Soviet Medical Expeditions in Tuva and the Making of Tuvinian Healthcare, 1928-1936 by Vsevolod Bashkuev doi:10.55337/KGGH4265 PDF This paper aims to expose the role of Soviet medical expeditions in the construction of modern healthcare in the Tuvinian People’s Republic. Based on archival sources, the study traces the activities of four successive medical teams working in Tuva from 1928 to 1936. The first expedition thoroughly reconnoitered the health situation in the republic, picking out the most troublesome areas, diseases, and spheres of life. The ones that followed consolidated the initiative of the first team, turning healthcare in Tuva into a state affair and an international venture with political undertones. Keywords: medical and sanitary assistance, Tuva, Narkomzdrav, expeditions, syphilis, chronic diseases, epidemics, healthcare, medical facilities, Soviet physicians. Introduction The Tuvinian People’s Republic (TPR), or Tuva, was a quasi-independent non-capitalist state and Soviet protectorate that existed from 1921 to 1944. While generally resembling the neighboring Mongolian People’s Republic (MPR) in its political setup, Tuva differed in population composition. Being very close to the Mongols in terms of religion (Lamaism, or Tibetan Buddhism) and culture (nomadic cattle-breeders), the Tuvinians are a people of Turkic origin akin to the Khakas and Yakuts. There was also a sizeable Russian minority, which had formed early in the twentieth century as a result of Tsarist colonization policy. The first official Tuvinian census, conducted in 1931, recorded some 17,300 non-Tuvinians (mostly Russians) and 64,900 Tuvinians. As a consequence, when the Soviet government launched a program of medical assistance to the TPR in 1928, these factors influenced the process, making it distinctly different from the similar experience in the more ethnically and culturally homogeneous MPR. The issue of healthcare development in Tuva is still only sparsely covered within historiography. In the Soviet period, there was only one monograph on the history of Tuvinian healthcare, written by M. G. Shabaev and published in 1975. Like other Soviet works on the history of medicine, the book interprets the development of healthcare as a linear process, highlighting the successes of Soviet medicine and focusing on the growth of the hospital network and the increasing number of qualified medical personnel. The author only briefly mentioned such important aspects as the activity of Soviet medical expeditions in Tuva during the early stages from 1928 to 1936, or the formation of an expatriate Soviet medical community. Shabaev was also heavily reliant on regional archives. During this period, the fund of the People’s Commissariat of Health of the Russian Soviet Federative Socialist Republic (RSFSR; hereinafter – Narkomzdrav) at the Central State Archive of the RSFSR, today the State Archive of the Russian Federation, or GARF, where the bulk of documents covering these issues were housed, often remained beyond the reach of most historians. Since the end of the Soviet Union, however, the relative accessibility of archives and declassification of the Narkomzdrav papers has resulted in several articles on the history of Tuvinian healthcare. Most of these studies focus on the period from 1944 to 1991, when Tuva joined the USSR as an autonomous region of the RSFSR. However, a few articles do concentrate on the period beginning in 1928 to the early 1940s. Some are based on the documents from Fund A-482 (Narkomzdrav RSFSR), housed in GARF’s archival collections, while others mostly utilize less detailed sources from the State Archive of the Republic of Tuva. Somewhat unsurprisingly, there are many discrepancies between the documents in the regional archives and the Narkomzdrav papers at GARF, even the dates of the Soviet expeditions and names of their staff members differ. As a result, the documents from Fond A-482 are broadly viewed as more accurate because it was within the Narkomzdrav that the main development vectors for Tuvinian healthcare were devised. The All-Union Bureau of Foreign Sanitary Information (OBZSI) of the Narkomzdrav that staffed and coordinated all Soviet medical expeditions abroad, as well as financed each of these ventures through special governmental subsidies. Consequently, GARF not only houses the personal files of the medical personnel dispatched to Tuva, but also the majority of the official plans, reports, requests, and complaints. Alongside journal articles, essays and chapters on the medical history of the TPR are also scattered across various edited volumes focusing on Tuvinian history. Sections of volume three of the History of Tuva, edited by N. M. Mollerov, for example, contain valuable information on the making and development of Tuvinian healthcare during the independence period and following unification with the Soviet Union. However, these sections, along with studies by the Research Institute of Medical and Social Problems and Management of the Republic of Tuva, either continue the linear approach adopted by Soviet historiography, or are comparatively limited in scope, concentrating on the founding and development of certain hospitals or branches of regional medicine. Chapters covering Tuva in more recent analyses on the history of Russia’s medical interaction with the Mongolian peoples of Inner Asia, however, offer newer methodological approaches, such as the hypothesis that the Bolsheviks used medicine as a form of geopolitical “soft power” and an informal conduit for the transmission of Soviet ideology. Such research also tends to view the development of Tuvinian healthcare as a form of cultural interaction, highlighting relations between Soviet expeditionary physicians, Tuvinians, and local Russians as an aspect of the new history of medicine. However, the experience of Soviet-Tuvinian interaction in the context of medicine and health protection offers much more in terms of comparison with other parts of the “Mongolian world” as well as a more in-depth understanding of the USSR’s political and medical interests within the TPR. A student of early Soviet cultural policy towards national minorities would search for theoretical beacons to position the Tuvinian case within the broader context of the Sovietization campaigns along Siberia’s southern borderlands. At present, there is a distinct lack of historical and multidisciplinary research on how Soviet medical assistance in Tuva promoted Bolshevik ideology and the Sovietization of everyday life. Nevertheless, there are works on similar cases of interaction between Soviet medicine and traditional nomadic societies in Buryat-Mongolia, Kazakhstan, or Mongolia. In her 2003 book Curative Powers: Medicine and Empire in Stalin’s Central Asia, Paula Michaels, for example views the introduction of biomedicine in Soviet Kazakhstan as indicative of Soviet colonialism, comparing it with British colonial medicine in India and Africa and drawing on Edward Said’s seminal text Orientalism. Writing in 1993 and 1995, Susan Gross Solomon assesses Soviet-German medical cooperation in the case anti-syphilis measures in Buryat-Mongolia, a Soviet autonomous territory that was not only geographically contingent, but culturally and confessionally very close to Tuva. Her rigorous analysis of this joint scientific-medical venture as a political enterprise to break the geopolitical isolation of both Weimar Republic and Soviet Russia has proven to be foundational to my own concept of Soviet medicine as a “soft power” instrument in Mongolia and Tuva. Soviet-style cultural campaigns for personal and communal hygiene in Mongolia are also focused upon in Ines Stolpe’s research, based on interviews and personal accounts of prominent Mongolian historians and journalists. Profound knowledge of the Mongolian language and culture has allowed Stolpe to reveal and scrutinize aspects of history often lacking in other publications on the subject, such as the formation and interiorization of the previously non-existent Mongolian terms for “hygiene” or the differences in the symbolic and real use of personal sanitary items in everyday nomadic life. Social historians have also written on Soviet-inspired hygiene and medical practices in the traditional nomadic societies of Inner and Central Asia. Baasanjav Terbish analyzes a frequently overlooked aspect of the Soviet-style hygienic modernization in socialist Mongolia: the changing concepts, perceptions, and practices of sex in the MPR. Key to his work is an accentuation of the differences in understanding and moral interpretation of sex between Mongols, Russians, and the Russian-educated socialist Mongolian elite. Terbish’s research also explains the role sex had played in Buddhist religious practices before socialism, analyzing perceptions in pre-socialist Mongolian society, and noting changes brought about by the Sovietization of day-to-day life for most of the Mongolian population. In a recently published article, Rebekah Ramsay examines the widespread Soviet phenomenon of “red yurts,” which served the combined goal of political enlightenment, female emancipation, and health improvement in nomadic societies throughout Central and Inner Asia. Focusing on Kazakhstan, her work discusses how these “red yurts” served as a manifestation of the ideal Communist household among Kazakh cattle herders. Ramsay makes the interesting suggestion that the “red yurts” not only played the role of agents for cultural and sanitary change, but also as showcases for the emerging Kazakh market advertizing milk separators, kitchen utensils, soap, tablecloth, and other goods. She also maintains that the “red yurts” precipitated the transformation of the traditional nomadic lifestyle from within and, as such, disappeared when this task was considered done during the collectivization campaign. While the article format is too constrained to allow for a comprehensive discussion as to whether the Tuvinian case represented a continuation of Bolshevik social and cultural policy pursued in Buryat-Mongolia, Kazakhstan or Turkestan, these studies are valuable milestones for the positioning of the TPR within the context of Soviet medical assistance in Inner and Central Asia. This paper therefore marks an early stage in this process of historical scrutiny. In the virtual absence of international scholarship on the topic, all the above works may be viewed as delineating numerous thematic undercurrents in the general flow of Soviet hygienic modernization of nomadic societies in the 1920s and 1930s. Some of these proved