Polina Aronson is a post-graduate student in sociology at St. Petersburg State University and was formerly a DAAD exchange student at the University of Freiburg (Germany). Central European University recently awarded her course, "The Sociology of Medicine," taught at Smolny College of Liberal Arts in St. Petersburg, a Curricular Development Grant. She plans to continue her research at the University of Warwick (UK).
Rejecting Professional Medicine in Contemporary Russia
by Polina Aronson
The rejection of professional medical care (except for acute cases demanding urgent or specific treatment) has become common in contemporary Russia (Maximova 2002, Rose 2000). Although the statistics for major life-threatening conditions (cardiovascular diseases, cancer, diabetes) show a decrease in their treatment, high mortality levels from the same conditions are observed (Shilova 2005). The lowest number of consultations with medical professionals is observed in the adult working population, although this has been the population group with the highest mortality rates since the mid-1990s (Garrett 2000). Clearly, this dangerous trend deserves to be analyzed and explained in greater depth.
In this paper I will review two major theoretical avenues which could account for this trend, income-based approaches and value-based approaches, while arguing that neither pays enough attention to a basic lack of institutional trust, which causes people to avoid interactions with professional healthcare and instead rely on private networks and lay healing methods. The Soviet healthcare system’s disregard of the individual has resulted in the substitution of professional medical knowledge by traditional healing practices, particularly those given by women to men in the course of traditional gender roles.
This paper will present an analysis of the legacy of Soviet medicine, as well as preliminary evidence from the author’s own qualitative field study conducted in 2004-2006 (Aronson 2006a, 2006b). Originally, the central objective of the study concerned social networks among chronically ill individuals. However, non-compliance with and avoidance of professional medical care and the prevalence of self-healing have revealed themselves as crucial topics within many of the narratives of the study’s informants. This article is not written with the purpose to present the results of my own field work. Rather, the objective is to shape a new research agenda for studying the phenomenon of the delegitimation of professional medicine and increasing distrust towards healthcare institutions.
I. Current Theoretical Explanations
There are two major approaches to explain why people might avoid professional medical care: income inequalities and health values.
Several authors stress the high cost of medical services as the main reason to avoid professional medical care. Each Russian citizen has a constitutional right to participate in the Obligatory Medical Insurance Program (fond obyazatelnogo meditsinskogo strahovaniya). This state program provides insurance meant to allow free access to all major areas of medical care. However, according to a survey conducted in 2001 (Sidorina, Sergeev 2001), this system fails to reach the whole population. A great number of citizens do not participate in the program, and those who do are extremely poorly informed about the provisions – i.e. they do not know how much the insurance will cover or the services and rights they are entitled to under the program. At the same time, less than 5% of the population holds private insurance (Sidorina, Sergeev 2001: 91).
Panova and Rusinova have found that the provision of primary medical care through the Obligatory Medical Insurance Program is such that persons who need it, low-income patients and individuals who report the worst state of personal health, report the greatest difficulty in obtaining primary healthcare services as well as the greatest dissatisfaction in the doctor-patient relationship (Panova, Rusinova 2005: 135). Shishkin (Shishkin et al. 2004), Sidorina and Sergeev (2001), Zarutskaya (2003), Boikov (1998), and Panova and Rusinova (2005) have all argued that the state has essentially ceased to finance healthcare and makes patients pay for medical services themselves. Correspondingly, a survey on medical expenses conducted in 2001 found that Russian households generally spend about 17-18% of their total monthly income on healthcare (Sidorina, Sergeev 2001: 75) and, according to WHO data published in the Russian daily newspaper Kommersant (“Meditsina iz karmana,” issue 231, 9/12/2006), “out-of-pocket” (not reimbursed by insurance) medical expenses constitute about 40% of all the healthcare expenses in contemporary Russia, which is much higher than in other European countries (for instance, in Germany it is 18%).
This is aggravated by the fact that a significant amount of healthcare expenditures is consumed by informal payments (bribes and informal fees). For obvious reasons it is difficult to obtain reliable and up-to-date information on this issue, but a survey taken in 2000 found that 27% of respondents have sometimes made informal payments at state medical institutions, and 8% have regularly paid them (Klyamkin and Timofeev 2000:219). The reason this informal system has emerged will be discussed later. For now it is enough to say that high out-of-pocket expenses, augmented by informal payments, deter patients in Russia from seeking professional care. However, this is not the only reason.
William Cockerham (Cockerham 1998), Michele Rivkin-Fish (Rivkin-Fish 2005), and Laurie Garriet (Garriet 2000) have discussed the health-related cultural values particular to post-Soviet Russia. They stress the paternalistic expectations of the Russian public towards healthcare and a perception, shared both by patients and care providers, that health is a secondary resource necessary to achieve other goals (make more money, receive an earlier pension, raise one’s status). This has produced a dangerous behavioral pattern whereby patients do not consult a doctor on their own initiative, even after symptoms have appeared.
