Addiction, Gender, and the Limits of Public Health Solutions to IV Drug Use in Ukraine

Jennifer J. Carroll University of Washington Box 353100 Seattle, WA 98115 Jencarr2@uw.edu

Submitted to the AIDS and Anthropology Research Group for consideration for the 2011 Graduate Student Prize

Submitted October 15, 2011

INTRODUCTION Public health responses to the intravenous drug use and HIV epidemics in Ukraine are shifting. New national policies have allowed for the use of methadone in addiction treatment and for the expansion of opiate substitution therapy across the country. These changes are particularly important for Ukraines foreign aid-dependent non-profit sector, which operates practically all of Ukraines HIV-prevention and harm-reduction effortsincluding substitution therapy. International donors, the sole benefactors of Ukraines HIV-prevention NGOs, have been the primary supporters of the expansion of substitution therapy, due in large part to tendency of these powerful organizations to define narcotics addiction as a disease in Western biomedical terms. Recent anthropological scholarship on foreign aid in Ukraine and Russia has revealed that the goals of Western development and public health projects are often been hindered by donors misunderstandings of local contexts and by the unanticipated consequences of the encounter between the unexamined assumptions of foreign aid projects and the cultural presuppositions, existing networks, and organizational strategies of local actors (Hrycak 2006:70-71; see also Phillips 2005, 2008 and Rivkin-Fish 2005). In the context of HIVprevention and addiction treatment in Ukraine, the universal validity of a biomedical approach to addiction is an example of such an assumption. Using ethnographic evidence collected in 2010, I illustrate that the local reinterpretation of Western biomedical models in Ukraine has incorporated traditional notions of Ukrainian gender roles. I argue that this has produced gendered tropes of addiction, which frame to mens addiction as a biomedical disease with potential for successful medical treatment and recovery and womens drug use as a personal weakness that lies beyond the scope of medical help. I argue

that such discourses limit womens access to public health responses to the drug use and HIV epidemics by undercutting the classification of their drug using behavior as a medical disease in the first place. This is particularly significant in todays Ukraine, where harm reduction and public health programs are the source of the vast majority medical, psychological, or social services for drug users. There exists a diversity of discursive approaches to addiction among public health professionals, and the observations presented here should not be construed as an exhaustive account of Ukrainian perspectives on public health; however, gendered associations between addiction and disease are so pervasive that their influence on public health policy and outcomes is unquestionable. In order to illuminate these possible effects, I outline the mechanisms by which drug use is and is not medicalized in the Ukrainian context, illustrate barriers that perpetuate the exclusion of women and womens drug use from biomedical discourses, and cautiously suggest that public health approaches to drug addiction in Ukraine might, for these reasons, be doing Ukrainian women more harm than good.

HIV PREVENTION IN UKRAINES CIVIL SECTOR Opiate substitution therapy with a synthetic drug called buprenorphine was legalized in Ukraine in 2004 (Semigina et al. 2007:42). This was a legislative sea change for the Ukrainian government. Methadone, which was once banned outright, was reclassified as a legal prescription drug by the Ukrainian Ministry of Health (MoH) as recently as 2008 (UNAIDS 2008). The number of persons actively receiving substitution therapy remains small, but a growing body of public health professionals and harm reduction activists are calling for a significant increase in the availability of such treatments. Substitution therapy is generally

accepted as an effective intervention for intravenous drug usersso much so that UNAIDS considers the availability of substitution therapy to be a basic human right (Druce et al. 2009:14). It is also seen as an important tool in the regional fight against HIV/AIDS, since intravenous drug use was far and away the primary driver of new HIV infection in Ukraine until 2007 (UNGASS 2010:11). Today, drug use remains a major cause of new HIV infection, and the historical dominance of this route of transmission has left in its wake a significant population of intravenous drug users who are HIV-positive. For this reason, nearly all services and support systems for drug users in Ukraine are implemented and operated within the scope Ukraines internationally funded HIV prevention efforts. While a number of individuals claim to have been advocates for HIV prevention as far back as the 1990s, HIV prevention efforts in Ukraine began to develop seriously in 2002, when the Global Fund accepted its first round of applications from national governments to fund HIV prevention and treatment efforts. Ukraines Ministry of Health (MoH) was the primary recipient of a Round 1 grant for HIV/AIDS programs from the Global Fund; they began receiving funds in early 2003 (International HIV/AIDS Alliance in Ukraine N.d.). The MoH soon frustrated the Global Fund executive board by failing to disburse any money towards the programs outlined in Ukraines Round 1 application. In March of 2004, the Global Fund stripped the MoH of its status as primary recipient and transferred this role to the International HIV/AIDS Alliance in Ukraine, an NGO that had only entered into operation as an independent entity that year (International HIV/AIDS Alliance in Ukraine 2009; The Global Fund 2010). By the summer of 2010, the Alliance had received a total budget of USD99,057,868 from the Global Fund, which made it one of the most prominent organizations in HIV-prevention in Ukraine (The Global Fund 2007).

