Stress and social change in Poland

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Health & Place 12 (2006) 372–382 www.elsevier.com/locate/healthplace

Stress and social change in Poland Peggy Watson Faculty of Social and Political Sciences, University of Cambridge, Cambridge CB2 3RQ, UK Accepted 22 February 2005

Abstract The paper reports the findings of qualitative research carried out in Nowa Huta-Krako´w, which sought to explore the influences perceived to contribute to the experience of stress. Stress was seen as the main danger to health in transition, and as such a socially produced phenomenon linked to the lack of security of employment and low income, as well as to changing social relations, where social inequalities were increasing, and the enrichment of some was seen to be occurring at society’s expense. The paper outlines a framework for conceptualising psychosocial health influences, where these are represented in terms specific to social space/time, indicating the implications of the findings for public health discourse. r 2005 Elsevier Ltd. All rights reserved. Keywords: European enlargement; Health inequalities; Mental health; Health care reform; Nowa Huta; Democratisation

Introduction This paper reports the findings of qualitative research carried out in Nowa Huta-Krako´w, which sought to explore the perceived importance of stress as a health risk in transition, and the psychosocial influences that contribute to it. Until the end of communism Poland, in common with all Soviet Bloc countries, had rising adult mortality trends and higher adult male mortality than any country in Western Europe (Watson, 1995; Bobak and Marmot, 1996). Although overall adult mortality rates in Poland fell during the 1990s, the relative gap between Polish rates, and those in the EU changed relatively little. While all-cause mortality among Polish men aged between 25 and 64 years was 49.4% higher than in the EU in 1980, it was 99.5% higher in 1990, and remained 91.5% higher in 2000 (calculated on the basis of HFA-MDB data). For Polish women of working age, mortality exceeded that in the EU by 27%, 50.5% and Tel.: +44 1223 334888; fax: +44 1223 334550.

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46.8%, respectively, in these years. Deaths due to cerebrovascular disease remain high for both sexes and all ages, while the rate of improvement in cardiovascular mortality has been much modest in lower than in higher educational groups (cf. Zaton´ski, 2005). There is also evidence that democratisation has been accompanied by increasing levels of mental distress. Suicides have increased among middle-aged men since 1990, in contrast to EU trends, where deaths from this cause are on the decline. Moreover, the number of people receiving outpatient treatment for psychotic disorders in Poland rose disproportionately in the 1990s, with the number of outpatients per 100,000 inhabitants rising from 434 to 466 between 1980 and 1990, and to 566 by 1995 (Instytut Psychiatrii i Neurologii, 1980–1998). The health divide between Poland and the older EU member countries now poses a challenge for European public health (Merkel and Karkkainen, 2002). The reconfiguration of adult health during the 1990s in Poland cannot be readily explained in terms of relationships found to adhere in the West. They are not, for example, explicable in terms of overall changes in

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material welfare per se. Average real wages were only 70–75% of their 1989 level for most of the 1990s (Unicef, 2003), while significant social provisions were cut, but during this time mortality fell. Similarly, the relationship between social inequality and health found in Western countries (Wilkinson, 1996), has been confounded in Poland, where all-cause mortality has declined as social inequalities have increased. The relationship between psychosocial influences and health has been the subject of growing interest in recent years (Wilkinson, 1996; Baum et al., 1999), and an increasing body of evidence now links stress to health (McEwen, 1998; Brunner and Marmot, 1999; Tennant, 2000). The complex patterns of health transformation in Poland, coupled with the indications of rising levels of mental distress, suggest the need for a better knowledge of the psychosocial influences shaping experiences of change. Although stress has been specifically implicated in patterns of health during and after communism (Shapiro, 1995; Leon and Shkolnikov, 1998; Cockerham, 1999; Kopp et al., 2000; Watson, 1995), how such stress might be constituted in practice has been subject to little research. The present paper seeks, through an analysis of focus group interviews and archival research, to consider the ways the transition to democracy after communism may be implicated in stressful experience.

