Russian syndrome

On the attitude of Russian residents to health, illness, treatment and doctors

In Soviet times, there was a popular joke about the “six paradoxes of socialism”: there is no unemployment - but no one works, no one works - but plans are being fulfilled, plans are being fulfilled - but the stores are empty... etc. Today’s relations look approximately the same Russians with their own health and medicine. The only difference is that the paradoxes of these relationships are difficult to reduce into such an orderly chain - they branch and twist, weaving into a rather bizarre knot.

Forgotten value

In public opinion polls, health invariably comes out one of the first places among life values. True, depending on how you ask: this result usually occurs when respondents are asked to select several items from a closed list. If the question is open and any values ​​can be named, few people remember health. How few people remember about him in real life: according to a survey by the Public Opinion Foundation, two out of three Russians do not pay any attention to their own health - at least until they get sick. Moreover, this almost does not depend on education, income level, place of residence, social adaptability, etc. The proportion of people who regularly do at least something to improve their health is somewhat higher among pensioners (many of whom the body simply does not allow to forget about itself) and residents of megacities, but in neither case does it exceed 43%.

These oddities become even more clearly visible when we are talking about a specific disease or problem that requires very specific protective measures. For example, influenza, a disease that affects more people in Russia every year than any other. According to another survey by the same FOM, exactly half of Russian adults believe that timely vaccinations can prevent influenza, but only 14% actually take them. And when infection does occur, almost half of flu victims (44%) experience the disease on their feet. Sociologists tactfully did not ask how many of them still go to work.

The famous Russian sociologist, director of the Institute of Sociology of the Russian Academy of Sciences Leokadia Drobizhev, having encountered similar paradoxes in his research, explains them by the fact that health is perceived by Russians as an instrumental value: it is needed not in itself, but because without it it is impossible to achieve more attractive things - a good education, work, success with the opposite sex, etc. “Young people understand that without health there can be no success, but their desires are different,” she sums up. This allows us to explain why the position of health in the list of values ​​depends so much on the presence or absence of a hint: when answering an open question, a person rarely remembers instrumental values, but when he sees them on the list, he may note them. The same hypothesis is confirmed by more subtle studies. In one of them, respondents were asked to choose three cherished desires. With this formulation of the question, instrumental values ​​“do not dance,” even if they are offered to the respondent - why waste desires on them, if what is achieved in life with their help can be ordered directly? In such a test, only 8% of Russian teenagers aged 15-17 years remembered health - while among their Finnish peers almost 42% named this value, and it shared second and third places with “good family”, second only to material wealth . In another study, where young respondents were asked not only to choose values, but also to clarify their attitude towards them, “health” came out in first place. But the majority of those who noted it agreed with the formulation “Health is, of course, important, but sometimes you can forget about it for the sake of additional income or entertainment.” What follows is clear - what is defined as “sometimes” when answering a sociological questionnaire, in practice often means “whenever you have to choose.”

The “instrumental” health status manifests itself not only in excessive stress on the body, but also in treatment - sometimes turning it into something the opposite. The usual picture: an average city dweller caught the same flu. In a few hours, a seemingly healthy person turned into a seriously ill person: cough, snot, high fever, often headache and nausea. Treatment tactics are well known: bed rest, drinking plenty of fluids, preventing complications. But this is only if health is an independent value for him. And for our hypothetical patient, health is the ability to cope with his social (primarily professional) responsibilities; he has no time to be sick. And he takes measures: Galazolin for a runny nose, Halls for a cough, aspirin for a fever. Having added a glass of folk remedy for all illnesses at night, he goes to work in the morning, confident that he did everything he could. In fact, he did everything to make the disease as severe as possible: he suppressed the secretion of mucus, which washes away viruses and reduces their concentration in the nasopharynx, which means the rate of spread of infection; lowered the temperature, which slows down the reproduction of the virus, and went to a crowded place to disperse viruses and cause complications. The “instrumental” approach determined tactics that are exactly the opposite of those dictated by real health care. Moreover, such “heroism” is clearly encouraged by society (including the educated part of it) - which can be seen at least from the pride with which people talk about how they went to work completely sick and how exactly they spurred on the failing body. They clearly expect the sympathy and approval of others - and, as a rule, receive it. And vice versa: a person who openly shows concern for his health (say, interrupting a conversation in order to perform special gymnastics exercises exactly at the appointed time, or refusing to be in a freshly painted room), even in an educated society, risks becoming the subject of ridicule - at least in absentia.