This not only gave the Alliance and its partnership organizations an unprecedented ability to undertake massive public health efforts, but also firmly seated the responsibility of HIV prevention in Ukraine in the civil sector, away from government involvement and control. Even those organizations that are not participating as direct recipients of Global Fund grants, such as Ukrainian branches of USAID, UNAIDS, PATH, and the AIDS Alliance East/West, are closely networked with independent non-profits in Ukraine and are intimately involved in the drafting of proposals and the design and implementation of HIV prevention efforts across the country. The entire field of harm reduction and HIV prevention in Ukraine relies upon this specific channel of funding in order to stay financially viable. As one coordinator put it, Everything comes down to that [Global Fund] application. If something goes wrong, and that funding stream disappears, then [the total sum of HIV prevention efforts in Ukraine] could all shut down tomorrow. Fortunately, in December of 2010, a coordinating council composed of multiple Ukrainian organizations received a pledge of USD305,533,421 through the Global Funds tenth round of applications. This is one of the largest grants that the Global Fund has ever offered (Global Fund Approved Proposals). I began investigating the structure and implementation of harm reduction efforts in Ukraine in 2007. Since that time, my ethnographic research has taken me to five Ukrainian cities in the central, southern, and western regions of the country. I have been able to observe public health efforts in a variety of venues, including the national headquarters of Ukrainian coordinating organizations, regional offices of international funds and institutes, narcology clinics, rehabilitation clinics, mobile and stationary needle exchanges, numerous community centers, buprenorphine dispensaries, and the headquarters of many grassroots harm reduction agencies. I have observed trainings led by international public health experts for Ukrainians who

work directly with drug users and gatherings of representatives from numerous Ukrainian and international organizations in preparation for Ukraines single country application to the Global Fund. Ethnographic evidence presented here was collected in Ukraine during the spring of 2007 and the summer of 2010. The goal of this research was to begin examining the work of HIVprevention organizations in Ukraine by focusing on the social consequences of operating them and the political economies of being a client. Twenty-three open-ended interviews were conducted with public health professionals who work in regional harm reduction organizations for drug users, with program coordinators who manage treatment and prevention services for intravenous drug users at the national level, and with narcologists who operate Ukraines new substitution therapy programs. Learning from the diverse experiences of these public health professionals has allowed me to develop a fuller, richer picture of drug use and drug user services in Ukraine. To protect the privacy of my informants, I have used pseudonyms in place of the names of individuals and organizations throughout this paper.

THE [(POST)-SOVIET] LOGIC OF DISEASE Any approach to human illness and behavior operates according to its own system of logic and reason. Arthur Kleinman has referred to such frameworks, the culturally specific logics of disease, as explanatory models (1988:43). Explanatory models shape our perceptions of and interactions with the culturally constructed and socially organized lived experiences of illness. They provide patients and caregivers with answers to key question about illness, such as How does one contract this disease?, What are its signs and symptoms?, and How should one pursue treatment and care?(Kleinman 1988:43). The biomedical approach is, itself, an

explanatory model that serves as both instruction and justification for particular actions taken in response to human illness. In Kleinmans words, The modern medical bureaucracy and the helping professions that work within itare oriented to treat suffering as a problem of mechanical breakdown requiring a technical fix. They arrange for the therapeutic manipulation of disease problems in place of meaningful moral (or spiritual) responses to illness problems (1988:28).

In other words, the biomedical model assumes that solutions to medical problems will be physiological or biochemical in nature and that treatment ought to be directed towards the individual. Many addictive behaviors have become medicalized within Western biomedical culture. Singer and Baer have observed that the classification of alcohol addiction as a medical problem has become accepted as an established fact, due to concerted efforts to draw alcoholism into the realm of biomedical authority and render it a respectable disease (1995:303). The basic message is all the same: like all diseases, alcoholism is a malfunction of the individual, be it at the chemical, genetic, biological or psychological level (1995:304). However, Western and Soviet biomedical approaches to addiction have diverged significantly during the last century. Evidence of this split lies in the field of narcologythe study and treatment of addictive behaviors. Narcology is still a recognized medical specialization in many regions of the former Soviet Union. It is, in fact, a standard element in state-run medical institutions. In Kyiv, for example, numerous advertisements for narcology clinics are printed in newspapers and aired on day-time television programs. Even the subway cars are papered with fliers advertising narcology clinics and their institutionalized addiction treatment programs.

Eugene Raikhel (2010) has noted that the medical philosophies of the Soviet Union split from Western trends in biomedicine and psychology in the 1950s following the politically motivated adoption of Pavlovian theories of higher-order cognition into the Soviet medical canon. Pavlovs theories offered a way of conceptualizing the dialectical relationship between human biology and the environment, but, in practice, may have often meant a reduction of psychology to physiology, of mind to brainor more preciselyof personhood to reflex action (Raikhel 2010:142-143). The prominence of this particular ontology in Soviet psychiatry and biomedicine has resulted in a community of narcologists and other medical professionals in the former Soviet Union who embrace placebo-based therapies for substance abuse behaviors (Raikhel 2010). One such treatment option is coding, an aversion-therapy that relies on the power of suggestion to convince addicts that their brain physiology has been altered in such a way that would render the ingestion of any drugs or alcohol painful or fatal (Murney 2009). Such a therapy would seem to be a conflation of medical and behavioral interventions, as well as ethically problematic, to Western medical professionals. This treatment aligns well, however, with the Soviet perspective that physiological and psychological mechanisms in the body are not necessarily mutually exclusive. During the 1990s, as the Soviet Union collapsed and individual governments suffered the political and economic shock of sudden independence, public health systems began to withdraw from their roles as active caretakers of the population. Raikhel has noted that this shift has had the effect of [rendering] alcoholism, previously treated as a social disease, increasingly individualized and medicalized by default. Thus, even while biomedical explanations of heavy alcohol consumption remain unpopular among many lay people in Russia, medical (and quasi-

