The second annual Health in Transition (HiT) Conference was held June 7-8 in Bucharest, Romania. The HiT Conference had its genesis last year thanks to the vision and dedication of Edit Szenassy, a PhD student at Charles University in Prague. She envisioned an environment where social scientists who research matters of health, illness, and medical care in Central and Eastern Europe could come together, an event that could “serve as an open space to rethink the place of anthropology among social science disciplines in the region.” This year’s conference pressed forward in this tradition, bringing together scholars from over one dozen countries to present and discuss some of the most cutting-edge research in the field of medical anthropology and medical sociology in Europe’s post-socialist regions.
As the goal of this conference is to break away from monolithic conceptions of the “post-socialist” and to highlight the diverse realities health and illness in Central and Eastern Europe, it was decided that a single account, rooted in a single perspective, would be unable to do justice to the exchange that the HiT Conference engenders. For this reason, a summary of these conference proceedings is provided below in three parts, each by a different participant: Ann Dill of Brown University, Hubert Wierciński of the University of Warsaw, and Jonathan Stillo of CUNY. Their reflections on this year’s conference follow below.
Reflections from Ann Dill
A key contribution of ethnographic research in post-socialist settings is to provide grounded understandings that break through monolithic references to macro-level institutions, whether those of health care, the state, biomedicine, neoliberalism, or, indeed, post-socialism. The Health in Transition Conference revealed many such local groundings and constitutive processes; to name a few, the situational enactment of PTSD among war veterans in Bosnia and Herzegovina; the reordering of family relations by genetic cancer screenings in Poland; the transformation of pain in identity formation by Brazilian Jiu Jitsu practitioners in Romania; the uses of surgical birth and private medical care as status indicators in Romania and by Romanians who migrate to Ireland or engage in “medical travel” to Vienna; and responses to chronic social crises by mental health services in Sarajevo and elderly pensioners in Romania.
A challenge in this work is to manifest the particular without becoming idiographic, or, conversely, to advance broader conceptualization while retaining the richness and tensions of ethnographic description. In the sites studied by presenters, this issue is further complicated by the discourses that drove, and drive, the dynamics of “transition,” a term that itself connotes agendas and discourses of change – democratization, privatization, marketization, state retrenchment — set by extra-local institutions. Even attaching a descriptor to the geographic locus of these changes carries ideological and geopolitical freight now critiqued as post-colonialist.
To highlight one set of such issues emerging from research at the conference, there is the question of how people in the study sites themselves experience what it means to be “post-socialist,” and in what relation to their health. Jonathan Stillo’s study of social cases in Romania voices the frustration of self-termed “losers of socialism,” workers in formerly favored industrial and agricultural occupations abandoned by the state care once they became tubercular. Uršula Lipovec Čebron describes health care denied, or surreptitiously provided, to the estimated 25,000 “erased” people who were removed from the registry of permanent residents of Slovenia (a country whose uncritical treatment as one remnant of “Yugoslav exceptionalism,” in itself illustrates the problematic layers involved in unpacking the meanings of socialism and what has followed). These instances share conceptual ground with other populations rendered invisible, and contesting their invisibility, and provide both critique and counter-example to the concept of “biological citizenship” as cases where state authorities have actively removed possibilities of claims on the state. How can such de-surveillance be more broadly theorized?
Other presenters had additional critical takes on the conceptualization of a “socialist mentality” and the ways it is used to explain disappointment with current conditions or failures to adapt to newer regimes. In her keynote, Erin Koch queried the ontology of mentality: is it psychological, social, biological, a “local biology ” (in Margaret Lock’s term), or is it more usefully considered as an ascription that breaks through such categorizations? When doing “what the government should be doing but isn’t” is ascribed separately to mental health NGOs in Sarajevo (in Peter Locke’s work) and to HIV programs for female sex workers in St. Petersburg (in Elizabeth King’s study), the contention seems less a yearning for old, inefficient public systems than acknowledgement of the essential, if residual and vulnerable, work of a new social sector. Similarly, the TB patients who lamented to Stillo the loss of “a land of milk and honey” were making broader moral claims that those of socialist nostalgia. (It is also possible, as Tanja Bukovčan noted in examining health systems in contemporary Croatia, that they were voicing generational complaints having little to do with socialism, milk, or honey.)
