Health and medicine 20 years after the Soviet Union

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Health and medicine 20 years after the Soviet Union

This article is part of the series: 
Nearly two decades have now passed since the dissolution of the Soviet Union. Over the next several months we will be running a series of articles which consider a specific issues related to health and medicine in the former Soviet Union.  The articles comprising “20 Years After the Soviet Union” will highlight research by anthropologists and other social scientists on topics including psychiatric deinstitutionalization, HIV/AIDS, disability rights and population health.
By way of introduction, I’d like to mention a recent special issue of the open-access journal, the Anthropology of East Europe Review on “Health and Care Work in Postsocialist Eastern Europe and the Former Soviet Union.”  A number of the authors in this issue will also be contributing posts to our series, so look for them in the weeks and months ahead.  (For those articles which do not have abstracts, I have selectively quoted from introductory paragraphs).
Anthropological approaches to the study of health open up a range of questions and ways of conceptualizing social processes that are particularly valuable for understanding the transformations underway in the aftermath of state socialism. While public health and demographic analyses capture important macro-level shifts—from the dire spikes in Russia‘s male mortality and sexually transmitted infection rates that began in the early 1990s, to reductions in fertility and abortion that have continued throughout the region for over twenty years—public health scholars‘ efforts to understand these shifts are fraught with methodological and theoretical limitations that too rarely go unexamined. Anthropologists’ contributions to the study of health are thus important in several ways. First, they bring together attention to macro-level changes with ethnographic-based inquiry into what such shifts mean to the various persons and institutions involved in them. Second, the anthropological lens requires us to reflect continuously upon the assumptions and interests that guide our research in light of the meanings, practices, and contradictions we encounter in the field. This iterative, reflexive, and critical attention to our own analytical processes serves, ideally, as a safeguard against unwittingly projecting our own assertions of the real or the important onto others‘ lives. At the very least, we need to articulate and justify our perspectives and our questions, and clarify their relevance vis-a-vis the concerns of local actors.
In this brief essay, I propose that questions related to health after socialism help explain the trajectories and trials of life (and death) in former socialist contexts by revealing how daily life is embedded in shifting formations of citizenship, practices of distinguishing public and private, and changing notions of personhood. I also suggest that anthropological aims to understand the complex changes in this region critically—that is, through the continual questioning of our own assumptions and paradigms as outsiders—may require us to engage more closely with scholars from the region. If anthropologists have done much to consider health as a situated and historical practice, we have perhaps done less to examine our own production of knowledge about health and postsocialism in this light. I will conclude by arguing the need to enrich our analyses through more systematic processes of dialogue and debate with our colleagues in Eastern Europe and Eurasia.
This article will examine the dramatic changes that have occurred in Georgian healthcare since the Rose Revolution of 2003. What were the motives for the abrupt privatization of the Georgian economy, including the healthcare sector? The research for this article draws on interviews with Georgian physicians and healthcare administrators, the few reports that have been written about the attempts at privatization, lectures by Georgian politicians who have come to the US to explain the reform processes in Georgia, and my own observations working for the American International Health Alliance in Georgia over the past decade.
When HIV first appeared in Ukraine in the mid-1990s, it spread like wildfire through users of injected narcotics. By 2008, Ukraine was estimated to be home to 29% of all reported cases of HIV in Eastern Europe and Central Asia, making it the nation with the highest infection rate per capita in the region (UNAIDS 2008:24)…. In response to this, many non-governmental organizations have formed to implement prevention efforts among drug users specifically…In this article, I share a few insights about drug use as a social marker and women’s access to prevention programs, which were gained through several weeks of observations and interviews at [a non-profit HIV-prevention program in southern Ukraine]….
I argue that the daily interactions of both current and former injection drug users at [the program] are mediated by this social and biomedical identity in a way that shapes not only their behaviors and relationships, but also affects their access to different social roles and physical spaces. Furthermore, I argue that this social construct that defines who and what an injection drug user is has primarily incorporated masculine tropes of identity. Simply put, drug users are generally assumed to be male. This puts female addicts, who already suffer greater social and logistical obstacles in accessing preventative and therapeutic health care (Pinkham and Shapoval 2010), in an even more difficult position.
This paper will explore how mental health reforms in Ukraine—specifically the push for community mental health services—are playing out on the ground through provider and patient perspectives. I focus especially on the human rights discourse that is often utilized by mental health activists as a way to package these issues. I argue that the international agenda promoted in Ukraine, which pushes for western neoliberal-based political and economic reforms, has produced cultural and structural discrepancies and tensions which can be seen in the mental health field. Amid these cultural and structural changes, moreover, the neoliberal agenda forces Ukrainians to replace deeply rooted cultural tenants shaped by socialism with those of western capitalism. Human rights discourse has been adopted by a non-governmental organization (NGO) called ―Human Rights for Psychiatric Patients‖ or HRPP, as a way to mediate these processes of cultural change induced by transformations in political economy. I use psychiatry and mental health as a window into this struggle.
The past decade has seen a marked proliferation of volunteering programs in Czech hospitals. These have been established with the help of national and international funding and take various organisational forms. For the most part, these programs enable lay citizens to provide hospitalized patients with company and social support for a few hours per week. This article considers the ways in which hospital volunteering is promoted and understood as a free gift, in anthropological terms (Parry 1986, Laidlaw 2000). Specifically, I probe why it is possible and desirable for participants on volunteering programs to think about volunteering in this way. I argue that the social construction of volunteering as a free gift promotes a particular ideology of autonomous personhood, which, when considered alongside other political and economic developments in Czech healthcare over the past two decades, can be thought of as part of its neoliberal transformation.
