The story of postsocialism (so far) in Russia, and especially of Western interventions that aim to build democracy and a market economy there, is largely a story of unexpected paradoxes and unintended consequences. Michele Rivkin-Fish's Women's Health in Post-Soviet Russia, a rich and compelling ethnography of the transforming system of maternal health care in 1990s St. Petersburg, shows how strategies intended to democratize health care by empowering women have had rather the opposite effect. They have individualized responsibility for health care to such an extent that a serious consideration of the connections between social and economic dislocation and health—let alone collective action by women to demand changes in maternal health care—has become almost unimaginable.
The book is divided into two main sections: "Projects" and "Practices." The three chapters of the first, more theoretical, section discuss formal programs for reform in three spheres: maternity care, health care financing, and sex education. In each, Rivkin-Fish (who worked during her fieldwork in the early 1990s as a consultant on the WHO's "Healthy Cities" project, described in this section) details the assumptions and models that lay behind these interventions, and finds that they are unified by a discourse of individual responsibility. For example, women were encouraged to "take responsibility" for their own health by paying for care; payments were supposed to create an "interest" in the quality of care on the part of providers. These apparently utilitarian and mechanistic models for reform, however, were unable to contain a moral discourse in which changing oneself was increasingly seen as the only available route to social transformation—an inward turn that was a familiar reaction against both the state of socialism and the market of postsocialism. Sex educators of various stripes, for instance—whether psychological, biomedical, or religious in orientation—emphasized the need for personal moral development to counteract a social sphere always conceived as a site of moral danger and decay.
In each case, Rivkin-Fish details something becoming increasingly familiar to ethnographers of postsocialism: that "democratization" that comes in the guise of neoliberal economic policies is a strange kind of democratization indeed. It creates an increasing inequality which, when combined with a focus on the moral rectitude of the individual, renders collective mobilization, whether by physicians claiming the status of professionals or by patients insisting on more control over their health care and birth process, moot. It is a democratization which, paradoxically, disenfranchises.
One of the conceptual strengths of Rivkin-Fish's book throughout, and of this first section in particular, however, is her consistent refusal to set "Soviet" and "neoliberal" modes of providing health care in a too-neat opposition to one another. Instead, she shows that individualizing and personalizing strategies developed in the socialist context—such as blat—persist, even as they are transformed, in the postsocialist era, and that the two systems shared a certain tendency to focus on the transformation of individual subjects as a means of transforming society.
In her introduction, Rivkin-Fish distinguishes among "individualizing," "personalizing," and "privatizing" strategies, and the contours of these processes on the ground become clearer, even if the distinctions between them become a bit more blurry, in the second section of the book, "Practices." Here, Rivkin-Fish elucidates, through vividly drawn narrative and dialogue, the dilemmas faced by providers, hospital administrators, and pregnant women as they try to navigate the new "market" conditions. In particular, Rivkin-Fish shows how the meaning of networks of personal connections and reciprocal exchange have been transformed by the advent of privatized medicine. Paradoxically, as these stories of conflict and tenderness, joy and disappointment, suggest, the discourse of individual responsibility, despite liberal feminist predictions, has strengthened, rather than weakened, the exercise of biomedical authority and the medicalization of birth. The deprofessionalization of medicine characteristic of the Soviet era has been exacerbated, not overcome, as physicians answered their newly "empowered" patients with even stronger assertions of biomedical and moral authority. And while patients who could do so chose paying wards, thinking that their payment was a recognition of their doctors' status as experts and professionals, they could not, in this era of state disinvestment and deregulation, be sure that the quality of care they would receive—as opposed to the quality of the furnishings—would be any higher than in the free wards.
One of the most compelling features of the ethnography in this second section is Rivkin-Fish's relationship with her informant Karina, who worked as a housekeeper in one of the maternity hospitals where Rivkin-Fish conducted fieldwork. Throughout the second part of the book, Karina's insights—those of an insider-outsider not unlike Rivkin-Fish herself—shed light on the social dynamics at work in the hospital. In many places, Karina's is a kind of second ethnographic voice, supplementing and sometimes contesting Rivkin-Fish's interpretations. The effect is to emphasize that ethnography is always a collective project and one ideally based on mutual trust and affection, a fitting subtext in a book that is conceived as a feminist critique of an individualism that makes women's solidarity difficult.
In her conclusion, Rivkin-Fish suggests some of the ways in which feminist projects need to take better account of the local realities of women's lives in Russia. While there is not much new in Rivkin-Fish's noting that Western feminism is based in a liberal language of rights that may not have the same moral resonance in other cultural and political contexts, it is always worth remembering this. Rivkin-Fish not only explains why strategies of empowerment based on gender solidarity and democratic individualism have been ineffective and even counterproductive in Russia, but also, insofar as she remains committed to a radically democratic feminism, suggests specific strategies that interventions into women's health care might take. This is welcome and important.
Women's Health in Post-Soviet Russia would be suitable for undergraduate courses in postsocialism, medical anthropology, or gender studies—it is clearly written, highly readable, and, especially in the second half, draws lively, often funny, and sometimes heartbreaking ethnographic portraits of the lives of Russian women from diverse social strata. It is also conceptually and theoretically rich enough to be of interest to graduate students and specialists in any of the above areas.