Distributing international aid can prove to be a problematic process if background situations and local considerations are not thoroughly regarded. International intervention within the post-socialist Russian health care system was fraught with difficulties stemming from misconceptions, flawed perceptions and a lack of coordination between locals, international NGO workers and the state. The legacy of the socialist period cast itself on the future of development assistance, as public prejudices regarding expectations were transferred from communism’s failure to the failure of capitalism. How has international intervention and aid to the Russian health care system shaped the relationships between citizens, civil society, and the state; and how has this changing shape been affected by the socialist legacy? How have the concepts of public and private spheres in the socialist context affected the way aid is being received? What are the problems facing international health care aid to this region and what is the best way to overcome these problems?
This paper will explore the transformation of health care services in Russia from the Soviet period to the post-socialist era, detailing the realities of the health care situation on the ground. It will attempt to describe the changing perceptions of public and private space and the expectations that coincide with these spaces, recounting the growing dominance of one space over the other under socialism, and later its repackaged continuance under capitalism. It will then turn to the emergence of international intervention (in the form of NGOs and development assistance) that were focused on transforming the socialist state into a market democracy, and how this assistance was misinterpreted and perceived by many as insulting, damaging the possibilities for overall success. The difficulties facing the depoliticizing of aid are explored, as well as the misconceptions precipitated by the Cold War ideologies. Pro-natalist agendas are discussed as shifting the perceptions and institutionalizing moral responsibilities, a practice that was continued in the delivery of international assistance. The devaluation of Russian skills and knowledge (by Westerners) as a mechanism for change is explored, as well as the disregard and disrespect for Russian input which resulted in the marginalization of the local. The paper will then describe Western attempts at ‘democratizing’ the health care system from the ground up, and how this was limited because of vertical hierarchies in existence. It then details how the perceptions of the socialist state cast themselves on the perception of international aid and intervention, and prevented it from succeeding. The example of Uryupinsk is then described as a type of home-grown “civil society” that is able to meet the needs of its population, followed by recommendations for strengthening the health care system and ensuring aid is better received in the future.
Health Care in Russia
During the socialist period in Russia, there were two phases of health care, the first taking place during the 1920s. This first period was dominated by the Marxist perception that illness within society was primarily the product of sickness (inequality and capitalism) in society and that the “cure” to problems such as alcoholism, drug abuse and prostitution would be socialism. This phase deemphasized the value of scientific and clinical approaches to health care and instead narrowed in on socio-economic factors. Beginning in the next decade, the second phase saw more scientific approaches to care exhibiting a belief that work force capacity was dependent on the health of its workers (Bar and Field, 1996). Poorly managed and poorly funded programs that left physicians without pay, resulted in fees-for-service, extending hospital stays and providing unnecessary treatments as money-making ventures (Rivkin-Fish, 2005:86). After the fall of socialism, a third phase occurred and involved reigning in already minimal payments by the government to the healthcare system and reducing the hospitalization rates and lengths of stay of patients as a means of limiting spending and becoming more “cost-effective” and “efficient” (Rivkin-Fish, 2005: 89).
During the Soviet period, education, healthcare and child care were to be provided by the state at no cost to the citizenry. The health services in particular however, were often under-resourced and segregated based on the person’s position within the Communist Party, their access to extensive personal networks and their ability to pay the increasingly expected fees and tips for supposedly free services. The government publicly prioritized the training and recruitment of doctors and provided large numbers of hospital beds, but often neglected the quality of the personnel or facilities being offered as the percentage of GDP spent on healthcare services plummeted (Bar and Field, 1996).
