Skip to content

Insecurity and Economies of Care 

Struggle of healthcare professionals in Sarajevo against Covid-19
Healthcare professionals are on duty, in Sarajevo, Bosnia and Herzegovina on December 12, 2020. (Photo by Samir Jordamovic/Anadolu Agency via Getty Images)

Download the Essay Here

For more than three years, starting with the onset of the COVID-19 pandemic in March 2019 until December 2023, the largest hospital in the Bosnian capital Sarajevo – Clinical Center Koševo – remained closed to visitors. And every day, for those three years, the same scene repeated itself at the main entrance to the hospital complex.   

Rain or shine, a large group of people would assemble around 2:30 p.m. In their hands they clutched plastic bags filled with nightgowns and underwear, medications and magazines, carefully hidden and disguised food items, and money for bribes. On the bags, they wrote patients’ names and names of their clinics. While waiting, they walked around, sometimes for more than an hour, anxiously talking about their loved ones in the hospital. They exchanged information about medical staff, grumbled about how difficult they were to reach, and whined about public transportation and rising prices. 

All talk would stop with the arrival of nurses from nearby clinics who came with carts and wheelchairs to collect the bags. In exchange, the nurses delivered dirty clothes, soiled linens, empty plastic containers, and occasional letters from the patients. As the nurses approached, the crowd would rush through the gates. Whispers turned into shouts; everyone desperately trying to engage the nurses in conversation, attempting to extract at least some news about the status of their loved ones. The nurses rebuffed dialogue, sometimes rudely. The crowd would then disperse, holding tightly the bags they had just received, each person back to their pain and a solitary trek home.  

Security is imagined differently when all one values in life can fit into a plastic bag. People carrying the bags – in the Western Balkans region and throughout peripheral worlds where conflict reigns – recognize each other when they see them. They are migrants, refugees, internally displaced, living on the margins, generally powerless. They do not figure in the peace agreements, infrastructure deals, resource politics, and military procurement that preoccupy stakeholders at home and in the big metropolitan centers, where key decisions about the periphery are often made. Yet contemporary politics thrives on their insecurities, on fears emanating from the precarity contained in their bags, on everyday violence they encounter, and on repeated messaging that their lives are disposable and insignificant.  

There is a reason why protests in Western Balkans are so frequently driven by concerns over babies’ and children’s lives, health care, wrongful deaths, or gender-based violence and discrimination. To understand how power operates in Western Balkans and where the region’s politics may be heading, it is imperative to look beyond geopolitics and ethnic politics, where the gaze of outsiders is most often focused. Feminist perspectives, which “make invisible visible,” help illuminate structural forces at work that keep the Western Balkans in its perpetual security limbo and easy prey to predatory powers in its broader neighborhood.  

Feminist Political Economy and Security Studies 

The Western Balkans is a fictional political space. It denotes a group of countries in Southeastern Europe whose main common feature is their status as rejects by the European Union. Although most states in the region except Albania were once part of Yugoslavia, even that common past has been violently pushed back – not only by the wars of the 1990s but also by the uneven politics of international interventions and oversight in the post-conflict period. To speak of security of the Western Balkans is therefore a contradiction in terms: The region’s real or perceived insecurity is the very reason for its continued rejection and marginalization by the EU. Without that abject insecurity, which is constantly reproduced by the world’s great powers and their client local elites, the Western Balkans would not need to exist as such.   

Feminist security studies and feminist political economy enable us to see the Western Balkans differently – not only as a perpetual site of geopolitical competition and instability but also as a terrain of everyday struggles and survival: of love and funerals, of child-rearing and existential worries, of laughter and gossip, of home and distant caring. And while there are many feminisms, and now even many feminist foreign policies, most feminist scholars of international politics would agree on two aspects of war, aspects not sufficiently recognized by scholars and practitioners of international relations and international security.  

First, feminist political economists emphasize continuums and circuits of violence, thus questioning the usual dichotomies of war and peace, economy, and security, domestic and international, public and private. By raising the treacherously simple, quintessentially feminist question – where are the women? – feminist scholars see wars as extending along conceptual, temporal, and spatial lines of usual inquiry.  

