How did we get here? ‘It does not require a big brain to understand.’

The ‘Greek Crisis’, care, and health care

Giorgos Kostakiotis, Deanna J. Trakas

01 Dec 2014
doi.org/10.17157/mat.1.1.208

Abstract

The economic crisis in Greece, which officially showed itself in 2008, is blamed for a wide variety of negative changes in the country’s social, political, and moral fabric. Health care – and the deficits of a medical system already under stress even before the crisis – are particularly central in public complaint and political debate. Issues of community and family care have emerged with a strength that challenges the conventions of earlier generations. This essay shifts the gaze away from the well-documented indictments of the deficiencies of the Greek health care system to look at the ways in which families and communities are working to provide care within the changing landscape.
'Midnight Bus' by Spyros Papaspyropoulos, Attribution-NonCommercial-NoDerivs 2.0. www.streetphotographer.gr'Midnight Bus' by Spyros Papaspyropoulos, Attribution-NonCommercial-NoDerivs 2.0. www.streetphotographer.gr

For both laypeople and health professionals in Greece, medical and health care are in a continual state of crisis, a situation that predates the current economic crisis and includes perceptions of disorganization, inequality, bureaucracy, mistrust, corruption, and the insensitivity of care providers. Intellectuals and observers of social phenomena in Greece present the situation as a manifestation of neoliberal tactics and rhetoric in action. This is consistent with wider social theory regarding the very notion of ‘crisis’ as a manipulation of historical moments, usually in relation to the mobilization of public opinion, action, and reaction as a part of the manoeuvres of governmentality. People in Greece have their own explanations, for example, ‘it does not take a big brain to understand’, indicating that intellectualizations and political rhetorical rationalizations obscure the ground-level realities of the situation. In this Think Piece, we organize our thoughts around the concepts of crisis, corruption, and equality … and, perhaps less apparent, considerations of moralities in health care and care.

Questions about the ‘effect’ of the present economic crisis on health care are usually focused on the formal medical and health system, and ‘answers’ are provided by statistics about the insured population, the management of hospital budgets, the control of prescriptions, the allocation of public or private funds for health care, and so on. In contrast, we ask questions about the crisis as it manifests itself in care at a more informal level, for example, the initiatives of friends and family members of persons requiring care, who allocate their time and resources in institutional or homecare settings. In this essay, we combine our fieldwork experiences and personal reflections about health care and care in Greece, beginning with ‘pre-crisis times’ as a comparative point of reference. Trakas draws upon her first impressions of health care in rural Greece in the mid-1970s, when she was searching for a dissertation research site (see Trakas 1980), and Kostakiotis offers insights from his 2006 experience as both ethnographic field researcher and the coordinator of an at-home care programme on a small Greek island (see also Kostakiotis 2010, 2014).[note 1]Kostakiotis’s research on the care of elders in Greece is co-financed by the European Union (European Social Fund–ESF) and Greek national funds through the Operational Program ‘Education and Lifelong Learning’ of the National Strategic Reference Framework (NSRF), Research Funding Program, Heracleitos II: Investing in Knowledge Society through the European Social Fund.

During her first months in Greece, Trakas observed that health care seemed to be in difficulty. In the two urban centres of Athens and Thessaloniki, the marathon to embrace modern medical technology was definitely on, with both health professionals and care consumers participating, but the rural areas remained in almost another time and place. The health needs of the countryside villages she observed were attended to by agrarian physicians, graduates fresh from medical school who were assigned to compulsory service in the form of weekly visits to a town, village, or region. Conflicts between physicians’ organizations and the government’s plan to implement a national health-care system resulted in strikes and stagnation in health care, until the 1980s when a national health system was created – at least on paper. Herculean attempts were made to decentralize care services with an emphasis on primary care; new hospitals and health stations were quickly erected in the periphery, without allocating the necessary medical personnel to staff them. Health care consumers preferred to receive care from the private sector, particularly for maternity care. 

