Will to Live: Aids Therapies and the Politics of Survival.

João Biehl. Princeton, NJ: Princeton University Press. 2007. xiii + 466pp.

Reviewed in conjunction with the publication of Ethos 36.3 by: Cristina Redko, Research Assistant Professor, Wright State University.

Brazil constantly receives international recognition (e.g., media, scientific arena) for being the first developing country to universalize access to life-saving AIDS therapies.  This has transformed AIDS from a fatal to a lifelong disease.  João Biehl has given readers a fascinating ethnography illustrating the “behind-the-scenes” stories of those affected by AIDS under the backdrop of Brazil’s much praised antiretroviral drugs (ARVs) policy.  He describes how poor and marginalized AIDS patients in urban settings engage with the AIDS policy and how their lives are transformed over time. He also identifies the particular pathways by which AIDS becomes (or does not become) a chronic disease amidst poverty.  To accomplish this objective, Biehl explores a series of interconnected problems linking AIDS to pharmaceuticals, global health initiatives, the state, inequality, social experience, and subjectivities – subjectivities that are refigured by a Will to Live. Biehl’s careful analysis is complemented by Torben Eskerod’s photographs evoking the singular trajectories of long term AIDS patients crossing a time (over ten years) before and after ARVs.

Biehl begins by calling attention to the worldwide “pharmaceuticalization of public health” which is defining public health less as prevention and clinical care, and more as access to medications. In Brazil, universalized access to ARVs was made possible through social mobilization within the state and transnational ramifications among activists, government reformers, development agencies, and the pharmaceutical industries.  As this social mobilization weakened certain inequalities, it also created new ones.  Brazilian AIDS policy exemplifies the “global politics of survival” defined by an “intermediary power formation” sustained through constant negotiations in the market place operating without predetermined strategies or normalizing effects: “the AIDS policy thus becomes a co-function of political and market institutions, as well as individual lives (p.94).” 

Biehl slowly uncoveres a “hidden epidemic” by paying close attention to grassroots movements and grassroots care facilities. He demonstrates how those AIDS patients who are unemployed, homeless, involved with prostitution and drugs are completely marginalized, and not accounted for by the official statistics.  It has been difficult for these patients to self-identify or to be identified as AIDS victims who deserve treatment and are capable of adherence.  Much more effort is required to make the “accessible” ARVs present and effective in the everyday lives of these poverty-stricken patients.   On one side, access is only the first step. It does not mean that AIDS patients actually receive or adhere to any medication regimen.  Is it possible to achieve the self-discipline and care required for prolonged treatment adherence in a context of multiple scarcities?

Conversely, the possibility of becoming a welfare recipient via AIDS introduces a new kind of politicized sociability; many impoverished patients manage to survive economically by becoming “diseased citizens.” According to AIDS survivors the will to live is often associated with having a place they call home, having a steady if meager income, and a social network, even if that only means loose ties to grassroots facilities. This manufactured will to live is also essential for people to adhere to ARVs: “I am not concerned with HIV. What I want is to live. If there is medication, let’s take life forward. Life is to fight for (p.400).”  Millions of poor AIDS patients worldwide (at least those who follow first-line ARVs regimens) seem to live in constant flux, moving between institutions, as they look for usable resources, and consider immediately the next step to be taken in order to guarantee their survival. This is what Biehl refers to as the “local economies of salvation.”

The work of the ethnographer is interpreted by Biehl as the art of recording the dynamic trajectories that people experience in their lives and without which “they would not become” because their internalized trajectories are inseparable from becoming full selves. While not explicitly a work of psychological anthropology, I consider that Biehl’s ethnography is already a paradigmatic example of how transformations in subjectivities and social experience can be investigated at all levels: personal, social, political, and global.  The book is also exceptional, while describing in fruitful ways, complex interconnections that might occur within and across levels of lived experience.  In summation, Biehl illustrates with artistry how  collective and individual experiences  are intertwined together, how power and meaning also run together, and how they are  intimately linked to these  experiences  (Biehl, Good, and Kleinman 2007). I strongly recommend this book to all those interested in pursuing anthropological investigations emphasizing the conceptual significance of lived experience through “experience-near” analyses and “thick description.”

REFERENCES CITED 

Biehl, João, Bryon Good and Arthur Kleinman

2007   Subjectivity. Ethnographic Investigations. Berkeley: University of

          California Press.

Nunn, Amy S., Elize M. Fonseca, Francisco I. Bastos, Sofia Gruskin, and Joshua A. Salomon

2007   Evolution of Antiretroviral Drug Costs in Brazil in the Context of

          Free and Universal Access to AIDS Treatment. PLoS Med 4(11):

          e305.doi:10.1371/journal.pmed.0040305.