Ludmila Shilova (Shilova 1999, 2000, 2005) refers to the notion of “health exploitation” (Shilova 2005), which designates particular patterns of social behavior that create serious health risks. Such risks include growing overtime and work-related stress due to working several jobs or regularly working long hours. These patterns of behavior can cause chronic fatigue, which may lead to other chronic conditions. A survey conducted by the VTSIOM (All-Russian Center for Public Opinion Research) in summer 2006 supports this argument: 24% of the respondents claimed that although they were not entirely healthy they would prefer to ignore their symptoms, and only 11% of the whole sample regularly schedule check-ups or practice preventive care (VTSIOM, 2006).
The reasons for this, again, will be discussed later. What is important at this stage is to stress that these attitudes cannot be reduced to economic conditions or to values only. That is, it might seem plausible that perception of health as a secondary resource is a result of low income but, as Shilova argues (Shilova 2005), it is not just the poor who jeopardize their health; this behavioral pattern may also be observed among those who enjoy a high and stable income and is typical for private sector employees, especially managers. It is both a workload necessity and a part of corporate culture to prove dedication to the company (Shilova 2000).
Meanwhile, limited income and perception of health as a secondary value are not an exhaustive explanation of why people avoid professional medical care. According to surveys conducted in Russia within the last decade (Brown, Rusinova 1993; Shilova 1999, 2000; Pachenkov 2001; Maximova 2002; Shishkin 2004; Brown, Rusinova 2005), people are making efforts to improve their health and even purchasing health-related products and services. However, they often employ self-healing or consult alternative medical practitioners while avoiding contacts with professional clinical medicine. Research conducted in St. Petersburg in 2005 (Goryunov, Hlopushin 2005) showed that 24% of the city’s population consult an alternative medical practitioner about twice a year. The study estimates that the minimum sum annually spent by the population of St. Petersburg on alternative healing is nearly 8 million USD. However, experts believe that the true sum might be as high as nearly 20 million USD per year (ibid). Generally, those who choose alternative healing methods are dissatisfied with professional medicine (Maximova 2002). A telephone survey of 1502 residents of St. Petersburg found that 23% of respondents prefer self-treatment over medical consultation (Baranov, Sklyar 2004). Moreover, the longitudinal study by the N.A. Semashko Institute for Social Hygiene, Economics and Management of Healthcare showed that 8% of the population prefers alternative to professional medicine. Russian journalist Konstantin Krylov in his LiveJournal blog recently commented on this:
The Russian people have some kind of a special mentality when it comes to their health: they hate to be medically treated. Actually, there are plenty of people who love self-healing, but nobody is seeking professional help. Well, they do seek help when they are nearly dying, that is when they call for an ambulance. But usually everybody is waiting till the last minute, hoping that “it will be ok,” “will heal itself,” and then, hopefully, everything will be all right. As if some broken record is stuck in their heads: “don’t go to the doctor, don’t go to the doctor.” Just don’t go to the doctor, for God’s sake! The sickness (bolyachka) will get better (peremozhetsja), will go away. One can forget about the sickness, and it will go away. In the most acute case, well, lie down. But not to the doctor, never, ever, the doctor will treat you to death! If you are a healthy guy or a robust woman, you can beat the sickness without any pills; you will survive. And if not, well, that means nothing would help you anyway: you are rotten inside. So, just lie down, drink some herbs. Herbs are good for you. Getting only worse? Tough luck, your time has come then. No one can cheat death by taking pills anyway! And if you are really keen on being treated, go see baba Nura, she will whisper something into water, breathe on your sickness, and it will go away. Also, take some Chinese stuff, Jen Sing or however is it called, is said to be really good, eat it, and you will live a hundred years. Some Japanese mushrooms are good, too. And drink urine, that is what all the intelligent people do! Urine is health! Doctors with their pills just want to cheat you! Who knows what they put in these pills, probably, some chemical crap. The doctors will treat you to death! Who needs their clinics!
This text clearly shows that the lack of trust between doctors and patients is the main reason to avoid professional medical care. Linda Cook (Cook: 2003:18) argues the following:
The post-authoritarian state can provide social goods – education, social security, poverty relief – only if the society minimally trusts it to manage redistribution of resources fairly and reliably across age and income groups and individual life cycles, and so pays taxes and social security contributions. Obviously trust is not the only factor here; the state’s capacity to enforce payment compliance also matters greatly. But the argument is that in the Russian system, with its large potential for escape into the informal sector, the state must establish credibility as a condition for generalized compliance.
Credibility, a component of public trust in healthcare professionals and institutions, has not yet been studied exhaustively in Russia and needs closer attention. However, several surveys by Russian and Western sociologists have begun to address the issue. In particular, Nina Rusinova and July Brown in 1993 studied the impact of private networks on individual health in St. Petersburg (Brown, Rusinova 1993) and found that having an acquaintance or a relative among medical professionals significantly improved respondents’ self-rated health. Patients who had friends among medical professionals had the best access to healthcare resources and were generally more satisfied with the quality of the services they received.
