Introduction for Decolonizing Medicine

INTRODUCTION

WAITING FOR REFORM

IN THE WAITING ROOM OF the municipal hospital of Machacamarca,¹ a small but growing town in the Bolivian highlands, a large red and yellow sign hung overhead, welcoming patients in both Spanish and Aymara. The brightly painted, polished sign hung over rows of black chairs near the reception desk, where patients lined up starting at the crack of dawn to get an appointment slip for the day. The walls of the waiting room had also been painted a warm, peachy yellow at the hospital director’s instruction—because, he insisted, it would create a more welcoming space for the region’s majority Indigenous Aymara residents, whom he described as preferring warmer colors.²

The bilingual sign and yellow walls were rarely a source of overt commentary among patients. Most, waiting for several hours for their name to be called after they received their appointment slips, chatted with other waiting patients. Some watched over their children, gleefully running back and forth to pass the time, while other patients quietly stared up at the television on the far wall, which was usually showing reruns of Los Simpsons or El Chavo del Ocho.

As I was conducting ethnographic research in the hospital in 2015, I frequently chatted with patients in the waiting room who talked to me to pass the time, some sharing concerns about long trips from their home villages and long wait times (“es un quita tiempos”—“it’s a waste of time”), others, uncertainties over whether doctors would be able to help. This was how, one morning, I met Violeta, a middle-aged woman whose son had broken his arm, and who was still waiting for the doctor to call them back in after her son had gotten an X ray that morning. Wryly glancing at those of us sitting nearby, she declared in a mix of Aymara and Spanish, “I bet the doctor doesn’t even speak Aymara.” As her small audience murmured in agreement, she looked around conspiratorially and, with laughter in her voice, said in Spanish, “Me va a decir, ‘¿Quéee?’” (“He will say, ‘Whaaat?’”). She exaggerated the last syllable, parodying the tone that doctors sometimes used with patients.

The bilingual sign and yellow walls were among several additions to the hospital building undertaken in the name of creating an intercultural and decolonized space for the region’s majority Indigenous Aymara residents. Although the original structure of the hospital closely mirrored the white-tiled, laboratory-like exam rooms long found in most public hospitals and clinics in Bolivia, later extensions to the building, funded by a transnational NGO, also added orange-hued birthing rooms and a greenhouse filled with medicinal plants. One of the existing exam rooms had also been given over to Aymara traditional healers so that they could care for patients in the hospital.

While a range of institutional actors—a transnational nonprofit organization, the municipal government, and the hospital director himself—made adjustments to the hospital architecture over the years, most were in agreement: the transformation of hospital space had largely been made possible by health care reforms under President Evo Morales Ayma. Governing from 2006 until his ouster in 2019, Bolivia’s first Indigenous president undertook a sweeping series of reforms in the name of descolonización (decolonization), vowing to reverse intertwined colonial and capitalist systems of oppression and restore an Indigenous ethics of good living. Often, the decolonial project was rendered visible through material and symbolic markers in public institutions: the wiphala—the Indigenous social movement flag—flying over government buildings; the paintings of the Aymara revolutionary leaders, Túpac Katari and Bartolina Sisa, hanging in offices; a cable car public transport system in the nearby cities of La Paz and El Alto that likewise marked place names in both Aymara and Spanish. Hybrid efforts to transform the Machacamarca Hospital’s built environment carried echoes of these other material projects and accumulated in seemingly warm spaces designed to make patients feel cared for.

Clinical architecture was one of several sites of care under the newly decolonized state, and it reflected broader policy transformations. In the realm of health care, policies invoking the framework of decolonization proposed the transformation of biomedical care practices to incorporate greater attentiveness and cultural competency, including by requiring practitioners to take Indigenous language classes appropriate to the region where they worked. They also included the incorporation of traditional healers and midwives into clinical settings, and greater community participation and decision making over local health policies.

Yet Violeta’s offhand comment in the waiting room was not the first time I had been confronted with patients’ criticisms (some of them humorous, some of them not) of clinical care. While the tenuousness of health care could be a subject of concern for many in Bolivia, it was especially so for low-income Indigenous patients, who often encountered long wait times and material shortages in public hospitals and clinics, as well as dynamics of paternalism, discrimination, and neglect. Even as various institutional energies had been put into reforming spaces and practices of care, many Aymara patients and residents of Machacamarca continued to describe their local hospital as a place donde no hay atención (a phrase that might be translated from Spanish as “where there is no treatment” or “where there is no care”). They continued to worry out loud about the violence and neglect they might encounter there.

Decolonizing Medicine is an ethnographic account of Bolivian state-led efforts to decolonize health care during Evo Morales’s presidency—an account that shifts primarily between policymaking in the city of La Paz and care practices in the rural municipality I give the pseudonym of “Machacamarca.” It emerges from a total of twenty-six months of ethnographic research I conducted in Bolivia between 2012 and 2019, with the longest continuous stretch unfolding over eighteen months from mid-2014 to the end of 2015. Engaging with the perspectives of patients, biomedical practitioners, traditional healers and midwives, community health representatives, NGO workers, and state bureaucrats, I consider how care becomes an ambivalent site of decolonial praxis. I demonstrate how Bolivian state and medical institutions turned to what I call warm care as the primary path to decolonial transformation; yet this focus on warm care unevenly reentrenched colonial moral paradigms. This reentrenchment had myriad material effects on relations, the body, and politics.

By “warm care,” I refer to a cluster of moral, material, and affective care practices centered on a project of inclusivity, cultural sensitivity, and generally humane forms of attention. Sometimes, warm care was infused in signs and walls, accreted in peach-yellow paint and Aymara words of welcome. Other times, it permeated bodily gestures and ways of speaking and seeing. I argue that warm care became central to state efforts to decolonize health care in Bolivia by yoking an ongoing liberal paradigm of inclusion to the image of the newly caring state and its project of limited economic redistribution. I draw the term “warm care” from the common framing that practitioners were learning to provide care con calidad y calidez (“with quality and warmth”)—a phrase also used elsewhere in Latin America.³ In the Bolivian context, it was discursively bound up with state promises during Evo Morales’s presidency to repair colonial-capitalist violence and restore Indigenous good living. This emergent mode of care created points of commensuration between multiple political goals of the Morales administration—and yet it also displaced other proposals for decolonization that came from activists and also, at times, from others working within the state apparatus.

In the rural but urbanizing town of Machacamarca, residents reckoned with how colonialism was not an event in the past but continued to shape the present and spur illness. Located on either side of a major highway, the town had grown rapidly in recent years, as Aymara migrants from nearby villages left behind a life of agriculture or mining and moved to town to work in informal commerce and transport. Still, Aymara residents whose families had lived in Machacamarca for generations had long memories. In conversations with me, neighbors frequently invoked the site near the river where a Spanish colonial refining mill once stood. At night, mysterious fires burned and strange figures that appeared human but were not wandered about. If one stumbled across the site, one might go mad. Rumors about the haunted refining mill pointed to the enduring, illness-inducing effects of colonial and capitalist extraction.⁵ Simultaneously, conversations with my interlocutors urged me to think about colonialism as an iterative process, one that manifested not only in the ghosts of the past, but could be continually found in enduring modes of social inequality. Understanding health inequity as tied to enduring colonialism points to the multifaceted ways that illness emerges from historical and ongoing projects of domination. Attending to these dynamics, moreover, foregrounds how medical institutions continually reinvent biopolitical regimes of intervening in racialized Indigenous patient bodies, replicating hierarchies of knowledge, and displacing local relations among human and other-than-human beings.

