III Anthropology of East Europe Review THE EFFECTS OF PERCEIVING "WEAK HEALTH" IN RUSSIA: THE CASE OF BREASTFEEDING Cynthia Gabriel The state of Russian health has declined dramatically since the collapse of the Soviet state in 1991, according to both lay and expert accounts. This trend receives enormous attention; political, medical and everyday discourses often focus on the "weakness" of Russian health and the demographic crises faced by the nation. Doctor Mikka Vienonen, head of the World Health Organization in Russia, claims that "Russian medical figures show that only one baby in lOis born healthy here, while pregnancy is around ten times more dangerous for a Russian woman than for her British counterpart" (Wyatt 200 I). An oft­ quoted statistic is the depressingly low Ii fe expectancy for Russian men. From a high of 64, this number plummeted to a low of approximately 56 in 1993 and is currently recorded as 58.9 (WI 102003; Cockerham 2002). As birth rates have also fallen, most Russians are keenly aware that Russia is losing population. According to the conservative estimates of President Putin, the death rate outstrips the birth rate by 750,000 persons per year (Putin 2000). More poetically, in the words of one informant, Dr. Yakoleva, "Russia is dying." Concerns about a weak and dying national body intermingle with and help constitute another set of fears - fears about food, including the earliest food of all: breastmilk. Fears that post­ socialist food (domestic and imported) do not contain necessary, life-supporting nutrients arc especially acute among pregnant and lactating women. In this paper, I will examine the phenomenon of "low breastmilk supply," a problem that both Russian women and Russian medical workers find to be serious and widespread. Official statistics support such fears that the post-socialist period has had negative effects on pregnant women's and infants' health. Kulakov, et ai, claim that whereas in 1993,25% of babies were born completely healthy (already a drop from previous Soviet times), in 2000 that number has dropped as low as 7-9% (Kulakov 2000:9). Kulakov warns that future generations could be even worse off~ since teenage girls today (the mothers of the next generation) are not eating well and generally have a weakened state of health (ibid). The purpose of this article is not to dispute these statistics directly, but to understand the cultural context in which, firstly, such statistics can be collected and, secondly, in which they can contribute to the adoption of particular medical practices. I will focus here specifically on the medical practices surrounding breastfeeding. By explicating some of the important cultural-medical factors in breastfeeding practices, I hope to open up a dialogue with both Russian and international health professionals. In particular, I am addressing western professionals who are attempting to shape breastfeeding practices and policies in Russia in the post-socialist period. In this cross-cultural context, then, I am also interrogating 1) how Russian understandings of health differ from dominant, western, biomedical understandings and 2) how the culturally-appropriate treatments for weak health in Russia, including weak health that leads to problems in breastfeeding. differ from western treatments. 1 found that a prevalent discClurse Jbout "weakness" has profound and \\ idel: reach in:,' effects in Russia today. Whereas :\orth Amer<"Jrl and western European medical professionJls tcnj to talk about women or babies "at risk." RussiJn medical professionals tend to use the discourse and category of "weakness." A diagnosis or suspicion of weakness implies that the mother will have trouble breast/ceding, probably due to an inadequate milk supply, and that the baby will also have trouble breastfeeding, especially getting enough nourishment and nutrients to gain weight and thrive. The Russian medical professionals with whom I worked emphasized, first of all, the need for rest (and concomitantly doing away with stress) and, secondly, the need for an improved diet in order for the women and babies to overcome their weakness. Both the conceptualization of the problems and the treatments themselves are understood differently by most western medical practitioners. In the breastfeeding model adopted by the World Health Organization (WHO), for instance, most mothers and babies are assumed to be healthy -- not weak. With this assumption, there is no need for "extra" rest or supplemental herbs/nutrition; instead, there is an emphasis on the mother-baby relationship and close contact. From this perspective, Vol. 17. No. I 2003, Page: 91 Anthropology of East Europe Review "'rooming-in"" (the practice of leaving babies in the same room as the mother) is assumed to be a universal solution to breastfeeding problems. Theoretical-Practical Approaches to Breastfeeding Here I will say afew words about my fieldwork and the theoretical-practical approach to midwifery and breastfeeding that I took with me into thefield. I conductedfieldwork primarily in two urban settings in European Russia, Nizhni Novgorod and St. Petersburg, during the year 2000 and on a month-long research trip in 2002. I also conducted some interviews and attended some classes in Yaroslavl and Moscow. In Nizhni Novgorod, I worked closely with Valentina Zakharova, a homebirth physician, attending classes that she taught, accompanying her on pre­ and post-partum home visits and attending births. IfiAlowed several families closely, including some families who gave birth at home with Valentina und others who gave birth at a state hospital, both bejiHe alld after they gave birth. In addition, I conducted interviews with over 100 Russians about their birth experiences. 1also attended state­ sponsored and private infant care and childbirth education classes at various biomedical offices. 