Another study (Brown, Rusinova 2005) focused on the prevalence of traditional self-healing methods over professional treatment of non-acute cases. In this qualitative research, which will be drawn upon extensively throughout the remainder of this paper, they argued that the growing popularity of alternative medicine is due to the delegitimation of professional medicine and declining public trust in healthcare institutions in contemporary Russia.
Others agree. Laurie Garrett (Garrett 2000) showed that the resultant breakdown in healthcare after the collapse of Soviet Union not only caused a massive hike in mortality rates, epidemics and social inequalities, but also shaped public perception of professional medical care as harmful and risky. Moreover, Ludmila Shilova found that distrust was further deepened because services were not clearly defined as free or paid, resulting in confusion and inconsistency (Shilova 2005). Michele Rivkin-Fish also showed in Women's Health in Post Soviet Russia (Rivkin-Fish 2005) that distrust among all actors was directly detrimental to the quality of reproductive health services and patients’ quality of life.
II. Trust in Doctor-Patient Relationships in Soviet Institutional Settings
As a first step to defining trust as a new focus for studying the rejection of professional medical care, the next paragraphs will briefly address specific aspects of the historical doctor-patient relationship in the USSR. This historical interpretation will also be complemented and buttressed by interview data from my own research in recent years.
Institutional distrust is a phenomenon which is not peculiar to the post-Soviet period. According to a well-known study by Alena Ledeneva of the informal economy and private networks in Soviet Russia, the level of trust granted to government institutions was very low even before the collapse of the USSR (Ledeneva 1998). Bo Rothstein argues that dishonest behavior toward these institutions was often justified and even praised in the face of what was perceived as illegitimate power (Rothstein 2004b:13).
In general, trust extended only as far as one's personal network of family and close friends (ibid). Several studies on the development of civil society in Russia within the last decade show that the level of trust outside personal networks remains very low. A national survey conducted in 1996 by James Gibson (Gibson 2001) revealed that only 31% of Russians believe that most people can be trusted (with another 19% being uncertain whether most can be trusted). In 1998, when Gibson repeated his study (Gibson 2001), the figures were roughly the same (31% and 11%, respectively). A survey by the New Russia Barometer demonstrated similar results (Rose 2000: 1426): only 7% of Russians said you can usually trust people, and 27% thought people can sometimes be trusted, whereas almost 66% said you need to generally be careful in dealing with people.
Modern distrust in healthcare institutions has been particularly shaped by the history of the doctor-patient relationship. During the Soviet period, the healthcare system boasted high numbers of hospital beds and doctors but paid scant attention to the quality of care (Schecter 1997:38). Doctors had almost no professional autonomy and performed as administrative servants, rather than independent experts. They were supposed to cater to the needs of the Soviet state by controlling the well-being of its workforce, and thus doctors had the status of and served the functions of state workers. This bureaucratic, vertical structure led Mark Field to call Soviet healthcare a “medical military corps” (Field 1987: 66).
One of the most important bureaucratic procedures in the doctor-patient encounter was the issue of sick leave, which was studied in detail in one of the early works by Mark Field (Field 1957). Sick leave was often the only legitimate reason for absence at the workplace, especially under Stalinism, when labor legislation differed little from criminal legislation. Militant discipline in many industries pressured people to malinger in order to receive a sick leave. Under institutional pressure, doctors could only issue a certain amount of sick leave per day and carried personal responsibility if a malingerer missed work. As a result, patients carried the burden of proof for convincing the doctor that a sickness was “real.” As Field observed (Field 1957), doctors were more inclined to trust patients that were of a social background similar to their own: the intelligentsia. Manual workers and peasants had the most difficulties establishing trust relationships with medical professionals.
Formation of trust was also impaired by the fact that a patient could not choose a doctor: In a Soviet clinic a patient would have to see the doctor “on duty,” whichever one had consultation hours at the moment the patient came, and this doctor would then oversee the patient's entire healing process. In many cases doctors and patients managed to make their relationship more constant; however, their agreements were only personal ones and were not supported by institutional regulations.
Despite the official ideology of egalitarianism, Soviet healthcare was highly stratified (Schecter 1997: 39; Field 1957, 1987). The party elite and privileged persons (favored actors, athletes, writers, etc.) had access to special hospitals where doctors were of the highest rank and the best equipment was available. Most people knew this and accepted the double standards, but also distrusted the healthcare system more because of them.
