Red Medicine: Socialized Health in Soviet Russia

General Considerations on the Medical Care in Large Communities

IT HAS already been indicated in the Introduction that our inquiry into Russian medicohygienic arrangements was intended as an extension of the International Studies (referred to on page 1) on the arrangements and procedures in eighteen European countries. The evidence derived from those studies was subsequently summarized in Medicine and the State (1932), and a number of farreaching conclusions were reached, which, if followed by appropriate action, would go very far towards integrating medical provision and rendering it universally available. As our Russian inquiry proceeded, it became evident that, if it were to be as fully useful as was possible, it must have a wider social scope than the preceding inquiries in other countries.

In order that the position of Russian medicine as related to the ideals of medical practice may be more fully considered, it is proposed to set out in this chapter the postulates of a good medical service, and to indicate points in which in Soviet Russia a nearer fulfillment of these postulates has been reached than in other countries. For the purpose of this statement, the general propositions set out in Medicine and the State are utilized in the following paragraphs. Although no quotation marks appear, the emphasized sentences in most instances are derived verbatim from this source.

1. The health and therefore the hygienic and medical care of every person in a community is a matter of concern and responsibility not only for himself, but also for every other person in the same community. [Medicine and the State, Chapter 1]

No person liveth to himself. If through sickness he becomes dependent or is rendered less efficient, the rest of the community necessarily suffers. This is the selfinterested motive for providing medical service, the force of which is being increasingly realized. But there is also the higher motive of love of one's neighbor.

2. It follows that the organized community through its government is called on to concern itself with the practical application of all the known laws of health and of all remedial measures which will help in the restoration of health. [Ibid., Chapter 2]

The only acceable alternative to this universally called for governmental action is that every person in the community shall be alive to and shall undertake all needed hygienic and medical work, personally or through mutual help. This alternative is scarcely conceivable in large communities; for medical and hygienic needs are complex and require, in some respects at least, action on a communal scale. This alternative, furthermore, can only come completely within the sphere of "`practical politics," when the roots of selfishness have been removed from every human breast.

3. This being so, governmental bodies are called on to act with full realization of the facts that everywhere there is a lamentable amount of inadequacy and discontinuity in the medicohygienic provision for the community; also that for a high proportion of the total sick adequate medical care necessitates the organization of measures and of institutions beyond what the individual medical practitioner can provide.[Ibid., Chapter 2]

It is unnecessary to give here the evidence on which these universally acceed propositions are based. In the experience of no single country can their accuracy be denied ; but the defects in some countries are much greater than in some others.

4. It is abundantly clear that for a large section of the population in all countries the cost of sickness is overwhelmingly great; and that while domiciliary medical care does not ensure for a large proportion of the total sick satisfactory treatment and rapid convalescence, the cost of hospital treatment is beyond the means of a large proportion of the total population.[Ibid., Chapter 3]

5. The preceding statements necessitate the conclusion that, in order to supply adequate medical aid for all, either private charity, or provident insurance,⁽¹⁾ or taxation (in which the needed expenditure is distributed over the whole community according to means) must be forthcoming in a continuous, even, and adequate stream.

This conclusion follows from the axiom acceed in all civilized countries, though nearly everywhere acted on most inadequately, that no person shall be allowed to die or suffer serious harm through the lack of shelter or food or medical aid.[Ibid., Chapter 4]

6. A sick person is seldom in need solely of medical aid (the doctor and ancillary medical services). His sickness has been determined in part and is likely to be increased and repeated by adverse factors in his personality and in his environmental circumstances, whether industrial, economic, sanitary, or mental and spiritual; and therefore economy and wisdom alike demand that each illness shall be investigated and treated socially as well as medically, with a view to the ascertainment and removal of conditions inimical to health.[Ibid., Chapter 4]

7. It is essential that, whether domiciliary or institutional treatment is required for the adequate skilled care of a sick person, this treatment should be available to the fullest extent necessitated by the patient's illness, irrespective of his financial circumstances.[Ibid., Chapter 5]

To regard medical treatment otherwise than in accord with this proposition implies a misconceion and contradiction of the communal principles laid down under 1 and 2 above.

This does not necessarily imply that gratuitous treatment (that is, treatment paid for by the community as a whole, according to the means of each taxpayer) shall be offered unconditionally to all applicants; but it does mean that it is incumbent on governmental bodies to anticipate the contingency of illness, and to ado measurescompulsory when necessarywhich shall ensure that every member of the community has contributed his share, to the extent of his competence, to provide against the contingency of sickness.[Ibid., Chapter 5 & 6]

8. It is an acceed principle that prevention (of disease) is always more important than (medical) provision.[Ibid., Chapter 7]

This being so, all medical work must be assessed according to its approximation to fulfillment of this principle.