Defining psychosocial influences on health in transition The study of stress brings to the fore psychosocial influences in the understanding of health, and calls for a framework that can treat the social, psychological and physiological as integrated aspects of experience (Frankenhauser, 1989; Bartlett, 1998). Stress has been defined as deriving from distressing encounters between person and environment (Lazarus, 1984). However, conceptual approaches to the study of stress have been diverse, including models where stress is seen to result objectively from life events (Dohrenwend and Dohrenwend, 1974), as well as models based on cognitive theory, where stress is seen primarily in terms of individual interpretive frameworks and strategies of coping (Lazarus, 1966). They also include models that focus on work stress, and are oriented towards the impact adverse psychosocial characteristics of working environments can have on health, for example Karasek’s (1979) demand–control model, and Seigrist’s (1996) effort–reward model of stress. The latter is tied to a notion of redistributive justice and assumes that the sense of self is key to the experience of stress, which occurs where the self is compromised as a result of a perceived imbalance between work effort and reward. It is said to be equally applicable to Western and Eastern Europe (Siegrist, 2002), and both Karasek’s and Siegrist’s models have formed the basis of research which has sought to

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establish the relation between stress and mental and physical health in a postcommunist context (Pikhart et al., 2004; Bobak et al., 1998). This paper is based on the view that the transition to democracy after communism represents a specific social context, and that the study of stress in this context brings to the fore questions regarding assumptions informing existing stress research. In postcommunism, the transformation of ideology, subjectivities, indeed the social order as a whole, is rapid and overt. Such farreaching transformations cannot be excluded from the study of stress. This contrasts with the situation in the West where considerations of the overarching social order, with notable exceptions (e.g. Wilkinson, 1996; Coburn, 2000), are mostly absent from research. In their critique of the role of psychosocial influences on health, for example, Macleod and Davey Smith (2003, p. 569) claim that pragmatic public health interventions mean turning away from consideration of the social order, suggesting that the latter is for all intents and purposes beyond change. After communism, however, public health policy cannot be separated from the issue of broader social relations, if only because public policy is one means of putting the new order in place. A related point concerns the individualism that informs stress research. Existing models of stress implicitly invoke the notion of an individual who, on entering into interaction with others, or in encountering the environment, is not already socially produced. This invocation of the pre-social individual is made explicit by Siegrist (2000, p. 1285), who concludes that methodological individualism must underpin the study of socio-environmental effects on health. During the Cold War, health scholarship was pushed in the direction of individually oriented explanation, and away from the social production of health (Krieger, 1994; Susser, 1985). After communism, however, such individualism cannot be so easily sustained. One paradox of the transition to democracy after communism is that it depends on the notion of the autonomous individual becoming hegemonic at a time when subjectivities are visibly changing as the social context, of which they form part, is being transformed. This being so, the study of stress in transition urgently presses for an approach which can transcend individualism and overcome the person/society divide. In practice, all experience is psychosocial, since material phenomena cannot be known except through the structures of socially produced meaning through which people interpret and assess their world (Berger and Luckmann, 1984 (1967); Wittgenstein, 1953; cf. also Kawachi et al., 2002; Lupton, 2000). This suggests that stress is not exclusively a matter of inadequacy of external social environment vis a` vis transhistorical human psychological need. Rather, it suggests that psychosocial experience depends on evaluations by

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persons of phenomena in terms of categories, values, and social relations which are specific in place and time. To this extent, the subjectivity of an individual person can be seen, in non-linear fashion, as constituted by the social environment, a social environment of which that person represents a constitutive element at the same time. A non-linear conceptualisation of context/person is sustained by a metaphor of Einsteinian instead of Newtonian social space (Watson, 2004). This way of thinking offers a non-ethnocentric approach to the study of psychosocial influences on health in postcommunism which can, to paraphrase Scott (1991), take account of the way history is re-defining social space, relocating subjects, and producing their experiences.

Organisation of the research The study was carried out in Nowa Huta, a steelproducing area in the city of Krako´w in the South West of Poland, as part of a continuing programme of sociological research in this locale. The empirical study involved focus group interviews and archival research. It also drew indirectly on individual interviews. In all, 92 persons were interviewed between 1998 and 2000, in fifteen focus groups varying in size from two to ten persons. Interviewees were recruited to the research with the help of the personnel section of the steel plant, the steel plant branch of the Polish Red Cross, and the steel plant Centre for Pensioner Care, and the interviews took place on these premises, as well as in two core production departments within the steel plant. The interviews were organised so that manual and nonmanual workers of both sexes would be represented, and had as a criterion for participation employment at the steel plant in 1973. The latter condition was intended to provide a link between the present study and the followup of vital status in a historical cohort comprising the steel plant workforce in that year (Watson, 1998). The final composition and patterning of the focus groups was the outcome of these initial criteria, and the relative accessibility at each recruiting point of people belonging to these social categories and willing to take part in the research. Given the wide scope of the steel plant’s activities, people from a broad range of occupations took part in the interviews. The 1973 employment criterion was met in all but four cases; the youngest participants were in their late 40s, the oldest was a former manual worker aged 80 years. Women represented about half of those taking part. Nine of the focus groups involved a mix of manual and non-manual employees who had retired; two of these comprised only women, two only men, and the others both women and men. Six of the focus groups comprised people who were still currently employed; of these four were made up of