Indigenous movements and decolonial theorists across what are now known as the Americas have pointed to how, in contexts where European colonizers settled long term, colonialism did not end with formal independence from European crowns and the creation of new nation-states. When Indigenous movements across the hemisphere protest “five hundred years of colonialism,” they point to the ways political, economic, ideological, and ontological orderings continue to maintain structures of domination over Indigenous communities and ongoing settler access to Indigenous land and labor.⁶ As Aymara sociologist Silvia Rivera Cusicanqui has argued in her work on Bolivian history, “Both colonial transformations and those that emanated from liberal and populist reforms signified successive invasions and aggressions against Native peoples’ and ayllus’ forms of social, territorial, and economic and cultural organization. . . . [Reforms] introduced renewed mechanisms of oppression and material and cultural plunder” (2010, 41, my translation). Attending to these continuities across time does not entail collapsing past and present. Rather, it is a means of analyzing how projects of colonial domination are continually reinvented in new forms, including under projects of democratic and liberal state-building.

Particularly within Latin American contexts, scholars have emphasized how what Aníbal Quijano (1999; 2000) has called la colonialidad del poder (the coloniality of power) continues to operate through multiple scales and modes. They argue coloniality is a global system that has been co-constitutive with modernity and capitalism,⁷ giving shape to Eurocentric epistemological and ontological hierarchies, material inequalities, and enduring formations of race, class, and gender.⁸ Tracing the workings of coloniality in Latin America has on the one hand entailed looking toward global neocolonial knowledge production and economic resource flows, including those forged through U.S. empire (Escobar 2004; Quijano 2000, 227). It has also simultaneously involved looking to how nation-states maintained systems of social hierarchy and access to labor and resources, most centrally through projects of mestizaje (racial and cultural mixing) that sought to assimilate Indigenous and Black populations into whiteness⁹—a form of colonialism through the Latin American nation-state that some also discuss in terms of settler colonialism (Castellanos 2017; 2021; Speed 2017).¹⁰

In tracing the coloniality of Bolivian health care, I foreground how historical and contemporary dynamics of plunder have unequally distributed illness across sectors of society. Simultaneously, I emphasize how institutions created to address illness are rooted in a biopolitical project of regulating Indigenous life. This project has been essential, especially from the mid-twentieth century onwards, to Bolivian mestizo nation-state building and control over territory, even as it has also been sustained through transnational health programs and resource flows (see Pacino 2013; 2015).¹¹ Across multiple administrations, health policies have forwarded the racialization of Indigenous patient bodies as sources of pathology while positioning the adoption of biomedicine as a path to both modernization and social whitening. Echoing colonial biopolitical projects elsewhere (Million 2020; Morgensen 2011; Stevenson 2014), Bolivian health care provisions have also centrally revolved around remaking Indigenous and campesino lifeways in the name of sustaining biological, or bare, life. Health policies often positioned nonbiomedical ontologies of health and the body—for example, those rooted in relations with kin or with the surrounding landscape—as key targets of intervention and reform. Simultaneously, however, people’s ability to “cooperate” in ostensibly life-saving projects (Stevenson 2014) was also undercut by the precariousness of institutional care in Bolivia: patchy state and transnational health infrastructures often meant that services were underresourced or difficult to access.

These histories have underpinned how health care contexts in Bolivia continue to be key sites of racialization and racial formation. More broadly, because of shifts in legal and political categories and layered histories of assimilation,¹² how people identify themselves and others is often context dependent. In Machacamarca, for example, while the vast majority of residents of the municipality of Machacamarca identified as Aymara on the census (Instituto Nacional de Estadística 2001; 2012), their use of terms such as Indígena (Indigenous) or, more rarely, Indio (Indian), also varied. Especially since the 1990s, as the term “Indígena” began to circulate more nationally and globally in association with emancipatory struggles, some town residents embraced it as a political identifier. Others, however, used it to refer to relatives who lived in more rural areas “as we did before.” Still others preferred to use more class-based terms, distinguishing between rural campesinos (peasants) and urban vecinos (neighbors) who lived in the town center. Yet biomedical clinics also created specific sites for both enacting and entrenching racial formations. Emphasizing the malleability of conceptions of race in much of the Andean region, Elizabeth Roberts (2012) highlights how medical technologies—along with other material markers such as language, dress, and geographic origin—can racialize patients as more mestizo or more Indigenous. In the public hospital in Machacamarca, biomedical providers (including some whose parents or grandparents were Aymara rural-to-urban migrants) were often positioned as mestizo—or simply, unmarked—because of their professional and class status and access to biomedical knowledge. In turn, in biomedical encounters, both urban and rural residents of the municipality of Machacamarca were often racialized as Indigenous—that is, as patients who could rarely access the personalized attention of private care, who had to deal with long wait times and clinical resource shortages, and whom practitioners often presumed to be ignorant.

Still, as Indigenous Studies scholars have emphasized, indigeneity cannot be reduced only to an experience of colonization—not least because colonialism has never been a complete or totalizing process. To this end, many have called for centering the relations, knowledges, and practices that constitute indigeneity, in ways that also unsettle dominant legal, political, and scientific constructions (Arvin 2019; Lambert 2022; TallBear 2013). In Machacamarca, long-standing relations with both human and other-than-human beings that formed the basis of healing have also never been fully subsumed into dominant approaches to health and medicine. Attending to the endurance of such relations does not mean treating them as pristine or unchanging over time, but it does highlight how relations—including localized projects of care and life-making—were continually refashioned and reasserted in new ways. These relations formed part of everyday practice, but also were at the center of wider conversations and debates in Bolivia about what a decolonial health policy might entail.

One of the reasons Machacamarca had become an exemplar was because long-standing state, municipal, and NGO collaborations in the municipality had already built up local health infrastructure. The hospital, constructed in 2001 with partial support from a European country’s bilateral aid funding, served residents of the town and surrounding villages in the predominantly Aymara municipality. The location of the town of about eleven thousand residents was also attractive to aid organizations: a two-hour drive from La Paz, it was urbanized enough to have amenities like electricity, running water, and internet, yet still closely connected to numerous rural villages deemed in need of care and intervention (Figure I.1 and Figure I.2). Even before Evo Morales was elected president, municipal health services had worked with NGOs to foster collaborations between biomedical practitioners and Aymara traditional midwives and healers. These projects were then significantly expanded and reworked with the enactment of national health care reforms in the Morales era.

The trajectories that brought me—a white Swiss-Bolivian researcher affiliated with a university in the Global North—to Machacamarca closely followed the paths that brought numerous others to the highland Andean municipality. I joined a small trickle of other journalists and researchers writing about Bolivian health care reforms who had likewise passed through the town on similar recommendations. In positioning Machacamarca as an exemplar, state and NGO workers hoped to showcase the goals toward which they were working. Simultaneously, however, they frequently reflected on the challenges of putting policy into practice, describing implementation in Machacamarca and elsewhere as an unfinished work-in-progress.

As I came to understand, Bolivian state-led decolonization of health care was a contingent process, involving building up and rerouting existing infrastructures to implement new policies. For example, despite officials’ stated hopes to decrease reliance on foreign aid organizations, they often worked closely with national and transnational NGOs to enact national health policies. Still, in contrast to the disaggregated forms of governmentality that often characterize aid projects under neoliberalism (Gupta and Sharma 2006; Nguyen 2010), NGOs operating in Bolivia during the Morales era often repositioned themselves as working continuously with the state. Emphasizing their technical experience and expertise, many organizations increasingly situated themselves as working to support the implementation of national policies and infrastructures (Cordoba and Jansen 2016). GHA, the main health NGO working in Machacamarca at the time of my research, was a well-known global organization with branches in many countries. While the Bolivian branch received its mandate from its parent organization in Europe, it was staffed entirely by Bolivians with backgrounds in sociology, education, and medicine. The nonprofit worked closely with Bolivian state officials to help implement reforms, including by running workshops and building new constructions such as culturally adapted birthing rooms and greenhouses at various clinics across the Altiplano, the Andean high plateau.

FIGURE I.1. Machacamarca from a distance. Source: Photograph by the author.

FIGURE I.2. The main highway that cuts through the town of Machacamarca. Source: Photograph by the author.