1n Sf. Petersburg, 1worked as a midwifery apprentice in a more orthodox biomedical environment: a maternity hospital or roddom, through the Russian Birth Project. This project, run by an American midwife, Molly, is designedfor American students to learn midwifery and gain experience at births. Six interns participated in the summer of2000. The Russian staffhad widely varying attitudes toward us, as a group and individually. Some openly accepted our group and eagerly shared their knowledge and expertise; others appeared to resent our presence and interacted with us only begrudgingly. Most of the interns in our group actively espoused a particular set offolk beliefs about birth that are relatively counter-cultural or alternative beliefs to hold in the United States, but that are more accepted internationally, for instance, by the WHO. (One intern did not; she was a biomedically-trained nurse). Most ofus associated ourselves with the midwifery model ofcare, which stands in sharp contrast to yet anotherfolk medical system, biomedicine. 1use the term 'folk medical system" to highlight that all medical systems are cultural systems; that is, our understandings ofscience, bodies, illness and healing are culturally constructed (Lock 2001). Though the midwifery model ofcare differs greatly .trom the biomedical model in the United States when it comes to labor and delivety practices, they are increasingly harmoniolls, at least in theory, when it comes to breastfeeding. What we found in the roddom was a system that is certainly not oriented on this midwifery model of care, but that also differs from western biomedical practices in significant ways. I will first describe what we found to happen in the immediate post-partum period and then I will examine a particular encounter with a Russian mother and physician. The practices we observed and participated in at Roddom #2 may, in some particular ways, be unique to this field site. (For instance, babies at this roddom often wore a soft neck brace for several days to prevent and heal spinal trauma; this practice was not widespread at other roddoms.) However, I found that many of the practices that I relate below are quite common. They were described to me by dozens of women, in four different Russian cities, when I interviewed them about their birth experiences. At Roddom #2 in St. Petersburg, I struggled to understand these beliefs about breastfeeding. As part of the Russian Birth Project, I was learning midwifery and cultural practices from the Russian staff, but also providing American-style labor support to the birthing women. After babies were born, I, along with other Americans, often tried to get breastfeeding going early, based on our American folk medical beliefs that this is the proper way to establish breastfeeding. Though we usually asked permission of the Russian midwife or doctor on call that day, moving a baby from the examining table to the mother's gurney in the first hour or two after birth always felt like a transgression. We knew we were doing something counter-cultural. The new mothers did not seem to feel this same sense of transgression and this helped to embolden us; I am rather sure that they, themselves, were mostly unaware of what is considered normal practice in the hours after delivery. Birth Practices in a Russian Roddom Normally, after the cursory "bonding" moments, newborn babies are separated from their mothers for the first few hours after birth. While the mothers lay on a gurney in the hallway with a weight on their stomachs (to help the uterus contract), the newborn babies lay alone in the birthing room, on the newborn examining table, underneath warming I ights (Figure I). Eventually, a pediatrician retrieves the baby from the birthing room and moves it to the nursery. This can take Vol. 17, No. I 2003, Page: 92 • Anthropology of East Europe Rcvie\\ anywhere from 45 minutes to up to two hours. The mother, meanwhile, moves to her post-partum room sometime between one and three hours after she gives birth. Depending on the time of day or night that the woman gives birth, she will probably see her baby again in the evening or in the morning following delivery. At this first meeting, the baby is tightly swaddled in warm blankets (Figure 2). A nurse or pediatrician hands the well-packaged infant to its mother, who is usually laying or sitting in bed. Only the baby's face is visible. The mother is given breastfeeding advice and help, but many women do not succeed in latching their babies on during these sessions. The advice that Russian medical professionals give to new mothers about breastfeeding problems tends to focus on herbal and dietary remedies to promote breastmilk production as well as admonitions to rest. There is no breast pump in the roddom and I never heard medical advice about pumping or storing breastmilk. In the nursery, all the babies were given bottles of glucose water and/or formula. In general, there was acknowledgement on both the part of the Russian women and the staff that breast feeding was a "problem," and, specifically, that many women were not producing adequate supplies ofbreast milk. The American midwife with whom 1 worked explained this problem one way; the Russian staff explained it quite another. Molly emphasized that the babies were being bottle-fed on a schedule, so they were not hungry when they were brought to their mothers. Also, though swaddling helps calm infants, it made them too sleepy to breastfeed. Skin-to-skin contact, she believes, helps stimulate the infant's sucking reflex. The Russian staff: on the other hand, took this phenomenon - that the babies had trouble latching on right away - as an indication of the basic weakness of both mother and infant. The practice of giving glucose water and/or formula to newborn infants is so widespread that even in cases when new mothers specifically request to breast feed exclusively and on demand, they often find their wishes thwarted. For instance, in Nizhni Novgorod, I interviewed Sveta immediately after she returned home from the roddom with her 6 day old baby girl on March 26, 2000. She already had one child, born at horne with Valentina, whom she breastfed quite successfully. She had planned a homebirth, but because Valentina was