non-manual workers of both sexes, and two of male manual workers in the steel plant. The purpose of the research was to provide an indication of the relative importance ascribed to stress as a health risk in transition, and to contribute to an understanding of experiences of stress in this context. On the basis of previous research, the study started from the hypothesis that stress would figure strongly as a perceived threat to health, and in order to provide a verification of this, the focus group interviews were framed in terms of a general discussion of health risk. The interviews began by asking the groups what the implications for health risk of the previous decade had been. Respondents were free to approach the discussion as they chose. As the issue of stress was introduced by the participants they were invited, if necessary, to elaborate. These elaborations would generally include reference to stress’s health effects. The focus group interviews were tape-recorded, with respondents’ consent, and transcribed. The analysis identified the main themes emerging from the interviews, and was concerned to ascertain the aspects of transition that were seen as stress-inducing, and to explore how respondents’ interpretations were implicated in their perceptions and experiences. In presenting the data, some identifying details have been omitted to ensure confidentiality.

Nowa Huta: Exemplifying state socialism With a population of 210,000 as of 2002, Nowa Huta accounts for 28% of the population of the city of Krako´w (census data), but when it was built just after the second world war, it was designed as a self-contained entity—as Poland’s first socialist town. The city was seen as one way of realising socialism’s social project: an equal society, where through concrete and overt political action, class differences, as well as the differences between urban and rural areas would be erased (Nieroda, 1952). Nowa Huta was intended to demonstrate the way state socialist society would work. Many of the young people who came from all over Poland to build Nowa Huta, stayed on to work at its steel plant. As with other industrial enterprises in Poland, the steel plant’s activities extended to providing a wide range of goods and services, including sport and leisure facilities and activities, health care, education, cultural activities, shops and catering, housing and holidays for the benefit of the community of current and former employees and their families. Collective catering services organised through the workplace were originally seen as a means of influencing consumption and the general living conditions of the population as a whole. The structure of food consumption, it was thought, could be influenced by both pricing policy and propaganda (cf. Bitter, 1967, p. 28). Pay levels, which were relatively

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low in Poland, presupposed the provision of such services (Hrynkiewicz, 2003), as well as fixed prices in shops. Important among the social facilities underwritten by the steel plant was its health service, which became a formal entity in 1953. By 1988, the health service employed 821 people, including 154 qualified physicians, 40 dentists and 181 nurses and midwives working on site (Z˙ abicki, 1988). Although in the socialist project health and social welfare were seen as integral, rather than opposed, to work, steel production itself brought recognised health hazards, which evolved over time. These included high temperatures near the furnaces, exposure to cold and draughts from the use of fresh air to cool the atmosphere, the effects of dust and noxious fumes, damage to vision and to hearing (high levels of noise prevailed in most departments of production), as well as the danger of accidents (Mazanek, 1956). Between 1952 and 2002, a total of 202 fatal accidents occurred at the steel plant (calculated on the basis of steel plant figures). Output, originally planned at 1.5 million tons of steel per year, increased to almost 7 million tons in 1979. The pressure to increase productivity coupled with limited funds for investment in new technology, existed in tension with the maintenance of safe and healthy conditions of work. By the late 1970s levels of air pollution had greatly increased. In 1979, the enterprise produced 60 tons of sulphur dioxide and 625 tons of carbon dioxide within a span of a year (Praca Zbiorowa, op.cit.). The political landscape changed in 1980/1981 with the rise of Solidarity. Strikes at the steel plant in 1988 contributed to bringing communism down (Smolen´ski, 1989). During the 1980s, the health risks associated with industrial pollution were used as an argument by Krako´w environmentalists to have the enterprise closed (e.g. Gumin´ska and Delorme, 1990). Nevertheless, comparative mortality data since published for the years 1987–1995 showed that although Nowa Huta was an industrial place, mortality rates were systematically lower there than in any of the other districts of Krako´w, a city with relatively low mortality in Poland, including those parts of the city that were home to its academic and theological elite. This suggests that the rhetorical and material advantages accruing to the industrial workers, had tangible health effects (cf. Watson, 1998). In 1995, the last date for which such data are available, the age standardised mortality rate for Nowa Huta men was 111.84 per 10,000 as compared with a rate of 120.69 for the whole of Krako´w; the figures for women were 68.13 and 81.23, respectively (Urza˛ d Miasta Krakowa, 1998). From the mid-1990s onwards, the welfare functions of the enterprise were shed, leaving pay and pensions—as elsewhere in Poland—at state socialist levels that presupposed that those services were still in place (Hrynkiewicz, 2003). Although most prices are now at

