The Russians are seemingly a very unpredictable lot. People who couldn’t find Russia on a map have probably heard Winston Churchill’s famous, and vapid, description of Russia as a “mystery wrapped inside a riddle inside an enigma.” After a rotten 20th century filled with two world wars, three revolutions, and more famines than one can reasonably keep track of, somewhere around 2000 the Russians finally seemed to have settled down and decided to leave the world alone. True, there would be an occasional outrage in Chechnya, a village burnt down or a group of men disappeared, but on the international stage it seemed that Russia had disappeared.

What’s more, the Russians didn’t seem overly concerned about this or, if they had doubts, kept them to themselves. American foreign policy thinkers, particularly the neoconservatives, to the extent they still talked about Russia pondered not the challenges of an aggressive and powerful regional hegemon but the problems that would accompany the country’s complete collapse and dissolution: worries about the Fulda Gap and the number of motor-rifle divisions in Germany were replaced by worries about nuclear proliferation, ethnic strife, refugees, and the spread of drug-resistant TB.

To the surprise of just about everyone, though, shortly after the painful humiliation of the 1998 government debt default the Russian economy started to boom and the Kremlin’s formerly bare coffers were overflowing. For many years this economic growth was overlooked, ignored, or explained away as trivial and unimportant (The Wall Street Journal was particularly adept at this), but it continued at a brisk pace. Before anyone in the West really seemed to know what was going on, oil was over $100 a barrel, Russia had hundreds of billions of dollars in foreign reserves, and Vladimir Putin had, if nothing thing else, succeeded in getting the world to pay attention to Russia once again. It was in this context that the war in the Caucasus (absurdly compared to either the 1956 invasion of Hungary or the 1968 invasion of what was then Czechoslovakia) took place, providing irrefutable “proof” that not only was Russia back, but that, just like the Soviet Union, it was a malignant force.

Every compelling narrative, of course, needs a villain, and the role of villain in Russia’s resurgence as an enemy of democracy, freedom, and self-determination has been played with great aplomb by Vladimir Vladimirovich Putin. Putin seems to personify virtually every Western cliché about Russians, and seems to have come to the Kremlin directly from a Hollywood casting call for a “creepy, devious, and morally repugnant KGB apparatchik.”

The problem, though, is that unlike previous Russian strongmen who had frequently, if not constantly, to revert to the use of brute physical force and pervasive political terror to subdue their own populations, Putin has been broadly and genuinely popular (this popularity might very well, as argued by some political scientists, be “a mile wide and a foot deep”, but it is no less real). In the mainstream Western press the Russian population’s support of Putin - despite the onset of a painful economic crisis he remains among the world’s most popular leaders and during his two terms as President routinely enjoyed the approval of 80% of Russia’s citizens - is touted as evidence that there is something uniquely dark and disturbing about the Russian soul. Only truly horrifying and morally deficient people, so the thinking goes, could support such a fearsome character so unreservedly. But why do Russians really like Putin? Is it some quasi-genetic predisposition towards authoritarianism, as Richard Pipes would have it? Or is there some more logical, more intelligible, and quite possibly more banal reason for his popularity?

While Russia’s unique culture and troubled past have certainly imbued the majority of its citizens with a hatred of “chaos” and a preference for stability and order, the cliché of Russians as passive automatons is just that, a cliché. Even during the nightmare of Stalinism Russian society was never totally quiescent, and when he assumed the presidency Putin inherited a country that was chaotic to the point of disintegration. Russians conclusively showed during the Yeltsin years that they could be just as boisterous, unpredictable, and free-spirited as any nation. Why, then, has there been so little resistance to Putin? I want to attempt to answer this question by focusing on healthcare, partially because, having written an M.Phil thesis about the topic I ought to know something about it, but also because I truly believe that it is a very effective way to illuminate both the positive and negative aspects of the past decade of Russian history and to understand why Russians have, up until now, been such fans of Putin and the system he has created.

First, a few words about the history of the Soviet/Russian healthcare system are necessary. Universal access to healthcare that was free at the point of delivery was one of the crowning achievements of the Soviet welfare system, and one of the most genuinely popular articles of social provision (according to opinion polls, Russians would have a Scandinavian-like social economy if they could). Under the Tsars, Russia had a truly abysmal record of public health: its citizens suffered from diseases at rates two, three, and even four times higher than did Western Europeans and had life expectancies that were almost twenty years shorter. Through the first decades of Soviet power, buoyed on by slogans such as Lenin’s humorous formulation that “either Socialism will defeat the louse or the louse will defeat Socialism,” the health authorities made impressive progress in combating a host of infectious and parasitic diseases and health indicators improved dramatically. The average life expectancy of a Soviet citizen rapidly converged with those of a European or an American, and by the early 1960s all relevant public health data showed that the Soviet Union had largely succeeded in its effort to catch up with the West.

What happened next, though, was totally unanticipated. Instead of surpassing the West, or even continuing to improve at a slower pace, by the mid 1960s Soviet health indictors had begun to deteriorate. In fact, over the past half century Russian life expectancy has never come close to matching its early 1960s peak. This deterioration continued and accelerated through the 1970s, 1980s, and 1990s, especially during the economic chaos that followed price liberalization and the mass voucher privatization of state-owned enterprises, affecting virtually all sectors of the population but working-age men most severely of all. The life expectancy gap with the West, which had narrowed to nothing at the start of the 1960s, yawned into a giant chasm by the time Communism fell in the early 1990s and then expanded even more dramatically over the next decade. By 2000, Russian health indicators were more comparable to sub-Saharan Africa than to Europe.