Kostakiotis began fieldwork thirty years later, in the mid-2000s, and was caught in a time warp between visions for the humane organization of health-care services and the seemingly sudden drop in their funding, both from the Greek Ministry of Health and Social Welfare and the European Union. Programmes to decentralize medical services, de-institutionalize psychiatric care, and extend care to special groups such as the elderly were severely cut back. Elevated expectations suddenly dropped with the first indications of the economic crisis and hope turned to despair in the social fabric.

Some quick figures

In anthropological thought, ‘crisis’ (just as ‘epidemic’) is a conceptual or perceptual category and analytical tool; this contribution focuses more on the concept of crisis than on proving that one exists. We will not be venturing into a presentation of effects through the use of tables and charts; there are abundant quantitative articles of this type in scientific journals and the national and international press (see Siomou et al. 2014 for a critical review). However, to satisfy readers who want at least a few figures:

1) according to the president of the Greek national care system, more than three million people had no access to primary medical care or hospital care in 2013 (‘More than 3 Million’ 2013);

2) an estimated one in eleven residents of greater Athens uses a soup kitchen daily (Farr Louis 2012); and

3) according to Minister of Health Adonis Georgiadis, approximately 2,500,000 Greek citizens lack health insurance as of March 2014 (‘A. Georgiadis’ 2014).

A quick qualitative view

In any small Greek village today one could find nearly the same scene as Trakas did in 1976: a small, one-room doctor’s office, with the street outside serving as the ‘waiting room’. The physician might be a recent medical school graduate, or, in rare cases, a local person who has made a medical career in the village, thus providing greater continuity in care. Today, a few aspects are slightly changed, for example, care seekers do not need to wait in the rain. Outpatient clinics in public hospitals have introduced the concept of ‘making an appointment’, but people can also just show up and negotiate to be seen using various tactics. Both require a ‘ticket’ that costs five euro, even for people officially covered by the national health service through compulsory payments from salaries and wages.

The concept of crisis

Textbooks and dictionaries often overlook how the concept of crisis is a social and historical phenomenon. One of its symptoms is the collapse of social ideals or the rise of deviations in morality; this is accompanied by a general unwillingness or inability of the populace or policy makers to review events within a framework other than a politically expedient one. Thus, a crisis is subject to political goals and the exploitation of public anomie, loss of the sense of civil society, and individual debilitation.

This is part of the conflicted story of the effect of the economic crisis on health and health care in Greece. There has been a slow realization that the modern populace, for many decades, really had no expectations of the health-care system, though it did have expectations of physicians – as both therapists and caregivers. A short walk through the public hospital outpatient clinics of Greece shows people passively (with occasional shouting confrontations) being given their therapy and providing their ‘health booklet’ (certainly a misnomer) for signatures, stamps, and verifications. Prior to the crisis, the health booklet served as a history of prescriptions, medical treatments, and therapeutic recommendations. Its use rarely entailed the exchange of money between patients and physicians; instead, physicians were reimbursed for services and consultations with the submission of health booklet receipts to the insurance accounting office(s). Slowly, beginning around 2010, the services of physicians acquired possibilities for a fee: five to twenty euro for written prescriptions, and twenty and upwards for various in-office treatments and clinical tests. In addition, some physicians began to avoid issuing a receipt by offering a discount price on in-office treatments – clearly a trade-off in their favour when reporting taxable income. Even though patients feel they are given a ‘better price’, they are also left without medical care receipts for their own tax declaration. Trakas, who has been following the negotiation of patient payments to their doctors in Greece for three decades, finds that even physicians trusted by their patients of many years are not exempt from offering the no-receipt ‘choice’. Even though it is illegal, there seems to be no hesitation or shame to openly quote the cost of a treatment at twenty euro without a receipt, or thirty with a receipt. To make this transaction legal with a receipt, the patient will need to pay at least ten additional euro. 

Western physicians take an oath, following the philosophy of Hippocrates, which frowns upon the exploitation of patients for physicians’ economic gain. Greece is certainly in a state of amnesia about that value – even if it remains quick to showcase the cultural value of its antiquities. Indeed, the pedestrians of the country (it is questionable if the concept of citizen exists anymore) appear to completely, silently, accept their medical and health care; they are grateful for anything they can get. It is as if we are walking through the jungle of an incredibly complicated and continually altered health care system – where the concept of health is totally lacking, and the concept of care assumes that all the pedestrians are dead.