to be openly visible in the Tuvinian case, while others manifested themselves in alternate ethnic, confessional, and cultural settings. Within the analysis itself, I will focus on the activities of the Soviet medical and sanitary expeditions to highlight the salient role they played in the development of Tuvinian healthcare during the interwar period. For historical background, I will provide a brief survey of European medicine in Tuva before the 1928 Narkomzdrav expedition. The article will then pay close attention to the medical activities undertaken by the first expedition headed by M. S. Arutyunyan. This initial incursion was significant in several respects. First, the expedition severed to thoroughly reconnoiter the medical situation during the early years of the TPA. Second, it developed the methods of approaching and examining various social groups within Tuvinian society from which the Soviets were then able to formulate a general development strategy for healthcare. Finally, the expedition was responsible for creating the Tuvinian Health Department (Tuvzdrav), the first healthcare administration in the republic out of which Tuva’s entire medical framework emerged throughout the 1930s and 1940s. The first and second Soviet medical expeditions will be analyzed together. Both missions were headed by M. S. Arutyunyan, who pursued a consistent policy of turning his expeditionary into the purveyor of European medicine and its development in Tuva. While the second expedition generally followed a similar pattern to that of the first, the third, headed by Dr. I. D. Rudenko, operated mostly in the Tuvinian capital of Kyzyl, and received a personal appraisal from the TPR’s government at a concluding conference. The fourth expedition, however, exposed the various internal tensions within Tuva’s nascent medical community, granting historians a degree of insight into the complex relationships between Soviet medical practitioners. For the sake of brevity, I will also consider the third and fourth expedition together in one subsection. As already detailed, this paper is primarily based on archival documents from Fond A-482, Opis 35 (“The All-Union Bureau of Foreign Sanitary Information”) currently housed in GARF. The file contains detailed reports on expeditionary activities in the TPR as well as other important sources, such as internal memos of the expedition heads and rank-and-file medics, complaints, letters, expeditionary cost-sheets, and work plans. Through these documents, researchers can trace the cultural interaction between Soviet doctors, native Tuvinian herders, and local Russian colonists. These archival materials are equally important in that they constitute a knowledge base on the sanitary situation in Tuva, without which any further healthcare planning by the Soviet authorities would have remained impossible. In my view, the preconception that Soviet archival documents do not offer an objective impression of reality due to ideological reasons is not applicable here since the Narkomzdrav required an accurate picture in order to develop adequate responses to Tuva’s medical and sanitary issues. Moreover, Soviet physicians indicated that their estimates were approximate if the scope of research was limited or based on data acquired from local sources. Of course, certain documents, especially those offering subjective, personal impressions of traditional medicine or nomadic lifestyles, should be viewed with a degree of analytical circumspection. However, there is no reason to believe that Soviet medics somehow doctored their reports. Too much personal and professional effort was invested in the acquisition of this data, most of which was crucial for the overarching enterprise of constructing a modern Tuvinian healthcare system. Overall, the selected source base enables the historian to reconstruct important aspects of the Soviet-Tuvinian relations in medicine that have long been neglected in Soviet and contemporary Russian medical history, and completely ignored by Western historiography. Medical Network and Health Problems in Tuva before the 1928 Narkomzdrav Expedition Until 1900, Tuva had remained largely outside the professional remit, and geographical imaginations, of Russian and European doctors. Nevertheless, the first Russian travelers to the region had brought with them the elementary aspects of European medicine: first aid kits, which they readily shared with the sick Tuvinians. In 1898, a feldscher’s (paramedic) station was founded in Usinsky county on the Russian side of the border, allowing the local Tuvinian inhabitants access to qualified medical assistance. Word of the station quickly spread across the countryside. Thus, long before Soviet physicians arrived in Tuva, the local population had already formed a broadly positive attitude toward European medicine. In 1909, the Russian physician A. M. Saf’yanova organized a well-equipped European medical aid post in Turan, a town today located northwest of Kyzyl which had been founded by Russian settlers from Siberia in 1885. She subsequently served as head of the ambulatory clinic at the “Uryankhai Settlers’ Station,” also located in Turan. Saf’yanova was the first professional qualified European physician in Tuva and many Tuvinians living around Turan turned to her for medical assistance. However, large-scale measures to provide more comprehensive medical assistance to the settlers only began after 17 April 1914, when Tuva, or, to use its Russian exonym, Uryankhai, officially became a Russian protectorate. By late 1914, three medical facilities were operating within the territory’s borders: the ambulance clinic in Turan, as well as the Znamensky and Khemchiksky feldscher’s stations. With the construction of the town of Belotsarsk - that would later be renamed to Kyzyl - a 22-bed hospital also opened. However, at this point the institution still only served a few dozen patients a year. Nevertheless, the native Tuvinians reportedly made more active use of European medical assistance than the local Russians. During the revolution and subsequent Russian Civil War, the hospital in Belotsarsk was closed down with the population having to resort to traveling feldschers for medical assistance. Only in 1924, at the behest of the Russian Self-Administering Labor Colony (RSTK), were the former medical stations reopened in Kyzyl, Znamenka, Turan, and other large settlements. The RSTK hospital in Kyzyl had two buildings: one hosted an outpatient clinic and pharmacy while the other included a 12-bed in-patient facility. Since there were no surgery facilities at the hospital, surgical patients were obliged to travel northwest to the Russian provincial town of Minusinsk. There was also a chronic shortage of medicines. In 1926–27, the head of the Russian hospital in Kyzyl, a Dr Vasil’ev, and his wife also worked part-time at the Tuvinian governmental hospital. From the summer of 1926, the RSTK hospital in Kyzyl began charging considerable fees for medical treatment. Although there was an insurance office for Russian colonists, insurance payments amounted to 32,000 roubles a year, of which 18,000 went directly to the hospital as medical fees of the insured. At the same time, the medical network of the Tuvinian government had only one hospital in Kyzyl with an outpatient clinic, pharmacy, and a six-bed in-patient facility. Before 1930, Tibetan medicine was still officially practiced in Tuva with the governmental hospital offering both European and Tibetan forms of healthcare. The European medical team consisted of a physician, a doctor’s assistant, a translator, and a female cook. Moreover, the Tuvinian-run hospital frequently experienced severe shortages of medicines, especially anti-syphilis drugs, as well as surgical instruments, bandaging material, and bedclothes. Until 1929, there were no independent pharmacies in Tuva, with medicines being distributed to the general population directly via the hospitals; all medical goods and equipment were supplied by the Tomsk Pharmaceutical Administration of the settlers’ station. In 1929, however, the first modern pharmacy selling medicines and materials was opened in Kyzyl. By contrast, Tibetan medicine was much more developed in Tuva than its European counterpart. As in Mongolia and Buryatia, it had spread across the territory with the advent of Lamaism in the seventeenth and eighteenth centuries. Drawing on the ancient Indian medical canon, Tibetan medicine featured an elaborate system that had, over the centuries, developed its own forms of diagnostics, pharmacology, surgery, and dietetics. The lamas used their superior medical skills to impress the nomads, which facilitated conversion to Lamaism. The German Mongolist Walther Heissig, cites a seventeeth-century Mongolian source on the conversion of the Buryats, noting that the lamas living in the Selenga and Khori Buryat districts “were of help to the people with prayers and medicine.” Moreover, as the translation further notes: “the faith spread while lamas trained at the medical facilities, treating the diseases and venereal contagions and reciting prayers relieved human beings from the fear of being afflicted by various diseases and of premature death”. In a sense, Tibetan medicine had represented an earlier form of “soft power” that the lamas utilized in a manner similar to the Bolsheviks’ use of modern European medicine. The healing emzhi-lamas were educated in large Buddhist monasteries, or lamaseries, the first of which appeared in Tuva in 1772. In 1926, there were 26 large lamaseries and over 4,000 lamas. The Ministry of Internal Affairs of the Tuvinian People’s Republic kept an official register of the lama healers. According to Soviet doctors, in 1927, there were 235 officially registered emzhi-lamas, however, their numbers may have been considerably higher. As in Buryat-Mongolia, Kalmykia, and Mongolia itself, the healing lamas in Tuva were ubiquitous and provided readily accessible healthcare to the most distant corners of the republic. Deeply entrenched in the culture and everyday life of the nomads of the Mongolian world, Tibetan medicine was even officially recognized as state medicine in both Mongolia and Tuva until 1930, with its cultural authority in both the government and among the general population remaining high. Russian doctors had expressed skepticism towards Tibetan medicine, noting that most emzhi-lamas had not received any formal medical training in Mongolian or Tibetan monasteries, but had picked up practical skills from their mentors. However, with few European medical