Red Medicine: Socialized Health in Soviet Russia
AN ESSENTIAL difference between the practice of medicine in the U.S.S.R. and in capitalist countries is that every doctor is a State official, and in most instances is exclusively so. A few doctors, especially older doctors, still retain some private individual practice; but their number is diminishing, and practically all the younger doctors are exclusively officials of the State.
Each State doctor is expected to work six or six and one half hours each working day for the State. Every fifth day he has complete cessation from work. If he is a specialist, e.g., in Roentgen ray [X-ray] or radium [radiation] work, he may have only a four-hour day. Like every worker, he has at least two weeks' holiday annually; and he may receive longer leave if he is a specialist or for special reasons. The triennial longer leave of the rural doctor has already been mentioned.
Medical salaries are paid by the Government, being graduated according to work and duration of service. In some instances an increase of to per cent in salary is given annually; or of 20 per cent after service in special institutions. Some indication of relative salaries is given on page 250. Earnings may be increased by working for two or even more institutions daily. Only in the event of a calamity can a doctor be transferred to another district without his consent. Many doctors are still overworked; and although at the public clinics special precautions are enforced to prevent hasty consultations, this overwork must tend to lower the quality .of medical care.
In Russia, before the Revolution, there were approximately 26,000 physicians. In 1931, according to Dr. Roubakine, the total number of physicians was about 76,000.
For ordinary illness the treatment is undertaken: (a), in the homes of the sick (in small part), and much more (b) at factories or other institutions where they work, and (c) in dispensaries and polyclinics. For more serious disease, treatment is given to a preponderant extent in hospitals and other residential institutions; while for convalescent patients, and for others with a view to warding off illness, a vast amount of provision is made in rest homes of various kinds. In this chapter domiciliary treatment and other forms of medical treatment which cannot be discussed clearly in separation from home treatment are considered.
It is noteworthy that Russian doctors seldom attend mothers in childbirth in the cases which are still confined in their homes. Midwives and, much oftener in rural districts, unskilled women are employed, unless or until some serious complication arises.
As already stated, very few doctors now have private practice, independent of State arrangements. Those who have are chiefly physicians who have acquired special reputations.
In the following pages we give the reader the substance of a series of interviews, with practically no change in the notes taken at the respective interviews. Although this method involves repeated discussion of the same topics, we hope that this will be compensated for by the documentary directness gained for the reader.
Dr. Vladimirsky,. Commissar of Health of the R.S.F.S.R., informed us that legally any physician can engage in private practice, the tendency of three years ago to forbid this having ceased. For many doctors, as those employed in hospitals and public health physicians, private practice is impracticable; and hospital physicians are prohibited from treating at home privately their patients treated in hospitals.
In villages private practitioners are almost nonexistent. Social help is free; and the district doctor is so fully occupied that there is no time for private work.
In cities also the average physician, being fully occupied with official duties, does not engage in private practice, but consultants and a few others do. In fact 90 per cent of Russian physicians work in State institutions, said Commissar Vladimirsky, and do not practise medicine privately.
Even before the Revolution it was usual for district physicians to treat most of the people without fees. In this respect the Commissar contrasted his experience during three years in which he worked medically in a French village, with corresponding work in a Russian village. In the former, patients would be amazed if they were not charged; in the latter, they would be amazed if they were charged!
In this interview the Commissar emphasized the fact that medical aid was given without payment to all workers and peasants, who form the bulk of the population. For the rest the desire is to serve all gratuitously, but hitherto they were not included in the general service, the first call being for the workers. Thus in a dispensary an intellectual will have to wait until all the workers have been treated.
For venereal disease, this being a social menace, no such distinction is made, and no charges are ever made; and the same applies to various forms of emergency treatment. Similarly attendance in childbirth is free to all, irrespective of social position.
A writer of English books on Russia, who has lived many years in that country, stressed the fact that the element of profit has been almost entirely eliminated from national and private affairs. A few private doctors continue, but young graduates do not go into private practice. The same remark applies to dentists. New dentures are supplied free for workers. In villages there is no private medical practice, and in some cities it has entirely disappeared.
