Nearly two decades have now passed since the dissolution of the Soviet Union. Over the next several months we will be running a series of articles which consider a specific issues related to health and medicine in the former Soviet Union.  The articles comprising “20 Years After the Soviet Union” will highlight research by anthropologists and other social scientists on topics including psychiatric deinstitutionalization, HIV/AIDS, disability rights and population health.

By way of introduction, I’d like to mention a recent special issue of the open-access journal, the Anthropology of East Europe Review on “Health and Care Work in Postsocialist Eastern Europe and the Former Soviet Union.”  A number of the authors in this issue will also be contributing posts to our series, so look for them in the weeks and months ahead.  (For those articles which do not have abstracts, I have selectively quoted from introductory paragraphs).

 

“Health and Care Work in Postsocialist Eastern Europe and the Former Soviet Union,” a special issue of Anthropology of East Europe Review

 

 Maryna Y. Bazylevych, Ema Hresanova, Introduction: Health and Care Work in Postsocialist Eastern Europe and the former Soviet Union

 

Michele Rivkin-Fish, Health, Gender, and Care Work: Productive Sites for Thinking Anthropologically about the Aftermaths of Socialism

Anthropological approaches to the study of health open up a range of questions and ways of conceptualizing social processes that are particularly valuable for understanding the transformations underway in the aftermath of state socialism. While public health and demographic analyses capture important macro-level shifts—from the dire spikes in Russia‘s male mortality and sexually transmitted infection rates that began in the early 1990s, to reductions in fertility and abortion that have continued throughout the region for over twenty years—public health scholars‘ efforts to understand these shifts are fraught with methodological and theoretical limitations that too rarely go unexamined. Anthropologists’ contributions to the study of health are thus important in several ways. First, they bring together attention to macro-level changes with ethnographic-based inquiry into what such shifts mean to the various persons and institutions involved in them. Second, the anthropological lens requires us to reflect continuously upon the assumptions and interests that guide our research in light of the meanings, practices, and contradictions we encounter in the field. This iterative, reflexive, and critical attention to our own analytical processes serves, ideally, as a safeguard against unwittingly projecting our own assertions of the real or the important onto others‘ lives. At the very least, we need to articulate and justify our perspectives and our questions, and clarify their relevance vis-a-vis the concerns of local actors.

In this brief essay, I propose that questions related to health after socialism help explain the trajectories and trials of life (and death) in former socialist contexts by revealing how daily life is embedded in shifting formations of citizenship, practices of distinguishing public and private, and changing notions of personhood. I also suggest that anthropological aims to understand the complex changes in this region critically—that is, through the continual questioning of our own assumptions and paradigms as outsiders—may require us to engage more closely with scholars from the region. If anthropologists have done much to consider health as a situated and historical practice, we have perhaps done less to examine our own production of knowledge about health and postsocialism in this light. I will conclude by arguing the need to enrich our analyses through more systematic processes of dialogue and debate with our colleagues in Eastern Europe and Eurasia.

 

Kate Schecter, The Privatization of the Georgian Healthcare System

This article will examine the dramatic changes that have occurred in Georgian healthcare since the Rose Revolution of 2003. What were the motives for the abrupt privatization of the Georgian economy, including the healthcare sector? The research for this article draws on interviews with Georgian physicians and healthcare administrators, the few reports that have been written about the attempts at privatization, lectures by Georgian politicians who have come to the US to explain the reform processes in Georgia, and my own observations working for the American International Health Alliance in Georgia over the past decade.

 

Jennifer Carroll, A Woman Among Addicts: The Production and Management of Identities in a Ukrainian Harm Reduction Program

When HIV first appeared in Ukraine in the mid-1990s, it spread like wildfire through users of injected narcotics. By 2008, Ukraine was estimated to be home to 29% of all reported cases of HIV in Eastern Europe and Central Asia, making it the nation with the highest infection rate per capita in the region (UNAIDS 2008:24)…. In response to this, many non-governmental organizations have formed to implement prevention efforts among drug users specifically…In this article, I share a few insights about drug use as a social marker and women’s access to prevention programs, which were gained through several weeks of observations and interviews at [a non-profit HIV-prevention program in southern Ukraine]….