in Moscow when she went into labor, she ended up delivering at a roddom and staying there for the standard five days. This time, she encountered breastfeeding difficulties that she attributed to the practice of bottle- feeding babies in the nursery. She relates, When they brought her to me, she was already full and asleep. I couldn't wake her up. Not for anything. The pediatrician who came in the morn ings made a note that, 'Marina has a lot ofmilk, please don't supplement this baby,' so one day the nurse came in and asked, 'Whose baby aren't we supposed to feed')' 'Mine~' But by the next day, they'd forgotten. In Roddom #2 in St. Petersburg, I also found that mothers who desired to breastfeed on demand had trouble communicating this desire effectively. They sometimes asked for our American help to intervene. I often found myself pleading with a reluctant nursery doctor or nurse for permission to take an infant to its mother for feeding. On the one hand, such requests certainly created more work for these medical workers (the reason that many new mothers gave for their reluctance). On the other hand, comments such as this one from the medical worker on duty July 20. 2000, made me realize that more than that is g(ling on: "Sure, you can take her the bab:. But J don't understand. We're tahng care of her [the hab; j and she can sleep. \\'hy rush things' '\ext \\ eek [when she can't sleep throut'h the night] ,he'll understand things difterently.-- I understand comments such as these to indicate that these requests also conflicted with medical workers' understanding of the proper use of maternal time in the roddom, which was to rest. Ethnographic Encounters: My Breastfceding "Success Story" I will turn now to an encounter that helped turn around my thinking about these very different approaches to breastfeeding. In July 2000, I gave labor support, along with two other American interns, for eight hours to a woman named Natasha. After the birth, Natasha's baby (Danil), was left alone in the same room where he was born, underneath warming lights, while Natasha was wheeled to a separate room for suturing. When the suturing was completed, Natasha's gurney was left in the hallway, outside of the room where her baby lay swaddled. One of the other Americans, Sara, and I decided to ask Natasha whether she'd like to try breastfeeding. I felt comfortable and close to Natasha, after spending so many hours with her throughout her labor and delivery. VoJ. 17. '\0. I 2003. Page: 93 Anthropology of Fast Europe Rc\ iL\\ It was already almost two hours after the baby's delivery (about 9 p.m.) when we approached Natasha about breastfeeding. She was very tired, but agreed to give it a try. We retrieved Danil from under the warming lights and brought him to her gurney in the hallway. We knew the Russian midwife and doctor were just down the hallway and could hear us, but they did not make a move to intervene, and we continued. Natasha lay on her back, with a weight on her stomach. and was reluctant to move from this position since the midwife had told her that the weight was very important. Though this is not the optimum position for a new mother just learning to breastfeed, Sara and I said we would hold Danil so that he could reach her breast. Danillatched on right away and sucked voraciously. We let him breastfeed for about ten minutes on one sidc and, as he seemed eager to continue sucking, moved him to Natasha's other breast for another ten minutes. At this point, Natasha indicated that she was tired, so Sara and 1 brought Danil back to his warming table. Natasha was moved to her post­ partum room about hal f an hour later and saw Danil again the next morning. Sara and I happily shared our "breastfeeding success story" with the other Americans the next day. They, too, were enthusiastic and thrilled that we succeeded in helping a new mother establish breastfeeding in the first post-partum hours. I did not think of Natasha's story again specifically for some time. But one evening, about a week later, I found myself alone on the evening shift with the same Russian doctor, Dr. Taglieva, who had attended Natasha. She brought up the subject of breast feeding. Dr. Taglieva had, like everyone else at the roddom, expressed unequivocal support for breastfeeding. But during our conversation, it slowly dawned on me that she was reprimanding me-quietly and respectfully, but reprimanding nonetheless -- for "pushing" Natasha too hard. She explained that sucking took a lot of energy out of newborns - energy that babies born these days do not have and cannot afford to lose. "It's easier for them to eat from a bottle. It takes less energy," she said. She gave me a demonstration with her own lips to show how different these actions are for the newborn and how much more difficult it is for a newborn to breastfeed. In the interest of giving a weak neonate the best start in life, giving a bottle for the first few days to help bolster their strength (especially after the exhaustion of being born) is much better for the baby than "forcing" them to suck. Not only is the action of learlling how to suck harmful to a baby in a weakened state, the liquid they receive from the mother on the first day is not filling or nutritive, according to this doctor. Colostrum is fine for healthy babies who can afford to lose weight, she said I. But most babies born in Russia, she claimed, cannot afford to lose even a Iittle weight. Likewise, young mothers are usually very weak right after giving birth. They need time to rest and recover before they can produce milk. "Pushing" breastfeeding on new mothers right after birth, in their weakened state, will probably make them have a "bad feeling" toward breastfeeding. she said. When I countered with my thoughts on the benefits of early breastfeeding, this doctor diplomatically agreed that 1 was probably right- in the case of "healthy mothers and healthy babies." But she clearly believed that, in Russia, the vast majority of women giving birth in 2000 did not meet this criteria. She explicitly stated that, in her opinion, this is a change from Soviet times, when women were strong and healthy and there were "far fewer complications in general." Seeing that I did not seem persuaded, she suggcsted that, if I did help a new mother breastfeed. 