Professional associations for physicians were outlawed during the Soviet period. This resulted in the removal of an important system for monitoring the quality of care and the chance for physicians to lobby for better working conditions and rights. Claims of bribery, corruption and network favoritism cast shadows on the admission and graduation processes of many physicians, causing their skills to be considered extremely sub-par or non-existent by Western standards. Doctor’s wages came last among state spending, many receiving lower salaries than factory workers, leaving them with little choice but to charge their patients fees in order to survive. Pharmaceuticals and supply shortages lead to a reliance on gray and black markets for the provision of basic materials. Many hospitals lacked even adequate plumbing or sanitation systems, and electricity or the equipment necessary to run basic tests (Bar and Field, 1996). Patients were asked in some cases to provide their own bed sheets, nourishment and even blood for transfusions brought from home if having an operation while in the hospital (Rivkin-Fish, 2005:87) The dissolution of the state after the fall of communism led to a further erosion of these already abysmal services (Hemment, 2004, Spring). The World Bank and International Monetary Fund (IMF) restructured loan payments with the government, and advocated for the state to eliminate promises of universally free healthcare and to reign in their health spending, exacerbating the underlying problems and compromising patient care (Rivkin-Fish, 2005: 87-9).
The Changing Relationships between the State, Civil Society and the Individual
Radical economic and social reforms enacted by the new governments, who were under World Bank and IMF pressure, failed to install more equitable socio-economic structures. Rising unemployment, withheld wages, and hyperinflation forced the already poor and desperate to rely on personal networks in order to obtain the social security that the government was failing to provide (Hemment, 2004, Spring). Janine Wedel (1998:3) comments that many Westerners were and still are “naïve to the realities of the Eastern world and the political skills it took just to survive” on a daily basis. The changing relationships between the individual and the state and the growing institutionalization of the private sphere exacerbated the citizen’s distrust for the state. This distrust was later projected from the state onto Western aid and interventions (which will be discussed in a later section).
The public sphere is traditionally regarded as an inclusive space where private individuals could come together as a public to debate issues of public authority such as governance. The private sphere complemented this sphere as an area traditionally outside of the reach of the government or public institutions (Habermas, 1989:27). Civil society was seen to occupy the space between the state, the market and the private; and conventionally consisted of NGOs, associations, community groups, trade unions and social movements (Centre for Civil Society, 2004). The public, private and civil society spheres have been referred to as the legs on a “three-legged stool”, with a separate but equal balance existing between all three legs. In reality, the situation is slightly more complicated as balance is not necessarily equitable, and the legs are not entirely separate. A common neoliberal assumption asserts that there should be a distinct separation between the private, civil society and the state. This assumption neglects to realize that the boundaries between these entities are not always clear (Drue, 2002: 187-200).
Modern housing made available after the fall of communism allowed many citizens their first access to a truly “private” sphere, a location reserved specifically for families that could be closed to neighbours and other uninvited visitors previously forced onto the private sphere by institutionalized situations such as communal apartments during the Soviet era. The “official” or “public” sphere (that being controlled by the Communist party) became increasingly dominant in daily life under socialism, as housing was communalized, and a wide array of topics became too dangerous to be discussed in “public” spaces, which were now extended to sometimes include areas within people’s own homes such as shared kitchens, hallways and bathrooms (Oswald and Voronkov, 2004).
The state privileged the public over the private sphere. Increasing productive and reproductive duties were nationalized and incorporated as individual moral responsibilities making once private issues public concern (Einhorn, 1993:31-3). This private and public tension was further exacerbated by the secularization process undertaken by the state during socialism that strove to limit private influence in the public sphere (Richardson, unpublished, 2008). Destined for disaster, the state increasingly took on more responsibility by broadening its political reach into the private realms, overburdening and overstretching its already thin capacity. The state lacked equitable distribution capabilities, dooming it to be resented by the people whose needs were increasingly being ignored. The increasing control of the private sphere where individual responsibilities became public responsibilities only intensified the already deep resentment towards the state for its distributional failures. The fact that the state lacked the structural capabilities to fulfill its existing promises without taking on increasing responsibilities, made these private intrusions all the more hated (Oswald and Voronkov, 2004).