Conceptually, they do not just see women as victims of violence or discrimination, as usually assumed, but instead illuminate a wide gendered space of difference, in which men, women, and queer people, whose status is always complicated by race and class, experience wars and their aftermaths in dramatically divergent ways. In this wide terrain, feminist scholars conceptualize violence as stretching from daily and seemingly disorganized acts of gender-based violence to organized violence of conflicts, including sexual violence, and then to post-conflict violence propped by pathologies of postwar political economy as well as trauma.  

As a corollary of this reconceptualization, wars are also temporally altered. They do not have clear beginnings and ends as scholars of war insist that they do; they are enunciated with extremism, crime, femicides, various acts of symbolic violence – and they last well into the future with suicides among the veterans, domestic abuse, partner-killings, war-related diseases, mnemonic wars and denials, and yet more femicides.  

Spatially, too, wars are not bound to battlefields in specific territories. Instead, they are linked to areas of alleged peace – and to each other – via moving armies, mercenaries and arms trafficking, refugee flows, humanitarian assistance, and the aid industry. Thus, wars cascade into each other and translate into new forms of violence, linking people and places who would otherwise have little in common. Consider, for instance, the impact and the resonances of the Yugoslav wars on a seemingly lone extremist like Andre Brevik in Norway, or on terrorist attacks in Western Europe, or on the Ukrainian war

Second, and as previously argued in relation to the 1995 Dayton Peace Agreement in Bosnia, and the war in Ukraine,  feminist scholars stress enduring and transformative aspects of wars, analyzing ways in which wars affect men, women, sexualities, and gender relations more broadly. Wars can mobilize women, pushing them into activism and participation but also entrench power agreements dominated by men even after wars end. 

Wars reshape the economic landscape, creating new wealth and obliterating livelihoods with significant consequences for gendered divisions of labor. They redistribute resources and create new gendered hierarchies based on politics of commemoration and narratives of mourning, heroism, and victimhood. Economic reconstruction typically privileges marketization and privatization of natural resources, physical infrastructure rebuilding, and other foreign investment opportunities that overall benefit men’s jobs, incomes, and assets more than women’s, even when controlled for age, race or ethnicity.  

In our work on the World Bank and International Monetary Fund in conflict and post-conflict settings, my colleague Vesna Bojičić-Dželilović and I have demonstrated that although such frameworks increasingly include measures that are sensitive to gender inequalities and differences, such as gender budgeting, they nonetheless exacerbate gendered insecurities. Such insecurities are often carried by women, whose unpaid labor predominantly attends to human trauma and recovery and whose paid labor is neglected in financing for post-conflict reconstruction.  

For both these reasons, from a feminist perspective, wars – and their aftermaths – are not isolated phenomena; they are integral to the global political economy and its gendered and racial hierarchies. Viewed through such lens, the Western Balkans is not an exiled region with deep, self-inflicted wounds and problematic sovereignty issues but rather a space intimately connected to the European and world economy through movements of bodies, transfers of remittances, and networks of care, which further accentuate its insecurities.  

Western Balkans: Economy of Care and Neglect 

It is, indeed, care – with its multiple, even contradictory meanings – that most radically transforms our understanding of the Western Balkans’ security needs and geopolitical positions. “Care” has long been associated with women’s invisible work. Relegated to the “hidden abode” of social reproduction, it was assumed to be unpaid, voluntary, sacrificial, and fundamentally feminine. Mothers would care for children, daughters would take care of parents and in-laws, sisters would cover care for their brothers. Indeed, in the Western Balkans, as in many parts of the world, caregivers, cleaners, and housekeepers are simply called “women.”  

In post-conflict contexts, care is almost never treated for what it is: the key factor of sustainable peace. For, in post-conflict spaces, care is more than just a feminine duty; it is also an affective disposition, shared by both men and women. It is an antidote to the harms and violence of wars, a connective tissue for renewal of communities, a collective mechanism of self-help that acts as a surrogate for destroyed institutional infrastructures of support. In the world of capital and profit, driven by privatization and reduced social spending, care is also an economic sector – formal and informal, increasingly transnational, and no longer as clearly linked to gendered households as it was once assumed to be. 