I was reminded of the labor and coordination needed to implement policy when I attended a series of intercultural health workshops run by GHA in 2015 for biomedical practitioners at the Machacamarca Hospital. Both NGO and Ministry of Health officials frequently offered workshops and courses for biomedical practitioners, traditional medical practitioners, and grassroots organization representatives. The goal of these didactic events was both to convey changes to national health policy and to encourage participants to shift their approach to care. Over the course of this specific workshop, GHA staffers running the meeting taught hospital practitioners about the definition of culture and provided several key examples of Aymara health beliefs and practices. They also explained the three main health care models described in an essay by anthropologist Eduardo Menéndez (1992): the hegemonic system; the alternative system; and home remedies. Interculturality, the NGO staffers explained, was an important tenet of the new national health policy: health establishments and providers should be working toward the “articulation and complementarity” between biomedical and traditional medical systems, the “cultural adaptation” of health services, and the strengthening of traditional medicine.

As the NGO staff members wrapped up their presentation, Alicia, the director of field operations for GHA, asked the workshop participants to share their own experiences engaging with patients’ cultural beliefs. Many of the hospital providers commuted to work in Machacamarca from the cities of La Paz and El Alto; thus many of them were also unfamiliar with the local context until they began working at the hospital. A young practitioner named Dr. Estela volunteered that once she had treated a patient who came in with a gastrointestinal problem but was convinced that he had been attacked by a kharikhari (a monster that stole the fat from one’s body). She was taken aback when the patient asked her to diagnose him as having been attacked by a kharikhari. Other providers jumped in to describe occasions when patients had not wanted to receive an injection because they had been victims of kharikharis. Several of those describing their experiences emphasized that interculturality in health care was all well and good, but there should be limits.

At this point, Alicia joined the conversation to assure the providers that she agreed with them. Interculturality was important, she stressed, but practices that were damaging for health should not be incorporated into the hospital setting.

The discussion was one of many I would encounter over the course of my research, as biomedical providers, NGO staffers, and state and regional health officials negotiated, debated, and tinkered with how to best care for an Indigenous patient population. “Culture”—usually understood as a bounded, static marker of Indigenous difference—was often the basis for conversations about providing for others. Echoing wider dynamics of liberal recognition politics (Povinelli 2002), institutional actors’ negotiations often entailed drawing boundaries around what kinds of practices were commensurate with hospital practice and which ones were deemed too threatening to life itself—although providers, NGO staffers, and state and regional officials sometimes had differing ideas about where the line should be drawn. Simultaneously, these negotiations around cultural inclusion were tied to new forms of attention: through formats like the workshop, providers were encouraged to provide care con calidad y calidez, to treat patients humanely and equally, and to be sensitive to difference even while working within a biomedical frame. These were the kinds of practices that came to characterize what I think of as warm care.

In national policy documents, discussions of decolonization and interculturality in health care often went beyond a focus on warmth and cultural sensitivity. Drawing from Indigenous and decolonial activist projects, Bolivian state reformers proposed a system that would move beyond treatment of the biological body and instead foreground Indigenous conceptions of health grounded in relations with “family, community, and nature” (Ministerio de Salud y Deportes 2008, 20, my translation). They also proposed the construction of a radically pluralist health system, in which Indigenous traditional medical practitioners might work alongside biomedical doctors and in which patients might choose multiple options of care (Bernstein 2017; Johnson 2010).

Yet if activist proposals for decolonization often centered a process of unsettling and undoing, in practice, state, medical, and nonprofit institutions struggled to hold tension. One easy read of the interculturality workshop might be that the transnational NGO was reinterpreting state policies in ways that aligned with models of interculturality within regional and global health—thereby watering down the more radically disruptive proposals written into Bolivian state policy texts. However, while it was the case that the NGO brought its own approach to state policies, it was not the only institution to do so; state, regional, and local health officials, as well as hospital providers, all tinkered with policies in different but overlapping ways, often with the goal of rendering plural health practices and ontologies commensurate with existing biomedical forms. Building on my conversations with bureaucrats, providers, and patients, I trace how elements of health policy designed to subvert the status quo (for example, via a focus on relational conceptions of health and the emphasis on parity of knowledge systems) were folded into a practice of warm care that maintained existing colonial structures.

Understanding this subsuming process as tied to care, I suggest, is particularly helpful.¹³ For Medical Anthropology and Science and Technology Studies (STS) scholars writing about care, care might be best understood capaciously—as a form of “providing for others” (Aulino 2019, 5) or “the way someone comes to matter and the corresponding ethics of attending to the other who matters” (Stevenson 2014, 3). As an analytic, care draws attention to the variety of ways individuals, communities, and institutions engage questions of who should be provided for and how.¹⁴ Importantly, care can also move between dominant and resistive forms; it can work to sustain social hierarchies and to undo them (Matza 2018). Analyzing care as an integral component of colonial projects means attending to how institutions have invoked benevolence when providing for colonized subjects, while furthering control over Indigenous land, labor, knowledges, and lifeways. It also highlights how institutional projects might seek to assimilate, monitor, or intervene in nonhegemonic relations of care, even as they never fully succeed in erasing them (Million 2020).

Examining how global reproductive rights organizations mobilize care, particularly in interventions geared toward the Global South, Métis STS scholar Michelle Murphy cautions against conflating “care with affection, happiness, attachment, and positive feeling as political goods” (2015, 719). Calling for a focus on care’s “non-innocent genealogies,” Murphy traces how good feelings can operate in support of hegemonic structures: “This vexation of care is important because there is an ongoing temptation within feminist scholarship to view positive affect and care as a route to emancipated science and alternative knowledge-making without critically examining the ways positive feelings, sympathy, and other forms of attachment can work with and through the grain of hegemonic structures, rather than against them” (719). Thus projects of care and compassion—at least when mobilized through dominant institutions—can also operate as an “antipolitics” that forecloses structural change (Ticktin 2011). While writing less directly about care, others have likewise noted how liberal settler states’ projects of reconciliation mobilize good feelings of sympathy (Simpson 2020) and promise to build a “kinder, gentler society” (Million 2013, 50); these affective moves ultimately depoliticize and deny Indigenous claims to self-determination.

Such works offer an important basis for understanding how, in the Bolivian context, warm care—as an affective, ontological, material, and ethical mode of providing for others—extended colonial dynamics. Warm care, I suggest, kept intact colonial biopolitical projects to monitor, regulate, and intervene in Indigenous bodies and populations. In fact, under Morales-era health reforms, disciplinary technologies expanded in scope, as health officials developed new bureaucratic mechanisms for collecting data on rural household practices, mapping community risk factors, regulating Indigenous healing and midwifery practices, and more. These bureaucratic mechanisms positioned rural, Indigenous, and low-income populations as racialized sources of risk, whose cultural practices needed to be regulated and managed in the name of sustaining life itself. Yet warm care tied these biopolitical interventions to new forms of inclusion, kindness, and gentle attention. It became a modality through which bureaucrats and medical providers attended to the perceived cultural difference of Indigenous patients, while also rendering that difference commensurate with biomedical and biopolitical modes of intervention.

