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FAULT LINES OF CARE

Medical Anthropology: Health, Inequality, and Social Justice
Series editor: Lenore Manderson
Books in the Medical Anthropology series are concerned with social patterns of
and social responses to ill health, disease, and suffering and how social exclusion
and social justice shape health and healing outcomes. The series is designed
to reflect the diversity of contemporary medical anthropological research and
writing and will offer scholars a forum to publish work that showcases the theo-
retical sophistication, methodological soundness, and ethnographic richness of
the field.
Books in the series may include studies on the organization and movement
of peoples, technologies, and treatments; how inequalities pattern access to
these; and how individuals, communities and states respond to various assaults
on well-
being, including from illness, disaster, and violence.
Carina Heckert, Fault Lines of Care: Gender, HIV, and Global Health in Bolivia Joel Christian Reed, Landscapes of Activism: Civil Society and HIV and AIDS
Care in Northern Mozambique

Artistic depiction of Ana, a Bolivian woman living with HIV. Credit: Victoria De Anda.

FAULT LINES
OF CARE
Gender, HIV, and
Global Health in Bolivia
Carina Heckert
Rutgers University Press
New Brunswick, Camden, and Newark, New Jersey, and London

Library of Congress Cataloging-in-Publication Data
Names: Heckert, Carina, 1983– author.
Title: Fault lines of care : gender, HIV, and global health in Bolivia / Carina Heckert.
Description: New Brunswick : Rutgers University Press, [2018] | Series: Medical
anthropology: health, inequality, and social justice | Includes bibliographical
references and index.
Identifiers: LCCN 2017054097| ISBN 9780813586915 (cloth : alk. paper) |
ISBN 9780813586908 (paperback : alk. paper) | ISBN 9780813586922 (epub) |
ISBN 9780813586939 (web pdf)
Subjects: LCSH: AIDS (Disease)—
Bolivia. | HIV infections—Bolivia.
Classification: LCC RA643.86.B5 H43 2017 | DDC 362.19697/9200984—dc23
LC
record available at https://lccn.loc.gov/2017054097
A British Cataloging-
in-Publication record for this book is available from the British
Library.
All photographs by author unless otherwise noted.
Copyright © 2018 by Carina Heckert
All rights reserved
No part of this book may be reproduced or utilized in any form or by any means,
electronic or mechanical, or by any information storage and retrieval system, without
written permission from the publisher. Please contact Rutgers University Press, 106
Somerset Street, New Brunswick, NJ 08901. The only exception to this prohibition is
“fair use” as defined by U.S. copyright law.
The paper used in this publication meets the requirements of the American
National Standard for Information Sciences—Permanence of Paper for Printed
Library Materials, ANSI Z39.48-1992.
w
ww
.rutgersuniversitypress .org
Manufactured in the United States of America

vii
CONTENTS
Foreword by Lenore Manderson ix
1 Fault Lines 1
2 Decolonizing Bolivia 29
3 When Care Is a “Systematic Route of Torture” 50
4 Aiding Women 68
5 Synergistic Silences 88
6 Blaming Machismo 106
7 The Biopolitical Drama of HIV Funding 125
8 Decolonizing Global Health 145
Acknow
ledgments
159
N
otes
163
R
eferences
169
I
ndex
183

ix
FOREWORD
Lenore Manderson
Medical Anthropology: Health, Inequality, and Social Justice is a new series
from Rutgers University Press designed to capture the diversity of contempo-
rary medical anthropological research and writing. The beauty of ethnography
is its capacity, through storytelling, to make sense of suffering as a social expe-
rience and to set it in context. Central to our focus in this series on health and
social justice, therefore, is the way in which social structures and ideologies
shape the likelihood and impact of infections and injuries, bodily ruptures and
disease, chronic conditions and disability, treatment and care, social repair
and death.
The brief for this series is broad. The books are concerned with health and
illness, healing practices, and access to care, but the authors also illustrate the
importance of context—
geography, physical condition, service availability, and
income. Health and illness are social facts; the circumstances of the maintenance and loss of health are always and everywhere shaped by structural, global, and local relations. Society, culture, economy, and political organization as much as ecology shape the variance of illness, disability, and disadvantage. But as medical anthropologists have long illustrated, the relationships between social context and health status are complex. In addressing these questions, the authors in this series showcase the theoretical sophistication, methodological rigor, and empir-
ical richness of the field while expanding a map of illness and social and insti-
tutional life to illustrate the effects of material conditions and social meanings
in troubling and surprising ways.
The books in the series move across social circumstances, health conditions,
and geography and their intersections and interactions to demonstrate how individuals, communities, and states manage assaults on well-
being. The books
reflect medical anthropology as a constantly changing field of scholarship draw-
ing on diverse research in residential and virtual communities, clinics, labora-
tories, emergency care, and public health settings and with service providers, individual healers, households, social bodies, human bodies, and biologies.

x Foreword
While medical anthropology once concentrated on systems of healing, particu-
lar diseases, and embodied experiences, today the field has expanded to include
environmental disaster and war, science, technology and faith, gender-
based
violence, and forced migration. Curiosity about the body and its vicissitudes remains a pivot for our work, but our concerns are with the location of bodies in social life and with how social structures, temporal imperatives, and shifting exi- gencies shape life courses. This dynamic field reflects an ethics of the discipline to address these pressing issues of our time.
Globalization has contributed to and adds to the complexity of influences on
health outcomes; it (re)produces social and economic relations that institution- alize poverty, unequal conditions of everyday life and work, and environments in which diseases increase or subside. Globalization patterns the movement and relations of peoples, technologies and knowledge, and programs and treat-
ments; it shapes differences in health experiences and outcomes across space; it informs and amplifies inequalities at individual and country levels. Global
forces and local inequalities compound and constantly impact individuals’ physi-
cal and mental health and their households and communities. At the same time, as the subtitle of this series indicates, we are concerned with questions of social exclusion and inclusion, social justice and repair, again both globally and in local settings. The books challenge readers to reflect not only on sickness and suffer-
ing, deficit and despair, but also on resistance and restitution—
on how people
respond to injustices and evade the fault lines that might seem to predetermine life outcomes. While not all the books take this direction, the aim is to widen
the frame within which we conceptualize embodiment and suffering.
Carina Heckert’s book Fault Lines of Care: Gender, HIV, and Global Health in
Bolivia is the first book in this series. The setting is the city of Santa Cruz, Bolivia;
the key actors are poor women living with HIV; the backdrop is the agendas of global health agencies. Heckert is concerned with the uneven translation of global funding strategies. In Bolivia, enduring understandings and relations
of sex and gender influence the possibility of HIV infection and access to treat-
ment and shape the development and implementation of HIV care programs. Other local fault lines, including class and ethnicity, also complicate the rollout, accessibility, and acceptability of programs and so influence how people live
with HIV.
Heckert offers us a compelling, nuanced, and provocative account of
women—
and men and children—subject to local HIV policies and programs.
In writing this narrative, she interrogates the relationship between gender and the politics of both global health and life itself. HIV, we see, is everywhere entan- gled with gender. As Heckert illustrates—
setting out a theme that will recur in
later books in this series—infection, illness, treatment, and care are patterned by
the complex interactions of individuals in communities and at state and global

Foreword xi
levels. In illustrating how HIV tracks social fault lines, Heckert insists that we
maintain our engagement with the infection and resist yielding to a discourse
that HIV has run its course. But she also illustrates, as will others whose work
will appear in this series, how any infection, disease, or decline in capacity is
inflected by social structures—
class, gender, and race—and by the unevenness
of power within and beyond nations.

FAULT LINES OF CARE

1
1 • FAULT LINES
On October 2, 2013, I was just over a month into a 12-month stretch
of fieldwork in Santa Cruz, Bolivia. Unlike the Andean region that people often
associate with Bolivia, Santa Cruz is in the tropical lowlands and is hot and
humid throughout most of the year. There is some relief from the heat in the win-
ter months that comes from surazos, or cold Antarctic winds that make their way
across the Argentinian Pampas and cause a sudden drop in temperature. That
morning in October marked the end of what would be the last surazo of win-
ter, and the temperature was just beginning to warm up. On this pleasant spring
morning, I waited inside the main entrance of Epua Kuñatai
1
(or Epua for short),
an NGO that provides social support for women and children affected by HIV.
Epua’s social worker, Carmen, had requested my assistance with an acompa -
ñamiento, accompanying a patient in her quest for care. This service can help
ensure that patients are able to find their doctors’ offices and understand the
instructions for having lab work and taking medications and provide an overall
source of support as patients navigate the health care system. According to my
phone conversation with Carmen the night before, a young woman, Gabriela,
had recently arrived from Puerto Suárez, a town that lies near Bolivia’s border
with Brazil and is a 12-
hour bus ride from Santa Cruz. Gabriela had traveled
with her mother, Hilda, and her three-year-old daughter. Both Gabriela and
her daughter had recently tested positive for HIV after Gabriela began showing symptoms of tuberculosis. Given the family’s lack of familiarity with the city and the number of places they needed to go that day, Carmen thought I could be of some assistance. Carmen arrived at Epua a few minutes after me, followed by Hilda and her cousin, Jimy, who lived in the city. Jimy had agreed to drive every-
one around for the day in his 1970s Toyota sedan.
Upon Jimy’s arrival, Hilda went upstairs to help Gabriela. Gabriela had been
staying in one of the extra rooms in Epua where women can stay if they have nowhere else to go. The image of Hilda struggling to help her adult daughter

2 Fault Lines of Care
down the stairs seared itself into my memory. The moment captures the love
that drives people to follow every possible route, often sacrificing their own
well-
being, to help a loved one survive. Gabriela’s physical state also struck
me. Although she was bundled up, her baggy clothes hinted at wasting. Her eyes, sunken into the sockets, peered out above the face mask that marked her
as having tuberculosis. The image was reminiscent of media portrayals of AIDS patients as “suffering strangers” (Butt 2002) prior to the availability of lifesaving antiretrovirals (ARVs). It was also an image I would become familiar with during my research, despite the availability of free ARVs.
Once everyone was in the car, Carmen gave Gabriela an extra blanket to stay
warm even though it was a comfortable temperature for the rest of us. Gabriela revealed her pain as we drove toward the Red Cross clinic in the center of the city. She had not slept at all the night before. She moaned that she felt like her head was going to explode and that her heart was going to rupture, but it was her back that hurt the worst. Every few minutes, she moved her mask to the side, gasping for breath.
Until just before Gabriela’s arrival in Santa Cruz, the Red Cross clinic had
been a primary center for tuberculosis testing and the initiation of treatment. When we arrived, Jimy and I helped Gabriela out of the car and into the waiting room while Carmen went to ask for an appointment at the front desk. Once we were finally seated, Carmen came back looking frustrated, saying, “We are going to have to go to the clinic in La Villa.” Even though doctors typically referred patients who were exhibiting signs of tuberculosis to the Red Cross clinic, the nurses had told Carmen that because of a new protocol aimed at integrating tuberculosis care with other health care services, the clinic was now only test-
ing and referring people to other health centers for treatment. Carmen had not known about this new protocol. If Gabriela wanted to start treatment quickly, she would need to go to a municipal health center instead. Carmen decided it would be best to go to the clinic 18 de Marzo in La Villa Primero de Mayo, a working-
class neighborhood on the northeastern edge of the city, since that was
where one of only two pediatric HIV specialists in the city worked. Carmen could take Gabriela’s daughter to the pediatrician while I accompanied Gabriela for her tuberculosis test.
As we fought traffic on the way to La Villa, Jimy vented his frustrations, yell-
ing, “Don’t they see her condition? She could die waiting!” As we drove, we stopped in the market La Mutualista to pick up one of Jimy’s friends. So that
Gabriela could sit comfortably up front, Carmen, Hilda, Jimy’s friend, and Gabri-
ela’s daughter squeezed with me into the back seat, piling on top of each other. Although the rusted Toyota stalled several times along the way, we managed to make it to the clinic in La Villa.

