In the summer of 2008 I had the pleasure of beginning my anthropological dissertation fieldwork in Ukraine. I was particularly interested in the mental health field. I had much experience with mental health issues in the U.S. through my Master’s thesis at the University of South Florida where I interned with the National Mental Health Association. I had also worked at a community mental health center, and grew up with a parent with mental illness. I felt Ukraine would be an interesting place to study mental health for a number of reasons: the number of anthropologists working in this part of the world remains relatively small. Moreover, because of its history Ukraine seemed a good place to study the relationship between mental health, psychiatry and politics. And, possibly the most convenient reason I chose Ukraine is that my husband was born there.
I conducted my fieldwork in Ukraine from June 2008 until February 2010. I worked with a local (Ukrainian) non-governmental organization whose goal is to protect the human rights of psychiatric patients. Their main office is located on the grounds of a psychiatric hospital – therefore much of my research was conducted at this particular hospital.
My interest in the field of mental health was fueled by my sincere desire to understand my mother’s struggle with mental illness and her constant battle to stay afloat. Her relationship with the mental health system in the U.S. only made things worse; she has been given several different diagnoses, each with its own set of prescriptions. She struggles on a daily basis with the side effects of medications, and it’s a full time job keeping up with the paperwork to qualify for Medicaid and various other programs for housing, treatment and medications. This “system” that my mother has had to navigate on a regular basis was the result of changes that came about during the 1960’s and 1970’s, known the world over as “deinstitutionalization.” This process—which chiefly refers to the closure of the large public psychiatric hospitals which had, until then, provided the majority of care for the severely mentally ill—was pioneered in the U.S. and has been imitated, with varying degrees of success, in many countries mostly in Western Europe, North America and Australia/New Zealand (Fakhoury et. al. 2002). Deinstitutionalization in these countries is said to have been possible because of the development of medications for the treatment of severe mental illness. With the advent of these medications—particularly antipsychotics, severely mentally ill people in these countries were no longer considered a threat to society. In the U.S. deinstitutionalization took place alongside the development of the “community mental health movement” enacted into legislation in 1963 (Kenig 1986:96). The idea was that instead of care being provided inside a psychiatric hospital it would come from an individual’s local community – care such as outpatient facilities for treatment, housing and so forth.
There are, however, critical problems with deinstitutionalization in the U.S. Deinstitutionalization is linked to the neoliberal agenda through its larger project to de-fund public sector services and move towards privatized care. Levin and colleagues point out that before deinstitutionalization in the United States, state hospitals provided their clients with things such as food, clothing and education (2004:81). After deinstitutionalization people with mental illnesses had to rely on separate delivery systems in order to find housing, education and so forth. However, many of these systems are funded by different agencies and organizations, most of which are not designed for the cyclical needs of those with mental illnesses, but rather are driven by the demands of the bureaucracies that fund them (2004:81). In my own Master’s thesis research on community mental health centers in Tampa, Florida, I found there to be a large gap in the availability and quality of mental health services, especially for those of low socio-economic status that can be linked to inadequate funding. This lack of funding affects cost, availability, quality, and quantity of services (Yankovskyy 2005:69). Also, because of limited funding, much of the mental health budgets are geared towards “emergency stabilization,” as opposed to preventive care (Yankovskyy 2005:68). In the U.S., deinstitutionalization was meant to provide a more humane system of mental health care – to end human rights abuses that were found in large, state–run hospitals. Instead the social and political changes associated with neoliberalism, such as deregulation, privatization and the focus on profit and consumerism have only strengthened private profit and corporate capitalism. As a result, the reality for many who are severely mentally ill is that they have been moved from hospitals to “homeless shelters, the streets, jails, and prisons” (NAMI 2002).
So, what does this have to do with the twentieth anniversary of the end of the Soviet Union or with health and medicine? To me it has everything to do with suffering throughout the world, in part because the highly problematic mental health system of the United States is being promoted globally – including in Ukraine. There is no doubt that the Ukrainian mental health system needs reforming; at least that’s what both practitioners and patients said when I interviewed them. However, if the current health care system in Ukraine is “broken,” does it really make sense to replace it with a different, arguably also “broken” system?
