Lectures

Wounded Attachments: Intimacy, Infrastructure, and Harm in the National Public Hospital

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The first thing you see from the highway is a massive building. The Hospital is simply enormous. In front of the Hospital plaza is a roundabout. In the center of the roundabout, a big flag of Argentina flies high: the white and light blue stripes encase the symbol of the smiling sun, moving in the wind on some days and resting tired on its mast on others. It is only when getting off the bus and approaching the Hospital on foot that you truly appreciate its scale. Turning your back to the building, you see the highway, the autopista that leads from Buenos Aires to here, the vast periphery to the west. Standing between the Hospital and the highway underpass, you feel very small.

Image 1: The Flag and The Highway
(all photos by author)

The Hospital is public. In Argentina, this means that anyone – regardless of citizenship or resident status –  can receive its services free of charge. The healthcare system in Argentina is fragmented and quite complex: while some people pay to access private hospitals or have coverage through their labor union, about thirty-six percent of the population receives their care in public, state-funded hospitals (Novick 2017).  Public hospitals are associated with professional prestige, medical research, and community solidarity, while efficiency, new equipment, and short queues live in private clinics. But “public” also means that everyone is well acquainted with these hospitals’ shortcomings: lack of equipment, poor salaries, long waiting times, and infrastructure that is often crumbling. The Hospital is no exception.

If you turn away from the flag post and enter the grandiose main entrance, you will notice the white marbled walls. The slabs that coat the interior of the building were imported from Carrara, Italy and glimmer like snow all year round. Michelangelo carved his masterpieces from the same material that drapes the hallways of the most important hospital of the nation. Marble literally and figuratively solidifies and renders immortal the Argentine commitment to “salud pública,” public health, in line with the triumphant Peronist narrative that President Juan Domingo Peron and his wife, Eva – better known as Evita – sought to establish as their political legacy (Plotkin 2003).

The National Public Hospital was inaugurated in 1958 and planned by the Fundación Eva Peron. Directed by Evita herself, the Fundación aimed to consecrate the state as the ultimate provider of social services. The Hospital’s layout was inspired by a renowned medical institute in Sweden, which has an almost exact blueprint: a design that screams “I’m a hospital!” as architect and medical historian Annemarie Adams notes, with the mid-century “aesthetic of looming towers and identical windows” (Adams 2017:18). Via this architectural tribute, the Peronist project not only wanted to scream “I’m a hospital!” but also to stress its modernity and its commitment to public medicine and Argentine achievement.

Image 2: The Hospital

The Hospital is national. It is arguably the most important hospital in the country; everyone knows its name. Since the Hospital is state-funded and under the direct administration of the Ministry of Health, its dynamics mirror each change in national government, which swings like a pendulum from left-wing populism to neoliberal austerity and back. The Hospital’s reputation precedes it. The Hospital is known for both brutal military repression and intense political activism, for both caring deeply for and about its community and surveilling it, for both rampant employee absenteeism and clinical excellence. Rumors have it that ghosts roam the hallways at night. Facts have it that equipment disappears and that you should not leave your belongings unattended.

In the morning, the main hall swarms with people, and fills with white coats, paperwork, medical charts, long queues, street vendors selling pastries. There is even a Banco Nación ATM machine, which always has a line and always maxes out at a certain time of the day, as many ATMs in Argentina do. Women stand in line to enter the bathroom, most times finding no toilet paper or soap. In a country where the most common refrain is “it is what there is” (es lo que hay), aspiration and pessimism are not oxymorons, but strange siblings; synonyms once removed.

The Hospital is multiple. During my fieldwork from 2018-2019, the Hospital, along with the people inside of it, became my research companion. From my first encounter, and as I learned to navigate its insides, it was clear that the 83,000 square meter building itself deserved some in-depth observation. When I walked through the Hospital’s hallways to get to the ICU where I was doing research, I often ended up in an entirely different place, even when I was sure I knew my way around. Lost yet again, I had to retrace my steps in the seemingly endless labyrinth of seven floors and six pavilions. Guiding me through one of my first visits, a veteran physician walked me from the front of the building, which had recently undergone renovation, to the back. “Here’s Puerto Madero,” he said, naming the priciest neighborhood of Buenos Aires as he pointed to the glass windows and the Hospital’s administrative offices. Once we reached the back corridors and the marble slabs gave way to chipped paint, he sighed. “And this is Villa 31,” he mumbled, comparing this part of the building to one of the most famous urban shanty towns in the capital. With the marble slabs in the front and the crumbling terraces in the back, the urban contradictions of Puerto Madero and Villa 31 all in one building, the Hospital is literally multiple: Side A, the glass façade, the tall flag, the administrative offices; and Side B, the dingy hospital rooms, the malfunctioning bathrooms, the only CT machine broken for months.