Fault Lines 3
We arrived to a crowded clinic, but a nurse quickly shuffled Gabriela toward
the tuberculosis testing office. Once inside the office, the nurse explained that as
a part of the tuberculosis test, Gabriela should also take an HIV test. An already
weak Gabriela asked, “Do you really need to take more blood? They already tested
me, and it came back positive.” The nurse insisted she should have the test done
again. Gabriela rested her head in the palm of one hand as the nurse pricked a fin-
ger on her other hand and squeezed a drop of blood onto a small strip of paper.
The HIV rapid test result would be available in minutes. Next, the nurse said she
would need to take Gabriela’s weight and blood pressure. In pain, Gabriela stood
up to walk to the scale—
“38 kilos” (84 pounds), the nurse read.
As this was being done, another nurse asked Hilda for Gabriela’s carnet , or
national ID card. Before passing the nurse the ID, Hilda showed me the healthy, vibrant young woman in the photo, lamenting, “She was always a good weight. She wasn’t fat, but like you.” Gabriela then struggled over to a chair, gasping for air and begging for water. I walked over to a water stand, noting a faded United States Agency for International Development (USAID) sticker on the tank as I poured a small cup of water. The USAID sticker served as a reminder that the clinic had been established in partnership with the international development agency. Just months before, the Bolivian government had expelled USAID as a part of broader efforts to distance the country from what it described as agents of imperialism.
The nurse then came over, giving me two small specimen cups, explain-
ing that someone would need to collect two sputum samples the following morning—
one at 5:00 a.m. and one at 7:00 a.m. Then someone would need
to bring the specimen cups back to the clinic before 8:00 a.m. to complete the full test. After that, it would still take several days to have the results. Although Gabriela exhibited all the classic symptoms of tuberculosis and had received a positive test result in Puerto Suárez, her results were meaningless in Santa Cruz. The Ministry of Health
2
protocol for treating tuberculosis prevented her from
starting treatment until the health center where she would receive care had con- firmed a positive test result. The purpose of following this protocol, developed in line with the World Health Organization (WHO) guidelines, was to ensure that patients began a drug regimen appropriate for the tuberculosis strain with which they were infected in order to avoid potential development of drug resistance. However, this protocol can prolong the wait before a patient begins treatment, especially when there is a lack of coordination among the various health centers where a patient may seek care.
As Hilda helped Gabriela back to the car, I found Carmen sitting on a
bench outside of the pediatrician’s office with Gabriela’s daughter on her lap. I explained to Carmen the protocol for the sputum cups. We began to speculate

4 Fault Lines of Care
that we thought Gabriela had a good chance of recovery, especially with so much
help from her family. At that point, the pediatrician stepped out of his office. The
doctor, a short, silver-
haired man with a potbelly, bellowed to the mothers with
crying children, “None of you are feeding your children correctly. Before I will see anyone else today, you must all go to a nutrition consultation.” He declared that an intern from the university would start the demonstration in an hour. He would take no other patients until after the nutrition session.
Carmen’s face dropped. “You aren’t in a hurry, are you?” she asked me,
explaining that she could not possibly wait, as she needed to return to Epua to prepare the materials for an employment skills training session she was in charge of in the afternoon. I agreed to wait with Hilda and the child while Jimy drove Carmen and Gabriela back to Epua.
After I sat with Hilda and her granddaughter for more than an hour in the
crowded waiting area, a student intern led the line of mothers and restless chil-
dren into an empty room filled with desks. The nutrition session consisted of the student intern teaching the mothers two recipes for healthy baby food, using a blender and foods that included liquid yogurt, cooked vegetables, and rice. Hilda was an eager student, asking many questions and requesting that I write down the recipes for her. Following this session, we went back to the waiting area, where we waited. And waited. And waited. During the wait, Hilda began to
peel and slice several apples that she had in her purse, forcing her grandchild
to eat. As she did so, she told me about her life and Gabriela’s illness.
Hilda was a domestic worker, but she requested the week off to bring her
daughter to Santa Cruz, where she thought the medical care would be better. The trip had wiped out her savings; at one point she commented, “Everything costs something.” Gabriela had worked as a street vendor selling prepaid phone cards for cell phones. Hilda attributed the tuberculosis to this line of work, saying that all the dust from the street had damaged Gabriela’s lungs. Gabriela had been los-
ing weight for about a year, but she did not seek medical care until about six weeks prior to her trip to Santa Cruz, when her health began to deteriorate more rap-
idly. According to Hilda, Gabriela had feared how much it would cost to see a doctor, and at one point, she had started to feel better. At the time, Gabriela was unaware that she had HIV and that there were free medications to treat it. Fol-
lowing her HIV diagnosis, Gabriela disclosed her status to her daughter’s father, and he blamed her for it. According to him, his own test had come back negative. Hilda looked upset and became quiet as she recounted this detail. I found Hilda’s unfaltering support for her daughter touching, and I could not imagine someone in Gabriela’s condition being able to survive without that kind of support.
“Is she going to die?” Hilda asked me at one point. Finally, we saw the pediatrician. He asked many questions: “Will she be stay-
ing here or returning to Puerto Suárez? What tests have been done so far? Did

Fault Lines 5
they give you her CD4 count?” Hilda looked ashamed, as she was unable to
answer these questions. No one had given me any of the child’s medical paper-
work, nor had I thought to ask for it, and I felt impotent as the doctor looked
at me, expecting me to answer on Hilda’s behalf. The doctor then examined
the child quickly, commenting, “She has intestinal bugs.” At the end of the ses-
sion, the doctor rattled off a list of medications he was prescribing and gave
instructions for lab work.
On the bus ride back to Epua, Hilda’s granddaughter fell asleep in her arms.
The young child’s stomach, bloated from parasites, poked out from under a shirt
she had long outgrown. Back at Epua, I helped carry the child to Gabriela’s room.
Gabriela was sitting upright on the bed, shirtless. She was heaving in pain and
drenched in a feverish sweat.
Two weeks later, Gabriela died in Puerto Suárez. Before her death, her tuber-
culosis test came back negative. The doctors immediately suspected a false
negative, but the clinic’s protocol required that she wait at least two weeks before
taking another test. Smear testing of sputum samples, the type of testing Gabri-
ela received, remains an imprecise means of detecting tuberculosis, especially
for patients coinfected with HIV (Steingart et al. 2012). Use of sputum testing
alone detects roughly 59.6 percent of positive cases, with this number dropping
to 47 percent for patients with HIV (WHO 2010). Beginning in 2010, WHO
guidelines began recommending the use of a new rapid test for tuberculosis (the
Xpert test) based on evidence that it detects more than 91 percent of tubercu-
losis positive cases, with HIV coinfection not significantly impacting the test’s
validity. A comparison of data from several countries indicates that when a
smear test yields a false negative, the additional use of the Xpert test results in an
average wait time of four days before beginning tuberculosis treatment. Without
this additional test, the average wait time before beginning treatment is 58 days
(WHO 2010). For patients like Gabriela, a 58-
day wait is a death sentence.
Despite the fact that Bolivia has one of the highest rates of tuberculosis infection in the Western Hemisphere and received more than $10 million specifically for tuberculosis testing and treatment from 2004 to 2013 from the Global Fund to Fight AIDS, Tuberculosis, and Malaria (or simply the Global Fund; Global Fund 2017a), the Xpert test was unavailable.
Following Gabriela’s test results, Hilda had to make a decision. Should Hilda
wait in Santa Cruz with Gabriela until she could take another tuberculosis test and risk losing her job in Puerto Suárez? Should she leave Gabriela in Santa Cruz with no family to look after her? In the end, Gabriela, her mother, and her daugh- ter returned to Puerto Suárez together. Gabriela died at home with her mother caring for her.
Upset by the circumstances of Gabriela’s death, I spent the remainder of my
time in Bolivia seeking to understand why events had unfolded the way they did.

6 Fault Lines of Care
Hilda’s question, “Is she going to die?,” and my response to her question con-
tinue to haunt me. I began my research with a sense of optimism about the role
that ARV rollout had played in saving lives around the world. In my graduate
training in medical anthropology, I read a heavy dose of the work of medical
anthropologist and physician Paul Farmer. This included looking at his pho-
tos of the “Lazarus effect” of ARVs in Haiti (Farmer 2010)—
before-and-after
images of individuals on the verge of death who had regained their health in a span of months after beginning ARVs. With these images in mind, I responded to Hilda’s question with a confident “No, she will get better” and proceeded to
explain to her how the ARVs could help rebuild Gabriela’s immune system. Hilda responded quietly, “My son died last year in an accident. I can’t lose
another child.”
Gabriela’s death was the first AIDS-
related death I witnessed in Bolivia during
a period of fieldwork that spanned 12 consecutive months in 2013 and 2014. In my remaining time in the field, more than a dozen people whom I would come to know, some more closely than others, died from AIDS-
related causes. After
returning to the United States, I continued to receive updates about my inter-
locutors, some of whom had become friends, who had died from AIDS. During a return trip in the summer of 2016, I learned of yet others who had died. Most of these deaths occurred because the person fell out of care, did not seek care, or sought care when it was too late.
These deaths are a part of a larger pattern in Bolivia and bring to light the need
to interrogate the ways that HIV interventions continue to leave people behind. At first glance, it is easy to assume that the HIV epidemic in Bolivia is rather unre- markable in relation to the epidemic on a global scale. The 17,334 cases of HIV registered in the country between 1984 and October 2016 (CDVIR 2016) pale in comparison to the 78 million cases of HIV documented globally (UNAIDS 2016). With an estimated HIV prevalence rate of 0.15 percent, Bolivia has one of the lowest rates of HIV in Latin America (Medrano Llano 2014). Although the overall rate of infection in Bolivia is low, more than half of all reported cases have consistently been in Santa Cruz.
Under pressure from HIV activists, the national government declared access
to free and comprehensive care for HIV a legal right in 2007. Further, treatment and prevention programs received $42.8 million in funding from the Global Fund between 2004 and 2016, with the aim of making universal treatment for HIV a reality (Global Fund 2017a). Massive funding for HIV in Bolivia was part of a larger global health effort to respond to HIV as an exceptional condition given the biological, social, and cultural contexts of the disease, which justi-
fied an exceptional response (Benton 2015). As a part of HIV exceptionalism, global governing bodies have set the lofty goal of ending AIDS by 2030, and the United Nations (U.N.) outlined mechanisms for achieving this goal in the

