Abstract
Abstract	Introduction	Demographics	Health Care	Health Education	Health Values	Physical
Nutrition	Smoking	Alcohol	Prevention	Suggestions	Acknowledgments	References

Americans are increasingly asked to provide technical assistance to Russia. This paper reports on some of the issues that face the American health educator in Russia in 1998. Topics included are: health-related demographics; the health care system; health education and health educators; health values and specific health-related behaviors; and prevention. The article closes with suggestions for other health educators planning to work in Russia.

Introduction
Abstract	Introduction	Demographics	Health Care	Health Education	Health Values	Physical
Nutrition	Smoking	Alcohol	Prevention	Suggestions	Acknowledgments	References

As Russia opens its doors to the West, American health educators are increasingly asked to provide technical assistance to this colorful, intriguing, and sometimes frustrating country. With the collapse of the Soviet Union, the Russians are struggling to rebuild their health, education, and social services infrastructure. This endeavor is made even more difficult by the current political and financial destabilization. The Russians are eager for information and expertise that might help with their effort.

In Summer, 1998, I was visited by Russia to teach human service professionals and educators in Togliatti about substance abuse prevention programs for youth. It is impossible to obtain much information about Russian health and social conditions, and conditions are changing so rapidly that the few recent books and articles are quickly outdated. The purpose of this paper is to share my crude needs assessment: my observations about the health-related conditions I found. Perhaps more important, this article might alert future health educators visiting Russia to issues that require further investigation and regular updates.

I have limited my report to things observed on multiple occasions and in multiple contexts, and/or which are consistent with other sources of information. My informants included various colleagues: faculty at the Togliatti Social and Economic College, the working professionals I taught, and officials in the city's human service agencies and school system. Interactions with some of these people were purely professional, others were social as well. I also had the opportunity to meet and socialize with several working class families. The Russians speak freely of social and political issues with those they trust, although my access to information (and perhaps its accuracy as well) was limited by my reliance on translators.

It is important to stress that my observations cannot be generalized to the entire country. Russia is a vast and diverse place, encompassing 11 time zones and over 100 ethnic or nationality groups. It combines modern European cities with extremely rural regions in which Tolstoy would still feel at home. I worked with city dwellers, but most Russians still live in the countryside, and their world view and values are dramatically different from those of city folk. The visual difference alone is vastly more striking than in the U.S. Just a few short miles outside Togliatti, which bustles with cars, cell phones, and stylish miniskirts, farmers pulled hay-filled carts with draft horses, children herded cows bedecked with bells, and old women searched the birch forest for herbs and mushrooms.

Moscow was my gateway to Russia. Even superficially, much had changed since I was last there 15 years ago, and I had mixed feelings about these dramatic alterations. On the one hand, Moscow was more prosperous, less shabby. The beautiful 18th and 19th century European-style buildings had been rehabilitated; the ancient churches were gleaming and open to worshipers; well-stocked stores (including Gucci and the Gap) beckoned to customers. Stylish clothing, cellular phones, and foreign cars were much in evidence. The more negative aspects of "progress" were also easily seen. Traffic and auto emissions were horrific on the wide, once almost-deserted boulevards, and there was litter on the sidewalks once scrupulously maintained by 'broom ladies". A few elderly women were begging on the streets; in Soviet times this would not have been necessary. Victims of mental illness and alcohol were also seen on the street, which would not have been permitted in former times. Billboards lined the main highways, advertising American and European products. One popular billboard featured a decadent and peculiar-looking musical group. Only after repeated viewings did I realize that it advertised the upcoming "Rolling Stones" concert. For the first of many times on the trip, the shift in cultural perspective had taken me by surprise.

I worked in Togliatti, a southern city of 740,000 located on the Volga River 600 miles southeast of Moscow. Built under Stalin in 1954, it lacks the historical and cultural character of older Russian cities. Togliatti has a strong industrial base, so unemployment is lower than in other parts of the country, and the city is said to have the third highest per capita income in Russia. Togliatti is an homely city with a beautiful soul. Drab cement housing blocks are bordered by tiny, colorful gardens. The people are friendly, and tend to a sunny, "southern" disposition rather than the more stolid demeanor associated with their northern neighbors. Togliatti was designed in three districts, separated by large tracts of forest. My American colleagues and I were housed in the Stavropol, a "dispensary" (also variously referred to as a sanitarium and health resort) in the Green Zone, a pine-forested resort area on the Volga River. The Stavropol is run by a fertilizer plant, which offers its workers and their families annual vacations to "recover their health".