The Hospital is friend and foe. The doctors and nurses I spent months with referred to it as “el hospital.” But when they were speaking about it affectionately or mentioning it amongst themselves, they simply called it “el hospi,” using an intimate name as for someone who you resent and admire, who gives you joy and sorrow, whom you hate and love. “I want to keep working here, we chose to work here en el hospi in all its ups and downs” said Veronica, after laying out her ambivalent attachment. She had done her residency in intensive care medicine here, yet her contract was renewed on a year-by-year basis.

As I listened to her and others, I too found myself developing contrasting feelings for the Hospital. As the staircases, corridors, noises, and people became more familiar, fear and intimidation lessened, but never dissipated. In time, I learned to open the clunky door of the intensive care unit (ICU) by twisting the metal lock first left, then right, then left again; I found the bathrooms that had the most chance of not being crowded; I nodded to familiar faces and kissed the ones I had befriended.

As I became more intimate with the Hospital and its contours, I realized that intimacy – as deep, tactile closeness and relational attachment – is what the Hospital elicited, and required, from its dwellers and visitors. The Hospital was enormous, yet it forced people into crammed quarters. It enclosed families waiting to hear about their loved ones in overflowing hallways; it exposed those staying in some wards to bodily fluids and the smell of disease; it enabled the handshakes of first clinical encounters and bedside caresses of comfort; it looked over the critical care nightshift doctors sleeping not too far away from their intubated patients. One ICU doctor called this intimacy “promiscuity:” this kind of physical co-mingling was a perfect environment for the proliferation of bacteria and nosocomial infections. It also was an ideal setting for affection and solidarity, as much as it was for rumors, secrets, and institutional backstabbing. Intimacy is developed in, afforded by, and linked to infrastructures, be they particular objects, buildings, roads, or technologies. Sociologist Ara Wilson (2015) connects the rubrics of intimacy and infrastructure by suggesting that “intimate relations involve places or conduits” (274). Infrastructure is often, she notes, an “embedding environment for intimate life” (ibid). Relations that are private, intimate, proximate have as much to do with institutions, social contracts, and power differentials as they do with emotional and physical closeness.

Being intimate with the Hospital meant caring for it and about it, but also meant exposing yourself to the harm it could perpetrate. Upon arrival in the morning, I always noticed the military trucks of the gendarmeria, the military police, parked on the highway overpass looking down on us. After 2015 and the election of center-right president Mauricio Macri, a change in political tone and economic governance in Argentina swiftly reached the Hospital administration, which was completely replaced. Between 2017 and 2019, the new Hospital management fired over 300 employees, starting with janitorial staff and auxiliary personnel, then nurses, and finally physicians. There were some egregious cases of people fired while on sick or maternity leave, currently pregnant or receiving no formal notification. Because of the expressions of dissent in the history of the Hospital, some of which took the form of vocal protest both there and in marches in the capital, headquarters of the military police were placed on Hospital grounds as a strategy of intimidation: police walked around in hospital hallways and were placed to “guard” the directors’ floor.

Hospital management also implemented a number of policies to contrast supposed absenteeism and tighten surveillance. When I left with Agustina, an ICU doctor, at the end of her shift to go back to Buenos Aires, we usually stopped at the biometric sign-off machine. Agustina was always nervous signing off, putting her thumb on the machine and punching her employee ID number to clock out for the day. “Who knows, I might be next,” she commented, always sighing with relief when everything went smoothly. Many employees who had been fired – despedidos – had learned of the end of their decades-long, intimate work relationship through the machine not accepting their ID number.

The Hospital is a witness. You realize the building has been precisely made to embody history, present, and future, the epitome of infrastructure as “spatiotemporal project” (Anand, Gupta, and Appel 2018). Originally envisioned as a specialized institute for the research and treatment of tuberculosis and other pulmonary diseases, the Hospital soon became a center of clinical excellence. After it was finally converted in a full-fledged clinic and trauma center in 1970, the Hospital evolved to being a point of reference for the surrounding community. In the early years of the tense 1970s, new young doctors brought to the Hospital a commitment to community health by establishing community clinics in the neighboring villas. They also brought Marxist political activism, a radicalization that was repeatedly contrasted and repressed by the succession of dictatorship governments.

Image 3: “The Future Lives in Memory”

Four days after the military coup of General Videla, in March 1976, military forces stormed the Hospital with helicopters, tanks, and 100 soldiers, seeking to find alleged dissidents against the regime. A house-like structure on the Hospital grounds, used as therapeutic space for psychiatric patients, became one of the many clandestine detention centers in the country. In a massive collective gaslighting, the regime set up secret centers where it kidnapped, held without trial, tortured, and murdered dissenters. Eleven healthcare professionals, who had disappeared shortly after the military irruption, were being detained and tortured on the Hospital’s grounds. They were ultimately killed, now tallied up as part of the 30,000 desaparecidos of the regime (Bertoia 2013; Crenzel 2010). As Argentine historian Emilio Crenzel (2010) notes, during the dictatorship “care and reinstatement of health coexisted with perpetration of torture and killing” in the Hospital (80). Years after, in 1984, the pictures of those eleven swallowed by the decade before would find their way on the marble walls, along with the words, “el futuro habita en la memoria,” the future lives in memory. In a temporal short-circuit,  several family members of the disappeared work in the Hospital today and see the faces of their dead mothers, fathers, brothers when they arrive at work each morning. Another reminder of the future living in the past occurred in December of 2017, when construction workers installing a gas pipe found the remains of one of the physicians who disappeared in 1976. Hiding and revealing at once, the Hospital was both covering up and telling its truth.