Fault Lines 7
2016 Political Declaration on HIV and AIDS (U.N. 2016). Yet Bolivia offers a
disturbing example of why reaching the goal of ending AIDS by 2030 is simply
not going to happen.
Despite the legal right to care for people with HIV, the massive ARV rollout
made available via support from the Global Fund, and a low disease burden,
Bolivia has consistently had the lowest ARV coverage in the Americas.
3
The
most recent figures indicate that only 35 percent of individuals with advanced
HIV infection were accessing ARVs (Medrano Llano 2014; PAHO 2012). Many
activists and public health officials whom I met insisted that the percentage
was actually far lower than this, referencing their experiential knowledge of large
numbers of cases going unreported. One factor contributing to underreporting
is that a positive test result has to be recorded at a public health facility in order
for the case to be registered. People who receive a positive result at a private
facility or in a massive testing campaign, such as at a health fair, are told to report
to a public clinic for follow-
up care. Often, this never happens and the case goes
unreported (Ramírez Hita 2013). Those who do not access care or fall out of care succumb to opportunistic infections and eventual death. Additionally, a significant percentage of newly registered cases of HIV in Bolivia are detected when the patient has already progressed to AIDS (Medrano Llano 2014).
4
As
was the case for Gabriela, by the time a patient has progressed to AIDS, there may not be enough time left for the ARVs to enable a person’s immune system to recover. The gap between lofty global health goals and the reality of people dying from AIDS in Bolivia points to the persistence of the fault lines that continue to drive the epidemic.
This book is about the fault lines that produce AIDS-
related deaths like Gabri-
ela’s in Bolivia at a time when an HIV diagnosis should no longer be a death sentence. By the late 1980s, scholars of HIV widely recognized that the disease was spreading along the fault lines of society (Bateson and Goldsby 1988; Fine- berg 1988), as it most heavily affected social groups marginalized by structures of oppression (Parker 2001; Schoepf 2001). The fault lines generated by eco-
nomic injustice, racial hierarchies, heteronormative expectations, and gender inequality are clearly relevant in Bolivia, which has long been one of the poor-
est countries in the Western Hemisphere and is characterized by deeply rooted racial hierarchies dating back to the Spanish conquest. While these dynamics of social oppression are central to understanding HIV in Bolivia, I expand upon the conceptualization of fault lines to interrogate how global health initiatives pri-
oritize addressing some fault lines over others while generating a new system of fault lines in the process. I focus specifically on the fault lines of care—
the ways
that the system of HIV care itself generates gaps in who accesses services, under what circumstances, and the ways that people experience care, stay in care, fall out of care, or avoid seeking care.

8 Fault Lines of Care
International development agencies, including global health organizations,
are keenly aware of certain forms of fault lines, especially those related to gen-
der and poverty, and have attempted to address some aspects of social inequality
as a part of HIV interventions. For example, beginning in the late 1990s, the
World Bank began experimenting with financing cash-
transfer programs as
both a poverty-reduction and HIV-prevention strategy. The underlying assump-
tion was that with increased financial security, the beneficiaries of cash transfers would be less likely to engage in risky sexual behaviors. These interventions have had mixed results, with cash transfer programs resulting in reduced risk behav-
iors in some contexts while actually increasing risk behaviors in others (Kohler and Thornton 2011). In Bolivia, the World Food Programme financed a pilot livelihood intervention by integrating nutrition counseling and food supple- ment access into existing HIV treatment programs. An evaluation of this pro-
gram found that patients felt the focus on nutrition alone was limiting because it did not capture the complexity of their livelihood needs, such as the need to migrate for work or the inability to take time off from work to go to the clinic (Palar et al. 2013).
These examples illustrate that fault lines are complex and not easily alleviated
by targeted and clearly defined interventions. Furthermore, as epidemiological evidence increasingly shows, the relationship between HIV and structural vul-
nerability is far from linear. Following the end of the civil war in Sierra Leone, public health officials expected to see high rates of HIV, yet the prevalence rate remained low (Benton 2015). Conversely, in Kenya, middle-
class individuals
appear to be more vulnerable to HIV and less engaged in prevention and test-
ing services than are Kenyans living in poverty (Moyer and Hardon 2014). It is with these points in mind that I interrogate the relationship between fault lines
and HIV.
In a geologic sense, fault lines rarely consist of clean fractures; more often,
they are zones of tension with ragged edges. Some fault lines are clearly visible; others are deep within the earth’s surface, and their only evidence is seismic waves. Certain stressors, such as the movement of magma, can create enough pressure to generate new fault lines or weaken already existing fault lines. The fault lines of society are equally complex. The health effects of poverty, gender inequality, and racial inequality are often obvious. Less obvious are the ways that health interventions with good intentions can create rifts. For example, HIV interventions have at times generated new social inequalities by granting resources only to those who are HIV positive in contexts where almost everyone is struggling to survive (Kalofonos 2010).
Despite this complexity, global health interventions too often conceptualize
fault lines as clear-
cut rifts that can be fixed with enough resources. Over the past
three decades, HIV has become a multi-billion-dollar industry that has given

Fault Lines 9
birth to global health bodies dedicated to fighting the epidemic, including the
Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Global
Fund. Jim Kim (2007), a medical anthropologist and physician who became
president of the World Bank in 2012, described the decade preceding my field-
work as the golden age of global health. Unprecedented global health invest-
ment in HIV programs and efforts to provide widespread access to lifesaving
medications in resource-
poor settings characterized this era. As HIV funding has
continued, in 2015 alone, global spending on HIV reached an estimated $19 bil-
lion (Kates et al. 2016). Bolivia has relied on these global health efforts, with the Global Fund providing more than 75 percent of all financing for HIV-
related
programs in the country between 2004 and 2014 (Medrano Llano 2014; PAHO 2012). A central tenet of the U.N. Political Declaration on HIV and AIDS is a call for more funding (U.N. 2016), further indicating that some policy makers view funding as the magic bullet for ending HIV.
Despite the massive funding efforts behind HIV, Gabriela fell through the
cracks. After hearing about and watching similar circumstances unfold for other Bolivians with HIV, I began to understand the complexity of the fault lines behind Gabriela’s death. There were the commonly recognized disadvantages associated with being a poor woman in a poverty-
stricken country. The services
provided by Epua sought to address these issues by offering Gabriela a place to stay, support in seeking care, and if she were to recover, job training opportuni-
ties. Yet the fault lines ran deeper than this; some of these are the product of the history of global health interventions in Bolivia.
Global Health Governance in Bolivia
Gabriela’s experience crossing the city from an NGO to a public health clinic in search of care illuminates the fragmentation of Bolivia’s health care system, which is composed of an “unruly mélange” (Janes and Corbett 2009, 175) of services that often have a disease-
specific focus. The public health care facili-
ties in particular typically have long lines of poor patients waiting for care, while they are utterly avoided by those who can afford private clinics. It is a system where facilities are chronically understaffed, wait times can be disastrously long, employees are frequently on strike, and on some occasions, facilities do not even have a clean water supply
5
(Castro 2016; Página Siete 2017; Ramírez Hita
2011). The Departmental Health Services (Bolivia has nine departments, or states) admits that the health care system is of such poor quality that it has “lost all credibility among the population” (SEDES 2014). On top of the poor quality of care, the health care system remains prohibitively expensive for most of the population. Fifty-seven percent of Bolivians have no form of health insurance
coverage (Ledo and Soria 2011) and nearly 40 percent live below the poverty

10 Fault Lines of Care
line (World Bank 2015a). Prohibitive costs and poor-quality services have cre-
ated a scenario where patients like Gabriela wait until the last possible moment
to seek care or, in other cases, do not seek care at all.
The historical context of the current state of the Bolivian health care system,
and the role of disease-specific global health interventions within it, is important
to consider. The AIDS epidemic has been described as emblematic of the ills of neoliberalism. The 1980s and 1990s saw the withdrawal of policies of redistribu- tion and weakening of public health care infrastructures in the developing world. This was the result of the conditions for receiving loans from international lend-
ing giants such as the World Bank and International Monetary Fund (IMF), which limited government investment in public services in the name of promot-
ing free-
market policies. It is within this context that HIV emerged, with steep-
ening inequalities and insufficient access to health care fueling the epidemic (Comaroff 2007; Nguyen and Peschard 2003; Pfeiffer and Chapman 2010).
Considering the connection between HIV and neoliberalism, and given
that Bolivia was the darling of neoliberalism (Gill 2000), it is remarkable that the HIV prevalence rate is so low. In 1982, Bolivia emerged from a decades-
long
s
eries of right-
wing military dictatorships that had the clandestine support of the
Central Intelligence Agency (CIA) of the United States (Dinges 2004). With the return to democracy, the national government began drawing up plans for a comprehensive primary health care system as a part of their vision of health as central to the progress of the nation. These plans fell apart in 1985 when the Bolivian economy collapsed, the government fell to the mercy of international lenders, and the IMF and World Bank mandated the adoption of economic restructuring policies as a condition of receiving loans (Molenaers and Renard 2003; Tejerina Silva et al. 2011). As a part of adopting World Bank policies, the government restructured the health care system in accordance with the USAID Health Sector Reform Initiative. Under this initiative, disease-
specific interven-
tions replaced plans for a comprehensive primary health care system, and private investment in the health care sector received priority over the development of public health care infrastructures (Tejerina Silva et al. 2011). Alongside health system restructuring came a reliance on NGOs to provide health care services and other social programs financed by external aid agencies such as USAID. NGOs, as independent entities, could bypass weakened state infrastructures and were favored for receiving development funds. During the 1980s and 1990s, NGOs boomed throughout Bolivia (Gill 2000). Health-
related NGOs for the
most part took on a disease-specific focus, reflecting the goals of international
aid programs.
During this time, USAID emerged as a key player in the development of
health programs, including those for HIV. When Bolivia’s Ministry of Health registered the first case of HIV in 1984, there was no national HIV/AIDS

Fault Lines 11
program or policy. In 1988, with a mere 13 registered cases of HIV (CDVIR
2006), USAID issued a $0.5 million grant for three years to begin the Proyecto
contra el Sida (Project against AIDS). As a condition to receiving the grant, the
Ministry of Health developed a national program with a strategy imported from
USAID and Centers for Disease Control and Prevention (CDC) frameworks.
As a result, this strategy drew heavily from a risk-
group focus that targeted sex
workers and homosexual men (Wright 2006).
This risk-group focus had a lasting impact on HIV services in Bolivia. This is
most evident in the system of CDVIRs (Centros de Control de Vigilencia y Ref- erencia / Control, Surveillance, and Reference Centers) that exist in each of the country’s major municipalities. The Ministry of Health initially created the CDVIR system for registering and monitoring sex workers, who are required to report for a health check every two weeks or risk losing their work authorization. As a leader of the national sex worker union explained to me in an interview, “They are only interested in the vagina,” making sure that workers are free of STDs to receive work authorization. CDVIRs serve not only as the monitoring center for sex workers but also as the primary source of HIV testing and care. When Bolivia began to develop a national strategy to respond to HIV, with the USAID focus on risk groups, health authorities deemed it logical to house HIV services with pre-
existing services for sex workers.
As poverty and employment flourished during the height of neoliberalism,
social movements began to gain power. Such movements included challenges to the privatization of water (Olivera 2004); demands to end draconian, U.S.-

led antinarcotic policies that harmed peasants (Gill 2004); and outcry over the
exploitation of the country’s natural gas resources (Gustafson 2011). In 2005, the combined efforts of various social movements helped elect Evo Morales
as the first indigenous president of a country in which a European and mestizo minority had long held power over what is a predominately indigenous popu- lation. President Morales’s political party, MAS (Movimiento al Socialismo / Movement toward Socialism), has maintained power in the Legislative Assem- bly, enabling the comprehensive implementation of the party’s agenda. Political, economic, and social transformations in more than a decade under Morales have included a new constitution, land reforms, nationalization of natural resources, and rejection of coca eradication programs financed by the U.S. In 2016, voters narrowly rejected a constitutional referendum that would have allowed Morales to run for another term in 2019, leading to speculation over the future of the politically polarized country. In the meantime, President Morales’s promises for a more just society have included a plan of decolonization, or undoing the sys-
tems of domination produced through colonialism and neocolonialism. Health care reform was central to this broader agenda. While the national government made it a goal to develop a single-
payer health care system based on a model