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Western levels in Poland, average monthly income is only 500 Euros (Hrynkiewicz, 2003). The steel plant’s health service was closed down at the end of 1995, and reopened as a private service in January 1996. From 1997 onwards, a rapid reduction of the workforce took place, in line with pre-accession conditions laid down by the EU designed to protect Western European producers from competition from Polish steel (Keat, 2000). The unemployment rate in Nowa Huta in 2002 stood at 18.1%, slightly lower than the national rate of 20% (census data). Only 10% of the registered unemployed in Krako´w in 2002 were in receipt of income support (calculated on the basis of census data). Among those attending the Krako´w Izba Wytrzez´wien´ (Drying-Out Centre) in 2003, only 10.5% were gainfully employed (calculated on the basis of Izba Wytrzez´wien´ figures). At a national level, the Centrum Badan´ Opinii Spo!ecznej (CBOS) public opinion polls that are regularly conducted in Poland consistently show negative evaluations of change. Recent surveys have shown, for example, 68% of respondents to be dissatisfied with democratisation in Poland,1 67% to consider that the health care system functions badly,2 and 90% to consider the labour market situation bad.3 In the light of such opinion, and given the pattern of local change outlined above, how important was stress as a health risk in transition, and how was change implicated in stressful experience?

Perceiving health risk in transition Commonality and diversity in the focus groups: The focus groups were asked to consider the implications of the previous 10 years for health risk. While their accounts reflected some of the diversity among them, for example, personal experience of post-war reconstruction, or the type of work that they did, the commonality of the interviews lay in the emphasis placed on stress. Many participants offered accounts of their personal situation; inevitably these were also accounts of institutional and social change. One commonly perceived cause of stress was the threat of unemployment—the focus group discussions coincided with a programme to reduce steel plant employment by about half. Across the focus groups three other interrelated causal themes—financial strain, health care reform, and social unequalisation gained prominence in the stress narratives. These are discussed in more detail in the sections below. Certain 1 CBOS poll carried out during 7–10 May 2004; representative sample of 1006 adult Poles. 2 CBOS poll carried out during 3–6 September 2004; representative sample of 969 adult Poles. 3 CBOS poll carried out during 1–4 October 2004; representative sample of 988 adult Poles.

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issues were also conspicuous by their absence from the discussions. For example the reduction of environmental pollution caused by the steel plant, was not a live issue for the focus groups, even though pollution had figured largely in local media debate. In the present discussions this was mentioned three times. Nor were issues relating to individual behaviour or risk management discussed. Rather, a theme of danger and threat permeated the narratives, as did the centrality to lives of work. Only one participant engaged explicitly with the language of risk, and only once did a participant suggest that the reduction of dangers to health in transition might depend on what people themselves did. Diminishing resources after communism: The significance attributed to the threat of unemployment for stress, is exemplified in the views cited below of a female administrative employee and retired male manual worker, respectively: The most important risk (ryzyko) which influences health, in my view, is stress (stres). Stress connected at the moment—maybe I’ll begin from the backroom, from the work that I do at the moment—stress linked to employment. Because you’re frightened for the jobs. At the same that’s connected, as we know, with a deterioration, in the case of dismissal, with a deterioration of material conditions. That’s the gradation I would give it, that first of all—stress. Well that stress, it certainly was less looking backythat’s to say—it’s been growing. I’ve been working (here) since 1970 myself. Stress before was less. We had the work guarantees, there wasn’t such a turnover, there weren’t those tensions amongst us. Well, there weren’t the lay-offs, first of all. Material conditions—well they were what they were and not anything else—at that stage, in the 1970s, as far as we were concerned they were good. Today there would be no comparison. At the moment, moving towards the year 2000, we know that we had nothing, we realize that we had nothing. But certain social matters were guaranteed; we got flats, we used to go away on holiday practically for freeythe children got very big subsidies for their holiday camps, and (we got them) for ordinary holidays as well, for that matter. (y) things have just developed and developed, as far as Huta was concerned, until now it’s just dramatic. When we used to work, you were at ease, in spite of the fact that earnings were low, but you worked calmly, you weren’t afraid that—Oh! they’re going to fire me in so many (days or months)—even though there were various infringements of work discipline, at the most he’d be punished, usually by docking a bonus,—but that protection was there tooythere was nothing of the kind that they’d lose their work. And so a person used to live peacefully and at least