The chief difficulty is the shortage of physicians. The number of doctors is increasing, but quality is not increasing so fast as the quantity.
Domiciliary medical practice in Russia is not carried on independently of institutional practice in residential institutions and at polyclinics. The only exception is formed by the rare instances in which patients afford a private physician.
In most instances, domiciliary medical visits are almost entirely limited to emergencies and restricted to patients who cannot attend at a dispensary.
The people of Kazan are medically attended under a general dispensary system, the city being divided into four dispensary districts each serving some forty to fifty thousand people.
Although private medical treatment is allowed, it is rapidly disappearing and probably does not now apply to 1o per cent of the population. Most doctors, of whom there are about thirty in Kazan, are Government officials. In the Tartar republic outside Kazan, doctors number about seven hundred, and there is no private medical practice.
Every sick person in Kazan can send for a doctor from the polyclinic of his district to see him at home, but there appear to be strict rules to minimize unnecessary home calls. These can be made by telephone. The doctors of the polyclinic make home visits.
In four polyclinics in the town free treatment is given, and in five a small payment is required. In the latter, two to four rubles may be paid per consultation. These are under the control of the People's Commissariat or the Red Cross organization.
At Rostovon-Don we were informed by a member of VOKS and by others that a few private doctors remain, chiefly those who have acquired special reputations.
Most patients in the town are attended from ambulatoria (dispensaries) and polyclinics. The distinction between these two is not very definite; but broadly the lastnamed are more fully equipped in the special departments of medicine, while ordinary cases go to the ambulatorium.
A patient can choose his own doctor at the medical centre for his district; and he can subsequently change his doctor if reasonable cause is shown. There is the right to complain to the head of the institution or to the Commissariat of Health. Similarly a patient can refuse to be operated on by a particular surgeon if another is available.
Patients who are very ill can be seen at home by the dispensary doctor for that district, or they are taken in an ambulance to the ambulatorium or direct to a hospital. Each doctor attends at fixed hours at the dispensary, but severe cases are seen at home at once. A fine is inflicted if an ambulance is demanded unnecessarily. The application for a doctor at home cannot be for a special doctor, but only for the doctor allotted to that district.
All the doctors are overworked ; but to avoid hasty work, the number of patients a doctor may see in a given time at the dispensary is limited to six in an hour; and in the registration department the number allotted to him is limited to this extent. Often the doctors work overtime.
From the ambulatorium cases may be referred to the polyclinic for special consultations, or may be admitted into a hospital.
Each patient admitted into a hospital takes his written report with him and brings back from the hospital a continued statement of his case. Hospital doctors do not give the certificates needed for social insurance; this is done by the doctor of the ambulatorium when attendance under him is resumed.
A doctor may undertake several tasks and thus increase his income. He nearly always undertakes popular hygienic lecturing, and he may engage in private practice if any is forthcoming. Not infrequently he helps in a hospital in the morning and in an ambulatorium in the evening.
Dr. Kuchaidze, Commissar of Health of Georgia, informed us that medical care in that republic is arranged similarly to that in other parts of Russia.
Every doctor is attached to some medical institution, all of which are State institutions. Special doctors are attached to ambulatoria and polyclinics, to hospitals, and to each factory or collective farm.
Every official doctor can also take private paying patients, outside his official work. But private is almost entirely superseded by the public practice of medicine.
The workers always take precedence in any provision that is made. All medical treatment at publicly provided centres is free; but patients desiring it can resort to private doctors and pay them out of their personal funds. This is seldom done, though older and distinguished physicians still have some private practice; and no objection is raised to any official physician receiving private patients outside official hours.
Dr. Kuchaidze himself was formerly a chief physician at the Georgian mineral-water cure places, and his opinion regarding the comparison between the past and present in Russian medicine, similar to what we heard from many others, may be placed on record at this point.