12 Fault Lines of Care
of socialized medicine, which MAS called a communitarian health care sys-
tem, the funds have remained unavailable to do so. Instead, patchwork efforts
expanded insurance coverage for children, mothers, and the elderly (Johnson
2010). In response to this gap, some local governments made attempts to pro-
vide greater health care coverage at the local level. In Santa Cruz, the city govern-
ment announced in early 2014 that it would begin a plan to provide additional
financing to municipally funded clinics and hospitals. This initiative eliminated
user fees but still required patients to purchase all necessary medications and
supplies (Ortiz 2014).
In the case of conditions like HIV and tuberculosis, patients’ lives remain at
the mercy of funding through global health programs, as health care costs would
be prohibitively expensive for most citizens without this support. The Global
Fund has been the most significant source of funding for these conditions. Estab-
lished in 2002, the Global Fund transformed global health efforts by funnel-
ing an unprecedented amount of resources into expanding access to treatment
and prevention for HIV, tuberculosis, and malaria. Since 2004, grants from the
Global Fund have changed the nature of HIV initiatives in Bolivia. From 2004
to 2009, Bolivia received a grant of $16 million for HIV-
related projects, which,
most significantly, enabled ARV rollout. In 2009, the Global Fund renewed the grant until 2015, committing a sum of $21 million for HIV-
related projects
(Global Fund 2014). Apart from providing the funding for ARVs, Global Fund grants have been used for purchasing medications to treat the most common opportunistic infections, such as toxoplasmosis; lab supplies for CD4 and viral load testing; and hiring health care providers within the CDVIRs. Local HIV-

related NGOs also received grants to operate peer educator programs, support
groups, and prevention and testing outreach activities.
In 2013, the Global Fund announced that it would be restructuring its grant
process beginning in 2014. Under the new funding model, the primary goal was to maximize impact by reaching a higher number of people, setting the two most important factors in allocating funds as disease burden and a country’s economic status (Global Fund 2013). This announcement began to generate panic. Given Bolivia’s low rate of registered cases of HIV combined with the nation’s recent shift from a low-
income country to a lower-middle-income country, many HIV
activists assumed that the country would lose Global Fund eligibility altogether. However, when the Global Fund announced its new eligibility criteria in 2014, it revealed that in the next funding cycle, to begin in 2016, Bolivia would maintain similar levels of funding to what it had received in the past.
The fact that the Bolivian government was trying to move away from neo-
liberal policies during the same period it was the recipient of a massive influx of global health funding has generated tensions and contradictions. In 2013 and 2014, as a part of decolonization efforts, the national government expelled

Fault Lines 13
multiple international development agencies. Two of these—IBIS and USAID—
had played a central role in HIV programs throughout the country. Calling
USAID “an instrument that still has a mentality of domination” with “political
ends, not social ends,” President Morales explained his decision to expel the
agency in May 2013 (El Deber 2013). The same rationale warranted the expul -
sion of the Danish agency IBIS in December 2013. The effect of IBIS’s expulsion
was more profound for HIV, as it had been the Principal Recipient of HIV grants
from the Global Fund. In this capacity, IBIS acted as an intermediary, moni-
toring and disbursing grant money from the Global Fund to local community
organizations.
In a dramatic continuation of this trend, in May 2014 the Ministry of Health
announced that it would begin managing the Global Fund grants. The minis-
ter of health described the decision as coming “in the public’s best interest for
their health, and for the state’s corresponding obligation to the health of the
individual, the family, and the entire population.”
6
This announcement came in a
letter sent from the minister of health to the Country Coordinating Mechanism
(CCM), a group of local stakeholders that includes people with HIV, representa-
tives from NGOs, and Ministry of Health officials. The takeover of management
of funds was in violation of Bolivia’s grant agreement with the Global Fund. This
agreement states that the CCM must vote to determine what entity will manage
the grant. While the Ministry of Health could theoretically manage funds, the
power to do so could only be granted through a vote of the CCM. In violation of
this mandate, the Global Fund froze Bolivia’s grant.
When the Global Fund freezes grants, it continues to provide money for
ARVs and lab supplies for up to two years, or until the country meets criteria
to have funds unfrozen. During the period of the freeze, however, funds are not
available for additional programs of support, care, and prevention. In the final
months of my fieldwork in 2014, HIV-
related NGOs, HIV activists, people with
HIV, and local public health officials entered a state of panic, organizing meet-
ings and negotiations with the Ministry of Health in order to reestablish grant management procedures in accordance with Global Fund guidelines. In Santa Cruz, activists created a Regional Coordinating Mechanism (RCM) as a means to organize people with HIV and public health officials on a local level in the absence of a fully functioning CCM. At the national level, the CCM established an ad hoc committee that voted to make the minister of health the president of the CCM but did not make the Ministry of Health the Principal Recipient for HIV-
related grants. This decision appeased the Ministry of Health without turn-
ing over the management of funds to them. It took more than a year for Bolivia to regain its access to funding from the Global Fund, having funds reinstated in mid-
2015. This drama placed Bolivia in a liminal status in terms of funding for
HIV programs during the height of my fieldwork.

14 Fault Lines of Care
Although Bolivia regained access to its Global Fund grants in 2015, there
continued to be a sense of uncertainty about future funding. As Bolivia’s GDP
has increased, its World Bank classification has gone from that of a low-income
n
ation to a lower-
middle-income nation, which comes with stricter limits on
the amount of funding that Bolivia can receive from the Global Fund in the future. When the CCM reapplied for funding in 2016, it was awarded $8.7 mil-
lion for HIV programs until mid-
2019 but was told that it would be expected to
transition out of receiving Global Fund support. As a result, activists and civil society organizations have continued to scramble for other sources of HIV fund-
ing. This has included increasing pressure on the national and local governments to commit more funding to HIV—
a commitment that government authorities
have been hesitant to make given that they view the disease-specific approach to
health to be a contradiction to the goal of developing a comprehensive commu- nitarian health care system.
The perceived incompatibility between earmarking funds for HIV and
strengthening the overall health care system is a key issue. A central argument behind the push for massive investment in HIV was that these funding efforts could help strengthen primary health care infrastructures by driving funding to the health care system as a whole (Farmer 2003; Mann 1999). However, in many contexts, funding has gone to disease-
specific initiatives at the cost of failing to
invest in other health challenges or social programs that would be beneficial
to the overall health of a population (Benton 2015; England 2008; Pfeiffer et al. 2010). This critique is a primary concern in Bolivia, where HIV services are delivered largely via distinct health centers—
namely, CDVIRs and NGOs that
focus exclusively on HIV. The broader public health care infrastructure has his-
torically been poorly funded and poorly equipped to deal with an array of press- ing health issues that have plagued Bolivia, including a high maternal and infant mortality rate, endemic Chagas disease, and one of the highest disease burdens of tuberculosis in the Americas (Bastien 1998; Tapias 2015; Zulawski 2007).
On a global scale, well-
funded systems of care for HIV within contexts of
otherwise struggling health care systems have emerged due to HIV exceptional-
ism. As the case of Bolivia demonstrates, HIV exceptionalism has had limited success in containing the epidemic and ensuring universal access to ARVs. There are multiple ways of thinking about this paradox. Some scholars argue that HIV remains exceptional because the social experience of the condition remains exceptional (Moyer and Hardon 2014). Others argue that HIV exceptional-
ism limits health care systems by funneling resources away from other pressing health conditions while further driving HIV-
related stigma and discrimination.
Roger England (2008) goes as far as calling for the shutdown of UNAIDS. Adia Benton (2015) argues for somewhat of a middle ground, pointing to how HIV remains complex and challenging. The resulting attention, however, can draw

Fault Lines 15
resources away from other pressing health issues. Thus HIV exceptionalism has
created a double bind (Benton 2012).
This double bind has generated new fault lines in the HIV epidemic, not only
with the potential to ignore other prevalent health issues, but also because of
problematic methods of decision-
making about how HIV funding should be
allocated. Countries that are recipients of global health dollars are under con- stant pressure to produce studies to justify the expenditure of resources and provide evidence that the resulting interventions were successful. The medical anthropologist Susana Ramírez Hita has been a part of various Bolivian research teams contracted by the Global Fund and the Pan American Health Organiza-
tion (PAHO) and has been a vocal critic of the research methods used by these organizations. Citing Global Fund studies that have served as the basis for allo-
cating HIV funding, she points to how the research instruments used in Bolivia were flawed because they failed to consider the particularities of the local con- text. Part of the problem lies in the reliance on Rapid Assessment Procedures, which are seen as efficient and cost-
effective but result in data that lack any sort
of depth or contextualization (Ramírez Hita 2011, 2013).
Ramírez Hita’s work points to a broader critique of global health’s reliance
on metrics to develop programs and make funding decisions (Adams 2016; Erikson 2012; Sangaramoorthy 2014). Numbers have been given extraordinary power in the global health realm, allowing decisions from a distance (Latour 1987). When these numbers bypass local realities by assuming uniformity in diverse local contexts (Erikson 2016; Whiteford and Manderson 2000) and try to force local life onto a pre-
established international template (Pigg 2001), new
fault lines emerge. In Bolivia, this is particularly evident in relation to gender.
The Gender of Fault Lines
A major failure of public health institutions in the early years of the AIDS epi-
demic was the delay in recognizing women’s vulnerability to HIV. This was largely the result of a reliance on metrics. Initial epidemiological trends per-
petuated a risk-
group focus, even after mounting evidence showed the flawed
construction of these risk groups (Oppenheimer 1988). In retrospect, there is widespread agreement that ignoring women further perpetuated what was a growing public health crisis.
Throughout the 1990s, it became increasingly clear that there was a need to
address the HIV epidemic among women. Carol Bellamy, former director of UNICEF, captured this point at the 2002 International AIDS Conference when she stated in a speech, “AIDS has a woman’s face.” Global health documents,
the media, HIV activists, and public health officials have now recited this phrase countless times. But what does it mean to say, “AIDS has a woman’s face”? The

16 Fault Lines of Care
motive behind this mantra has been to bring attention and resources to women
and HIV, and images of suffering women and children were central to generating
the compassion needed to fuel global health responses to HIV (Fassin 2011).
The focus on gender and HIV within global health emerged following
decades of efforts to make gender a part of modern development discourse
(Merry 2006). Various international declarations and agreements mandate a
focus on gender within global health bodies and development organizations
that are influential in the financing and development of HIV/AIDS programs.
Through the Fourth World Conference on Women in Beijing (1995), U.N. Gen-
eral Assembly Declarations of Commitment on HIV/AIDS (2001 and 2006),
and the Millennium Development Goals (2000), global governing bodies have
publicly declared their commitment to addressing the gender inequalities driv-
ing the epidemic. Global health bodies have also taken up this task, as exempli-
fied by the Global Fund. Through a human rights statement, the Global Fund
declared its commitment to prioritizing vulnerable populations. It elaborated
on this commitment in its Gender Equality Strategy, which encourages fund-
ing for “programs and activities that address gender inequalities and strengthen
the response for women and girls,” citing the rationale that “harmful gender
norms—
including those that reinforce the submissive role of women . . . are key
drivers of the epidemic” (Global Fund n.d., 4–5).
My ex
periences watching women, including Gabriela, struggle to gain access to
resources left me wondering—
were women really being prioritized in Bolivia?
My answer to that question is no, despite appearances to the contrary. Two pri-
mary concerns have led me to this conclusion. First, despite its claims to priori-
tize programs aimed at women, the Global Fund has consistently denied funding for such programs in Bolivia. Second, the ways that global health bodies have approached gender draw on oversimplified, stereotypical understandings of gen- der that have led to an array of unintended consequences. The ways that the lived experiences of individuals conflict with gendered social imaginaries create fault lines (Smith 1990).
To elaborate, the Global Fund has consistently denied funding to programs
that would focus on women through claims that such interventions are not high-

impact or cost-effective. A clear example of this is from Bolivia’s 2012 Grant
Renewal Scorecard. Grant Renewal Scorecards serve as monitoring tools to demonstrate that countries are using funds in accordance with grant agreements and to demonstrate that resulting programs are having the intended impact. As a part of the scorecard, the CCM must respond to a series of questions devised to reflect that they are fulfilling the mission of the Global Fund. The questions on the scorecard, and responses to them, are telling.
One question asks, “Has the Country Coordinating Mechanism request
considered issues of human rights and gender equality?” The CCM vaguely

