mohan Rao (ed.), Disinvesting in Health: The World Bank’s Prescriptions for Health(New Delhi, 1999).
100 In the case of India, the NACP-I in 1992 was an agreement between the World Bank’s
International Development Agency and the Indian Ministry of Finance.

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101 In the rationale for IDA Involvement in India’s AIDS crisis in 1992, it states that theloan is in line with “IDA’s strategy for enhancing human capital development in India
through high return investments. They also go along with our emerging objective ofassisting India in controlling major health problems, while simultaneously improving thequality, effectiveness and efficiency of health systems in a sustainable manner.”
Memorandum and Recommendation of the President of the International Development
Association to the Executive Directors on a Proposed Credit of SDR 59.8 Million to India
for a National AIDS Control Project, 9 March 1992, Report No: P-5693-IN, World Bank,
p. 2.
102 Linsey McGoey, No Such Thing as a Free Gift: The Gates Foundation and the Price ofPhilanthropy (London, 2015).
103 Jennifer Brier, Infectious Ideas: U.S. Political Responses to the AIDS Crisis (Chapel
Hill, 2009).

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