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Politics by Other Means: Health in Việt Nam

My research in Việt Nam addresses how medicine, health, and disease function as political and cultural signifiers as well as telegraphing – in the form of epidemiological data and public health outcomes – important features of the socioeconomic order. While health and disease are highly politicized everywhere in the world, these issues take on intriguing significance in socialist and formerly socialist settings – in part because they reveal the cultural features of a political economic system whose heyday is increasingly difficult for North Americans to imagine. Though Việt Nam’s status as a socialist country is complex, certain features of the socialist period remain influential. At the same time, Việt Nam’s transition to a capitalist economy has radically reshaped key social institutions – with concomitant radical changes for the way people live, work, consume, experience health and illness, and experience their bodies in everyday ways. To say this more simply, health – as a physical state of being as well as a social and cultural ideal – is politics by other means. My research addresses how transformations in Việt Nam’s national political economy have affected public health outcomes, the organization of the health sector, and the cultural idea of “health.”

The author with Lý Thị Mai (pseudonym), 57. “I want our nation to develop so the health services can have doctors return to lower levels. The hospitals are far, kilometers away. We should have many hospitals and health stations close to the people in their districts, and they should have excellent doctors so people could be treated quickly and be cared for better.”

To ask “How are you?” in Vietnamese, one asks “Are you healthy?” When I started fieldwork in Hà Nội in 2008, I confess I lacked a nuanced understanding of what the seemingly straightforward concept of “health” might mean in this complex sociocultural setting. My fieldwork – which entailed ethnographic interviews with poor and working-class families as well as with Vietnamese specialists in medicine, public health, and epidemiology – helped me form grounded impressions of how these issues matter locally. As I have come to understand it, health and disease are culturally meaningful insofar as they resonate specifically with complexes of ideas and values that are essentially ethical, political, and philosophical – about, for example, personhood, gender, deservingness, fate, and the proper role of society and the state respective to citizens’ private lives (c.f. Lincoln and Lincoln 2015). The research that I have published on the more empirical aspects of health in Việt Nam has argued that infectious disease epidemiology reveals the shifting priorities of the national health sector, that the respective states of more and less prestigious health facilities betray the effects of new disparities in health care financing, and that the state’s management of poverty and public health exposes shifts in commonly held conceptions about morality, the public sphere, and the terms of the social contract.

To provide some background for these claims, it is important to describe the last few episodes in Vietnamese political history. During the socialist period (1945-1975), supporters of the Democratic Republic of Việt Nam represented the health sector as a critical resource abetting the nation’s anti-imperial struggles against foreign powers, emphasizing the heroism and ingenuity of doctors who often doubled as combatants. The new national model for health prioritized the local provision of primary health care by community practitioners with basic training – much like the “barefoot doctor” movement in China. Mass mobilizations to vaccinate the population, improve community sanitation, increase agricultural production, and limit family size took place during this period and were understood as directly furthering the cause of national independence. State propaganda circulated images of selfless doctors, revolutionary communities, and a population of healthy, hard-fighting men and women. In a sense, these projects literalized the idea of a body politic, as the nation made increasingly intrusive claims on the bodies of citizens, which in turn became increasingly important to the political agenda of the state. The legacy of the socialist system for public health – at least according to the accounts of the Vietnamese state – was an enormous reduction in the national burden of infectious diseases and conditions caused by poverty, such as malnutrition and wasting. At the same time, the impact of the Second Indochina (“Vietnam”) War and a tightly budgeted subsidy economy meant profound consequences for both the body politic and the physical bodies of citizens.

Phan Thị Thu Nguyệt (pseudonym), 33, a hospital cafeteria worker, with her 2-month-old baby and mother-in-law and sister-in-law. She and her husband share a small house with his parents. “I just want a house and better conditions and stable work for my husband.” Phố Huế ward, Hai Bà Trưng district, Hà Nội.

Nguyễn Thị Loan (pseudonym), 70 years old, and her daughter and grandson. “I’m a farmer. In the old days my parents were farmers too. (…) Out on the street, I feel sorry for myself because they have enough to eat and enough to spend. I’m poor and don’t have anything. I have to run after every meal I eat. (…) So much money poured out for medicine, that’s why we turned out poor like this.” Đại Kim ward, Hoàng Mai district, Hà Nội.