1 should at least limit the amount of time to two or three minutes. She ended this conversation with the warning, "I would think very carefully about whether the woman [in the immediate post-partum period] I was pushing to breastfeed was strong enough to handle it and whether the baby was strong enough to handle sucking." Through such encounters, 1 came to understand that these Russian midwives and doctors did, in fact, "support breastfeeding," but that Russian support looks very different from that of the support of the midwifery-model, Americans, or WHO. The doctors and midwives with whom 1 worked perceive mothers and babies in Russia today as basically unhealthy and weak, in need of special help and health-promoting strategies. First and foremost, new mothers and new babies need to rest and recover fi'om the strains of birth. Secondly, new mothers need to give special attention to their diets to make sure they are getting enough vitamins and nutrients to support lactation. Unfortunately, according to another physician, Dr. Lipinsky and many ofthe new mothers with whom I spoke, the realities of Russian life in the beginning ofthe 2l't century make fulfilling both of these needs quite difficult. Food itselfis considered unhealthy and lacking in nutritive qualities (Gabriel 2003). And as another Y01. 17, No. I 2003, Page: 9~ • Allthropolog) of East Europc Rcvic\\ doctor from the same maternity hospital complains, women lack the time and the resources to be healthy. Due to the introduction ofjob insecurity and new, federal spending priorities that divert federal money away from maternity pay, many women must work until late in their pregnancy and go back to work soon after giving birth. "We used to have sensible leaves. Women had time to take care ofthemselves. But now, no one can afford to take time off and take care of themselves," says Dr. Taglieva. "A few days here [at the roddom] is their only rest." Weakness as a Cultural Discourse Dr. Taglieva is not the only one concerned with weakness in post-socialist Russia. The statistics about weakened Russian health, as I've indicated, are quite dramatic. I understand these statistics as paJ1 of a larger discourse on weakness that pervades Russian culture in the post-Soviet period. Not only are pregnant women interpreted as weak, so is general human nature, post-socialist domestic food (weak because of a lack of vitamins and minerals) and the political and economic position of the nation in the international arena (Gabriel 2003). I see concern with the low quality and low production of breastmilk as consistent with overall concerns about low food quality in the post-socialist period. Some informants have even told me that food quality is so bad that continued human life is threatened (Gabriel 2003). This discourse of weakness, combined with concern about a "dying" population, underlies and constitutes interpretations of and treatments of breastfeeding mothers in Russia today. Food, from the earliest days of life, is broadly understood as inadequate. In an environment in which this discourse is so prevalent, I find a general expectation of weak health. In many instances where I (and other American visitors) saw no indication of illness, Russian doctors diagnosed problems. However, two common western responses to these statistics and diagnoses seem problematic, from a cultural­ interpretative point of view. First of all, accepting these statistics on their face as an indication of the total "collapse" of health - and the healthcare system-as some have done (see Wines 2000 or Massey 2002) does not take into account the possibility that certain health categories may mean different things in different cultures or that over­ diagnosing that may be taking place. On the other hand, simply dismissing the diagnoses of Russian medical workers as misguided, as do many visiting physician observers and researchers, does not address the fact that these diagnoses are real and valid within their cultural context." [\sewhere 1describe the common practice of diagnosing health problems as a preventative measure that 1 found to occur at maternity hospitals, and, indeed, throughout the medical system, of European Russia. One doctor at Roddom #2 called this practice, "preventative diagnostics," but in common parlance, most Russians call this practice peresrrakhovat, loosely translated as "diagnosing to cover all one's bases:' Indeed, diagnosing diseases and pathologies in their early stages does help prevent serious complications, so my analysis is not intended solely as criticism; however, one side effect is that many more patients undergo treatment. I will give two examples of this practice here. In the first case are diagnoses of pre-eclampsia, which have nearly doubled since 1985 (Kulakov 2000:5). At Roddom #2 at least twelve women were confined to maternity hospital beds in the summer of 2000 for several weeks with the diagnosis of "early" or "light" pre-eclampsia. Pre-eclampsia is a serious complication of pregnancy that certainly deserves serious attention; however, these women generally exhibited only one or two of several possible symptoms. Whereas western practice limits diagnosis of pre-eclampsia to cases in which several symptoms (usually 3 or more. depending on severity) are present. in Russia. after n, ent: weeks of pregnancy, a diagnosis of··light"· pre­ eclampsia is possible based solely on edema, or water retention. This obviously leads to much higher rates of diagnosis - and higher rates of hospitalization -- than in western countries. My second example shows how the practice of perestrakhovat can have a real and immediate impact on breastfeeding. In 1997, one of my informants kept a pregnancy journal in which she complains about not being allowed to breastfeed her son in the immediate post-partum period. On