Among the forms of medical work which are specially noteworthy in their preventive value are:

Prenatal and postnatal care of expectant mothers. Medical care in childbirth.
Infant consultations and health visits for children up to school age.
School medical supervision.
The adoption of measures of personal hygiene in shops, offices, workshops, factories, etc.
Complete medical overhaul of all patients when, first they come under a doctor's care, and at intervals.

It will be noted that, in most of the items enumerated above, persons can be examined as to physiological conditions before aberration from health has occurred.

The preceding postulates of a good medical service for the community involve certain further desiderata, failing the fulfillment of which a medical service will be unsatisfactory in one or more respects. To some extent these desiderata are embraced in the postulates already stated; but they are now stated separately as they serve to indicate in partial outline the medical machinery needed for the fulfillment of the preceding postulates.

1. It is necessary that, for a fairly large proportion of the patients who come under treatment, there should be exchanges of insight between the general and the special practitioner of medicine.

2. It is further necessary that each of these, and especially the general practitioner, should have a fuller acquaintance than is now usual with the normal physiological state and social conditions of patients, through contacts with these patients prior to the occurrence of illness.

3. There should be an end of that greatest evil in medical practice, especially among wage earners, the frequent treatment of illness without accurate diagnosis to the fullest extent that this is attainable.[Medicine and the State, Chapter XII.]

4. The governments of all civilized countries have subsidized or themselves undertaken various forms of medical work, including much treatment of sickness. Medical work, with or without official financial support, is being done in more or less watertight compartments by:

public health authorities;
public assistance authorities (charities) ;
private voluntary charities (hospitals, dispensaries, etc.) ;
private medical practitioners.

In different countries the activities of these various medical bodies overlap to a varying extent. They often work in competition, direct or implied. They usually work without, or with little of, that interchange of facts concerning their patients which is needed for the patient's satisfactory treatment.

In some countries official medical work has very largely replaced the work of private medical practitioners and of voluntary charities.

5. A most notable feature of medicine in recent decades is the extent to which local and central governments acting as public health authorities have been impelled into medical work for the maintenance and restoration of personal health, as well as for the improvement of environmental conditions. This has shown itself particularly in infant consultations and clinics, in school medical inspection and treatment, in tuberculosis dispensaries and sanatoria, in the treatment of venereal diseases, of cripples, of the feebleminded, and so on. The more recent development of prenatal consultations and the vast extension of institutional provision for childbirth will also be remembered.

In most countries also the treatment of the destitute for ordinary sickness is now in the hands of public health authorities, and this is true also for the provision of mental hospitals.

The process of unification of medical services under public health authorities has already proceeded far in most countries. In some countries it is complete, except in so far as the treatment of persons under sickness insurance schemes is concerned; and in the U.S.S.R. this also is included in the unified national medical service. Furthermore, in the U.S.S.R. the unification has proceeded to the inclusion of any domiciliary medical care which is given apart from insurance.

To contemplate the provision of a statesubsidized medical service of group practice separate from the already extensive medical service provided by public health authorities, which covers a large part of the same ground, would be to submit to a continuance and extension of present unsatisfactory incoordinations, redundancies, and defects. Whether in the United States or in Great Britain any such additional provision which fails to be part of an extended public health service will necessarily prove unsatisfactory.

Nor can a continuance or extension of duality be justified scientifically. Public health administration is not concerned solely with "communicable" and "preventible" diseases. The day for this distinction has passed. Public health administration concerns itself with all failures in health and efficiency; and it is doing some of its best work when it curtails the duration of inefficiency, even when the occurrence of this inefficiency was unavoidable. The vast work now being done by public health authorities for cripples is perhaps the best instance of this.

6. To promote unification of medical work, modifications of public and private medical practice are needed for all except the rich.

This unification does not necessarily imply fusion of various medical organizations, though fusion of some of these is highly desirable; but it necessitates accurate planning for cooperation at every point, in order that completeness of provision and prevention of gaps and overlapping in provision may be attained.

