Healthcare: Public Policies, Social Practices, and Individual Experiences. An Introduction

Public Health Strategies and Practices

The opening article by Trifunović (2024) examines, from both a historical and anthropological perspective, the locally produced polio vaccine in Serbia during the socialist and postsocialist periods. The construction of a technological instrument against an infectious disease with a global impact reflects vaccine developers’ ideological, cultural, and economic visions, along with their scientific preferences. Trifunović (2024) shares the aforementioned understanding of public health as a multilayered construct most explicitly. She defines the polio vaccine itself as a “sociocultural artefact” and a part of “techno-cultural heritage” to underline the sociopolitical goals that it serves alongside public health needs. Moreover, the cultural level of ideas, values, and symbols is regarded as implanted in the otherwise material, technological nature of vaccines, thus transcending the domain of allegedly objective science.

The perception of vaccines as complex artifacts is also addressed by Glaurdić and Lesschaeve (2024) and Brujić (2024) in this thematic section. Both of these articles discuss the context-specific negative health effects of the Covid-19 pandemic, and the widespread vaccination hesitancy in Bosnia-Herzegovina, Croatia, and Serbia (Glaurdić and Lesschaeve 2024), as well as among Serbian migrants in the Netherlands (Brujić 2024). While the first of the two contributions focuses on political attitudes and their effects on the public health system, the second approaches the culture-political dynamics of vaccination hesitancy against the background of the “risk society” concept (Giddens 1991) and governmentality studies. Moreover, Brujić (2024) expands the regional scope of the case studies discussed. By bringing the Netherlands’ public health policies to the fore, she enriches the analysis in this thematic section with a comparative transregional perspective. In another article, Goncharova and Karamelska (2024) examine quite a different health issue—care for people with dementia in Bulgaria. This case study reveals the tensions between the subjective experiences of informal caregivers, the lack of institutional support provided by the state, and the pressure of sociocultural stereotypes about care and old age. Unlike acute infectious diseases, dementia is a chronic condition and coping with it exposes problematic interactions between disabled people and/or their carers and healthcare systems.

What brings together the case studies of tackling polio epidemics, Covid-19 pandemics, and care for people with dementia is not only the shared regional context of public health in Southeastern Europe, which is important for understanding the systems’ flaws. All four studies also argue that the interplay of political, socioeconomic, and cultural factors has a crucial impact on public healthcare strategies and their implementation.

The political dimension is dominant in the analytical framework of Glaurdić and Lesschaeve (2024). Employing data on more than 6,000 individuals surveyed in Bosnia-Herzegovina, Croatia, and Serbia, the authors find evidence that respondents who support nationalist populist parties and ideas are less likely to accept the Covid-19 vaccination, while trust in national politicians and scientists is positively correlated with vaccination status. These findings underscore that specific political attitudes are strongly linked with vaccination acceptance or hesitancy.

Trifunović (2024) also seeks to identify the political meaning of vaccines, not at the level of individual choices, but at the level of their production by the state. The article shows that the choice between live virus and inactivated virus types of polio vaccines in socialist Yugoslavia and later in postsocialist Serbia depended on global geopolitical factors, including ideological cooperation, competition, and conflicts, and the vaccine production itself also depended heavily on economic priorities and market imperatives. The political and economic factors also had cultural overtones: locally produced vaccines symbolized national prestige, advancement, and autonomy.

From the perspective of the governmentality theories adopted by Brujić (2024), vaccines can be treated as “technologies of government”. According to Brujić (2024), a positive stance on vaccine-taking relied on the strong economic and political systems established in the Netherlands before the pandemic. Hence, vaccine hesitancy among Serbian parents in the Netherlands during the Covid-19 crisis is interpreted as a form of individual resistance to political and public health institutions that failed in terms of health risk management.

The inefficiencies of the healthcare sector, that is, underfinancing, a deficit of experts, inadequate diagnoses, etc., all translated into political and economic definitions of the weak—if not entirely invisible—state in the field of public healthcare for people with dementia (Goncharova and Karamelska 2024). While outlining the main problems of institutional politics and practices, however, the authors focus on the “individualization” and “intimization” of the experience of care for people with dementia. Goncharova and Karamelska (2024) pay special attention to the cultural values that underpin individual “politics” of care: stereotypes of filial duty and conservative representations of aging.

Health Crises as Trust Crises

The relationships between individual experiences and attitudes and the institutional, political, and societal aspects of healthcare provision explored in this thematic section are conditioned by the common problem of institutional (dis)trust in the region. With this in mind, all contributions to this thematic section discuss the issues of trust and distrust in the healthcare system and national policymakers.

