Touted as an inspiration and model for activists and governments, Brazil’s public health system in late 1996 implemented a treatment roll-out dispensing free antiretroviral treatment to all registered HIV/AIDS cases. As anthropologist João Biehl argues in his Will to live: AIDS therapies and the politics of survival, Brazil’s program effectively rebuts claims about the unfeasibility of universal HIV treatment in resource-poor settings, and it has leveled certain inequalities, especially among working- and middle-class Brazilians. In the first section of the book, Biehl describes the extraordinary social mobilization that successfully advocated for free and universal HIV treatment access as a human right guaranteed by the 1988 Brazilian Constitution; activists and progressive health professionals integrated into government and played a critical role in organizing innovative alliances between government, non-governmental organizations (NGOs) and international development agencies, especially the World Bank. However, the public–private collaborations between government and pharmaceutical industries that facilitated the production of low-cost generics have also reinforced what Biehl critiques as a ‘magic bullet approach’ to public health, a focus on medicine and drug distribution at the expense of more basic health issues, like access to clean water (p. 86). Moreover, as Biehl documents throughout his text, Brazil’s HIV treatment program has introduced and consolidated new forms of what he terms pharmaceutical and public health governance, as well as marginalization, particularly of the underclass.

Biehl’s book is most compelling when he tracks the institutional practices and economic calculus that maintain what he defines as a hidden epidemic among the very poor and marginalized in Bahia, Salvador, the ‘African heart of Brazil’, where he focused his ethnographic fieldwork and research from 1995 to 1997 and in shorter follow-up visits in 2001 and 2005. As his research reveals, only 26 percent of AIDS cases between 1990 and 1996 that were registered in Caasah, a community-run AIDS service, were recorded in official databanks (pp. 14, 203). The exclusion of the poorest and most marginalized from care is compounded through the stigmatizing epidemiological and medical categories of ‘drug addict’, ‘prostitute’ or ‘noncompliant’ that, as Biehl notes, blame the dead for their own deaths and account for the poor primarily as ‘risk vectors’: ‘the complex social and economic interactions that exacerbate infections and immune depressions remain unaccounted for’ (pp. 224, 235).

Biehl tracks the forms of normalization that enable the surviving 10 of the original group of 22 Caasah patients whom he interviewed to manage AIDS as a chronic condition, and he attempts to foreground the conditions that reinforce the marginalization of those who, in other contexts, would be termed subaltern (although as Gayatri Chakravorty Spivak writes, the term has ‘lost its power to indicate people from the very bottom layer of society excluded even from the logic of the class structure’ [2008: 276]). However, he seeks not only to critique and contest ‘technologies of invisibility’ that exclude certain bodies from care and treatment, but also to rectify their effects. Biehl defines his text as traditional ethnography—‘charting the lives of individuals and institutions over time through open-ended interviews and participant observation’—supplemented with other ‘evidence’, including quantitative research (pp. 218–223, 251, 253–255). When these ‘fall short’, he turns to photographs, mostly of residents and former residents of Caasah taken in 1997 and in 2001 by Torben Eskerod, a collaborator in his previous book, Vita (2005). Biehl describes the photographs and accompanying extended excerpts from interviews as ‘highlight[ing] the plight and singularity of the abandoned AIDS patients with whom I worked’ (p. 5). The patients, effaced epidemiologically, medically, socially and politically, are here rendered mostly in close-up head shots:

The black-and-white of the portraits signals a realist documentary aesthetic and promotes the fantasy of intimacy and transparency further heightened by the presentation of extended direct quotes from interviews, often without commentary. In the introductory section, ‘Lives’, for example, Biehl presents a series of eight interviews and photographs of patients, only at the end of which does he offer an analysis of what he views as the reconstitution of subjectivities of people living with HIV at the margins. As he argues, their reconfigurations, propelled by a ‘will to live’, further reconstitute conceptions of care and citizenship (italics in original, pp. 48–49). In contrast, in the later chapter ‘Experimental subjects’, Biehl details how the technical procedures of HIV testing generate new subjectivities, individual ‘libidinal and moral economies’ among the middle and working class (p. 245). Here, he draws from Michel Foucault, Eveyln Fox Keller, Sigmund Freud and Jacques Lacan, among others, to analyze each interview subject and his or her account of the significance of HIV testing. None of the middle- or working-class subjects is photographed, and all are assigned pseudonyms to protect their anonymity.