Gal and Kligman (2000: 39) suggest that the private and public spheres are not mutually exclusive and are more like a nested set of ideologies that are overlapping and malleable, sometimes permitting the private within the public and vice versa. The exact distinction between public and private is completely relative to the interactional situation to which it is applied. Civil society often appears as a sort of public within the private sphere, or as a private interaction between individuals and the state existing usually in public space. During the Soviet era, “civil society” in the western sense was almost non-existent, as its functions were being primarily met or excluded by the state. Thus civil society came to be known as anything not being determined or offered by the Communist Party (Hemment, 2004 Spring). International foundations in the post-socialist context presented civil society as the antidote to the state, which was characterized as corrupt and obsolete in Russia even though the state was needed for these NGOs to gain recognition, practice legally and distribute resources (Drue, 2002: 183).
The growing distrust for all things public, stemming mostly from a lack of adequate resource distribution, favoritism and corruption amongst unequal hierarchies, increased estrangement from the state or public sphere and induced a withdrawal of many citizens from the routinization, institutionalization and standardization that socialism was providing. The boundary between public and private was blurred and permeated by the resource-attaining practice of blat, a collection of personal networks that transcended the private sphere while attempting to obtain public goods (Oswald and Voronkov, 2004). Public space became increasingly masculinized after the fall of communism, as competition for jobs forced many women from public roles and back into the home, leaving little space for female involvement outside the private sphere. These women, barred from the traditional public sphere, often became increasingly active within civil society, organizing associations and NGOs and leading to a feminization of the civil society sector (Hemment, 2004, Spring).
International NGOs Combating Communism
International aid and nongovernmental organizations (NGOs) entered the former USSR upon its collapse, with the original intention of combating communism and transforming the state from communism to capitalism (Wedel, 1998). Expanding civil society was seen as instrumental to the development of free markets and democratic ideals (Hemment, 2004, Spring). The main categories of aid and NGO work being supplied internationally to Russia were interested in privatizing former state services, developing the private sector (including private property reform), democratization and basic humanitarian assistance such as health care. A disconnect between the West and the East facilitated by the Cold War ideologies however, prevented this work from being fully effective (Wedel, 1998: 4). NGOs were painted in opposition to the state, as inherently “good” and representing everything the state could not provide in a less bureaucratized, and more efficient manner that was able to reach local populations more effectively than centralized resource distribution (Fisher, 1997).
The West was originally regarded with suspicion, but also lauded as a potential savior whose eventual assistance was never really in question since it was perceived as fully capable of distributing resources. The East considered the West as a kind of rich Soviet Union able to furnish the vast array of products and services not being supplied under communist rule (Wedel, 1998: 22). The West lumped most of the former states of the USSR into the category of “undeveloped”, akin to the Third World, as they began providing aid, NGOs and development schemes to ease the transition from communism to capitalism in the region. This was interpreted by Russians as insulting since many saw themselves as being more or equally “civilized” and “cultured” as the West, needing institutional and social changes instead of economic growth and handouts (Wedel, 1998: 20). The problems in the post-socialist era were difficult to address as Hemment (2004) explains in her example of a highly educated woman with graduate degrees, who lives in a tiny two-bedroom apartment with no hot water, her family of five and her in-laws. The socialist situation was comprised of a highly educated population living in extreme poverty, with few rights and unable to make a living, and differed greatly from the Third World situations.
International anti-communist, pro-natalists intent on transitioning Russia towards capitalism after 1989, were accused by Russians of working to strategically depopulate the country due to their push for abstinence and individual moral changes in the face of existing East-West tensions, perceptions and suspicions (Rivkin-Fish, 2005: 215). Applying pre-existing and inappropriate models of aid in the Russian context had the reverse effect of transference to capitalism by solidifying support for the socialist parties and strengthening “mafia-style” networks that were clinging to resource possibilities and the power vacuum created upon the state’s retreat. The lack of transparency along the aid-distribution channels intensified the connection between the realities of the former socialist state and the realities of capitalism, as Western aid, untracked, was assumed to be in the pockets of the elites, much as under socialism. Many Western aid officials were assumed to be spies sent by the West to evaluate the potential competition of the Eastern producers, with as much as two-thirds of the Russian population believing that the US had a calculated anti-Russian foreign policy (Wedel and Creed, 1997).