Russia’s population has been rapidly decreasing for several decades. Political fears over falling birthrates and growing mortality rates have recently reemerged as a staple in every conversation concerning the future of the Russian nation. In May 2006, in his annual address to the Federal Assembly, President Vladimir Putin identified Russia’s decreasing population as the most acute issue facing the country. Later that year, the government launched a new, high-priority policy to address the “demographic problem,” which was built around monetary incentives for women to have multiple children. As the state made an effort to revise and implement its new policy measures, different groups of experts took part in the debate about the demographic future of the nation. Alongside demographers and social scientists, medical and public health experts became visible as playing a crucial role in this debate.
To address the role of this community of experts in Russia’s most heated debate, this paper examines how a group of obstetricians and gynecologists in the large provincial city of Yekaterinburg, Russia appropriate existing discourses of the “crisis of underpopulation” and demographic policies, and assign new cultural and social meanings to them in their clinical and research practices. An ethnographic study I conducted among these medical professionals demonstrates how they negotiate their power not only through individual patient care (Rivkin-Fish 2005), but also outside their clinics as they participate in the demographic debate and in the development of regional family planning programs.
The relationship between the state, the market and professions has been in focus of sociological theories on professions. This study explores how Lithuanian physicians perceive these three sectors, called logics in sociological theories, to influence their work in a health care context which has experienced a rapid change.
The results show that the physicians perceived the state regulated health care system as a limitation to their professional identity and practice. Market elements of care did not seem to work and instead two other mechanisms bridged the provision of services between the client and the physician: peer referrals and gift-giving. The peer referral system enabled physicians to directly refer patients to a professional colleague outside the formal referral system and thereby to improve access to health services that the state directed system could not handle efficiently. Gift-giving and gratitude payments provided some consumer influence in the delivery of health services in a failing market system. The conclusion is that in a post-socialist health care system physicians are often operating in a system guided by four logics: the state, the market, professional culture, and the informal economy of peer referrals, gift giving, and extra payments.
Globally, healthcare worker shortages are increasing, giving rise to a need for a migratory healthcare labor population (Buchan 2006; Choy 2003; Kingma 2006; Ross, et al. 2005; Võrk, et al. 2004; Zulauf 2001). Countries such as India and the Philippines have long-term experience with this practice, often operating state-run placement services to place nurses in countries such as the United States, United Kingdom, and Saudi Arabia. Recently, new origin countries have entered the global market. Healthcare workers from Central and Eastern Europe are being recruited for this work and are increasingly discovering the opportunities available to them as in-demand, mobile professionals. However, entering this labor market is not simple and workers often need recruitment firms to mediate the complex process of transnational skilled labor. Negotiating between the different labor and cultural environments, these staffing firms must ensure that the laborers they represent will be successful on the job market. They train them accordingly, essentially ―producing migrants. This article uses the Czech Republic as a case study to explore this phenomenon.
Starting with th[e] basic premise that economism and cosmology do not explain the new health practices in post-socialism, I bring an ethnographic attention to plural forms of health care that tend to the experience of barely living, to invite a rethinking of the relationship between embodiment—local forms of bodily being in the world—and economic forms. Anthropology and critical political economy have long questioned the assumptions that body and economy are separate domains. Medical anthropology has shown pluralism to be the norm rather than an exception in health care the world over, notwithstanding the global dominance of biomedicine and pharmaceuticals. My inquiry into the relation of market and health, however, shifts the focus from symbolic anthropology and local cosmologies to plurality and materiality of bodies. Following the local medical travels, bodies emerge as ontologically plural, inasmuch as they lend credence to multiple forms of diagnostic assessment of the same aches and complaints. Bodies also respond to therapeutic management along divergent maps of organs, fluids, or energies or treat a physical ill or well being as extending beyond the bodily limits and accessible to spiritual entities and other incorporeal extensions, such as thoughts, looks, and wishes of benevolent or envious others. The aim of this paper is to revisit theories of medical pluralism with an eye on the Bosnian lived reality and efficacy of experience, to ask whether bodily ontology, not only medical epistemology, might not be plural.
Prior to the communist period most Romanian Romani communities depended mainly on traditional healing methods as a primary source of health care. After its ascension to power, the Romanian communist government introduced a universal, Semashko-style health care system. The implementation of these requirements dramatically disrupted the traditional health care patterns for Romani communities for over 40 years. Since the collapse of communism these constraints have been lifted and social health insurance (SHI) has been adopted in Romania. Insurance coverage is based on formal participation in the labour market. It is well established that the Roma have fared poorly during the transition to liberal democracy and have suffered particularly in the labour market. Consequently, many Roma are unable to qualify for SHI and remain uninsured and in poverty. Understood within this context, it could be expected that a resurgence in and reclamation of traditional healing methods in the Romani community might be found. This paper draws upon qualitative data from Romani groups in Bucharest and explores the practice, perceptions, and attitudes toward traditional health care in a socially liberalized and increasingly market-driven Romania.