Fault Lines 17
responded by saying it would use funds to support “activities promoting human
rights of people with HIV and of key populations,” making no specific reference
to gender (Global Fund 2012).
This is followed by the question, “Are the activities to be funded in the next
implementation period appropriate given the specific country and disease con-
text?” The response is as follows: “Compared to Phase 1 and to the originally
approved proposal, all preventive activities have been focused on most at risk
groups and the activities targeting other groups (such as women, young people, and
public drivers
7
) have been removed from the budget. Resources have been repro-
grammed to increase funding for high-
impact interventions” (Global Fund 2012, 10,
emphasis added).
Examining these two questions in relation to one another illustrates a major
contradiction. Despite repeating claims to “champion and fund proposals” that focus on gender-
related vulnerability (Global Fund n.d., 5), when the CCM
proposed testing and prevention activities aimed at women, such activities were “removed from the budget.” The Global Fund’s funding strategy is essen- tial for understanding this paradox. The funding strategy is based primarily on two factors—
a nation’s ability to pay for programs itself, defined in terms of
GDP, and disease burden. Infection rates alone, however, do not define a dis-
ease burden. Having a concentrated epidemic among “high-risk” populations
such as injection drug users or men who have sex with men (MSM) also factors into a country’s disease burden. The Global Fund considers a 5 percent rate of infection among a subpopulation as a critical threshold for defining a local epi-
demic as a concentrated epidemic, with a country qualifying for grants if it can demonstrate infection rates at or above this threshold within a given risk group. Consequently, for Bolivia to maintain access to Global Fund grants given its low rate of infection among the general population, it is essential to demonstrate a concentrated epidemic within a risk group. The majority of funding then goes toward programs that target these risk groups. Since Bolivia has a concentrated epidemic only among the problematic epidemiological category of MSM, nearly all of the Global Fund grant money for HIV, with a few exceptions, is funneled to LGBT
8
organizations. The interventions that reach women are limited in scope,
and the groups of women who are the intended subjects of these interventions are telling—
namely, efforts to test pregnant women and sex workers consistently
receive funding. Testing pregnant women has become widespread practice on a global scale as a means of achieving the Millennium Development Goal of eliminating mother-
to-child transmission. In Bolivia, among sex workers, HIV
rates have consistently been very low, at 0.57 percent in 2012 (Aguilera Hurtado 2014), and do not reach the 5 percent critical threshold defined by the Global Fund as a high-
impact intervention; however, sex workers are the only group of
women consistently named as a target population in both testing and prevention

18 Fault Lines of Care
efforts. Funding for women who are not pregnant or sex workers exists only for
HIV treatment programs, when women have already tested positive for HIV.
Thus the ways that programs aimed at women receive financial support hinges
on a very limited understanding of women’s sexuality—
women are either moth-
ers, having sex for reproduction, or whores, potential vectors of infection.
In Bolivia, the CCM must work within the risk-group language to maintain
funding, even if this model ignores the complexity of women’s vulnerability and does not make sense within the local contours of the epidemic. Even epide- miological patterns indicate that the Global Fund’s approach is problematic in Bolivia. In 2005, the year after Bolivia’s first Global Fund grant went into effect, the Ministry of Health registered only 330 new cases of HIV. From 1984 to 2005, nearly 80 percent of registered cases of HIV were in men, primarily MSM (Red-
Vihda 2005; Wright 2006), providing some justification for focusing preven- tion efforts on this group. However, in 2009, 43 percent of new cases were in women, marking a trend that has continued to the present day (CDVIR 2016). This shift in the sex ratio of new infections may in part be a reflection of global health programs in Bolivia as much as it is a reflection of epidemiological shifts. Beginning in 1988, USAID focused its efforts almost exclusively on MSM and sex workers. It was following the first grant from the Global Fund that epidemio-
logical data began to show a dramatic increase in the number of new infections among women. With testing pregnant women as a major initiative as a means of preventing mother-
to-child transmission, women were more systematically
tested for HIV for the first time. Prior to the Global Fund grant, PAHO research- ers estimated that HIV cases were underreported by 70 percent (Protto et al. 2008). Although this study did not look for gender biases, it is possible that cases among women were disproportionately underreported given the lack of atten- tion to testing women.
Whether or not earlier statistical data were flawed, the focus on MSM has
always been problematic. Epidemiological studies suggest a prevalence rate of 11.6 percent among men who reported having sexual relationships with other men (Global Fund 2012). These studies group a diverse range of sexual iden- tities under the category of MSM, failing to account for local constructions of sexuality. In Bolivia, there is a distinction among travestis (transgender women),
maricones (or los gays), and other men of the ambiente. The term ambiente (liter -
ally “ambience”) refers to a subculture of men with same-
sex desires. Travestis
often describe themselves as the only real homosexuals, fully embodying their sexuality through how they perform gender. Maricón, when not being used as a pejorative term, refers to a man who identifies as homosexual within the ambi-
ente, although he might or might not actively embody this identity in all realms of life. Men of the ambiente who do not identify as gay also actively seek sex with

Fault Lines 19
other men but often perform heterosexuality both within and outside of the
ambiente. Here, it is important to note that taking on the “active” role in sexual
encounters allows a man to perform heteronormativity even when it involves sex
with another man or a travesti.
9
These men often have steady female partners.
Similar trends have been observed in multiple contexts in the Americas (Car-
rillo 2002; Parker 1999). Given these dynamics, the focus on MSM while ignor-
ing women overlooks one of the most fundamental aspects of sexual relations in
the local context. Additionally, funneling money aimed at MSM through LGBT
organizations can be ineffective and even counterproductive, since many men of
the ambiente actively distance themselves from the LGBT label (Wright 2000).
It is important to consider what the Global Fund’s funding strategy means for
women like Gabriela. Gabriela was never the target of an HIV testing or preven-
tion program and only had an HIV test when she began showing symptoms of
tuberculosis. When she did test positive, access to the services available through
Epua greatly facilitated her ability to navigate a fragmented and confusing health
care system. However, Epua receives no funding from the Global Fund. Without
access to Global Fund grants, Epua relies on piecing together grants from smaller
donor agencies, and its primary source of funding comes from a Catholic charity.
This leaves Epua in a perpetual state of funding insecurity, and two months fol-
lowing Gabriela’s death, Epua had to make substantial cuts to its acompaña-
miento program. Funding from a Catholic institution also has implications for
prevention. Although I witnessed employees from Epua counsel women on con-
dom use and birth control, they never provided condoms.
Aside from the lack of resources to back up claims of focusing on gen-
der, global health bodies often rely on essentialized understandings of gender
(Bleiker and Kay 2007; Chong and Kvasny 2007; Fassin 2011; Le Marcis 2014;
Seckinelgin 2011). Raewyn Connell (2012) makes similar observations of
global governing bodies more broadly, pointing to portrayals of men and women
as fixed categories. This categorical thinking about gender sees biology, gender
roles, and social norms in essentialist terms, underplaying the diversity within
gender categories (Connell 1987, 2012). This observation is striking in exam-
ining key global health documents.
10
For example, the WHO’s (2009) toolkit
“Integrating Gender in HIV/AIDS Programmes in the Health Sector” lays out
four focus areas for responding to women’s needs—
HIV testing, prevention
of mother-to-child transmission, treatment and care, and home-based care.
The categorization of these areas is telling. The only mention of prevention is preventing mother-
to-child transmission. Further, the specific points and rec-
ommendations within each of these areas overwhelmingly portray women as passive, without agency, in their sexual relationships. One passage states, “Gen- der influences sexuality, sexual behavior, and the risk of HIV in several ways.

20 Fault Lines of Care
This includes ideas that women have to remain pure and virginal until marriage”
(WHO 2009, 3). Absent is any discussion of women having sex for pleasure; the
emphasis is on sex as fulfilling a reproductive role for women. Men, on the other
hand, are often framed as transmitters of infection within intimate relationships.
Global health discourses, especially those originating from the WHO, become
institutionalized within local HIV programs. In accordance with the Global
Fund prerequisites for granting funds for a country, a National Strategic Plan for
HIV that aligns with WHO guidelines must be in place.
Gabriela’s death from AIDS highlights the fault lines that were ignored and
new fault lines that have been produced via the Global Fund in Bolivia. Despite
massive funding for HIV, the public health care system has remained of such low
quality that patients use it as a last resort, contributing to late diagnoses of HIV.
As a woman, Gabriela was not the subject of HIV interventions, despite a global
health discourse that mandates a focus on gender. Gabriela did not even receive
an HIV test while pregnant, even though testing pregnant women was one of the
only major Global Fund HIV initiatives aimed at women in Bolivia. The fact that
the father of Gabriela’s daughter reportedly tested negative for HIV is indica-
tive of why assumptions that women are “pure and virginal” are problematic. It
is possible that Gabriela’s partner lied about his result or had a false negative;
neither of these scenarios is uncommon (Piwowar-
Manning et al. 2014; Rhine
2016; Whyte 2014). But it is also possible that Gabriela was infected otherwise, and the assumption of women as “pure and virginal” ignores the complexity of women’s sexual lives. As I will detail in chapter 4, it is common for women to test positive while their long-
term male partners test negative, yet this pattern has
gone largely unacknowledged.
Global Health as a Politics of Life
“Now everyone receives the medications for free, but it might be different in the future,” a psychologist with the CDVIR in Santa Cruz warned a group of patients who were required to participate in a group therapy session before beginning ARVs. The psychologist went on to explain that medications might not always be free in Bolivia, so in the future, “there might be stricter criteria. For example, during pregnancy women will always get the medications for free. If you aban- don treatment, you might have to pay for it if you want to start again.”
The psychologist’s attempt to encourage patients to take their medications
hinted at a broader issue—
the ways that public health interventions involve
decisions about whose lives are worth saving and on what grounds, creating fault lines of survival (Petryna and Follis 2015). To understand the processes behind these fault lines of survival, medical anthropologist Didier Fassin (2007a, 2009)

