{"id":1182,"date":"2017-11-29T10:01:50","date_gmt":"2017-11-29T10:01:50","guid":{"rendered":"https:\/\/processing.matteringpress.org\/?page_id=1182"},"modified":"2018-06-27T17:14:41","modified_gmt":"2018-06-27T16:14:41","slug":"18-the-case-of-the-cake-dilemmas-of-giving-and-taking","status":"publish","type":"page","link":"https:\/\/processing.matteringpress.org\/ethnographiccase\/18-the-case-of-the-cake-dilemmas-of-giving-and-taking\/","title":{"rendered":"18. The Case of the Cake: Dilemmas of Giving and Taking"},"content":{"rendered":"

Welcome. Plea<\/i>se read the\u00a0instructions<\/a>\u00a0for reviewing before commenting.\u00a0We ask contributors to be generous when thinking along with our pieces and to keep in mind that the final chapters are intended to be short essays.\u00a0Visit matteringpress.org<\/a> for more information on its other books. Readers might\u00a0also want to have a look at this resource<\/a> created by one of the book’s editors, Emily Yates-Doerr, which catalogues key Open Access anthropology publications.\u00a0<\/em><\/span><\/p>\n

By\u00a0Rima Praspaliauskiene<\/em><\/p>\n

In my fieldwork at the Cardiology Unit at Vilnius public hospital I encountered what I call \u201cthe cake case.\u201d In 2009-2010 I was in Lithuania to study how medical care was transforming as the state embarked on health care reform that aimed to rationalize and privatize public services. In particular, the neoliberal reform projects targeted informal payments, or \u201cbribes,\u201d that were prevalent in public health care. The state sought to transform these transactions into a system of transparent co-payments, one of many efficiency-producing transitions underway, including the introduction of private health care insurance and increasing the number of private clinics. Meanwhile, I was observing how doctors, patients, and their relatives engaged in ambiguous practices of giving that policy makers and some scholars would define as non-transparent, informal, and corrupt. The cake case helped me understand how multiple forms of care coexist in any exchange, such that what counts as efficient and acceptable care is not stable or solid.<\/p>\n

\u201cDid you see that?\u201d nurse Violeta asked another nurse and a resident at the nursing station when a tall and sizable woman in high heels, carrying an oversized black bag, marched into the four-bed male patient room.\u00a0 They nodded. \u201cWhat do we do now?\u201d asked Violeta. Her colleagues rolled their eyes. The medical staff was clearly uncomfortable, unsure of how to react to the situation. Shortly afterwards, the woman emerged from the room proudly carrying a large chocolate cake with a red rose on the top and entered the nurse assistants\u2019 office. I recognized the woman, Galina, as the wife of a man in his late fifties who had been hospitalized twice in the previous two months.\u00a0 He was a former alcoholic with a liver condition that further complicated his heart problems. After both of his previous discharges, Galina brought three cakes as a gesture of gratitude. After the first time, nurse Violeta thanked Galina and told her that it was \u201creally unnecessary.\u201d Later she explained to me that the patient\u2019s family was barely making ends meet: the warehouse where Galina worked was cutting hours, her husband\u2019s disability payment was very modest, and their heating bills were increasingly high.<\/p>\n

When Galina rolled out her husband in a wheelchair and the sound of her high heels faded away, a doctor named Regina commented, \u201cI don\u2019t know what to do with her; they will be back soon. I told her not to bring the cakes or anything else even though they are so tasty but you know their situation. I feel so sorry for the wife.\u201d<\/p>\n

Violeta nodded in affirmation. \u201cI told her:\u00a0 your life is hard, don\u2019t do that, but she just doesn\u2019t listen.\u201d<\/p>\n

\u201cShe is a good baker, I gave her extra diapers,\u201d the nursing assistant Irena added.<\/p>\n

\u201cI packed an extra supply of medications for the poor woman, she has to suffer because of that alcoholic,\u201d concluded Regina.<\/p>\n