Depoliticizing the Political
Perceptions can shape the success or failure of any aid mission, and to be most successful aid must be apolitical, not operating within the standard political debate (Creed and Wedel, 1997). The depoliticization of aid became nearly impossible in Eastern Europe as the socialist legacy ensured the economy was completely controlled by the political apparatus. Personalistic connections were required for the NGOs and associations to distribute, arrange and acquire resources, lending legitimacy to the existing inequalities and undermining attempts at institutional and social reform. Many sectors, such as health care and agriculture were highly politicized. Collectivized farms, for example, were seen as the biggest threat to capitalism, with Communist support being saturated mostly in rural areas. Attempts to decollectivize were promoted as the best way to defeat the remaining Communist influence that was primarily in control of the collective farms, essentially restricting the possibility of production to non-collective means, eliminating a way of life for many and hailing capitalist production as the only possible way (Creed and Wedel, 1997).
In health care during the socialist period, the state largely ignored its purported responsibilities to its citizenry by blaming “low levels of culture” (Rivkin-Fish, 2005:91) and an “underdeveloped sense of individual character” for ill health. It began targeting the individual for moral transformations instead of examining the possibility of structural or policy reforms. This essentially privatized perceptions and shifted the blame from state to individual. The widespread use of abortion during the socialist period offers a prime example of this politicization. The Soviet pro-natalist and state-production agenda originally passed restrictions on abortion, focusing on the size and quality of the population as being most important to national production and essentially making the issue one of national security (Rivkin-Fish, 2005:4-5).
Abortion was later institutionalized as the most accessible means of fertility control with all other choices being almost non-existent. As a result, abortion rates more than doubled the live-birth rate and the population began to decline. Official policies institutionalized the focus onto the individual as potentially antisocial and degenerate, changing health education to conform to standards of ‘proper’ hygiene and sexual restraint and making the problems individual moral problems as opposed to state structural ones such as growing inequality, poverty and the decline in universal services (Rivkin-Fish, 2005: 93-4).
Reinforcing Social Inequalities and Hierarchies
International aid officials decided they had seen the problems of the Russian health care system before and applied inappropriate and existing models from the Third World to ‘fix’ them. They were critiqued as not listening to Russian input or promoting cooperation and sharing of ideas between the East and the West; instead lecturing and devaluing the professionals in existence even though they claimed to be working in a democratic fashion in collaboration with the locals. They assumed total Russian ignorance and ignored the scientific and research opportunities in the socialist context that gave many Russians knowledge and abilities equal to or surpassing Western knowledge and abilities. Aid officials attempted to make appeals to change more receptive to the Russian audience by entirely disregarding their knowledge and former modes of care (Creed and Wedel, 1997). Westerners also completely ignored Russian priorities while claiming to be promoting them. Russian officials in the early nineties placed low priority on the health care system instead focusing on socio-economic and ecological causes of disease, while the WHO (professing to be following the priorities of the Russians) prioritized sanitation and maternal and infant health as the most pressing issue (Bar and Field, 1996).
An anthropologist noted the disrespect offered by many international organizations to local organizations at local-run events. This disrespect was evidenced in their sending low level workers with little decision-making capability that “dressed in blue jeans”, “appeared bored” and were unable to comprehend the language or situation at hand (Drue, 2002: 192). Drue (2002: 205) also illustrated the marginalization of local groups who had to account for their lives and convince sponsors of their social worth in order to receive funding or acknowledgement. This was compounded further by a complete lack of attention from the government and media even after receiving extensive NGO training in media and governmental relations by international parties and attempting to implement this generic training in the Russian context.
