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Scientific Stuff: The (Re)Negotiation of Local Knowledge and Medical Discourse in Ukraine Jennifer Carroll Presented at the 110th

Annual Meeting of the American Anthropological Association Montreal, QC, Canada November 2011 My research has focused on public health responses to two major epidemics in Ukraine: HIV and injection drug use. The combination of an overburdened state health care system, harsh criminalization and social marginalization has created insurmountable barriers for HIV+ or drug using persons in Ukraine who are seeking medical services of any kind. In response, many internationally-funded NGOs have taken root in Ukraine to implement prevention and treatment efforts for intravenous drug users. These public health organizations acquire funding from international charities and benefactors instead of from the state, which generally has little to offer. With this international money, HIV-prevention organizations adopt Western, biomedical public health models that have delivered positive results elsewheresuch as needle exchanges, free clinics, and harm reduction serviceswith high expectations that their efficacy will maintain in this new environment, and with significant oversight and monitoring from the international organizations that are footing the bill. The work of Bruno Latour is frequently relied upon by scholars who seek to problematize the interactions between so-called universal or scientific and local knowledge. Latour has argued that scientific knowledge is created through a chain of abstractions, with each act of measurement or observation placing more and more distance between concrete reality and scientific discourses about that reality (1999). For this reason, scientific knowledge claims the ability to operate at a certain distance from world, giving it the ability to travel far without ever being far from home, without sacrificing its relevance and its applicability (1987). Judy Clark

and Jonathan Murdoch described this process beautifully. As scientific artifacts move through the world they must reshape locales in a fashion which allows these artifacts to work. Herein lies the success of science and the basis of its universal claims. It remakes the world in its own image (41) Local forms of knowledge differ from this by their rootedness to a particular environment. Unlike the universal knowledge of science, local knowledge loses salience when it is exported to another place. I find this framework to be apt in a number of ways, but I take issue with the assumption that scientific discourses of public health will (or at the very least will try to) enter onto the Ukrainian stage like a bulldozer and leave no room for local forms of knowledge and understanding to exist. It may be appropriate in some cases to be critical of a hegemonic western paradigms that obstinately demand that local social structures and systems of belief bend to accommodate it, but the Ukrainian case is not this straightforward. HIV and drug user-oriented health services in Ukraine are almost entirely funded by two major donors: The Global Fund and USAID, both organizations that value evidence based practices, and prefer to see evidence-based programming in the public health infrastructure that they fund. Despite this support, though, sentinel surveillance and adequate voluntary testing for HIV is practically non-existent in Ukraine, and there is no system in place to track or monitor drug use in any way other than a drug user registry that is rarely utilized, not to mention ethically questionable. In short, public health programs for injection drug users are blossoming in Ukraines civil sphere, and they are doing so in the complete absence of reliable epidemiological knowledge about what the drug use or HIV epidemics even look like. This certainly weakens the foothold of scientific discourse in Ukraine. The blow is manageable, of course. Science survives, but this does create ample room for other types of local knowledge to creep in and challenge the meaning and the purpose of the

dominant scientific discourse. This brings us to one of the central questions that I have had since first beginning fieldwork in Ukraine in 2007: how Ukrainian public health workers manage in this environment; how they succeed at running what are ostensibly evidence-based public health programs in the absence of reliable evidence. I believe that two elements are in play that allow for Ukrainian public health workers to resist and, in some ways, redefine dominant global health paradigms and the powerful international organizations that fund them: namely, the robustness of general uncertainty about the HIV and drug use epidemics and a flexibility in scientific discourse that is unique to the PostSoviet region. When I was in Kyiv in 2010, I developed a working theory of how local knowledge is built and perpetuated among Ukrainian public health workers. So much that was shared by NGO staff and public health professionals in ethnographic interviews was rooted in personal anecdotes and on-the-job experiences. Every question I asked, no matter how general or how vague, was connected to a particular story. You want to know about female drug users? Let me tell you about this one woman that I had to take to the hospital. You think drug users are stigmatized? You have no idea. This one time the police stopped me in the street for no reason and so on. I suspected that working with drug users was a nuanced, learned skill that resisted generalized explanations and required routine events and repeated on-the-job experiences to develop. I saw Ukrainian NGO workers as the epitome of Bourdieus virtuoso. In his own words: Only a virtuoso with a perfect command of his art of living can play on all the resources inherent in the ambiguities and uncertainties of behavior and situation in order to produce the actions appropriate to each case, to do that of which people will say There was nothing else to be done. (1984: 8) Like self-taught painters or pianists who have learned to play by ear, it seemed reasonable to suppose that public health workers had learned their craft not by rote through standardized