In Việt Nam’s current period, which is often characterized as post-socialist or late-socialist, a healthy body and access to high-quality medical care remain resonant symbols, but they signify very different ideas about deservingness, socioeconomic status, and power. When I began research in Việt Nam, twenty years after liberalization had begun, I expected that the legacy of socialism might be evident in the built environment of health care provision. It seemed possible that some of the historic ideas about socialized medicine might have endured despite significant changes in the country’s economic arrangements. What I encountered instead was the consequences of de-socialization: hospital doctors moonlighting in private practice to make up for low public-sector salaries; long rows of private clinics and pharmacies near the entrances to state hospitals; hospital courtyards overflowing with patients and family members. Elsewhere, gleaming new English-speaking clinics served a clientele that was so nearly exclusively European and North American that they might have hung signs saying “Whites only” – a phenomenon that I have described as medical stratification (Lincoln 2014a).

Political and economic changes have had other consequences for what “health” means in Việt Nam. In everyday ways, ideas about health and what is healthy have become commodified. Increasingly, people are encouraged to pursue private solutions to environmental and social problems that threaten their health. As a new middle class and young, increasingly Westernized cohorts of consumers emerge in Vietnamese society, they are interpellated with messages about healthy foods, behaviors, and lifestyles. In Vietnamese cities, a mostly Westernized gym and fitness culture has been on the rise for the last decade or so (c.f. Leshkowich 2008 – though the undoubtedly fascinating history of physical culture during the socialist period has yet to be written). In the last few years, a U.S.-inspired anti-vaccination movement has begun among mostly middle-class Vietnamese women – a shocking development in a country where mass vaccination campaigns were pivotal in eradicating many infectious diseases. Pharmaceuticals are available over-the-counter in spectacularly deregulated fashion (c.f. Do et al. 2014) and many poor patients self-treat illnesses instead of visiting a doctor (Nguyen et al. 2008). Nutritional supplements and tonics are also widely consumed, sometimes circulating via multi-level marketing methods like Amway. One evening in Hà Nội, a friend took me to an informational session for a red melon fruit (Momordica cochinchinensis) product that could, the organizers claimed, cure brain tumors.

A row of private clinics opposite state-owned Bạch Mai Hospital, Hà Nội. Signs advertise blood tests, x-rays, ultrasound, and abortion services.

These changes have come about as a result of a process of privatization whose local descriptor, “socialization,” references the concept of shifting the cost of social services to private individuals and families (London 2008). Since market reforms begun in 1986, Việt Nam has largely done away with its erstwhile ambitions for free universal health care, disposing of much of its mandate to steward the health of the population. Fees for services in the health care system were introduced in 1989, and private health care provision became legal in the same year. Universal free health care has ended; today, only children under age 6 are entitled to receive free services. When I was conducting ethnographic interviews in Hà Nội with the help of staff at commune health centers, I was surprised that care providers seemed to be at loose ends. Though some nurses and pharmacists were busy, others played computer solitaire and gossiped at their desks, treating patients very infrequently. This was a manifestation of the large-scale shifts in funding for health care in Việt Nam. The market reforms of the 1980s decollectivized agriculture and slashed state employment: with the end of agricultural collectives, the commune health stations lost the social basis of their funding. Within just a few years after the beginning of reforms, commune health centers received only a small fraction of the national health budget and, as a result, came mostly to rely on user fees for drugs and services. Vietnamese people now typically perceive health care at the lower administrative levels to be of poor quality and avoid it when they can. As a result, the former vanguard of Việt Nam’s national health strategy is mainly a relic and a destination of last resort.