Convinced that the Russian health care system was akin to medical practices in the West in the 1960s and 70s, the international community emphasized the Russian’s problems as being “familiar” or “behavioural” and not technological or induced by systemic poverty. They moved away from the original focus of maternal mortality to narrow in on issues such as changing the practice of separating mother and child at birth, promoting breastfeeding over scheduled feedings; allowing companionship during birth, removing the “dehumanized” nature of practices and changing the emphasis from institutional demands to consumer wants and needs. This characterization of “dehumanized care” led the World Health Organization (WHO) to promote the reorganization of post-natal care from concentrating on biomedical expertise to the individual needs and demands of the patients. This essentially recontextualized the original issue of maternal health into a women’s social issue that ignored the local cultural norms and standards. It blamed the physicians while ignoring the role of the state attempting to be apolitical. What the aid officials didn’t realize is that the political was already thoroughly intertwined in the health care system through the unequal hierarchies (where physicians received low status against the powerful state), and the blurred boundaries that existed between public and private spaces that allowed for state control on almost all levels (Rivkin-Fish, 2000: 79-80).
‘Democratizing’ Clinical Practices
The Russian physicians blamed their problems on a lack of proper supplies, equipment, communication and financing from national sources, and placed little value on the institutionalized and medicalized nature of their health system. The WHO’s focus on eliminating embarrassing (by Western standards) procedures such as the forced provision of enemas and pubic shaving, routine in Russian birthing practices, reflected a lack of local cultural understanding of the body and its care in this region as Russians saw this to be an unimportant issue. Westerners assumed the medicalization of health care practices during childbirth equated to the subordination of women as a need for physicians to assert their power, much as doctors had in the West in the 1960s and 70s (Rivkin-Fish, 2005: 60-90).
International bodies assumed that the Russian physicians’ resistance to change was induced by a self-interested quest for power, much as in the West, due to their prestige and position as a physician and the lack of knowledge of their patients. They neglected to realize however, that physicians in Russia were not afforded the same status as in the West. In fact, the deep investment in the ideology of biomedicine, which stressed technology, knowledge and research in medical practices, was rooted in the need for physicians to achieve professional efficacy in a hopeless socio-political environment. Little chance for advancement of material or symbolic power due to low wages and poor status as a physician resulted in many clinging to their knowledge over their patients as a way to express their social dominance and experience social power that was otherwise missing from their lives. In fact, the feminization of the position was seen as caused by declining wages and low political socio-economic status, resulting in more than seventy percent of doctors in Russia being female. The West’s assumption that the Russian present was the same as their past neglected to address the low status to which doctors were afforded in Russia, and prevented the Russians from heeding the advice to individualize and humanize care (Rivkin-Fish, 2005: 60-72).
The international aid community failed to acknowledge the undemocratic position that physicians were accorded due to their limited access to state communication, policy direction and financing. Instead, they plowed along promoting a ‘democratic’ clinic setting hoping it would vertically transcend the hierarchies in existence, but not realizing the physicians didn’t have the technical, political or financial means to make it happen. By “throwing out ideas” at the individual level and hoping that they “plant seeds” into larger structures, the international community essentially commoditized these ideas, making them “seemingly available for any individual to choose according to their desire and whim” and un-attaching them from the structural positions in which they are embedded (Rivkin-Fish, 2005: 61).
The perception of international aid as being able to actually distribute resources and make changes quickly faded, casting it in much the same light as the former Communist state that was also unable to equitably distribute. The promises of change and lack of actual structural transformations brought about by the promises, only further isolated the population from the hierarchal structures of aid, and made them continue to be reliant on their own networks for survival. Individual blame and expectations of personal change as a way of achieving democracy, with no demands on institutional or structural changes, angered the population into resistance and reminded them of the public intrusions by the state into their personal affairs. The lacking levels of transparency and use of blat networks to distribute resources also painted international assistance in much the same light as the state. These perceptions and associations determined the fate of international intervention and prevented it from being a true success.
Hope for the Future
Is it possible for international aid and intervention into this region to be successful? Is international intervention even necessary and what can be done to ensure that this intervention is not reinforcing current hierarchies? The example of Uryupinsk, a city in the Volgograd region, demonstrates the ability of the community to strengthen itself without international intervention.
Uryupinsk has an incredibly active population with a strong sense of community and incredibly proud citizenry whose needs are being primarily met through local initiatives. The local cell of the Communist Party of the Russian Federation (KPRF) has taken on the role of civil society within the community and has been able to provide quality services for its citizenry. Since the KPRF is no longer the party in charge, it is able to play the role of intermediary between the population and the state. Zhensovets (women’s councils), trade unions and street committees are extremely active and powerful and are being fully promoted and funded by the KPRF.