The scene at the gate of the Koševo hospital is a window into the dynamics that frame life, death, and security in the Western Balkans. Woefully understaffed, like most other hospitals in the region, Clinical Center Koševo bled health workers during the pandemic because of mismanagement, corruption, and low pay. At one point, an entire team of anesthesiologists left in protest over faulty respiratory ventilators. The breathing machines had been purchased from China, without a tender, by a company that otherwise traded in raspberries. The owner, a TV personality, had close ties to the governing Bosniak Party. The hospital’s director – wife of the most powerful Bosniak politician – insisted on the continued use of the ventilators to save face at the expense of patients’ lives.  

The staff continued to leave the hospital. By December 2022, there were wards at Koševo hospital where one nurse was responsible for as many as 24 patients plus countless visitors in the outpatient clinic. Patients complained of poor treatment, while families suspected that visitors were not allowed just so that no one would witness the conditions within the hospital. Meanwhile, the director – by that point also embroiled in a politicized fight over her own academic credentials – openly used visitation rights as a bargaining chip to demand funding for new hires from the local government.  

For most ordinary people in the Western Balkans, the entire world revolves around care. Tensions surrounding its financing, availability, and delivery bring people together and pull them apart. For years now, the supply of cancer-treatment drugs has been spotty. CAT scans and MRI appointments can take years. Mammograms are not a part of regular care provisions.  

Not surprisingly then, everyday conversations inevitably include references to doctors, discussions about hospitals, suggestions of alternative remedies, confessions about health problems, recollections of recent ailments, deaths, and funerals. Far from being morbid, or too intimate to be voiced, these conversations forge bonds within families and among friends. They are also clear indicators of priorities: In a world with so much violence and hardship, life is reduced to bare life. It is also meant to be shared. Like food, talk about health is an offering that once made must be reciprocated, no matter how poor the household. 

But because it is so central and existential, care is also subject to perpetual political manipulation. In Bosnia and Herzegovina, for instance, public expenditures on health care are higher than in the EU, but nearly one third of that spending is private, mostly on treatments and medications. The public system is bloated and inefficient, a reflection of the complex institutional structure created by the Dayton Peace Agreement. The private system is poorly regulated and insufficiently integrated with the public one. Thus, while a majority of Bosnian citizens are nominally covered by insurance, their access to health care is limited by politics, location, and decaying infrastructure. The politicization of the Koševo hospital and its director, which was even highlighted by the U.S. Assistant Secretary of State James O’Brien during his February 2024 visit to Bosnia, is just a small part of a system where both jobs in and delivery of health care are completely driven by party patronage and private interests.  

In Serbia, by contrast, health care is centralized and ripe for exploitation by the ruling party. During the COVID-19 pandemic, Serbian President Aleksandar Vučić skillfully played his “neutrality” card to obtain vaccines in excess of Serbia’s population – from Russia, China, and the EU. Vučić then offered vaccines to citizens of neighboring countries, benefitting from this generous “vaccine diplomacy.” In a similarly shrewd gesture, based on astute readings of the critically important women’s vote, Vučić opened new mammogram screening facilities around Serbia in the months before the December 2023 parliamentary elections. The legitimacy of those elections is being challenged by citizens’ protests, international observers, and the European Parliament.  

Conditions are not significantly different in Kosovo, Montenegro, North Macedonia, or Albania. Scandals keep rocking their health care systems, despite new generations of doctors and varied levels of public expenditures on social infrastructure. The reasons for the catastrophic state of care in the region are similar: During the multiple transitions from conflicts and communism, the entire sphere of social protection – associated with women who were never part of peace agreements – was depleted, neglected, and ultimately destroyed. At the same time, changes in the global political economy, and particularly in the EU, as well as wars elsewhere, have transformed Western Balkans into an attractive source of care labor and mineral resources and, increasingly, a depository for Europe’s unwanted migrants. This is now a volcano of misery that simmers under the geopolitical fragility of the entire region. 

Global Crisis of Care and Western Balkans 

The crisis in care industries is a global phenomenon, But the crisis in the Balkans has been exacerbated by its handling by the European Union and especially in Germany. Demographic decline, an aging population, and the shortage of care workers make many European countries dependent on immigrant labor in the care sector. According to the OECD, migrants’ role in health care is essential – they represent around 23% of medical doctors and 14% of nurses in the EU. Migrants make up half of the doctors and nurses in London and Brussels. COVID-19 put additional pressure on health care workers throughout Europe, who had the highest absolute number of infection and mortality, leading to quitting, early retirement, and frequent strikes. The response in the most affected states was relaxation of work permits and visa requirements for workers in critical sectors, including care.  

