274 C. Kierans
require patients and their families to request referral letters from their
doctors. These referrals do not move patients along a predetermined
pathway to care, but are, instead, letters of introduction, which legiti-
mise a family’s capacity to negotiate access, particularly to new technical
forms of care, much of which are organised via private clinics or phar-
maceutical companies. These letters also help justify visits to charities,
philanthropic organisations, social assistance programmes or private
sector organisations in order to appeal for financial aid. They are, in
effect, critical cultural documents that function as passports for mov-
ing between the different strata of support that practically underpins
Mexican healthcare. The labour involved is continual, unpredictable
and highly contingent on the willingness of others. It requires, to draw
on Latour ( 1987 ), extraordinary “trials of strength” (see Kierans 2015
for discussion).
These “trials of strength” reflect Hannah Arendt’s orientation to
“labour” as distinct from “work”. Labour, for Arendt, “is that activity
which corresponds to the biological processes and necessities of human
existence, the practices which are necessary for the maintenance of life
itself. Labor is distinguished by its never-ending character; it creates
nothing of permanence, its efforts are quickly consumed, and must
therefore be perpetually renewed so as to sustain life” (Arendt 1958 : 7).
Work, by contrast, has a very different temporal signature and signifi-
cance: it generates a world of things, things which endure, often well
beyond the activity of creation.
Acquiring an organ transplant in Mexico requires Arendtian labour,
and it is through this unrelenting and repeated activity that we learn
something crucial about the compromised but indispensable status poor
bodies have within transplant medicine, the manner in which value
is created and the form it ultimately takes. As Mexican families amass
resources and forms of care, they draw into orbit diverse social relations,
comprising not only kinship and friendship networks, state, welfare
and healthcare services, but also a multitude of private sector interests:
pharmacompanies, medical suppliers, laboratories and pharmacies; the
doctors who shift from being state actors to part of private enterprise
depending on the manner in which they are approached and the new
science and technology capabilities which have emerged in the presence