he was never frightened that he would lose his job like he is now. Today it’s just, well—psychosis! The stress consequences of the unemployment, it was often made clear, could extend well beyond the person directly concerned. For example, the fear of increased crime was a common theme, particularly among the retired, one which was invariably linked to the lack of work for the young. Unemployment also often led into, or was embedded within, a broader discourse of financial strain that was prominent among both the retired and the employed. Some comments revealed how unemployment combined with other aspects of transformation to produce a cumulative effect. In one instance, a retired manual worker broke down as he described his family situation: I used to machine precious metals, where it’s all bad for your health, yes and now they’ve taken the harmful (work supplement) away (from the pensions). Before, I had medicine free of charge, today I can’t afford to buy it. My daughter worked in the laboratory—by the first of the month she’ll be out of a job. My son-in-law worked at the KPR,4 he’s been unemployed for a month now, fired. And I’ve got that slim pension, and on top of that I have to supportythemyWhere am I going to get it from so that I can help them out? yAnd it’ll comey A slightly different example was offered in a core production department focus group. Although pay had fallen far behind prices, work conditions all agreed were themselves in some ways more exacting, and productive of stress. For while there had been longer-term technological improvements, including the air-conditioning of overhead cranes, current limits to investment meant production was not fully computerised although the quality of cast steel was required to be world class: ‘We have to stand in for that computer. Tie up the loose ends (y) and if—that’s what the stress is all about—if something happens it’s not the Chinese computer that’s at fault—it’s (me).’ A skilled manual worker in this department referred to the strains caused by having to pay for his daughter’s studies, where the quarterly fees of 1200 zloty (£200), were now the equivalent of his monthly wage. Although his job was already demanding, this meant he was sometimes obliged to do extra work: I’ve got a lot of stress, because my daughter worked five years at the kombinat as well. (y) She was dismissed, she took the redundancy package of course, because she was slightly pushed. Now she’s 4 Krakowskie Przedsi˛ebiorstwo Remontowe, a Krako´w-based construction firm.

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studying, (y) And she has to pay rent too. (y) And well, unfortunately at the present moment she doesn’t have a job, she doesn’t work, she’s studying, and unfortunately I have to provide all the money (for it) from my own pocketyand that’s the stress. Well, I would like her to get her degree, but unfortunately sometimes I’m obliged to take a second job. Among the retired, much of the discussion focused on their financial predicament. Transition had, for example, brought significantly higher monthly charges on the housing that people had originally received via the steel plant. A former manual employee gave the following account: At the moment, my income, and my wife’s, together we’ve got 1,200 zloty invalidity pension. Well, if I pay 309 just for the rent and the central heating, that leaves me with 900 zloty, and there’s still the television to pay, the phone to pay, other things to pay, so there’s only a few pennies to live on. And you go to the shop, and every day, every other day, the prices go up, and up and up. The shop assistants just (go round with) that machine (y) they just click and re-do the prices y (y) and perhaps to all that we should add that I’ve given my sixth litre of blood—I used to get medicines free, but now there’s no free medicine for regular blood donors.5 Well, because medicine is going up, and why would they give it to anyone for free? As one production worker noted, the prospect of an impoverished retirement could reflect back to create a sense of insecurity among workers still employed: I’m talking about stress. If I’m going to retire in a year, and if I’ve calculated, very roughly of course, that the pension I’ll get after 36 years’ work (y)— category I employment—I’ll get less than whatever the national average is. So if at the moment I can hardly make ends meet, every year you get older, you get less resistant to certain things, healthwise too, (y) already you think: ‘what’s it going to be like later on—don’t you? Will it perhaps come to the point where there won’t be anything for that rent, if you buy medicine. (y) You already live with that subconsciously. Well, because there is the situation of other colleagues who have left. (y) Either the medicine or the rent. Health care reform was a theme that emerged strongly in the interviews. Three main issues were implicated here: difficulty of access, financial strain and confrontational encounters with health care personnel. New 5 Regular blood donors have limited exemption from prescription charges.

