Familial sacrifice and national aspiration in Mexico
— Reviewed by
Megan Crowley-Matoka, Domesticating Organ Transplant: Familial Sacrifice and National Aspiration in Mexico, Duke University Press, 2016. Paperback, 336 pp., $25.95. ISBN: 978-0-8223-6067-4.
In her first book, Megan Crowley-Matoka endeavors to demonstrate the ‘processes of signification and materialization’ (p. 4) through which kidney transplantation appears in Mexico at the beginning of the 2000s. The study presents an ethnography of the everyday life of two transplant programs in Guadalajara’s hospitals, where the anthropologist encountered more than three hundred transplant cases and seventy potential cadaveric organ donation cases. These are contextualized by quantitative data shared by the medical institutions. The city is described as equally global and traditional: global because it hosts the most active kidney-transplant program in the country, signaling a stake in modernity and serving as a source of state pride; and traditional in the specific ways that organ transplant technology takes place in Mexico, in particular the use of explicit and implicit criteria for choosing rare potential donors and ‘sufficiently worthy’ recipients.
The local transplantation system is based on living relations and their organ donations, which contrasts with other procurement schemes often discussed within anthropological literature, primarily relating to cadaveric donation (in the United States, see Fox and Swazey 1992) and living, unrelated donor donations (in Egypt, see Hamdy 2012). Questioning the idea that organ transplant technology would be ‘out of place’ in Mexico, the author invites us to look beyond the division between the global South and North as supplier and user of organs for transplant, respectively. Given that kidney failure is among the top ten causes of death in Mexico, and that the familia Mexicana works ‘as a social world where personhood is enacted through relatedness, interdependency and the endless give-and-take of family obligation’ (p. 11), kidney transplants from living donors constitute, in some ways, a pragmatic answer to a health care dilemma.
The structure of the book is clearly organized. The first part illuminates the process of asking for and giving a kidney, a process that occurs among relatives of the patient suffering from kidney failure. Focusing closely on the gendered dimensions of this process, the author demonstrates how the kidneys of living related family members are made – or fail to be made – available for donation. Besides the logic of familial arrangements, the relative availability of living beings is closely associated with the inverse bio-unavailability of the dead. The book challenges the framing of this organ shortage as a problem of ‘culture’ or ‘family refusal’, as the reader follows the work of transplant coordinators in their uneasiness with the ‘actual science of brain death’ (p. 75) in a context that lacks tools such as MRI machines to help determine it. Indeed, changing the status of a potentially brain-dead person from being a patient to an organ donor involves organizational as well as emotional resources that are sometimes difficult to access.
The second part of the book relates the story of the recipients. Emblematic cases of patients are described through ‘discursive pictures’ (p. 135) elaborated about them in the hospital. Each success or failure to access the surgery is read through the patients’ capacity to move with agility through the bureaucratic health care system of the slippery State of Mexico, defined by the author as ‘a deeply biopolitical body of governance that operated as a source of both life-giving, practical benefits and everyday experiences of insecurity and disillusionment’ (p. 14). This valued quality is captured in the verb agilizar (literally: accelerate), used by patients and doctors to describe the sense of initiative of the transplant candidate, such as paying for medical tests in a private hospital instead of counting on the resources and delays of the transplant institution. It is also manifested by those who remain available or in close proximity to the institution, and those who retain employment needed for health care insurance. Agilizar is raised to the rank of a cultural style by the author, for the way it captures the institutional workings in Mexico. A third and final part of the book addresses some of the main public and anthropological framings of this specific human-to-human type of transfer. The author engages here in a vivid explication of the limits of the conceptual opposition between gift and commodity.
Three transversal aspects of Crowley-Matoka’s approach are worth highlighting: the theoretical framework, the temporality of the cases that unfold, and the continuous reassessment of her findings. Icons and representations are central to her theoretical framework. Each of the three parts of the book is characterized by a central iconic figure: the mujer sufrida (the suffering woman or selfless mother), who symbolizes the emblematic giver; the agile patient, who condenses gendered and racial values in the transplant endeavor; and El Niño Doctor (Baby Jesus, Doctor of the Sick), whose imagery helps to interrogate the patient–doctor relationship. A tour de force of the study is that it relates these symbols to the materiality of transplantation. Icons are not studied away from their context, as the author focuses on the way these symbols influence what people do and how people make sense of their situations. Paying attention to icons circulating in the field also allows the author to observe several levels together, from the local hospital in Guadalajara to the state, and from the individual kidney donor to ‘the imagined body of the nation’ (p. 125).