facilities available to much of the populace, Tibetan medicine had remained a vital substitute. It was widely available, familiar, and well-respected, albeit far from cheap. Indeed, medical fees were often exorbitant: some herders paid the emzhi-lama with their last sheep or even a yurt. From 1922 to 1926, official recruitment of emzhi-lamas for public service was provided by special governmental orders with practitioners being recalled from the countryside to Kyzyl in order to serve, on a rotating basis, for 72-day periods. In 1928, the Tibetan Hospital Bill was passed, and a permanent Tibetan clinic opened in the capital, staffed by three emzhi-lamas: a chief physician, a doctor, and a paramedic. In addition, positions for a nurse, medicine maker, and stoker-courier were also made available. The candidacies of the chief physician and the doctor were approved by the government, whereas the rest of the staff were appointed by the Ministry of Internal Affairs. Therefore, by 1928, when the first Soviet medical expedition arrived in Kyzyl, Tibetan medicine formed an inseparable part of the local healthcare and was positively perceived by the Tuvinian leadership. Conversely, the general health situation in Tuva remained far from adequate. Prophylactic and anti-epidemic activities, for example, came under the remit of the capital’s Tibetan hospital but, like their Mongolian and Buryat counterparts, the Tuvinian emzhi-lamas were notorious for being unable to deal with infectious diseases. Syphilis was especially rampant among the Tuvinian populace, yet in 1927 only one Russian physician at the Kyzyl hospital was known to be treating it correctly with neosalvarsan, the rest, including other Russian medical personnel, still relied on mercurial ointment and potassium iodine. Moreover, limited resources and trained staff also meant that the bulk of patients remained untreated and had to turn to shamans and emzhi-lamas who knew nothing about microbes or the medicinal treatment of venereal diseases. The first detailed Soviet record discussing the characteristics of health problems in Tuva was written by A. P. Preobrazhensky, a physician who had accompanied a scientific expedition to the TPR, headed by the anthropologist Viktor Bunak, in 1926. Preobrazhensky examined 297 Tuvinians in various parts of the country and wrote a general assessment of the epidemic situation, sanitary and hygienic conditions among the Tuvinian autochthones, and medical-geographic peculiarities. Of the more serious vices recorded as prevalent among the indigenous populated, Preobrazhensky noted alcohol abuse, smoking, premature sexual activity, and unsanitary conditions. As he put it: The sanitary conditions of the Tuvinian population are very bad. Any notion of hygiene and cleanliness is missing. There is no washing of the body, only of face and hands on very rare occasions. Clothing is not washed either, worn until it rots away and falls apart. Kitchen utensils are shared by family members and guests and are also never washed, so that they are covered with a thick layer of filth from the inside. Modern historians may perceive his observations, not inaccurately, as indicative of European colonial thinking. One must bear in mind, however, that this description was itself typical of Soviet medical representations of traditional nomadic lifestyle from the epoch when the socialist experiment was still in its early phase. Physicians such as Preobrazhensky viewed such cultures as an outdated phenomenon that would soon be replaced by a new hygienic reality and the more shocking the descriptions were, the more hope there was that efforts would soon be made to ameliorate the situation. In this way, his description did not imply any contempt for an alien culture but a genuine expression of deep concern for the indigenous population’s living conditions. Such hyperbolic rhetoric would have also been deemed essential in order to draw attention to the situation. Moreover, university educated physicians tended to base their assumptions around a certain hygienic norm stemming from the study of modern medicine; hygienic condition of, for example, a traditional Tuvinian yurt would be viewed as illustrative of the extent to which this norm was neglected, or ignored, in a nomadic cultural environment. For those like Preobrazhensky, this was not an anthropological description, but an attempt to call attention to an aberrant deviation from the accepted standard for base-line human hygiene. Such passages in medical narratives must therefore be understood within the literary and scientific contexts of this early-twentieth-century period. Of the 297 Tuvinians whom he examined, 89 were diagnosed as having syphilis. Indeed, Preobrazhensky noted that it was widespread in all of the TPR’s districts, specifically around large lamaseries. By contrast, of the approximately 200 Russian colonists, whom he had also examined, syphilis was discovered to have been extremely rare. Instead, most Tuvinian Russians suffered from catarrhal gastritis and rheumatism. Among other widespread infectious diseases Preobrazhensky noted scabies and trachoma as being especially prevalent, however, actual epidemics were rare. The most recent outbreak of relapsing fever, for example, had occurred in 1921, claiming many lives. As a result of an earlier inoculation drive, which even the emzhi-lamas had the necessary resources to provide, cases of smallpox were seldom recorded. Dr. Preobrazhensky was the first Soviet physician to propose basic organizational principles for the nascent Tuvinian healthcare. Key to this was the principal that medical assistance should be openly available to both Tuvinians and Russians, while possible financial obstacles as a result of independent RSTK and Tuvinian budgets could be removed by the proportionate funding of healthcare by both sides. He also offered a tentative scheme for establishing a more efficient network of medical facilities network focused on a central hospital in Kyzyl and four district medical aid posts. Two of these would be based in Tuvinian settlements and two in the Russian-inhabited villages, located 100-220 versts (approximately 110-242km) from the capital. Preobrazhensky also proposed dispatching several medical detachments to assess the situation in remoter districts, as well as a serious study of Tibetan medicine. Nevertheless, while the TPR had several very basic European and Tibetan medical facilities by 1928, this humble network was still unable to provide the population with a sufficient or quality level of service. European-trained physicians were mostly preoccupied with the health problems among Russian colonists, while Tibetan healers continued to mostly serve the native Tuvinians but could not offer effective protection from infectious diseases. The two branches also had separate budgets, further complicating the management of healthcare. Tuvinians also continued to face rampant levels of syphilis, trachoma, and skin diseases, while Russians suffered en masse from chronic gastritis and rheumatism. These issues required urgent medical measures, for which the TPR’s government had neither the specialists nor the funds. The only feasible solution was to seek foreign assistance. The Early Stage of Soviet Assistance: The First and Second Medical and Sanitary Expeditions of the Narkomzdrav to Tuva (1928–1930) In 1927, a delegation from the TPR paid a friendly visit to the Narkomzdrav and, on behalf of their national government, asked for assistance in organizing European medical aid for the population. To satisfy this request, the leadership of the Narkomzdrav decided to urgently send a medical expedition with three doctors, a paramedic, and two nurses. The expedition’s departure was planned for the spring of 1928. First, it was decided to dispatch an experienced and socially active physician, who would be able to properly administer the RSTK executive committee’s hospital, and the European department of its Tuvinian counterpart; prepare a workable plan for future Soviet expeditions; and propose realistic measures for the organization of Tuvinian healthcare. It was decided to allocate an additional 20,000 rubles from the Narkomzdrav funds to equip the RSTK hospital and include a further 30,000 rubles to support the Russian hospital in 1927–28. Order No. 440 of the People’s Commissariat of Health of the RSFSR of December 2, 1927, appointed Martiros Sarkisovich Arutyunyan, a trained surgeon, as head of the expedition. Alexander Ivanovich Nikolaenko, and Isai Grigor’evich Misezhnikov were hired as the expeditionary venereologists and Maria Evgrafovna Kvartseva as a nurse and midwife. Based on each member’s personal file, the most experienced physician was Nikolaenko, who had had years of experience in private practice in France before the October Revolution. However, this also made him unsuitable to lead the expedition due to class principles. Arutyunyan, a peasant by birth and a former political activist for the Red Army, was instead designiated as the leader owing to his social background. This was despite the fact that he had only qualified as a doctor in 1924, after graduating from the Medical Department of Moscow State University, and was the least experienced medic among the assembled staff. Yet, it was Arutyunyan who later proved to be an able and competent organizer and, figuratively speaking, the “founding father” of Tuvinian healthcare. According to the “Statute on the Medical and Sanitary Expedition of the People’s Commissariat of Health of the RSFSR to the Tannu-Tuvinian Republic,” the work was to be carried out in the following directions: a) providing qualified outpatient and inpatient medical care to the Tuvinian and Russian population of the republic both in sedentary and nomadic areas; b) developing and carrying out activities aimed at improving the health of the Tuvinian population; c) studying sanitary and living conditions of the local population; d) sanitary education of the population in the forms appropriate in local conditions; e) involvement of the population in health promotion activities; f) studying the current state of Tibetan medicine and its forms in Tuva. The main principles of the expedition were to strengthen the local population’s trust in cultural institutions and establish medical services on an absolute free-of-charge basis. Indeed, the expedition’s medical personnel were strictly forbidden from conducting any private practice or accept any payments, even voluntary, from patients. The role of financing the expedition was entrusted to the Narkomzdrav