However, the demands of health come into conflict not only with the interests of business or the temptations of youth.

What should we be afraid of?

Once the author of these lines happened to see a characteristic scene. It happened at the Grushinsky festival, a crowded company of educated and intelligent people was sitting around the fire. There was an impromptu festival market nearby, and someone’s children brought from it a pile of luminescent toys, which were just coming into fashion at that time. For their parents, the glowing tubes and hearts caused serious concern: what kind of radiation is this? isn't it harmful? They did not calm down until they received authoritative advice from a doctor of chemical sciences who was present.

The matter, I repeat, took place around a fire, which - together with tens of thousands of other camp fires - filled the air of the clearing with a whole bunch of proven harmful agents: the most powerful carcinogen benzpyrene, microparticles of ash that can cause pulmonary diseases, etc. A fair portion of the participants in the conversation in I also smoked during it. But neither the fire nor the cigarette frightened them at all - unlike the ill-fated glowing tube, the label on which indicated that it had passed some kind of certification.

It is often said that Russian residents do not care about any risk factors. This is not entirely true: our compatriots are afraid of many things and consider many things harmful to their health. However, the hierarchy of threats they have developed strongly resembles the ideas of a mouse from a fairy tale, who shied away from all the animals he encountered, except for a cat.

I think each of the readers had to be present (if not participate) in the discussion of the environmental merits of different urban areas: this one has a forest park on the side of the prevailing winds, and that one has some kind of suspicious factory... I don’t want to say that these features of local geography actually have no health implications (although the real picture of their effects on people is much more complex than is usually imagined). But the best commentary on this problem that I know comes from Professor Simon Avaliani, head of the department of pulmonary diseases at the Moscow Academy of Postgraduate Education: “If you smoke more than a pack a day, you can even live right under the chimney of a coke plant - it won’t add anything significant to your lungs.” .

The persistent reluctance to take into account the harm of smoking (as well as alcoholic beverages) is usually explained by a well-known effect: the user of any drug creates a powerful psychological defense system around the object of his passion. “What is smoking there?! - says psychologist Georgy Rubchev, an employee of the Mental Health Center of the Academy of Medical Sciences. — Teenagers who were addicted to heroin were brought to our Center. The consequences of this addiction are clear and immediate, and some of the guys already had dead friends. So, our patients did not want to see a connection between their death and drugs.” There is no doubt about the reality of such an effect, but all cases of selective concern among Russians about their health cannot be explained by them alone. Any practicing gynecologist can cite an impressive collection of means and methods of “folk contraception” - up to beating a removed condom with a hammer in order to destroy sperm or punching a partner in the stomach immediately after the end of the act, “to kill the fetus.” Of course, this can be considered medical tales, but the fact that abortion is still the main means of regulating the birth rate in Russia is an immutable fact, annually recorded by state statistics. And when a doctor (or one of his enlightened acquaintances) suggests using modern hormonal contraceptives, the answer very often is: “But it’s harmful!” It is unlikely that abortion can be a drug for anyone other than clinical masochists, but, as we see, this does not change anything: the same superstitious horror of conditionally harmful or completely harmless influences (to the given examples we can add radiation from a computer screen, products from genetically modified plants, etc.) with amazing fearlessness in relation to truly dangerous things.

Usually the reasons for such an attitude are seen in ignorance, ignorance, lack of general and medical culture, etc. The validity of such characteristics is confirmed by studies showing that even in cities, no more than a third of adults know what vaccinations they have received during their lives and even what , what blood type they have - not to mention their genetic predisposition to certain diseases, risk factors contributing to their development, etc. The fact is that even among people with higher education almost no one sees the difference between a bacterium and virus (and, accordingly, can easily try to treat a viral disease with an antibiotic), I regularly have to be convinced from my own experience. However, it is impossible to attribute everything to ignorance: a person may not know the nature of luminescent radiation or believe that only transgenic soybeans have genes, and regular soybeans do not, but he certainly knows about the dangers of smoking - the phrase about a drop of nicotine that kills a horse, we all heard long before we met the cigarette.