Even as warmth extended state care in new directions, it also foreclosed other possibilities of care. Take, for example, the kharikhari, which the biomedical providers in the workshop described as antithetical to biomedical diagnosis and a source of patient refusal. Kharikharis (also called karisiris or pishtacos elsewhere in the Andes) manifested bodily extraction: often appearing in the guise of a white outsider, the kharikhari stole the fat (one’s life force) from unsuspecting individuals. Anthropologists working with Andean Indigenous communities have often pointed to the kharikhari as a local theorization of colonial and capitalist extraction, as well as a violation of moral norms centered on reciprocity and mutual obligation (Abercrombie 1998; Canessa 2012; Weismantel 2001). Among residents of Machacamarca, however, the very existence of the kharikhari was also contested. Rural urbanization and shifting ontologies of health and illness prompted some of my interlocutors to wonder out loud if the kharikhari even existed. Others suggested that perhaps it was not fat that the kharikhari stole, but blood, for they had seen bags of blood in the hospital.¹⁵ Residents of Machacamarca, in short, often disagreed on the nature of the kharikhari, or whether it existed at all. For some, the kharikhari remained a powerful (and yet ontologically unstable) being emerging from extractive medical practices in the hospital. Yet as institutional actors weighed the kharikhari primarily as a uniform cultural belief that should or should not be incorporated under new paradigms of inclusion, they foreclosed other relational possibilities opened up by the kharikhari. If some town residents worried the kharikhari emerged in a context of extraction, they also hoped that providers might engage in care more centered on relationships of mutual obligation. For many, establishing relations of exchange with providers—in which providers were expected to attend to patients in the long term, to be imbricated in patients’ social and moral worlds—could restore bodily health and well-being. In this book, I dwell on how warm care not only flattened more radical proposals for decolonization, but also partially foreclosed more accountable engagements with patients’ contexts and worlds.

The proposal for the new institutionality of the Bolivian State consists in taking on its own decolonization from within its own structures, practices, and discourses. The colonial composition of the state apparatus and the urgency of dismantling the explicit and implicit mechanisms that connote and denote this coloniality is due to the ways [this coloniality] is impregnated in the structure of the State and its daily functions. The continual reconstruction of the colonial penetrated all social spheres and within this were mixed elements of domination, ethnic exclusion, racism, and hegemony, mystified by the liberal and neoliberal modernization of segments of society. (Ministerio de Planificación del Desarollo 2007: 14, my translation)

Drawing from the work long undertaken by Indigenous movements and public intellectuals in Bolivia, the National Development Plan drew attention to the continual reinscription of colonialism and its embeddedness in the very structures of the state. But what did it look like in practice for the state to undertake “its own decolonization from within its own structures, practices, and discourses”? How did this project come to shape approaches to medical care and health policy?

When I started working on this project in 2012 and began sharing research proposals with others, I received a number of responses from colleagues and reviewers based in the United States who expressed confusion about what “decolonization” entailed—or surprise that Bolivian officials would use a term primarily associated with a period of post–World War II nation-state formation. However, in the years since then, the term “decolonization” has become seemingly ubiquitous in academic circles. Its use has become increasingly widespread in institutional spaces and fields of knowledge production, particularly as it has become mainstreamed in the Global North. Calls for decolonization, for example, have emerged within fields of medicine, science, and global health to reckon with historically entrenched inequalities and exclusions.¹⁶ Humanistic and social science research has been described as currently going through a “decolonial turn.” That is, if Indigenous, Black, and subaltern movements have long undertaken a range of projects—across a range of contexts and timescales—to dismantle colonial apparatuses, there has been an increasing turn (seemingly) to thinking within dominant spaces about how to reckon with oppressive legacies and presents.

At the same time, the growing institutional use of this framing has also raised concerns that decolonization has become metaphorical or equivalent to “diversity, equity, and inclusion,” rather than entailing the material reversal of colonial processes of domination and dispossession (Tuck and Yang 2012; Todd 2015). As Eve Tuck and Wayne Yang have powerfully argued, decolonization “is not a generic term for struggle against oppressive conditions and outcomes. . . . [It] specifically requires the repatriation of Indigenous land and life” (2012, 21). Concerns about the limits of institution-led decolonization have also emerged in the interrelated fields of science, medicine, and public and global health. Attentive to decolonization’s demands for structural undoing, Seye Abimbola and Madhukar Pai directly ask, “Will global health survive its decolonization?” (2020, 1627). It might, they suggest—but only if its practitioners “commit to its transformation” (1627) through antisupremacist and antiracist practice. In the environmental and lab sciences, Max Liboiron echoes Tuck and Yang’s insistence that decolonization entails nothing short of the return of Indigenous land and life—and prefers to take up the term “anticolonial” to describe methods that “do not reproduce settler and colonial entitlement to Land and Indigenous cultures, concepts, knowledges (including Traditional Knowledge), and lifeworlds” (2021, 27). These vital conversations and critiques point to the multiplicity of work toward transformation—as well as the ways projects of liberal inclusion might deflect from or co-opt this work.

In Bolivia, where state moves to decolonization slightly predated the term’s global mainstreaming, activists and intellectuals have expressed resonant preoccupations about superficial institutional appropriations of the term “decolonization” (Portugal Mollinedo 2011; Rivera Cusicanqui 2014). Nonetheless, I also want to be careful to avoid conflating conversations about decolonization in Bolivia with conversations happening elsewhere around the globe. Bolivian institutional efforts emerged from situated activist genealogies and took shape amid a national politics that, if not exactly socialist, was moving toward state-led redistribution and public investment. Attending to institutional processes in Bolivia illuminates how proposals for transformation move from activist circles to bureaucratic policymaking to implementation in multiple, nonlinear, and entangled ways. In this text, I think with ongoing debates in Bolivia about the possibilities and limits of this institutional transformation.

Actions toward and debates about decolonization in Bolivia are wide-ranging and multivocal; I do not cover all of them here. But I point, especially, to ongoing debates among Aymara and Quechua activists and scholars¹⁷ as well as allied communities about whether the state could be a vehicle for decolonization. As members of the intellectual collective Grupo Comuna argued, the state was a “battlefield” (campo de lucha), where questions of its reproduction and transformation were always in question (García Linera, Tapia, Vega, and Prada 2010).

Broadly, one historical line of decolonial thought emphasized the abolition of the Bolivian state as a fundamentally colonial institution, governed by a European-descended minority, that maintained conditions of Indigenous oppression across multiple sites. Perhaps most influentially, the Aymara activist and political theorist Fausto Reinaga called for a “struggle of national liberation” (1969, 442, my translation) to overturn the white-mestizo-ruled state and colonial order. Thinking both with and against Marxist currents, he grew disenchanted with the limits of Marxist conceptions of revolution for Indian struggle. He called for a shedding of Eurocentric conceptions and a centering of Indian cosmologies to build a more just society. In the 1970s, members of the Aymara-led Indianista-Katarista intellectual and political movement directly drew on Reinaga’s writings to call for the abolition of the colonial state and reconstitution of the Tawatinsuyu (the Incan realm) (Choque Canqui 2010; Dangl 2019; Sanjinés 2004). But this project of articulating political worlds outside the state also emerged across multiple other sites, in other forms. The work undertaken by the Andean Oral History Workshop (Taller de Historia Oral Andina, THOA) demonstrated how communitarian and anarchist thought had long been central to Indigenous and popular struggle in Bolivia (Lehm Ardaya and Rivera Cusicanqui 1988). Building in part from work undertaken by the THOA, the National Council of Ayllus and Markas of Qullasuyu, an Aymara, Quechua, and Uru movement, formed in the 1990s to restore the ayllu, a kin-based system of communal governance that had once been central to the organization of Andean Indigenous communities. Many members of the movement pointed to the persistence of forms of rotational labor, reciprocal practice, and other forms of the communal as having resisted colonial attempts at eradication—and positioned the restoration of the ayllu as part of a project to ultimately restore Indigenous good living.

Others, in turn, proposed not so much the rejection of the state form as a profound restructuring of relations between citizen, state, and society. Yet these positions were not completely separate from more anarchist or abolitionist lines of thought; rather, there was considerable debate and cross-fertilization across these perspectives. Aymara activists and members of the THOA Maria Eugenia Choque and Carlos Mamani (2001) argued, for example, for a deepening of a pluralist state, in which Indigenous communities would both have the power of self-determination for their own nation and be able to engage in dialogue on equal footing (rather than in a subordinate position) with those who were descended from the colonial invaders. Others, like Félix Patzi Paco (2004), an Aymara sociologist who became minister of education under Morales, argued that the ayllu itself was the basis of a communal politics that should inform the remaking of the colonial state—a state that itself would be decolonized through an emphasis on pluriversalism, reciprocity, and abundant redistribution. Carrying echoes of Reinaga’s earlier work, activists articulated notions of the communal that were in part resonant with and in alliance with other leftist projects (that were calling for redistribution and critiquing capitalist exploitation), but also situated this as coming from a specifically Indigenous world-making project (Mignolo 2010).