while it’s work was to be carried out both in Kyzyl and the Chadan, Chergak, Chedy-Karasuk, Chakul, Shagonar, Turan, Malo-Yeniseisky, and Podkhrebtinsky counties. In the opening stages, a mobile medical group was dispatched to Chadan county in January 1928, where they organized a medical aid post. As it turned out, the place was well chosen. The new Soviet medical facility was located in a large Buddhist monastery (probably the Upper Chadan kure) that already hosted around 500 lamas and their disciples. The Russian doctors were granted access to the inner workings of the lamasery and managed to conduct an all-out examination of its population. It was a rare and fortunate occasion within the complex, and often fraught, cultural relationship between European doctors and Central Asian Buddhist clergy. Parallel to the opening of the medical aid post, the Soviets launched a sanitary exhibition, which attracted all of the lamasery’s inhabitants. The resident monks asked many questions concerning anatomy and physiology, allowing the physicians to conclude that the emzhi-lamas had only a vague understanding of what had evolved as the cornerstones of European medicine. Indeed, those monks who were ill themselves even began turning up for treatment during the post’s first days of operating, although most only appeared to be suffering from mild illnesses. There were several tertiary syphilis cases among the patients and their examination showed that they had contracted the venereal form of the disease. The young disciples mostly suffered from scabies and other skin diseases due to inadequate sanitation and overcrowded dwellings; from the Buddhist abbot, Misezhnikov learned that religious edict prohibited bath-houses within the lamaseries. Nevertheless, a total body examination of about 200 disciples showed that their physical conditions were generally good due to a healthy lifestyle, with the lamas abstaining from drinking and smoking. The local Tuvinians who started to arrive in week following the opening also mainly suffered from mild illnesses. Generally, they came of their own free will, although some were afraid that the Russians would “cut them up.” Fortunately, the expedition’s work coincided with an official visit by the Tuvinian Prime Minister Kuular Donduk (a former lama himself), whose encouraging, jovial demeaner helped assuage any lingering concerns. The fact that the Tuvinians were already familiar with, and highly praising of, smallpox vaccinations played right into the hands of the Soviet medical team. Local peasants continually requested further inoculations. If there was no chance of vaccinating the local Tuvinians in one area, doctors were asked to leave some vaccine doses as the emzhi-lamas were already familiar with the procedure. In total, the Soviets vaccinated over 6,000 persons, while the lamas made a further 200 inoculations. After two weeks, it was decided that the team would be divided into two groups in order to broaden the scope of the expedition. Misezhnikov subsequently travelled to Chedy-Karasuk where he organized another medical aid post in a desolate house in the middle of the steppe. The local authorities informed the population about the arrival of Soviet doctors: within a week, a yurt settlement inhabited by patients suffering the effects of syphilitic infection, and in need of a prolonged course of treatment, had grown-up around the facility. Misezhnikov specifically noted that the Tuvinian patients accurately followed all medical instructions. It is important to note that this feature of the expedition was the direct result of a long process of interaction with local Tibetan healers. Unlike European physicians, who practiced at stationary medical facilities, the emzhi-lamas were itinerant healers who could afford to stay in a patient’s yurt for days or even weeks while administering treatment. They also paid attention to individual diets and often prescribed particular foodstuffs, with patients required to follow each prescription exactly. In this way, the emzhi-lamas had played a historical role in instilling a cultural sense of discipline among the Tuvinians, who often surprised Soviet doctors by scrupulously following all medical-related advice. In late February 1928, Misezhnikov’s team moved to Shagonar county, populated by around 6,000 Tuvinians and 1,500-2,000 Russians. The Russian hospital hosted a Soviet medical station and, from the first day, the physicians experienced a large influx of syphilitics, with the disease having also been rampant in Shagonar. Indeed, the majority of patients were either women or young people with freshly contracted forms. As Misezhnikov noted, Tuvinian women were as accurate as men in following his instructions and were unperturbed by the prospect of denuding in front of a male Russian doctor. This removed of intercultural barriers between the Soviet doctor and their Tuvinian patients, proved ideal in facilitating the anti-syphilis program’s swift implementation. With the arrival of spring, the medical team once again relocated to the Russian-inhabited Podkhrebtinsky and Malo-Yeniseisky settlements, while the subsequent summer season was spent examining the resident population along the Khemchik river. During the summer, the nomadic Tuvinians left their winter camps in the highlands and settled along the cooler river valleys. The method of conducting these examinations was simple but efficient. A doctor would approach a Tuvinian yurt, inform the inhabitants of his intended aims, and propose a smallpox vaccine, which the inhabitants would usually welcome. That made all further medical administrations much easier. Following the inoculation, the doctor would conduct a survey of the household, asking after the health of the family, the number of live children in the yurt, and how many members had recently died. If an individual was revealed as being ill, they would be sent to the medical aid post that the second physician had already opened in the local area. On average, the examination of a district’s entire population would take about three weeks, after which the expeditionary detachment would move on to the neighboring district. A caravan of sick Tuvinians who had not completed their syphilis treatment usually followed the Russian medical team to each new district. The Soviet doctors, in a manner that echoed the practices of the emzhi-lamas, accommodated them alongside themselves, fed them, and oversaw their treatment; in the case of syphilis, such treatment required a long and regular series of injections. The success of these medicinal courses had a great propaganda effect on the Tuvinians. As Misezhnikov pointed out in his report to the Narkomzdrav: “It is clear that trust was attained thanks to a strong effect from salvarsan treatment.” In the vast Inner Asian steppes, salvarsan was truly a “magic bullet,” living up to the name that its creator, the German immunologist Paul Ehrlich (1854–1915), had given it. The drug’s quick healing effect on the seemingly doomed, disfigured, and hopeless Buryats, Mongols, Tuvinians, or Uyghurs ostensibly proved miraculous, simultaneously shattering the historic reputation of the healing lamas, shamans, or tabibs, who were unable to administer it due their lack of requisite special training. Soviet expeditionary physicians were also able to confirm Preobrazhensky’s earlier observations that scabies and trachoma were probably the most widespread diseases among the Tuvinian population. Scabies, in particular, often affected whole families or even settlements. As Misezhnikov noted, “The Tuvinians view scabies as a trifling ailment and learned to live with it, so that sometimes when we asked if there were sick persons in a yurt, they would give a negative answer though there were some.” Nikolaenko further observed that Tuvinians suffering from trachoma would not seek out medical assistance. This, he hypothesized, was due to the fact that the local Tuvinian emzhi-lamas were unable to cure it themselves. Their would-be patients thus simply learned learned to live with it rather than try to find some alternative cure. However, by far the most troublesome disease was syphilis. Across the entire “nomadic world” of Inner and Central Asia: Buryats, Mongols, Tuvinians, Yakuts, Kazakhs, Kyrgyz, and other pastoralists suffered from syphilis in their thousands. In terms of human development, this problem was closely connected to reproduction, infant and maternal mortality, fertility, heredity, and untimely death or incapacitation. The expeditionary physicians were therefore primarily preoccupied with attempting to carry out even approximate assessments of the problem’s scale. This was also important in terms of planning all requisite medical activity from staffing each expedition and pharmacy procurement to the creation of specialized facilities and clinical work. Unable to organize a large-scale examination of the population, personnel were obliged to make hypothetical calculations using the data they gathered during fieldwork. Misezhnikov’s own estimate was based on the territory’s total population (58,000), the total number of yurts (12,000), and the average service radius of a Soviet medical aid post (15-30 versts or 16.5-33km). He speculated that if the maximum service radius of 30 versts (the average distance a Tuvinian horseman could ride in a day) encompassed an average of 400 yurts, it would take 30 medical aid posts to serve all 12,000. Taking the average number of exposed syphilitics per medical station as 50 persons and multiplying 1,500 persons by four (an arbitrary coefficient designed to reflect the number of unexposed syphilis patients), Misezhnikov concluded that there where around 6,000 syphilitic Tuvinians in the TPR, approximately 10% of the indigenous population. Nikolaenko’s calculations were even more approximate, believing that it was wrong to estimate the disease’s prevalence based on the percentage of syphilitics among the total number of Tuvinian patients in outpatient clinics. Out of 2,830 clinical visits made by Tuvinian patients, 546, or 20%, were recorded as syphilis cases. Nikolaenko considered this estimate to be wrong as an examination of 4,271 yurts had revealed an average of 2.5 children per dwelling, which meant a minimal, yet still visible growth of the Tuvinian population. Nikolaenko thought that a 20% prevalence of syphilis would result in much higher infant mortality and numerous cases of hereditary or non-venereal syphilis, which those physicians who had examined nearly all child patients had never observed. He was