Fault Lines 21
has used the concept of “politics of life”
11
as a framework for understanding how
political decisions enacted via humanitarian interventions, immigration poli-
cies, global health interventions, and an array of other public policies involve
decisions that can have life and death at stake. While such decisions are often
framed as apolitical when humanitarian goals are at stake (Ferguson 1990), they
are, in Vinh-
Kim Nguyen’s words (2010, 13), “political in the strongest sense,
projecting the power of life or death.” Extending Foucault’s (1997) work on biopolitics, or ways that states exert control and power over populations, Fas-
sin (2009) adds that meanings, values, and moral frameworks factor into policy decisions. Resulting policies, interventions, and resource allocations have the potential to generate inequalities by granting resources to some and denying them to others. Additionally, the bureaucratic public health institutions that wield power in implementing policies have consequences for individual action (Heyman 2004). The very stakes include life itself. Nguyen (2010) examines the ways that global health policies surrounding HIV/AIDS interventions in West Africa served as a politics of life by granting some people access to ARVs while systematically denying access to others. This was especially the case in the years immediately following the development of effective AIDS therapies when only a limited supply of the drugs was available. As activist organizations and minis-
tries of health needed to provide body counts and the stories of lives saved to justify massive global health spending on AIDS therapies, individuals willing
to disclose their HIV narrative gained access to medications more easily than those not in a position or unwilling to publically disclose their status. In this sense, illness narratives became a commodity that could attract donor invest-
ment for massive treatment campaigns. Those with the commodity, in return, gained access to lifesaving medication and care.
In considering the politics of life, it is necessary to interrogate what counts as
politics. In its most obvious sense, politics refers to the act of governing. Politics is also about the exercise of power, which includes social interactions and the debates and tensions that unfold as part of these interactions. It is rather obvi-
ous that the development and implementation of HIV interventions involve acts of governing at the global health and local levels and that resulting policies define what resources will be available and who can access these resources. Less obvious, but no less significant, are the latent ways that personal relationships and interactions factor into an individual’s ability and willingness to engage with HIV-
related services. Social hierarchies, gender ideologies, and the exe-
cution of global health agendas in the local context frame these everyday inter-
actions that shape a person’s experiences of care (or not seeking care) and his or her illness experience. What Foucault (1976) called the micromechanics of power and others have called micropolitics (e.g., Waitzkin 1993) are useful

22 Fault Lines of Care
for understanding how everyday interactions in medical encounters involve an
exercise of power between individual subjects. These encounters occur within a
social context produced by broader ideologies and systems of domination.
Contradictions abound in global health policies, as official statements and
policies suggest a moral agenda of prioritizing women and children while pres-
sures of producing numbers of lives saved limits the allocation of resources. This
becomes more complex as policies and funding filter through into the local level.
Global health policies not only determine resource allocation; they also influ-
ence how health care workers imagine their patients. Health care workers receive
training in line with guidelines and manuals produced by global health bodies,
but these guides intersect with pre-
existing ideologies and understandings of the
social order. Nowhere is this more problematic than in relation to gender.
As a discourse of aiding women has become central to driving global HIV
interventions, it is important to interrogate the relationship between gender and the politics of life. Gendered discourses of deservingness that hinge on images of women as victims of the AIDS epidemic have been central in generating the compassion behind massive funding for HIV/AIDS. As Miriam Ticktin (2011) shows in her research on asylum seekers in France, constructions of innocence, or morally legitimate suffering, are central in driving humanitarian compas-
sion. While compassion has been a necessary force in generating the political and social will to make lifesaving HIV care widely available in resource-
poor set-
tings, the narrative driving this compassion frames some individuals—namely,
children and some women—as innocent, implying that others are not innocent.
This framing has implications for how individuals experience care and, at times, feel and may be actively excluded from care. To understand how HIV interven- tions create systems of exclusion in relation to gender, the gendered politics of life is at the core of this book.
Through an analysis of the gendered politics of life, I examine the ways that
gender factors into not only the development and implementation of HIV pro-
grams but also the everyday experiences of individuals seeking care. Beyond insufficient resources for substantiating claims of prioritizing women, social imaginaries tied to gender shape interactions in the context of HIV interven- tions, playing a role in how individuals experience their illness and the care they receive for it. The illness narratives in this book provide a striking critique of the stereotypical discourses surrounding gender that frame the implementation of HIV programs. In this sense, illness narratives are political, transmitting the complexities of all that is “historical, social, gendered, ordinary” about one’s ill-
ness (Fassin 2007b, 25).
In line with feminist theory on intersectionality (Crenshaw 1989; Collins
2000), the gendered politics of life is not exclusively about gender but about the ways that gender intersects with other systems of domination, such as class,

Fault Lines 23
ethnicity, race, and sexual identity. Hence I give attention to the ways that gender
intersects with other axes of structural violence (Farmer 2003) and structural
vulnerability (Quesada et al. 2011) for understanding how the politics of life
shape illness experiences and experiences seeking care.
Conducting an Ethnography of Care
Carolyn Nordstrom (2009, 63–
64) says of fault lines, “[They] do not reside
within landmasses, but in certain political, economic, and ethical relations that span the world’s countries. Fault lines are flows—
often unrecorded—of goods,
services, monies, and people that precipitate unstable inequalities, uneven access to power, and unevenly distributed resources. They represent fissures in humanity.” Understanding the fault lines of care requires understanding care as a product of a complex global system that involves the exercise of power and sys-
tems of inequalities. To understand this complex system, I engaged in various levels of analysis that included a focus on individual experiences of care, perspec-
tives of health care providers and public health officials, and analysis of global health policies. Along with others (such as Myers 2015), I call this approach an ethnography of care.
While an ethnography of care involves multiple levels of analysis, I prioritized
understanding care from the ground up, or from the perspective of those receiv-
ing care. Drawing inspiration from hospital ethnography (Long et al. 2008) and clinic-
based ethnography (Smith-Morris et al. 2014), I used clinics and orga-
nizations such as Epua that provide support for people with HIV as a starting point for meeting people, arranging interviews, and conducting participant observation. My research often took me beyond these initial points of contact and into a much deeper nexus of care. With Gabriela, I joined in the frustrations of fighting traffic, being sent from one clinic to another, and partaking in what at times seemed like an endless wait for services—
aspects of care-seeking that are
central to illness experiences but that I would have never witnessed had I stayed inside clinic walls.
At other times, people asked me to go with them to their doctor’s appoint-
ments, invited me into their homes, introduced me to family members, brought me to church with them, requested visits in the hospital or in drug rehabilita-
tion centers, and introduced me to their friends from HIV support groups. I also accompanied health care workers, mainly social workers and peer educators, as they sought to provide care to patients outside of the clinical setting. By fol-
lowing individuals through their various realms of care, I sought to gain an in-

depth, experience-near understanding of their illness experiences (Kleinman
1997). However, an ethnography of care would have been difficult without first becoming a part of the institutions and organizations that provide care. Because

24 Fault Lines of Care
of this, I used the CDVIR in Santa Cruz and several HIV-related NGOs as
launching points.
The CDVIR in Santa Cruz is inside an old, deteriorating building on a heavily
trafficked road that leads into the city’s largest market. Crossing the street to
get to the clinic can be a daunting task. After getting off the bus, I often found
myself dashing across the street, ducking my head down in the process to
blind myself from the buses and cars that were racing toward me. Upon enter-
ing the gate that surrounds the building, a large sign reads CDVIR-
VIH, and
patients refer to the clinic simply as CDVIR. The “VIH” (HIV) on the sign has spurred more than one passerby to comment, “This is the center where los sidosos go,” drawing on a derogatory term for people with HIV. There are usu- ally dozens of people inside the building, waiting, at any given time. Many wear the face masks that mark them as having tuberculosis. Occasionally, sometimes assisted by a family member, patients like Gabriela are near death, having put off treatment or having received diagnoses when it was too late for ARVs to save them. Until 2009, in order to receive ARVs, patients were required to attend regular monthly appointments at CDVIR. Beginning in 2009, Santa Cruz began a decentralization
12
process that focused on integrating HIV care into pub-
lic clinics and hospitals throughout the city as opposed to only offering care through CDVIR. Despite this shift, roughly 90 percent of people with HIV in Santa Cruz who were in care during the time of my fieldwork went to CDVIR
for HIV-
related services (CDVIR 2013), primarily because they felt discrimi-
nated against in other health care facilities where few doctors have had HIV-
related training. Through my collaboration with CDVIR, I had regular hours
when I had access to office space and could conduct interviews with patients who were sent my way by the psychologists and doctors at CDVIR or by
those who had heard about me through the waiting room gossip chain. Some- times, these interviews turned into something else—
an invitation to visit
someone at home or a request for more information about support groups.
I also collaborated with several HIV-related NGOs and activist groups,
including Epua. When I began my fieldwork, Epua operated a free childcare center; offered job training activities; had an artisanal co-
op where women
made textiles, glass jewelry, and ceramics to sell; and had a social worker, psy-
chologist, and peer educator who met with women at the center, made home visits, and conducted acompañamientos. By the time I completed my fieldwork, these activities were beginning to disappear as a result of funding cuts. Most significantly, the childcare center closed in January 2014. I also collaborated
with RedVihda, the most well-
known HIV community organization in the coun-
try. RedVihda roughly translates to “HIV life network.” “Vihda” is an intentional misspelling of vida (life) as a way to evoke a double meaning, as Vih translates
to HIV. RedVihda has consistently received funding from the Global Fund and

Fault Lines 25
other international organizations to host support groups for people with HIV,
maintain an extensive peer educator program, provide legal support for cases of
discrimination, and engage in quality-
of-care initiatives, such as a campaign to
train health care workers to be more sensitive to the needs of people with HIV. Part of RedVihda’s success in receiving funding has been a result of the organiza-
tion’s flexibility in reframing its programs to fit within the goals of international funders such as the Global Fund. For example, by dedicating a substantial amount of work to LGBT outreach, RedVihda focuses on what the Global Fund refers to as a target population. Several other organizations that focus on LGBT rights more broadly, most notably Fundación Igualdad (Equality Foundation),
have also successfully secured HIV funding as a part of its effort to reach the LGBT target population. I engaged in some activities with Fundación Igualdad, but not to the extent that I did with Epua and RedVihda.
These NGOs are often included under the umbrella term civil society, but
civil society also encompasses other community-
based organizations that do
not necessarily benefit from international funding, as is the case of the Bolivian Network of People Living with HIV (RedBol). As an activist network, RedBol engages more in community organizing than in provision of services. Their com- munity organizing efforts are closely tied to the work of NGOs, evidenced by the fact that RedBol and RedVihda often collaborated in organizing activities.
Santa Cruz also has a small inpatient hospital on the outskirts of the city
that provides care exclusively for patients with HIV. This hospital, Comunidad Encuentro, receives funding from a Catholic foundation, and two doctors work there on a volunteer basis. As a result, patients do not have to pay to stay at the hospital. Additionally, ARVs and other medications available via the Global Fund were free. However, a patient’s other needs, such as a blood transfusion or IV solution, are not free. Patients frequently go without recommended care if they do not have the necessary funds. Given the precarious status of the patients, it was never my intention to involve patients at Comunidad Encuentro in my research. That changed when José Luis, a patient whom I initially met at CDVIR, entered Comunidad Encuentro with a suspected case of tuberculosis. José Luis had no friends or family members to visit him. When the nurse asked if there was anyone she could call on his behalf, he gave her my card. After receiving a call from the nurse, I began to visit José Luis. During these visits, other patients became curious about what I was doing in Bolivia. Some saw my research as an opportunity to tell their stories. As a result, I interviewed a small number of patients whom I met at Comunidad Encuentro. Additionally, informal conversa-
tions with patients and family members informed my understanding of the ways people fall out of care or delay seeking care.
Through these various organizations, I observed support groups, assisted with
health fairs, and as in the case of Gabriela, joined health care workers in various