Image 4: Doctors participate in the “abrazo al hospital”

The Hospital is a home to be protected. In reaction to the series of firings on the part of the administration, Hospital employees started weekly demonstrations. Some were too scared to participate, fearing backlash. Others felt they had nothing to lose. On a September day in 2018, hospital workers lined up all along the massive hospital. In a long human chain, doctors, neighbors, nurses held hands and engaged in an “abrazo al hospital,” a hug to the Hospital. As the hug was complete and the first and last hands met, everyone broke into cheer. Patients from the hospital windows manifested solidarity with the demonstration, waving down. While this was occurring, I kept asking myself what it meant for hospital employees to hug the building that was the source of their labor but also of their fears, a place for healing but also for torture. As they attached to each other, they also attached to the building itself. In the hug to the Hospital, there it was again, the oxymoron: the publicness of healthcare and the private intimacy of an embrace, the holding close of that which heals yet harms, a wounded attachment.[1]

Image 5: Attachments in the hug to the Hospital

The Hospital changes. And remains the same. The Hospital, in everyone’s eyes, words, and hearts, still leaves much to be desired. But, perhaps, that is also the point: there always is, and always was, a lot to be desired, imagined, conjured. In November 2019, with the government’s shift to the left, the Hospital began yet another phase of its existence. Some employees were re-hired, the gendarmeria headquarters disbanded, the military trucks on the highway gone, a renewed commitment to socialized medicine. But now, the pandemic. The ICU has undergone renovations and received new ventilators from increased government funding, even while the need for qualified personnel is more urgent than the need for new equipment (Garofalo 2020). The Hospital has implemented procedures to limit the intimacy of contagion. Masks hide smiles and no kissing is allowed. Yet, ICU doctors ironically note that Chernobyl is less dangerous than the Hospital’s critical care ward. As of October 2020, several healthcare workers have lost their lives from the virus. The neighboring communities in the conurbano, the large urban periphery, are exponentially more infected than those in the Capital. Healthcare providers and hospital employees always expected to make do with what is available, have to resort to this tried and true strategy even more in recent months.

The Hospital is metonymic. It teaches that the public institutions that keep failing are the same ones that elicit the most investment. It shows that the national projects that hold the most promise are the same ones that rarely keep them. Hospitals, as places of care and uncare, are primed for the creation of such wounded attachments.

At the Hospital, now as ever, idealism and disappointment, precious marble and no soap, clinical histories and histories of torture, desire and what is left to be desired, live side by side.


Livia Garofalo is a PhD/MPH Candidate in the Department of Anthropology at Northwestern University. Her dissertation, “Wards and Worlds: Critical Care in Critical Times in Argentina” examines the relationship between intensive care, trauma, and economic crisis in public hospitals in Buenos Aires. You can follow her on Twitter @livgar_


Notes

[1] In States of Injury (1995), Wendy Brown uses “wounded attachments” to describe political positions that are rooted in suffering and victimization. I use the term differently here to capture a bond that is ambivalent.

Works cited

Adams, Annmarie. 2017. “Decoding Modern Hospitals: An Architectural History.” Architectural Design 87 (2): 16–23.

Anand, Nikhil, Akhil Gupta, and Hannah Appel, eds. 2018. The Promise of Infrastructure. Durham: Duke University Press Books.

Garofalo, Livia. 2020. “Ventilators Alone Won’t Save Us”, SAPIENS, published May 20, 2020 <https://www.sapiens.org/culture/ventilators-covid-19/>

Novick, Gabriel E. 2017. “Health Care Organization and Delivery in Argentina: A Case of Fragmentation, Inefficiency and Inequality.” Global Policy 8 (March): 93–96.

Wilson, Ara. 2015. “The Infrastructure of Intimacy.” Signs: Journal of Women in Culture and Society 41 (2): 247–80.

Plotkin, Mariano Ben. 2003. Manana Es San Peron: A Cultural History of Peron’s Argentina. Translated by Keith Zahniser. Wilmington, Delaware: Scholarly Resources Inc.


One Response to Wounded Attachments: Intimacy, Infrastructure, and Harm in the National Public Hospital

  1. Livia, me emociona tu trabajo. Perdón por escribir en español, pero me sería muy difícil pensar algo que emocionalmente me afecta en inglés. Describís con precisión y belleza lo que muchos vivimos en el hospital, aunque pocos seamos concientes de ello. Confieso que tuve que pasar algunas partes del texto por el traductor, para ver si realmente había entendido el sentido de las frases. Creo que por puro mecanismo psicológico de defensa, ya que no habría detectado la “puñalada institucional” de la que hablás, la cual creo conocer…

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