At the same time, this institutional setting contradicted patients’ expectations about what a good doctor should be. Fields’ informants believed that the medical profession implied specific personal characteristics (Field 1957:156). Despite a sometimes negative experience with Soviet medicine, they had a highly idealized understanding of what a doctor should be, which was to a great degree shaped by the Russian literature of the nineteenth century (Chehkov’s Uncle Vanya providing one of the main role models). A doctor was supposed to be, first, “a good human being,” capable of commitment and sensitive to the pain of others (both literally and metaphorically). A study by Rusinova and Brown demonstrated that this can be seen in contemporary Russia as well (Brown, Rusinova 2005:166-167):
Very few Peterburgtsy regard the ideal physician as a mere technician whose role is to mend damaged bodies. Most expect far more. They believe that doctors should also exhibit particular qualities of character, without which their ability to heal is severely limited. [...] Good doctors are specialists with good education, high qualifications, and they work in good institutions. Equally, or even more important, however, are human or spiritual qualities, particularly those that manifest themselves in interactions with patients. The men and women of St. Petersburg describe ideal physicians as sympathetic, compassionate, and caring. They always listen to patients, are attentive to their concerns, and offer warm words of support. People do not regard these as extraordinary or superhuman qualities. On the contrary, they represent the most essentially human ones. A good doctor, as one woman put it, is “a Person with a capital ‘P.’”
The doctor’s role is not confined to medical knowledge, but draws on wider expectations and traditions. One of the informants in my own study, Ludmila, a woman of 70, said:
You know, sometimes the doctor simply gives you a friendly look, has received you nicely, has shown some commitment to your problems, and you decide straight away that it is a good doctor. Because it means so much! And sometimes you ask for a prescription, the doctor writes you one, and does not even ask you why you need it, what reasons you have to ask for it, nothing. Just gives you a prescription or sick leave, and that's it. We are like blind kittens! We can only act by our own intuitions and feelings in these relationships.
In such a setting the doctor not only performs his or her professional duties, but also grants the patient personal favors which need to be rewarded. The only possible strategy of interaction with an institution becomes through personalization, building a relationship with a particular person, not with the organization he or she represents. Private networks start substituting for institutional structures and become the real mechanism of obtaining social goods such as healthcare. In addition, paternalistic expectations towards medical professionals mean that patients look for personal guidance and assistance, which could only exist in a personalized relationship. Galina Lindquist mentions the following in her case study of a Russian family’s choice of healing methods (Lindquist 2002: 338):
In the West, in this period of late modernity, we are used to having specialised authorities and guarantees for the source or status of facts: what these say, we believe (cf. Giddens, 1990). In other cultures, this faith in experts is not so steadfast. This may be because faith in the official or in what is presented as the authoritative word has been undermined by an epoch of ‘double think’ and ‘double talk’, as is the case in Russia after the 70 years of the Soviet regime (at least for some social groups). [...] [T]herapeutic efficacy, a sensory process of betterment, is (especially in non-biomedical treatment) connected with the acceptance of the healer as a person with ‘power’ or ‘charisma’: with the recognition of his or her ‘charismatic legitimacy.’
To make these informal relations happen in the institutional setting, a special set of norms is developed. Thus, patients are not only expected to give small presents or favors, but to make other informal payments. By the middle of the 1990s, such informal payments had become a crucial part of medical professionals’ income.
Klyamkin and Timofeev (2000) argue that informal payments should not only be considered as corruption, but also as a specific form of cooperation between the impoverished population and the impoverished healthcare system; in the 1990s, informal payments became needed salaries, drawn from patients rather than the state. Additionally, Klyamkin and Timofeev assert that the provision of actual medical treatment was still a possibility in the dysfunctional setting. However, if the patient did not already have a personalized relationship with his/her healthcare provider, this informal system created suspicion and distrust. The ambiguity of rules and imbalance of control in medical care was often a traumatizing experience, unless an informal relationship and personalization could moderate it.
With the collapse of the USSR, state public health guarantees also collapsed, and institutional interaction became even more inefficient (Field, Twigg et al 2000, Garriet 2000, Shishkin 2004). Free medical care was an important ideological issue during the Soviet epoch, and the state’s inability to provide it has had a strong negative impact on the popular perception of post-Soviet reforms. Mark Field mentions (Field 1957: 203):
In its attempt to capture and retain the loyalty of its citizens the Soviet regime affirms that one of its major concerns is the welfare of the individual (zabota o cheloveke). In the realm of health the individual is said to be entitled, as a matter of the constitutional right, to high-quality medical assistance at the expense of the state. This constitutional provision is, of course, constantly and continually commented upon and amplified in all the means of mass communication. It would be very surprising, indeed, if such a campaign did not mold expectations concerning medical care, particularly in view of the fact that it caters to deeply felt anxieties. If a person believes that he should receive medical services when he needs them, and if, furthermore, he is told time and again, day in and day out, that it is the duty of the state to make these services available, the time will soon come when he will expect the services.
Given the ideological importance of free medical care, the reforms of the 1990s increased institutional distrust. Michele Rivkin-Fish argues (Rivkin-Fish 2005: 181):
Neoliberal reforms introduced monetary exchange as a newly legitimate tactic for accessing quality care, but largely neglected the ongoing structural impediments providers and patients faced, such as political disenfranchisement, the lack of material resources, lack of state oversight of quality, and the absence of health users’ groups empowered to ensure women’s rights.