26 Fault Lines of Care
types of support and outreach work. Through these activities, I met additional
people who participated in interviews, some of whom invited me to learn more
about them beyond a formal interview context. In all, I conducted formal inter-
views with 70 people with HIV and 16 health care workers while also regularly
engaging in informal conversations and interactions with many of these people
and their broader social networks. While I interviewed roughly equal numbers
of men and women, in this book, I focus largely on women’s experiences. To a
lesser extent, I also consider the experiences of men and those with diverse gen-
der and sexual orientations (whether or not they identified as LGBT). In focus-
ing on women, my intention is not to ignore other genders. Rather, I do not wish
to duplicate the extraordinary work already done by Tim Wright (2000, 2006)
on male sexuality and HIV in Bolivia. Additionally, as a part of interrogating the
fault lines of care, the ways that women have been the subjects of global health
interventions have produced a set of gendered fault lines that deserves particular
attention.
A few months into my fieldwork, I became an invited member of the Santa
Cruz Social Control Committee for HIV (or simply Committee for HIV)—
a
new gr
oup formed by members of activist groups and HIV-
related organizations.
The goal of the Committee for HIV was to develop mechanisms for putting pres-
sure on the national and local governments to respond to HIV in the absence of international support. My participation with this committee included attend-
ing meetings with government officials and representatives from international development agencies. It also allowed me to observe several RCM meetings. My involvement with this committee gave me greater insight into the execution of global health policies in the local context, along with the tensions that emerge as part of this process. After leaving Bolivia, I was able to access key documents produced by this group, such as notes from the CCM meetings, as a means to continue following the evolution of HIV interventions.
Overview of Chapters
I have structured this book to interrogate the various dimensions of the fault lines of HIV care in Bolivia. In chapter 2, I move into a more detailed discussion of the local context. This context includes a history of social hierarchies tied to
race, class, and gender. Since 2005, political transformations have attempted
to break down some of these hierarchies as a part of the process of decolonization. However, decolonization is filled with paradoxes, and this is especially clear in attempts to decolonize the health care system. As Bolivia tries to move away from a neoliberal model that relies on international funding, the country con- tinues to lack the necessary resources to provide health care for all. This creates tensions that have the potential to upset the structure of HIV care.

Fault Lines 27
The ways that social hierarchies create fault lines in care is crystallized in chap-
ter 3 through the illness narrative of one woman, Magaly. After Magaly’s daugh-
ter was born with HIV, Magaly became the first person with HIV in Bolivia to
file charges of medical negligence against anyone in the health care system. Mag-
aly’s status as a poor, indigenous woman, and her mistreatment within the health
care system, reveal how long-
standing social hierarchies contribute to wide-
spread medical negligence and discrimination within the health care system. The normalization of medical negligence highlights the ways that people with HIV continue to be excluded from care despite the existence of free services for HIV.
In chapter 4, I turn to a greater focus on gender, using the illness narratives of
several women to challenge the global health imaginary surrounding women. I show how many women’s experiences run contrary to the ways that women are imagined within HIV interventions, showing how stereotypical constructions of women within global health allow gendered fault lines to persist.
In chapter 5, I draw on the stories of two people—
Cassandra and Carlos—
who both h
ave secrets. Through these secrets, I interrogate the significance of
various forms of silence surrounding sexuality. In Santa Cruz, in certain realms, there is substantial silence surrounding both female sexuality and male same-
sex relations. Silence and secrets offer protection for those who have something
to lose if those secrets come out. This local enactment of silence, however, rein- forces stereotypical assumptions about sexuality that abound in the global health realm. The global health failure to acknowledge the realities and complexities of local sexualities is effectively a form of silence. In this respect, local silences and global health silences reinforce one another synergistically.
Chapter 6 continues with the focus on gender as a part of the global health
imaginary, but here, I turn my focus to men. A discourse that blames machismo for HIV has emerged at the intersections of global health policy and local gender ideologies. In this chapter, I break down the ways that HIV-
positive men experi-
ence care in light of often feeling that they are targets of blame.
In chapter 7, I delve into the drama surrounding the freezing of Bolivia’s
Global Fund grant. I look specifically at the tensions that exist among the Global Fund, the Bolivian Ministry of Health, and civil society organizations. With large amounts of money at stake and disagreements over the appropriate use of funds, biopolitical dramas begin to unfold at the local level. I use the term biopo -
litical drama to describe the friction that emerges as civil society organizations, governmental bodies, and international bodies generate policies and regulations that guide HIV interventions and the allocation of grant money. Resulting inter-
ventions ultimately define the fault lines of survival.
I conclude by reflecting on ways that both global bodies and local actors can
think about addressing the fault lines of care. In order to address fault lines, it is essential for global health bodies to recognize the unequal power dynamics that

28 Fault Lines of Care
they have created and to renew calls for using HIV funding as a way to develop
public health care infrastructures.
Gabriela’s death is a stark reminder that the fault lines of care are ultimately
about life and death. Short of a cure for HIV, existing medications offer the
potential for people with HIV to live a healthy life. They also serve as a power-
ful form of prevention, as ARVs reduce a patient’s viral load, lowering the risk of
transmission (WHO 2011). Thus the technological tools exist for ending HIV.
However, as the individual experiences that form the core of this book demon-
strate, consistent and timely access to care remains out of reach for many Boliv-
ians with HIV.

29
2 • DECOLONIZING BOLIVIA
In January 2010, I made my first trip to Santa Cruz, Bolivia. The
American Airlines overnight flight departing from Miami made a one-hour stop
at the La Paz–El Alto airport and then continued on to Santa Cruz. La Paz and El
Alto are sister cities, with populations of roughly 800,000 and 900,000, respec-
tively, in 2016 (INE 2012). El Alto sits at a higher elevation, overlooking the
bustling center of commerce and government buildings in La Paz. The airport is
located in the heart of El Alto. With an elevation of 13,325 feet, it is the highest
international airport in the world. During the short stopover, the sun was just
beginning to rise. Looking out of the window, I could make out the sea of small
redbrick houses that made up the urban sprawl. Illimani, the second highest
mountain in Bolivia, towered in the distance.
As the plane took off for Santa Cruz, we floated above the glacier-
capped
peaks of the Andes. My husband fidgeted anxiously in the seat next to me. Boliv-
ian by birth, he had immigrated to the United States with his parents and youn- ger sister when he was 14 years old, becoming one out of roughly 1.6 million Bolivians living outside of the country (International Organization for Migration 2016). In a country of roughly 11 million inhabitants (INE 2012), migration has
served as an economic survival strategy to cope with a struggling economy and limited employment opportunities. For migrants who return to Bolivia, the money saved working abroad can offer social mobility that would have been unattainable without migration. This was my husband’s first time returning to Bolivia since he had left more than a decade earlier. For both of us, this trip was exclusively to visit family, but I would return the following summer to conduct preliminary research for my dissertation.
In less than an hour, we began our descent into Santa Cruz. The rocky peaks
of the Andes first transformed into lush rolling hills before opening up to the endless plains of the Santa Cruz department. Santa Cruz de la Sierra is the full name of the department’s capital city, but locals shorten the name to Santa Cruz,

30 Fault Lines of Care
sometimes creating confusion as to whether someone is talking about the city
or the department. Locals joke that their city is the heart of South America, ref-
erencing the city monument that marks the geographic center of the continent.
The land below us consisted of vast landholdings belonging to the region’s
elite. Cattle ranches, along with sugar cane, soy, and cotton crops, power the
agro-
industrial hub of the nation. Santa Cruz’s Viru-Viru International Airport
lies on the northern edge of the city, so planes arriving from La Paz do not fly
Map 2.1. Bolivia, the heart of South America. Source: CIA World Factbook.

Decolonizing Bolivia 31
over the city. Had we flown in from a different direction, I would have been able
to see the urban sprawl of 1.6 million residents in a city that in 1976 had a popu-
lation of only 256,000 (Kirshner 2013). The peri-
urban areas and satellite cit-
ies surrounding Santa Cruz had also experienced rapid population growth, with the satellite city of La Guardia undergoing an 802 percent population increase between 2001 and 2012 (INE 2012). Rural-
to-urban migration has spurred this
population boom.
An aerial view of the city would have also offered me an introduction to the
city’s layout, which consists of a city center that spreads outward in concentric circles called anillos (rings). Older residents speak of a time when the city only
had four rings, with the fourth ring consisting of mostly open land with a sparse number of houses. There are now twice as many distinct rings, although the Piraí River creates a geographical barrier on the northwestern edge of the city that prevents any ring after the fourth from forming a complete circle. Because of this, the urban sprawl is concentrated in the eastern half of the city. Within this sprawl, the rings begin to disappear. Historically, middle-
and upper-class resi-
dents have occupied the three innermost rings, with the neighborhoods becom- ing increasingly poorer the farther one moves away from the city center. This pattern has shifted over the past decade, however, with gated neighborhoods sprouting up on the outskirts of the city. Most notably, on the western side of the Piraí River, Urubo has become the city’s most exclusive neighborhood, boast-
ing its own country club. Furthermore, in recent decades, increased opportuni-
ties for social mobility as a result of the economic boom from an illicit cocaine industry, money saved working abroad, and increased access to education
have created a new middle class (Shakow 2014). Some members of the new middle class have remained in historically working-
class sectors of the city,
resulting in a growing number of larger houses in the middle of poor and working-
class neighborhoods on the urban periphery.
After our plane landed and we made our way through customs, we were
greeted by nearly 30 friends and family members. Amid the chaos of emotional relatives, an aunt adorned each of our heads with a saó, a traditional straw hat
that is a symbol of regional pride. Someone draped the Santa Cruz flag over my husband’s shoulders as we posed for pictures. As we made our way outside, I was immediately caught off guard by the suffocating humidity; the change in hemi-
spheres had taken us from winter to the dead heat of summer. We climbed into a car with two of my husband’s male cousins, who blasted cumbia music as we drove
toward the home of my husband’s grandparents. I quickly became distracted by the messages in the city’s rampant political graffiti. Messages of Evo cumple (“Evo
fulfills”) and fuera el imperialismo (“out with imperialism”) stood in contrast to No MAS Evo (“no more Evo,” evoking a double meaning with the acronym for the political party MAS) and Evo = Narcotraficante (“Evo = narcotrafficker”),

32 Fault Lines of Care
reflecting a deep political divide in the city. Days later, I would see a taxi with
a swastika painted on the rear windshield. The driver was possibly a member of
the UJC (Unión Juvenil Cruceñista / Santa Cruz Youth Union), the strong arm
of the right-
wing group of business elites that form the Santa Cruz Civic Com-
mittee. The UJC has violently expressed opposition to the MAS political party, and at one point, they publicly beat indigenous leaders. Its members occasion- ally wear armbands with swastikas (Fabricant 2009; Miranda 2012).
My first impression of Bolivia made it clear to me what outsiders have fre-
quently noted—
it is a land of contrasts and contradictions. With 36 ethnic
groups, Bolivia has tremendous linguistic and cultural diversity. Although a majority of the population is of indigenous descent, with Aymara and Quechua being the largest indigenous groups, the European and mestizo minority held economic and political power at the national level until the 2005 election of Evo Morales. Leading up to the election of Morales, there has been a long history of indigenous resistance (Ari 2014; Kohl et al. 2011; Reinaga 1970; Rivera Cusi-
canqui 2011). The elites’ struggle to maintain power in spite of this resistance has contributed to persistent political divides that have triggered more than 150 coups or attempted coups since Bolivia gained its independence from Spain in 1825. Bolivians themselves make fun of this aspect of their country’s history, pointing out that they even went on to elect a former dictator as president. Gen- eral Hugo Banzer, who led a violent coup that brought him to power as a dictator from 1970 to 1978, was elected president in 1997.
My arrival in 2010 followed a series of mass protests that had culminated in
the most recent attempted coup. These protests, concentrated in the country’s eastern region known as the media luna (half moon), had erupted surround-
ing the passage of a new constitution. It was a constitution that upset the old structure of power by granting greater protections to historically marginalized groups, limiting the amount of land individuals could own, increasing the role of the state in the economy, and granting the state authority over the use of natural resources. The region’s political elite managed to gain substantial popular support in protesting the new constitution, even among the working class, by framing the region’s problems as a result of neglect on the part of the national government (Fabricant 2009). At the height of the protests, a group of wealthy businessmen and ranchers brought in mercenaries and intended to organize a militia separatist movement. Plans unraveled when police uncovered an assassi-
nation plot against President Morales as a part of this attempted coup (Miranda 2012). The wave of violence and use of mercenaries backfired on the opposition leaders, as it caused the opposition to lose support from the local population. However, the sense of regional pride invigorated by the protests (Fabricant 2009) continued to linger, reflected through symbols such as the straw hats with which my husband’s relatives had greeted us.