I argue that the daily interactions of both current and former injection drug users at [the program] are mediated by this social and biomedical identity in a way that shapes not only their behaviors and relationships, but also affects their access to different social roles and physical spaces. Furthermore, I argue that this social construct that defines who and what an injection drug user is has primarily incorporated masculine tropes of identity. Simply put, drug users are generally assumed to be male. This puts female addicts, who already suffer greater social and logistical obstacles in accessing preventative and therapeutic health care (Pinkham and Shapoval 2010), in an even more difficult position.

 

Shelly Yankovsky, Neoliberal Transitions in Ukraine: The View from Psychiatry

This paper will explore how mental health reforms in Ukraine—specifically the push for community mental health services—are playing out on the ground through provider and patient perspectives. I focus especially on the human rights discourse that is often utilized by mental health activists as a way to package these issues. I argue that the international agenda promoted in Ukraine, which pushes for western neoliberal-based political and economic reforms, has produced cultural and structural discrepancies and tensions which can be seen in the mental health field. Amid these cultural and structural changes, moreover, the neoliberal agenda forces Ukrainians to replace deeply rooted cultural tenants shaped by socialism with those of western capitalism. Human rights discourse has been adopted by a non-governmental organization (NGO) called ―Human Rights for Psychiatric Patients‖ or HRPP, as a way to mediate these processes of cultural change induced by transformations in political economy. I use psychiatry and mental health as a window into this struggle.

 

Rosie Read, Humanising Healthcare: Volunteered caring and the free gift in Czech hospitals

The past decade has seen a marked proliferation of volunteering programs in Czech hospitals. These have been established with the help of national and international funding and take various organisational forms. For the most part, these programs enable lay citizens to provide hospitalized patients with company and social support for a few hours per week. This article considers the ways in which hospital volunteering is promoted and understood as a free gift, in anthropological terms (Parry 1986, Laidlaw 2000). Specifically, I probe why it is possible and desirable for participants on volunteering programs to think about volunteering in this way. I argue that the social construction of volunteering as a free gift promotes a particular ideology of autonomous personhood, which, when considered alongside other political and economic developments in Czech healthcare over the past two decades, can be thought of as part of its neoliberal transformation.

 

Inna Leykin, Population Prescriptions: (Sanitary) Culture and Biomedical Authority in Contemporary Russia

Russia’s population has been rapidly decreasing for several decades. Political fears over falling birthrates and growing mortality rates have recently reemerged as a staple in every conversation concerning the future of the Russian nation. In May 2006, in his annual address to the Federal Assembly, President Vladimir Putin identified Russia’s decreasing population as the most acute issue facing the country. Later that year, the government launched a new, high-priority policy to address the “demographic problem,” which was built around monetary incentives for women to have multiple children. As the state made an effort to revise and implement its new policy measures, different groups of experts took part in the debate about the demographic future of the nation. Alongside demographers and social scientists, medical and public health experts became visible as playing a crucial role in this debate.

To address the role of this community of experts in Russia’s most heated debate, this paper examines how a group of obstetricians and gynecologists in the large provincial city of Yekaterinburg, Russia appropriate existing discourses of the “crisis of underpopulation” and demographic policies, and assign new cultural and social meanings to them in their clinical and research practices. An ethnographic study I conducted among these medical professionals demonstrates how they negotiate their power not only through individual patient care (Rivkin-Fish 2005), but also outside their clinics as they participate in the demographic debate and in the development of regional family planning programs.

 

Elianne Riska, Aurelija Novelskaite, Professionalism and Medical Work in a Post-Soviet Society: Between Four Logics

The relationship between the state, the market and professions has been in focus of sociological theories on professions. This study explores how Lithuanian physicians perceive these three sectors, called logics in sociological theories, to influence their work in a health care context which has experienced a rapid change.