Formerly there were almost no private doctors for the very poor, and patients had to pay almost impossible fees. Hospitals for the poor were few and most inadequate. Even in hospitals the treatment they received in the main was "general practitioner treatment"; they had no chance of being treated in the valuable cure places of Georgia. Now the number of doctors has been multiplied, and a still larger number are being trained. The former hospitals for the rich are now devoted primarily to the workers, and their accommodation has been greatly increased. New hospitals for general and special diseases have been built; and the poorest in the land have the advantage, in every department of medicine, of skilled aid in need. The cure places, furthermore, are used by the entire population, and patients from every part of Russia are sent to them. Thus efficiency and universality of medical aid have succeeded a system under which medical care could be secured only by the wealthy, or by the fortunate few among the workers who could gain admission to a good hospital.
The doubt was raised as to whether under the new regime enterprise and energy of work would not be lowered, now that the incentive of high professional earnings had disappeared. This, we were told, was actively debated among doctors "after the October Revolution," and most of the better physicians feared such a result. Now, after fifteen years of planning and execution of better medical work, it could be definitely said that the fears then entertained were groundless, and that the younger doctors in all respects display greater efficiency and zeal than was shown in the past. They now work in teams, in close cooperation with other doctors, and their work is scientific in character.
The doctors working in villages, in whom all-round competence is required, have their salaries increased after three years of work, and their children are entitled to all the privileges of workers' children. The rule of giving a three-months postgraduate course of instruction to all doctors after three years of clinical work is carried out for only half the doctors. The high tempo of medical changes has made it impossible to go further than this at present.
Returning now to our general discussion, we take up the subject of costs to patients. Most workers and their families receive free medical treatment as insured persons, but the funds for this treatment do not come from insurance funds, but from general taxation; and, as previously stated, medical care is administered, like other branches of public health work, by the Commissariats of Health for each constituent republic and its subordinate divisions and by the local Boards of Health.
All trade unionists, all insured persons, all unemployed persons and their dependents, are entitled to free medical treatment, as are also students and the incapacitated. Persons in the "deprived class" are not included in the scheme of free medical service, though as already stated they are not cut off from treatment.
Published statements could be quoted as to workers who were dissatisfied with the medical service of the State. The dissatisfied patients objected to the many formalities before they were allowed to see a doctor at the public clinic, and to the fact that the intervals before they saw him again were excessive. Other complaints have been of lack of hospital beds when needed, and that medical attendance at home is unsatisfactory.
In our own observations we discovered no evidence of the earlier conditions which led to complaints. Such complaints are heard in other countries, including England, in which the insurance medical service is, as a whole, fairly satisfactory.
The crowding and insanitary housing which prevail render domiciliary treatment very difficult; and actual medical care at home is limited in extent. The private medical practitioner having almost disappeared, the work of the district medical officer for each district consists in large measure in arranging the details of institutional (resident or nonresident) treatment for the patient. As already stated, nearly all confinements in towns occur in hospitals, and expectant mothers, their infants and children receive treatment at various clinics, as do also workers who are not too ill to attend them.
Any worker requiring a home visit by a doctor makes application personally or by telephone at the nearest station and receives home treatment free of charge. A physician attends from this station and certifies the illness if it is incapacitating, thus enabling the patient to obtain his full wages for a maximum period of ten days dating from the beginning of the illness. Further financial benefit can be given only after a medical consultation.
It is officially stated that "in all cases of life and death an emergency service is rendered to all citizens free of charge." The word "citizen" does not appear to be defined.
In some places the arrangements for domiciliary medical attendance continue to be imperfect. Thus one observer informed us that long waiting for a doctor sometimes occurred. At Kazan there are strict rules tominimize unnecessary home visits, which, when needed, are made by the doctors of the polyclinic.
At Kharkov we met a physicianrara aviswhose earnings from private and public practice were about equal; but he informed us that most medical practice is official and gratuitous. In the Ukraine many appeals from the first medical opinion occur.