In the cardiology unit, patients from across the economic spectrum waited for pacemakers, medications, and tests, or were recovering from heart surgeries. All day long, family members, friends, and acquaintances came and left. Many of these visitors brought their favorite foods \u2013 not only for the patients, but for the medical staff as well.\u00a0Boxes and bars of chocolate, coffee, cakes, home-made cottage cheese, jars of honey, apples, and smoked meats and fish were objects that patients and caregivers offered to the doctors and nurses. I saw bottles of wine and brandy visibly sticking out of paper and plastic bags. A few times I smelled smoked eel, ham, and sausages. Their smell sharply contrasted with the blandness of sterility and of hospital food.<\/p>\n

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\"\"<\/p>\n

I also saw quite a few boxes of chocolates that were gifted to the doctors and nurses. The less expensive chocolates were often shared immediately, while the ones from gourmet chocolate stores in Vilnius would be quietly taken home. Sometimes, these boxes were paired with envelopes that contained money destined for doctors\u2019 pockets. At the end of the week, when many patients were discharged, boxes would pile up on desks and shelves. Residents and interns, constantly on the run between the ER and the hospital\u2019s multiple units, consumed most of these chocolates. They saved leftovers for night shifts and gave chocolates to their fellow residents. At other times, boxes were left unopened: the medical staff had been saturated with too many, were too busy, or were (possibly, I thought) inhibited by my presence.<\/p>\n

Stories about giving, anxiety, humiliation and gratitude in medical encounters are a shared memory and a present practice in Lithuania.\u00a0 I am not innocent of these practices. My mother worked at a hospital during Soviet times in Lithuania and occasionally brought home sweets that she had received from discharged patients. When my father was sick, she took gift bags and envelopes with money to the medical staff. At the cardiology unit, giving and taking \u2013 however ambiguous \u2013 constitutes a form of life and caring of Lithuanian public health.[i]<\/a><\/p>\n

Things, money, and people are enmeshed within these circuits and constitute a specific form of\u00a0enveloped care<\/em>.[ii]<\/a>\u00a0\u201cLittle envelope\u201d \u2013\u00a0vokelis \u2013\u00a0<\/em>is the most common form of handing money to doctors in public health care. The envelope with money, along with boxes of chocolates, cakes, and other food items, carries more than just money or sweets. It encapsulates the linkages between notions of health, relation to medical power, belief, hope, vernacular history, and political economy.\u00a0 It is not only an economic transaction, but also an aesthetics of communications and a form of care embedded in social relations and driven by webs of obligation that both exceed and are included in notions of the gift, the commodity, or the bribe. We might understand Galina\u2019s cake to be a sign of gratitude, a gift given\u00a0after<\/em>\u00a0hospital care was received. Yet, chronic patients, like Galina\u2019s husband, will be returning to the hospital. The temporal markers \u00a0\u2013 before and after \u2013 that are often applied (by doctors, patients, and anthropologists) to distinguish gifts from bribes cannot be applied in illness encounters. \u201cAfter\u201d is also \u201cbefore\u201d for the sick and their caretakers.<\/p>\n

While observing the work of doctors and nurses and their interactions with patients and their social networks, I realized that accepting these \u201cthank yous\u201d was as complex as giving them. The cake case is an example of such tensions. Cakes or envelopes with money can be both signs of attention and expressions of sincere gratitude for the nurses and doctors. They might also be neither, but rather an expression or display of care towards the patient. Both and neither.<\/p>\n

The encounter I described might be read as an economic transaction where the cake is exchanged for a bag of diapers and compassion.\u00a0Indeed, medical practitioners\u2019 act of giving diapers and medications to Galina resembles a way \u201cto settle accounts,\u201d to acknowledge and make exchange and reciprocity visible, to prevent Galina from bringing another cake in the future, and thus continuing the pattern of her relationships with the doctor, nurse and the aid. However, Galina\u2019s encounters do not fit within these rational logics of exchange. Galina, like other caretakers, was concerned about being a caring wife, daughter, or friend. Giving the cake was a way of caring for her kin as well as for the doctors. Both and neither: breaking the logic of equivalence and staying within it could each, at once, be true.<\/p>\n