medical) treatments have gained significance as the primary means by which alcoholism is governed. (Raikhel 2010:133)

Despite this shift in the treatment of alcohol addiction, narcotics addiction has been dealt with as a criminal matter rather than a medical one (Raikhel 2010; Ball 1998; Human Rights Watch 2006). The hope of many development agencies and NGOs is that new harm reduction programs based on Western bio-medical approaches will subvert the rampant criminalization of addiction, which has only exacerbated the harms and injustices experienced by drug users in Ukraine (Human Rights Watch 2006). What exists today is a partially disconnected set of institutionalized responses to addictionsome still closely tied to the state medical system and the legacy of narcological approaches, others having developed in the civil sphere with a closer affiliation to Western biomedicine. Substitution therapy represents a hybrid of these two approaches, since national law requires that methodone and buprenorphine dispensaries be operated under the authority of a federally licensed narcologist.

MAKING ADDICTION MEDICAL In the spring of 2007, I made several visits to a buprenorphine dispensary in the company of Igor, an anesthesiologist who volunteered some of his time with a local harm reduction organization. Addicts enrolled in this program are required to appear daily for their dose, regardless of holiday, travel, or other extenuating circumstances. Isnt that difficult? I asked Igor, To be here every single day of your life? Yes, he replied. It is difficult, but this is better, because they see a doctor everyday. These are very sick people.

At the time, I interpreted Igors statement as a reference to the high rate of blood borne and sexually transmitted infections among Odessas injection drug users. As my research progressed, however, I began to see his words as an indicator of the growing acceptance of the biomedical model of addiction. People may be sick from infections or other communicable diseases such as HIV and hepatitis, but they may also be sick from drug addiction. A biomedical model of addiction is appealing to Ukrainian organizations that interact directly with drug users. Ukrainian non-profits maintain their very livelihood by positioning themselves and their activities squarely within the realm of public healthas defined by international donors. The concept of addiction-as-disease has also flourished due to a local marketplace of ideas that affords a high value to approaches that appear newer and more advanced than those prominent during the Soviet regime. Such value is often granted to medical paradigms of Western origin. The following comment from Anton, a program director at an elite, national NGO, is illustrative: Most of our work is actually to get the best expertise we can get from around the world in our area of interestAnd were trying to get as much as we can. Many more informants referred to biomedical definitions of addiction as advancements obtained from authoritative foreign sources. Sveta, an HIV/AIDS activist and a strong supporter of substitution therapy, explained: Drug addiction is not a bad behavior. Its a disease. Even doctors [ten years ago] didnt want to hear it. And in society was this attitude towards drug-addicted people: Oh theyre so bad. We must have special place for them to live--to throw them away from society. And I had learned from foreign experience that its real. It is, it was, and it is a disease. [emphasis mine]

Sveta considers most Ukrainians to be behind the curve in their failure to adopt this view that she believes to be more rational and modern. For her, this belief carries not only scientific, but also moral implications. By declaring drug use to be a disease, she begins to scrub the stigmas of immorality and personal weakness out of the public image of addicts. The implication is, in part, that people who are caught by addiction cant instantly change the nature of their troubles any more than a person who has a cold can shrug off their viral infection. Authority over this biomedical knowledge of drug use and drug users is claimed through appeals to the scientific nature of the production of that knowledge. For example, Sasha, a supervisor in an elite NGO, emphasized the scientific aspects of her work. 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. There appears to be a consensus among NGO workers that current knowledge about the shape and extent of the IDU and HIV epidemics in Ukraine is largely inadequate. This makes any surveillance effort, even an imperfect one, an important step towards more fully understanding patterns of disease and behavior. The social power to shape and frame conceptions

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of drug use is also gained through the use of scientific methods. Claims that certain organizations embody scientific and modern approaches validate the social agency and political authority of those organizations, and a strong engagement with biomedical paradigms of addiction is central to those claims to power.

