Ostrach book cover

[ REVIEW ] Ostrach, Bayla 2017 Health Policy in a Time of Crisis

[Review Originally published on Anthropology-News ]

In Catalunya and beyond, abortion is never just a medical or even a moral issue. It is an explosive nexus of intense social conflict over power, ‘rights,’ bodily autonomy, access to health care and the equal distribution of resources in society” (Ostrach 2017: 69).

Ostrach 2017

Health Policy in a Time of Crisis stems from ten months of institution-based participatory research in a healthcare clinic—Public Clinic—providing state-funded abortion services in Barcelona. Using a mixed-method approach, Ostrach surveyed 350 women who sought abortion care at the Public Clinic, interviewed 11 women on their experiences with the public health system in seeking abortion as well as 11 providers on their perspectives of the experiences of the hundreds of women for whom they provided abortion care.

This methodologically grounded and theoretically innovative ethnography is informed by the author’s long-standing engagement with the topic of abortion rights and access in the United States. In a context of global restrictions on women’s reproductive rights and the fight of activists worldwide for legal access to abortion, the author vividly demonstrates how legal abortion does not necessarily equate with abortion access. Health Policy in a Time of Crisis takes abortion as a window to analyze the everyday impact of austerity measures (national and European) and shifting status for immigrants on abortion access. The shadow of La Crisis, the widespread recession that struck most of Europe from 2007 on, and the consequent austerity measures, forms the background of women’s decisions to get abortion care, health personnel’s struggle to provide it, and the Public Clinic’s ability to maintain full access to all women seeking its services. Austerity cuts during the author’s fieldwork translated in a drastic reduction of the number of publicly funded abortions, illustrated by women who had come for a procedure in previous years’ saying, “better a crowded clinic than no clinic!”

Contrary to much of Latin America, where some countries have the strictest abortion laws of the planet, there is little stigma associated with abortion in Barcelona, and even women who personally oppose abortion strongly contest legislative attempts to put restrictions on women’s bodies. Ostrach builds on feminist critique to analyze the notion of “bodily autonomy,” which is central to Catalan activists’ demand for abortion access for all. The emphasis on bodily autonomy challenges mainstream discourses on reproductive rights. Catalan activists’ grassroots demands for access to reproductive care and bodily autonomy rather than the right to abortion echoes many demands of activists and indigenous peoples across Latin America, who frame access as rights in practice, rather than theoretical human rights.

In Catalunya, demands for bodily autonomy are interwoven with protests for regional autonomy, and a strong commitment to healthcare access for all, no matter their residency status. In this peculiar context, one might think that barriers to access are reduced. However, Ostrach’s research showed that 51 percent of the 350 women surveyed were not aware that their abortion would be fully state-funded, even as they had interacted with at least one health system representative. Building on Harvey’s civilized oppression framework, Ostrach vibrantly reveals how the power imbalance between women seeking information about abortion services, with some healthcare workers abusing their authority, shape women’s access to health services. In particular, immigrant women were most likely to report being misinformed on the gestational limit for abortion, encountering delays in seeking abortion services, and being provided with the incorrect referral voucher, for example. In some cases, structurally marginalized women faced ongoing stereotypes and had to convince providers that they were worthy of public funds.

Health Policy in a Time of Crisis is an empathic ethnography on women’s frustrations, as they face a wide-range of obstacles such as terminating a wanted pregnancy because of La Crisis, the lack of access to transportation to the only publicly-funded clinic in the region, or finding a companion to wait for them after the procedure, as required by the clinic protocol. The women Ostrach interviewed were particularly insightful on the multiple challenges they had to face in addition to seeking abortion care—as single mothers, sex workers, and students. The author eloquently describes these efforts in the “Superwoman complex”: the strategies deployed by women to balance fewer economic resources and less perceived support for their abortions. Ostrach’s vivid descriptions of women’s journeys, and the long quotes of women themselves bring las dones (the women) to life, as they share their frustrations with the health system and these personal and structural obstacles.

Immigrant women in particular (from South America, other parts of Spain, and other European countries) encountered more delays in accessing abortion and arrived on average two weeks later than Catalans at the clinic. Factors accounting for this delay included women’s lack of awareness that the procedure would be covered upfront, and the shifting status of immigrants, which led to misinformation about their health coverage. Ostrach eloquently describes how providers’ attitudes can shape women’s access, and how some stereotypes shape the staff interactions with certain groups of patients like Roma or Muslim women, but the impact it might have on women’s experiences and their willingness to access the service is left unanswered. The author acknowledges the limitation of her study on immigrant women’s experiences, as she focused on those women who accessed the clinic, and raises important questions for future research, such as, what happens to immigrant women who are completely unaware of the public healthcare coverage for pregnant women? And, what are the stories of those who encountered too many delays and were unable to get the procedure?