That is, the reformers might have imagined that the introduction of market relations in healthcare would compensate for the lack of adherence to institutional norms by providing competition and thus raising the quality of medical care, once the providers had to become economically interested. However, in practice this process has led to quite an opposite result. It was originally intended that paid services would be introduced only for wealtheir patients, and free healthcare services would remain available for poorer patients. Some services (such as emergency and ambulance) were also meant to remain free to everyone. However, the state did not have a sufficient budget for such medical services; the percentage of GNP spent for healthcare never exceeded 3% (compared to 6.5-13% in Western countries (Rivkin-Fish 2005:71)), which was not enough to pay for all the free medical care promised to Russian citizens as part of the Russian constitution (Schecter 1997: 39, Field, Twigg et al. 2000: 62).
As I have mentioned in the section on income-based explanations, the introduction of obligatory state insurance for all Russian citizens has not greatly improved this situation. Medical institutions have also had difficulty in adapting to the new market funding schemes, growing a Petri dish of informal tariffs. A quote from Kate Schecter, a well-known expert on post-Soviet healthcare, illustrates this situation very well (Schecter 1997:40):
By the end of 1980s, the aging medical institutions could not provide basic care and specialized high quality care was not even a consideration. Epidemics were spreading, infections were not held in check by primitive sterilization methods, and the Russian population was no longer receiving even adequate care. Medical education and preparation of medical personnel came under sharper scrutiny as the country tumbled down into an increasingly serious health crisis. Home remedies and homeopathic medicine have become popular. Confidence in the healthcare system has dipped so low that it will take many years to reestablish authority and recover from the setbacks it has suffered.
This process can only contribute to the delegitimation of professional medicine.
3. The Delegitimation of Professional Medicine
In the following paragraphs I will argue that the decline of trust is a result of negative relationships with healthcare institutions, as well as commonly-held beliefs about health. In one of my group interviews two informants, Tanya and Lida, both about 26 years old, say:
Tanya: I think I have always hated doctors.
Lidà: Right. Just think of the medical check-up in school.
Tanya: Right. They kick you into the gym and you gotta walk around there in your underwear, from one doctor to another, together with everybody! Pull up your underpants and go!... I don’t really remember. I remember there were these desks, with a different doctor sitting in front of each, and you had to see all of them. This I remember well.
Lida: Yep. And a gynecologist behind the curtains.
The prevalent emotions about “state” medicine and hygiene expressed here are disgrace and humiliation as well as expected danger that is associated with professional medicine. In a recent survey by Nina Rusinova and July Brown, 42% of informants claimed to have had at least one treatment experience which has negatively affected their health (Brown, Rusinova 2005:165), and which has led them to believe that professional medicine should be considered only in the most acute cases due to the risks involved with treatment.
In many of my interviews in St. Petersburg, as well as with Russian immigrants in Germany, I encountered narratives about clinical medicine shaped by a binary opposition of “live – dead” and almost never into “healthy – sick.” Linguistically, this is expressed in such structured sayings as “if alive, then ok” (zhiva, i ladno), “While I'm still living, to no sickness I’m responding” (poka zhivu, ni na kakie bolezni ne reagiruyu), and so on. “Healthy – sick” is much more frequently used in the context of domestic medicine, while professional medicine is symbolically tied to the world of death. Pharmaceuticals and other medications sold in the drug stores also belong to this world, and are also avoided. Drugs are said to interfere with the “natural processes” in the body, to weaken its immune system and cause other negative side effects. Lida and Tanya had this to say about the subject:
Lida: Well, speaking of migraines… If you have a migraine, go to the bathroom, stick two fingers in the throat, and here you go. If I have a migraine, I always hug the toilet, and then I feel better. Then I fall asleep, and next day I feel totally fine. And the pill… The pill does not treat the reason you have a migraine. It only kills the pain. I think a headache is something one can bear. It’s all right to have a headache. Tanya: I don’t know… I can’t do anything then.
Lida: You can go lie down. You know, the folk wisdom has it: “The head is not the ass, tie it up and lay you down” (golova ne zhopa, zavjazhi da lezhi).
Interviewer: So, if the ass hurts, something has to be done?
Lida: Nah, its just folk wisdom. People say it.
Tanya: Aah, you are like my mother. She is always like that. “Mom, I have a headache” – “Go lie down.” “Mom, I am cold” – “Go wash the floor, you will be hot soon.” End of discussion.
Homemade remedies, treatments offered by alternative healers, and use of non-pharmaceutical medications sold in drug stores (herbs, balms, tonics), are regarded by informants as likely less effective, but definitely less dangerous. Another informant, Olga, a woman 70 years of age and an asthma patient for at least half her life, says:
I try to take as few pills as possible and only if I really can’t do without it. And I always half the recommended dose. I mean I take the drug twice as long, but in portions twice as small as were recommended. I always read the product insert carefully, and if I don’t like something, I rather don’t take these pills at all. I was in the hospital once, and the doctor gave me some pills. I told her to give me the insert, and she says, woman, the insert is for me, not for you. So I said, look, whose life is it, mine or yours? It’s mine! And the doctor is there only to help me save it! So, I need to be the first person to know what I am taking into my body!