Although the Morales administration clearly took the stance that, yes, the state could self-decolonize, it drew from multiple genealogies to articulate its project of decolonization. As Mark Goodale (2019, 217) describes, Morales administration officials also handed out copies of Fausto Reinaga’s La Revolución India (The Indian Revolution) (1969) at events and positioned themselves as the inheritors of his project to recenter Indigenous ontologies as the basis for a more just society. Broadly, moves toward state-led decolonization revolved around two key goals. First was the notion that state policies might be guided by an Indigenous relational ethics to guarantee “good living”—usually glossed in Spanish as Vivir Bien and sometimes also referred to as Suma Qamaña in Aymara and Sumak Kawsay in Quechua. Policymakers and advocates positioned Vivir Bien as stemming from principles of collective well-being and harmonious relations with both human and other-than-human communities; these ethical orientations, moreover, would offer a substantive alternative to a colonial and capitalist extractive system of vivir mejor (living better) (Albó 2009; Choquehuanca 2010; Huanacuni 2010). Second was a focus on supporting epistemological and ontological pluralism—in which, for example, Indigenous knowledge-practices might be incorporated into the health care, judicial, and educational systems (Johnson 2010; Patzi Paco 2014). This approach was echoed in the rewriting of the Bolivian constitution, which established Bolivia as a plurinational state—that is, a state made up of thirty-six officially recognized nations that could also exercise cultural and territorial autonomy, albeit still within the ambit of the centralized state (Postero 2017; Regalsky 2009; Schavelzón 2012).

The paradigm of decolonization came to shape a large range of Morales-era policies. Turning specifically to projects to decolonize the health care system, I center on the making and implementation of two key policies. The Family, Community, and Intercultural Health (Salud Familiar Comunitaria e Intercultural, SAFCI) policy, enacted in 2008, centered the creation of a health care system that combined tenets of social medicine (such as equality of access and an emphasis on primary and preventative community-based care) with those of interculturality (including recognizing plural knowledge systems) (Bernstein 2017; Johnson 2010). State officials described the law as a “new way of feeling, thinking, understanding, and doing health” that would also be based in an Indigenous relational ethics of Vivir Bien. In doing so, it would offer an alternative to strictly treatment-based models of biomedicine to instead foreground “relations with family, community, and nature” as a central component of health (Ministerio de Salud y Deportes 2008, 20, my translation). Building from this earlier Morales administration policy, the Law of Traditional and Ancestral Medicine (Ley de Medicina Tradicional Ancestral), passed in 2013, instated a system for regulating and credentialing the practice of traditional medicine, significantly expanding the protections of prior legalization efforts (Babis 2014; 2018). As with the SAFCI, Bolivian state officials situated the law as part of a move toward decolonizing health care that would place multiple knowledge systems on equal footing within institutions.

Significantly, Morales administration officials distinguished health and other decolonizing reforms from policies of neoliberal multicultural recognition that had come before. In the 1990s, in response to national and global Indigenous rights movements, President Gonzalo Sánchez de Lozada enacted policies to extend new rights and cultural recognition to Indigenous peoples, albeit on limited terms. Policies included measures such as popular participation, bilingual education, and, in the realm of health care, some initial efforts to integrate Indigenous traditional medicine and home birthing into clinical settings. These policies unfolded alongside neoliberal economic reforms that also deepened many inequalities and put Indigenous and impoverished Bolivians in a precarious position (Albro 2010; Gustafson 2009b). Nancy Postero (2007) argues that frustration with the limitations of neoliberal multiculturalism prompted Morales’s political party, the MAS, to both promise a deepening of Indigenous rights and embrace a more redistributive economic model. For many officials I interviewed, the framework of decolonization went further than prior models of rights and recognition, laying the groundwork for remaking existing state structures to be oriented toward Indigenous good living. For them, “the route to decolonize the State from the State” entailed thinking with Indigenous cosmologies as the basis for reshaping institutions from within and imagining a more just and equitable society.

Reinscriptions that unfolded in health policy were continuous with other, wider tensions that took shape within the Bolivian state’s decolonial project. Most visible, perhaps, were tensions that emerged as Bolivian state projects of extractive development—in which investment and taxation on oil and gas industries might fund public infrastructure projects—eroded its promised strengthening of Indigenous sovereignty (Anthias 2018; Calla 2020; Gustafson 2020; Postero 2017). Other tensions also began to emerge. While the MAS continued to enjoy support among many Indigenous, labor, and populist movements, some argued that the party had ultimately backtracked on its commitments to them—for example, as it adopted watered-down versions of movement proposals for the constitution or made concessions to lowland agribusiness (Postero 2017; Goodale 2019). Thus whether the state had succeeded in acting as a vehicle for change or whether it had simply co-opted movement language while maintaining the status quo continued to be a point of ongoing discussion among Indigenous and worker movements in Bolivia (Calla 2020; Rivera Cusicanqui 2014). Aymara public intellectuals such as Carlos Macusaya Cruz (2014) and Pedro Portugal Mollinedo (2011) argued that the Morales administration was deepening a politics that romanticized Indigenous difference while offering Indigenous peoples little real justice or transformation. Others, in turn, emphasized that the MAS did achieve many concrete goals that transformed lives for the better: rising standards of living, new antidiscrimination and gender parity laws, popular conditional cash transfer programs, and much needed public infrastructures continued to make Evo Morales a popular president.

Scholars working in Bolivia have suggested that some of the contradictions, fragmentations, and dilutions that took shape within the MAS’s decolonial project need to be understood in connection to the limitations of the liberal settler state as a vehicle for change. As the MAS shifted from a project of “emancipation to one of liberal nation-state building” (Postero 2017, 5), it largely maintained an existing capitalist economy and state legislative system, even as it sought to reroute these to achieve goals the Morales administration put forward (Postero 2017; Goodale 2019; Grisaffi 2019; Winchell 2022). More broadly, scholars have argued that liberalism—reflecting Enlightenment ideals of rationality, progress, and individual freedom—cannot be separated from the historical rise of “colonialism, slavery, capitalism, and empire” (Lowe 2015, 4) that positioned European Man as the locus of rationality, civilization, and the human (Wynter 2003). Policy efforts to extend legal rights and protections in new directions—for example, under liberal multiculturalism and recognition politics—continue to maintain, rather than challenge, dominant structures of carcerality and dispossession (Coulthard 2014; Povinelli 2002; Shange 2019; Simpson 2014). In the Bolivian context, scholars have likewise highlighted how channeling decolonial proposals through liberal mechanisms of government constrained possibilities of change. Mareike Winchell (2020; 2022) argues, for example, that MAS policies intended to emancipate Quechua farmers relied on the liberal presuppositions of earlier land reforms, positioning both colonial systems and Indigenous kinship practices as equally irrational. Penelope Anthias locates the “limits to decolonization” in the MAS’s ongoing reliance—despite statements otherwise—on paradigms of cultural recognition, first implemented under the neoliberal state of the 1990s. She argues that projects of recognition were not confined to a single administration, but “always conditioned by colonial knowledge-power inequalities and settler interests in indigenous territory and resources” (2018, 10).

Like other scholars working on the Morales era in Bolivia, I have found it relevant to turn to the limitations of enacting change through the liberal state form. Warm care, I suggest, emerged in part out of a liberal paradigm of inclusion. Providing for others was tied to acknowledging Indigenous patients’ cultural difference through partial engagements with their worlds and through gentle and warm affects. But it was primarily oriented around making difference manageable and bringing it into the fold of dominant state and biomedical systems. However, where I differ slightly from others who have written about liberalism and the MAS is in my focus on the relationship between liberalism and unequal flows of resources and labor that conditioned the provision of public services. Warm care, I suggest, required resources and labor to maintain, but also became a means to deflect from how these dynamics continued to constrain the health care system.