The framing of the portraits of the most marginalized, generally nonliterate patients as identifying and speaking for themselves (‘These are their texts’) elides the mediating roles of the anthropologist and photographer, and obscures the forms and conditions of their engagement with their subjects (p. 285). At moments, mostly in parenthetical asides, the reader catches glimpses of the anthropologist conducting his research and of the complex negotiations fieldwork entails. Biehl writes about the work of Dona Conceição, who distributes food and provides support to street patients living with HIV, at first informally, then through an NGO that she founded. She introduces Biehl and Eskerod to a group of homeless people living on a concrete platform near a soccer stadium, and Biehl requests permission to visit again: ‘they agreed to let the “Gringo” (as they called me) come back, which I did for the following two weeks’ (p. 226). One of the street patients, Ciro, asks for money for a cooler, and although Biehl does not detail his response, he observes: ‘A lot of [the street patients’] conversations with me were about an immediate need that they thought I could provide.’ In a parenthetical comment, he notes that ‘to the best of my capacity, I tried to help them materially’ (p. 231).

During a follow-up interview with Rose, a former resident of Caasah, Biehl comments: ‘she was always captioning her moves: “Who would have imagined that Rose, from Pelourinho, would be giving interviews, telling the professor and the gringo [Torben] what life is all about?”’ (p. 367, brackets in original). In response to Biehl’s questioning, Rose refers to herself in the third person as both interview subject and commentator, her rhetorical question resisting interpellation into the format of the interview or of a confessional narrative of ‘personal travails’, even as she underscores the deep disparities structuring their exchange. As Biehl further remarks, the pressures of daily survival clearly impel her decision to be interviewed: ‘Rose also made it evident that she was expecting some financial aid at the end of our session’ (p. 367). Although here again, Biehl declines to elaborate on his response to Rose’s expectations, he writes that when he meets another struggling former Caasah resident, Evangivaldo, by chance during his final visit to Caasah: ‘[w]e were happy to help him out so that he could provide for his family’ (p. 368). In the narrative chronology, Eskerod and Biehl first ‘help’ Evangivaldo, then Eskerod shoots his photographs and Biehl interviews him. Biehl attempts to provide an ethnography that attends to how ‘the sheer materiality of life’s necessities makes a great deal of difference in the knowledge we produce’, but his text tends to sidestep discussion of how these material realities inform his interactions with the underclass and ‘vulnerable’, and the ethnography of them that he produces (p. 378).

Biehl analyzes at length the ‘circuits of care’ and ‘economies of survival’ mobilized by his subjects, and the transformations some of them undergo as ‘patient-citizens’. Occasionally, he depicts but never directly addresses his own complicities within these circuits and economies, and the power differentials that his exchanges with the subjects of his research reproduce and reinforce. His accounts of his entanglements in fieldwork contradict and complicate his descriptions of the ethnographer as merely ‘charting’, ‘recording’, ‘track[ing]’, and in telling visual metaphors, ‘highlight[ing]’, ‘mak[ing] visible’, ‘illuminat[ing]’, ‘bring[ing] into view’ (pp. 5, 7, 114, 132, 327, 396, 406). They also problematize the uninterrogated celebratory invocation of imperial metaphors of exploration and mapping, the ‘anthropologist [who] demarcates uncharted territories and tracks people moving through them’ (pp. 399, 406).

