Red Medicine: Socialized Health in Soviet Russia
PRIOR to the Revolution, Russia was extremely backward in its medical provision for the mass of the people. Since that time a vast advance has been made. The sanitation and public health of Russia, which were also imperfect, remain so, though to a much smaller degree, to the present day.
Our review of present conditions in preventive and clinical medicine in Russia is based on inquiries and inspections during a relatively short visit; and although it has been associated with much study of authoritative writings, we do not pose as competent to judge the merits of Russian medicine as a whole, but only of this medicine as we have been able to observe it. We are confident, however, that even when all its present incompleteness and imperfections are emphasized, the wide sweep of the newly organized medicine of Russia presents features from which other countries may derive important lessons.
In judging the present position of medical practice in Russia, her past in medicine must be borne in mind.
An excellent account of Russian medicine in the past is given in Colonel F. H. Garrison's "Russian Medicine Under the Old Regime" in the Bulletin of the New York Academy of Medicine, September, 1931. The following statements are derived largely from this source.
In the reign of Ivan IV, "the Terrible" (1533-84), a contemporary of Queen Elizabeth of England, four physicians, two surgeons, eight surgical dressers, eight barbersurgeons, and four apothecaries were brought from Germany, but how many of these escaped the enemies by whom their ship was attacked is not clear. In 1557 two English physicians were brought to Moscow by the Russian ambassador. At the end of the sixteenth century, Garrison states, the first Russian medical publication was printed.
With the reign of Peter the Great (1682-1725) a new. order of things began. He may be regarded as the creator of Russian medicine, as he was the first person in power who attempted seriously to Europeanize Russia. It is to him that the first hospital (1706) and medical school (1707) in Russia owe their foundation; and in some other respects, he acted in accord with his motto : "I am of those who seek knowledge and are willing to learn." He gave his army an organized medical service. During his European travels he "picked up all the training he could get on medicine and surgery" and is said to have tapped dropsies and even couched cataracts on his own subjects, "sometimes with untoward results." (Garrison)
The reign of Catherine II (1762-96) was a period of cultural awakening, rather than, in Garrison's words, a time of "true progression towards economic and social betterment." Queen Catherine was inoculated against smallpox by an Englishman. In this reign a medical college and hospitals for the insane and for venereal diseases were opened, as well as foundling asylums. By 1804, according to Garrison, there were medical faculties in five Russian institutions, namely, the Universities of Moscow, Dorpat, Kharkov, and Kazan, and the Medico-Chirurgical Academy in St. Petersburg. But, except at the academy, which became the Military. Medical Academy in 1835, the teaching was "poor and feeble in quality." The Napoleonic wars had left Russia exhausted and unready for any scientific advance.
Pirogov (1810-81) became professor of surgery at the Military Medical Academy in 1840, and he lifted it to a very high level of efficiency. He introduced dissections and pathological anatomy into the teaching of medical students; and he deserves to be regarded as the greatest figure in the history of Russian medical practice.
A succession of distinguished medical scientists have followed him; among whom the names of Metchnikov (1845-1916), whose work was done chiefly in Paris, and of Pavlov, born in 1849 and still living, are of worldwide repute.
But although there were distinguished Russian scientists, physicians, and surgeons, the number of practitioners was entirely inadequate and the vast majority of the people of prerevolutionary Russia outside the large cities were almost destitute of medical aid.
The emancipation of the serfs in 1861 was both an effect and a cause of greater attention to the wellbeing of the individual. Shortly afterwards territorial selfgovernment in the form of district (zemstvo) assemblies was established, and along with this came local administrative control of medical aid. But for most of Russia medical care remained in the hands of unskilled persons and sometimes of the country clergy; and in view of its vast extent of territory and the widely scattered distribution of its villages the problems of supplying medical aid for these inevitably remained unsolved. The Russian peasant could not, and, if he were called upon to do so, could not now, afford to pay a doctor.
Gradually, however, medical provision became less exiguous, and here and there some hygienic propaganda and actual preventive work began.
Medical provision and hygienic work increased each decade, and in the years immediately preceding the Revolution there were some hospitals in most large centres of population, and a limited amount of medical aid was accessible to the poor. For the welltodo, medical aid of a high standard was generally available, and many sanatoria and hospitals were provided. This provision for the poor remained miserably inadequate.
The medical departments of universities were well equipped, and medical students were well trained, better than now; but their number was very inadequate for Russia's needs.