the first day after giving birth she writes, "The doctors covered all their bases (Vrachi syebye perestrakhovali), they wrote down [that we had] all sorts of illnesses and didn't put [himJ to the breast." Though Russian medical practitioners and western aid workers all decry the supposedly low rates of breast feeding in Russia, I see this as, itself, part of the national discourse of weak health in Russia and, internationally, as part of a discourse about Russia's collapse. Official statistics actually place Russian breastfeeding rates above or equal (0 those of many industrial nations, including those of the United States. According to Kulakov, et ai, Vol. 17, No.1 2003. Pag~: q, in Managing Safe Motherhood, 44.lWo of babies are breast fed until three months of age and 32% or Russian babies are at least partially breast fed until they are six months old (2000:433, 10). (Bv comparison, the percentage of women wh~ breastfeed until six months of age has only recently reached an all-time high of32.5% in the United States) (Pediatrics 2002). Helsing, et ai, quote even higher Russian statistics from Archangelsk; their breastfeeding rates at 3 months are reported to be 74% and 36% at 6 months of age (Helsing 2002:579). These statistics are at odds with the discourse, and indeed the practices [ observed, surrounding breastfeeding among new mothers I knew and among medical professionals with whom [ worked. 3 Time and again, they told me that breastfeeding rates are abysmally low in Russia and that, in the words of Dr. Yakoleva, there is "an epidemic of women with low milk supplies." Russian Medical Support for Breastfeeding Certain maternity hospitals in Russia have technically signed on to a World Health Organization/UNICEF project called the Baby Friendly Hospital Initiative (BFHI). [n St. Petersburg, even doctors and midwives at maternity hospitals (in Russian called roddoms) not atliliated with BFHI were aware ofthe program and some of its goals and criteria. The WHO program requires that, hospitals in participating countries promote breastfeeding and allow rooming-in of mothers and babies.4 Russian maternity hospitals also operate with guidelines from the federal government dictating that mothers be shown their infants immediately after birth and that they be given five minutes of uninterrupted bonding time with their babies. De jure and de facto are not always the same thing, however, and these regulations I have described are not in mv experience nor in the experiences ofwom'en I ~ interviewed, well-adhered to. Rooming-in continues to be uncommon even in most of the otherwise most "progressive:' or "western-style" maternity hospitals. And though the midwives and doctors I observed in St. Petersburg almost always placed newborn babies on their mothers' abdomens, the required five minutes was usually, in practice, a matter of seconds. In my fieldnotes, I comment frequently on my own reaction to this. I worried that some of the new mothers did not have time to really assimilate what was happening and that the baby was often whisked away before the mothers could make sense of th i ngs and reach out to touch their newborn, much less breast feed. At first, I found mvself confronted with an inexplicable dichotomy between the words of Russian staff at the roddom where I apprenticed and their actual practices. Whenever we discussed brcastfeeding directly, Russian doctors, midwives and other staff members expressed no ambivalence about the benefits of breastfeeding. "The best is breastfeeding," said one midwife, Lena, on my second day at the roddom. "We encourage all new mothers to breastfeed" Since I had been told repeatedly that breastfeeding rates in Russia are low, I thought, at first, that this maternity hospital - with its open endorsement of breast feeding ­ must be unusual. [n later interviews I found that in fact, most doctors and midwives i~ urban ' European Russia openly extol the benefits of breastfeeding as opposed to formula. They also express, however, that it is "very difficult" for Russian women to breastfeed. Lena, the same midwife who claimed that "the best is breastfeeding," told me that Russian mothers, these days, tend to have problems with their milk supply. Maintaining an adequate milk supply, she explained, "is very difficult in these times." Women's health is often too fragile and weak to allow for breastfeeding and the inadequate food supply in Russia deepens the problem. Indeed, one of the few questions pregnant women thought to ask at childbirth education classes that I attended throughout 2000 was, "How can I maintain an adequate milk supply?"s Pregnant women even in their first trimester trade herbal advice for "keeping up milk." Accounting for Breastmilk Culturally The question of how to best "keep up milk" is answered quite differently by Russian and western birth professionals. I soon realized that importing western ideas such as "rooming in" or "breastfeeding on demand" (that have improved breastfeeding in western countries) does not solve the problems that many Russians blame for low breastfeeding rates and unsuccessful breastfeeding. Like Dr. Taglieva, most of the Russians with whom I worked emphasize the importance of rest and physical recovery as well as diet in order to promote breastfeeding. [n their view, a new mother, in a general state of weak health that is weakened even further by the exertions oflabor, needs to rest for several days in order to build up her strength - and her milk supply. The stress of taking care of an infant around the clock is, in this view, counterproductive. So is going home too Vol. 17. No.1 2003, Page: 96 Anthropology of Last Fmope Revic\\ early from the roddom. The WHO and most North American lactation consultants, by contrast, emphasize close physical contact between mother and baby (starting, preferably, in the first hour after birth) and frequent suckling as the most important contributors to establishing successful breastfeeding (Helsing 2002: Davis 1997). Clearly, rooming in addresses these western concerns.6 But to