El señor de las curvas que tanto nos suenan

Fuente: Rafa Bravo

Via: Primum Non Nocere
Paul Meier, who was among the most influential biostatisticians of his generation and helped bring mathematical rigor to medical research in the years after World War II, died Aug. 7 at his home in Manhattan.
Pues bien, el problema de analizar observaciones incompletas por su dispersión en el tiempo era un viejo problema. Charlie Winsor estaba trabajando en el, y se acercó a Princeton y habló con Tukey al respecto. [Joseph] Berkson de la Clínica Mayo había escrito un artículo sobre él, pero no había estimado la varianza. Alguien me preguntó cómo hacerlo, y yo le dije, “Oh, eso es muy difícil: tienes que hacer esto y aquello y. . . “.
Entonces uno de mis colegas me mostró un artículo de Mayor Greenwood que me abrió  bastante los ojos, y me contó lo que había hecho Winsor y que me abrió los ojos aún más..
Así contestaba Paul Meier en una entrevista publicada en la revista Clinical Trials cuando le preguntaron por su famoso artículo uno de los más citados de la historia que describía el famoso método de la curvas de supervivencia de Kaplan- Meier que vemos como grafico prácticamente en todos los ensayos clínicos. Sigue la entrevista comentando la anécdota de su forzada unió a Kaplan para escribir el artículo que finalmente se publico Como yo estaba trabajando en ella, le escribí a Tukey sobre el problema, y ​​me dijo que Kaplan – otro de sus estudiantes – estaba haciendo algo similar………..Tras hablar con el editor de JASA “Trague saliva y supongo que Kaplan también, nos pusimos a trabajar duro, y casi al tiempo yo resolví un problema que el no podía resolver y él, uno de los que yo no podía
Que son las Curvas de supervivencia de Kaplan -Meier
Cuando la variable que se desea medir es el tiempo hasta que ocurre un evento, se utilizan para analizarlas un conjunto de técnicas estadísticas  conocidas como“análisis de supervivencia”– al principio se usaron sobre todo para analizar el tiempo hasta el fallecimiento del paciente o supervivencia y de ahí el nombre, pero los eventos pueden ser la muerte, o cualquier otro perjudicial o beneficioso”
Cuando medimos los  datos relacionados con el tiempo hasta que ocurre un evento podemos encontrarnos con varios tipos de problemas
  1. Que al final del periodo de observación no todos los pacientes habrán presentado el evento objeto de estudio.
  2. Los pacientes se incorporan durante todo el periodo de observación, por lo que los últimos en hacerlo serán observados durante un periodo de tiempo menor que los que entraron al principio y por lo tanto la probabilidad de que les ocurra el suceso es menor.
  3. Que algunos pacientes se hayan perdido por causas diversas, no habiendo sido posible determinar su estado.
  4. Al final del estudio habrá pacientes que no presentan el suceso.
Dentro de los análisis de supervivencia, el método de Kaplan-Meier se caracteriza por calcular “la supervivencia” cada vez que ocurre un evento y se basa en algo obvio: para sobrevivir un año hay que sobrevivir cada uno de los días de éste. Calculamos entonces para cada día la proporción de sucesos que se observan en ese día. Para cada instante de tiempo la supervivencia se calcula como la supervivencia en el instante anterior multiplicada por la tasa de supervivencia en ese instante. Como se ve en la tabla, el procedimiento de Kaplan-Meier calcula la estimación de la probabilidad de supervivencia de cada uno de los períodos de tiempo t, excepto el primero, como una probabilidad condicional compuesta
 El método produce  también un gráfico,  como el de abajo que a todos nos suena mucho y que la proxima vez que veamos asociaremos a ese hombre con gafas y  aspecto de empollón que acaba de fallecer. D.E.P 

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Declaración de Helsinki

City Hall Square in Helsinki, Finland in 1820,...Image via Wikipedia

Declaración firmada en Helsinki, Finlandia, por los representantes de las 35 naciones miembros de la Conferencia de Seguridad y Cooperación en Europa, el 1 de agosto de 1975. Los objetivos declarados son el derecho a la autodeterminación de todas las personas y el respeto a las libertades individuales, incluidas el pensamiento, la conciencia y la religión o creencias, independientemente de la raza, lenguaje, sexo o religión. Los acuerdos de Helsinkis e desarrollaron a partir de las resoluciones precedentes de las sentencias de los juicios de Nuremberg –dichos crímenes contra la humanidad son delitos sujetos a persecución criminal–.El principio y práctica del consentimiento informado en asistencia sanitaria se desarrolló a partir de este documento.