The representational authority of fieldwork can speak back powerfully to dominant discourses. Doing so is a project approaching some urgency these twenty years after “transition” was engaged and appropriated by actors, both local and extra-local, for countries sharing socialist state systems but differing in much else. Providing a space for critical dialogue among ethnographers from inside and those from outside those settings, the Health in Transition conference is playing an important role in the reframing that accompanies such a project.
Reflections from Hubert Wierciński
The Health in Transition conference in Bucharest was my first HiT meeting so just before it I did not know what to expect. Questions like ‘what is health in transition or a post–socialist Europe?’ confused me a bit, maybe because I`ve felt like a possible object or subject of presented papers. I was born in Poland just when the communist government was ready to go. During the conference my doubts vanished immediately. I was simply overwhelmed by the amount of solid ethnographic data collected in countries, which seemed to be quite well known and “obvious” for people from “central Europe.” Presented papers, many by western scholars, have thrown a new light on topics and dilemmas with which I thought I was familiar. The case of “transition,” itself, is no longer so obvious, easily recognized and experienced. The papers clearly have proved that it is not a flat and one dimension process but, rather, a diverse and complicated set of phenomena, determined by strictly local contexts. Such – I believe – is good to say about “ethnographies,” but equally it is also good to say about “transitions”.
The HiT conference has also shown that there is a strict correlation between political climate, economy and health. In many papers, researchers depicted the influence of political and economical changes over healthcare systems and its organization and definitions of health, itself. Neoliberal changes have occurred in most countries of the region, but the ethnographic research presented during the conference indicates that the privatization of the healthcare sector may be not the best solution for health and care related issues. Papers presented by Maria Węgrzynowska from Dublin City University and Athena Peglidou of Aristotle University, Thessaloniki, uncovered a broad scale of phenomena, like a sense of insecurity experienced by patients and corrupt practices. The latter have their roots not only in so-called “culture,” and grounded local practices, but are also rooted in the previously mentioned sense of insecurity and lack of control over actions and processes taking place in one’s world when one is in hospital.
Many papers also proved that health and disease are not only an “objective,” biological categories. They have strong social and cultural backgrounds, as Cristina Pop from Tulane University has shown. Her paper concerns the rationalizing of C-section births with the ease of surgical sterilization during delivery in post-socialist Romania. This paper depicts a situation in which medical doctors and politicians decided what is ‘normal’ in terms of having babies. The role of state and administration was also stressed by Michael Rasell, from the University of Lincoln, in his discussion of disability in contemporary Russia.
What I found surprising was that the only paper about cancer-related phenomena was my own. Central and Eastern European countries suffer from relatively high cancer morbidity. What is more, this mortality rate is much higher than in the Western world. Cancer is thus a burning question for health institutions, governments and local authorities. I hope that next year, in Warsaw, we all be able to her more about this – in my opinion – essential dilemma.
Reflections from Jonathan Stillo
I entered graduate school in the age of biological citizenship. Adriana Petryna’s groundbreaking book, Life Exposed (2002), had just been released and shortly thereafter, I took my first trip to a mountaintop Romanian tuberculosis sanatorium looking for biological citizens. There were none to be found, but it took me years to come to terms with this. Poor Romanians were not forming activist patient groups, actively consuming medical knowledge, or even making political demands based upon their biological affliction. They were struggling to survive (Stillo 2012). Even those patients who engaged to some degree in these activities (sometimes at my request) did not benefit in terms of becoming cured or securing additional resources. They died just like the others.
At the Health in Transition (HiT) conference held in Bucharest, Romania June 7-8 2012, there was little mention of biological or health citizenship. This was refreshing. There was also virtually none of the ambiguous critiques of neoliberalism that anthropologists sometimes resort to. My paper was the only one to mention it and called into question the usefulness of the concept. Even Hubert Wierciński’s work on cancer patient advocacy groups in Poland did not situate their claims for resources and respect in terms of citizenship. Similarly Gerard Weber, who presented on stress among pensioners in Northeastern Romania grounded their struggles in the difficulties of everyday survival rather than their shared psychological disturbance.