THE GENDERED MEDICALIZATION OF ADDICTION Anthropological research on health care in Eastern Europe has shown the utility of medical interventions for achieving social and moral ends. Jack Friedman (2009) has identified an ad-hoc diagnosis within Romanian psychiatric institutions known as the social case, which empowers doctors to use psychiatric treatment and care as a proxy for non-medical social services. Jarrett Zigon (2010, 2011) has argued that a church-based drug rehabilitation programs in St. Petersburg focuses primarily on developing a competent neoliberal identity among its patients. Maureen Murney, who has studied womens alcoholism in Ukraine, has observed that: The medical model [of addiction] presumes the need for medical guidance and supervision, while the moral model presumes that addiction is the result of a persons weak will and bad choices. These models are not mutually exclusive, and the medical model assumes a moral value based on scientific rationality. (2009:249)

Murneys work, in particular, leads us to ask not only how the medicalization of addiction can be seen as an attempt to reclaim control over moral issues, but also what social ends become accomplished via biomedical paradigms. I argue that we should take these inquiries one step further and ask whether those paradigms might be obfuscating social issues of inequality and access to care.

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The moral framework behind biomedical approaches to addiction in Ukraine is not difficult to uncover. Sveta, the HIV activist, engaged the concept of addiction-as-disease in order to address the moral responsibility that drug users hold for their own behavior. Yesterday in the evening I saw the syringes in my hall where I live, and I understood, oh, its an ill, poor guy. How to help him or her? Because, what I understand of drugs, and I tell it everywhere, is that three components are damaged. Its not only the physical body. Its mind and its soul.

For Sveta, disease replaces personal weakness or immorality as the driving force behind drug use and the symptomatic, immoral behaviors that accompany it. Her comments speak to the unquestionably psychological component of addiction, as it is understood in the Post-Soviet contextwhat Raikhel referred to as a reduction of psychology to physiology (2010:143). Psychological traits, such as the weakness of moral character, become incorporated into the physiological framework of biomedicine, and the severity of ones disease, as well as the efficacy of treatments and interventions, can be measured in the severity of the behavioral and psychological symptoms that are displayed. This logic is frequently used in order to provide evidence of substitution therapys efficacy as a medical treatment for addiction. If the symptoms fade, if socially problematic behavior decreases, then it can be assumed that the treatment is bringing the disease under control. Sveta made this point very clear: Methadone programs, I strongly believe in them. I strongly believeI think that people with diabetesthey receive insulin, and they live a normal life. I compare it to methadone or [buprenorphine]. If people use it, receive it in the right formnot just to be

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in the program, to have the bones of it but still be thinking as a drug user, because then it doesnt workbut if they can live normal lives, not do crimes, have families, why not?

Not only is methadone clearly characterized as a pharmacological intervention for physiological disturbances within the body, just like insulin for diabetics, but the proof of substitution therapys efficacy appears to be, so to speak, in the pudding. Narcologists and social workers in every city I visited spoke to me of patients on methadone who are no longer aggressive, who are no longer criminals, who are adapting to their families and their communities, who are peaceful in their homes and in society at large. One narcologist insisted that she knows beyond a doubt that substitution therapy works, because she often sees such positive results as these in her patients. However, most medical and public health professionals I spoke with insisted that drug use and drug addiction are mens problems. In the terms of Kleinmans concept of the explanatory model (1988:43), it is in the culturally-determined answer to the question, How does one contract this disease, that gendered variation appears. The socio-medical narratives available for describing the genesis of mens drug use and womens drug use are so different that they are almost mutually incompatible. When asked whether her program had more men or women, the manager of a small needle exchange responded, Well, men, of course [, ]. One national program coordinator even went so far as to question the validity of national surveys that observed equal numbers of male and female intravenous drug users. 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. This bit of conventional wisdom is, perhaps, best illustrated by an insight shared by an experienced narcologist named Andriy. I have my own test for knowing exactly when

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new clients became involved with drugs, he told me. This test, which he claims is nearly fail proof, requires him to question the wife or girlfriend of the client. When she is ready to speak with me openly, I ask her when was the last time that they had sex. Six, seven months ago? A year? This person doesnt even need condoms because he is unable to have sex [due to effects of narcotics]. During this interview, Andriy and I had been discussing the politics of drug use in general; only upon hearing this comment did I realize that Andriy had assumed that, unless specified otherwise, we were talking about men. Among those female narcotics users who do exist (in either small or smaller numbers, depending on whom you ask) social stigma is considered to be the most significant problem that they face, followed closely by issues of childcare and domestic responsibilities. Women are, of course, harder to work with [ o], a needle exchange director explained to me, because when they come to us, they always bring their children. They have to solve this issue of their children. Who will watch the children? [ . ?] For this reason, motherhood is often perceived as a barrier to service. Ironically, though, children and family obligations are also the main reasons why so few female drug addicts are believed to exist in the first place. As one social worker put it: There are a higher percentage of men in our [substitution therapy] program, because a higher percentage of drug addicts are maleWomen are psychologically stronger than men. Woman can cope with their problems. They are also very home-oriented and are focused on things like their jobs and their kids. Here, people are on drugs because they cant cope with their problems. [Emphasis mine]