Resources presented a central paradox of state care under Evo Morales. While the MAS largely maintained a capitalist system, it vowed to reinvest wealth from natural resource extraction into social infrastructures, cash bonuses, and other projects of state care that would distinguish it from predecessors’ neoliberal austerity. Yet if the Morales administration did increase health care spending,¹⁸ the new regimes of state extractivism were not sufficient to overturn decades of state underfunding, neocolonial global resource flows, and patchy infrastructures for health care delivery. The landscape of Bolivian health care in practice remained fragmentary, as the Ministry of Health continued to rely on nonprofit organizations to help with implementing public policies, and as private and employer insurance schemes remained preferred options for patients who could afford them. In pointing out ongoing conditions of fragmentation and underfunding, I do not suggest that state officials should have extracted even more resources from lowland Indigenous territories to fuel national services. Rather, conditions were already rigged to reproduce inequalities: the promise of popular health care was still predicated on colonial extraction, still operated within a global capitalist system, still shaped by national and global conditions that came before.

Amid resource constraints in the health care system, the sustenance of warm care relied heavily on un- and undercompensated labor of those deemed closer to “patient culture,” such as Aymara midwives and traditional healers. While norms varied by municipality, many healers and midwives (including those based in the Machacamarca Hospital) did not receive salaries when working in clinical settings. Within regimes of limited institutional funding, Indigenous midwives and healers were often given low priority. Most officials I interviewed agreed on principle that traditional practitioners should be systematically paid, but they had not instated formal mechanisms for ensuring that they would be. Yet midwife and healer labor was also central to sustaining institutional projects of warm care: they were often expected to do the work of cultural translation, to show kindness to patients, and to bring more patients into the clinic. For healers and midwives themselves, participation in this system (even without pay) remained an important path to prestige and to legitimating their practice, particularly in a context in which the state had historically criminalized their work. They refigured institutional projects to reflect their own approaches, exceeding the paradigm of warm care by restoring patient relations with human and other-than-human beings. And yet, in practice, their labor was also appropriated to sustain much of the daily functioning of warm care in the hospital.

Attending to questions of resources, funding, and labor is important because it highlights the broader structural dynamics that continue to shape not only the incidence of illness but also the conditions of care itself. Contestations over how resources should be used in medical contexts were inseparable from global dynamics of privatization and aid, as well as from the Bolivian state’s turn to resources to reassert national sovereignty. These, too, were extensions of deep-rooted colonial and capitalist dynamics, at both the global and national levels. But if Bolivian state bureaucrats—and policy texts themselves—frequently referenced problems of colonialism and capitalism, they positioned their solutions in limited terms of liberal inclusion, affective warmth, and kindness. As reformers continued to enact change within existing state and medical apparatuses, warm care became a way to maintain existing infrastructures, coordinations, and ways of approaching health that had long made health care hang together, however imperfectly, as a biopolitical system. Simultaneously, warm care—as both an institutional discourse and an everyday practice in medical contexts—worked to obfuscate and deflect from enduring structural inequalities. For example, it could simultaneously entrench racializing dynamics of patient care, while (through the invocation of good feelings) also obfuscating the very existence of racial hierarchies and material inequalities in the clinic. Warm care also underpinned the recruitment of Indigenous healers and midwives, as institutions extended promises of inclusion; yet these very promises of inclusion were also leveraged to offset healers’ concerns around compensation.

Such forms of accountability also shaped many of my interlocutors’ engagements with state and medical projects. Mareike Winchell (2022) notes that rural Andeans have long expected powerful actors to provide for others as a fulfillment of their moral obligations—a form of ethical accountability across hierarchies that, she argues, many also came to expect from the Morales administration. For Winchell, these notions of accountability underpin what many understand to be appropriate expressions of authority versus inappropriate ones. Building on this work, I show how my interlocutors emphasized state and medical institutions’ obligations toward patients, particularly in a context in which many residents of Machacamarca felt that through their political activism, they had directly helped bring Evo Morales and the MAS to the presidency. While some of my interlocutors refused engagement with state and medical institutions entirely, for many others, relations of obligation were a means to hold the Bolivian state accountable to its promises and shape its trajectory of action (including, for some, in ways that still held to the aspirational project of the MAS). For example, uncompensated healers positioned state obligations to redistribute resources as essential to healing relationships that had been ruptured through urbanization, alienation, and labor precarity. Many patients, in turn, asked biomedical providers to become godparents, understanding kin relations to be an ontological ground for constituting health and well-being. Machacamarqueños often worked within existing social hierarchies to demand accountability, building on wider and long-standing forms of kin-making and patronage that figured into the moral norms of everyday life in the rural Andes (Winchell 2022).

Through conversation with my interlocutors, I came to understand such expectations as a continued partial engagement with state projects. Aymara residents of the municipality of Machacamarca sometimes desired aspects of warm care—for example, as patients requested use of the culturally adapted room, as healers and midwives asserted their right to practice in the hospital, and as patients lodged complaints about practitioners’ mistreatment. Violeta’s joking commentary that opened this introduction pointed to a desire for care that was promised but not fulfilled—highlighting how some patients might welcome multilingual care that functioned in practice. Simultaneously, my interlocutors refigured institutional projects of care through local ethical norms. As others have argued, people rarely internalize biopolitical subjectivities directly—but may creatively rework them (Brotherton 2012) or refract them through other relations (Han 2012). In Machacamarca, relations of ethical obligation among both human and other-than-human beings became a central ground for redefining institutional projects toward other ends of care. These forms of obligation and accountability subverted the ontological separations that still underpinned warm care—for example, between practitioners and patients, between bodies and landscapes—and instead positioned relations among various entities as central to constituting health and illness.

In other instances, when institutions’ obligations to patients appeared to fall through entirely, residents of Machacamarca developed critiques of the state through practices of contention and complaint. Complaining (renegando) about state services (including health services) was sometimes an intimate practice between confidants, or a response to a moment of mistreatment in the hospital. But it could also take on public forms, as complaining became a common practice of speech-making in civil society spaces and forums for popular participation. As others have noted, practices like resentment, contention, and complaint are key resources and modes of engagement when countering the workings of liberal settler institutions (Ahmed 2021; Coulthard 2014; Simpson 2016). Likewise, I turn to practices of complaint to engage how residents of Machacamarca pushed beyond the limits of warm care, including its demands for commensuration and collaboration.

If warm care often foreclosed possibilities for transformation, practices of obligation and complaint raised questions about care as a site of political transformation and repair. Engaging with genealogies of Black and Indigenous feminist thought, scholars have suggested that relations of care can be central to what Aisha Finch describes as “a deliberate and purposeful creation of collective well-being” (2022, 2) that carves out spaces for radical alterity that reject colonial and capitalist orders.¹⁹ As Hi’ilei Hobart and Tamara Kneese (2020) argue, if care can be co-opted or take on oppressive forms, it can also carry radical possibilities for survival and crafting worlds otherwise, particularly amid institutional failure and neglect. As they put it, “Reciprocity and attentiveness to the inequitable dynamics that characterize our current social landscape represent the kind of care that can radically remake our worlds that exceed those offered by the neoliberal or postneoliberal state, which has proved inadequate in its dispensation of care” (2020, 3). Care is not necessarily a replacement for other forms of political action, but it can be continuous with them, a terrain, even, for articulating them—a form, as Felicity Aulino suggests, of “plodding the revolution” (2019, 17).

