What happens to public health care when military conflicts break out? How do caregivers and administrators navigate evolving categories of "us" and "them"?
Jennifer Carroll, a research associate at the Alpert Medical School at Brown University, will give a talk entitled "Beyond Biological Citizenship: Public Health in Ukraine in Wartime" at HURI's Seminar in Ukrainian Studies on February 27th, 2017. Carroll notes that following the Russian annexation of Crimea and outbreak of military conflict in eastern Ukraine, public health institutions have found themselves caught between the human right to health and shifting state-citizen relationships. During her talk, Carroll will consider "how numerous individuals—whether they are HIV patients in Slavyansk, internally displaced persons living in Kharkiv, or LGBTQ activists working in Kyiv—find themselves slotted into social categories that are always already othered." At the same time, she'll show how public health institutions play a role in solidifying conceptions of "us" and "them." All are welcome to attend the seminar.
We asked Carroll a few questions to learn more about her work.
HURI: Why did you choose this topic for your seminar?
Carroll: The question of public health in Ukraine is increasingly relevant. Not only does Ukraine possess HIV and TB epidemics unique from many of its global neighbors (for reasons including but not limited to the fact that HIV has historically been driven by injection drug use rather than sexual contact), but it also presents an unusual social and political environment for evaluating public health knowledge and practice. The legacies of Soviet medical systems and practices, the professional crisis among Ukrainian medical professionals, and the ongoing military and geopolitical crisis imbue public health policies and interventions (such as HIV testing and care, medication assisted treatment for substance use disorder, and the diagnosis, treatment, and prevention of TB) are deeply entangled in struggles—both historical and contemprary—that has long given Ukraine a unique role on the world stage.
HURI: Your background is in sociology, anthropology, and medicine. What first drew you to researching Ukraine?
Carroll: I began work in Ukraine in 2007, when I was a Master's student at Central European University in Budapest. I had worked for several years before this in harm reduction programs in the US, such as syringe exchange and distribution programs for injection drug users. I was intrigued by the harm reduction philosophy and inspired by the ability of programs like these to have massive and positive impacts on community safety and human welfare. My proximity to Ukraine (a day's train ride from Budapest) afforded me the opportunity to begin exploring the grassroots efforts of health advocates and community leaders to provide health care and safe living to injectors who were most at risk of HIV and other infectious diseases.
Though my first visit to Ukraine was as a tourist in L'viv, my second visit was a four-week stay in Odessa, where I shadowed outreach workers from a local NGO who sought to connect local users with methadone, clean equipment, social services, and health care. I was so impressed by the creativity and intellect displayed by these NGO leaders and staff as they carried out their duties that I never ceased returning to Ukraine to learn more from their work and experiences.
I came into formal public health work long after I began working in Ukraine as a sociologist/anthropologist at the Master's and then the Doctoral level. I earned my MPH in 2015, understanding that I needed a firm grounding in public health science and method in order to study the effects of these methods as they are deployed across cultural divides.
HURI: Your talk deals with the situation caused by the current military conflict in Ukraine. Can your insights be applied to other conflict-ridden areas, or are there too many factors that make your research very specific to Ukraine?
Carroll: War is devastating for society on many fronts, including public health. In addition to direct casualties resulting from military conflict and assault, war also weakens government structures, reducing the ability of the state suffering from conflict to protect its citizens from risk and respond to ongoing humanitarian needs.
In the context of war, it is especially important to understand that the most successful and pervasive public health interventions are preventative. We process our drinking water to prevent bacterial diseases. We organize traffic, sidewalks, and cross walks to prevent pedestrian injuries and accidents. When these key infrastructures are compromised and prevention abilities damaged, disease and injury proliferate.
Iraq suffered its first cholera outbreak in decades during 2007 amidst the American military occupation, as the physical damage inflicted across the city of Baghdad made the production of clean drinking water impossible. Similarly, in Ukraine, the severing of links in the state healthcare infrastructure has had devastating effects on care for diseases like HIV in the occupied territories, as the delivery of essential medicines and even the confirmatory lab tests for HIV diagnosis, typically carried out in Donetsk, have been interrupted.
HURI: What work does the Brown University Ukraine Collaboration, of which you are a part, do?
Carroll: The Brown University Ukraine Collaboration is a team of scholars from across disciplines (medicine, social science, and public health, to name a few) who are dedicated to ongoing research on infectious disease and public health among at-risk groups in Ukraine.
The work of the Collaboration is supported, in part, by a generous donation from Victor Pinchuk. This gift is managed under the stewardship of Drs. Tim Flanigan and Natasha Rybak from the Warren Alpert School of Medicine at Brown University. Under their guidance, members of the Collaboration have built strong relationships with numerous institutions in Ukraine, including The Ukrainian Institute for Public Health Policy, Peace Corps/PEPFAR Ukraine, Ukrainian Catholic University, The National University of Kyiv Mohyla Academy, Bohomolets National Medical University, and specialized TB and HIV/AIDS treatment facilities across the country.
HURI: What should Americans know about public health institutions and the health care system in Ukraine as background information for your talk?
Carroll: Much of this background information will be discussed in my talk, but key characteristics of the Ukrainian health care system, which will help us put the current state of public health of Ukraine into context, include the survival of Soviet structures in the current medical system (including regional health councils, regional laboratory authorities, and other forms of geographic and political hierarchy); the ongoing professional crisis in the health care profession (meaning that physicians are highly underpaid and often lack the clout or prestige needed to advocate for themselves as highly skilled workers, which leads to various manifestations of poverty, bribery, disillusionment, disengagement with care, and the informal monetizing of health care services); and the role of international donors like the Global Fund who have almost singlehandedly propped up HIV and substance use treatment infrastructures in Ukraine for more than a decade, creating a large, financially cumbersome system of services rooted in civil society, which the government is understandably reticent to take full responsibility for.
HURI: Your dissertation and forthcoming book look at drug use, drug therapy, and drug users. Will your talk touch on this topic, as well?
Carroll: Drug use and "addiction" are interesting topics for a medical anthropologist, because these terms and behaviors are so deeply entwined with local moralities and social distinctions. The ways in which the social and the medical spheres interact and amplify or hinder each other are relevant to any discussion of public health and public welfare. In Ukraine, I have found that the health and wellbeing of drug users is often a litmus test for many other social and political realities.
Jennifer J. Carroll, PhD, MPH, is a postdoctoral fellow in the Division of Infectious Diseases at The Miriam Hospital and a Research Associate at the Alpert Medical School at Brown University, where she is part of the Brown University Ukraine Collaboration. She earned her Ph.D. in Socio-cultural Anthropology and M.P.H. in Epidemiology from 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.