Red Medicine: Socialized Health in Soviet Russia

Concluding Observations

PRIMARILY our inquiries in the U.S.S.R. were concerned with its medicohygienic activities, and if we were literally restricted to these domains, any statement of conclusions as to the more general policy and activities of the Soviet Government might be avoided. Even then, however, we could scarcely evade the question: Does the Soviet organization — including all that is implied in the unification of financial responsibilities and control of the entire resources of the country — assist to an exceptional extent a complete medical and hygienic service for the entire community? To this question we can at once give a definitely affirmative answer.

The Soviet Government is the most gigantic experiment in the deliberate public organization of social and economic life in the history of the world.

That it is a system of government under control of a minority is a well-recognized fact, more so even than the so-called democratic government of certain countries in which centralized wire-pulling and local boss control have sapped the reality out of representative government. There is a universal basis of representative government in the U.S.S.R. grounded in ubiquitous electoral meetings open to all but the "deprived classes"; but in practice, authority is wielded by an exclusive, highly selected companionship or order called the Communist Party, the numbers of which are systematically kept down by the exclusion of all who fail to maintain its high standard of obedience and good conduct. This "companionship" is directed by a small committee (see page 93). True, every item of policy is exhaustively discussed before it becomes the policy of the Party; and at these earlier stages free and public debate is welcomed. Once a decision has been arrived at, the rule is one of absolute obedience, enforced by the penalty of exclusion from the Party. Continued intrigue or rebellion is drastically punished by transportation to a remote part of the Russian world, or even exile.

Loyal members of this companionship occupy most of the important positions in the government and dominate the whole social structure. As defined by Lenin, the dictatorship of the proletariat, or government by the workers, becomes the "dictatorship of its determined conscious minority."

Or in Trotsky's words "just as France stepped over the Reformation, so Russia stepped over the formal democracy"; and instead it adopted the policy of "rule of the toilers," whose "general will" the Communist Party claims (it may be with no little warrant) to interpret and embody in legislation. This authority, if we believe an opponent of the present regime, "whatever its immediate political vicissitudes, has penetrated as irrevocably into the consciousness of the masses as did in its day the system of the Reformation or of pure democracy."(1)

Lenin is quoted by F. J. P. Veale(2) as stating that "among a hundred so-called Bolsheviks there is one genuine Bolshevik with 39 criminals and 60 fools." This may be merely a cynical variation of Thomas Carlyle's oft-quoted cynical descriion of the British people as "mostly fools"; but it is consistent with the deliberate Soviet view that the mass of the people will accept the policy imposed by an active, belligerent minority who have in one or another way obtained and continue to hold power.

In the establishment of Marxism and of the policy needed for its enforcement, the standard of Soviet ethics is definitely utilitarian, any particular conduct being judged according as it tends to bring about an approximation to the earthly paradise expected from Marxism and Leninism; and in discussions of Soviet policy, extracts from the writings of these two masters are used and regarded as finally authoritative, just as texts of Scriure have been employed in theological discussions.

The utilitarian principle is applied in the administration of criminal justice, which, as we have stated (see page 132), shows some excellent features, but which for the same offence may inflict capital punishment when the offence is directed against the Government or the commonweal and only nominal imprisonment if it injures only a private person.

This is seen most markedly of all in the treatment of those small farmers who have been unwilling to give up their holdings in favor of collective farming. It is doubtful if the terrible hardships of these individualistic sufferers will ever be fully told. Many of these may have been guilty not only of individualism but also of actual crime. During 1932-1933 severe treatment was being meted out to members of communal farms who had not given full service in their new position. Multitudes had stolen or hidden the wheat of the collectivity for their personal benefit, or otherwise lowered the productivity of their work for the common advantage, with the result, it is reportedit is hard to say with what truththat during the winter of 1932-1933 the urban population of Russia was being grievously underfed.(3)

The severity against the kulaks is defended on the ground that small farms and peasant holdings are incompatible with any adequate productivityas they areand that in the establishment of a complete socialist system the obstacles to it must ruthlessly be swept away. This is the method of war; and the policy of the Soviet Government implies and is openly acceed as requiring for many years to come action on the lines of warfare against those who obstruct or injure the policy of collectivism.