Decolonizing Bolivia 33
To understand the tumultuous political climate I had entered, it is helpful
to turn to Bolivia’s history. Colonial domination under Spanish rule followed
by a system of internal domination characterized by persistent racial and class
hierarchies mark the nation’s history. The United States played a crucial role in
upholding this internal domination through its clandestine support of right-

wing regimes (Dinges 2004; Dorn 2011). However, there has also been a his-
tory of resistance to these hierarchies, contributing to periods of revolution. At the heart of this resistance has been a push for decolonization, or an undoing
of colonial and postcolonial hierarchies. For many Bolivians, the 2005 election of
Evo Morales symbolized one of the most important achievements in the path to decolonizing Bolivia (Ticona 2011). Resulting political transformations, how-
ever, generated a new wave of tensions.
Colonial and Postcolonial Structures of Power
The Cerro Rico (Rich Mountain) mine made Potosí, Bolivia, one of the most important cities in the New World for nearly 200 years. Beginning in the mid-

1500s, Cerro Rico enriched the Spanish Empire with its vast silver deposits.
Although Cerro Rico has been depleted of silver since the early 1800s, Boliv-
ians have continued mining it for tin in unsafe and toxic conditions (Nash 1979; Perreault 2013). Miners refer to Cerro Rico as “the mountain that eats men,” in response to the number of deaths that have occurred in the mine as a result of accidents as well as long-
term health problems such as lung disease (Nash 1979).
Popular legend claims that the Spaniards took enough silver from Cerro Rico to build a bridge of silver from Potosí to Spain and that enough indigenous people died working in the mine to build a bridge of bones back. The Uruguayan writer Eduardo Galeano put the number of Bolivians who died in Cerro Rico under the Spanish Crown at 8 million (Galeano 1971), although some historians dis-
pute this claim (Bakewell 2010). To many Bolivians, the number of deaths is less important than the history of exploitation represented by the mine.
This history of colonial exploitation remains meaningful on multiple levels.
The colonial centers of the Spanish Empire are now the least developed regions of Latin America. Sociologist James Mahoney (2003, 2010) argues that this is in part because systems of extractive wealth led to the consolidation of wealth and land among an elite class. To maintain their privileges, the elite class relied on racial distinctions to justify forced and coerced labor. The maintenance of these hierarchies rested on limited investment in public goods that would have bene- fitted the indigenous population. This underdevelopment limited social mobility and perpetuated colonial racial hierarchies even after independence from Spain. The Bolivian indigenous intellectual Fausto Reinaga (1970) described how this continued subjugation of indigenous people created two Bolivias—
one of the

34 Fault Lines of Care
mestizo-European and one of the indigenous people.
1
In these two Bolivias,
social class remained closely tied to race.
Although indigenous groups are often described as ethnic groups, the Ayma-
ran scholar Waskar Ari (2014) describes indigeneity in Bolivia as the basis for a
racial classification system. The term ethnicity implies a shared cultural heritage,
whereas race is a social construct tied to perceived differences that can be used to
justify social hierarchies that benefit the dominant group. Perceived differences
between indigenous and nonindigenous people have been used as a justification
for social oppression throughout Bolivia’s history.
Apart from the perpetuation of racial hierarchies, the mining industry
enabled the vast accumulation of wealth among a small number of families. As
silver was depleted from the mines, three families began to turn toward mining
tin. By the early twentieth century, three Bolivian tin barons—
Simón Patiño,
Moritz Hochschild, and Carlos Aramayo—controlled more than half of all tin
extraction in the world. This economic power translated into political power, as the tin barons held significant sway in national politics and flexed this power
by financing coups against presidents whom they saw as threats to their monop-
oly (Dorn 2011). Because of this, scholars often describe Bolivia as an oligarchy until the 1952 revolution (Barragán 2009; Nash 1979).
While mining played a central role in the sociopolitical history at a national
level, mining was never a feature of Santa Cruz’s local economy, and the region remained relatively isolated until the mid-
twentieth century. As an agricultural
hub, control over land played a critical role in reproducing social hierarchies. Additionally, two major indigenous groups—
the Aymara and Quechua—
occupied the western highlands. The eastern lowlands had a larger number of
distinct indigenous groups with smaller populations.
In 1561, the Spanish conquistador Ñuflo de Chavez established the city
of Santa Cruz. Resistance from local tribes, most notably the Chiriguano (or Guaraní),
2
characterized the early colonial era. Over the next two centuries,
the conquistadors eventually gained control over several of the most significant indigenous groups. Under the Spanish Crown, the encomienda system granted Spaniards labor from conquered groups. This system viewed indigenous people as vassals of Spain who were expected to pay tribute taxes in the form of gold or labor. The Spaniards who were granted labor under the encomienda system were expected to civilize the indigenous people on behalf of Spain, thereby jus-
tifying forced and coerced labor as a civilizing process. Some indigenous popula-
tions, especially in more isolated areas, were able to maintain their territories and some degree of autonomy (Laguna 2013). These conditions produced what the Bolivian sociologist Arian Laguna (2013) described as two images of the indio (a
derogatory term for an indigenous person)—
the “savage,” uncolonized indio and
the “good savage” who labored for the Europeans and converted to Christianity.

Decolonizing Bolivia 35
Under the encomienda system, indigenous people could gain rights to com-
munal lands if they paid tribute taxes. In theory, this system offered some sem-
blance of independence, but in reality, indigenous people were often forced to
labor in order to pay the taxes (Postero 2007). In 1720, the encomienda system
came to a legal end, and the Spanish Crown mandated that laborers receive pay
for their work. Landowners, however, still had large land holdings and continued
exploiting indigenous people for labor in various ways. Even in the twenty-
first
century, there have been accounts of Guaraní people working in debt bondage in eastern Bolivia (Gustafson 2010; Laguna 2013).
The conditions of the colonial era had a profound effect on the health of
indigenous populations. Traditional healing practices could not counteract the death toll and ill health that resulted from exposure to new diseases like small-
pox, changes in dietary patterns, and the physical toll of forced labor. Even access to health care became a tool of conquest as health posts established by religious orders simultaneously acted as charities and institutions that promoted conver-
sion to Catholicism (Cueto and Palmer 2015).
Following independence from Spain on August 6, 1825, the national govern-
ment focused on the mining-
rich western region, resulting in the continued iso-
lation of Santa Cruz. However, land policies at the national level were influential in reinforcing social hierarchies, since only landholders were citizens. Under land reforms in 1874, communal properties held by indigenous people during the colonial era became state property. Individuals could then purchase land titles to state land, but most indigenous people did not have the means to buy back their land. Instead, wealthier landowners were able to purchase massive plots of land. To survive, poor indigenous people often became laborers and, without land ownership, were denied the rights of citizenship (Postero 2007).
In the early postindependence period, there was little investment in health as
a public good, despite the widespread existence of debilitating conditions such as tuberculosis and Chagas disease and high infant and maternal mortality rates (Zulawski 2007). It was not until the early 1900s that politicians began grappling with how to address health as a part of nation-
building. According to medical
historian Ann Zulawski (2007), the development of the health care system dur-
ing the early twentieth century served to perpetuate social hierarchies, especially along the lines of race. The push toward developing a public health care system was rooted in elite fears of contagion that blamed indigenous people for the health problems that were stunting economic growth and progress at a national level. Thus the early foundations of public health in Bolivia sprung out of racism.
In the 1930s, Santa Cruz became more significant on a national level when
Bolivia went to war with Paraguay in a border dispute over the oil-
rich Gran
Chaco region of the Santa Cruz department. The Chaco War brought in a wave of migration to the area. The war ended with the nationalization of oil reserves,

36 Fault Lines of Care
which the U.S. company Standard Oil held at the time. With an economic inter-
est in Bolivia’s tin, the United States responded with a plan aimed at ensuring a
favorable trade agreement with Bolivia. This plan granted $25 million to Bolivia
and put economist Mervin Bohan in charge of grant oversight. The resulting
Bohan Plan focused on the agricultural potential of Santa Cruz as a means to
diversify the national economy (Sandoval et al. 2003). As a result, funds went
toward industrializing farmland, with the greatest impact on the sugar cane
industry. Landowners became owners of agro-
capitalist enterprises, with new
roads and access to credit made available through the Bohan Plan facilitating entry into markets. Thus the Bohan Plan transformed landowners into a new capitalist elite, further exacerbating local structures of inequality (Laguna 2013).
As the Bohan Plan was unfolding, social unrest was growing in response to
economic turmoil and high inflation at the national level. Between 1935 and 1952, a series of coups from both conservative and liberal factions resulted in failed social reforms. In the meantime, the MNR (Movimiento Nacional Revolu- cionario / National Revolutionary Movement) began developing an alliance of middle-
class and working-class Bolivians. In 1952, the MNR took power in a
military coup. Land reform, universal suffrage, health care reform, and national-
ization of the mines followed. Land reform focused first on lands in the western part of the country, barely touching the eastern part of the country before the revolutionary reforms lost power (Fabricant 2012). Further, land redistribution focused on unproductive lands, allowing land “modernized” under the Bohan Plan to remain in the hands of the new capitalist elite. Concurrent health care reforms that established the state’s obligation for providing medical care also proved to have limited reach. This is primarily because internal factions within the revolutionary party resulted in the MNR shifting from a revolutionary party to a center-
right party. As a result, the Bolivian Revolution was an incomplete
revolution (Laguna 2013). Party factions also contributed to a coup in 1964.
From 1964 to 1982, a series of right-wing military dictators held power, and
despite the widespread suppression of political dissent, organized efforts of resistance persisted. This was especially true in the mining sector, where many workers joined the Communist Party (Kohl et al. 2011). In 1966, the legendary Latin American revolutionary Che Guevara arrived in Bolivia with the goal of organizing a guerilla force and spurring another revolution. The following year, the Bolivian military captured and executed Che near Vallegrande, a small town in the Santa Cruz department.
General Hugo Banzer, a member of the landholding elite of Santa Cruz, was
to become the most notorious of Bolivia’s dictators from 1971 to 1978. In addi-
tion to overseeing the tortures, disappearances, forced exile, and imprisonment of thousands of Bolivians, General Banzer also made it his mission to favor the Santa Cruz elite. Undoing land reform efforts, he granted national loans to

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Fault Lines Of Care Gender Hiv And Global Health In Bolivia Carina Heckert

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