Review of Chronic Failures: Kidneys, Regimes of Care, and the Mexican State. Ciara Kierans, New Brunswick, NJ: Rutgers University Press, 2019, 178 pp.

In Chronic Failures, Ciara Kierans discusses the alarming rate of chronic kidney disease (CKD) among the poor, who comprise approximately 50% of Mexico’s population and are two to three times more likely to develop this disease. Globally, Mexico has the highest number of deaths from CKD. Yet many of them simply die at home, lacking access to expensive organ transplants, while approximately half of them die prematurely within six months of their dialysis initiation, the other treatment for CKD. Kierans discusses the everyday suffering of the poor patients and the regimes of renal care (transplant and dialysis) in a profoundly fragmented public health infrastructure in Mexico.

Drawing on ethnographic research with patients, family members, organ donors, social workers, hospital nurses, pharmaceutical representatives, and policy makers, Kierans describes how the poor and uninsured patients struggled to amass enough money for any form of renal care. They resorted to borrowing money from friends, neighbors, and moneylenders, selling their lands and inheritances, fundraising from charities, appearing on the television, and begging on the street. If they were able to collect the money, they had to pay in full for medical treatment, including hospitalization, medications, diagnostic tests, hemodialysis, and transplant surgery. In one instance, the patient’s resources had been so drained that her family was finding it difficult to maintain the post-transplant monitoring and checkups, not to mention the taxi fare to get to the hospital and back. Patients’ families also sacrificed their spare organs, jobs, and money, and moved constantly from hospital to hospital, while preparing their homes for their loved ones (i.e., painting their room, installing a new door, treating old windows, and buying supplies such as tubes, face masks, hand gloves, and a microwave oven for warming up dialysis solution).

While CKD amplifies economic, social, and political challenges, particularly for the poor, the causes of this condition are often categorized as “unknown.” Kierans explicates that the etiologies of CKD are distinctly complex and difficult to diagnose. In Jalisco, Mexico, where she conducted her ethnographic fieldwork, older patients were told their condition was the result of diabetes, hypertension, genetic predisposition, or injury, while younger patients were diagnosed for a congenial condition or renal hypoplasia, meaning they had been born with small kidneys or were diagnosed with kidney shrinkage that causes CKD. At the same time, patients, scientists, and public health officials, among others, speculated that a wide range of factors were associated with CKD, including: post-NAFTA economic deregulation, toxic waste management, excessive use of pesticides, environmental pollution, hot weather, dehydration, and presence of heavy metal. These factors exist alongside their everyday intersection with poverty, inequality, poor nutrition, unsafe work conditions, weak health care systems, and environmental degradation. Clearly, not only individual and behavioral factors, but also social and structural concerns account for the complex etiologies of CKD.

Using the longitudinal data extrapolated from Jalisco, Kierans reports that the causes of 80% of patient cases were classified as unknown, however the regimes of renal care continue to grow in Mexico. At this paradox, she poses the questions: How do uninsured patients access resource-intensive transplant medicine in Mexico? What are the catastrophic consequences for poor patients when health care is reconfigured and made accessible via the cash nexus, instead of as social entitlement of the welfare state? Who are the beneficiaries of this new interface between medicine, market, and the modern state?

Kierans argues that those at the periphery of social welfare in Mexico have little choice but to engage with various forms of exchange to access organ transplantation. These include “gifts solicited and unsolicited; conditional and unconditional forms of support; social transfers in the forms of benefits and social insurance payouts; and contractual obligations, barter, and monetary exchange, among other things” (p. 93). These varied forms of exchange involve very different kinds of actors, including kinship and friendship networks, charitable associations, and civil society organizations. In so doing, as the author argues, they “co-produce new markets in medicine” (p. 94). Kierans articulates that the growth of transplant medicine is increasingly dependent on the markets and the production of surplus value that sick and poor bodies reproduce. The limited resources of the poor are extracted to multiply the regimes of renal care and maintain the neoliberal economic arrangement that co-produce new forms of disenfranchisement in structurally ambivalent ways. In other words, the hybrid corporatist/neoliberal welfare state serves to amplify rather than ameliorate the plight of the precarious poor.

The suffering and sacrifice of the poor, uninsured, and sick show the failures of the renal regime and of Mexico’s welfare state. Kierans explains that patients are governed by constant acts of movement that underpin medical procedures, from diagnosis to dialysis, and from transplantation to post-transplant care, “where the labor of the patients and their families are emptied out to the point of depletion” (p. 34). Families are not only obligated to pay the overwhelming costs of renal care, they also put themselves to work. Others donate their bodily organs, which they then buy back through the services of transplant surgery, a process in which need is translated into market value, opportunities for others’ labor and profit. “As poor patients and their families move, as their bodies are worked on, they generate capital for others (scientifically, commercially, and socially)” in facilitating the exploitation of one (the patient) and all (the family) (p. 53). Here, “profit and poverty mutually implicate and shape each other: one allows for and underpins the other” (p.112).

In clinical encounters, poor patients petition doctors to produce paperwork, a prerequisite for accessing health care across public, private, and charitable domains. Paperwork keeps the poor patients on the move and materializes their responsibilities to others. As Kierans reports, doctors manipulate prescriptions for medications or increase prescription quantities so that medically insured patients can share them with uninsured patients. These localized, unpredictable, and contingent arrangements underpin “the vulnerability of care for patients,” while keeping them and their families continually “on the move” (p. 76). At the same time, these local practices validate doctors as “ambivalent agents of the state and market, who simultaneously embody and subvert their operations in the course of their everyday work” (p. 76). In sum, Chronic Failures is a theoretically driven, ethnographically rich, and methodologically engaged book that addresses a wide range of ordinary issues, but extraordinary concerns of organ transplantation. It examines how the poor cope with commodified medicine, as they cannot afford the high cost of renal care. It analyzes how market-driven medicine without any social entitlement produces hardship and harm rather than health. For some scholars, the book can be viewed as an ambitious project, as the author weaves together a wide range of constantly fluid and flexible phenomena (as opposed to structurally predetermined or fixed concerns), without specifying how these phenomena co-produce and re-produce the nexus of medicine, market, and the state. It begs the question: How are biopolitics embedded in different forms to sustain, spread, and thrive in this new market? Despite this criticism, the book is sensitive to multiple theoretical lenses that unpack the rich ethnographic details in the local complex settings. It is a must-read for those interested in medical anthropology, clinical nephrology, science and technology studies, global health, and biomedical ethics as it shows how organ transplantation, a “miracle” medicine of the twentieth century, actually exploits the poor.