therefore inclined to agree with claims made by a lama who estimated the total number of syphilis cases in Tuva to be no more than 10 per 100 persons. As Nikolaenko concluded: It is not important whether there is 6 or 10 %. What is important is that syphilitics gladly come to the Russian doctor and the lamas themselves acknowledge the superiority of Salvarsan to mercury vapor treatment. It is important that health improvements among the Tuvinian population are possible because the entire issue comes down to the work of one or two physicians in Tuva. He also believed that the existence of syphilis pestholes in Tuva made it easier to fight the disease. Indeed, Soviet doctors had been quick to determine the location of two such pestholes: Shagonar, where 129 out of 296 of Tuvinian patients examined had various forms of lues, and Chakul, where there were 75 syphilis cases out of 225 Tuvinians. Thus, these two Tuvinian villages, lying at a distance of 25 versts (27.5km) from each other were viewed as the main source of the infection that had subsequently spread across all southwest Tuva. In Nikolaenko’s opinion, it was in these two settlements that the campaign to improve the health of the Tuvinian population should be centered. What made the case of Tuva unique were health condition among the Russian minority. Paradoxically, the settler colony proved far more troublesome than the Tuvinian-populated areas in terms of health problems, including attitudes towards the Soviet doctors. Somehow, the colonists had learned about the arrival of the expedition in advance but mistakenly believed that Moscow specifically sent doctors to treat them. Indeed, Nikolaenko complained that the treatment of Russian colonists took 50% more time than that of the Tuvinians. Misezhnikov wrote that Russian-inhabited settlements almost every villager would come to the medical aid post, many with minor ailments, but the overall impression was that there were more sick than healthy persons. The TPR’s Russian community mostly suffered from non-infectious chronic diseases, such as various forms of gastritis, hysteritis, and rheumatism, with trachoma also being rather widespread. Syphilis and skin diseases, however, were extremely rare and most patients were women with infants. Both expeditionary physicians agreed that the prevalence of stomach diseases could be attributed to an unhealthy and monotonous diet of poorly baked bread, sauerkraut, fried potatoes, salted fish, greasy dumplings, pickled cucumbers and mushrooms, and copious amounts of tea. Nikolaenko also suspected that the stomachs of Tuvinian Russian women in particular, had been weakened in early childhood, by a combination of heredity factors, poor diet, and nervous and physical defatigation. Moreover, unlike the native Tuvinians, Russian women and men alike believed that “miraculous mixtures” of pills, and powders, rather than lifestyle changes, would cure their “pressures” and “stitches” forever. When female patients received dietary advice instead of being prescribed medicine, their reaction tended to be one of disappoint and even incited written complaints to the local government. By contrast, the local Russian men mostly suffered from chronic rheumatism as a result of hard peasant labor in Tuva’s severe environmental conditions. They also tended to express disappointment when the doctor’s responded to their complaints by issuing recommendations for local trade organizations to procure rubber boots in order to help the peasants keep their feet dry during spring tillage. As Nikolaenko wrote, “men were only marginally satisfied in their illusions.” High incidences of disease among infants were traced to maternal negligence and unhealthy feeding. During the summer months, peasant women would leave their babies in the care of older children, who fed them with whatever was available. Nursing Russian mothers would also begin supplemental feeding before the prescribed age of six months. Not only was this too early, but the inappropriate foodstuffs given to infants proved highly detrimental for their underdeveloped stomachs and bowels. By contrast, Tuvinian mothers continued to breastfeed till the age of three or four, with their toddlers being noted as significantly healthier than Russian ones. The health of schoolchildren was also poor, as were their overall physical condition and teeth. Local Russian schools proved highly unsanitary, compounded by poor lighting and ventilation and small, dirty teaching spaces. As with infants, comparisons between the health problems suffered by Tuvinians and Russians favored the former. As Nikolaenko opined, “Among Tuvinians a doctor does not feel as helpless and disarmed as he feels among Russians. And the very attitude to medicine, as strange as it may seem, is more reasonable among Tuvinians than Russians.” He explained the most important difference as follows: Thanks to the lamas, who always prescribe their patients this or that diet, the Tuvinian population places the same importance on their dietary prescriptions as they would on prescription drugs. But you will never hear a Russian patient question whether he can eat this or that. The Tuvinians always pose this question and strictly follow the doctor’s prescriptions. These early Soviet medical expeditions to Mongolia and Tuva also established a tradition of organizing a concluding conference to mark the end of each excursion’s term. The first such conference opened in Kyzyl on 6 December 1928. The principal conclusion was that health improvements among Tuvinians presented no particular challenges. Indeed, the conference resolution stated that Tuvinians easily picked up hygienic practices and trustfully followed the advice of Soviet doctors while the TPR’s government readily supported all sanitary measures. As long as there were enough qualified physicians maintaining the underlying principles of Soviet medicine, and an appreciation of the importance of medical work in Tuva, health improvements among the Tuvinian people would be well underway. By contrast, the conference concluded that health improvement among the Russian colonist population remained extremely difficult, being chronic and systemic, with a serious comprehensive approach being required to improve the situation. The conference’s speakers believed that the key problem was the total ignorance of Russians regarding the importance of dietary, hygienic, and prophylactic treatment of chronic illnesses, multiplied by a blind belief in the power of medicine. Any improvement required vigorous sanitary propaganda, especially among women, to familiarize them with correct nursing methods, modern obstetrics, stomach physiology, and culinary art. Women’s health also required rest houses where they could recover from nervous exhaustion, overworking, and frequent pregnancies. Settlements were also in dire need of daycare facilities and sanitary cells, local schools lacked proper hygiene controls, and schoolchildren needed a rationally organized program of physical education. Alongside these proposed improvements, physicians also set themselves the task of weaning the Russian peasants off their cultural fixation on the omnipotence of medicine. Instead of drugs, useless for chronic rheumatics but indispensable for sick Tuvinians, Soviet doctors proposed the organization and development of health resorts. The first Soviet medical and sanitary expedition in Tuva yielded significant results. In Kyzyl, the Tuvinian and the RSTK hospitals were merged, enabling the formation of a centralized medical authority. This new healthcare department, known as the Tuvzdrav, was opened as part of the TPR’s Ministry of the Interior with all healthcare activities approved and supported by both the country’s Minor and Great Khuruldans (elected people’s authority bodies in Tuva). Medical services were also made available free of charge to both Tuvinians and Russians alike. The government considerably increased funds for the development of healthcare: from 10,000 roubles for maintaining the Tuvinian hospital in 1927, to 89,000 for the development of the medical network in 1928–29. Healthcare in Tuva thus became a state affair. The expedition also drew important conclusions that challenged earlier apocalyptic speculation surrounding the possible extinction of native Tuvinians. Based on the data obtained during mass medical examinations, current medical statistics, and personal observations, Soviet physicians refuted the opinion that Tuvinians were on the brink of extinction. Indeed, the expedition even registered a tendency among the Tuvinian population towards natural increase. The second Soviet medical expedition commenced working full-time on 20 June 1929. While its goals remained the same as the first’s, its strategy was slightly altered. Soviet medics preferred “deepening” the work conducted by their predecessors, rather than broadening its scope, carrying out their main activities via hospitals and dormitories at medical aid stations. These dormitories were a makeshift solution to provide syphilis patients who had travelled long distances with shelter and daily provisions of food. Moreover, the dormitories also served as cultural organizations demonstrating the benefits of personal and communal hygiene. This strategy of “deepening” pre-existing medical work proved successful. The main achievement of the second Narkomzdrav expedition was therefore a considerable increase in the number of Tuvinians seeking medical attention at Soviet medical facilities. Of the 14,183 persons visiting outpatient clinics in 1929, there were 5,397 (41.9%) Tuvinians and 7,786 (59.1%) Russians. Furthermore, among the 783 patients being treated in hospital wards, 273 (34.8%) were Tuvinians and 510 (65.2%) were Russians. As the expedition’s head Arutyunyan noted, more persons with acute forms of diseases had started seeking treatment, signifying an increasing trust in Soviet medicine and the success of pro-sanitary propaganda. Both Tuvinians and Russians learned that a timely visit to the doctor guaranteed more efficient therapy. The first two Soviet expeditions played a key role in the making of modern healthcare in Tuva. Indeed, it is surprising that the first expedition, which consisted of only four medics, managed to achieve so much over such a brief period of time. A mere two venereologist had succeeded in overseeing a survey of the entire country and develop approaches to the problems facing its various social and ethnic groups: Tuvinian Buddhist monks, government officials, common Tuvinian herders, and Russian peasant