programming models, but through a sort of muscle memory that is consistently accessible on the job, but defies generalization. Stories, anecdotes, and personal relationships become indices for perceived patterns of drug use in society at large. It is through this type of narrative work that facts about individual persons and events become salient and an authoritative body of knowledge about drug use and drug users is produced. Today, I still find this explanation compelling, but insufficient to address the question of how public health workers succeed in running programs that they themselves describe as very scientific and advanced, despite the ability to draw reliable scientific conclusions through adequate testing or population monitoring. Katherine Verdery has argued that a critical exploration of the new social realities (and here, medical realities) in the Post-Soviet sphere requires a theoretically grounded understanding of the system that has crumbled and an ethnographic sensitivity to the particulars of what is emerging form its ruins (10). Following her insight, it seems necessary to take into account not only the forms in which local knowledge about the drug use and HIV epidemics in Ukraine emerge, but also of the historical legacies that have made the social and political character of scientific knowledge much more tangible in the Post-Soviet sphere. Amy Ninetto, who has conducted ethnographic work among scientific communities in Russia, discusses this legacy, noting that even as Western science recognizes its transformation into what Latour (1998) has called the culture of research an enterprise whose authority can no longer rest on a denial of its multiple contextualizations Russian science is faulted for having yet to become properly Mertonian: inadequately disinterested, skeptical, open, and universalistic (Merton 1973). (Ninetto 488) In other words, all scientific discourse is embedded in the social structures and political schemas that surround it, but in the case of Russian and, I would argue, many other Post-Soviet sciences, this fact that science is often tool of politics is no secret.

Among public health workers in Ukraine, this legacy allows for two things to happen. First, it helps to maintain a tenacious skepticism about scientific knowledge whenever and where ever it is produced. For instance, a staff member at the Alliance told me that it is impossible to know anything about drug overdoses in Ukraine, since most hospitals classify these deaths as either heart failure or as accidental poisoning. One of her coworkers later noted that fully powered randomized control trials or other kinds of cohort studies were simply impossible in Ukraine, because no one has the money to fund such things. In these instances, scientific data that might otherwise be useful is perceived as categorically unattainable. On many other occasions, I heard public health professionals contradict scientifically generated estimates for the prevalence or incidence of drug use and HIV. One program coordinator openly questioned the validity of epidemiological surveys. One, which observed that equal numbers of men and women can be found in the intravenous drug using population, seemed particularly preposterous to her. She said, That just isnt the real picture. Female users are much more stigmatized, and if they even get drugs at all, its from their husbands. Some scientific research might be conducted, but it has its limitations. Perhaps there are logistical barriers, or perhaps someone isnt sharing all the information. Regardless of how or why scientific data is questioned, the end result is that knowledge gained through research is unable to trump the understanding that NGO workers gained on the job, the local knowledge that is produced through their virtuosity in this field. Second, this extreme level of uncertainty opens the doors for science and scientific discourse to be considered an end as well as a means. Sasha, a supervisor in an elite NGO, emphasized the scientific aspects of her work saying, We have a team, which also does a lot of regular studies and surveys and so on. Like sentinel surveillance and quite scientific stuff, using respondent driven sampling and going deep into the population [emphasis mine]. Later