The essential change in private medical practice needed to this end is the cessation of remuneration for each medical act, and the substitution of medical work on a contract basis. The idea of "contracts" in medical practice is. obnoxious to many conservative minds. It is forgotten that family practice, in which patients loyally send for their doctor when needed, is a form of contract practice without financial definition. The essence of a contract is the engagement or implied engagement of a person to supply service and of another person to receive and to continue to receive service from the firstnamed person. To the sensitive doctor the abolition of any financial motive for increasing or decreasing consultations or visits is an enormous relief and conduces to the welfare of his patients.[Medicine and the State, pages 40-42, 249-255, 259-264.]

Whether remuneration under the altered conditions comes from the patient himself, or from him (partially or entirely) under an insurance scheme, or from taxation must depend on circumstances. [Medicine and the State, Chapters VI, VII, XV.]

7. The cessation of payment of private practitioners according to the current number of consultations or visits will render it easier to ado group practice when it is needed for a patient. The consultative work rendered practicable by group practice should always be available for entire families. A team of doctors on the medical side must be the counterpart of the family on the patient's side. [Ibid., Chapter XIII.]

But as regards the need for group practice it is important to remember that the public mind is too much obsessed with the belief in a wide necessity of specialist medical aid. A majority of cases of illness can be satisfactorily treated by an intelligent experienced general practitioner. [Ibid., Chapter XV.]

8. Group medical practice, including hospital treatment as needed, is only practicable for the majority of the community if fees on a low scale are acceed; and assistance is indispensable from insurance funds (paid over a series of years by the insured family with additions perhaps from the employer of the wage earner) and from taxation imposed on the general community, if group practice is to become possible for the majority of the population.

In view of the last statement the only form of group practice worthy of consideration, for wage earners and for the lower salaried population, is one in which the municipality or county forms the unit of administration, as in other forms of government; in which the local governing body contributes material financial aid to the unified medical service; and in which the central government of the state also gives financial support to the scheme, and in return has a voice in determining minimum standards of efficiency and adequacy of the services to be rendered.

This is entirely consistent with selfgovernment by doctors in medical matters.

The idea of financial or professional competition between groups is inadmissible.

Group practice, if it is to be satisfactory, should be so arranged as to permit of the continuance of individual medical practice, in which, so far as is consistent with an economical and efficient geographical distribution of doctors, a given doctor may be chosen by and remain the trusted adviser of the family; but in which he is constantly supported by group workers, whether in hospitals or clinics, to the fullest extent which is desirable.[Ibid., Chapters XIII-XVI.]

Evidently in rural districts the possibility of choice of private doctors must always be limited, but inaccessibility to consultant and hospital aids to family practice cannot be allowed to continue without prejudice to many patients.

Tests of Medical Service

Having given some of the chief conditions which in our opinion need to be fulfilled in a satisfactory medical service, it remains to compare these with the Russian conditions outlined in this book.

In judging of the merits of a medical service there are three main tests of efficiency and success:

1. How far does the system tend to reduce the amount of sickness in the community by curtailment of duration or by preventive action?

2. Does it supply all the health needs of the community, medical, dental, nursing, and all necessary ancillary needs?

3. Is the service so arranged that it provides an efficient service both to rural and urban populations, without gaps or overlapping in this service?

These measurements overlap; but stated thus, it may at once be said that no civilized community has hitherto developed medical service or services which meets these tests in all respects satisfactorily and completely.

Applying the first test, we find that the reduction of morbidity in Soviet Russia has been general, and in the case of certain acute infectious diseases must be termed sensational. Cholera has been stamped out, no cases having been registered since 1927. Smallpox, which had a case rate of 5 per 10,000 in 1912, and 6 in 1914, shot up to a rate of 30 in 1919, was brought rapidly down to 7 in 1922, 2 in 1924, 0.6 in 1928, and the remarkably low rate of 0.37 in 1929. The epidemic of typhus in 1920-1921 resulted in a total of four million cases. During the four years 1925-1929 the annual average was only slightly more than 40,000 cases.

Typhoid fever, on the other hand, is still a problem. The cases reported in 1929 numbered 171,263, which is at a rate of 10.5 per 10,000 inhabitants as compared with a rate of to in 1927. The rates for scarlet fever and diphtheria were also higher in 1929 than in 1927.

The comparative incidence of tuberculosis in Tsarist and Soviet Russia is almost unknown. Before the Revolution as in the earliest years following it there was relatively poor organization for recording cases of tuberculosis. Hence a much larger percentage of the number of the tuberculous was then left unrecorded as compared with the results in recent years. Russian authorities say that this circumstance and not actual increased incidence explains the following figures, which we received from Dr. Roubakine :

The recorded cases of syphilis, primary and secondary, soft chancre, and gonorrhoea showed a marked decline in the reports for the three years 1927-1929, according to the International Health Year-Book. Dr. Roubakine has stated that "in 1913 in the Army the rate of venereal disease cases among the soldiers was 12.8 per 1,000 whilst in 1924--1927 the rate was only 8.02." In ChapterXXII we have cited marked reductions for Moscow and Rostov.

