Contemporary societies are imbued with uncertainties. Yet, there are settings where uncertainties multiply, making decisions, practices, and relations in everyday life precarious. Post-Soviet locations are among such settings, where uncertainties multiply, and actors are left to navigate them at their own risk. This book investigates how actors deal with the uncertainties that permeate the interfaces of health, technologies, and politics in post-Soviet settings. It makes visible rich repertoires of skills, innovation, and creativity in navigating continuous flux, surviving instability, and exclusion. In so doing, this book encourages critical learning about ways to ensure the resilience of individual and societal health in situations of profound uncertainties. Our project is to set two worlds in dialogue: the world of science and technology studies (STS) and the high-income liberal democracies of the West which this discipline has mostly focused on to date, on one hand, and studies of post-socialism and post-Soviet settings, on the other, to allow these worlds to learn from each other.
Let us begin by using the example of HIV/AIDS to show what âmultiplying uncertaintiesâ means here and how these uncertainties permeate health, technologies, and politics in the settings in question.
In December 2016, the Russian Academy of Sciences (RAS) proclaimed that it would innovate a strategy of combating the HIV/AIDS epidemic in the country. Instead of the promotion of traditional family values that had dominated the local disease control measures to date, academics insisted on moving towards a more âscientifically soundâ approach. During a dedicated meeting of the Academyâs council on December 28, Vadim Pokrovsky estimated that currently 1.5 million Russian citizens were infected with HIV and predicted that in five years that number would grow to 2 million. The scientist went on to explain that the HIV epidemic was halted in Germany, for example, by sensible prevention measures, including sex education for adolescents, legalisation of prostitution, and medical surveillance of sex workers, as well as opioid substitution therapies for drug users, and needle and syringe exchange programmes. Academics criticised Russian officials for being, in the words of Anatoly Vishnevsky, âembarrassed to say the word condomâ; the mass media for focusing on Ebola and Zika, which had not killed a single Russian citizen, instead of discussing HIV/AIDS, which had already claimed 240,000 lives in the country; and decision makers for not funding HIV/AIDS research. One after the other, the speakers called for âscience-basedâ efforts to combat the epidemic and stressed the significance of this development for the countryâs future and its very existence (âWho will need missiles, when we wonât have population in the country in fifty years?â). They also highlighted the importance of supporting HIV/AIDS science for the national economy (âIf you do not invest in your own science, you will be buying foreign drugsâ) and international standing (âOtherwise Russian scientists will never catch up with Western onesâ). At the end of the meeting, the RAS vice-president concluded that the matter of science-based HIV/AIDS control measures was a political issue, admitting that implementing sex education, opioid substitution therapy, and harm reduction strategies required âpolitical decisionâ, and that the RAS must work closely with the state decision-makers to make this innovation possible.
This episode illustrates the complex relations between health, technologies, and politics. We see how the issue of HIV/AIDS prevention and treatment becomes linked with morality. The participants in the RAS council meeting present an apparent dichotomy between the idea that health policies should contribute to a âpureâ and âvirtuousâ society through promoting âfamily valuesâ, and a disease-control approach that emphasises decreasing the numbers of new infections through science-based methods and appears to have little concern for the moral characteristics of the citizens. We see how the topic of HIV/AIDS plunges us into debates about the role of technoscience in societal development. Would knowledge and technologies improve the societyâs well-being through helping to contain the epidemic, or would they stimulate the erosion of âtraditionalâ boundaries to the point of eventual societal downfall? We also see struggles over national identity, sovereignty, and visions of the national future when different approaches to combating the HIV/AIDS epidemic tap into different visions of what Russia is and should be.
Interfaces between health, technologies, and politics with regard to HIV/AIDS in Russia remind us of what has been so convincingly articulated by STS scholars. They have shown that decades of technoscientific development did not eliminate uncertainties , but, instead, have stimulated the emergence of new questions and dilemmas. Numerous studies of interdependencies between health, technologies, and politics in various parts of the world attest that decisions about how to improve peopleâs health continue to be made amidst the greatest uncertainties. The development of new reproductive technologies, for example, has made in vitro fertilisation (IVF) a routine procedure in many countries but also stimulated debates on the moral status of embryos and the meanings of kinship, with politics seeping into protocols that detail who is eligible for publicly financed treatment, the flow of ova between countries, and donor selection practices.
While STS research has demonstrated how the dynamics of health, technologies, and societies go together with new uncertainties , there is something about the meeting at the RAS that also sets it apart from much of the STS literature on the topic. It is difficult to gather this distinctiveness only from reading about the episode. But by zooming out of it to take a broader look at the context where it is embedded, one would notice multiple uncertainties of a different kind. The RAS, the most important organisation representing scientists in Russia, has recently undergone sweeping government-initiated reforms and lost its independence and property; its status, form of existence, and future prospects are uncertain . Health-care provision is precarious because of the rapidly changing regulations. For example, the centralisation of procurement procedures urgently designed by the Ministry of Health to combat price increases and corruption has resulted in critical shortages of antiretrovirals in several Russian regions at the beginning of 2017âor so the patients claim, while officials disagree. Plans have been announced by another governmental body for foreign-produced antiretrovirals to be excluded from the state-financed reimbursement programmes. How, then, will the quality and availability of the locally produced substitutes be ensured? What else will be changed and when, and how will it play out in practice? In this brief outline, one senses uncertainties that exceed those linked to the limits of science in informing the governance of society, uncertainties that can be linked to specific characteristics of political processes in post-Soviet settings. Apart from uncertainties linked to advances in technoscience itself, the post-Soviet health domain is characterised by multiple and profound uncertainties borne out of rapid societal transformations, major instabilities in governance arrangements, and non-transparent and often exclusionary decision-making. To understand the costs and consequences of these multiple uncertainties, we need to study how they are dealt with in practice. The specific focus of this book is on how actors in post-Soviet settings navigate these uncertainties in healthcare, public health, and research and development (R&D), and what the implications of their chosen navigation routes are for relations between health, technologies, and politics.
Now that we have discussed the emergence of multiple uncertainties in post-Soviet settings and their relation to health, technologies, and politics as the focus of the book, let us situate our work among the relevant bodies of literature. In our undertaking, we bring together insights from the two domains of scholarship that, for the most part, have flourished independently from each other: first, STS research on health, technology, and politics and, second, studies of post-socialism concerned with informality. To date, the body of STS literature has provided many insights about the mutual influence of science, technology , and society but has paid little attention to the multiplication of uncertainties related to health, technology, and politics in post-Soviet settings and ways in which they are dealt with. Post-socialist studies of informality have highlighted informality as one of the defining elements of post-socialist societies: it is understood as an instrument used in various forms by citizens to deal with the absence of formal state-defined processes and structures or with their inadequacy. Yet this literature has tended to bracket technology and uncertainties associated with technologies themselves. By drawing on these two scholarship domains, the book explores the dynamics of health, technologies , and politics in settings where healthcare, public health, and R&D are continually destabilised. For the purposes of this book, we take technology broadly to include artefacts as well as non-physical, systematic methods of making or doing things (Hecht 2009, p. 15).
This book explores how multiple uncertainties evident in the post-Soviet health domain are navigated and the implications of navigation routes that actors develop. This implies, first, a specific reading of politics not only as formal policy procedures but also as everyday (informal) practices. Inspired by the STS tradition of looking for politics beyond official spaces, such as state regulatory structures, parliaments, and policies, we also locate politics in d...