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Throughout my interviews, I heard this last point repeated again and again. People begin using drugs because they are depressed, because they feel lost or helpless, because they are unable to adjust to the social and economic changes that Ukraine has witnessed in the past twenty years. Ones susceptibility to drug addiction is inversely proportional to ones ability to cope within an increasingly uncertain and neoliberal Ukraine. This is the double standard at play. Mens failure to cope with lifes troubles, while hardly free from all moral judgments, tends to evoke pity from onlookers and can be perceived as worthy of a certain degree of assistance. This emotional and caring response can be seen in Svetas description of the ill, poor guy who was shooting up in her hallway. Women, on the other hand, are described as stable, totally focused on their kids and their family. They are, and as one activist put it, so serious. Women are expected to be able to cope and manage stressors in a way that men, it seems, are not. Mens opiate addiction is most often perceived as the result of an inescapable and highly understandable decline into depression. It is the biological result of psychological malfunctions, which lends itself readily to the bio-medical explanatory model of addiction. In contrast, the assumption that women are supposed to be psychologically stronger, too focused and responsible to mess with something like drugs, makes womens drug use seem like an anomaly. A womanly disposition should have prevented drug use in the first place, meaning that many female narcotic users become addicted because they lack these psychological strengthsnot because they are ill, but because they are, in one way or another, failures as women. One consequence of this explanatory model is that women who use drugs are primarily associated with stimulant use. The staff of a needle exchange in central Ukraine, estimated that 30% of their clients are female. They were clear to indicate, however, that nearly all of these

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women were stimulant users and, therefore, not really the same as the narcotics users that they thought I wanted to discuss. One narcologist reported that the number of women he sees in his clinic is increasing but quickly clarified that this shift is due to the fact that these women are using stimulants, not opiates, thus making these patients a different matter altogether. In his personal opinion, women turn to stimulants because they are suffering in the absence of a mans (their mans) love. Women need sex. If they do not have sex with men, they use stimulantsThis is the majority of cases. As a rule, stimulant-using women live with drug addicted men. I have rarely met a woman who uses stimulants and lives alone. [ - -- - . , .] According to this perspective, womens stimulant use the result of neither a physiological nor a psychological disease; rather, it is misguided attempt to satisfy certain social and physical desires that are part of a normal and healthy psychology. Once, again, we find that drug-using women are not considered to be ill. The causes of their drug use are completely external and, as of yet, there is no standard medical treatment for being married to a psychologically weak or physically inattentive husband.

WOMANHOOD AND THE UKRAINIAN NATION The double standard apparent in these gendered patterns of medicalization is rooted in gender roles and stereotypes that are intimately connected with the current social and political realities of Ukraine. Soviet rhetoric credited communist labor policies with the social and economic liberation of women, although political discourse regarded them as mothers first, workers second (Hrycak 2005:70). According to Soviet authorities, the matter of the womens

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question was considered resolved from the beginning of Stalins rise to power (Marsh 1996:1), but since Ukraines independence in 1991, Soviet gender roles have been deconstructed and reincorporated into a nationalist discourse that stands in deliberate opposition to both Soviet and Western feminist constructs. Contrary to the Soviet ideal of the liberated, working woman, current Ukrainian feminine ideals have refocused on private, family oriented, and domestic duties. Marian Rubchak calls this an attempt to return the nation to real Ukrainian-ness by means of birthing and raising real Ukrainians (1996:318). She observes, the Ukrainian womans God-given mission is constantly affirmed to be one of giving birth to saviors, that is to say the geniuses, philosophers, and military leaders of the nation (1996:319). Soviet policies certainly focused on the reproductive contributions of womenso much so that womens professional work was closely monitored and medicalized in order to ensure optimal reproductive productivity (Hyer 1996). However, whereas Soviet ideology connected the motherly role of women with issues of the State, such as population growth, the project of postindependence nation building connects the motherly role with the preservation of Ukrainian culture and the growth of a national identity (Zhurzhenko 2001:5). In other words, the realization of the Ukrainian nation is rooted in the actualization of a symbolic female body, which is the source of true Ukrainian-ness (Zherebkina 2001:3). A common belief among Western aid and development organizations was that a feminist backlash would occur organically as Ukraine became increasingly democratic. Instead, with the foundation of numerous womens civic and social organizations focused primarily on supporting Ukrainian cultural and national identity in the early 1990s, this domestic feminine ideal has grown into something of a womens political cause (Kutova 2005:3). These gender norms have entered more and more into Ukrainian social and political discourse in the absence of any acknowledgement that gender is, itself, a social

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construct (Kutova 2005:4). Rather, the notion of women as domestic, motherly creatures has been naturalized, and the return to such natural roles is often considered a welcome change after decades of Soviet policies based on false notions of gender equality that ultimately resulted in a double burden of both professional and domestic labor for Soviet women (Marsh 1996:6). This powerful connection between gender norms and the health and development of Ukrainian nationhood has allowed the motherly feminine ideal to become deeply rooted in all aspects of Ukrainian life. The public perception of and response to addictive behaviors is no exception. Murneys research (2009) among female alcoholics in Lviv confirms that women who are addicted to alcohol face social stigma and barriers to health services that are far greater than those of their male counterparts. Alcoholic men more often than not elicit pity, but women who are addicted are perceived to have abandoned their femininity, their families, and by extension their nation. They are seen to have consciously rejected the very essence of Ukrainian womanhood (Murney 2009:217). Womens addiction is perceived to be rooted in not simply a failure to achieve feminine ideals, but in an outright rejection of those ideals, which brings harm not only to the self, but to the nation as a whole. If we consider these gender norms in the context of addictions treatment, substitution therapy, or public health programs, we can expect the consequences of the gendered medicalization of addiction may take a number of forms. Firstly, womens access to harm reduction services has been a major focus of a number of international donors for several years, yet there continue to be major barriers preventing women from accessing these programs (Pinkham and Shapoval 2010). An androcentric model of addiction has fostered an environment with little space for women to benefit from harm reduction efforts, simply because so few of