The street committees are the most power organization at the grassroots level, and are able to deal with about half of the problems, conflicts, sanitary and welfare conditions of its population without using any state judicial or structural authority, literally reaching everyone in the community. They have also been described however, as the political machine of the mayor, as they use his access to networks and resources to negotiate supplying the population with their needs and desires in return for votes in the elections. The people who lead the street committees are actually neither directly imposed on from the state or criminal groups, and are able to use negotiation with these groups to provide for the welfare of their community. Their primary responsibility remains to the population (Kurilla, 2002).
If this is the case, it would seem a local form of ‘democratic’ structure has taken root here, sprung from the communist remains. The politicians are providing the citizens with their needs in return for votes. If the politicians failed to meet their promises, the citizenry could choose to change their votes in the next election, and find other ways to meet their needs. This example shows that the Russians are able to meet the needs of their population by themselves and use the existing networks to negotiate change. It is not without difficulties and problems, but shows that collaborative efforts created specifically for the Russian context by Russians have the ability to work and need to be encouraged.
International intervention would best be served as a two-way, collaborative effort between East and West as opposed to an imposition directly led by the West. Russians should direct their own priorities and be given the voice to strengthen their own structures. The international community would be best to address the issues of socio-economic inequality in the light of structural hierarchies that exist instead of focusing on individual changes to achieve democracy. The Russians have the ability, knowledge and passion to change their own future, but are being denied this possibility because of structural and institutional problems. Changing the role of the state sphere so that it doesn’t interfere into personal freedoms would be the first step for the Russians to attain balance and respect within their own system. International financial institutions like the World Bank and the IMF should promote the strengthening of certain state structures, such as the health care and education systems, so that they are functional on at least a basic level instead of trying to privatize all enterprises, to ensure the population is able to be productive and thus pay back their loans.
The governments need to prioritize their spending so that the basic needs of their citizens are being met, and restructure their system to allow for public input and opposition. The individuals need to be empowered by the state to take on this role, so that they are directing the services and in charge of their own future. The state must be supported by the international community in its efforts to be more transparent and accountable to its population. Specific sanctioning and provision of aid given on the conditionality of being as transparent as possible could help push the state towards this goal and help to ensure that aid is being received where it is needed. Investment into proper facilities, wages and equipment within the health care system is necessary for adequate levels of care. The encouragement of physician’s associations who can lobby for better conditions, education and services by the state and international officials, could help to strengthen the health care services and provide the physicians back their sense of pride and status. Most importantly, the Russians should decide how their systems should run, and all initiatives should be on a thoroughly collaborative, Russian-directed and specific basis.
This paper has demonstrated the state’s intrusion into the private sphere under socialism and how this intrusion led to resentment and withdrawal by the citizenry. It has shown that Western intervention and aid was received in this context, using these structures and reinforcing them in the way it structured and provided its assistance. It described the attempts of international officials to remain apolitical in a highly politicized environment and how this reinforced the structural hierarchies and prevented success. It detailed the crumbling health care system in Russia and how the undemocratic structure within the system left physicians with little power to make change. International intervention placed their emphasis for change upon these individual physicians while ignoring the larger structural problems that were preventing actual change. The need for a balancing of public, private and civil society was addressed as well as the importance of cultural specificity in the design, implementation and delivery of aid.
The Russians are fully capable of directing their own systems, and are in the most appropriate position to design programs that will exact positive change within their region. Aid supplied in non-specific, and unaccountable ways will only further exacerbate the underlying problems and provide temporary solutions to short-term needs. The international community would be best to provide assistance in the form of knowledge sharing, technological transfers, promoting localized solutions to problems and the restructuring of the state so that it is able to meet the needs of its population. It cannot do this without transparency in the face of clouded cultural perceptions. The international community needs to learn to work in collaboration with populations, governments and local organizations, in a more secondary or assistive and not authoritative and superior manner.
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