As a PhD student, I carried out dissertation research on a series of cholera outbreaks in Hà Nội that had taken the health officials by surprise and whose causation inspired some lively debates in the Vietnamese blogosphere. In an effort to determine how prevalent cholera might actually be in urban neighborhoods, I interviewed 120 urban families; I also asked questions about how households sourced their food and water, what their access to health insurance and health care was like, and how they balanced their budgets. On the strength of these interviews as well as meetings with experts in offices of governmental agencies and non-governmental organization, I came to the conclusion that cholera was likely not being transmitted in the ways that news reports suggested, and that these accounts represented a deliberate effort at misdirection. This was, I further argued, informed by the history of cholera in Việt Nam, which is associated with rural poverty and the externally inflicted backwardness of the colonial period and the “feudal” dynastic period before it. In the episodes of cholera that traveled through north Vietnamese provinces in 2007-2010, though, it was not so much rural backwardness that was to blame but an overloaded urban water and sanitary system, barely capacitated to meet the needs of Hà Nội’s population boom (c.f. Lincoln 2014b).

Following the publication of this research, I have been able to reflect on the accounts that I collected in conversations with poor urban families, some of which were haunting and disturbing. Because Việt Nam has experienced periods of nearly runaway economic growth since market transition, the lives of poor individuals are little represented in the nation’s new self-image, and despite a wonderful florescence in foreign-authored anthropological studies of Việt Nam over the last decade, there has been surprisingly little curiosity about exactly how poor people in the city and the country are living their lives amid rapid and often unfavorable socioeconomic changes. What seemed like background information to me when I was talking to respondents – how much they spent on household expenses, the struggles they faced with local authorities, and so on – now strike me as very important and precious public secrets, neglected by local powers and foreign researchers alike.

Trần Thị Thuỷ (pseudonym), 37, with her teenage nephew. Her husband was hospitalized for schizophrenia and she was caring for his mother, who was paralyzed. “My parents were just farmers. (…) Now I work as a security guard at the parking area of an office. I watch the motorbikes and clean the bathrooms. (…) I worry that my children are very stunted. I’m also very weak. Now I take medicine and it makes me tired. I can’t sleep, I’m melancholy and horribly tired.” Quỳnh Mai ward, Hai Bà Trưng district, Hà Nội.

In consideration of the way that poverty poses a problem for governance in Việt Nam and the way that poor people exercise agency in making claims on the state, my most recent writing about Việt Nam has addressed how the concept of biopower comes to bear in that society. While I am cautious about the typically uncritical application of European theories to local life conditions in subaltern places, I suggest that socialist and late-socialist Việt Nam constitute, with the rest of the socialist world, a critically important place for the consideration of how state power is animated through an interface with the bodies of citizens – both individually, as subjects; and collectively, as masses or populations. In the last century of Vietnamese history, both productive and coercive biopolitical imperatives have constituted a key part of state power. This can be observed, for example, in mass mobilizations, state efforts at famine relief and disease prevention, surveillance of the population through the residence registration system, the provisioning of families via subsidized food and social services, the conscription of soldiers, the disciplining of Southern Vietnamese collaborators (and, more recently, drug users) in state-run camps, and the control of the population via measures from public health campaigns to restrictions on family size.

Late-socialist biopower appears more subtle than its socialist iteration, insofar as the tight marshaling of masses is perhaps becoming a thing of the past. However, I suspect that the current form of biopolitical control may also prove coercive, insofar as people are now required to submit to the discipline of a capitalist market in order to retain a grasp on welfare, life, and health. As poor families in Hà Nội emphasized in conversations with me, the shrinking availability of state entitlements even for quite needy families means that labor force participation, often in informal and makeshift fashion, is what shores up the state’s incapacity. And as other anthropologists have demonstrated, free-market biopower can have extremely nefarious effects.

In Việt Nam, though absolute poverty today is less prevalent than it was even a few decades ago, poverty has become increasingly concentrated in social groups who are structurally less able to compete for well-paid work – women, the elderly, the disabled and unwell, people in rural areas, and ethnic minorities. The selective redistribution of poverty in a society experiencing rapid economic growth and cultural change should represent an issue of substantial concern to both ethnographers as well as policymakers. Going forward, medical anthropology in Việt Nam would be improved by a significant investment of time and resources in understanding the welfare, health, and experiences of poor people and communities, because they are the most vulnerable to the ill effects of market transition. Accordingly, they have the most to teach scholars who wish to better understand the paradoxes of public health during late socialism.