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them were ever expected to show up. It is easy to simply erase female drug users from both the public and the professional imaginations by reiterating the common wisdom that women are just too serious to be involved in that kind of behavior. Secondly, it becomes more difficult to integrate a woman-centered approach to public health into existing HIV-prevention and harm reduction networks, because the core issues that are believed to drive a woman to drug use in the first place are considered to be personal problems that are not within biomedical purview. Its certainly not the case that anyone wants to exclude women from harm reduction and prevention services. Its simply that, from this perspective, womens inclusion into these services doesnt seem to make a lot of sense. It is too easy to consider female drug users statistical outliers or fundamentally different from male narcotics addicts due to their dependency on their husbands for drugs or their alleged preference for stimulants over narcotics, which further undercuts the classification of their drug use as a medical disease. It could be argued, then, that the exclusion of women from public health services is not only unconscious and unintentional, but that there is potential for exclusion to occur in spite of targeted communication efforts and the expansion of services to include parenting and domestic support.

THE COMMON ADDICT Heroin users. I think they are the same everywhere. This blunt observation was made by Oleksandr, an independent contractor who has worked with a variety of elite, international organizations and HIV-prevention NGOs. He, like many others, believes that high-risk drug users have common behavioral, psychological, and physical traits. When I was working in Western Europe, I saw so many drug users, and they were all spaced out, dirtyit looked just

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like a Ukrainian needle exchange, he said. To Oleksandr, the characteristics of drug users are not only common, but are also self-evident to anyone willing to give them an honest look. This sentiment was repeated by Olga, a program coordinator from an elite NGO in Kyiv who works with a successful pharmacy-based referral program for intravenous drug users and commercial sex workers. When describing the program, she insisted that the pharmacist will know the drug users from their appearance []. Sex workers cant be visually detected in the same way, and the pharmacist must pay attention to specific medical complaints, which may indicate a sexually transmitted disease. Drug users, however, can be visually spotted almost immediately. The shabby, distressed appearance of drug users was assumed to be self-evident. Yes, Olga said, waving her hand up and down her whole body. From their appearanceyou know. While sitting with several staff members in a local NGO in central Ukraine, I asked how the staff had recognized a client as a stimulant user rather than an opiate injector. How are stimulant users different? I asked. Well, came the first response, They are a whole lot faster! [, !] The group erupted into laughter. A moment later, social worker turned to me and revealed the joke, stating matter-of-factly that stimulant users are recognized the moment they walk through the door. Several outreach workers nodded in agreement. Any experienced harm reduction worker knew as much. Nina G. Schiller (1992) has illustrated the extreme degree to which intravenous drug users in North America become homogenized when categorized by dominant biomedical discourses as a risk group. Others have noted that the homogenization of risk groups may be crucial for the coherent and consistent administration of public health interventions, but the maintenance of these constructed groups relies on the socio-political management of individuals

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engaging in common, risk-group-specific, deviant behaviors (Bourgois 2000; Frankenburg 1993). It is not surprising, then, that so many NGO workers in Ukraine spoke of drug users as though all individuals in this population shared the same key characteristics. More importantly, though, popular notions of the common addict inhibit the incorporation of diverse or divergent identities and narratives into these discourses. Olga, for example, shrugged off many of my questions about how pharmacists reacted differently to different types of drug users. Do female addicts have a harder time finding referrals? I asked. What about addicts with financial means? She shook her head and said, The major point is that these are ill people. They are pitied. They are guilty of their disease, but the pharmacists pity them and tried to counsel them, even when they didnt know where to refer them. They tried to tell them that things were going to be all right.

Olgas words reflect the way in which the medicalization of addiction and the social homogenization of drug users complement one another. The signs and symptoms of drug use mark addicts as bearers of common physical, behavioral, and psychological traits. As an explanatory model, the concept of addiction-as-disease is able to subsume all of these traits, to render them meaningful and comprehensible within local social contexts. Within the sphere of HIV prevention in Ukraine, where tropes of narcotics addiction are deeply androcentric, the notion that all drug users are alike actively reinforces that androcentricity and the discursive exclusion of women from popular imaginings of drug addiction.