Then came the two revolutions of 1917; and during the four years which followed, external war and civil war, revolution, famine, and disease decimated the population and left the survivors impoverished and enfeebled.
The protracted struggle against famine and disease had serious effects on medical education and practice. Medical schools and hospitals received scarcely any funds. No repairs were possible, and food and means of heating for these institutions and their staff failed.(1) Students and professors suffered alike. Only bare subsistence was possible, and professors stood in line for their daily rations. Gantt says, "distinguished professors spent part of their time in squads shoveling snow."
On the inceion of the New Economic Policy in 1921, with its partial supersession of "war communism," the position of hospitals somewhat improved. Medical schools also improved slowly, and during later years there has been a marvelous advance in the volume of medical education and in the amount and quality of medical aid provided for the masses of the people. The new medical education, hitherto, in view of the very great increase in the numbers educated, is, as might be expected, inferior to the old in quantity and quality; but for the first time this education is bringing medical aid of a fair quality to the masses of the people.
General, cannot be separated entirely from medical, education, and a few words are needed as to this, additional to what is stated in Chapter X. Prior to the Revolution the few were well educated, while the people generally were almost entirely illiterate. The new regime meant the abolition of the existing schools for the children of the upper classes and the substitution of a system in which millions receive at least elementary instruction. Civic instructionnaturally communism as taught by Marx and developed by Leninoccupies a prominent place throughout school life. In 'every school elementary education, to quote official language, is "combined with a course of political and cultural education," including "the basic principles of the social order under the Soviets."
The amount of illiteracy has been enormously reduced, and, as we have said in Chapter X, 90 per cent of adults, aged, from eight to fifty, have received a primary education. This, however, still leaves a considerable part of the adult Russian population unable to read or write. It is the steady policy of the Soviet administration to reduce this illiteracy of adults, and we saw elementary school teaching undertaken as a side activity in factories, in sanatoria, and also in institutions for the treatment and reform of former prostitutes. The voluntary work undertaken by the Pioneers often takes the form of teaching the illiterate. The creches and kindergartens, to which most children in the first eight years of life are taken, are also centres of elementary instruction; and all those seen by us were well equipped and models of cleanliness. In them the children are instructed in selfcontrol and cleanly personal habits. They are taught at a very tender age to wash and dress themselves and in all respects to conform to hygienic habits. In the elementary schools, in the vast numbers of open air schools and day camps, and in the juvenile clubs which belong to the Youth Movement, education, including Communist civic instruction, is proceeding continuously.
That is the background for the recent extension of medical education. As members of the proletariat receive preferential nomination, many students now starting their medical training have had inadequate education. Many candidates are adults and sometimes married. They are selected by committees of their. fellowworkers, as are also nonmedical university students. The choice depends greatly on the social occupation of the student, manual workers having a preference. There is probably some favoritism in choosing candidates for training, as well as in medical appointments. But "graft" is treason in Russia, and it is doubtful if it exists in this connection. This does not mean that there is an absence of "political pull" in the sense of influence of the Communist Party on behalf of any candidate. We met doctors who had been selected for medical training by these committees, and in the instances thus encountered the selection was justified. Evidently, however, deficiency of preliminary general and scientific education must lower the standard of subsequent medical service. This is recognized by hygienic and medical leaders in the official world of Russia, and doubtless the quality of students selected, as well as the details of present medical instruction, will improve as they need to do. Even now it is indubitable that, although the average individual standard of training of the multitude of medical students of today is lower than that of the fewer students in pre-Revolution days, the aggregate quantity as well as the quality of medical aid available for the mass of the people is being enormously increased and improved.
We were informed by Dr. Vladimirsky, Commissar of Health of the R.S.F.S.R., that in 1932 there were 36,000 medical students, and it was hoped that by 1937 the present deficiency of doctors would be overtaken. He estimated that Russia was still short of 20,000 physicians, as compared with the quota of the Five Year Plan, and that this meant retardation of public health and of medicine. It was officially considered that eventually as an ideal there should be one doctor to 1,000 population.
He stated that they were quite aware that Russian methods of medical education needed overhauling, as, he believed, was the case in other countries.
The extension of medical education is indicated in figures supplied by the Commissar of Health of Moscow. In 1912 there were six institutions for medical training in the Soviet Union; in 1930 there were thirtyfour. In 1912 there were no medical research institutions; now there are one hundred and six such institutions, thirtyfive of which are supervised by the Governments of constituent republics, while seventyone are regional and autonomous, i.e., under separate cities and autonomous republics.