It seems that another factor plays a significant role here. In one of the FOM surveys, respondents were asked the question: “What is the biggest threat to your health?” “Bad environmental situation” came in first place (21%), followed by “stress, nervous stress” (13%) and “low standard of living” (9%). “Bad habits” (7%) took only fourth place, and “own negligent attitude towards health” was mentioned in less than 1% of responses. The pattern is obvious: the main harm is attributed to what does not depend on the respondent, what he cannot change.

The desire of a post-Soviet person to evade responsibility, to shift it to some authorities and circumstances beyond his control is well known and manifests itself not only in matters of medicine (although it is precisely in these areas that such an approach can turn out to be literally deadly). But there is another side to the coin: the absolute distrust of the Russian average person towards any official information and, in general, towards any formal structures - be it government agencies, commercial firms or public organizations. From this point of view, the information about the dangers of tobacco and the harmlessness of hormonal contraceptives is equally unconvincing (“doctors say? What can they say when all these companies are telling them?!”). Only information received unofficially - from acquaintances (regardless of even the degree of acquaintance - “Valya’s husband’s first wife lay there, so he says ...”) or in an impersonal form (“and I’m somewhere here” can pass this filter I read..." or "I heard..."). It is clear that such selectivity of perception greatly contributes to the spread of remedies and methods of treatment based, at best, on distorted and simplified medical information, and at worst, on ordinary household magic. This is probably where the popularity of all kinds of “non-traditional methods of treatment” (from those mimicking conventional medicine to outright charlatan ones) is rooted, which, according to FOM, every fourth adult resident of Russia has turned to at least once.

However, some forms of treatment are not formally classified as “non-traditional”, but they cannot be classified as official medicine either. In recent years, the volume of sales of medicines has been growing very rapidly in Russia, while the number of requests for medical help has been falling. It seems that patients believe that they themselves have a mustache and know perfectly well what needs to be taken in this or that case (especially since treatment is often perceived as a means of quickly returning to work - which means that the medications chosen are mainly symptomatic). “The doctor has been replaced by a learned neighbor and a commercial,” Sergei Shishkin, director of scientific programs at the Independent Institute for Social Policy, formulated this trend. It is unlikely that the main reason for this behavior can be considered the notorious widespread advertising of specific drugs in the mass media - in this area, as in others, advertising does not create needs, but tries to find and exploit existing ones. However, there is no doubt that advertising supports and encourages such behavior (to the point that many commercials end with a direct call to “demand in pharmacies!”), Convincing the patient-buyer that he is doing the right thing.

Here we come to the attitude of our people towards medicine, the healthcare system and the medical profession. It deserves a separate discussion.

I don't want to see a doctor

The basis of this attitude is simple and unambiguous: the Russian average person does not like to go to the doctor. Experts, doctors themselves, and “people on the street” agree with this. The latter usually cite as an explanation either a lack of money (“now they have to pay for everything there”), or poor quality of care, sitting for many hours in the corridors of the clinic, and the inability to get to the right specialist.

It would be ridiculous to say that all of these are excuses: we all know from our own experience both the technical (and often staffing) level of district clinics, and the mocking registration rules, when in order to get to the right doctor, a patient, even if he is disabled, must queue after dark. But here are the results of a study by the Institute of Social Policy: the share of those who visited a doctor during the year among representatives of the “upper middle class” (small and medium-sized entrepreneurs and top managers) is almost no different from the same indicator for those living below the poverty line. Moreover, in 1994-2002 the dynamics of this share in both groups was almost the same: until the very end of the 90s it was consistently about 40% (and among the “rich” it was always even slightly lower than among the “poor”), and by 2002 it had dropped to 30%. Although the “rich” had access to a rapidly growing network of paid medical institutions in these very years (with completely different financial capabilities and standards of treatment of patients), while the “poor” could rely mainly on municipal institutions. It turns out that the frequency of requests for help does not depend in any way on the patient’s financial capabilities or the quality of medical services.

