Fault Lines of Care: Gender, HIV, and Global Health in Bolivia by Carina Heckert (review)

Comprehensive and impressively written, Carina Heckert initially draws the reader into her first book with a story about the sad demise of Gabriella, who was infected with HIV, as she tried to navigate the health care system in Santa Cruz, Bolivia. In the same initial section, Heckert engages the reader with a wide scope of topics (politics, history, health care, donor organizations etc.) surrounding Gabriella.

Heckert's goal is to investigate and describe the "fault-lines of care" that produced Gabriella's death. She calls her method an "ethnography of care" (23), but she states that the core of the book is about "gendered politics of life" (22). To investigate these elements, Heckert launched two research phases to Santa Cruz from 2010 to 2014, observing and interviewing 70 people with HIV, as well as many health professionals. She eventually highlights narratives from another 18 of the 70 HIV infected individuals, probing their surroundings and experiences. She thoroughly explores health care connections at the local, national, and international levels, along with these programs' flourishes and collapses.

Bolivia's efforts to help those with HIV/AIDS is pésimo. Only 35% of those with advanced HIV receive antiretrovirals; there is a horrid lack of coordination between health centers and a lurid indifference from doctors; most HIV related deaths are because the client disappears from the system. This profile transpires from a stew of contradictions so stark it leaves one breathless: for one, Bolivia has universal health care! Yet, these health care fault lines have analogues in education, welfare, transportation and other social services. In addition, one may argue that similar situations exist in Latin America. We are tempted to chalk this scenario up to corruption. This realization seems to take Heckert by surprise and—kudos to her—she explores cracks in the labyrinth. Is it indeed corruption? Heckert's brilliant third chapter has the reader ponder how to depict the difference between corruption and a merely inefficient bureaucracy. In other words, is there truly medical negligence behind Gabriella's death, or simply a lack of resources? Unfortunately, Gabriella's decline would have been the same whether Bolivia's politics is socialism or neoliberal capitalism.

Too often health experts intimate blame in failed health care. Heckert does not attack any one system or policy, to her credit. The reader is assured that she is fully aware of the complex cruceña society, and within that, the feuding worlds of clinician, public health official, and health educator. Heckert wraps up her book with an aggressive chapter probing global health policies. Then the bombshell: She clearly blames the Global Fund—a major funder for HIV programs—for many of these problems, and her argument is impressive. Still, in this discipline, organizational failure is no surprise. In a 2009 article from the World Health Organization, the authors argue that funding to Bolivia (from the Global Fund) was destined to be inefficient predicated on the country's low HIV prevalence rate (Bulletin of the W.H.O. 87: 930–939). A November 2012 article in The Economist lays out how the Global Fund goals are rife with politics and contention within their arsenal of programs to combat malaria. Certainly, one would expect this to be the case in HIV/AIDS programming.

It might be interesting to explore beyond Bolivia's boundaries. Heckert does this to an extent, for instance, regarding Bolivia aligning with Cuban and Venezuelan socialist policies leading up to the 2013 expulsion of USAID from Bolivia. It is fascinating to read about macroeconomic and political circumstances woven together with an exploration of women's sexuality (chapters 4/5), machismo (chapter 6), or sexual orientation.

Concerning sexual orientation, it would be helpful to consider history from other Latin American countries; Heckert's research into surrounding countries is limited. For example, she mentions that the HIV/AIDS prevention model came from "western" countries, but does not recognize that an early LGBT...