At Rostov we obtained interesting information as to the training of medical students in its university. Until last year there was a fouryear course of medical training; now it has been increased to five years, as before the war. It was stated that most of the large cities now had a medical faculty for training students. "Each student is carefully chosen as a medical student, and he has a monetary allowance to cover expenses. For definite work in the hospital done 'by him, he is paid according to current rates. The choice of candidates for medical students is decided by a commission, applications for vacancies being sent from schools and works. On these applications a Workmen's Committee first sits, and their recommendations come before a commission consisting of a representative of: (1) the administrative medical faculty, (2) the professorial staff, (3) the trade " unions, and (4) the student workers.
The final decision as to candidates rests with this commission. Any exhibition of favoritism means a "row" and much discussion in workers' journals.
From the beginning of his course each student must engage in practical work bearing on his future career.
In his first year he must assist in minor medical and surgical work, including cleaning up after the work is finished.
In his second year the medical student has to help in actual nursing; and in his next three years the student likewise engages in practical medical work at various hospitals, polyclinics, and ambulatoria, while continuing his scientific training.
When qualified, the doctor is offered a post at once. He may have specialized from the end of his third year, though this is a debatable policy. He is required to be fairly competent in all branches of medicine, as he may have to practise alone in a country district.
The risks of inadequate training of new doctors are appreciated, and still more the need for additional trained nurses. Lay workers in hospitals are being utilized, and it is intended to give selected candidates from these full medical training. A recent regulation has made the conditions for becoming medical students more stringent.
Postgraduate courses are given to doctors every three years, so far as is practicable.
Some home visits are made by nurses, in relation to child welfare, tuberculosis, and venereal disease, but these are not fully organized.
In Tiflis the population has been augmented, apart from growth of trade, by the growth of the city as a university centre for Georgia and the neighboring republics. A separate section of the town has become a university centre in which some 15,000 students live. There are special institutes in various branches of science and medicine at the university; and students have special residential quarters. The largest of these institutes is devoted to agriculture, as this is the chief industry of Georgia. Before the Revolution the university had only some 2,000 students.
In Tiflis there are 945 doctors, and in all Georgia 2,080. Dr. Kuchaidze, Commissar of Health for Georgia, declined to draw a distinction between physicians and public medical officers; for "all doctors are health officers," and only the chiefs of public medical departments do not engage in some form of clinical work.
Dr. Kuchaidze stressed the fact as had been done in every centre visited by usthat the general plan of medical and of public health work is identical throughout Russia, local circumstances necessarily implying some variations in detail.
There is a medical institute attached to the University of Georgia, in Tiflis, where since 1919 medical students are trained. Practical medical work is begun in the second year of training. All students are paid by the Government and are also trained gratuitously. The full medical course is five years.
There is a special "technicum" for training of midwives and a subsidiary variety of doctors. Instruction to midwives is given not only in the Russian and Georgian languages, but also in several other languages of the Trans-Caucasian confederation of republics. Midwives are required by law to call in a doctor on the occurrence of an obstetric complication. Their course of training covers three years; and the practice of unqualified women is prohibited, though not strictly so. In towns at least 95 per cent of the midwives are trained. In most villages are voluntary social workers who assist in maintaining the standard of maternity and child welfare work.
There was evidence of the provision of postgraduate courses of instruction in each chief city visited by us. These are said to be a new development, not seen in pre-Revolution Russia. The extent to which this postgraduate instruction is utilized varies much in different parts of Russia. In one city we were told that while normally it is obligatory for every doctor each second or third year to have four months of postgraduate medical teaching, this has not so far been generally practicable, owing to dearth of doctors. In one or two cities we were informed that it was generally enforced; in others, that the scarcity of doctors had prevented this. Rural doctors are specially encouraged to take these courses; their expenses are paid during the course, as are those of other doctors.
There is no complete provision, as yet, for the special training of sanitary officers, or for insisting on their possessing a satisfactory diploma before they undertake public health supervision and control. Some special training is given to medical men for public health work at the Institute of Health, Moscow, which we discussed with Professor Landis, its head. This institute is concerned both with the teaching of hygiene and research in that field. Hitherto graduation at the institute is not made a condition of official appointments; but such graduates have preference for important posts. Doctors appointed to administrative posts are sent to the institute for instruction and training.
(1) A review of this period is given in an article on "Medical Education in Soviet Russia," by Dr. W. Horsley Gantt, in the British Medical Journal, June 14, 1924.