my Russian informants, rooming in can contribute to unsliccessjzll breastfeeding. This perspective is beh ind the advice of Dr. Tsaryegorodtsev and Dr. Tsaryegorodtseva, the authors of "Be Healthy, Little One: How To Care for a Child from Birth To Three Years." Their easy-to read, widely-distributed, pamphlet­ like book sells tor five rubles (the cost ofa subway token) and is endorsed by the Russian Association of Pediatricians and Chi Idren' s Surgeons of the Ministry of Health. Their advice about breastfeeding succinctly expresses some of these fundamental beliefs about breastfeeding: I) that successful breastfeeding depends on the robust healthy state of the mother; 2) that early breastfeeding in the hours after birth contributes most to bonding, not successful breastfeeding; and 3) that a low milk supply is best treated through rest and attention to diet. Not anywhere do they emphasize a cause and effect relationship between the amount of suck I ing by a newborn and the amount of milk produced by the mother. In answer to the question, "When should you put the baby to the breast?" they answer, "It is most desirable to put the baby to the breast immediately after birth." Their reasoning, however, is not explained in terms of establishing successful breastfeeding; rather, they emphasize "mother-child bonding": At the moment of the first latching on to the breast, all sensory organs of the infant are turned on: he [sic] feels himself to be safe, in warmth, he hears the beating of his mother's heart, with which he has already become familiarized in the womb, and he calms down ....Eye-to-eye contact gives emotional nourishment to the baby, which is just as necessary for him as breastmilk. [The sense of] hearing is turned on: the baby hears the mother's voice and reacts to it... In this way, the first impression is made: the newborn takes as his mother the first person that he sees, hears, feels, smells, from whom he receives fi)od, in whose presence he feels protected - this is a universal, biological law ( 12). The Russian Ministry of Health's regulations are consistent with this interpretation of the first few minutes ofa baby's life. As I've indicated. the regulations governing the operation of Russian maternity hospitals require that newborn infants be given to their mothers for five minutes immediately after birth for the purpose of bonding. There are few regulations designed specifically to encourage breastfeeding and this initial mother-child contact is not understood as a time to establish breastfeeding. Treating Breastfeeding Problems in Russia Requires Attention to General Health and Diet When I paid attention to the ways my Russian informants discussed breastfeeding, I realized that most conversations about breastfeeding quickly turn to the topics of stress reduction and diet. These are prevalent concerns in everyday Russian life, quite beyond the particular issue of breastfeeding. Some of these concerns, such as the stress caused by unstable and unpredictable government and financial institutions, has been studied in some depth. Other concems, such as fears about inadequate \itamins and minerals in Russian food. hZi\ e been less \\ c'1! acknowledged (Gabriel 2003). \ 1 an;. of 111:­ informants also worry that the introductic1n llf 'l'­ called capitalist economic practices (such as all emphasis on efficiency in the workplace at the expense, many argue, of sat is tying, deep human relationships between colleagues) has added unhealthy stress to Russian lives. These cultural anxieties are significant, because they underpin any discussion of breastfeeding - including cross­ cultural discussions. In general, I found physicians and medical professionals - as well as lay Russians ­ more willing to make explicit links between "stress" and ill health than I have tound alld experienced in the mainstream culture of North America. Russia's work policies follow this more European attitude about the physiological and medical need for rest and relaxation. Throughout Soviet times, workplaces were responsible for providing workers with several weeks (usually six weeks/year) of time off of work specifically to promote health. Workers who had to work in "unhealthy" conditions, naturally needed even more time off to achieve and maintain health (Pondoev 1959). "Vacations" from work were medical events; they were not understood or experienced as weeks of leisure to spend with Vol 17. ",0. I 2003. Page: 97 one's family. Workers generally spent several weeks each year at resorts or sanatoria, where they adhered to specific, health-promoting regimens that included attention to diet and plenty of time for rest and relaxation. Russian medical professionals also tend to emphasize a link between a general state of healthfulness, especially a healthy pregnancy, and successful breastfeeding, more so. I find, than western texts (Davis 1997; Sears 2000). The doctors Tsarycgorodtsev(a) exhort women who desire to breastfeed to prepare as early as possible, during pregnancy. Thc most imrortant factor in establishing successful breastfeeding, according to these doctors, is that the mother "be in maximum health." To attain such a state of health, they recommend that these women engage in "strengthening the immune systcm, tempering7 , healthful eating, and anti-stressful living. Pregnant women [should] swim in a pool, do special exercises and relax to music'" Elvira Zakablukovskaya, a homebirth physician and author (who has interacted extensively with American midwives and subscribes to many international midwifery journals), also emphasizes, first and foremost "a healthy way of life and proper, rational nutrition" (1994:3). Like the doctors Tsaryegorodtsev(a), Zakablukovskaya emphasizes early preparation for breastfeeding, during pregnancy. In the pamphlet­ like book that she produced with funds from the Eurasia Foundation, she claims that an unhealthy diet and stress during pregnancy will havc negatiyc effects on breastfeeding. She writes that "stresscs produce neuroses in the woman, that in many cases can lead