In the effort to stave off an expected shortage of millions of nurses and doctors by 2035, Germany was particularly aggressive in its recruitment of health care workers in areas beyond the borders of the EU. According to a Pillars of Health report from September 2022, Germany imported as many as 200,000 nurses since 2013, 17.3% of whom came from the Western Balkans, representing 29.3% of nurses in the region itself. The move was facilitated by the Western Balkan Regulation of 2016, which opened Germany’s labor market to “Western Balkan nationals of all skill and German language proficiency level” if they had an offer from a German employer.  

The regulation made “refugee talent visible and accessible to EU labor markets.” While intended to ease political pressures over the “refugee crisis” in Europe, the development of these new “complementary pathways” effectively linked conflicts and crises elsewhere with the fulfillment of needs for skilled workers within the EU. The most recent German legislation, which came into effect in November 2023, raised the annual quota of workers from the Western Balkans from 25,000 to 50,000 and indefinitely extended the previous legislation. “The systematic brain-drain of health workforce towards Germany,” suggested a Pillars of Health report, “is a European and a global health scandal” that poses “a significant risk for the source countries.”  

Departures of care workers and health professionals from the Western Balkans are putting an added strain on the already precarious infrastructure of care in the region. According to some estimates, over the last 13 years, more than 400,000 workers have left Bosnia and Herzegovina, including more than a thousand medical doctors and thousands of nurses. In Serbia, a reported 600 doctors leave every year. In Albania, departures were estimated at 3,500 medical professionals over the last decade, prompting the Albanian government to work to keep them at home with home credit, wage increases, and requirements to practice locally. But most of the statistics remain inaccurate – individual caregivers and house care providers cannot be counted, as they often work in Germany for three months at a time without work permits or registration. And departures are putting upward pressures on pay for care within the Western Balkans, especially in the informal sector, which mostly caters to the elderly. Thus, in words of Alida Vračić, a Bosnian political scientist who works on migration, “emigration stretches health systems to the point of collapse and results in a loss of vital services.” 

Gendered Effects  

The exodus from the health care systems in the Western Balkans, demographic decline, and the escalating numbers of often quite literally abandoned elderly relatives puts women in a structurally untenable position. Consequently, labor participation is much lower for women than for men across the region. According to the International Monetary Fund, almost two thirds of working-age women in the Western Balkans were either inactive or unemployed in 2017. The labor participation gap is especially pronounced for women with low levels of education – who are usually the caregivers in their families and in the informal labor market. Indeed, lower educational attainment and family responsibilities are often cited as the primary reasons for women’s inability to enter into the formal labor force.  

These disadvantages are even more apparent among women in rural areas and women from minority groups that face high amounts of discrimination, such as the Roma. While many act as pillars of their families and informal breadwinners, they lack both time and resources to participate in public life and in politics. Low levels of labor participation translate into political invisibility despite an entire industry of nongovernmental and international organizations devoted to women’s empowerment, gender mainstreaming, and implementation of quotas in parliaments. Within such structural constraints, women who enter politics tend to do so by obliging the dominant ethno-nationalist or populist matrix, often – because they are so very few – with great success. Their leadership roles, however, only obscure the depth of the constraints that hold so many women back from meaningful participation.  

These structural constraints also translate into continued violence against women – both symbolic and physical. For women who survived the conflicts of the 1990s, the unfinished business of justice and war crimes, continued genocide denial, and political bullying are daily reenactments of the war trauma. Physical violence against women, which remains largely unaddressed by state institutions and political leaders, is a reminder that they will never be safe in their bodies. The number of femicides has been on the rise, not only because they are now being noticed.  

Echoes of #MeToo have traversed borders of Western Balkans and of different economic sectors where women are prevalent – from education to entertainment. Actresses, teachers, and pop singers throughout Western Balkans have shared their stories about sexual harassment and bullying in professional environments. And just recently, bringing together catastrophic conditions in health care and death among women, sparked by an experience of a Romani woman, Serbia has been shaken by a stream of testimonies from women who are alleging that they had been victims of obstetric violence as they were giving birth. The outcries, unfortunately, do not change policies. Often, like all scandals, they are simply used to divert attention from the institutional and power structures that made abuse possible in the first place. 