Currently the mental health system in Ukraine looks somewhat similar to the U.S. system one hundred years ago. Care takes place in large state-run psychiatric hospitals. Individuals are serviced by a particular hospital according to where they live (zoned by address). Healthcare in Ukraine is nominally free – however, in reality many patients have to pay for services due to insufficient hospital budgets. While mental illness the world over is usually associated with differing levels of stigma and discrimination, Ukraine has inherited a psychiatric system overshadowed by particularly disturbing legacies from the Soviet Union, where psychiatric diagnoses and confinement were used as forms of political repression (Korolenko, and Kensin 2002; Lindy and Lifton 2001; Ougrin et al 2006; Van Voren 2002).
There is a general trend in Ukriane to dismantle and privatize historically centralized state institutions, such as healthcare. Reforms are being initiated from within and outside of Ukraine. Many initiatives to change healthcare institutions in Ukraine are funded by organizations such as USAID, World Health Organization, and U.S. federal funding aimed at “stregthening civil society.” Monies from these organizations are being allocated to NGOs to promote change and reform from within. Like many other newly independent nations around the world, Ukraine engaged in structural adjustment programs (SAPs) to receive funding from the International Monetary Fund (IMF) and World Bank. These programs reflected neoliberal policies which promoted a particular set of requirements that countries had to meet in order to sustain funding such as reducing funding for health care, education and other social services. The idea is that cutting social service expenditures, decreasing industry protection, freeing interest rates, privatizing state-owned enterprises, and setting realistic currency exchange rates… will reduce state intervention while increasing competition and investment” (Shefner 2008:24), which is suppose to result in economic growth. Neoliberalism explicitly promotes what is called “developed capitalism” along with its assumed sociopolitical concomitants such as civil liberties and democratic institutions (Liu 2003:2). Policies reflecting the neoliberal agenda in Ukraine often promote “civil society and development” (Phillips (2005a:502) and “strategies to instill initiative, independence, and Western-style individualism” (Phillips 2005b:254), in addition to privatization. In other words, Western capitalist ideology is slowly trying to take root in Ukraine and displace Soviet ideology.
Thus far, the major focus of reform for Ukrainian policymakers has been the neoliberal transition from “institutional” to “community-based treatment”, a transition from socialized to privatized or insurance-based care, and the adoption of the U.S.– modeled International Classification of Diseases [ICD-10]. In other words Ukraine is transitioning from a Soviet, hospital-based, socialized system of care to more of a U.S.-modeled, privatized, de-centralized system of health care. Reform of the mental health system in Ukraine is generally welcomed by practitioners and patients alike, however each of these specific reforms are problematic. For example, transitioning from a hospital based system to community-based care in simple terms has meant cutting the number of beds each ward offers, and redirecting the money from the hospitals to the communities, which in this case means the local villages or cities. However, because of the lack of community infrastructure, or even physical structures this care is simply disappearing, along with the funds. Transitioning to private insurance-based care is still in the planning and testing phases, however the Ministry of Health has set the anticipated date to introduce the reform as early as 2015-2016 (Kiev Post 2011). Finally, the ICD-10 is already in use by many practitioners but with mixed reviews.
There are a couple of other things that stand out as being problematic for Ukraine in the adoption of these reforms. For example, while the current mental health system in Ukraine is fraught with many problems, several practitioners that I spoke with feel that the country is not ready to transition to community-based services. They are especially concerned about the abuse of mentally ill patients they have observed at the hands of family members, neighbors, police, and the state, as well as problems patients have in accessing quality medications and the lack of infrastructure required for community-based care. This is due in part to the understanding that the transition to a neoliberal arrangement requires the remaking of cultural orientations as much as structural and policy changes. As a result these reforms are producing tensions between the philosophical and cultural underpinnings of socialism and neoliberal capitalism, such as how providers view their patients, where the responsibility for health lies and the morality of money.