When trust in professional medicine declines, the value of traditional and lay knowledge increases. One of the strongest beliefs among informants is that a person can treat him or herself without consulting doctors. More than half of those interviewed by Nina Rusinova and July Brown have agreed that “individuals understand their own health better than any physician” (Brown, Rusinova 2002:164).
It is also worth mentioning that this knowledge has a distinct gender structure. Russian culture emphasizes a woman’s ability to possess sacral knowledge about the natural world. In fact, traditional medicine is often believed to be best performed by “babki” – “grandmothers” or old women. Home care is an important element of a woman’s identity, and self-healing is performed as part of her gender role. In fact, my own field observations show that it is mostly women who refuse taking pharmaceutical drugs. While men simply avoid consulting a doctor, women use a broad range of replacement strategies which vary from pharmaceutical self-healing to homemade medicines or folk healers (Lindquist 2001).
Traditional knowledge about treatment methods is rooted so deeply that it is often still a part of the local culture retained by Russian emigrants (Remennik 1997). One of my informants, Tanya, lives in Germany and is married to a German man. Whenever he is sick, she tries to treat him with homemade medicines commonly used in Russia.
Tanya: I tried to give him herbal teas. He says “OK,” but he does not really drink them. I give him the cup, he looks at it, but does not touch it.
Interviewer: He is not used to it, is he?
Tanya: No, that’s the thing. He is not used to it at all. He is worse than a little baby, you really have to control him, to make sure that he really drinks it. Or, for instance, he loves to be massaged with ointments. To that he agrees straight away. But if I make him some herbal inhalations, I really have to control him, I have to cover him with towel and make sure he sits and inhales! And he starts complaining straight away: “Oh, it’s hot, it’s hot!.”
Interviewer: What kind of treatment does he choose himself?
Tanya: He runs to the drug store straight away and gets himself some pills. He takes what they give him in the drug store. Sometimes he needs a prescription, so then he goes to the doctor first, but most of the stuff he needs is sold without prescription.
Employment of homemade medicines is an important family practice for this young woman, a practice which shapes her understanding of gender roles: by making medicine for her husband herself, she performs the role of a caring wife, and reproduces social norms common in Russia. Tanya continues speaking about her husband:
Men can’t overcome pain at all! If something hurts them, it’s a total drama. First, he starts being sick straight away. I tell him, c’mon, get up, go gargle your throat or drink some herbs. But no, he will lie on bed and moan: “Oh, I am so, so sick!” I offer him dozens of treatment methods, but he does not want to do anything. He just moans about how sick he is. He just wants all eyes to be on him. Of course, I am happy to help him, but he has to do something himself! I also want to be sick sometimes, and have everyone dancing around me! But no one does this.
In Russian culture, the male sick role traditionally involves a female as an active caregiver (Shilova 2000, Remennick 2001). Pharmaceutical drugs do not allow these roles to be performed, because in this case, lay women do not have the power of knowledge and control, which is the essence of their gender role in this situation. Prescription drugs and clinical medicine take the traditional knowledge away from the woman, making her less competent in family matters and undermining her traditional gender role as a caregiver.
Thus, the perception of professional medicine as dangerous and prone to negative side effects might on the one hand be the result of an immediate negative experience within the healthcare system, and on the other hand can be shaped by popular beliefs and gender roles.
The delegitimation of professional medicine and strong distrust of healthcare institutions in contemporary Russia should be regarded as a product of the legacy left by the Soviet healthcare system. Professional clinical medicine preserves its dominating role in the broad range of medical services, but it is considered by many to be the most undesirable. Russians tend to employ lay and alternative medical knowledge as well as self-healing practices as a rational strategy to decrease the perceived risk to their health.
Without considering trust as a crucial factor, income and health-related values cannot fully explain why Russians avoid professional medical care. Moreover, pure materialistic or culture-based attempts to solve this problem fail, since neither growing income nor the desire to be treated will necessarily lead to interaction with professional medicine. By no means should alternative, folk medicine or self-healing as a whole be regarded as “false.” Lay treatment methods can be very successful in some individuals, especially for long-term, chronically ill patients who develop their own ways of dealing with their illnesses. Also, the role of the private network and its ability to care about the patient should not be underestimated. However, one must take into consideration that in modern society institutionalized forms of knowledge and social networking have much better access to state social goods. Russia’s long tradition of informal economies has a negative effect on health by detaching individuals from these goods, which are provided by a state healthcare system.
