In my fieldwork at the Cardiology Unit at Vilnius public hospital I encountered what I call “the cake case.” 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 “bribes,” 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.
“Did you see that?” 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. They nodded. “What do we do now?” 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’ 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. He was a former alcoholic with a liver condition that further complicated his heart problems.