Abstract:This article examines medical utilization patterns and attitudes toward the medical care system among the citizens of Russia's second largest city, St. Petersburg. It focuses upon the extent to which both attitudes towards and usage of medical care institutions have changed in the immediate post-Soviet period. A particular concern has been to determine the degree to which utilization and perceptions vary across the socioeconomic status hierarchy. The data were collected in two stages: a mass survey (N = 1500) conducted in mid 1992 and intensive follow-up interviews (N = 44) conducted in late 1994. The findings indicate that urban Russians were very critical of their medical care system at the end of the Soviet period. Most feel that the system has deteriorated even further since the end of 1991, and they are particularly worried about the emergency care system and about hospital conditions. Although people believe that the system now includes more alternatives, very few have changed their medical utilization patterns to take advantage of these new possibilities. This is more a product of their perceived high cost than of principled opposition to "pay" medicine. The analysis also demonstrates the extent to which medical utilization differs by socioeconomic status. Lower status individuals tend to utilize the formal medical care system. High status individuals seek help from a variety of sources and, in particular, rely much more heavily on informal connections to the medical care system. The medical helpseeking strategies of higher status groups have proven to be reasonably adaptable to the post-Soviet medical marketplace, while for others finding good quality medical care remains more problematic.Key words: Russian medical care, medical utilization, health attitudes, socioeconomic status INTRODUCTION This paper examines recent developments in the medical care system of Russia, focusing on how the system is perceived by the ordinary Russian citizens who utilized the medical system before the Soviet Union ceased to exist in late 1991 and who continue to utilize it now. The data for this analysis were collected in St. Petersburg, Russia, between 1992 and 1995. While the attitudes and experiences of Peterburgtsy may not typify those of all Russians, it is our contention that examining the perspectives of an urban population which has traditionally been provided with better than average medical care is an important step in understanding how the population as a whole is responding to the current situation.

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This article examines the relationship between social status and medical help-seeking strategies in St. Petersburg, Russia. Analysis of in-depth interviews with a cross-section of the population revealed that access to and use of medical care varied greatly across the urban social structure. Those in the highest social strata used their knowledge and connections to gain access to the best care. Their social position and understanding of the system also privileged them in interactions with physicians, enabling them to take greater advantage of "free" services. Even with similar levels of material well-being, people with less education received poorer health care. Lacking confidence in their ability to assess quality and reluctant to consider options outside the impoverished, inefficient state medical system, they bore the brunt of its inadequacies. This reinforced a long-standing, culturally based predisposition to delay treatment until health problems had become more difficult and costly to manage.

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From its inception after the 1917 Bolshevik Revolution, the centrally controlled Soviet medical system attempted to monopolize medical practice-stigmatizing and punishing alternative practitioners who worked outside the state system. Nonetheless, alternative medical practitioners survived the seven decades of Soviet power. Ordinary people never stopped seeking them out, and since the late 1980s, the number of alternative healers in the Russian Federation has increased astronomically. The aim of this article is to analyze the forms of alternative medicine that exist in contemporary Russia and to offer an explanation for their continuing popularity in terms of popular conceptions of health and healing, the functioning of the state medical care system, and the attitudes of Russian physicians toward alternative healing. Article: In the years following the Revolution of 1917, the new Bolshevik government created the world"s first national health care system, a highly centralized structure designed to provide Soviet citizens universal access to medical services at no direct cost. From its inception, the system reflected the commitment of its organizers to "modern" biomedicine. They excluded other kinds of healers and implemented a variety of measures designed to wean the masses from their "dangerous reliance" on more traditional forms of treatment. The seriousness with which this endeavor was regarded is suggested by the warning of a prominent late nineteenth-century physician about peasant medical practices: "Many healthy people die in Russia because of [them], and even more are crippled and remain broken, weak, or feebleminded for an entire lifetime" (Frieden 1981, 91). Imperial Russia did, in fact, have the highest mortality rates of any European nation, and the physicians who ventured into the countryside in that era quickly discovered that they faced powerful local opposition (Ramer 1991; Ransel 2000). While some peasants welcomed the medically trained outsiders, many others regarded the doctors" interventions as at best irrelevant-perhaps even dangerous or sacrilegious. During cholera epidemics in the 1890s, medical personnel were violently attacked by angry peasants suspicious of both their methods and their motives (Frieden 1981). Like their predecessors, Soviet era medical leaders regarded stamping out health-related "superstitions" and suppressing the activities of nonphysician healers as vital to the nation"s health. Over the course of the twentieth century, substantial resources were devoted to those tasks. Nonetheless, at the dawn of the twenty-first century, neither biomedical nor alternative practitioners have total hegemony over the minds and bodies of Russian patients. Despite repeated efforts by Soviet authorities to marginalize or punish alternative healers, ordinary people never stopped seeking them out. In the post-Soviet era, these practitioners are more visible than ever. Our aim in this article is to examine some aspects of alternative medical practice in the USSR and in post-Soviet Russia and t...