In carrying out what is really the policy of Communism - in which punishment is apportioned according to whether the crime injures the community or only an individualthe OGPU can by its own secret tribunal accuse, convict, and punish (even with death), those judged by it to be offenders against the State.

It is the fond hope of the Party that the young people approaching adult lifemore than 100,000,000 of the present population are under twentyfivewill be enthusiastic supporters of the new regime; and if persistent and universal indoctrination can do this, the hope will be realized. There are indications suggesting that it is succeeding according to plan.

A complete national socialism implies the ownership by the nation of land and other forms of industrial property and the suppression of all private business carried on for profit. This has been largely achieved in the U.S.S.R. without the compensation due to private owners. This confiscation partially explains the enormous provision of holiday homes, convalescent homes, and sanatoria in Soviet Russia.

At the present time the progressive income tax is as severe as that of Great Britain, whilst the death duties rise steeply to the point of virtual confiscation of all above a modest patrimony. The ownership of houses, of motorcars, and similar possessions is restricted to personal use without pecuniary profit to the owner. In fact "civil liberties" as understood in other countries are abridged to a great extent.

All this carries with it the almost complete abolition of the motive of private profit, as distinguished from wages or salaries for actual work done. Wages and salaries are not uniform, and to this extent rivalry may come in; but its scope is limited, and were it otherwise, the spending motives of high salaries are lacking to a noteworthy extent. The Soviet teaching is that private profit is at the root of the evils of capitalism; and furthermore that the internal market of a country is inexhaustible under noncapitalist conditions where the object of production is not profit but consumion. The last proposition remains to be proved by experience. At present (1932-1933) the international position is that in capitalist countries extensive unemployment prevails along with a glut of food and other products for which purchasers cannot be found; while in Russia, with no involuntary unemployment among those competent to undertake industrial work, there is still inadequacy, with a steady increase in the production and distribution of food and of manufactured articles for daily use.

But the motive of private profit has been practically abandoned; and a story told by Louis Fischer may be repeated as embodying a basic principle of Soviet industrial organization.

A boy was asked : "If a man buys 6 dozen apples at 18 kopeks a dozen and sells them at 36 kopeks a dozen, what does he get?" The boy's answer was: "A jail sentence."

The motive of private profit having been abolished or minimized, can a high standard of individual effort be reached and maintained?

Evidently the intensity of the individual economic struggle among the former employers and owners of capital has been reduced. Workers do not work so hard as they did. Social competition on the monetary plane has nearly gone; though the struggle for power may replace to a large extent the struggle for wealth.

With average human nature as it is, one can scarcely expect that in those circumstances a standard of production will be maintained equal to that developed under competitive conditions in a capitalistic country. Yet our own observations did not give color to this anticipation so far as the vast numbers who have to work for wages or salaries are concerned; and anyone who has witnessed the intense enthusiasm of the younger population of the U.S.S.R. for Communism and the fanatical belief and equally fanatical "shock working" of a large part of the older manual workers will appreciate that forebodings may not be generally realized, once the difficulty of inexperience of workers has been overcome.

But already, especially in the rural population, among the peasants whose immemorial desire for independent tilling of the soil has been interfered with by the organization of collective farms, there has been evidence of serious "slacking," and for slackers a government is faced with the alternative of supporting

idleness or of coercion of the worker as a condition of relief. An omnipotent bureaucracy is inevitable in a socialist government; and everyone becomes in fact an employee of the State. This is stated neutrally and not necessarily as a desirable or undesirable result. As altruistic motives increase and predominate, the Christian ideal that "whosoever would be first among you shall be servant of all" will approach realization, and compulsion will become unnecessary. It is to be expected that, in present civilization, coercion will sometimes be needed for a section of the population in which the motive of private profit has disappeared, or from which it is excluded.

In our view the most serious objection to the Soviet State is that it is a system of class preferences. Its policy is often compared with that of the French Revolution with its triple slogan of liberty, equality, and fraternity. The French Revolution never fulfilled its ideals; and if the Soviet State were to be tested by the French ideals of 1789, it also might fail. There cannot be said, at present, to be complete equality of opportunity and privileges for the entire community; and no state has ever yet practiced universal fraternity. Meanwhile the existence of a continuing condition of warinpeacetime is alleged as justifying all the various shortcomings of Soviet Russia.