to serious pathology in the unborn child and after birth to a reduction in the amount ofbreast milk" (1994:4). But most telling of all is the section in which the doctors Tsaryegorodtsev(a) address the question, "What Should You Do IfYou Have A Low Milk Supply?" In this section, the doctors continue to emphasize the importance ofdiet and rest, to the exclusion of almost any other factors. They discuss at great length what foods promote the production of breast milk and how to prepare them. "The most effective food in the world" for this purpose, they claim, is honey. Milk products, especially those with biologically active ingredients (such as yogurt), are also helpful. Coffee and strong tea should be avoided. It is very important, according to these doctors, that the "breastfeeding mother sleep no less than eight hours a day. Since it can be difficult to do this at night. \\e recommend a nap during the day for I 1:22 hours. It is also absolutely necessary to take a walk in fresh air no less than 2 hours a day" (28). In addition, they mention breast massage and a time-consLim ing rrocess to prepare hot compresses. If these compresses are used filleen minutes before breastfeeding, write the doctors, they can increase the milk supply. Unlike American books about breastfeeding, such as The Breasrf('eding Book by Dr. Sears, this pamphlet does not suggest increased or improved suckling as a potential remedy for bolstering a low milk supply. Zakablukovskaya's publication, on the other hand, while emphasizing diet and rest as key factors in successful breastfeeding, also incorporates these aspects that are usually more emphasized in western approaches. She specifically states, for instance, that "breatstfeeding consists of a mutual dependency of 'demand-supply': the more the baby demands, the more your breasts will produce" (1994:8). But Zakablukovskay's approach, which gives attention to all of these aspects, is, in my experience in Russia, exceedingly rare. Even the highly scientific and western-informed book Managing Safe Maternity, which gives many details about the physiology of breastfeeding that are not widely accepted or propogated among Russian medical workers, does not state or explain this particular point: that breastmilk is produced in response to infant suckling (Kulakov 2000: 432-448). It is the priority that the factors of diet and rest are given, either to the exclusion or the minimization of other possible factors, that, I argue, underscores many of the medical practices I witnessed regarding breastfeeding in Russia.8 Conclusion This article highlights that the effects of believing that the state of Russian public health is weak are far-reaching. I have focused here on one particular case, breastfeeding, as an example of these effects. I hope that this article will contribute both theoretically, to medical anthropology, and practically, to cross-cultural breastfeeding promotion programs. Though breastfeeding in Russia, like in the United States, is medicalized to a large degree, Russian medical advice and opinions about how best to establish breastfeeding differs significantly from western sources. I argue that the belief that all Russians, but especially new mothers and babies, are weak underscores many medical decisions and diagnoses, especially about breastfeeding. I do not attempt to answer what I Vol. 17, No.1 2003, Page: '1X Anthropology of East Europe Review think is an inevitable but unanswerable question, "Is the health of Russian women weak?" The answer to this question is actually different, depending on the assumptions and belief systems one brings to it. Instead, I hope to redirect anthropological and medical inquiry to questions that are more pressing and, potentially, more answerable, such as, "How can we communicate about and act on issues of breastfeeding cross­ culturally, given this widespread discourse about weak health in RussiaT Western aid workers and WHO officials who have emphasized rooming-in and breastfeeding on demand as the essential components of any pro-breastfeeding program have encountered strong resistance to the introduction of these practices in Russian maternity hospitals (Helsing 2002). I argue that the prevalent discourse of weakness in Russian culture combined with culturally and mcdically­ appropriate approaches to dealing with weakness (emphasizing diet and rest) underscores this resistance. Western and Russian medical workers think about health and bodies in very different ways. These thoughts, discourses and belief systems have dramatic implications for medical practices and lived experiences. References cited CDC National Center for Health Statistics, 2000, Maternal and Child Health Compared in U.S. and Russia. www.cdc.gov/nchs/relases/99facts/99shee ts/russian.html Cockerham, William C,M. Christine Snead and Derek F. Dewaal, 2002, Health Lifestyles In Russia and the Socialist Heritage, Journal of Health and Social Behavior. 43 (I): 42-55. Davis, Elizabeth, 1997, HeaI1 and Hands: A Midwite's Guide to Pregnancy and Bil1h. Berkeley: Celestial Arts. Davis-Floyd, Robbie, 1992, Birth As an American Rite of Passage. Berkeley: University of California Press. Douglas, Mary, 1989, Purity and Danger: An Analysis of the Concepts of Pollution and Taboo. New York: Routledge. Gabriel, Cynthia, 2003, Healthy Russian Food is Not-For-Profit. Michigan Discussions in Anthropology. Forthcoming. Helsing, Elisabct. 