To conclude, this exceptionally well-written and engaging ethnography is a constant reminder that “abortion is nothing without access,” at a period of revival of conservative movements in Europe—making the news in France and Poland recently—and increased restriction on abortion access in the United States. Health Policy in a Time of Crisis provides a unique example of engagement in medical anthropology. Ostrach shared the results of her investigation on the concrete impacts of funding cuts for the public clinic with representatives of the public health system. Even though the meeting did not result in a change in policy, such engagement symbolizes important calls for action. This promising first book will speak to a wide audience, offering insights for discussions in research methods and ethics classes from all disciplines, and the fields of medical and applied anthropology, women and gender studies, and public health and migration studies, to name a few.

Book Reviewed: Ostrach, Bayla. 2017. Health Policy in a Time of Crisis: Abortion, Austerity and Access. New York and London: Routledge.

[ WRITING ] Chiapas health workers strike against reforms

[Article originally published in ROAR Magazine]

Workers of the Chiapas Health Jurisdiction have been on strike for one month, in protest against the structural reforms the government intends to pass.

It isis 8:30 pm and the nurses are just starting their 12-hour shift. “There are three teams. Now we have a 12-hour shift, until 8 am tomorrow morning, and then we come back 24 hours later,” one of them explains. Workers from different health institutions of the city of San Cristóbal de las Casas have organized the distribution of supplies in the tents blocking the road to the Woman´s Hospital and the Health Jurisdiction. During the long shifts, “some bring coffee, some bring food, and others come with hunger,” says another nurse, laughing.

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Nurses on strike

Workers of the Health Jurisdiction of Highlands Chiapas, which is comprised of workers from 18 municipalities have been on strike for over one month, in protest against the eleven structural reforms the government has been trying to pass. In particular, they explain that the so-called “universalization of healthcare” which would merge the different public healthcare institutions of the country would have disastrous consequences in Chiapas, one of Mexico’s poorest states.

The current universal healthcare (Seguro Popular) covers about 300 procedures. The previous program covered over 3,000. “And with this reform, there will be barely a hundred procedures covered, leaving out chronic illness such as diabetes and acute conditions like cancer,” a union representative explains. And in a country with vast income disparities, universal healthcare’s unique cost for uncovered procedures would not be accessible to poor peasants living in the states of Oaxaca (where the police repression led to 12 dead, a hundred wounded and 25 disappeared in Nochixtlan a few weeks ago),Guerrero (where 43 students were disappeared in September 2014) and Chiapas. The biggest health costs will thus be shouldered by patients themselves, and not by the state.

The privatization of healthcare is in line with international reforms promoted by lending agencies, such as the World Bank and the Inter-American Development Bank, and will benefit those already in the business of health, like the Mexican telecom magnate Carlos Slim. “This is a model that does not fit with the reality of Mexico, and what we as workers are starting to implement are local consultations with lawyers, researchers, and activists to find a new health model” decries another union leader at a press conference on June 30. Protesters are also calling out to the state’s lack of knowledge and interest in the operating conditions of the health institutions. “In the hospitals here, we lack medicine and even machines. Sometimes there are not even syringes. The only thing doctors can do is fill out prescriptions and send patients to buy out-of-pocket medications in pharmacies”. In the face of such shortages, staff members often help out their poorest patients by paying the costs out of their own pocket.

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Sign of protest outside of the Health Jurisdiction.

The discontent with the law is plenty: “For those of us who will be retiring, we would only be getting 1,080 pesos a month (about 60 USD)” explains one healthcare worker. “Our colleagues working in laboratories will be judged on their productivity, not on the number of hours; in order to comply with their goals they will have to either work more hours or increase the number of patients per hour,” describes another.

Even though the Highlands’ Jurisdiction is the only union on strike in the state so far, health workers from all over the country marched in protest on June 22. In Chiapas, teachers, families, students and residents of different districts of the city have shown solidarity with the movement: “Night after night, people from the barrios bring us coffee and show their support.”

Twenty-two days after declaring a “Permanent Assembly,” the 2,500 workers stand firm. So far, the health reform has been paused, “but this does not mean that it will not be reactivated,” cautions the union representative, “we will not dismantle our Permanent Assembly.” The health workers say they have learned a lot from the teachers, who have been mobilizing against radical changes in the education system as well. “We are barely learning how to walk. But we will walk together with the teachers and peasants.”