The Principal gestures: the student nurses lift the rice bag. It takes four of them. Sweat runs past their grimacing smiles but they stand ready in front of the health centre for a photo. The building’s white walls and red roof match the houses in the background; their uniformity strikes me as unusual for rural Laos. A plaque reads that Korean aid financed this centre after a dam collapse in 2018 swept away the old village. On the way here we passed its ruins, and just before it—where there once was forest—saw workers from Chinese-owned banana plantations bathe in chemical-polluted streams.
The Principal thanks the NGO for the rice, nutrition for her students during their six-week internship. She calls out: “Help each other!” “Show solidarity with the villagers!” Students shall develop the village and people’s health, educate, collect data, and gain experience.
“What do you think about this place?”, I ask nursing student Lom (pseudonym). “It’s ok. The way here is very far, I think it’s hard to find food”, she mumbles. She looks back to the dirt road where villagers on small motorcycles circumvent massive holes.
The teachers wish the nurses “good health” and “good luck”, then board the NGO-sponsored vans and drive off. They will return every week to hear a report. The students stay, with their mission to develop.
• • • • • • • •
Development aid to Laos has high visibility, even in the most remote places: buildings, plaques, vehicles, or photoshoots with rice bags. Public health care in the Southeast Asian nation of 7.7 million people is considered aid-dependent. My intention in the reflections I offer here is not to de-value aid to Laos—of which the Lao government is a proud recipient—but to ask: what is happening to develop the nation’s public health from within?
It’s a timely question since aid to Laos, historically volatile and often uncoordinated, is clearly decreasing post-COVID (from US$2.5 billion in 2018 to a US$1.2 billion yearly average in 2021–2023). Laos’ one-party government aligns its development plans with global health goals (not least in order to receive aid) and aims to soon leave the UN’s “Least Developed Country” list. But rather than simply adopting the Sustainable Development Goals’ neoliberal ideology, the Lao government pursues a vision of socialist health care that emerged during the Lao revolution. Health care forms part of mass mobilisation for societal development that approaches public health as common responsibility rather than state welfare or consumer choice—put simply by the current public health strategy’s vision of “Health for all, by all”.
Here I trace how this vision is embodied and enacted by those who train to be vanguards of this movement, work at health centres, eat the rice, and bear the weight: Lao nursing students. What follows are insights generated over eleven months of ethnographic fieldwork at a nursing school in Southern Laos as part of my doctoral research. Coming from political and medical anthropology, I want to understand how public health and development are entangled with a political culture of Lao socialism, what this means for training nurses, and for care.
Background
The Lao government is not the first to politicise health care in the region. French colonialists, historian Kathryn Sweet writes, used medicine as “tool of empire” to gain trust, demonstrate power and technological superiority (Laos was a French protectorate between 1893–1953, with a short period of Japanese occupation in 1945). During the Lao Civil War (1953–1975) and Second Indochina War (1964–1973), the health sector was divided along military lines: on one side, a royal government received aid from France, the WHO, and the US-funded “Operation Brotherhood”. On the other side, socialist revolutionaries established a health committee with North Vietnamese support. Ground fighting, and over two million tons of US ordnance dumped from the sky, disrupted health services. Revolutionaries shouldered medical care in midst the bombing and ran whole hospitals within caves. Young recruits trained as medics and journeyed on foot between villages to administer free vaccinations and medication. US medical aid was outweighed by military assistance against communist movements in the region. Even over fifty years later, unexploded ordnance kills and maims Lao people. This year’s cuts to USAID means less of US military “aid” is picked up.
From 1975, socialist approaches to health care continued and expanded: a free, single, government-managed service, and workers with both medical and political training. But when support from socialist allies dwindled in the late 1980s, Laos transitioned from a centralised to a market-oriented economy. The IMF’s Structural Adjustment Programs brought a package of user fees, private clinics, and increasing social inequality. Laos’ medical sector today not only counts on aid but on investment deals with corporations: you build us a new hospital, and we allow you to cut the forest for your rubber plantation. This was the case in Attapeu province, where my fieldwork was based.
Entering a Lao hospital today, a visitor may get the impression that this health care system is un-socialist. In Attapeu, patients and their relatives provide basics such as food, bedlinen and mosquito nets. Unless patients pay for a VIP room, the donors’ aircons stay switched off—no funds to cover the power bills. Like crumbling hospital walls, is the project of socialist health care in Laos withering away? My observations at a Lao nursing school suggest that the pairing of medical and political revolution that began in caves and on village runs lives on.
Public health vanguards in action
Lao nursing students train to be vanguards of health development—experts, forerunners and role models for society. I do not intend to caricature nurses in this piece, but wish to use the concept of the vanguard as a heuristic tool by which an elite of model citizens lead society on the path of socialist transformation. Following a Marxist perspective, education and development are not individual pursuits but depend on a society-wide movement. Nurses study Marx and learn what Laos’ own approach to “building and reforming society” via a “socialist path” means in theory and practice.