The results show that the physicians perceived the state regulated health care system as a limitation to their professional identity and practice. Market elements of care did not seem to work and instead two other mechanisms bridged the provision of services between the client and the physician: peer referrals and gift-giving. The peer referral system enabled physicians to directly refer patients to a professional colleague outside the formal referral system and thereby to improve access to health services that the state directed system could not handle efficiently. Gift-giving and gratitude payments provided some consumer influence in the delivery of health services in a failing market system. The conclusion is that in a post-socialist health care system physicians are often operating in a system guided by four logics: the state, the market, professional culture, and the informal economy of peer referrals, gift giving, and extra payments.

 

Heidi Bludau, Producing Transnational Nurses: Agency and subjectivity in global health care labor migration recruitment practices

Globally, healthcare worker shortages are increasing, giving rise to a need for a migratory healthcare labor population (Buchan 2006; Choy 2003; Kingma 2006; Ross, et al. 2005; Võrk, et al. 2004; Zulauf 2001). Countries such as India and the Philippines have long-term experience with this practice, often operating state-run placement services to place nurses in countries such as the United States, United Kingdom, and Saudi Arabia. Recently, new origin countries have entered the global market. Healthcare workers from Central and Eastern Europe are being recruited for this work and are increasingly discovering the opportunities available to them as in-demand, mobile professionals. However, entering this labor market is not simple and workers often need recruitment firms to mediate the complex process of transnational skilled labor. Negotiating between the different labor and cultural environments, these staffing firms must ensure that the laborers they represent will be successful on the job market. They train them accordingly, essentially ―producing migrants. This article uses the Czech Republic as a case study to explore this phenomenon.

 

Larisa Jasarevic, Lucid dreaming: Revisiting medical pluralism in postsocialist Bosnia

Starting with th[e] basic premise that economism and cosmology do not explain the new health practices in post-socialism, I bring an ethnographic attention to plural forms of health care that tend to the experience of barely living, to invite a rethinking of the relationship between embodiment—local forms of bodily being in the world—and economic forms. Anthropology and critical political economy have long questioned the assumptions that body and economy are separate domains. Medical anthropology has shown pluralism to be the norm rather than an exception in health care the world over, notwithstanding the global dominance of biomedicine and pharmaceuticals. My inquiry into the relation of market and health, however, shifts the focus from symbolic anthropology and local cosmologies to plurality and materiality of bodies. Following the local medical travels, bodies emerge as ontologically plural, inasmuch as they lend credence to multiple forms of diagnostic assessment of the same aches and complaints. Bodies also respond to therapeutic management along divergent maps of organs, fluids, or energies or treat a physical ill or well being as extending beyond the bodily limits and accessible to spiritual entities and other incorporeal extensions, such as thoughts, looks, and wishes of benevolent or envious others. The aim of this paper is to revisit theories of medical pluralism with an eye on the Bosnian lived reality and efficacy of experience, to ask whether bodily ontology, not only medical epistemology, might not be plural.

 

Dorian Singh, Attitudes and Praxis of Traditional Forms of Health Care in a Post-Communist Romanian Romani Community

Prior to the communist period most Romanian Romani communities depended mainly on traditional healing methods as a primary source of health care. After its ascension to power, the Romanian communist government introduced a universal, Semashko-style health care system. The implementation of these requirements dramatically disrupted the traditional health care patterns for Romani communities for over 40 years. Since the collapse of communism these constraints have been lifted and social health insurance (SHI) has been adopted in Romania. Insurance coverage is based on formal participation in the labour market. It is well established that the Roma have fared poorly during the transition to liberal democracy and have suffered particularly in the labour market. Consequently, many Roma are unable to qualify for SHI and remain uninsured and in poverty. Understood within this context, it could be expected that a resurgence in and reclamation of traditional healing methods in the Romani community might be found. This paper draws upon qualitative data from Romani groups in Bucharest and explores the practice, perceptions, and attitudes toward traditional health care in a socially liberalized and increasingly market-driven Romania.