CONCLUSION

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If the intersection of biomedical paradigms and Ukrainian constructs of gender and gendered personhood result in this robust form of discursive exclusion, then perhaps biomedical approaches to the problems of drug use, in their current form, have reached a unanticipated limit. Philippe Bourgois has observed that, Even the best of intentions to help or to serve the socially vulnerable can also simultaneously perpetuate or even exacerbate oppression, humiliation and dependency of one kind or another. (2000:168-169)

There are myriad social and scientific consequencesboth good and badof the construction and deployment of biomedical definitions of drug addiction and treatmentparticularly within the context of the global fight against HIV/AIDS. It is imperative that we recognize the social and political embeddedness of the dominant biomedical schemas of preventionparticularly when these schemas are engaged in parts of the world far from their geographic and cultural origins. A failure to do so may result in counter-productive social labeling, social fragmentation, marginalization, and ambivalence towards those who have been placed outside the limits of biomedical efficacy. In Ukraine, the sociology of addiction is still being negotiated. Is substitution therapy simply an institutionalized mechanism for the perpetuation of chemical dependency, or is it a valid form of treatment for the physical illness of addiction? Are there ways to better incorporate both women and tropes of female identity into existing public health programs for drug users? The moral and ethical worth of methadone and buprenorphine programs depends upon the answers to such questions, and the presence of tension and resistance amidst biomedical discourses of addiction indicates that these norms are, to a certain degree, still forming.

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However, so long as the national response to drug use remains inextricable from HIV-prevention efforts and is wholly grounded in public health paradigms, womens drug use will most likely remain marginalized until it is perceived not simply as a public health issue, but as a biomedical issue worthy of a biomedical response. At the national level, some public health and HIV-prevention professionals are exploring alternative programs that target at-risk women. One woman employed by a large national network discussed the possibility of setting special program hours at local NGOs that are open only to women. She said that such a policy requires the initiation of new gender sensitive policies and procedures, which is a mindshift for the local organizations. When you talk to people here in Ukraine about gender issues, she said, its like something from another planetYou know, they [local NGOs] dont have policies. They work the way they feel is right. Another national coordinator discussed the need for childcare and perhaps the creation of womens groups or clubs in order to attract women into harm reduction agencies. When asked precisely how these groups would be designed differently for women, however, the response became less clear: I mean, its not just giving syringes and saying that the hospital is around the street. Its more like asking about children, reproductive health and all the things which are, you know, more close to women. So, just getting something that is more important for women and not just a universal thinglike to everyone. I mean male or female. You know. So its just targeted communication I would say.

The desire of national organizations and NGOs to formally recognize the existence of female narcotics use and the needs of addicted women is genuine. The incompatibility between

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Ukrainian gender norms and the dominant tropes of medicalized addiction remain a significant barrier, though, and the complexity involved in generating and articulating solutions to this quandary is apparent. Finally, in revealing how the social landscape of contemporary Ukraine uniquely shapes these biomedicalized responses to addiction, deeper questions come into view. What kind of social capital does the medicalization of addiction provide, and how is access to such biomedical identities and narratives controlled? Will efforts to bring female addiction under the authority of biomedical interventions in Ukraine ultimately be worth it, or does this case begin to reveal to us the limitations of what public health approaches can accomplish in this particular case? Given the structure of international funding for drug user and HIV prevention services in Ukraine, is it even possible for effective responses to survive financially or politically outside of the realm of public health? The treatment of intravenous drug use as a public health issue is undoubtedly much more desirable and beneficial than the rampant criminalization of drug use that Ukraine has witnessed in recent decades. At this moment, though, while much of the national response to HIV/AIDS and intravenous drug use is still expanding, perhaps it is worth asking whether public heath approaches to drug use and addiction, alone, are capable of providing adequate solutions to the problems that Ukrainian communities face, or whether more innovative, holistic approaches are necessaryapproaches that might not rely on bio-medicine for either their philosophical or financial foundation.

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Ball, Andrw L., Sujata Rana, & Karl L. Dehne 1998 HIV Prevention Among Injecting Drug Users: Responses in Developing and Transitional Countries. Public Health Reports, 113(S1):170-181. Bourgois, Philippe 2000 Disciplining Addictions. Culture, Medicine and Psychiatry, 24:165195. Druce, Nel, Nadia Gittins, and Liliya Skotarenko 2009 UNAIDS Second Independent Evaluation: Country Visit to Ukraine Summary Report. http://data.unaids.org/pub/BaseDocument/2009/20090417_sie_countrysummaryreport_uk raine_en.pdf, Accessed October, 2010. Frankenberg, Ronald 1993 Risk: Anthropological and Epidemiological Narratives of Prevention. In Knowledge, Power and Practice: The Anthropology of Medicine in Everyday Life. Shirley Lindenbaum and Margaret Locke, eds. Pp. 219-243. Berkeley: University of California Press. Friedman, Jack 2009 The Social Case: Illness, Psychiatry, and Deinstitutionalization in Postsocialist Romania. Medical Anthropology Quarterly 23(4):375-396. The Global Fund 2007 Grant Performance Report: UKR-102-G04-H-00. http://www.theglobalfund.org/search/docs/1UKRH_428_228_gpr.pdf, Accessed August, 2010 2010 Ukraine: Country Grant Portfolio. http://portfolio.theglobalfund.org/Grant/Index/UKR102-G04-H-00, Accessed August, 2010. N.d. Approved proposals. http://www.theglobalfund.org/en/fundingdecisions/approved/, Accessed April, 2011. Hrycak, Alexandra 2005 Coping with Chaos: Gender Politics in a Fragmented State. Problems of PostCommunism 52(5):69-81. 2006 Foundation Feminism and the Articulation of Hybrid Feminisms in Post-socialist Ukraine. East European Politics and Societies 20(1):69-100. Human Rights Watch. 2006 Rhetoric and Risk: Human Rights Abuses Impeding Ukraines Fight Against HIV/AIDS. Human Rights Watch 18(2D). http://hrw.org/reports/2006/ukraine0306/ukraine0306web.pdf, Accessed August, 2007. Hyer, Janet 1996 Managing the Female Organism: Doctors and the Medicalization of Womens Paid Work in Soviet Russia During the 1920s. In Women in Russia