What biological citizenship is, especially in relation to the broad and class-blind usage of the term by Rose and Novas (2005), can be difficult to discern. Is it citizenship at all if the political and legal aspects are absent? Instead, aren’t we talking about the state’s role in entitlements? This becomes clear in the struggles for resources occurring at its margins. Many people receive health and social welfare from non-state actors. Doesn’t it obscure the role of the state to talk of biological citizens when the actual state is unresponsive to their claims or has shifted these responsibilities to the NGO sector? It is clear that in much of the world, especially in Eastern Europe and the former Soviet Union, the state’s role in health and social welfare is shrinking. At the same time, the expectation that citizens, whether sick or elderly or disabled become active neoliberal subjects is also increasing. Both trends are happening despite opposition from citizens, and with very mixed feelings according to Maryna Bazylevych among doctors.
My own research among Romanians dying of tuberculosis revealed the futility of biological citizenship claims. I began to ask myself if these claims are so difficult to make and so prone to failure, what, if anything are they worth? Joao Biehl (2007) and Vinh-Kim Nguyen (2010), while together adding a litany of new vocabulary to the discussion (therapeutic citizenship, biosocial mobilization, AIDS citizenship), also provide the beginnings of a critique of the limits of biological citizenship. Nguyen argues that most AIDS patients in Ivory Coast died without access to treatment except for the few who became the “pet” patients of Western NGOs because they could tell a good story. Similarly Biehl finds that even in Brazil where access to AIDS treatment is provided freely by the state, marginalized people were still not being reached.
HiT left me wondering if the creation of polarized and disconnected disease communities is a distraction from a broader desire on the people for their governments to provide health care. As Vintila Mihailescu reminded us in his closing address, research shows that health is a priority for people in this region. Does a lack of bio-activism let governments off the hook, with health services presented as a scarce resource that must be lobbied for— “fighting for things which we are already entitled to” as on NGO founder told me. Emerging from HiT was neither a naïve and unspecified criticism of neoliberalism and capitalism, nor a fetishization of questionable biological citizenship claims. Instead, there was a willingness to look at the state (in its complex and contradictory forms) and to see Eastern Europe and the former Soviet Union as a natural laboratory where a combination of state weakness and serious health problems may offer the possibility to think beyond biological citizenship.
Biehl, J. and T. Eskerod (2007). Will to live: AIDS therapies and the politics of survival. Princeton, N.J. Princeton University Press.
Nguyen, V.-K. (2010). The republic of therapy: triage and sovereignty in West Africa’s time of AIDS. Durham, NC, Duke University Press.
Petryna, A. (2002). Life exposed: biological citizens after Chernobyl. Princeton, N.J., Princeton University Press.
Stillo, J. (2012). “Who Cares for the Caregivers? Romanian Women’s Experiences with Tuberculosis.” Anthropology Now 4(1): 10-17.
Jennifer Carroll is a medical anthropologist who researches gendered identity and drug addiction in the US and in Ukraine. She is currently working towards her Ph.D. in Socio-cultural Anthropology at the University of Washington. She also holds an M.A. in Sociology from Central European University and a B.A. in Anthropology from Reed College. Her early work focused on identity and subjectivity among drug users in Ukrainian harm reduction programs. Currently, through her dissertation research, she seeks illuminate how and why opiate users in Ukraine decide to seek out substitution therapy and adhere to treatment protocols from day to day.
Ann Dill is an Associate Professor of Sociology and of Gender Studies at Brown University. Her scholarship focuses on issues faced by nonprofit/non-governmental organizations, including leadership dynamics, relationships with the state, and management and governance challenges. Her current research looks at how NGOs respond to growing inequalities in access to health care in post-communist settings, in particular Croatia, where she is studying new forms of NGO/state partnerships in services for people with disabilities.
Jonathan J. Stillo is a doctoral candidate in anthropology at the City University of New York Graduate Center, an adjunct lecturer at John Jay College and a Writing Fellow at Baruch College. He currently serves on Romania’s Global Fund Country Coordinating Mechanism. Jonathan’s research focuses on tuberculosis, the sanatoria system, and the medicalization of social welfare in Romania.
Hubert Wierciński is a doctoral candidate in the Department of Ethnology and Cultural Anthropology at the University of Warsaw. His dissertation focuses on cancer and experience in the context of biography and narrative. Hubert is also junior lecturer and coordinator of students research programs focusing on cancer experience and cultural dimensions of illness and healing.