High rates of unemployment and underemployment in Russia have led to social and health problems. Thirty to 50 percent of Russians live in poverty, depending on the data source. Many people have been left unemployed by the past decade's economic destablization. Many more are underemployed; some workers have not been paid for several years. It is said that men have been disproportionately affected by the country's economic difficulties. The situation is exacerbated by migrants moving from other Soviet republics back to their regions of origin, and by the large scale release of formerly institutionalized or incarcerated individuals. Both social and health conditions have deteriorated in these conditions. (Le Cacheux, 1997).

According to the Russian Federated Center for Disease Control (cited in Richmond, 1992), 1989 life expectancy was 69.8 years: 64.8 years for men and 73.6 years for women. More recent figures indicate that male life expectancy is declining sharply, and it is now set at 56 to 58 years. The all-age mortality rate in men over 20 is three times that of women. The poor life expectancy in men, and its recent deterioration, has been attributed largely to the growing prevalence of alcoholism and related accidents and illness. Infant mortality is also high, and the birth rate is low. The low birth rate has been variously attributed to poor economic conditions, inadequate housing stock, and other social factors. (Le Cacheux, 1997; Panov, 1996; Richmond, 1992). The birth rate is kept low through repeated abortion rather than contraception. Even now, Western-style contraceptives are difficult and expensive to obtain. According to 1991 data, the Soviet abortion rate is the highest in the world: 137 per thousand births, compared to 27.5 per thousand in the U.S. (Imbrogno, 1994).

Americans would find Russian "dispensaries" and hospitals uncomfortable, primitive, devoid of what we consider basic amenities (such as private rooms) and alarmingly lacking in what we would consider basic equipment. Russian physicians have the equivalent of a baccalaureate education. Most are women, and as my physician-colleagues were vocal to report, they have lack the social status and political clout of American doctors.

Under the Soviet system, basic health care was considered a fundamental element of social protection. This commitment continues, although how it is to be organized and financed in the future is of grave concern. For most Russians, services were, and still are, organized through the "enterprise" for which they work (factory, collective farm, etc.) or labor union, either through work-site clinics and hospitals, contracts with other, larger, industrial enterprises, or through insurance mechanisms. Local authorities provide care for others through dispensaries (ambulatory care facilities of various kinds) and hospitals. With deteriorating economic conditions, however, the health care system is in grave danger of collapse, and it is unclear what alternative health service structure can be devised (Le Cacheux,1997). In the meantime, my Russian colleagues were intrigued with the notion of organizing health education through work sites, as a logical extension of the current health service delivery system.

With regard to the public health infrastructure, I quickly became aware that we Americans take our public health system for granted. When wild dogs swirled around, I thought about rabies shots and animal control. When I learned that milk is often drunk unpasteurized, tuberculin tests for cows and food storage standards came to mind. When I forgot to use bottled water to rinse my toothbrush, I ruminated over sources of contamination. And, when an elegant cat staked out our table in a chic restaurant, sanitation ratings came to mind. Of course, the Russians seemed oblivious to any of these things.

There is no public health infrastructure in Russia, that is, no system for delivering population-based health programs or services. Under the Soviet system, it was difficult and sometimes dangerous even to acknowledge that there were public health problems, much less systematic efforts to monitor or manage those problems. Today, there is no adequate system for collecting health information, no clear structure for developing comprehensive health policies or promoting health legislation, and, as far as my informants knew, no authority for ensuring systematic prevention efforts (specifically immunizations). There is a Ministry for Public Health, but its organizational capacity is still very limited.