settlers. Meanwhile, Arutyunyan’s determination had successfully changed the existing structures of Tuvinian healthcare, purging the old personnel of the central hospital, leaving only two persons out of seventeen, and providing the necessary impetus for its consolidation under a single authority. It seems that his ambitious, but unaccommodating, character was well-liked in the Tuvinian government, for whom he was doing indispensable work by uniting the Russian and Tuvinian medical branches into a single healthcare system under the state’s control. It may also have impressed them that Arutyunyan often stressed his independence from Soviet authorities and direct subordination to the TPR. The Third and Fourth Narkomzdrav expeditions to Tuva (1930–1934) On 1 December 1930, the third Narkomzdrav expedition commenced its work. This time, the expedition’s core staff group (two doctors, a midwife, and an interpreter) remained in Kyzyl, while another was sent to the Chadansky district with the task of periodically going to the Barun-Khemchiksky district. The expedition consisted of doctors L. I. Gornshtein, Bakhromeev, Vengerovsky, and Rivosh. Dr. Gornshtein worked in Chadan, where there was an outpatient clinic serving the Chadansky and Barun-Khemchiksky districts. In addition, he received patients from neighboring Shagonar, with his staff consisting of a doctor, a paramedic, an interpreter, a nurse, and a janitor. Construction of the hospital had begun in 1928, but by the spring of 1930 hadn’t progressed beyond the first floor. In the 1930–31 financial year, the Tuvinian government allocated only 1,500 roubles for its completion, despite the fact that it had required 7,000 roubles just to build the first floor. Working and living conditions at the Chadan outpatient clinic were difficult. The facility had only one room in which all medical procedures, including injections, infusions, and minor operations, were performed. The adjacent dormitory had only four rooms and was able to accommodate up to 50 persons (all of whom were syphilitics), with no extra space to quarantine any patients who contracted infectious diseases; such problems were common throughout Tuva. For instance, in the winter of 1929-30, there was a measles outbreak in Chadan that infected the entire student body of the local school, resulting in three deaths. The overcrowded and unsanitary conditions of the Chadan school dormitory played a role in spreading the disease, with nowhere to isolate the sick students. The second Hemchik rebellion in May 1930 also revealed the urgent need for larger premises, as wounded Red Army soldiers had to be treated directly in local yurts. Despite the difficult working conditions and shortage of medical personnel, the expedition yielded good results. From November 1929 to October 1930, 15,492 patients received medical treatment at the outpatient clinic, 5,664 primary and 9,828 repeat patients. Among the primary patients, 3,778 were male (67.5%) and 1,886 female (32.5%), with the lower attendance rate among the latter was due to a psychological barrier experienced by Tuvinian women in going to a Soviet doctor. The average attendance rate at the Chadan outpatient clinic was 48 persons per day with the number seeking medical assistance increasing during the summer months and falling in the winter as a result of the nomadic Tuvinians migrating back to their seasonal highland encampments. The number of visitors also decreased in the autumn owing to the demands of harvesting work among the local peasantry. As with the earlier expeditions, scabies was believed to have still been the most common disease. While the second concluding medical conference had proposed sending a mobile bathhouse with a disinfection chamber to the worst affected regions, this had not implemented owing to a lack of funds. Handouts of soap by Soviet medics brought only temporary relief. Similarly, syphilis was recorded as the second most common disease, with the main issue being the difficulty in persuading patients to agree to isolation and systematic treatment. This brought an interesting behavioral quirk among Tuvinians to the attention of medical personnel. Locals, it appeared, would carefully collect information from those who had previously been treated in the Soviet outpatient clinic. Only after receiving good reviews, would they them come for treatment themselves. As the doctors wrote in their reports, some Tuvinians had to be lured to the outpatient clinic like children with sugar and candy. However, as soon as the patients were convinced of the efficacy of the treatment being dispensed, they would then start showing up for a second course on their own, without any external symptoms of syphilis. Soviet doctors would often discuss the nature and consequences of syphilis with their patients, in an effort to make them realize that they could not cure the disease with only one course of treatment. Given the importance of the syphilis problem in the TPR, Soviet physicians were tolerant of the numerous “deserters” who ran away from the dormitory in the middle of the night only to later return to the outpatient clinic asking to be taken back for treatment. Like their predecessors, the doctors of the third Narkomzdrav expedition noted that no more than 10% of the population in Tuva was infected. They were also happy to report that there had been no cases of neurosyphilis, aortitis, and syphilitic lesions of internal organs and systems. Delivering medical assistance to remote settlements represented another major challenge. It took several days to visit the faraway nomadic camps, during which the medical facility remained vacant owing to a lack of staff. Transporting seriously infected patients in Chadan was also difficult as the only available transport was horses. Gornshtein even asked the Tuvzdrav and the Tuvinian government to consider purchasing a car. The traditional concluding conference of the third expedition took place in Kyzyl on 17–19 November 1930. On this occasion, Soviet doctors invited high officials from the government. These included the Chairman of the Council of Ministers, S. Churmit-Tazhy; the Minister of Culture, Salchak Toka; the Secretary of the Central Committee of the Tuvinian People’s Revolutionary Party, A.-T. Khemchik-ool; and the Soviet Plenipotentiary N. V. Popov. The conference materials reflected not only the results of the third expedition but also their appraisal by the Tuvinian government. During the conference the TPR’s Prime Minister stressed that in comparison with previous years, the construction of healthcare had been more successful due to the more active role Soviet doctors had played in reorientating Tuvinian state healthcare exclusively towards European medicine. As a consequence, the official status of Tibetan medicine was withdrawn, prompted the government to enter into a political struggle with the Tibetan healers. Churmit-Tazhy asked the Soviet Plenipotentiary to pass the information concerning the needs of Tuvinian healthcare along to the Soviet government. He accentuated the need to invite more doctors and promised to allocate additional funds for the completion of the Chadan hospital. The Minister of Culture further noted that the third medical expedition had been working under much better conditions than its predecessors. As he stressed, at that time Tibetan medicine was still culturally dominant within Tuvinian society, and the former leadership had “tried to discredit the work of the European-Soviet doctors.” Toka recalled that during the “lama’s government” there had been complaints that “European doctors cut the people open” and that native Tuvinians had thought Tibetan medicine was superior as a result: “And only with the coming of the herders’ government European medicine receives support from the government and community organizations, and from this moment on we witness a colossal increase of visits to the Soviet doctors.” The minister’s criticism of the former government needs a brief explanation. Toka, who would later emerge as the future authoritarian leader of Tuva, whose rule was marked by unprecedented political terror, came to prominence on a wave of political rivalry that culminated in autumn 1929 at the Eighth Congress of the Tuvinian People’s Revolutionary Party with the complete defeat of the “right bias” government. Those who had been instrumental in developing the intellectual and legal basis for Tuvinian national sovereignty, such as Buyan-Badyrgy Mongush and Kuular Donduk, representative of the former Tuvinian aristocracy and clergy, were removed from power. Later, they were accused of political crimes and executed. Indeed, Toka’s speech followed the logic of the uncompromising political struggle. He denounced the former government by pointing at its “non-proletarian” social background but praised the policy of the new “herders’ government” whose main achievement, so far, had been to rescind Tibetan medicine’s official status. At the end of his speech, he added that it would be highly desirable if the Narkomzdrav increased funding for the expeditions while also covering travel expenses for medics that the Tuvzdrav hired in the USSR. The Secretary of the Central Committee, Khemchik-ool, highlighted the progress of Tuvinian healthcare as a result of Soviet assistance. A particular highlight was the contrast between 1926, when “in the whole of Tuva one physician worked out of a single small room”m and 1930, when there was a hospital with several departments in Kyzyl and nine medical aid stations in the regions, with the construction of several new hospitals currently underway. Khemchik-ool also stressed the population’s growing need for further medical assistance and the ongoing shortage of qualified staff. Closing the conference, the Soviet Plenipotentiary Popov suggested sending a letter to the then People’s Commissar of Health of the RSFSR, M. F. Vladimirsky, asking for additional funding for the fourth medical expedition and requesting more medical workers. He also proposed a future increase to the rate of prophylaxis and organize sanitary cells at Tuvinian and Russian schools. Finally, he asked the doctors to expand their public lecturing activity. While his propositions sounded formal, they were the logical conclusion of an important medical and political event. From the minutes of the conference, we can infer that in 1930 there were two main obstacles facing the development Tuvinian healthcare. As Rudenko observed, “The extremely weak budget of the Tuvinian government does not allow to unfold a sufficient network of