Corruption

Public discourse focuses on corruption as the cause of the Greek crisis. Either the nation has allowed some thieving citizens and politicians to prosper, or it has permitted foreign interests to place the country in debt. There seems to be no faith in government mandates or legislation to circumscribe the corruption, even though there is continual media discussion about petty income tax evasion and the avoidance of issuing receipts for all monetary exchanges for goods and services. The newly created computerized bureaucracy has resulted in a blueprint for heavy surveillance on the circulation and payments for pharmaceuticals and the tracking of laboratory and clinical tests (MRIs, blood work, etc.). In fact, on national tax forms, citizens must declare annual general expenses, listing medical ones separately, and keep receipts for all purchases in case of an audit (even though receipts usually fade, becoming blank slips of paper within a year, an observation which quelled the initial zeal, circa 2010, of everyday wage earners to accumulate shoe boxes full of receipts). 

Growing distrust and the expectation of corruption compound the experience of illness and the need for care. The loss of a sense of humanity and morality are often overpowering, independent of whether the present crisis represents a ‘critical event’ (Das 1995) that is created by a historical moment when both individual existence and the social order are severely challenged. A critique of neoliberalism implicates the concept of the critical event in the political construction of both the crisis and corruption, and the way that their interaction is argued by politicians and discussed in the media. But for many people, not declaring full taxes for small fix-it jobs (plumbing, electricity, etc.) is a way to send three children to university. And these pedestrians will never get proper health care. If they are hit by a serious and costly health problem, they will call in ‘loans’ (social and symbolic capital) from their family.

When crisis brings us close to one another: Solidarity and supermarket baskets

The crisis is most noticeable in the health sector of the public: in homelessness, the inability to meet dietary needs, and the difficulty in purchasing essential pharmaceuticals. Critical events generate new social categories and forms of action (Lock and Nguyen 2010), and some see in them an opportunity for creating or strengthening social solidarity (see, for example, Pantatzidou 2012).

Grassroots efforts have mushroomed, through organizing soup kitchens and protective lodging; establishing socially managed nonprofit stores that provide free or low-priced food, clothing, and household items that have been donated; and providing pro bono counselling services to facilitate access to health care. In spite of a general feeling of demoralization among doctors and health caregivers in hospitals and homecare, there are points of inspiration and resistance among them (Alderman 2012). While most of the attention about these efforts comes from the media, sometimes even from the foreign press, qualitative research about the social impact of health – for example, the public health dangers of the situation – is developing a stronger voice, perhaps to due to small increases in funding. At the same time, some established social solidarity organizations are facing increased financial difficulties (Zaracostas 2011). 

Homelessness and the new homeless: When crisis knocks on ‘our’ door

One could argue that among the positive outcomes of the Greek crisis is the new visibility of those groups who had been surviving on the margins of the pre-crisis Greek success story, such as the homeless and low, fixed-budget pensioners. The streets and squares of the major Greek cities were home to a numerically significant population long before the crisis ‘broke out’. Homeless people were an invisible group, mostly because Greek society turned away from them and looked instead at the pharaonic public construction works, new-fangled private houses, luxury cars, and glamorous lifestyles. Homeless people became visible only after a new subgroup appeared among them: the ‘new homeless’ (neo-astegoi) who come from the middle (or upper) class and are often people with university degrees.[note 2]For more information about the new homeless in Greece, see ‘The Neo-astegoi Middle Class’, Enet.gr, 18 December 2011, http://www.enet.gr/?i=news.el.article&id=332751.
 

In spite of the still relatively small numbers of this new group of street people, compared to the more long-term homeless, they are particularly vivid reminders for people in the middle class that any one of them could also end up in the same situation. There is a long tradition of creating a household among Greek people, and the desire to not only own a place of their own but also provide homes for their children. This practice has been a cornerstone of the unofficial familial safety net, which has been essential in caring for vulnerable people who, unfortunately, are not visible or provided for by the state or welfare system. In this sense, the crisis has really not deprived many citizens of what they never had in the first place.