In 1991, the USSR Government Committee of Labor and Social Questions set out a health education mandate: "To carry out among the population educational activities regarding a healthy life style, family planning and exercise of sanitary and hygienic norms, and the prevention of fire, accidents, and the violation of the law" (Imbrogno, 1994, p. 98).

Notably, this mandate was set for social workers, not educators or health professionals. In my work and in the professional literature on health care, I found that health-related issues were often thought of as a facet of broader social issues. Under the Soviet system, health services were among the various basic social services people were guaranteed, and therefore their organization and delivery fell under the social services umbrella. It is therefore not surprising that social workers have some responsibility for health education.

The term "health educator" conveyed no meaning to my Russian colleagues. Their most analogous position is the "valuologist". Valuologists are charged with providing health information, shaping attitudes, and motivating behavioral change. My discomfort with the term "valuologist" was puzzling to my Russian colleagues, (who also favored the term "propaganda" when referring to

The term "health educator" conveyed no meaning to my Russian colleagues. Their most analogous position is the "valuologist". Valuologists are charged with providing health information, shaping attitudes, and motivating behavioral change.

health messages). Pluralistic thinking is a foreign notion to their culture; and when I explained that Americans respect, even encourage, different points of view, reactions ranged from mystification to polite outrage. Needless to say, the definitions of health education I offered, with their emphasis on informed decision making, were not well received.

Health education is limited to the school setting. Valuologists offer special class sessions, and particularly target high risk students, it appears. In addition, physical education teachers teach basic hygiene concepts, and as in the U.S., their personal commitment to health education varies widely. "Social pedagogues", analogous to school social workers, offer prevention programs, primarily to at-risk youth.

Health educators do not work in community settings, and the Russians were especially interested in the health educator's roles in public and worksite health. Indeed, there appears to be a complete vacuum in health education at the community level. Not even physicians are involved in prevention education, according to my informants (who included physicians). They indicated that the physician's appropriate role is treatment and that physicians lack the training for prevention education.

Health Values and Behaviors
Abstract	Introduction	Demographics	Health Care	Health Education	Health Values	Physical
Nutrition	Smoking	Alcohol	Prevention	Suggestions	Acknowledgments	References

Many American health education professors open the semester by discussing the definitions of health. Although I did not do this in Russia, I feel confident that even my professional-class Russian colleagues would find our definitions that feature "integrated methods of functioning" and "higher order well-being" ill-suited to their reality. Certainly this would be true of the average Russian, who is struggling to meet basic needs of food and shelter, a struggle that has intensified without the safety nets of Soviet Russia. To be physically able to work, and carry out the activities of daily life, would certainly be the health priority of most Russians.

The idea of a long and healthy life motivates many Americans toward health promoting behaviors. In a recent book, Russians repeatedly observed that life doesn't hold the value for Russians that it does for Westerners. "Life is not so great for Russians that they want to hold on to it with all their might." (Montaigne, p. 5). It was apparent that my Russian colleagues were far more interested in the more immediate social consequences of health risk behaviors than with long term outcomes. Whether that reflects their personal values or their professional priorities is unclear. What is clear is that American health educators abroad need to explore what aspects of health are motivating to their Russian colleagues and the communities they serve.

Physical Activity
Abstract	Introduction	Demographics	Health Care	Health Education	Health Values	Physical
Nutrition	Smoking	Alcohol	Prevention	Suggestions	Acknowledgments	References

In many ways, the Russians live healthy lifestyles by necessity. The consumer goods and services we take for granted are luxuries for even the most prosperous Russians. Even the most economically deprived American has not experienced the physical rigors of Russian city life, and country life is still more difficult. Most Russians rely on public transportation, and in Togliatti and Moscow the bus stop can be a half-mile away. I was told that none of the elevators in Togliatti work, and pondered this information each time I climbed the five flights to my VIP room in the "dispensary". The better apartments are on higher floors, so presumably the most affluent citizens get the best exercise. In Togliatti, there are no supermarkets and few convenience foods (still fewer that most people can actually afford). People (specifically women) visit various shops for their groceries, often standing in long lines for the most desirable products. Then, they prepare meals from scratch without the modern appliances we rely on in the U.S. Russians who cannot meet the demands of daily life because of chronic illness, the frailty of age, or physical or mental disability live physically isolated lives and, if they have no family to care for them, are threatened with deprivation and neglect. Even wheelchairs are in short supply.