medical facilities necessary for a larger coverage of the Tuvinian population with medical assistance.” Even though the healthcare budget had increased from 10,000 to 121,000 roubles between 1927 and 1930, with a further 177,000 planned for 1931, there was still a considerable shortage of money. For the first time since the beginning of Soviet medical assistance, the doctors were seriously engaging in sanitary activity. This initially took the form of a draft sanitary bill to be passed and ratified by the Tuvinian parliament. By 1 May 1930, they had completed a campaign to clean up accommodation and administrative buildings in Kyzyl. Important steps were made toward the creation of state sanitary control. Five-month sanitary courses were organized, and the graduates formed sanitary commissions to check the city cleanup. The third expedition also marked the launch of the first child health center in Kyzyl on 20 May 1930, with Tuvinian mothers being invited to learn the essential basics of baby care and hygiene. Soviet medical personnel explained how to feed and properly bathe infants, and also distributed clean diapers and children’s underwear. Within a month, they had performed 600 vaccinations, 35 medical examinations, bathed 20 infants, and provided people with free baby food via the infant-feeding center. The fourth Soviet medical expedition arrived in Kyzyl early in 1934, headed by Dr. K. O. Kalnberz, with a plan that presupposed expanding medical examination work in the regions. To this end, several detachments consisting of two or three medical workers, were formed to operate from district hospitals over a radius of 25–50 km, depending on the strength of the local transportation network. The fourth medical expedition concentrated on several issues. First, it was decided to study the prevalence of social diseases among Tuvinian herders. Second, the doctors aimed to focus on the physical make-up of Tuvinians, starting with schoolchildren, youth, and Tuvinian women. Third, it was decided to thoroughly research the nutrition of native Tuvinians, including nutritional evaluations for the average Tuvinian diet. The expedition also intended to assess the adaptation of the Tuvinians to industrial processes and the associated pathologies as well further studying the intricacies of Tibetan medicine. The main problem facing the Soviet expeditionary medics this time was reliable and cheap transportation. Travel expenses devoured huge sums of money, with Kalnberz estimating that four or five traveling doctors could spend up to 10,000 roubles on local transportation alone. Therefore, he asked the Narkomzdrav to urgently take care of the transportation problem by purchasing an ambulance car and providing it with necessary maintenance. Alongside this, he had also requested an increase in the number of staff for 1935, with three additional doctors (surgeon, venereologist, and public health doctor), a second interpreter, and a janitor. However, the arrival of the fourth Narkomzdrav expedition coincided with a personnel crisis in Tuvinian healthcare. Yazykov, Bernshtein, and Vengerovsky, three of the previous expeditions’ most experienced physicians, had returned to the USSR, depriving the Central hospital in Kyzyl of much of its medical strength. In late 1933, Dr. Linkov was promoted to physician-in-chief, but he also headed a maternity welfare center and a child health center and was, therefore, overburdened. The remaining doctors hoped, in vain, that the arriving fourth expedition would improve the situation. Dr. Rivosh, the resident dentist, exacerbated the situation by writing to the Narkomzdrav and claiming that Kalnberz had began a policy of intimidation and repression, having fired Linkov, and appointed his wife as physician-in-chief of the Central hospital. In Rivosh’s words, the expedition’s head occupied himself with intrigues against the medical community instead of organizing sanitary measures. Moreover, following a large public fair in Kyzyl, serious epidemics of dysentery and typhoid fever had broken out in the TPR’s capital. At the Central hospital, one of the doctors, Livanova, had contracted the disease and nearly died. Several nurses working at the hospital, however, had not been so fortunate and tragically succumbed to the epidemic. As a result of overextension Dr. Buzutov, the hospital’s surgeon, developed an aggravation of tuberculosis and was temporarily incapacitated. The hospital was full of sick people, with Rivosh arguing that Kalnberz had gravely mishandled the situation: “Despite my comradely advice, he did not put on the medical overall and come to help in the hospital, but preferred to sit in the Ministry of Culture”. The complaints made to the Narkomzdrav showed that the Soviet medical community in Tuva was far from free of internal disputes and tensions. Since the heads of medical expeditions also headed the Tuvzdrav, they were able to amass executive power and, for some of them, this was a great temptation. The case of Dr. Kalnberz proves that other doctors did not perceive this situation as normal. For instance, Dr. Rivosh openly juxtaposed the medical community and the expedition in Kyzyl, writing to Moscow that “with such an expedition, the Narkomzdrav will earn Soviet medicine in Tuva neither glory nor honor, and will not bring any good to the Tuvinian people either.” The setbacks of the fourth medical expedition exposed the various problems that had been accumulating for years. Complaints against expedition heads started with the arrival of Arutyunyan who was notorious for his explosive character. The only expedition head who never raised any collegial criticism was Rudenko, apparently a calm and reserved individual. With so much power in their hands, expedition heads were also prominent figures in the political setup of interwar Tuva. It took much personal restraint not to cross the red lines in the relationships with fellow physicians and the broader community. Conversely, the rank-and-file doctors and nurses did not tolerate the dictatorial manners of some expedition heads and immediately filed complaints to the Narkomzdrav. It seems that as in the case of Arutyunyan, the Tuvinian government was content with the policy of Kalnberz, making it useless to file complaints. Whereas in Mongolia, denunciations became a daily routine among the Soviet medical community throughout the 1930s and 1940s and spread to the Mongols who began liberally using them to extract favors from Soviet doctors, in Tuva, the problems remained strictly confined to medical circles. The Narkomzdrav reacted to the complaints but, as Rivosh put it, “it is a long way to go back to Moscow on foot” meaning that the intimidation policy in the Tuvinian context worked and the Soviet doctors remained wary of the arbitrary expedition head. Conclusions Soviet medical and sanitary expeditions to the TPR during the interwar period played an indispensable role in the construction and development of Tuvinian healthcare. While we cannot say that these missions formed the foundation of the healthcare system, since Tuva had had a rudimentary network of medical facilities years before their arrival, the expeditions granted direction and a powerful sense of impetus to the spread and development of European medicine in the republic. Most importantly, they formulated a policy and strategy for healthcare construction. Unlike numerous Narkomzdrav detachments in the remote national republics of the USSR, the Tuvinian expeditions acquired a political identity from the very outset, earning the respect of the local government and engendering a laisser-faire attitude among the TPR’s national leaders. Suffice it to say that the first medical aid post founded in 1928 expedition was located in a large lamasery – a fact unprecedented in other parts of the Mongolian world where the lamas either prevented doctors from freely entering their monasteries, or fled en masse, rendering further medical examination useless. Figuratively speaking, the seeds of Soviet medicine in Tuva were being planted in fertile soil. Decades of coexistence with Imperial Russian physicians had already exposed the general Tuvinian populace to European treatment methods, while centuries of being served by the healing lamas disciplined them in preparation for the arrival of modern European biomedicine. In terms of health problems, Tannu-Tuva resembled other parts of the Mongolian world – Buryat-Mongolia, Outer Mongolia, Mongolian-populated parts of Xinjiang, and Kalmykia. Local pastoralists in these areas suffered from syphilis, gonorrhea, skin diseases, and numerous parasites. Syphilis was so widespread that travelers, local medics, and political activists openly spoke of the possible degradation and extinction of the entire Tuvinian people. The same fears and concerns, started by the oblastniki in the second half of the nineteenth century, were also applied to every Siberian indigenous tribe and were later utilized by the Bolsheviks as a useful frame for social mobilization in Buryat-Mongolia and other autonomous national regions in Siberia and the wider Far East. In the case of Tuva, the Narkomzdrav expeditions allowed the Soviet authorities to thoroughly reconnoiter the health situation in the country and determine that syphilis was concentrated in two districts of the republic from where it had spread further. More importantly, Soviet physicians were able to study Tuvinian syphilis in situ and determine that the scale of the problem had been overstated, the course of the disease being generally lighter than it was among Mongol, Buryat, or Siberian autochthones. At the same time, they stressed that the solution to the syphilis problem lay in systematic venereological assistance, necessitating a certain strategy which they developed as Soviet assistance progressed. The Narkomzdrav expeditions were medical as well as political ventures, but they did not have the explicit political content displayed by the first Soviet medical expeditions in neighboring Mongolia. In Tuva, these missions mostly played the role of a catalyst in the healthcare-construction process while acquiring a certain political weight thanks to Arutyunyan’s presence as a prominent organizer, and rather aggressive political player. The 1928 expedition was also key to the development of healthcare management in Tuva due to Arutyunyan’s founding of the Tuvzdrav, the territory’s first centralized medical authority. Although, years later, and under different administrative heads, the Tuvzdrav did acquire some negative reputational traits that