This situation calls for further research aimed at studying the problem of trust in professional medicine and in the healthcare institutions of Russia's transitional society. This approach will likely complement greatly the income- and value-based explanations for the avoidance of professional medical care. Such research would not only have academic value, but could also potentially help professional medicine to win the trust of the populace and hence improve the distribution of this essential social good.
 http://krylov.livejournal.com/1335666.html The post has received more than one hundred comments and was widely discussed. It should be noted that it is not quite possible to reproduce Krylov’s peculiar linguistic style in English, as he is choosing pseudo-folk wording to convey what he sees as “vox populi”. Translated from the Russian by the author; italics in original.
 Field describes malingering practices in detail, like injecting sour milk under the skin to cause fever.
 Residents of St. Petersburg
 The expression refers to “a kind person with a well-developed personality.”
 Translated from the Russian by the author
 Rivkin-Fish gives a very thorough analysis of market reforms in post-Soviet Russia (Rivkin-Fish 2005: 76-90).
 This excerpt and all that follow have been translated from the Russian by the author
Aronson, P. (2006a) Chto russkomu horosho, to nemtsu smert: Russkie studenty v Germanii russkih nemetskih normah meditsini // Teleskop. Issue 2 (56). P. 43-45.
Aronson, P. (2006b) Utrata institutsionalnogo doveriya v rossiyskom zdravoohranenii kak odna iz prichin otkaza ot professionalnoy meditsinskoy pomoschi //// Zhurnal Sociologii i Socialnoy Antropologii. Issue 2. P. 120-131.
Baranov I.N., Skliar T.M. (2004) Rol' strakhovykh meditsinskikh organizatsii v uluchshenii kachestva meditsinskogo obsluzhivaniia i uvelichenie ravenstva dostupnosti uslug zdravookhraneniia (na primere Sankt-Peterburga) // Sotsial'naia politika: realii XXI veka. Vyp 2. Moscow: Nezavisimyi institut sotsial'noi politiki. P.380-410.
Boikov V., Fili F., Sheiman I., Shishkin S. (1998) Raskhody naseleniia na meditsinskuiu pomoshch' i lekarstvennye sredstva // Voprosy ekonomiki. Issue 10, P. 42-54.
Brown J., Rusinova N. (1993) Lichnye sviazi i kar'era bolezni // Sociologicheskie Issledovaniya, Issue 3. P. 30-36.
Brown J., Rusinova N. (2002) “Curing and Crippling”: Biomedical and Alternative Healing in Post-Soviet Russia // ANNALS, AAPSS, ¹583, P. 161-170.
Cockerham, W. C. (1999) Health and social change in Russia and Eastern Europe. London: Routledge.
Cook, L. (2003) Social cohesion in Russia. The state and the public sector // Social Capital and Social Cohesion in Post-Soviet Russia, edited by Judith L. Twigg and Kate Schechter. NY: M.E. Sharpe.
Field, M. (1957) Doctor and Patient in Soviet Russia. Harvard University Press.
Field, M. (1987) Medical Care in the Soviet Union: Promises and Realities // Quality of Life in the Soviet Union, edited by H. Herlemann. Westview Press.
Field M., Twigg J. (ed) (2000) Russia’s Torn Safety Nets. McMillan Press.
Garrett, L. (2002) Betrayal of trust. The collapse of global public health. New York: Hyperion.
Gibson, J. (2001) Social Networks, Civil Society, and the Prospects for Consolidating Russia's Democratic Transition // American Journal of Political Science. Vol. 45, Issue 1, Pages 51–69.
Goryunov A., Hlopushin R. (2005) Rynok traditsionnoy meditsini Sankt-Petersburga // Zhurnal Sociologii i Socialnoy Antropologii. Vol. VIII, Issue 1, P. 179–185.
Kabalina V., Kozina I., Plotnikova E. et al. (2002) Tekhnicheskoe sodeistvie reforme sistemy zdravookhraneniia: rezul'taty sotsial'noi otsenki. Moscow: ISITO, Vysshaia shkola ekonomiki.
Kliamkin I., Timofeev L. (2000). Tenevaia Rossiia. Ekonomiko-sociologicheskoe issledovanie. Moscow: RGGU.
Krylov, K. K dohturu ne nadot! July 23, 2006. http://krylov.livejournal.com/1335666.html
Ledeneva, A. (1998) Russia's Economy of Favours: Blat, Networking and Informal Exchange. New York: Cambridge University Press.
Lindquist, G. (2002) Healing efficacy and the construction of charisma: a family’s journey through the multiple medical field in Russia // Anthropology & Medicine, Vol. 9, Issue 3.
Lonkila, M. (1998) “The social meaning of work: Aspects of the teaching profession in post-Soviet Russia” // Europe-Asia Studies, Vol. 50, Issue 4 . Pages 699-713.
Lorber, J. Gender and Social Construction of Illness (2000) AltaMira Press. Pages 1-51.