It was not my impression that exercising specifically for health was a common practice among adults. The trendy aerobics clubs of Moscow have not yet penetrated Togliatti, although some of my colleagues reported that they "walk for health" and cross-country ski in the winter.

The Russians were appalled at the minimal level of physical education required in American schools. Physical education is an important part of the school curriculum, and students have access to an impressive array of recreational sports. Sports activities are organized through the city (formerly, through the Communist party youth organization) rather than individual schools. Unfortunately, these activities are dwindling under current financial constraints, and officials working with youth preventive services worry about how students might choose to fill the vacuum.

Nutrition
Abstract	Introduction	Demographics	Health Care	Health Education	Health Values	Physical
Nutrition	Smoking	Alcohol	Prevention	Suggestions	Acknowledgments	References

I am often asked what the Russians looked like, and Americans have definite stereotypes in this regard. Contrary to stereotype, residents of Togliatti were quite slim. I saw very few overweight people, and almost none who were obese. The Muscovites were more typical of our image of the stocky Russian, but few appeared obese. Whether the regional difference is due to greater prosperity and conveniences in Moscow, less availability of fruits and vegetables, genetics, or some other factor I do not know.

Fresh fruit and vegetables were the focus of the Summer diet among both the middle-class and working-class people with whom I socialized. Togliatti, in "southern" Russia, is on the same latitude as Edmonton, Canada, and has a fairly long growing season capable of producing a wide array of fruits and vegetables. Most of Russia has a much shorter growing season, and with a poor food distribution system, most Russians have a more limited diet even in Summer. Sausage, cheese, bread, potatoes and cabbage dominate the Winter diet. The country imports 60% of its food, and food diversity for most Russians depends on these imports. (Newsweek, 1998).Thus, nutritional status is almost sure to decline with the country's recent economic crisis.

Bread is the staple of the Russian diet year round, and the Russians are justifiably proud of their many delicious breads. Meat was served in small portions, and sausage was the most common meat. Fish were available locally, although Russian fish stocks are threatened because of overfishing. The Summer diet in Togliatti is low in fat, with sausage and cheese the highest fat food products. A few celebratory foods were fried or prepared with oil, but this was not the norm. Only young children and the rural elderly drink milk (often unpasteurized), and my craving for milk became an ongoing joke among my Russian colleagues. Yogurt was available in some shops but was imported and therefore expensive. I had one fresh egg while I was there, and was never offered butter with bread.

In southern Russia, many old-age pensioners, whose economic and social safety nets have disappeared, rely on produce from their gardens, and what they can dry or can for winter, to eat decently. These are the lucky ones, because not everyone has access to a garden plot, and many are not physically able to work a garden. How senior citizens survive farther north is unclear.

The Russians in my classes were curious about nutrition education in the U.S. They knew that good nutrition is important to health, but were vague about the connection between nutrition and health, the roles of specific vitamins and minerals, etc. They were no different from the average American college student in this respect. Perhaps, too, the difficulty of translating nutrition terms accounted for some of their apparent lack of sophistication.

Cigarette smoking is common in Russia, and it has been charged that Russians are smoking themselves to death. Inexpensive American imports have fueled the habit. In July, 1998, a pack of Marlboro cigarettes cost approximately half as much as a liter of bottled water (and everyone drank bottled water). The price of foreign cigarettes has increased 76% since then (Newsweek, 1998), so they are still cheaper than water. American-style advertising, equating smoking with sophistication and sex appeal, has become common, and American movies and soap operas, shown in prime time, also glamorize smoking. The Russian professionals were outraged by these Western influences, and shocked that we "permit" smoking and drinking to be shown on-screen.

The demographics of smoking seem similar to those in the U.S. 20 years ago. The professional-class people with whom I socialized were smokers, both men and women. Among our working class hosts, the men smoked more than the women. Apparently the indoor air quality can be oppressive because of the cigarette smoking, especially in Winter. However, our hosts were considerate smokers, removing themselves from their nonsmoking peers when they lit up at home or in public. This sometimes caused social awkwardness when the nonsmoking Americans found ourselves alone at a banquet table!