Human Rights for Psychiatric Patients or HRPP (a pseudonym) is the non-governmental organization that I worked with in Ukraine. A leading voice in critiquing the current state of mental health affairs, HRPP uitilizes a human rights discourse in its struggle to see a more humane mental health system. They use this human rights language as a way to critique the past and orient the future and to mediate the tensions arising from neoliberal reforms. The abuse of patients that HRRP and practitioners see at the hands of family members and society as a whole are understood as resulting from the tension and hardship of the political and economic transitions happening in Ukraine more generally.
I am fearful that the adoption of neoliberal reforms in Ukraine will have the unintended (or intended, depending on your viewpoint) effects that it has had in the U.S. and other nations such as the restoration of class power through the channeling of wealth and income to upper classes and/or to richer countries which has led to the deterioration of lower classes (Harvey 2007). Harvey calls this process “creative destruction” where neoliberal reforms destroy not only prior institutional frameworks and powers, but also “divisions of labor, social relations, welfare provisions, technological mixes, ways of life, attachments to the land, habits of the heart, ways of thought, and the like” (2007:23). This will only continue to make life more difficult for the citizens of Ukraine, especially those that suffer from mental illness. Ukraine is in the middle of a complete transformation of its health and mental health system; it will be quite interesting to see what the next twenty years will bring. My research will continue to look at these cultural changes induced by transformation in political economy through psychiatry and the mental health system.
Fakhoury, Walid, Priebe and Stefan. 2002 The Process of Deinstitutionalization: an International Overview. In Current Opinion in Psychiatry. 15(2): pp. 187-192.
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Kenig, Sylvia. 1986 The Political Economy of Community Health. Medical Anthropology Quarterly. 17(5):32-134
Kiev Post 2011 National Health Insurance in Ukraine to be Introduced in 2015-2016, Says Health Minister. Accessed online October 5, 2011.
Korolenko, Ceasar P. and Dennis V. Kensin. 2002 “Reflections on the Past and Present State of Russian Psychiatry”. In Anthropology and Medicine. 9(1). Pps. 51-64.
Levin, Bruce Lubotsky with John Petrilia and Kevin D. Hennessy. 2004 Mental Health Services: A Public Health Perspective. New York: Oxford University Press.
Lindy, Jacob D. and Jay Lifton. 2001. “Invisible Walls”, In Beyond Invisible Walls: The Psychological Legacy of Soviet Trauma, East European Therapists and Their Patients. Jacob D. Lindy and Robert Jay Lifton eds. Pp. 196-233. Lillington, NC: Taylor and Francis.
Liu, Morgan Y. 2003. Detours From Utopia On the Silk Road: Ethical Dilemmas of Neoliberal Triumphalism. In Central Eurasian Studies Review. 2(2): pp. 2-10.
NAMI (National Alliance on Mental Illness). 2002 Policymaker’s Fact Sheet on the Mental Health System. Accessed online October 5, 2011.
Ougrin, Dennis, Semyon Gluzman and Luiz Dratcu. 2006 Psychiatry in Post-communist Ukraine: Dismantling the Past, Paving the Way For the Future. In Psychiatric Bulletin. 30:456-459.
Phillips, Sarah. 2005a Civil Society and Healing: Theorizing Women’s Social Activism in Post Soviet Ukraine. In Ethnos. 70(4). Pp. 489-514.
________. 2005b Will the Market Set Them Free? Women, NGOs, and Social Enterprise Ukraine. In Human Organization. 64(3): Pp. 251-264.
Shefner, Jon. 2008. The Illusion of Civil Society: Democratization and Community Mobilization in Low-Income Mexico. Pennsylvania: The Pennsylvania State University Press.
Van Voren, Robert 2001. Comparing Soviet and Chinese Political Psychiatry In The Journal of the American Academy of Psychiatric Law 30(1):1-135.
Yankovskyy, Shelly. 2005 Mental Health Services in Tampa Florida. M.A. Thesis. Department of Anthropology, University of South Florida.
Shelly Yankovskyy is a doctoral candidate in the Department of Anthropology at the University of Tennessee. Her current research focuses on issues of mental health in Ukraine, specifically the neoliberal transition from a socialized health care model to community and insurance based care.