The book’s emphasis on realist forms of representation is inseparable from Biehl’s intervention in AIDS policy and his advocacy of what he describes, quoting Albert O. Hirschman, as a ‘more realistic, better’ science, or an ethnography in which ‘people come first’ (pp. 378, 406). Through his representations of individual stories of the poor and marginalized, Biehl attempts to underscore what he defines as the gap between policy and reality. He critiques Brazil’s AIDS prevention programs for failing to address a ‘thorough vision of the social, economic and intersubjective dynamics surrounding AIDS’ or ‘the increased misery and social fragmentation linked to market-oriented reforms’ (pp. 163, 167). The accounts he details of casual brutality against and among his poor research subjects provide vivid challenges to reductive epidemiological models and to what Biehl characterizes as politicians’ self-interested political rhetoric. However, visual and textual aesthetics coded as realist do not provide more immediate access to the real, and the individual stories he narrates at times actually work to obscure the larger ‘vision’ that he seeks to foreground.

Biehl describes the ‘tragic death’ of Pernalonga, an AIDS activist, who is attacked on his way home. Fearing contamination, neighbors leave him bleeding on the street, as do the police. After hours of agony, Pernalonga is finally taken by a special medical unit to the hospital where he arrives dead (p. 176). In another chilling scene, two girls aged 13 and 15, forced into prostitution after being ‘lured from the interior to the capital’, run away. The girls are brought to the soccer stadium where they ‘had either consented or were forced into sex with several men’ (p. 231). Eventually they are taken by the police, who claim they will bring the girls back to their hometown. For Biehl, this incident ‘speaks volumes to the tragic unfolding of the AIDS epidemic among the marginalized urban poor’. He reads it as displacing the rubrics of ‘“impoverishment,” “feminization” and “interiorization”’ and ‘point[ing] to the real ways in which AIDS spreads among [the urban poor] and in their interactions with other young and impoverished subjects’ (p. 231).

Clearly, the catchwords or rubrics that Biehl cites prove inadequate to capture or convey the imbrication of HIV, poverty, homelessness, drug use, sexual and other forms of violence, and mental illness that he chronicles. But Biehl’s representation of ‘tragic death’ and the ‘tragic unfolding of the AIDS epidemic’ do not provide alternative, more ‘real’ accounts of the ‘larger dynamics surrounding AIDS’ and their manifestation in non-urban contexts—the interior—or of the differences that fracture the encompassing category of the ‘disadvantaged’. The stories he and others recount of intense struggle and suffering all too frequently function more as a kind of sensationalist and overdetermined, ‘tragic’, narrative closure or counterpoint. Rather than reflect a reality that highlights larger economic, political or social processes and put ‘[r]eal life … onto the map of AIDS policy’, they risk reinforcing the stigmatization and pathologization of marginalized subjects that Biehl persistently critiques elsewhere (p. 399).

In his conclusion, Biehl reiterates the importance of the social mobilization that made possible access to low-cost pharmaceuticals, but emphasizes that access does not imply either ‘delivery’ or ‘adherence’, and that the focus on drug distribution in large-scale programs, such as the President’s Emergency Plan for AIDS Relief (PEFPFAR), does not take into account public health care infrastructure or treatment for opportunistic infections (p. 385). He notes how the co-option of AIDS activists and the institutionalization of NGOs have brought about a ‘vanishing civil society’, and how an electoral-minded approach to HIV and institutional complacency contribute to Brazil’s growing HIV epidemic (p. 398). Ultimately, his suggestions for the future are modest:

‘Quality care’ would necessarily entail and effect radical political, social and economic transformations through the persistent engagements of individuals, organizations and governments. It would also require a re-evaluation of the terms of encounters with and representation of the ‘vulnerable’, in whose name the policies are implemented. As Biehl’s own book demonstrates, certain forms of representations, coded as enabling more direct access to the real, do not in fact provide that access and can actually serve to further reinforce the marginalization and effacement of the subjects they seek to render visible.