A number of Russian associates apologized that smoking was an unfortunate habit, so I assumed they understood the health risks. I came to question this assumption when, near the end of my stay, well-educated people asked me on two occasions why one should give up smoking if there were no signs of disease. Here was another lapse in my cultural perspective-taking.

It is not just an American stereotype that links Russians and vodka. Vodka is an important art of the Russian's cultural identity... the Russian equivalent of "mom and apple pie", only more so. My second day in Togliatti, I attended a "lunch" at which 12 bottles of vodka were consumed by 12 guests, along with at least three bottles each of champagne, wine, and beer.. Together, the five American guests probably accounted for about one bottle of vodka. For our host, alcohol was an important symbol of hospitality and prosperity, and it was good manners that he keep our glasses were filled at all times. For me, the event was an excellent opportunity to observe and practice the refusal and moderation skills I would be teaching in class. Lest the reader think this episode of binge drinking at its finest was quickly concluded, the "lunch" spanned countless courses of food, much music, dance, and conviviality, and lasted nine hours! It was my repeated experience that social occasions in Russia can require true stamina.

Vodka symbolizes the best and worst of Russia. It is the sign of a gracious host, a convivial guest, a trustworthy and entertaining comrade, a warm-hearted culture. At the same time, it is a major cause of absenteeism and low productivity, divorce, domestic violence, crime, traffic accidents, birth defects, and decreasing life expectancy. Alcohol problems were hidden in Soviet Russia. Pay was not based on productivity, so neither worker nor family suffered financial repercussions for the Monday morning hangover. Public drunkenness was forbidden, and legal sanctions quickly enforced. Chronic offenders were "institutionalized". During my prior trip to Russia 15 years ago, I never saw an inebriated person on the street; this trip they were more evident.

Alcohol-related problems are said to have increased precipitously with the collapse of the Soviet Union's industrial base, economic structures, and social safety nets. My colleagues' accounts of men no longer able to adequately support their families becoming mired in shame, hopelessness, and alcohol reminded me of the Great Depression. A dramatic increase in neglected and homeless children due to alcohol abuse were a factor in the decision to make alcohol prevention and treatment a priority in Togliatti's education and social service system.

There seemed to be a social class gradient in alcohol use, with far less use -- and less social pressure to drink -- among the professional classes. However, the professional people with whom I was socializing had a particular interest in alcohol and substance abuse prevention, so my experience might not have been typical. There are undoubtedly variations in alcohol-related attitudes and practices by community, ethnic-cultural group, and social class.

Alcohol use among youth is officially discouraged. Eighteen seemed to be the approved drinking age. And, although there are laws forbidding the sale of alcohol to minors, they are poorly enforced. It is common practice for parents to let their children "have a taste". Nor is this practice isolated to the less educated. "Pretend" drinking is said to be a common feature of children's play. At one kindergarten for wealthy children, school officials proudly showed off the "bar", where children could order "cocktails".

Even the professionals I trained in prevention skills had interesting attitudes toward alcohol use. Most revealing, some of my colleagues argued determinedly that "it is not possible to refuse a drink". I assumed at first that they were referring to physically dependency, but soon realized that they meant social pressure. When I drew to their attention the various strategies and social skills I had seen used to pace consumption, however, they could agree that moderation skills were possible. In general, I sensed a passive acceptance that alcohol use and abuse are a part of the culture and cannot be changed.

Drug use is also increasing in Russia. As many as 20% of youth under age 18 are said to use drugs regularly. At present, most of these young people are from disadvantaged backgrounds, but authorities fear that use will continue to spread. The well-organized Russian "mob" is heavily involved in the drug trade, and officials fear that the violence and other crime that always accompany the illegal drug trade will take hold in Russia.

When I asked about basic preventive services like immunizations, I was repeatedly told that "this is not a problem here". School children are immunized at school, but no one was able to tell me about immunizations for babies or adults. The various preventive screening services we promote in the U.S. (for cholesterol, blood pressure, the cancers) were not used by, or known to, my middle class informants. It is not clear whether these are unavailable or just not well-accepted.