Far from relying only on the symbolic world to explain how kidney transplants take place and make sense, Crowley-Matoka shows how these representations both simplify and obscure bodily realities. A striking example lies in the first part of the book, where she contrasts two types of data in illuminating fashion: ethnographic accounts and statistics. Through ethnography, the author observes the weight of the figure of the mujer sufrida, and its proximity to the gendered and relational model of the mothers, sisters, and wives who sacrifice themselves in order to support the men in their families. Her ethnographic data leads the author to initially conclude that women are donating more kidneys than men. However, further analysis using statistical data from hospital databases reveals a different gender disparity: men donate half of all kidneys but receive the majority of them (p. 46). A main reason for this, Crowley-Matoka explains, is the structure of the health care system. Given that women work predominantly in the informal sector, they tend to have less health insurance coverage. While it is not necessary to be covered to give a kidney, insurance is required to receive one.
The emphasis on temporality within the stories shared also distinguishes the author’s approach. Skeptical of the ‘temporal focus on the moment of exchange’ (p. 194), she argues that the narration of what matters to donors and recipients is important to make sense of each kidney transfer. This narrative starts well before the emergence of kidney disease and continues long after surgery. Moreover, the author argues that focusing on the moment of exchange tends to impoverish understanding of the diversity of people involved in the process. While the book focuses on cases and can at times frustrate the reader, who may hope for more contextual details (such as everyday scenes and routines, which are not described as extensively), the structure allows for an in-depth understanding of the social relations in which each actor is embedded, both within and beyond the doors of the hospital.
Finally, a continuous reassessment of findings underpins the author’s approach. Crowley-Matoka reflects on everything she brings to the attention of the reader, from organ transplantation’s status of ‘technology out of place’ in Mexico, to the significant presence of the Catholic church in her fieldwork, including in a narrative of not-so-miraculous post-transplant lives. This systematic work to define what is at stake and the attempt to convey its complexity pervades both the results of her fieldwork and the relationship to anthropological literature about organ transplantation. It is possible to read in this book a state of the field of the anthropology of organ transplant, as the author brilliantly reflects on the work of prominent, established researchers while also engaging with more recent studies addressing the relationship between bodies and states (such as DiMoia 2013; Edmonds 2010; Leem, 2016).
In this regard, Domesticating Organ Transplant not only documents how a renal disease and its related issues of giving, receiving, or transferring a kidney emerge within the lives of Guadalajara’s citizens but is also a remarkably well-written work of anthropology, enriched throughout with well-balanced, reflexive, and theoretically challenging insights.
About the author
Marie Le Clainche-Piel is a doctoral candidate in sociology at the EHESS, School for Advanced Studies in Social Sciences. Following French and British cases of the emergence of face transplant technology, her research interests fall within the fields of the anthropology of the body, the sociology of science and institutions, and disability studies. As part of her training, she has been a visiting researcher in the anthropology departments of the University of Oxford, Washington University in Saint Louis, and the University of Amsterdam.
DiMoia, John. 2013. Reconstructing Bodies: Biomedicine, Health, and Nation-Building in South Korea since 1945. Palo Alto, CA: Stanford University Press.
Edmonds, Alexander. 2010. Pretty Modern: Beauty, Sex, and Plastic Surgery in Brazil. Durham, NC: Duke University Press.
Fox, Renée, and Judith Swazey. 1992. Spare Parts: Organ Replacement in American Society. Oxford: Oxford University Press.
Hamdy, Sherine. 2012. Our Bodies Belong to God: Organ Transplants, Islam, and the Struggle for Human Dignity in Egypt. Berkeley: University of California Press.
Leem, So Yeon. 2016. ‘The Dubious Enhancement: Making South Korea a Plastic Surgery Nation’. East Asian Science, Technology and Society 10, no. 1: 51–71.