The question then becomes not whether care is inherently resistive or oppressive, but rather how and when it is enacted—and under what terms. For many people I interviewed in Machacamarca, building more habitable worlds often entailed hard, burdensome care work—work that could also involve tactics of resentment and complaint, as well as the continuous, unfinished work of creating accountability across hierarchies. Attending to this work was important because state, biomedical, and nonprofit actors often mobilized the seemingly warm, positive, good feeling aspects of care to shut down complaint—to imply, “We care, you are being included, you should be grateful.” Practices of obligation and complaint became a means to reroute care toward other goals of well-being. As I came to understand through conversations with town residents, these practices were oriented not only around what might make care better or constitute well-being in the moment, but also toward the wider conditions that might enable thriving more broadly. When enacted to fulfill ethical obligations, institutional care might entail more equitable resource distribution, move beyond inclusion to tackle racism, and forge modes of healing that did not demand commensuration with dominant norms. For many of my interlocutors, state and medical institutions continued to be sources of profound ambivalence. Through their engagements with care, they continually demanded more from the state than effusions of good feeling and nominal inclusion.

Chapter 1 contextualizes the making of Bolivian health policy. In doing so, it centers questions of when Indigenous worlds were recognized, when they were erased entirely, and on what terms they were invoked to reshape care. Tracking bureaucratic practices across state and regional governing institutions, as well as nonprofit organizations, I highlight a multiplicity of projects and efforts that invoked the promise of descolonización. My interest lies in tracing how, amid this multiplicity, a paradigm of warm care came to dominate state proposals for transformation. I show how this iteration of care became a key site of commensuration between projects, including in ways that facilitated alignment with regional and global health models. Yet while warmth articulated aspirational horizons for Indigenous good living, it largely maintained forms of fixing, improvement, and hierarchy that had long been embedded in health care provision. While highlighting the nuance of policymakers’ negotiations and efforts to rethink care, I illuminate the stickiness of coloniality through projects of state transformation.

Each of the five subsequent chapters takes up a different element of policy as it is enacted in Machacamarca: reorienting biomedical practice, cultural adaptation, the incorporation of traditional healing, community health work, and popular participation. Rather than simply describing policy implementation, this book takes each of these elements as a problem to think with.

Chapter 2 centers state efforts to “reorient” biomedical care via training courses and workshops that encouraged biomedical providers to incorporate moral practices of equality, kindness, and attentiveness into their work. For many biomedical practitioners in the Machacamarca Hospital, workshops became spaces where they could role-play an ideal form of care provision, in which all patients would be treated equally (and where the perpetual challenges of resource shortages were seemingly not a factor). Yet in everyday hospital practice, doctors and nurses often continued to treat patients paternalistically or harshly, leading many patients to describe their hospital experience as one of “no care.” Puzzling through this tension between aspiration and practice, this chapter situates hospital care within a deeper lineage of state and medical violence, as well as within layered histories of material scarcity and constraint. I show how, as biomedical practitioners came to embrace “warm” ideals of kindness and equality, they did not displace older, harsh forms of care; rather, they enacted multiple moral and material projects in tandem.

Following closely on the heels of the second chapter, Chapter 3 examines another effort to decolonize the conditions of biomedical care in the Machacamarca Hospital: the construction of culturally adapted birthing rooms—warm, orange-hued rooms, equipped with beds and a small kitchen to invoke the homes where many Aymara women preferred to give birth. Warm aesthetics and built environment became central to promises of good care in the hospital. Attending to ontologies of temperature, I describe how, during home births, residents of Machacamarca often attended to the cold as a lively, potentially dangerous force that could cause sickness or death of the laboring mother. Yet in the hospital birthing rooms, institutional actors enacted warmth, not as a matter of life and death, but rather in terms of invitation, inclusivity, and “psychological support.” While this mobilization of warm matter and practice at times enabled new forms of intimate care during hospital birth, it also extended racializing logics that positioned culture as a threat to be managed.

Chapter 4 shifts the focus to decolonial policy initiatives to certify traditional healers and invite them to work in hospitals and clinics. It foregrounds a central tension: even as they were granted new professional legitimacy, traditional practitioners who worked in clinical settings were rarely paid for their labor. This chapter examines how healers situated state institutions alongside human and other-than-human relations that could either sustain or impede patient well-being; they vocally demanded that the state materially invest in salaries, supplies, and maintenance to nourish relations essential to healing. Through anticipatory practices and forms of claims-making, healers redefined state promises of redistribution as a moral obligation to care for embodied relations and counter the illness-inducing effects of alienation.

Building on the theme of holding institutions accountable to promises, Chapter 5 turns to how patients worked to refigure biomedical care through lines of kinship and obligation. Under conditions of uncertain medical care, some residents of Machacamarca asked hospital practitioners to become godparents of their children. I read patient-initiated kinship practices critically against state efforts to move care out of the hospital and into the wider community. Efforts to create holistic and preventative care invoked the language of Indigenous relationality, but also subjected kin relations to biopolitical surveillance and monitoring of those deemed pathological threats to health. This chapter demonstrates how patient-initiated kin-work strove to refigure the colonial hospital in terms of intimacy and obligation, rather than monitoring and surveillance. It centers the forms of obligation, redistribution, and accountability across hierarchies that Machacamarqueños articulated through engagements with and against state promises of warm care.

The final chapter, Chapter 6, turns to practices of contention and complaint as sites of engagement with state health reforms, particularly in spaces marked off for community decision making at the local level. It ethnographically examines how residents of Machacamarca engaged in public speechmaking to complain about inadequate services, funding shortages, and unfulfilled promises in community fora. I examine the complaint as a demand for obligation and accountability in the aftermath of activism—a more minor political form that operates alongside major political forms in Bolivia like the protest and the blockade. This chapter ultimately considers how, in a context in which institutional care is always already wrapped up in colonialism, we might foreground complaint, resentment, and noncollaboration as sites of moral and political possibility. Specifically, I point to the unfinishedness of decolonization, but also to its aspirational horizons.

The book concludes with a discussion of the intertwined political and health crises that unfolded in Bolivia after the completion of fieldwork, as Evo Morales was ousted from the presidency in 2019 and as the Covid-19 pandemic hit in 2020. Ending with the return of the MAS through the election of Luis Arce in late 2020, I ask what possibilities for decolonization, accountability, and contention are still unfolding in Bolivia.

Notes

1. I use pseudonyms for the name of the town, the hospital, NGOs, and all individuals who are not known public figures. Anonymizing was a difficult decision, because many people I interviewed would have liked to see their town name in print. Moreover, towns and the land they are situated on have specific histories, and the use of pseudonyms can also have a deracinating effect. However, given the infrastructural and labor challenges faced by the local municipal hospital and the sometimes-sensitive nature of patient and practitioner experiences, I felt it important to follow anthropological convention in this case and de-identify people, place names, and institutions as much as possible. “Machacamarca” simply means “New Town” in Aymara, and it is the actual, commonly used place name of numerous towns and neighborhoods across the Altiplano. Long ago, the area where I conducted research was also called “Machacamarca” before the river changed course, houses were moved, and a new name was adopted. “New Town,” although in some ways generic, gestures both to a situated history and to a current context of rapid rural urbanization.

2. The Aymara are one of the largest Indigenous groups in Bolivia, with approximately 1,191,352 members (Centro de Documentación e Información Bolivia 2013).

3. For example, Lucia Guerra-Reyes’ (2019) account of intercultural birthing policies in Peru describes the common use of the phrase calidad con calidez (quality with warmth). In Bolivia, this phrase was also used, although I more commonly heard the formulation con calidad y calidez (with quality and warmth). Although slightly different in their phrasing, both point to notions that medical rigor (“quality”) should be combined with warmth, especially in contexts in which managing Indigenous cultural difference became a central concern.

4. On health policy and inequalities in Latin America, see Andaya 2014; Berry 2010; Briggs and Mantini-Briggs 2003, 2016; Guerra-Reyes 2019; Jarrín 2017; Vega 2018; Yates-Doerr 2015. For discussions of neoliberalism and health, see Abadía-Barrero 2022; Han 2012; Martínez 2018; Tapias 2015.