The Russians' notions of what constitutes preventive health behaviors would be an intriguing topic for systematic study. It was very difficult to get a broad picture of prevention in Russia, because the people I queried each had personal preferences they wanted to discuss. What did become clear was that they are fond of "complementary" approaches. Herbal preparations are popular for prevention. Several colleagues sold herbal teas imported from California, each of which was supposed to have particular health properties. An organism called Spirulina, was being touted by one physician as preventing everything from colds to AIDS. There seemed to be a common belief in the relationship between the state of children's spines and their physical and emotional wellbeing, and schools offered various therapies to "straighten" students' spines. (After visiting class rooms where 14 year olds were using chairs designed for kindergartners, I gave more credence to their beliefs). Massage therapy and relaxation techniques for school children were very popular, especially for those with emotional and behavioral problems. Children considered high risk because of social circumstances or behavioral problems are also taught stress management techniques.

Suggestions for Other Health Educators
Abstract	Introduction	Demographics	Health Care	Health Education	Health Values	Physical
Nutrition	Smoking	Alcohol	Prevention	Suggestions	Acknowledgments	References

If I could offer only one suggestion to health educators planning to work in Russia, it would be to arrive well in advance of beginning work. The literature on consultation has many grim tales about the consequences of having insufficient preparation time. Unless you have worked in a particular Russian city previously, you simply cannot be adequately prepared to begin teaching or consulting immediately.

Second, be prepared to have to search for the professionals who provide health education. They are not known as health educators, and as in the U.S, they work in a variety of different bureaucratic structures.

Third, consider the structure and protocol for decision making in the system where you are working. Despite repeated efforts, I was never able to determine who is responsible for making decisions about school health curriculum and services. I was variously told that (a) the curriculum is set entirely by "the central authorities" and (b) individual teachers have great flexibility. Thus, it seems appropriate to take both a top-down and bottom-up approach in promoting and organizing health education in Russia. Within the social service system, participatory decision making seems much more accepted (Imbrogno, 1994)). Here again, however, a systematic approach to involving all of the key decision makers is important. I found it helpful to think in terms of "educating" Russian professionals from the top down, and "organizing" them from the bottom up.

An obvious fourth recommendation is to learn as much as possible about the specific health-related attitudes and behaviors you are addressing within the populations with whom you'll be working. Don't assume anything. Obviously, customs, culture, and social and economic conditions in a particular locale will be crucial information. Do not expect to rely on existing data, because you are unlikely to find much available. Nor should you rely on professional colleagues as your sole informants of local conditions, either. It is tempting to do this when working in a strange culture, but you need to explore the community for yourself. Colleagues may help organizing tours of health care and social service facilities. Be mindful that they want to show you the best they have to offer, just as we would want to do. However, to better understand problem areas, however, you need to look further. I found Warren and Warren's (1984) description of "diagnosing" a neighborhood particularly helpful. Walk the streets, ride the buses, visit apartment complexes, browse the bazaar. Obviously, a translator makes this easier and more comfortable, but even with the language barrier you can learn a great deal.

Finally, take advantage of as many opportunities as possible to meet and mingle with the Russians. They are charming and conscientious hosts, so you are likely to be invited to many social gatherings. Because professional and social networks tend to entwine in Russia, these social events will give you opportunities to build valuable networks and trusting relationships with various Russian colleagues. Social occasions also provide opportunities to learn more about Russian culture and social arrangements.

Russia is a dynamic, energetic country, and despite its difficulties it holds great promise for development in the health and social spheres. The American health educator who has the opportunity to work there is sure to return home feeling enriched, enlivened, and with a new perspective on old assumptions.

Acknowledgments
Abstract	Introduction	Demographics	Health Care	Health Education	Health Values	Physical
Nutrition	Smoking	Alcohol	Prevention	Suggestions	Acknowledgments	References

The author wishes to give special thanks to my Russian and American colleagues at the Russian-American Summer University, Togliatti Social and Economic College, Yelena Yeremina, Director