affected wider perceptions of the Tuvinian medical community, but this failed to diminish its significance in the development of European healthcare within the republic. The expeditions also provided a constant means of liaison between the Tuvinian authorities and the Narkomzdrav, serving as a means for the replenishing the TPR’s still meager local medical community. Within the expeditionary framework, Soviet physicians and nurses gained more experience of the Tuvinian cultural context, matured as medical professionals, and chose to continue working for the Tuvinian government even after completing their original terms as expeditionary medics. Overall, the history of the Narkomzdrav expeditions to Tuva present historians of medicine with a number of unique research subjects and historical features missing from the history of Soviet medical assistance in other parts of the Mongolian world, and Central Asia more broadly. It offers an insight into the history of Soviet “soft power” in the geopolitical “underbelly” of the USSR. However, Tuva is not a typical example of the interactions between Soviet doctors and traditional nomadic societies. Rather, it is a unique case that requires further comparative study with other regions of Asia where Soviet medical assistance helped to build modern healthcare systems in the first half of the twentieth century. About the author Vsevolod Bashkuev is a leading research fellow at the Institute for Mongolian, Buddhist, and Tibetan Studies of the Siberian Branch of the Russian Academy of Sciences in Ulan-Ude, Russia. He has a Doctor of Science degree in Russian History (2017) and specializes in the history of medicine, focusing on the connections between medicine, politics, ideology, and geopolitics. His most recent monograph Evropeiskaya meditsina i traditsionnoe obshchestvo v mongol’skom mire (poslednyaya tret’ XIX – pervaya polovina XX v.) [European Medicine and Traditional Society in the Mongolian World (Last Third of the 19th – First Half of the 20th Centuries] was published in 2021. He is also the author of Rossiyskaya meditsina i mongol’skiy mir: istoricheskiy opyt vzaimodeistviya (konets XIX – pervaya polovina XX vv.) [Russian Medicine and the Mongolian World: Historical Experience of Interaction (Late 19th – First Half of the 20th Centuries)] (2016) and over 50 articles on the history of medicine in Russian and English. Endnotes  This research was supported by RSF (project No. 19-18-00031)  S. I. Vainshtein and M. Kh. Manai-Ool (ed.), Istoriya Tuvy [The History of Tuva], (Novosibirsk: Nauka, 2001), 314–327  M. G. Shabaev, Ocherki istorii zdravookhraneniya Tuvy [Essays on the History of Healthcare in Tuva], (Kyzyl: Tuvinian book publisher, 1975).  Maja S. Maadyr and Viktoria Ch. Mongush, “From the History of Health Development in Soviet Tuva (1944–1991),” The New Research of Tuva 4 (2017): 125–136; Mikhail A. Semenov, “The Development of Healthcare System in Tuva,” The New Research of Tuva 3 (2019): 103–115.  Vsevolod Yu. Bashkuev, “Sovetskaya meditsina i bol’shevistskoe kul’turtregerstvo: Mediko-sanitarnaya ekspeditsiya Narkomzdrava RSFSR v Tuvinskuyu Narodnuyu Respubliku (1928)” [“Soviet Medicine and Bolshevist Kulturtragers: The Medical and Sanitary Expedition of the People’s Commissariat for Health of the RSFSR to the Tuvinian People’s Republic in 1928”], Problemy sotsial’no-ekonomicheskogo razvitiya Sibiri 4, no.22 (2015): 59–67; Idem. “Mediko-sanitarnye ekspeditsii Narkomzdrava RSFSR v Tuvinskoy Narodnoy Respublike i stanovlenie Tuvinskogo zdravokhraneniya (Konets 1920-kh – seredina 1930–kh gg.)” [“Medical and Sanitary Expeditions of the People’s Commissariat for Health of the RSFSR in the Tuvinian People’s Republic and the Making of Tuvinian Healthcare (Late 1920s – Mid 1930s”], Vestnik Tomskogo Gosudarstvennogo Universiteta 426 (2018): 52–63.  Solangy Yu. Chyrgalan, “Deyatel’nost’ mediko-sanitarnoi ekspeditsii Narkomzdrava RSFSR v Tuvinskoy Narodnoy Respublike v 1928–1933 gg.” [“The Activity of the Medical and Sanitary Expedition of the People’s Commissariat for Health of the RSFSR in the Tuvinian People’s Republic in 1928-1933”], Genesis: Istoricheskie Issledovaniya 8 (2018): 44.  N. M. Mollerov (ed.), Istoriya Tuvy [The History of Tuva], vol. 3 (Novosibirsk: Nauka, 2016), 99–101, 297-309; M.M.-B. Kharunova, Sotsial’no-politicheskoe razvitie Tuvy v seredine XX veka [The Social and Political Development of Tuva in the Middle of the 20th Century], (Novosibirsk: Nauka, 2011); S.A. Khomushku et al, “Trudovye resursy meditsinskikh organizatsii Tuvy. (Analiz sostoyaniya za 2007-2013 gody) [The Labor Force of the Tuvinian Medical Organizatons (State Analysis for 2007-2013)],” Vestnik Tuvinskogo gosudarstvennogo universiteta. Estestvennye i sel’skokhozyaistvennye nauki 2, no.29 (2016): 48-55.  Vsevolod Yu. Bashkuev, Rossiiskaya meditsina i mongol’skii mir: Istoricheskiy opyt vzaimodeistviya (Konets XIX – pervaya polovina XX vv.) [Russian Medicine and the Mongolian World: The Historical Experience of Interaction (Late Nineteenth – First Half of the Twentieth Century)], (Irkutsk: “Ottisk”, 2016).  Vsevolod Yu. Bashkuev, Evropeiskaya meditsina i traditsionnoe obshchestvo v mongol’skom mire (Poslednyaya Tret’ XIX – Pervaya Polovina XX v.) [European Medicine and Traditional Society in the Mongolian World (Last Third of the Nineteenth – First Half of the Twentieth Century], (Irkutsk: “Ottisk”, 2021).  Paula A. Michaels, Curative Powers: Medicine and Empire in Stalin’s Central Asia (Pittsburgh: University of Pittsburgh Press, 2003), 9–11.  Susan Gross Solomon, “The Soviet-German Syphilis Expedition to Buriat-Mongolia, 1928: Scientific Research on National Minorities,” Slavic Review 52, no. 2 (1993): 204–232; Idem. “Das Reisetagebuch als Quelle für die Analyse binationaler medizinischer Unternehmungen,” [“Travel Diaries as a Source for Analyzing Binational Medical Enterprises”], in Lues, Lamas, Leninisten. Tagebuch einer Reise durch Ruβland in die Burjatische Republik im Sommer 1926, ed. W.U. Eckart (Pfaffenweiler: Centaurus-Verl.-Ges., 1995): 1–41.  Ines Stolpe, “Display and Performance in Mongolian Cultural Campaigns,” in Conflict and Social Order in Tibet and Inner Asia, ed. F. Pirie and T. Huber (Brill, 2008): 59–84; Idem. “From Purity to Cleanliness: Changing Concepts in Mongolia,” in How Purity is Made, ed. P. Rösch and U. Simon (Wiesbaden: Harrassowitz Verlag, 2012): 369–392.  Baasanjav Terbish, “Mongolian Sexuality: A Short History of the Flirtation of Power with Sex,” Inner Asia 15 (2013): 246–248.  Rebekah Ramsay, “Nomadic Hearths of Soviet Culture: ‘Women’s Red Yurt’ Campaigns in Kazakhstan, 1925–1935,” Europe-Asia Studies 73, no.10 (2021).  State Archive of the Russian Federation (hereinafter – GARF), F. A-482, op. 35, d. 287, l. 68.  M.G. Shabaev, Ocherki, 58.  Ibid., 60.  GARF, F. A-482, op. 35, d. 287, l. 60.  Ibid, l. 43.  Shabaev, Ocherki, 69.  Walther Heissig, “A Mongolian Source to the Lamaist Suppression of Shamanism in the 17th Century,” The History of Mongolia. Vol. II. The Qing Period. Twentieth Century Mongolia, ed. David Sneath and Christopher Kaplonski (Global Oriental, 2010), 584.  Galina B. Kopeliovich et al. “Historical Background to Tibetan Medicine in the Republic of Tuva (Russian Federation),”, http://tibmedcouncil.org/wp-content/uploads/2018/02/PP-1-galina.pdf (accessed 16/09/2021).  GARF, f. A-482, op. 35, d. 249, l. 25–27.  GARF, f. A-482, op. 35, d. 248, l. 44.  GARF, f. A-482, op. 35, d. 249, l. 25–26.  GARF, f. A-482, op. 35, d. 287, l. 48.  GARF, f. A-482, op. 35, d. 248, l. 42.  According to Preobrazhensky, in this period there were several large Buddhist monasteries in Tuva. The largest of them were the two Kemchik temples, Samagaltai, and Todzha lamaseries. Numerically, the lamas comprised up to 20% of the male population of Tuva, with the clergy lived at the expense of common Tuvinian herders (qara-gizhi). See: GARF, f. A-482, op. 35, d. 248, l. 42 reverse.  GARF, f. A-482, op. 35, d. 248, l. 43.  Ibid.  GARF, f. A-482, op. 35, d. 248, l. 45–46.  GARF, f. A-482, op. 35, d. 248, l. 55.  GARF, f. A-482, op. 35, d. 252, l. 12.  GARF, f. A-482, op. 35, d. 287, l. 50.  Ibid.  Kuular Donduk (1888–1932) was the Chairman of the Presidium of the Minor Khural in 1923–25 and the Prime Minister in 1925–29. He was also the Foreign Minister of the TPR. He was educated in the monasteries of Urga (Mongolia) and Tuva and had a degree of geshe (Buddhist monastic equivalent of a doctoral degree). Donduk was also one of the leading lamas of the Upper Chadan lamasery and, at that point, was working on developing the Tuvinian alphabet. He was arrested and executed in 1932. See: E.M. Ondar. “Pervyi Predsedatel’ Prezidiuma Malogo Khurala Tuvinskoi Narodnoi Respubliki Kuular Donduk,” [“The First Chairman of the Presidium of the Minor Khural of the Tuvinian People’s Republic Kuular Donduk”], Vestnik Tuvinskogo Gosudarstvennogo Universiteta. Sotsial’nye i gumanitarnye nauki 2 (2010): 162–164.  GARF, f. A-482, op. 35, d. 287, l. 66.  GARF, f. A-482, op. 35, d. 287, l. 51.  GARF, f. A-482, op. 35, d. 287, l. 55.  GARF, f. A-482, op. 35, d. 287, l. 52–53.  GARF, f. A-482, op. 35, d. 287, l. 53.  Ibid.  GARF, f. A-482, op. 35, d. 287, l. 69.  GARF, f. A-482, op. 35, d. 287, l. 55.  GARF, f. A-482, op. 35, d. 287, l. 70.  GARF, f. A-482, op. 35, d. 287, l. 71.  GARF, f. A-482, op. 35, d. 287, l. 61.  GARF, f. A-482, op. 35, d. 287, l. 57.  GARF, f. A-482, op. 35, d. 287, l. 61–62.  GARF, f. A-482, op. 35, d. 287, l. 62.  GARF, f. A-482, op. 35, d. 287, l. 58.  Ibid.  GARF, f. A-482, op. 35, d. 249, l. 33.  GARF, f. A-482, op. 35, d. 249, l. 35.  GARF, f. A-482, op. 35, d. 287, l. 132–133.  GARF, f. A-482, op. 35, d. 287, l. 28.  GARF, f. A-482, op. 35, d. 289, l. 3.  GARF, f. A-482, op. 35, d. 289, l. 3 reverse.  GARF, f. A-482, op. 35, d. 423, l. 67.  GARF, f. A-482, op. 35, d. 423, l. 34 reverse.  GARF, f. A-482, op. 35, d. 423, l. 35.  GARF, f. A-482, op. 35, d. 423, l. 35 reverse.  GARF, f. A-482, op. 35, d. 423, l. 36.  GARF, f. A-482, op. 35, d. 423, l. 37.  GARF, f. A-482, op. 35, d. 423, l. 55-56.  Chimiza K. Lamazhaa. Tuva mezhdu proshlym i budushchim [Tuva between the Past and the Future], 2nd ed. (Saint Petersburg: Aleteiya, 2011), 193–194.  GARF, f. A-482, op. 35, d. 423, l. 56.  GARF, f. A-482, op. 35, d. 423, l. 57.  GARF, f. A-482, op. 35, d. 423, l. 75.  GARF, f. A-482, op. 35, d. 423, l. 70.  GARF, f. A-482, op. 35, d. 423, l. 238.  GARF, f. A-482, op. 35, d. 415, l. 241.  GARF, f. A-482, op. 35, d. 415, l. 243.  GARF, f. A-482, op. 35, d. 415, l. 247.  GARF, f. A-482, op. 35, d. 415, l. 241.