Further evidence regarding morbidity in Russia may be inferred from the general and the infant death rates, which, though fluctuating in recent years, are decidedly lower than before or just after the Revolution. The tables given below are prepared from figures published in the International Health Year-Book.

Thus, tested by the changes in the rates of morbidity and mortality, the public health and medical service in Soviet Russia has already been associated with lowered death rates, including infant death rates.

Turning to the second test proposed, the question of adequacy of supply of health needsmedical, dental, nursing, and ancillaryan affirmative answer can be given in respect of many urban areas as to the medical services described and commented upon by us in preceding chapters.

Dental service, on the other hand, is admittedly inadequate, particularly in rural regions. Although we made no special inquiry concerning the supply of dentists, and have seen scarcely any printed material on this subject, it is our impression that a demand for dental care is being fostered through education and that corresponding measures are taken to train a professional personnel and to increase the number of dental clinics.⁽²⁾

The following figures for the Ukraine were given us by Dr. Roubakine, who said that there was no detailed information available for the other federated republics :

In 1926 the population of the Ukraine was 28,887,000.

In midwifery the U.S.S.R. has more complete arrangements for institutional treatment than any other country. Its system of dispensaries and polyclinics in cities is admirable, as is also the usual avoidance of special institutions devoted to a single disease.

A weak point in Soviet state medicine is the domiciliary treatment of illness. In view of present housing conditions in Russia, institutional treatment of most patients is desirable and inevitable. We had reason to doubt whether domiciliary medical calls for treatment, when made, received prom attention in all cases.

The great superiority of Russian medicine lies in its unitary arrangements, in the complete avoidance of redundancy or gaps in the city services, and in the special precautions taken to ensure that every patient receives as complete an overhaul as is required.

In Russia, as in other countries, but even more so, the health facilities in rural regions are less adequate than in the cities. But we have seen evidence that progress is being made, and undoubtedly the peasants and the workers in villages are receiving far better medical care, inadequate as it may be, than was possible before the Revolution.

Measured against the postulates set out earlier in this chapter, it would seem fair to conclude that Soviet Russia has, at least in many respects, come nearer to fulfillment of these postulates than any of the other countries studied by us or of which we have knowledge. Indeed, Soviet medicine is largely based on the general propositions which are here enunciated as standards for adequate medical care of all the people. In its program, at least, we must conclude that the Soviet system of medicine is more comprehensive and inclusive than is to be found in any other country. And while performance in many respects still stops short of the program, progress toward its fulfillment is being made with remarkable rapidity, so rapid in fact that unquestionably quality is temporarily being sacrificed to quantity. This feature appears to hold good in almost every phase of the planned economy of the U.S.S.R.

⁽¹⁾ It should be added that social insurance has not sufficed in the experience of any European country to provide a complete medical service without state aid.

⁽²⁾ After the text of our book was completed, we received interesting information regarding Soviet dental service from Dean Alfred Owre of the School of Dental and Oral Surgery of Columbia University, who had recently visited the stomatological institutes and polyclinics at Odessa, Kiev, Moscow, and Leningrad. We quote by permission from a letter: ". . . The achievements to date, in spite of tremendous handicaps, are remarkable. . . . Several men I talked with, all M.D.'s, had carried on largescale experiments in fundamental phases of dental practice. . I was astonished at the ingenuity shown in overcoming technical difficulties, for instance, the use of chrome and rustless steel for prosthetic work in place of gold and platinum." Dean Owre tells of the plan to give ro,ooo students a threeyear training course in technicums during the next five years: ". . . They will have the same preliminary education as university entrants. . . . They will get .. . a technical training in routine dentistry about like that of our average D.D.S. They will not get a degree. After three years' service in an outlying district, they may return to a university centre for scientific work. There they will help in a clinic part of the day and evening. In three and onehalf to four years they may complete the work for a medical degree. There are stiff examinations. . . . In one remarkably wellorganized laboratory at Leningrad I saw records to show a turnout of 35,000 dentures monthly, and 7,000 bridges. . . . The dentistry, except for `fancy' dentures and other work chosen in place of simpler types which would serve (e.g., gold plates and bridge work), is practically free. All education is free."

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