Like “health”, “trust” is a multilayered and contested concept. This thematic section refers to definitions of trust that connect the elements of vulnerability and care, in particular, people’s positive attitude and willingness to accept their own vulnerability when entrusting something precious to them to the care of others (Baier 1986; Hall et al. 2001). Trust presupposes certain discretionary powers of the trustee, who does not take advantage of the trustor’s vulnerability in the process of exercising these discretionary powers (Baier 1986). It can be argued that “trust is an attitude that enables us to cope with risk in a certain way” (Lahno 2001, 171). The correlation between risks and (dis)trust in political and healthcare institutions is central to Brujić’s (2024) analysis. Distrust occurs as a social reaction to institutions authorized to manage global risks when those institutions fail to maintain their scientific and moral legitimacy.

According to Lahno (2001, 180), shared aims, values, and norms provide a foundation for institutional trust, perceived as a “cooperative enterprise”. This is exactly what is missing in the attitudes underlying vaccine hesitancy, as suggested by Glaurdić and Lesschaeve (2024), since both political distrust and political populism imply a conviction that elites are not serving the interests of the populace. Therefore, the crisis of trust also signals a crisis of institutional legitimacy (Ullmann-Margalit 2004).

Trustworthiness is not an essential element of trust, but it is a vital part of warranted trust. In the article by Trifunović (2024), decision-makers evaluated the trustworthiness of different types of polio vaccines under the influence of many social, economic, and political variables. These influences did not follow a strictly scientific logic, but rather certain global agendas and local needs. Technological trends, ideological engagements, and the symbolic meanings of different polio vaccines determined the changing preferences of their producers over time. The gradual decline of postsocialist vaccine production was part of a process of structural healthcare transformation.

The withdrawal of the postsocialist state as a leading player in the biopolitical field is also reflected in the article by Goncharova and Karamelska (2024). The process of deinstitutionalization of health services for disabled people did not meet European standards of care for people with dementia. The state’s “abdication” of its public health responsibilities led to high distrust in public health practices. This led to the “over-responsibilization” of the families of people with dementia, who in most cases preferred to bear the exhausting burden of informal care all by themselves. As Goncharova and Karamelska (2024) argue, institutional distrust, accompanied by cultural stereotypes of filial duty, reinforced familiarism. A similar process of responsibilization of family members (parents) as a consequence of distrust of public health services during the Covid-19 crisis is outlined by Brujić (2024). The Covid-19 pandemic thus challenged the resilience of public health systems in both the East and the West, forcing individuals to deal with major health risks on their own.

From the Critical Power of Distrust to the Creative Potential of Policymaking

Distrust prompts individuals to engage in activism, which protects them from abuse of power by the authorities and ensures social justice (Krishnamurthy 2015). While distrust in vaccines does not seem to be well justified, despite governmentality critiques of vaccination as an instrument of biopolitical surveillance (Brujić 2024), it may fuel health activism aiming at eliminating inefficiencies in the healthcare systems, such as inaccessible or substandard health services and out-of-pocket payments (see also Mavisakalyan et al. 2021). The contributions in this thematic section agree that public health policies should focus on improving the efficiency of healthcare systems while accounting for the multidimensional nature of health and disease. As Lahno (2001, 171) argues, “If we want to promote trustful interaction, we must form our institutions in ways that allow individuals to experience their interest and values as shared and, thus, to develop a trusting attitude.” This argument is also supported by studies in economics, arguing that trust is an essential component of economic development (Knack and Keefer 1997; Nikolova, Popova, and Otrachshenko 2022; Tabellini 2010).

The contributions in this thematic section provide implications for health policies. For instance, Brujić (2024) underscores that, as a new technology, the Covid-19 vaccines elevated risk aversion attitudes among Serbian parents in the Netherlands and indirectly suggests that better-targeted informational campaigns regarding the benefits and risks of vaccination may help to overcome the issues of mistrust and vaccination hesitancy among the general population and among migrants in particular. Glaurdić and Lesschaeve (2024) argue that political attitudes and health policies are interrelated. Thus, understanding the formation of political attitudes and voters’ preferences may be associated with more effective health policies and healthcare provision. Finally, although looking at very different aspects, Trifunović (2024) and Goncharova and Karamelska (2024) implicitly come to a similar conclusion that institutional barriers to public health systems development, be they global or local barriers, may result in insufficient healthcare and worsen health outcomes. All contributions in this thematic section also concur that institutional and social trust are important foundations of effective health policies. Despite differences in their emphasis on the political, economic, and cultural aspects of public health, the four articles unite at the point of analyzing individual health beliefs and behaviors vis-à-vis the public health system. Vaccination hesitancy and negative attitudes toward institutional options for people with dementia have a common denominator: they all represent a lack of trust, a major intersection in the common “health map” already sketched out.