Where to, Western Balkans? 

The focus on the economies of care and on the perverse gendered effects of their neglect in post-conflict contexts is an important corrective to the dominant framings of security in Western Balkans. While the elite chatter in Brussels and Washington revolves around Western Balkans’ accession to the EU, NATO membership, and malign influences of Russia and China, it is the everyday insecurities and collective anxieties about the diminished value of life that govern and motivate political choices. They are a gold mine for populist and authoritarian leaders, the bedrock of corruption, and the key reason for the exodus from the region. They feed the vicious cycle upon which the key paradox of the Western Balkans rests: that its security would be best guaranteed if it ceased to exist as such, as a region defined by European rejection.  

But Western Balkan insecurities carry lessons for other conflict and post-conflict zones by illuminating how war kills: years, sometimes decades, after it is supposedly over, if gender is not made a part of the peacebuilding equation. As more and more wars intentionally target civilians, women, children, and social reproduction infrastructure, there is a lot to be learned from emphasis that feminists put on the political economy of gender-based violence and structures that uphold it. This includes research on depletion of resources – both material and emotional – through politics of austerity and extractivism, and, most importantly, from research on economies of care.  

No longer a domain of non-wage labor yet still almost entirely feminized, care is indispensable to social, not just individual, survival. If we were to combine childcare, health care, and care for seniors, it would be one of the fastest growing economic sectors – and women, and women’s bodies – still hold it together. At the moment, care is aggressively privatized and made more exclusive in many parts of the world. It could be otherwise. Care could and should be prioritized, especially in conflict and post-conflict zones. Thus, feminist political economy and feminist security studies both offer a more realistic picture of contemporary security posture in the Western Balkans and – by shifting priorities, by pushing our glance elsewhere to the huge swaths of the economy in which mostly women dwell – they also paint a way out from its abject insecurity. 

This essay originally appeared in the anthology “The Western Balkans 2024: Assessment of the Current Security Posture and Geopolitical Challenges.” To download the full anthology, click here.

Aida A. Hozić is an associate professor of international relations at the University of Florida, Gainesville. Her research is situated at the intersections of feminist political economy, cultural studies, and international security. She is the author of “Hollyworld: Space, Power and Fantasy in the American Economy” (Cornell University Press, 2002) and co-editor (with Jacqui True) of “Scandalous Economics: Gender and Politics of Financial Crises” (Oxford University Press, 2016). Her public writing has appeared in Slate, Foreign Policy, Politico, Al Jazeera, Le Monde, Guernica and other media. She is spending the spring of 2024 as a Fulbright Distinguished Scholar at Oxford University’s Pembroke College. 

The views expressed in this article are those of the author and not an official policy or position of the New Lines Institute.

Related Articles

The Security, Sustainability, Responsibility, and Geopolitics of Critical Mineral Supply Chains for Clean Energy Technology 

The Security, Sustainability, Responsibility, and Geopolitics of Critical Mineral Supply Chains for Clean Energy Technology 

Bottlenecks in the flow of materials crucial to green energy technologies could derail the global transition to low-carbon energy, making development of sustainable alternatives essential.

Countering the Growing Threat of Drone Attacks on Energy Infrastructure 

Countering the Growing Threat of Drone Attacks on Energy Infrastructure 

The proliferation and growing sophistication of UAVs puts the ability to wreak havoc within anyone’s reach, making addressing security vulnerabilities in energy systems imperative.

Post-Khamenei Iran: The Future of Evolutionary Regime Change 

Post-Khamenei Iran: The Future of Evolutionary Regime Change 

Download the Dossier Here Download the Executive Summary Here Executive Summary At present, international focus is on Iran’s increasingly aggressive

Russia, Ukraine, and Eurasia: the Future of Democracy

Russia, Ukraine, and Eurasia: the Future of Democracy

In this Contours episode, host Eugene Chausovsky sits down with Mike Smeltzer, the Senior Research Analyst for Nations in Transit, Freedom House’s annual survey of democratic governance from Central Europe to Eurasia. Together, they discuss the struggles of Ukraine's democratization, the increasing authoritarianism in Russia, and the importance of protecting Ukraine and its democracy against Russia.