25

in Ukraine. Rosalind Marsh, ed. Pp. 111-120. Cambridge: Cambridge University Press. International HIV/AIDS Alliance in Ukraine. 2009 ICF International HIV/AIDS Alliance in Ukraine: About us. http://www.aidsalliance.org.ua/cgi-bin/index.cgi?url=/en/about/index.htm, Accessed July, 2010 N.d. Programa Podolannya Epidemiyi VIL/SNID v Ukrayini http://www.aidsalliance.org.ua/cgi-bin/index.cgi?url=/ua/gfund/index.html, Accessed April, 2011. Kleinman, Arthur 1988 The Illness Narratives: Suffering, Healing, and the Human Condition. United States: Basic Books, Inc. Marsh, Rosalind 1996 Introduction: Womens Studies and Womens Issues in Russia, Ukraine, and the Postsoviet States. In Women in Russia in Ukraine. Rosalind Marsh, ed. Pp. 1-29. Cambridge: Cambridge University Press. Murney, Maureen 2009 Mores of Addiction: Alcohol, Feminimity, and Social Transformation in Western Ukraine. Ph.D. Dissertation, Department of Anthropology, University of Toronto. Pinkham, Sophie & Anna Shapoval. 2010 Making Harm Reduction Work for Women: The Ukrainian Experience. Open Society Institute. http://www.soros.org/initiatives/health/focus/ihrd/articles_publications/publications/harm -reduction-women-ukraine_20100429/harm-reduction-women-ukraine_20100429.pdf, Accessed June, 2010 Phillips, Sarah 2005 Civil Society and Healing: Theorizing Womens Social Activism in Post-soviet Ukraine. Ethnos 70(4):489-514. 2008 Womens social activism in the new Ukraine. Bloomington: Indiana University Press. Raikhel, Eugene 2010 Post-Soviet Placebos: Epistemology and Authority in Russian Treatments for Alcoholism. Culture Medicine and Psychiatry 34:132168. Rivkin-Fish, Michelle 2005 Womens Health in Post-soviet Russia. Bloomington: Indiana University Press. Rubchak, Marian J.

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1996 Christian Virgin or Pagan Goddess: Feminism Versus the Eternally Feminine in Ukraine. In Women in Russia and Ukraine. Rosalind Marsh ed. Pp. 315-330. Cambridge: Cambridge University Press. Schiller, Nina. G. 1992 What's Wrong with This Picture? The Hegemonic Construction of Culture in AIDS Research in the United States. Medical Anthropology Quarterly 6(3):237-254. Semigina, Tetyana, Irena Griga, Daryna Bogdan, Paola Pavlenko, Viktoria Bondar, Lesya Nechiporenko, Irina Schevchenko, and Neil Spicer. 2007 Tracking Global HIV/AIDS Initiatives and Their Impact on the Health System in Ukraine. Global HIV/AIDS Initiative Network. http://www.ghinet.org/downloads/UkraineReportJune09.pdf, Accessed June 2010. Singer, Merrill and Hans Baer 1995 Critical Medical Anthropology. Amityville, New York: Baywood Publishing Company, Inc. UNGASS 2010 National Report on Monitoring Progress Towards the UNGASS Declaration of Commitment on HIV/AIDS. http://data.unaids.org/pub/Report/2010/ukraine_2010_country_progress_report_en.pdf, Accessed December, 2010. UNAIDS 2008 Ukraine: Country Situation: July, 2008. http://data.unaids.org/pub/FactSheet/2008/sa08_ukr_en.pdf, Accessed July, 2010. Zherebkina, Irina 2001 Who Is Afraid of Feminism in Ukraine? How Feminism is Possible as a Post-soviet Political Project. In Gender in Transition in Eastern and Central Europe. Proceedings. Gabrielle Jaehnert & Jana Gohrisch, eds. Pp. 142-147. Berlin: Trafo Verlag. Zhurzhenko, Tatiana 2001 Ukrainian Feminism(s): Between Nationalist Myth and Anti-nationalist Critique. IWM Working Paper No. 4/2001: Vienna. http://www.multiculturedonne.com/files/ukr.feminism.pdf, Accessed October, 2010. Zigon, Jarrett 2010 A Disease of Frozen Feelings: Ethically Working on Emotional Worlds in a Russian Orthodox Church Drug Rehabilitation Program. Medical Anthropology Quarterly 24(3):326-343. 2011 HIV is Gods blessing: Rehabilitating Morality in Neoliberal Russia. Berkeley: University of California Press.

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