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financing arrangements in 1999 had imposed strict limits, beyond which people had to pay for services. One respondent, clearly frail, recounted the battle that he had 2 weeks earlier with a doctor, over his refusal to pay the 100 zloty asked. A woman with multiple health problems, reported her struggle over emergency hospital care. A third recounted his exchange with the doctor who asked him to return in 8 months although, as the interviewee said, poor circulation had turned his leg black. The costs of medicines were often prohibitive. For example, one woman who had retired after a lifetime of work indicated that her entire monthly pension of just over 480 zloty, was spent on medicines for her husband and herself. Typically, retired manual workers who had worked in conditions harmful to health experienced the shortcomings of health care in terms of a social contract where they had delivered without gaining what had been promised in return: I worked for over 33 years in Huta. My wife worked too. (y) I was a lathe-worker, only it was in the production hally In dust, in all thaty Today I spend more than 300 zloty (a month) on medicine. (The health service) is absolutelyy When I went to get a blood transfusion, I didn’t even know—25 zloty. After all, this is all Huta, people built it, it’s all ours, we built all this. Only one participant, relatively young, considered that reform had not negatively affected health care. Social unequalisation: Discussion of material difficulties often led directly to comparison with the increases in social inequalities that were taking place, with present financial difficulties defined in contrast to the situation of those visibly gaining in wealth and power. Themes of dispropriation and of absence and lack, also figured in participants’ accounts. A production worker emphasised this aspect of his experience. This was ours—ours—it was our health clinic—the kombinat’s. A person was courteously seen toy he felt greatyIf you come now—say I don’t feel well and I come here and I see the queues, well, I get high blood pressure, upset (nerwy). There was a sense that—even though work at the steel plant had often been bad for health, the enterprise had also been an asset that had been removed without anything being put in its place, as the commentary of a retired foundry worker’s illustrates: every month, every quarter, the plan was up, and up, and up and up. That plan was like elastic. They wanted to drive people to the limit, fingers got pulled off, people got hurt, accidentsy you had to teach (people) but the plan (still) had to be metythat dust. (y) (Recently) I went to that Department (of mine), because I was trying to get occupational illness

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(allowance) (y) and I don’t know what happened to me but (y) nothing was functioning, (it was like) a crematorium, worse than Auschwitz, so destroyed, so devastated, and (y) that was with our money, people’s money (ludzkie pienia˛dze), that that was built. (y) Here in Poland they built so many buildings and housing blocks, and all with our money, and today they’re selling it for pennies to foreign investors, and they are getting rich. And I ask you, which country and state is so stupid as to sell off the best work enterprises to abroad when they’ve got no money for invalidity pensioners! After all, those enterprises should be (y) working for those pensioners, and the profits should go for pensioners, increases. (y) And everything’s private, (it’s) firms, and there’s nothing there, there’s nothing there. Interviewees referred emotionally to the escalating disparities in income, pointing to the extremely high earnings, for instance, of politicians. For example, the oldest focus group member, a retired manual worker aged 80 years, who had a rural background, and who had worked at the steel plant from the start, declaimed: The nation feels ill! Nerves, nerves are worse than work. Nerves are worse than work. y nerves will finish a person off completelyyEveryone’s living on their nerves. It’s leany it’s all sand. I read the paper, I read how much money Ministers are takingy how much money the vice-Ministers are taking. They’ll take the money away from the whole country. In a similar vein, another retired manual worker expressed the direct link that he perceived to exist between disparities in wealth and mental health in the following terms: some people defend the present situation, the ones that have work for the moment, who don’t realise that at one time they raised their arm up and said ‘we will overcome’, but now they’re being dismissed from Huta. Because Huta struggled, and the tanks were here and so on. I was here at the time and I was working. And now they’re complaining about the present system. That’s to say, we don’t have a system today because it’s not clear what kind of a system it is. yand in the meantime those drawing-room political parties which are fighting among themselvesywell they only come together so others won’t get tempted, because they want to award themselves huge payouts.—Here the gentlemen mentioned a figure of 20–30,000. That’s not much! In the newspaper they said 270,000 was what the Lady Director of the Bank6 was getting. And isn’t it possible to go 6 A reference to Hanna Gronkiewicz-Waltz, then Director of the Polish National Bank.