on, Sasha described these same surveillance efforts as problematic, owing to inconsistencies in study design and method from year to year. The existence of these difficulties, however, did not prevent her from reportingwith pridethat these surveys reach nearly 1500 respondents year after year. She claims that her organization is unique in that it builds its programs based on evidencefrom the field. This evidence might not be ideal, but having hard numbers to report, regardless of their statistical strength, is a desirable end in and of itself. Another program manager spoke with heartfelt pride about an HIV-sensitivity training for doctors that she had been a part of. She was able to claim that the training was affective, because her organization had sought out the same doctors several months after the training for a followup survey that was meant to measure the their changes in attitude. This program manager beamed at me and said, Our results were 20%! At the time, I held my breath and kept waiting for her to let me in on the secret: 20% of what? But the answer never came, because the units of measure werent important. The measure itself was what she was excited about. Who knows if this is a good or bad result, she said, but it was so wonderful to have real numbers to report, and to receive the feed back from our colleagues. Since there exists a wide-spread belief that true, accurate, and unbiased scientific knowledge is generally unachievable, it seems apparent that those who continue to engage in scientific discourse are doing so for reasons other than the data. In these instances, and many more just like them, it seems that public health workers are repurposing science and the production of scientific knowledge. One cause for such repurposing is that Ukrainian NGOs have to be adept at speaking the language of their international benefactors. Strict records must be kept of how many people came in to the clinic, how many needles were distributed, how many condoms were taken, how many people were referred to an HIV test? This information is not just

for the Alliance and their partner organizations. Such record keeping is required by the Global Fund. I had the opportunity to ask a staff member at the Alliance whether the record kept by each of their partner agencies need to be repackaged before they are sent back to the Global Fund. Her eyes got wide and she said, oh yes. The Alliance has hired a full-time staff member who deals only with this issue of reporting for their more than 190,000 clients last year. In addition, it is believed that ability to be conversant in these scientific paradigms affords more legitimacy to Ukraine and its citizens in the eyes of the Western world. This sentiment, held by many public health workers, was illustrated well by a man who worked at The Alliance as an independent contractor. He said, Im totally pro-Western. This is the only good thing that can happen to usbecoming part of the international community, and not just part, but a full fledged member. Adopting scientific and biomedical approaches to public health and other ideas that public health workers describe as advanced or modern, is seen as an integral part of this project of becoming part of the international community. This state of affairs does not mirror that predicted by Clark and Murdoch, in which scientific ideas carve through local knowledge like an iceberg, remaking the world in its image. Instead, and this is what I find so terribly interesting, it seems like something of the opposite is going on. Ukrainian public health workers are adapting scientific discourses to their own political purposes, and that they are the ones working towards a correspondence between local and scientific knowledge on their own. Generating such coherence in networks like this often requires a great amount of energy for the mediation of internal conflicts and contradictions. However, because reliable science and evidence-based public health arent necessarily feasible, the inherent contradictions between universalized, scientific knowledge and local knowledge become manageable, and in most cases entirely avoidable. In Ukraine, where epidemiological

data on the HIV and drug use epidemics is thin, where statistics and surveys cant always be trusted, where having a research outcome at all can be as importantand sometimes more importantthan having a research outcome that is reasonable or even interpretable, the universal validity of science loses its teeth, and the ontological conflict is defused. A key question to keep in mind then, especially in the wake of the Global Fund pledging nearly $300million to Ukraine for HIV-prevention programming in December 2010, is what will happen if and when science gets its teeth back. It would be wonderful to see adequate coverage of health services, HIV testing and ARV treatment become a reality in Ukraine. I want to remain optimistic and say that this might happen sometime soon. But if it does, then local and scientific modes of knowledge production may once again be at loggerheads. Public health workers will have to find ways to adapt to this new ontological land scape, and the situation of many marginalized Ukrainians will likely shift in unexpected and unpredictable ways.

References Bourdieu, Pierre 1984. Distinction: A Social Critique of the Judgement of Taste. Cambridge: Harvard University Press. Clark, Judy and James Murdock. 1997. Local Knowledge and the Precarious Extension of Scientific Networks: A Reflection on Three Case Studies. Sociologia Ruralis 37(1): 3860. Latour, Bruno 1987. Science in Action: How to Follow Scientists and Engineers Through Society. Cambridge: Harvard University Press. Latour, Bruno. 1999. Pandoras Hope: Essays on the Reality of Science Studies. Cambridge: Harvard University Press. Ninetto, Amy 2006. An Island of Socialism in a Capitalist Country: Postsocialist Russian Science and the Culture of the State. Ethnos 70(4): 443-464. Verdery, Katherine. 1996. What Was Socialism, and What Comes Next? Princeton: Princeton University Press.

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