Coveting Grandma’s pension: The iron-hearted mesh of the Greek safety net

The public image of the Greek family as an institution that honours its elders has always veiled a darker picture, where the needs of frail elders comprised a problematic influence on the success narratives of families. Ethnographies about Greek life (usually rural) show that living with or caring for dependent elders has been typically characterized as ‘a problem’ (Hionidou 2004; van der Geest et al. 2004). Even before the crisis, elders were devalued as a source of income because their pensions were so small that they could not offer even a ‘little extra pocket money’ or hartziliki for the family. Stories about people putting their hands on an elder’s pension had been limited to local gossip and tabloid news reporting – hot topics for the yellow press to deflect attention from more important political matters. With the crisis these stories moved from the informal (local gossip) and the sensational (tabloids) to mainstream and conventional media. 

‘Good families’ were expected to care for their elders as an act of love, even though love was often constructed through major cross-generational economic transactions, with a privately owned house as the most valued asset. Now, as the crisis sweeps away the ‘certainties’ of the past, financial aspects of eldercare within the Greek family are becoming ridden with a sense of guilt and impotency that is being discussed in the conventional press. For example, a recent study by the Consumer Quality of Life organization[note 3]The association is referred to as ΕΚΠΟΙΖO.
 found that one in three adults who are indebted to banks resort to asking for help from their very minimally pensioned parents. One article describes a seventy-two-year-old man who cut his own basic expenses in order to help pay back the loans incurred by his son, a low-income freelance professional with two children (‘Cracks in the Safety Net’ 2013). 

Privately funded residential care centres for elders, which mushroomed in the 1990s and were then unable to meet the demand, now face a 30 percent vacancy rate. This is not due to a decline in the aging population, but rather to the return to home care, as neither elders nor their children can afford to pay for private care. Before the crisis, placing an elder family member in residential care was a difficult decision, calling up feelings of guilt and lack of family honour. Even so, elders were turned over to the care of nonfamily – for a price. Now, the preference is for families to save the expense as well as to keep eye on, and use, the elder’s pension for collective household expenses. In one article documenting this phenomenon, a member of the younger generation states that they feel ashamed of ‘coveting Grandma’s pension’ (Fotiadi 2011).

Under these circumstances, the family rises to new prominence as a redistribution network for government resources meant to cover the needs of elderly citizens (through disability, welfare, pensions). At the same time, the new power system of the family does not receive financial assistance or practical aid in order to provide extra care for its aging members. Simply identifying the self-regulating functions of the Greek family’s safety net to meet the needs of their elders fails to consider the power dynamics and the intensity of positive and negative sentiments that emerge during the process. In the midst of the crisis-shaped situation, the needs and desires of the elders are lost.

Philotimo

Observers and ethnographers of Greece have invoked the concept of philotimo (love of honour), early on discussed by John Campbell (1964) as a positive cultural trait. Recently some observers have reintroduced the concept as an element in the Greek character and society that could assist the country to bail itself out of the economic crisis. This can be seen, for example, in a newly circulated Internet video made by a group that promotes Greece’s role in ending World War II through of its love of honour.[note 4]http://www.oxidayfoundation.org/video-the-greek-secret/
 The authors find this argument completely culturalistic and even distasteful. In contrast, we observe quite impressive grassroots ‘solutions’ serving people in need – and we wonder about the Ministry of Health’s invisible policy. And we seriously look to the power of the people to creatively fill the spaces that the government has politicized.

About the authors

Giorgos Kostakiotis received his master’s degree from the Department of Social Anthropology and History, University of the Aegean (2008), for the thesis: ‘Thank God We Still Stand on Our Feet’: Bodily Capital, Property Transactions and Obligation about Elder Care on an Aegean Island’. Currently he is finishing his PhD dissertation entitled ‘Body and Politics of Care: Bodily, Symbolic and Emotional Capital in the Greek Family and Society’, based on research he conducted on the island of Vouni where he worked as the coordinator of the ‘Help at Home’ programme. He presently is employed as a caseworker for the Greek asylum service.

Deanna J. Trakas is a professor of medical anthropology, now retired from the Department of Social Anthropology and History, University of the Aegean. She continues to work with the undergraduate internship programme and MA and PhD candidates, and teach a graduate course in gender, body, and health.

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