Broadly it may be stated that the trend is to minimize the domiciliary treatment of illness; and in view of housing conditions this is wise, as is also the universal institutional care of parturition in cities. Something is lost in not securing the individual care and continuous treatment of each family by one doctor, but much is gained in the greater completeness of treatment and, when necessary, the specialized treatment which is obtained in clinics and hospitals.
Much work is being done in factory hygiene. Formerly the working day was eight hours, but the sevenhour day is being gradually introduced in all Soviet plants and factories; and a sixhour day is in force for all underground workers and for minors. A day's rest is given regularly on the fifth or sixth day, according to the working week of the plant. Every employee is entitled to twelve working days' annual vacation. This is increased to twentyfour days for trades injurious to health; and minors under eighteen years receive a month's leave.
All wage and salary earners are insured, trade unions controlling the organization for insurance. Seasonal workers come only partially under the insurance scheme; and according to a recent regulation the amount of nonmedical benefits under insurance is being made conditional on the length of time the worker has worked for wages. It is also intended (we were informed), in view of the excessive mobility or "turnover" of labor, to make the amount of insurance benefits depend in part on the length of stay in a single plant.
Some beginning has been made of systematic supervision of workers engaged in injurious trades; and with a view to prophylactic measures a periodical examination has been introduced for those handling foodstuffs, and for workers in lead, mercury, rubber, tobacco, and in some other industries.
Factory schools may be regarded as a part of Soviet factory hygiene. Here, from the age of fourteen, school life is continued for three years, combined with four hours' daily work in a shop or factory. This course is intended especially for the training of skilled workers.
Medical factory organization at its best was seen by us in Selmashstroy, the agricultural machine factory at Rostovon-Don, in which, in eighteen shops, some 18,000 workers are employed. There is a special doctor for each shop, who gives first aid in emergencies, supervises the hygiene of workers, and keeps daily records of the number of workers who are absentees and who are under dispensary treatment. This is shown on a graph in each shop. Those ill are visited by a fellowworker of the same shop. The means of exposing malingering and slacking have been discussed on page 104. Of malingering under the Soviet medical system, there is said to be little or none. If any complaint is made as to medical care, a hearing is given before a Medical Control Committee, on which sit two or three doctors appointed by the Commissar of Health, a worker sitting as chairman. This committee decides as to patients needing treatment at a rest home or a sanatorium.
A really important part of factory hygiene is the publicity given to the toper. Over his working bench or loom is a statement of his offence, possibly with a derisive picture or figure attached.
Factory workers when ill may be seen by a doctor at home if too ill to go elsewhere. Ordinarily they are sent by the factory doctor to the dispensary of the district in which they live; or they may be sent directly to a specialist in a polyclinic, to a tuberculosis or venereal disease clinic, or to special physical or other treatment centres. They may be treated in a night sanatorium while continuing their daily work; or they may be admitted from a nonresidential clinic into a general or special hospital, or, at the discretion of the factory doctor, sent direct to one of these.
In addition, the factory has, besides ordinary dining rooms for the workers, a special dining room where meals prescribed by the doctor can be given to employees who are under medical care.
It should be added that each worker when he begins his work at a factory is inoculated against smallpox and typhoid. When sent to his particular shop he becomes a member of a brigade which is medically examined at intervals. There is a commission of doctors for this purpose.
The work of the factory creche has already been described. It has great importance as bearing on the mother's maintenance of health and fitness.
At Kharkov we expressed doubt as to whether the ready access of workers to the specialists at its splendid polyclinics did not lead to their excessive use. The medical administrators of the Health Commissariat stated that only occasional difficulty arose from this. Each doctor in the dispensary and polyclinic is related to a special district of the city, and thus a local organization is created which takes the place of the Amer.. ican or British private practitioner, but with free and full use of expert medical aid. It was further contended that while the private doctor can do little to better the conditions of a worker's life, it is the duty of the Russian doctor to secure not only the personal but also the collective and environmental treatment of each patient. In fact the Soviet claim is that the dispensary and polyclinic in association with the factory and the hospital are securing the complete unification of medical work, so far as workers are concerned.