Partly, the long-term decline in Russian health was the result of a host of social pathologies: Russians smoke, drink, and eat unhealthy foods at rates vastly higher than in Western countries. Another important factor, however, was the dysfunctional nature of the healthcare system. Starved for funding because of the priority placed on the arms race with the United States, Soviet healthcare also suffered from a number of serious structural flaws, the most basic of which was that the planning mechanisms emphasized quantity at the expense of quality: healthcare policy was deemed a “success” if it produced more doctors, more hospital beds, and more procedures regardless of their efficacy.

Like most sectors of the Soviet economy, the healthcare system appeared formidable on paper but was terribly deficient in reality. Indeed, when trying to understand the wretched state of Russian healthcare we should keep in mind that, in the Russian context, words can have very different meanings. In the West the word “hospital” conjures forth a variety of images of cleanliness, modernity, efficiency, and a certain level of technological sophistication. In Russia, “hospitals” frequently lacked, and continue to lack, running water and central heating, much less any of the gadgetry on display in a typical episode of House. So what did Putin do in healthcare, and how does it explain his popularity? More than anything else he spent money. In fact, he spent an awful lot of it, and spent it in such a way that Russians knew he was spending it. Consider the following chart showing real health expenditure (1991 = 100) from 1999-2008.

Real health expenditure in Russia 1999-2008 (1991 = 100)

Most of the underlying structural deformities of the Russian health system have remained unaddressed, there are still far too many doctors and hospital beds, but, to modify a particularly elegant American expression, almost any pig can look good if you put enough lipstick on it and Putin and his government have been applying it to the healthcare system by the barrel full. At some point in the future, there will need to be an additional series of painful (and expensive) reforms, but Putin saw to it that Russian healthcare was funded better than it has been at virtually any point in history. The improved funding of the health system has, so far, been maintained in the midst of a severe financial crisis, a radical departure from past practice when health budgets were always the first to be pared.

Now I’m not nearly reductive enough to claim that the graph of real health spending explains everything about Putin’s popularity, or even the majority of it. But, just as clearly, Western complaints that Putin has “done nothing for the average Russian” are not so much hollow as they are flatly inaccurate. The typical Russian cannot afford treatment in a private clinic or (like the Oligarchs) in the West, and is reliant on the state-funded system of healthcare for a very vital and important part of his or her life. Thus any improvements in healthcare funding, such as those that Putin oversaw, will affect the vast majority of the country’s population, if not its tiny pro-Western minority. Now, keeping in mind Russia’s omnipresent corruption, it stands to reason that a good deal of new health spending has ended up in Swiss bank accounts or villas in the French Riviera rather than in hospitals in Saratov or Yekaterinburg. But, it also stands to reason that a good deal of that money has gone to help real people with real illnesses who would previously have gone without treatment. It is not exactly rocket science to expect that Russians would notice and appreciate any improvements in the standard of medical care, and since conditions were almost uniformly grotesque in the 1990s the improvements over the past eight years, and particularly the period since 2004, seem more dramatic than they might otherwise.

One should never discount the very real differences between cultures, and it would be extremely hubristic to suggest that Russians are in all respects identical to Westerners (however one defines “Westerner”). However, keeping that in mind, we should not go so far as to suggest that the Russians are aliens: their value system, while different from our own, is not totally incomprehensible, bizarre, or counter-intuitive. In many respects they share a very similar desire for improved living standards and increased economic opportunities. Russians, of course, weigh their current and future prospects in comparison to their own past experiences. Thus a typical middle class Russian, while aware that Americans and West Europeans have a significantly higher standard of living, compares his current circumstances to those he experienced during the 1990s and the early 2000s, and not the hypothetical circumstances he might experience in America or in a Russia that had perfectly followed a “liberal” course.

My main point, boiled down to its most basic formulation, is that it’s really not that surprising that Russians generally consider the Putin era to be an extremely positive one. Apart from all of the other benefits of economic growth, there has been sustained investment in healthcare and a very noticeable improvement in quality of treatment, albeit from a very low level. There is very little indication that Russians have any interest in the “ideology” of Putinism, which is so crudely stitched together that one really must use inverted commas when describing it, but strong evidence that they appreciate the improvement in the quality of life and expect this improvement to continue. During the Soviet era the state didn’t want to adequately fund healthcare (or other social programs) because of the priority placed on the military, during the Yeltsin era it couldn’t because it was bankrupt, and during the Putin era it has.

To the extent that the Putin/Medvedev regime is able to continue to implement policies, such as investment in healthcare, that improve the lives of ordinary Russians it will remain popular. To the extent that it is unable to do this, it will not, as the current economic crisis is making clear. Russians are many things, but they are not fools. Putin has, so far, presided over an economic miracle of historic proportions and a general revitalization of a broken and bankrupt society: it would be strange if he wasn’t enormously well-liked. That we consider his popularity amongst Russians to be bizarre or incomprehensible says far more about our biases that it does about Russian society.