 

Martha Lincoln is Assistant Professor of Anthropology at San Francisco State University. Her research interests include infectious disease, the public health consequences of economic change, and the cultural landscape of post-socialism. With interdisciplinary collaborators, she has also published on topics including feminicidio in Guatemala, the cultural politics of anatomical exhibitions, and the theoretical uses of ghosts and haunting. She is currently completing her first book, titled Remember The Source: Cholera and the Politics of Health in Vietnam. On Twitter: @heavyredaction.

 

Works Cited

An D.T.M., Minh H.V., Huong L.T., Hai P.T., Giang K.B., Xuan L.T.T., Hai P.T., Quynh Nga P., and J. Hsia. 2013. “Knowledge of Health Consequences of Tobacco Smoking: A Cross-Sectional Survey of Vietnamese Adults.” Global Health Action 6:1-9. https://doi.org/10.3402/gha.v6i0.18707.

Do Thi Thuy Nga, Nguyen Thi Kim Chuc, Nguyen Phuong Hoa, Nguyen Quynh Hoa, Nguyen Thi Thuy Nguyen, Hoang Thi Loan, Tran Khanh Toan, Ho Dang Phuc, Peter Horby, Nguyen Van Yen, Nguyen Van Kinh, and Heiman FL Wertheim. 2014. “Antibiotic Sales in Rural and Urban Pharmacies in Northern Vietnam: An Observational Study.” BMC Pharmacology and Toxicology 15, no. 6. https://doi.org/10.1186/2050-6511-15-6.

Hinh, Nguyen Duc and Minh, Hoang Van. 2013. “Public Health in Vietnam: Scientific Evidence for Policy Changes and Interventions.” Global Health Action 6. https://doi.org/10.3402/gha.v6i0.20443

Leshkowich, Ann Marie. 2008. “Working Out Culture: Gender, Body, And Commodification In A Ho Chi Minh City Health Club.” Urban Anthropology and Studies of Cultural Systems and World Economic Development 37, no. 1 (Spring): 49-87.

Lincoln, Martha. 2014a. “Medical Stratification in Vietnam.” Medicine Anthropology Theory 1, no.1: 21-33.

Lincoln, Martha. 2014b. “Tainted Commons, Public Health: The Politico-Moral Significance of Cholera in Vietnam.” Medical Anthropology Quarterly 28, no. 3:342-361.

Lincoln, Martha. 2016. “Alcohol Use and Drinking Cultures in Vietnam.” Drug and Alcohol Dependence 159:1-8. https://doi.org/10.1016/j.drugalcdep.2015.10.030

Lincoln, Martha and Bruce Lincoln. 2015. “Toward a Critical Hauntology: Bare Afterlife and the Ghosts of Ba Chúc.” Comparative Studies in Society and History 57, no. 1:191-220.

London, Jonathan. 2008. “Reasserting the State in Viet Nam: Health Care and the Logics of Market-Leninism.” Policy and Society 27:115-128.

McNeil, Donald G. 2016. “Vietnam’s Battle with Tuberculosis.” New York Times, March 26, 2016.

Nguyen Thi Bich Thuan, Curt Lofgren, Lars Lindholm, and Nguyen Thi Kim Chuc. 2008. “Choice of Healthcare Provider Following Reform in Vietnam.” BMC Health Services Research 8, no. 162. https://doi.org/10.1186/1472-6963-8-162

Truitt, Alison. 2008. “On the Back of a Motorbike: Middle-Class Mobility in Ho Chi Minh City, Vietnam.” American Ethnologist 35, no. 1:3-19. https://doi.org/10.1111/j.2008.1548-1425.00002.x

World Health Organization. 2016. “Viet Nam Tuberculosis Profile.” Accessed July 18, 2018. https://extranet.who.int/sree/Reports?op=Replet&name=/WHO_HQ_Reports/ G2/PROD/EXT/TBCountryProfile&ISO2=VN&outtype=pdf.


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