Macinko J., Shi L., Starfield B., Wulu J. (2003) Income Inequality and Health: A Critical Review of the Literature // Medical Care Research and Review, Vol. 60 No. 4, P. 407-452.
Maksimova, T.M. (2002) Sovremennoe sostoianie, tendentsii i perspektivnye otsenki zdorov'ia naseleniia. Moscow: PerSe.
Meditsina iz karmana // Kommersant, Issue 231, December 09, 2006.
Nazarova, I. (2000) Self-rated health and occupational conditions in Russia // Social Science & Medicine, Issue 51, Pages 1375-1385.
Pachenkov, O. (2001) Ratsional'noe "zakoldovyvanie mira": sovremennye rossiiskie "magi" // Nevidimye grani sotsial'noi real'nosti. K 60-letiiu Eduarda Fomina. Sb. statei po materialam polevykh issledovanii / Pod red. V. Voronkova, O. Pachenkova, E. Chikadze. SPb.: TsNSI,. Trudy. Vyp. 9. P. 96-109.
Panova L., Rusinova N. (2005) Neravenstva v dostupe k pervichnoi meditsinskoi pomoshchi // Sociologicheskie Issledovaniya, Issue 6, P. 127-136.
Remennick, L., Shtarkshall, R. (1997) Technology versus responsibility: Immigrant physicians from the former Soviet Union reflect on Israeli health care // Journal of Health and Social Behavior. Vol. 38, Issue 3. P. 91-202.
Reshetnikov, A. (2003) Sotsial'nyi portret potrebitelia meditsinskikh uslug v Rossii v period perekhoda krynochnoi ekonomike // Sociologicheskie Issledovaniya, Issue 1, P. 92-101.
Rivkin-Fish, M. (2005) Women's Health in Post-Soviet Russia. Indiana University Press.
Rothstein, B. (2004) Social trust and honesty in government: A casual mechanisms approach // Rose-Ackerman, S. , Kornai J., Rothstein B. Creating social trust in post-socialist transition. NY: Palgrave Macmillan, P. 7–30.
Rose, R. (2000) How much does social capital add to individual health? A survey study of Russians // Social Science & Medicine, Issue 51, pages 1421-1435.
Rose, R. (1999) Getting things done in an anti-modern society: social capital networks in Russia. In P. Dasgupta, & I. Serageldin, Social capital: A multi-faceted perspective Washington DC: The World Bank, P. 147-171.
Schecter, K. (1997) Physicians and Healthcare in the Former Soviet Union // Shuval J., Bernstein J. Immigrant Physicians. Former Soviet Doctors in Israel, Canada and the United States. Praeger: Westport, P. 29-40
Shilova, L. (1999) Problemy transformatsii sotsial'noi politiki i individual'nykh orientatsii po okhrane zdorov'ia // Sotsial'nye konflikty: ekspertiza, prognozirovanie, tekhnologii razresheniia. Moscow: Institut sotsiologii RAN. P. 86-114.
Shilova, L. (2000) Transformatsiia zhenskoi modeli samosokhranitel'nogo povedeniia //Sociologicheskie Issledovaliya , Issue 11, P.134-144.
Shilova, L. (2003) Neformal'nye platezhi za meditsinskuiu pomoshch' v Rossii. Seriia «Nauchnye doklady: nezavisimyi ekonomicheskii analiz», Issue 142, Moscow: MONF; Nezavisimyi institut sotsial'noi politiki.
Shilova, L. (2005) Transformatsii samosokhranitel'nykh modelei povedeniia naseleniia v usloviiakh reformiruemogo zdravookhraneniia // Presentation done at the seminar “Health in transforming society: Doscourse, politics and everyday life in modern Russia”, Saint-Petersburg, Centre For Independent Social Research, December 14-15.
Shishkin, S.V. et al. (2004) Rossiiskoe zdravookhranenie: oplata za nalichnyi raschet. Moscow: Nezavisimyi institut sotsial'noi politiki.
Sidorina T., Sergeev N. (2001) Gosudarstvennaia politika i zdorov'e rossiian. K analizu zatrat domokhoziaistv na zdravookhranenie // Mir Rossii, Issue 2, P. 67–92.
Tapilina, V.S. (2004) Zdorov'e i rabochee vremia: realii 1990-kh gg./ Sotsial'naia politika: realii XXI veka. Vyp 2. Moscow: Nezavisimyi institut sotsial'noi politiki. P.315-348.
Tkatchenko E., McCee M., Tsourous A. (2000) Public health in Russia; The view form the inside // Health policy and planning. Issue 15(2), P. 164–169.
WCIOM. Press-release: Kak zdorovie, strana? Issue 489, July 11, 2006. http://wciom.ru/arkhiv/tematicheskii-arkhiv/item/single/2873.html
Zarutskaia, E.A. (2003) Neravenstvo v dostupe k uslugam zdravookhraneniia // Spravedlivye i nespravedlivye sotsial'nye neravenstva v sovremennoi Rossii. Moscow: Referendum.