crazy? And with all of this people are going mad, because they don’t even speak to each other much because they get upset. The Interpretation of Health and Social Change. In highlighting stress as the key health risk of transition, and in tying the psychosocial to material and sociopolitical aspects of change, the focus group respondents implicated the social meaning of the material events of transition in the undermining of health. What were the structures of meaning, or in Williams’ (1977) terms, ‘structures of feeling’, through which experiences and perceptions were linked to stress? That the release from communist rule was a positive change, was beyond question. At the same time, however, negative evaluations of the present were framed by unfavourable comparison with the past. What was said, and the strength of feeling with which it was said, suggested a moral and cognitive framework—a ‘moral economy’ (Phillimore, 1993)—in terms of which such comparisons and evaluations were formed, one which also drew from the experience of living under state socialism. Herzlich (1973, p.139) has suggested that health and illness appear as a ‘mode of interpretation of society by the individual, and as a mode of relation of the individual to society’. The point to be made here, in contradistinction to Herzlich’s formulation, is that the interpretation of both individual person and society are implicated in health and illness, and that the rules governing the interpretation of society and person are a central aspect of what is at issue in the transition to a new social order after state socialism. For example, the primacy of a prior notion of society underpinning state socialist ideology and practice could here be seen reflected in the fact that the Nowa Huta respondents perceived health risk in such unequivocally socio-political terms. The unacceptability of widening social inequalities is linked to this society-centred worldview, and to an egalitarian ethic linking income to work. Conversely, the fact that social unequalisation was so strongly contested indicates the absence of an individualistic ideology which legitimates inequalities by seeing them as the result of the inherent qualities of persons, and in this way deserved (cf. Della Fave, 1986; Lefort, 1986). The high income of politicians or the owners of firms was not seen as a ‘private’ phenomenon, but as one occurring at ‘society’s’ expense. This reasoning informs the analysis of the connection between the perceived exploitative element in emerging social relations and health which was put forward by a retired engineer and which is reproduced below. The others agreed aloud as he spoke: As far as physical conditions are concerned, it’s a bit to the advantage of the workers, but not because conditions have improved, because social conditions have got much worse, in fact they’re completely spoiled, there’s no social care. It’s rather because

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Huta’s production has gone down from six million tons (a year) to less than two. And it will keep falling. On the other hand, people’s mental conditions have got much worse (y). Because in the first place they earn very little, the ones that are working. Every moment they’re trembling that they could be thrown out, at the moment. And there’s no security for the future. They’re talking about 8,000 people out of Huta. Well, they say there’ll be some kind of care, some education or training, but that’s for six months, and what then? The old ones who have left Huta, like us here, we have small pensions, pennies.yThe young ones have no prospects whatsoever. And that is damaging mentally. It’s very harmful for health, because if he works, he earns almost nothing, because the money’s being taken by the directors of firms, by the councillors.(y)Hundreds of councillors. They take around fifteen thousand each. And for that amount 20–30 people can work here (a chorus of agreement). They are taking it, not the Ministers, but the councillors, the directors of firms, everyone who has grabbed power.(y)There’s no limit to the earnings of the people who have grabbed power or the ones who run firms. They are taking that money from people. This is the impoverishment of people and people getting rich on the backs of the poorest onesy. A director of a firm takes 30,000, and a worker takes 500–700 zloty a month—well, what are the perspectives mentally?—He breaks down mentally. If physically he’s not so tired, ythen mentally, because they might tell him to go, or because he only gets that 500 zloty and what can he buy with that, wellyhis systemyand in a few years he’ll just be a mental case—there it is. Or he’ll hang himself. Another university-trained engineer employed at the steel plant offered a similar analysis. In his view, the cause lay with the abdication of social responsibilities on the part of the state: You have to take away from some people, so that other people can get it. That’s the whole philosophy of this transformation. In order to create that middle class in our country, everything was allowed to run wild. Whoever is stronger, whoever has access to some sort of dirty dealing, just to accumulate capital. And now the idea is put about that these people of the middle class who did everything illegally, because a blind eye was turned to it, they’ll create work, or work-placesybecause you have to make something out of something. And that was all allowed to run wild. And now the people that are the honest ones, the ones that have got an education who aren’t combative—they’re suffering because for someone to do something it has to be at the expense of something else.

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If liberalisation could be interpreted as letting developments ‘run wild’, the increasing importance of money and, along with it, the rise of the abstract, was seen as an indifference to the concrete person and actual need. This was the perception of the two manual workers who are cited below. The first had taken part in the construction of Nowa Huta in the 1950s and was now retired. The second was employed in a production department of the steel plant. And they don’t ask: where is the worker going to get it from?yJust pay yLike (they said) to my son, he’s an invalidy ‘Are you paying or not paying?’ But you have to ask: two children to support, a wife, works in an office—earns pennies.—You have to ask: is he able to pay? (It’s just) ‘Are you paying or not paying?’ (It’s just) a —Health Service Limited—They don’t care about the (actual) person. y It’s not only in the field of the health servicey because everyone puts a lid on it (y). Everything’s nice, it’s dandy—and that’s it—And (here) everything is just turning over on its own.yThere’s a lot of things that are dealt with that way. (y) everything’s (made out to be) OK. But in reality if you wanted to have the benefit— no chance. It’s just that everything’s (made out to be) just as it should be, I don’t know whyymaybe for the eyes of (people) abroady.