This conclusion is stunning: at first glance, it seems that this simply cannot happen. In fact, this is exactly what everything should look like if everyone - both poor and rich - goes to the doctor only when it is no longer possible not to go. Roughly speaking, if a person faints on the street, an ambulance will pick him up and he will receive some treatment, regardless of his level of income and his attitude towards medicine. The COI study shows that this type of relationship between doctor and patient prevails in all strata of Russian society. This is confirmed by the personal experience of doctors: every specialist has a collection of chronic patients who learned about their illness from an emergency doctor or through an accidental, unrelated visit to the clinic.

It would seem that with such an attitude towards medicine, people should be fairly indifferent to how exactly it is organized. However, any attacks on the existing system are perceived very painfully by Russian society. A sharply negative reaction was caused by a rather cosmetic project for the reorganization of health care institutions, unveiled in the spring of 2004, the most radical innovation of which was the merger of a network of children's clinics with general practice clinics. Met with unanimous indignation, the project was postponed - and sank into oblivion. It is difficult to even imagine what would happen if we were talking about the possibility of privatization of medical institutions (the legislative prohibition of which today greatly hinders the development of non-state medicine) or the renunciation of some state guarantees - for example, limiting the volume of medical care provided free of charge.

The attitude towards the problem of paid versus free medicine is striking in its inconsistency, even against the background of the above. Formally, polls record equality of power: approximately half of Russian citizens believe that medicine should only be state-owned and free, and the same number - that paid medicine has the right to exist. However, upon more detailed questioning, it quickly becomes clear that “supporters” of paid medicine most often see it as some kind of special medical service for the rich. In their opinion, it should differ from “conventional” medicine not by greater diagnostic and treatment capabilities, but by the level of comfort: separate rooms, personally assigned nurses, etc. (It is interesting, by the way, that respondents evaluate doctors mainly from the point of view of their human qualities: attentive-inattentive, sensitive-indifferent, kind-evil, soulful-soulless; professional qualities fade into the background.) Probably, opponents of paid medicine present it in the same way, but they believe that this is unacceptable.

Meanwhile, in practice, Russians, in cases where they still have to seek medical help themselves, not only willingly pay for it, but do it on their own initiative, persistently and sometimes even get offended if the doctor “doesn’t take it.” Moreover, as soon as a resident of Russia has the opportunity (primarily financial) to use paid medical institutions, he immediately ends all relations with free ones. If his level of income does not allow him to resort to the services of paid medicine in all cases, he turns to it in the most serious and severe cases. “If something is so frivolous, then you can go for free. And if you really have the urge, then it’s better to pay so that they can do it,” such statements are replete with interviews taken by sociologists and the minutes of focus groups devoted to the problem of payment for medicine. At the first opportunity, refusing free medicine in private life, people categorically do not want to agree with any limitation or derogation of the very principle of free medical care. By the way, the same patients who willingly pay a doctor or nurse (certainly in cash - any payment through the institution’s cash desk is perceived as “ripping off”) can wait months for the free medicines they are entitled to to arrive. Even if their illness requires continuous therapy, and their financial capabilities allow them to buy the same drug at a regular pharmacy.

Sociologist Olga Feygina believes that the actions of Russian patients are largely explained by the fact that the Russian healthcare system has ceased to be understandable to them: “Before, the rules of the game were known: if something happened to you, you had to go there and do this. How effective the actions were according to these rules is a separate conversation, but in any case, there was a well-known algorithm. Now he’s gone, and that’s what bothers people the most.” From this point of view, protesting against any new attacks on the heritage of Soviet medicine and seeking medical help through friends (with the obligatory “gratitude” from hand to hand) do not contradict each other - both are ways out of a situation with clear rules. Although, when applied simultaneously, they, of course, contribute to the perpetuation of a situation without rules. Additional difficulties are created by people’s lack of understanding about which clinic, center or institute is worth what. This problem is not specifically medical: any mechanisms based on reputation in Russia today do not work or work only with difficulty. But still, at least we already have ratings of universities or real estate agencies, but the market for medical services remains opaque.

Explanations for the strange relationship Russians have with their health may seem more or less convincing, but they do not answer the question of what to do about it. These relations have not developed today (much of the above was clearly noticeable at least back in the 70s of the last century), they are stable and show no signs of evolution towards greater adequacy. So far, in Russian society there is neither a social force interested in changing them (more precisely, one that has realized its interest in changing them), nor social tools that allow this to be done.