2002, Breasttceding, Baby Friendliness and Birth in Transition in North Western Russia: A Study of Women's Perceptions of the Care They Receive When Giving Birth in Six Maternity Homes in the Cities of Archangelsk and Munnansk, 1999, Pediatrics 91 :578-583. ---------, 2003, Breastfeeding: Baby's Right and Mother's Duty? International Project on the Right to Food in Development. Forthcoming. Kulakov, V.I., et aI., 2000, Rukovodstvo Po Byezopasnomu Matyerinstvu. Moscow: Uspyekh. Lock, Margaret, 2001, The Tempering of Medical Anthropology: Troubling Natural Categories, Medical Anthropology Quarterly 15:4. Martin, Emily, 1994, Flexible Bodies: Tracking Immunity in American Culture from the Days of Polio to the Age of AIDS. Boston: Beacon Press. Massey, Stephen M. , December 10,2002, Russia's Maternal & Infant Health Crisis: Socio­ Economic Implications And The Path Forward. http://psp.iews.org highlights.ctill'\ iew= detail&id=33 Pediatrics, December 2, 2002, News Digcst available at http://www.aap.org/ advocacy /releases/ dc cfeeding.htm. Pondocv, Gavriil Sergeevich, 1959, Notes of a Soviet doctor. New York: Consultants Bureau. Putin, Vladimir, 2000, What Kind of Russia Are We Building? Speech to Federal Assembly of the Russian Federation, 8 July 2000, printed in Vostochno­ Sibirskaia Pravda, 13 July 2000, 3. Ries, Nancy, 1997, Russian Talk: Culture and Conversation During Perestroika. Ithaca: Cornell University Press. Sears, William, 2000, The Breastfeeding Book: Everything You Need to Know About Nursing Your Child from Birth Through Weaning. New York: Little, Brown and Company. \. "I. 17. No. I 2003, Page: 99 http:http://www.aap.org http:http://psp.iews.org www.cdc.gov/nchs/relases/99facts/99shee Tsaryegorodtsev, Alexander and Larissa Tsaryegorodtseva, 1999 Be Healthy. Little One: How To Care for a Child from Birth To Three Years. Moscow: Elite Club. Verdery, Katherine, 1996, What Was Socialism, and What Comes Next? Princeton: Princeton University Press. Vladimirov, Aleksandr, 2000, How To Avoid Getting a Cold. Minsk: Molodozhni Mir. Wines, Michael and Abigail Zuger, December 4, 2000, In Russia, the III and Infirm Include Health Care Itself in The New York Times. AI, A8. Wines. Michael, December 22, 2000, Capitalism Comes to Russian Health Care in The New York Times. A I, A 14. World Health Organization, 2003 World Health Organization. January 13,2003. http://www . who. inti country/rus/en/ Wyatt, Caroline, January 3, 2001, Russia struggles with population crisis at BBC website: http://news. bbc.co.uk/l /h i/world/europe/1 098812.stm Zakablukovskaya, Elvira, 1994, Grudnoye Vskarmlivaniye. Nizhni Novgorod: TET. Notes I Colostrum is the name of the liquid produced by women in the first 3-5 days after giving birth. In fact, many breastfed babies do lose weight in the first week of Iife, which is ordinarily not considered a problem. In North America, for instance, medical professionals tend to worry about this only with babies who are considered underweight at birth (cite). 2 I observed this phenomenon personally when a delegation of physicians from Iowa visited Roddom #2 in St. Petersburg while I was working there in July 2000. I found this same tendency in informal interviews with several doctors who have visited Russia and Ukraine through American International Health Alliance programs in 1998-1999. I note also that Helsing, et aI, report that "In the course of the ... project we frequently observed the use of obstetric practices that were poorly justified, and often unhelpful, which had been developed over the years in the former Soviet Union" (2002:579). 3 Among nearly 100 informants, I found, mostly through interviews, that both in families that gave birth at home and at roddoms, mothers generally only breastfed for 2-4 months, introducing solid foods around 4 months; those who continued breastfeeding beyond 4 months often limited breastfeeding during the day. Throughout the breastfeeding period, most new mothers usually gave their children bottles of water and/or supplementary formula or cereal mixed with milk. 4 The roddom where I worked was not, technically, a participant in the WHO project, but doctors and midwives knew of the project and some of its goals and criteria. As I describe in this article, they expressed doubts that the WHO criteria were truly effective and in the best interests of mother and baby. 5 Elsewhere, I examine the discourse of doctors and pregnant women during childbirth education classes in Russia. In my ethnographic experience, pregnant women tend to limit their questions to a specific range of culturally-appropriate questions. The questions that they ask, and the format of the physician's answer, helps define what is appropriate lay knowledge and what is reserved for expert medical knowledge. Breastfeeding is one of the topics (together with nutrition during pregnancy, what to bring to the roddom and when to call an ambulance for transport to the roddom) that women feel comfortable and are encouraged to ask questions about during these classes. Other topics, such as the stages of labor, are defined as "medical knowledge" and are not often encouraged. 6 The concept of "rooming in" remains, literally, a foreign one, something distinctly"unRussian" as illustrated in a \ul. 17. No.1 2003, Page: 100 http://news http://www Anthropolog::- of East Lurope Revic\\ Russian-language brochure called ··One on One: About Breastfeeding." In this two­ page brochure produced by Hipp (a German company), new mothers are given ten tips about successful breastfeeding. Everything is in Russian, except the words "Rooming In," which are printed in English. 7 Tempering refers to the practice of exposing the body alternately to hot and cold, usually hot and cold water. g In fact, lactation specialists and biologists in the \vcst do not dispute that diet and rest playa large role in breastfecding. For instance, Elisabet Helsing, an academic who has also worked on the WHO Baby Friendly Hospital Initiative in Russia, points out that the bio-chemistry of breastmilk production is seriously disturbed by stress. She writes, "Should the mother be disturbed by for example someone using, or merely threatening to use, physical or mental force against her, her adrenaline level will rise, which in turn will block the action of oxytocin on the milk cells and make breastfeeding imposible (Helsing 2003:5). The influential midwife and activist, Elizabeth Davis. also writes that "Continued production of prolactin and oxytocin depends on frequent, relaxed nursing sessions. The more relaxed the mother is when she nurses, the greater the release of these crucial hormones" (1997: J80). Photos Figure J Figure 2 Vol. 17.No. 12003. rag.:: 101