“This isn’t American heroin!” he laughs. The joke is on me. This methadone patient has told me many times during our interview that I am asking questions like an American. I listen intently as he explains how I’ve got it all wrong. “This is Ukrainian smack,” he says. “We’re chemists. We extract the stuff ourselves from poppies and solvents… In America, you don’t do this kind of thing.” He is not the first person to remind me that foreign researchers have a lot to learn about what it is like to be a Ukrainian drug user. It is precisely this need to be attuned to the perspectives of the most at-risk groups that motivates my research.
Since the fall of 2012, I have been conducting ethnographic research among individuals seeking treatment for a combination of opiate addiction, HIV and TB in Ukraine. These stories are messy and complicated, and collecting them takes a lot of time and a lot of shoe leather, but the work is incredibly necessary. The success or failure of our strategies for controlling the massively concurrent HIV, TB, and drug use epidemics in Ukraine hinges on our ability to know and to understand the lived realities of the most at-risk members of our society.
"HIV and TB co-infection is a major global public health challenge, ... According to the World Health Organization, in 2011 there were 8.8 million new cases of TB, of which 1.1 million were among people living with HIV."
My initial findings reveal that many complicated incentives are at play in their treatment-seeking behaviors. Some want freedom from disease and chemical dependency. Others are struggling to fulfill social obligations, hoping that treatment will provide them with stable lives and stable bodies. Others are consumed by fatalism, believing (perhaps not incorrectly) that they have been permanently marginalized from an unwelcoming society, and seek only to make life a little easier for the time being.
Despite major public health advancements over the last decade, the situation of drug users in Ukraine remains grim. Rates of HIV and TB in this population remain staggeringly high (addicts represent a significant percentage of the cases of both diseases). Many caregivers see methadone, HIV treatment, and TB treatment for addicts as palliative care, helping to ease pain or suffering but not to cure. Others see HIV- and TB-positive addicts as unmanageable patients who refuse to adhere to treatment regimens and are, therefore, fundamentally untreatable. As one physician observed, “this [treatment program] is their last stop on the way to death.” If some patients receive this message from their medical providers, why do they continue to seek treatment at all?
A primary goal of ethnographic research is to understand “why some…ideologies, discourses, and symbols become compelling to social actors,”[i] while others are repeated as moral pronouncements but ignored in private lives. Likewise, this project seeks to understand how ideologies that have retained their hold upon post-Soviet life are revealed in how drug users navigate through a society increasingly defined by neoliberal rules and biom
edical ideals. The stories that patients in treatment tell me reflect conflicting values of independence and collectivity, of personal freedom and familial duty, of Soviet-era socialization, free market-based moralities, and the diverse social realities that emerge where these two worldviews collide.
Jennifer Carroll is a PhD candidate in the Department of Anthropology at the University of Washington. She traveled to Ukraine in 2012 as a participant on the U.S. Embassy Policy Specialist Program [11]. You can read her complete research brief here.
Image: A TB patient speaks to a family member through the iron gate closing off the hospital grounds. [Photo by Jennifer Carroll]
[i] D’Andrade, R. G. and C Strauss. 1992. Human Motives and Cultural Modes. Cambridge: Cambridge University Press. Page 1.