Galina\u2019s cake was indeed very tasty: not too sweet and not too rich. It was a special cake, different from other cakes shared by medical staff at the unit. The story of Galina and her husband was embedded in it. On that day, the cake was shared with other medical practitioners who came into the unit. At the end of the day the nurses and doctors took the leftovers of Galina\u2019s cake home to their own children, along with bits of an ongoing story.<\/p>\n

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\n

Rima Praspaliauskiene received her PhD in the UC Davis Anthropology Department. Her dissertation,\u00a0<\/em>Enveloped Lives: Caring, Giving, and Relating in Lithuanian Health Care, is an ethnography of health care practices in post-socialist Lithuania in the times of neoliberal reforms. Her research investigates relationship between health, care, and money. Currently she teaches anthropology at Mills College. She can be reached at rpraspal@gmail.com.<\/em><\/p>\n

\n

Notes<\/strong><\/p>\n

[i]<\/a> Things and money have been an important part of clinical relationships in other post-socialist contexts as well. See, for example, E. Andaya, 2009, \u201cThe Gift of Health. Socialist Medical Practice and Shifting Material and Moral Economies in Post-Soviet Cuba,\u201d\u00a0Medical Anthropology Quarterly,\u00a0<\/em>Vol. 23, Issue 4, pp.357-374; M. Bazylevych, 2010, \u201cPrestige<\/em>\u00a0Concept Reconsidered. Hybridity of Prestige in Post-Socialist Biomedical Profession,\u201d\u00a0International Journal of Social Inquiry<\/em>, Vol.3., Number 2, pp.75-99; J. Patico, 2002, \u201cChocolate and Cognac: Gifts and the Recognition of Social Worlds in Post-Soviet Russia,\u201d\u00a0Ethnos\u00a0<\/em>67 (3), 345-368; M. Rivkin-Fish, 2005,\u00a0Women\u2019s Health in Post-Soviet Russia. The Politics of Intervention<\/em>, Bloomington and Indianapolis: Indiana University Press; A.M. Salmi, 2003, \u201cHealth in Exchange. Teachers, Doctors, and the Strength of Informal Practices in Russia,\u201d\u00a0Culture, Medicine, and Psychiatry<\/em>, 27: 109-130; S. Sabina, 2012, \u201cNeither Commodities Nor Gifts: Post-Socialist Informal Exchanges in the Romanian Healthcare system,\u201d\u00a0Journal of the Royal Anthropological Institute (N.S.)<\/em>\u00a018, 65-82.<\/p>\n

[ii]<\/a> R.Praspaliauskiene, 2015,\u00a0Enveloped Lives: Giving, Caring and Relating in Lithuanian Health Care<\/em>, PhD Dissertation, UC Davis.<\/p>\n","protected":false},"excerpt":{"rendered":"

Welcome. Please read the\u00a0instructions\u00a0for reviewing before commenting.\u00a0We ask contributors to be generous when thinking along with our pieces and to keep in mind that the final chapters are intended to be short essays.\u00a0Visit matteringpress.org for more information on its other books. Readers might\u00a0also want to have a look at this resource created by one of […]<\/p>\n","protected":false},"author":2,"featured_media":4607,"parent":0,"menu_order":20,"comment_status":"open","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/processing.matteringpress.org\/ethnographiccase\/wp-json\/wp\/v2\/pages\/1182"}],"collection":[{"href":"https:\/\/processing.matteringpress.org\/ethnographiccase\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/processing.matteringpress.org\/ethnographiccase\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/processing.matteringpress.org\/ethnographiccase\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/processing.matteringpress.org\/ethnographiccase\/wp-json\/wp\/v2\/comments?post=1182"}],"version-history":[{"count":1,"href":"https:\/\/processing.matteringpress.org\/ethnographiccase\/wp-json\/wp\/v2\/pages\/1182\/revisions"}],"predecessor-version":[{"id":8628,"href":"https:\/\/processing.matteringpress.org\/ethnographiccase\/wp-json\/wp\/v2\/pages\/1182\/revisions\/8628"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/processing.matteringpress.org\/ethnographiccase\/wp-json\/wp\/v2\/media\/4607"}],"wp:attachment":[{"href":"https:\/\/processing.matteringpress.org\/ethnographiccase\/wp-json\/wp\/v2\/media?parent=1182"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}