5. Charles Briggs and Clara Mantini-Briggs (2016, 171) similarly point out in conversation with their Warao interlocutors that narratives about the origins and temporality of disease reflect positioned ways of knowing. For at least some of the Warao, illness begins not with the onset of symptoms, but with the negative effects of colonialism following the arrival of Christopher Columbus.

6. While some scholars have argued that land dispossession, rather than labor exploitation, is the central mechanism of settler colonialism, others have troubled this distinction. I follow Shannon Speed (2017) and Bianet Castellanos (2017), who have argued that land dispossession and labor exploitation are complexly interrelated processes in the context of Latin American settler colonialism. Their arguments also echo those put forward by Aymara Katarista activists who, in the 1970s in Bolivia, centered the uneven co-constitution of ethnicity and class (see Dangl 2019; Sanjinés 2004).

7. While dynamics of colonialism and capitalism should not be conflated (Liboiron 2021), they have often gone hand-in-hand, historically shaping one another’s trajectories (Ramones and Merry 2021).

8. For works on coloniality, see Castro-Gómez 2005; Espinosa Miñoso 2022; Lugones 2007; Maldonado-Torres 2007; Mendoza 2020; Mignolo 2012; Moraña, Dussel, and Jáuregui 2008; Quijano 1999; 2000; Segato 2013; 2016.

9. On mestizaje in Bolivia and the Andean region more broadly, see de la Cadena 2000; Molina 2021; Ravindran 2020; 2021; Rivera Cusicanqui 1984.

10. There has been some debate among scholars thinking with and about Indigenous critiques how to best describe the long-term, lingering, and reentrenching effects of European colonialism. Scholars working in the Americas have at times critiqued the use of the term “postcolonial,” first developed by subaltern studies scholars, many situated in recently decolonized, former franchise colonies in the mid-twentieth century. Critics have argued that “postcolonial” implies an “after” that is not well applied in contexts of long-term European settlement where the colonizers never left (Klor de Alva 1992). At the same time, scholars who do engage with the term have articulated a nuanced take on the “post-” in “postcolonial,” arguing that it is not so much about a clear before and after as the ways that domination has taken on new and different forms in context (cf. Hall 1996). In the context of enduring Anglo colonialism (e.g., the United States, Canada, Australia, New Zealand) the term “settler colonialism” is often used to describe processes of European settlement on land and simultaneous project of elimination of Indigenous peoples (Coulthard 2014; Simpson 2014; Wolfe 2006). Some scholars also apply this term to Latin American contexts—which share broadly similar patterns of long-term settlement, and where one might also draw important lines of continuity beyond contemporary nation-state borders (Castellanos 2017; Saldaña-Portillo 2016; Speed 2017). Others, however, have cautioned against the way that growing use of this term displaces ways that scholars in Latin America and its diaspora have long written about “coloniality” (colonialidad) to describe colonial reinscriptions (see Lugones 2007; Mignolo 2012; Quijano 1999), as well as specific differences in ways that Iberian colonialism had operated in these contexts. Others, still, point out that writings from Latin America on coloniality—which have gained global scholarly traction—are primarily from white and mestizo men, and have often failed to cite earlier writings pointing to similar processes on “internal colonialism” (colonialismo interno) (González Casanovas 1965; Rivera Cusicanqui 2010). These concerns raise questions about the terms on which academic terminology circulates and gains traction (Pérez-Bustos 2017). In an effort to think with these different genealogies, as well as how technologies of domination travel across contexts, I use the broader term “colonialism” (colonialismo) in this book, while attending to the specificity of the ways it continues to be rearticulated through the Bolivian state.

11. Growing academic conversations on colonialism and decolonization in medicine have focused heavily on the aftermaths of European and U.S. administrative colonialisms and their relevance for global health, highlighting how historically rooted structures continue to shape conditions of knowledge production and medical resource flows between Global North and Global South. Yet as Anpotowin Jensen and Victor Lopez-Carmen (2022) have argued, these discussions of colonialism in global health often ignore the experiences of Indigenous nations and how health care systems intersect with enduring settlement-based colonialisms. In my analysis, I foreground both the dynamics of state-based colonialism and the coloniality of global health, understanding these dynamics to also intersect in complex ways.

12. Spanish colonists used the term Indio (Indian) to classify the original inhabitants of the land they colonized. The term Indígena (Indigenous) also started to be used in Bolivian legislation by the early nineteenth century. Over several centuries, the meaning of both categories—as defined within state and legal documents—shifted, variably linked to a person’s geographic location, occupation, or language use (Arigho-Stiles 2024; Barragán 2011). After the 1952 national revolution, the Bolivian state sought to unite the nation around a shared mestizo identity and shed ethnic identifiers in favor of the class-based term campesino (peasant). Later, with anticolonial social movement activism beginning in the 1970s, the global rise of an Indigenous rights framework in the 1980s and 1990s, and the eventual recognition of Bolivia as a “multicultural nation” in the 1994 Bolivian constitution, the term Indígena came to the fore again, often in association with emancipatory struggles (Postero 2007).

13. The English-language term “care” offers an imperfect translation of multiple ways that my interlocutors talked about providing for others. In Aymara, the verb uywaña might be translated as “care,” but more accurately means to rear, nurture, and grow in relation; it is taken up less in the context of the clinic and more in the context of mutual care between human and nonhuman others in a sentient rural landscape. In Spanish, two words are often used. The first, cuidar, is closest to the English “care” and is often used as imperative te cuidas (take care) or for the act of taking care of another (cuidar a alguien). Second is the term atención, which is more along the lines of “service” but is used to describe institutional health care (la atención en salud) and care for a patient (atender a un paciente). When patients described their local hospital as a place donde no hay atención (where there is no treatment/care), they frequently pointed to the intertwining of bureaucratic and material with affective demands. Given this variation of terms, I attend to both the specificity and multiplicity of ways that patients, providers, and bureaucrats weigh questions of who should be provided for and how.

14. On care as a moral, embodied practice, see also Buch 2018; Kleinman 2007; Mol 2008; Mol, Moser, and Pols 2015.

15. Anthropologists who have written about the kharikhari (or karisiri or pishtaco) have frequently emphasized the importance of fat to Aymara and Quechua ontologies of the body, personhood, and well-being. Fat is the main source of one’s vitality and is constituted through social relations (Canessa 2012; Crandon-Malamud 1991). The fact that some of my interlocutors were suggesting that the kharikhari might steal blood instead was a recent conceptual shift (and not something upon which everyone agreed). My sense was that this shift emerged from increasing encounters with hospital biomedicine, as well as broader transformations in social norms and approaches to healing that accompanied rural urbanization in municipalities like Machacamarca.

16. Abimbola and Pai 2020; Affun-Adegbulu and Adegbulu 2020; Büyüm et al. 2020; Herrick and Bell 2022; Lawrence and Hirch 2020; Richardson 2020.

17. I am focusing primarily on highland Aymara and Quechua decolonial theory in this work because they share a context with many of my interlocutors and were also highly influential for how the MAS articulated its project. Nonetheless, this excludes a range of decolonial perspectives and work also coming from Indigenous communities in the Bolivian lowlands.

18. As a share of total government expenditure, health care spending increased over the course of the Morales administration from 8.75 percent in 2006 to 13.67 percent in 2019 according to Our World in Data (https://ourworldindata.org/grapher/health-expenditure-government-expend…). As a percentage of GDP, health care spending increased from 4.66 percent in 2006 to 6.92 percent in 2019 (https://ourworldindata.org/grapher/total-healthcare-expenditure-gdp?tab…).

19. On care’s radical potential, see Dokumaci 2020; Finch 2022; Grande 2021; Hobart and Kneese 2020; Puig de la Bellacasa 2017.