Stanford University Press, 2017, 262 pages.
Bringing children to the field can change an anthropologist’s relationship to fieldwork immensely. For University of Auckland anthropologist, Susanna Trnka, bringing her children to the Czech Republic quickly became a confronting medical experience when her nine-year-old daughter suffered her first-ever asthma attack within just hours of arriving in Prague. Her daughter had effectively become part of a widely acknowledged national epidemic of “blue children”—an epidemic that was hotly contested in Czech politics. Through this abrupt entry into the social and medical worlds of chronic lung illness, Trnka gained first-hand insight into the politics of health in relation to asthma treatment in the Czech Republic and New Zealand.
As dependents, children require the care and nurturance of others and are subject to intense socialization and cultural training, which makes childhood asthma a particularly compelling opportunity to study shifting neoliberal values. Childhood asthma, in both the Czech Republic and New Zealand, proved to be an interesting counterpoint for studying the contestation of burgeoning neoliberal models of healthcare—models that place an emphasis on autonomy, personal responsibility, and self-management. New Zealand has the second-highest rates of childhood asthma and the highest per capita use of asthma drugs in the world, but the epidemiology of the disease is largely obscured to the public by individualized approaches to healthcare. In the Czech Republic, the public is acutely aware of the epidemiology of asthma disease and carefully contests moves away from socialist era values and moves towards the adoption of neoliberal policies and practices. Trnka did not find the asthma situation in these countries to be in opposition. Rather, both countries evidenced a global push towards neoliberal values of self-management and responsibilization, albeit each in their own unique way. Through cross-cultural comparison, Trnka articulates the possible dynamics among patients, their families, healthcare providers and the state, and elucidates the multiple ways that responsibility for health is enacted in settings with distinct cultural, political, and economic priorities.
Asthma is a complex disease. It is manageable but not yet curable. Diagnostics, disease etiology, and the best methods of treatment remain hotly contested, which leaves patient experience and medical expertise operating within a blurry landscape of scientific knowledge. While more detailed attention to the shortcomings of contemporary scientific knowledge about asthma would certainly have added value to Trnka’s critical inquiry, her critique of the neoliberal rhetoric surrounding asthma care is hard-hitting. Analyzing research publications about self-management, for example, Trnka finds that omitting or downplaying the amount of quality, educational interactions between patients and healthcare staff in clinical trials compromises the success of the subsequent rollout of these programs. Self-management, as Trnka is careful to point out, “works best when undertaken collaboratively rather than individually” (p. 37).
One Blue Child is the accumulation of over four years of fieldwork in a range of diverse communities in New Zealand and the Czech Republic. Trnka covers familiar topics in medical anthropology—such as agency, knowledge construction, patient noncompliance, embodiment, and pharmaceuticalization—with refreshing insights into their relation to asthma treatment. She closely examines the international standards and national discourses and practices of self-managed asthma care, documents how New Zealander parents experiment with their children’s treatment to achieve results that often differ from what health professionals deem as important, unpacks the work of Czech parents and patients to secure quality care from healthcare staff in the context of a political environment vacillating between neoliberal reforms and the legacies of solidarity, and visits Russian Buteyko breathing retraining sessions in New Zealand and summer camps and health spas in the Czech Republic to explore the lengths to which people go in search of comprehensive mind-body therapeutics that enable them to retrain their bodies to diminish the impact of asthma on their everyday lives. A highlight chapter from this book, if I was pressed to choose just one, is chapter seven, “Redistributing Responsibility among States, Companies, and Citizens: Struggles in the Steel Heart of the Republic”, which eloquently describes the situation in Ostrava where necessary income generated by the local steel plant is in conflict with a public interest in environmental health and air quality. Ostrava has the highest rates of respiratory problems in the Czech Republic and the most intense air pollution. Trnka’s ethnographic account of the actors involved in negotiating responsibility over air pollution and respiratory illness, the stakeholders, activists, private companies and civic organizations, is rousing to say the least. The donation of asthma inhalers to children through AcelorMittal Ostrava’s corporate social responsibility program only receives a brief mention, but it is a very telling example of the genre of response by privately owned corporations to complex issues.
Trnka’s central arguments are nuanced and well-balanced. Examining the neoliberal rhetoric of ‘patient-centered care’, Trnka finds that patient empowerment, expertise and autonomy is only realizable within the context of interrelationality. Not to dismiss neoliberal rhetorics of self-responsibility and self-realization, however, Trnka sees the possibility for enabling more democratic forms of patient-doctor interactions through increased patient knowledge, medical literacy, and self-determination. While pharmaceuticals and evidence-based medicine ostensibly dominate asthma knowledge and healthcare service delivery on the surface, Trnka finds that patients, parents, and medical providers on the ground search for more comprehensive mind-body therapeutics such as climate therapy in the Czech Republic or Buteyko in New Zealand.
Trnka advocates for the need to address broad, structural factors exacerbating lung health; for patients to become co-authors of their asthma care and action plans; for the reduction of pharmaceutical-use in asthma self-management through increased and regular face-to-face interaction between patients and medical professionals; for mental health services to be provided alongside pharmaceutical treatment for asthma in order to minimize emotional distress, anxiety, and panic attacks; and for more comprehensive measures, such as air pollution controls and improved home environments, be considered in policy making to help reduce the impact of asthma.
One Blue Child is straight down the line, good, solid medical anthropology. The fieldwork is well documented, discussion is empirically grounded, and analysis is informed by the best current social theories. Trnka is to be commended for writing a book that not only contributes to theory and methods in anthropology, but will also be an enlightening resource for people who have been affected by asthma and their families. Respiratory healthcare workers, clinical researchers and policy makers will also benefit greatly from reading this book. My hope is that this book will go some distance to convincing policy makers, clinical researchers, and health advocates concerned with asthma to orient their efforts towards holistic, multi-stranded approaches that will improve lung health globally.
Paul H. Mason is a lecturer in anthropology in the School of Social Sciences at Monash University. He conducts research on the anthropology of the body with a current medical anthropology focus on tuberculosis in the Asia Pacific.