Nursing schools train more than nursing skills. At my school, students organised to create paths, garden beds and cleaned daily. They fought back grasses where venomous snakes hunt and mosquitoes breed—truly relevant skills for public health. They participated in extracurricular activities such as policy discussion meetings or ceremonies for national holidays. More than a mix of toil and partying, teachers said these activities are part of nurses’ education under a philosophy of “building good citizens”; they aim to instil key values of Lao socialism.
When students ventured out on internships, they role-modelled these values. Respect: seek permission from village authorities; democracy: consult villagers to see what health problems could be addressed how; cooperation: facilitate collective clean-ups; and unity and solidarity: attend local ceremonies and share meals. “We will love each other if we eat together”, one student told me. Nurses, she said, ”lead” communities to develop. To mentor and educate one’s disciples is key.
Nurses train to deliver public health education on vaccinations, nutrition, or contraception. Care includes to educate people in how to ”live clean, eat clean, sleep clean”, as a Lao saying goes. Public health messaging exists also in liberal democracies, but in Laos, nurses have an explicit mission to educate. Imagine a couple of nurses arrive at your house to check your daily hygiene practices, vaccination status, or if you’ve attended a pregnancy check. If you haven’t, they may administer this care there and then. Further, one of your neighbours would be assigned as ”village health volunteer” to make regular rounds, give advice and collect your data to pre-inform the health service. Loudspeaker announcements remind you to get vaccinated and throw out your rubbish properly.
All this might fit clichés of socialist state surveillance, but health education and home visits intend to teach people to “be one’s own master”. This political message means to take responsibility for one’s own life which usually relies on the life of one’s social group (e.g. family, village). Once the population is educated in health knowledge and manners of good citizenship, so the vision, everyone will unite and develop under the banner of “health for all, by all”.
A one-path development model
Students I interviewed know it isn’t so. They expressed frustration with the lack of medical equipment (especially in rural health centres), which meant that patients did not turn up and made nurses feel helpless. They acknowledged that people had no transport and money, and that rural roads were bad. And they knew that some agricultural developments like banana plantations caused pollution and reduced villagers’ access to nutrition. But the barrier to better health they emphasised most was that people did not develop because they “don’t know” or have “wrong beliefs”—referring to a particular category of citizen.
The Lao government seeks to reform people’s “superstitious” and “backward” ways, usually imagined in rural and remote Laos and amongst ethnic minority groups. In its current Public Health Reform Strategy, the government identifies as one reason for why targets are not achieved as planned, people’s “lifestyle patterns and reluctance to change”. Since the Civil War, Lao socialists sought to reform people’s so-called “backward” ways, usually imagined in rural and remote areas, and amongst ethnic minority groups who make up almost half of the nation. National integration and cultural homogenisation have shaped Laos’ public education and health care, as several scholars of Laos have pointed out.
Lao nurses, then, train in a one-path model to societal development: there is one correct knowledge and belief system that will help society progress. As Michael Walzer writes, vanguards are “at war with ‘backwardness’” and they can become “modernizing elites”. Some anthropologists criticise this attitude. For instance, Holly High writes about the Lao state’s promotion of technocratic birth in a drive to reduce maternal and infant mortality, and a symbol of progress. Her research participants from remote, ethnic minority groups feel judged by nurses, as if they had failed at being “civilised” when they homebirth.
To the nurses I met, educating society is an act of love. But sometimes tough love—where a patient’s immediate embarrassment or discomfort is taken to bring future benefits—can lead to avoidance of biomedical care and increases risk. Nurses’ training instils the belief that for self-development one must follow advice or orders from the more educated (“Students, pick up the rice bag”). They told me that “the teachers develop us, and we develop communities”. Students saw the hierarchical relationship to their teachers as natural as between “parents and children”—a notion that might linger in the nurse–patient encounter.
Yet, there is some positive recognition of Laos’ socialist development. During the COVID-19 pandemic, the population’s readiness to accept state orders, and to unify with one’s fellow citizens in a common struggle, perhaps helped to maintain comparably low levels of severe infections and deaths.
An ethnography of rural electrification in Laos
From flickers to full power: when reliable electricity arrived in Banmai
International aid is certainly welcome, such as rice bags to feed nurses on internships and petrol to get them there. But to the sector itself, material donations are less desirable: driven by the sustainability paradigm, aid workers I spoke to want to give more than materials, but impact people’s training for long-term effects. While international organisations help the government to develop curricula and offer workshops, foreigners cannot run medical schools in Laos. It appears that the state persists in its approach to combine medical and nursing training, and trainees’ “vanguardist” efforts become wrapped up in a broader socialist political mission.
Despite the challenges, nursing students I met were proud of their role as developing citizens and citizen-developers. Since the Lao government’s power has been stable for fifty years, it seems best to take its endeavour of socialist health care seriously: a path that keeps forming, with and despite the comings and goings of aid.
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