Discussion The Nowa Huta narratives indicated that the main threat to health in transition was perceived to be stress. The narratives brought together psychosocial and material considerations, as well as changing social relations, in a fundamentally socio-political interpretation of health risk. The political character of their interpretations contrast sharply with the individualistic explanations of health inequalities that emerged in the studies reviewed by Blaxter (1997), and the more materialistic understandings that were articulated in Popay et al.’s (2003) place-based research. In both of these studies, the framing of interview questions was recognised as influencing the kind of theories of health that the respondents produced. In the present study, the main interview question was framed in terms of time, where, given the historical events that had been occurring, time itself was inscribed in terms of competing social orders and as such was in the process of redefining place. The temporal frame of reference encompassed both communism and liberal capitalism, and was the occasion for considering factors giving rise to health risk, through a reciprocal comparison of present and past. As part of this comparative process, the categories, structures and norms through which

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comparisons were made themselves depended on experience in the present and under state socialism. The understandings of health risk and social change that were put forward in the Nowa Huta narratives were influenced by the social composition of the focus groups. That is to say, the narratives depended on the social perspective from which they were made, a factor implicated in the production of knowledge that is well recognised (cf. Jodelet, 1991; Lupton, 2000). The fact that the respondents did not belong to the ‘successful’ few or to a cosmopolitan elite, was a matter of significance to the research. The Nowa Huta narratives did not articulate a minority, but rather a publicly underrepresented, set of views. In this, the evaluations of health risk and social change that the Nowa Huta focus group participants offered, were at odds with the individualistic approaches to health risk reduction that now dominate Polish official health discourse, as well as with media and academic representations of public health (e.g. Ostrowska, 2000; Zaton´ski, 1996). However, as a place-specific representation of a broader process of social change, on the part of people who had no entry to the new elite, the Nowa Huta stress narratives, and the evaluations on which they rest, find resonance with the findings of survey research. The 2002 Polish Social Survey found that over 40% of those in work stated that they experience fear in connection with their employment (Hrynkiewicz, 2003), while a recent CBOS poll found high and rising levels of egalitarianism, with 80% believing that the reduction of social inequalities should be among the most important tasks in Poland in the following 10 years; those with higher education, a group in general benefitting from transition, are significantly less egalitarian in their views.7 ‘What changes, as the mode of production and productive relations change is the experience of living men and women’ (E.P. Thompson, quoted by Comaroff, 1982: p. 63, original emphasis). Experience cannot be understood without taking account of the socially subjective meanings and evaluations through which it is constituted, or conversely, without considering the concrete social contexts through which those meanings and evaluations have been produced. The undertaking to transform countries that were once communist into capitalist democracies entails a reshaping of societies that is historically without precedent. The strategy of economic transformation in Poland was an expression of the neo-liberal Washington Consensus (Ko"odko, 2000), that is, it was the outcome of global relations of power. The wholesale conversion of state property into property that is private, facilitated by the re-introduction of private rights and the liberalisation of the law, has meant a transformation of social relations where, 7 CBOS poll carried out during 9–12 May 2003, representative sample of 1264 adult Poles.

following a social order founded on an egalitarian ideology, one founded on increasing disparities of wealth and poverty has ensued. The Nowa Huta narratives give an indication of the extent to which such changes are giving rise to stress. Far from evincing a sense of social normalisation or the trust in progressive improvement that normative discourses of transition lead one to expect, the frequent references to madness in the Nowa Huta narratives convey the sense of a society out of control. They suggest that for some, ‘transition trauma’ (Sztompka, 2000) has not come to an end, thus helping to explain increasing levels of psychosis and stress-related mortality in Poland, as well as the persistence of a European East–West adult mortality divide. Given the degree to which stress was seen as a socio-political issue linked to the effects of radical social transformation, how effective will public health policy in Poland be if it is restricted to a discourse of the empowerment, efficacy or esteem of the self, thereby neglecting the broader issues of social change?

Acknowledgements The paper draws on research funded by the ESRC (Grant Number R000222627), the Isaac Newton Trust, the British Academy, and the Wellcome Trust. Thanks to all those who were interviewed. Thanks also to Jolanta Chmiela, Wac"aw Kmita, Elz˙ bieta Ku"acz, Jarek Lenartowicz, Barbara Matiasiewicz, Jadwiga Modzelewska, Jo´zef Ros´ kiewicz and Marek Stalmachowski for their help and advice.

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