Women's Health as a Prism of Social Change: An Anthropological Approach
Western "assistance projects related to family planning and education often get constructed in Russian press accounts as conspiring to hasten Russian depopulation," according to Michele Rivkin-Fish, Associate Professor, Department of Anthropology, University of Kentucky. Speaking at a 27 February 2006 noon discussion, Rivkin-Fish presented findings from her recently published manuscript, Women's Health in Post-Soviet Russia: The Politics of Intervention. During her fieldwork, Rivkin-Fish examined changes in the Russian health care system during the 1990s through six case studies involving public health and development projects. She found that resistance to these projects was not limited to the press—many health care professionals viewed Western trainers and programs with suspicion as well. She argued that, while traditional statistical data is vital to the study of public health, a deeper analysis of the contested processes of social change in post-Soviet Russia is necessary to find ways to counter suspicions in Russian society.
As an anthropologist, Rivkin-Fish became particularly interested in the clash of cultural assumptions that emerged between Russian doctors and their Western counterparts during Western development projects. The attempts of Western specialists to promote a value-free model of treatment, which emphasized democracy in health care, respect for women's rights, and providing the patient with the ability to make informed choices, was met with resistance deeply rooted in culturally specific definitions of medical treatment and the doctor-patient relationship in Russia.
Through her field research, Rivkin-Fish learned how the Soviet health system shaped Russian healthcare workers' experiences and strategies for working with patients. Under the Soviet system, the expertise of doctors was not questioned and a good doctor instructed a patient on how to best restore or preserve her health without presenting options. Doctors frequently scolded or berated their patients for living "unhealthy" lifestyles. This domination-based relationship between doctor and patient evolved as medical professionals were systematically "deprofessionalized" under Soviet rule, according to Rivkin-Fish. In the Soviet era, doctors were frequently paid less than skilled industrial workers and not permitted to form professional organizations. Yet the state emphasized the social importance of scientific expertise. Therefore, according to Rivkin-Fish, doctors, who were prevented from attaining political or professional authority in society, nonetheless felt entitled to social authority over patients. Medical information was the source of their authority, and the doctor-patient relationship reflected doctors' desire to maintain that authority.
Rivkin-Fish contended that the combination of Soviet deprofessionalization with the neo-liberal reforms of the 1990s that severely cut support for Russia's healthcare system only amplified the doctors' desire for validation as professionals. "In an atmosphere of distrust between patient and provider, they employed ever cruder means of domination over women, such as threats and intimidation, to demonstrate their social authority," she said. Although material conditions have improved in the expensive fee-for-service sector outside of the state hospital network, there has been little structural change in the health care system. Western-funded programs designed to inject change into this system by empowering individual women often do not take into account the lack of status held by the doctors, and the lack of trust women bring into the clinic. Consequently, stated Rivkin-Fish, providers saw Western calls to respect women's rights as irrelevant or even demeaning.
Rivkin-Fish emphasized that it is also important to understand that reproductive health, especially, is wrapped up in perceptions of sexual morality. Many Russians have decried the violent and sexual imagery from the West that flooded television and the print media in the 1990s. For many Russians, she continued, "this onslaught represented a frontal assault on family life." Many in Russia note that this decline in moral standards coincided with the demographic crisis that now confronts Russia. Right-wing Russian nationalists have attacked Western family planning and reproductive health programs as subversive attempts to hasten the demise of the Russian nation by promoting birth control to citizens whose numbers were already drastically shrinking. When defined in terms of "individual choice" and "birth control," women's reproductive health became a site of political and moral contestation.
Rivkin-Fish concluded by emphasizing the need to pay attention to local conditions, such as how the organization of local services generates particular beliefs and responses, rather than train doctors according to preconceived models that do not relate to local conditions. She urged that projects pay particular attention to the language used about health and to Russian modes of legitimate authority and forms of advocacy.
To be successful, she continued, it is necessary to adapt reform projects "to local idioms of meaning, even highlighting selective issues that may be more easily defended over those that seem more important in our context." Rather than framing heath projects in terms of women's rights, Rivkin-Fish recommends that aid projects speak in terms of achieving and maintaining well-being in order for women to conceive and deliver healthy children, thus removing the issue from ideological contention. Rather than sidestepping rights, she said, this strategy "is an important and incremental step that takes the Russian context seriously."