The Soviet system of class government has a further lamentable ethical aspect. To aid in the social war against the classes who were deemed to live without work or useful service (such as the landlord and the capitalist, together with such of the intelligentsia as defended them) there is persistent stimulation by word and action of hatred of these excluded classes.

We do not think this can continue. The Soviet Government for its own sake must give all who work, in all occupations permitted by law, equal privileges though not necessarily equal wages, if effort to build up a completely socialist community is to have its fullest chance of permanent success. An even higher ethical standard is necessary under a socialist than under a capitalist administration. Can this be secured so long as the Communist Party dominates the Government and continues its present attitude as to class distinctions and as to religious beliefs?

Russian administration under the Tsarist regime was characterized by the worst kinds of corruption; and the new Soviet regime inaugurated fifteen years ago, even if consistently honest, may prove inadequate to its task. If it should become also corrupt can Soviet Russia's government permanently succeed?

These are questions which cannot be answered with confidence. If everyone's character were impeccable, if personal motives were never allowed to conflict with communal interests, one could anticipate a successful future for Russia and its vast experiment in enforced idealism. But we live in the actual world, with its conglomerate assembly of conflicting, multifarious, and selfcentred interests, in which pure altruism plays a relatively insignificant part. Can Soviet Russia seriously expect to develop a higher standard of morality than Great Britain or the United States? The most favorable fulfillment of the arbitrarily enforced ideals of a minority that can be anticipated for Russia is a large measure of success, in the most colossal experiment in the economic history of the world.

Even if the Communist experiment fails, Russian government cannot be expected to revert entirely to capitalist conditions. The entire community has too great a stake in what has already been established to render this feasible. Hence the Russian experiment is a portent to the rest of the world; and it will have profound influence on the future outlook of the workers, especially the wage earners of the world, who constitute at least two thirds of the total inhabitants of all advanced countries. It is incumbent, therefore, on the leaders of thought and the governments of countries outside of Russia to consider whether, in order to obtain a reasonably high standard of living for all workers, free from the haunting fear of destitution in an indefinite but perhaps very near tomorrow, they can ensure, under modified capitalist conditions, what socialism of the communist type promises and may succeed at least partially in giving in the Soviet Union. It is not merely a question of livelihood. As Carlyle says,[In Past and Present, Book III, Chapter 13. ]

It is not to die, or even to die of hunger, that makes a man wretched; many men have died; all men must die,-the last exit of us all is in a firechariot of pain. But it is to live miserable ' we know not why; to work sore and yet gain nothing; to be heartworn, weary, yet isolated, unrelated, girt in with a cold universal Laissez-faire.

The U.S.S.R. not only permits but encourages the workers in every industry, rural and urban, to give suggestions or to criticize administration, and their comments become the subject of elaborate discussion. They are given a share in determining policy and are made to realize that the industry is theirs in part. They are as yet less efficient, on the average, than workers in capitalist countries, but they are exalted into partnership or at least into active concern with the industry of which they form an essential part; and this is a great social gain. This exaltation is not beyond reach in other countries, but it obviously necessitates cooperative action, attems at which have hitherto had little success.

Professor Harold J. Laski says [In Communism. New York, H. Holt & Company; London, Williams; Newgate, 1927.]:

The world has to find response to the promise of communism in alternative forms, or it will discover that neither the crimes nor the follies of the Russian experiment will lessen the power to compel kindred action. In other words, the only way to avoid communism is to prove by public policy that it is unnecessary. Thoughtful men and women in every walk of life are searching seriously today for such alternative forms; statesmen are seeking a public policy which will serve to rehabilitate capitalism and avoid the catastrophe which would probably be the attribute of communism.

First of all, in capitalistic countries measures are called for to establish economic security and to improve the standard of living of the poorer workers; secondly, deliberately planned cooperative action must somehow be secured between industrialists in the same country; and thirdly, corresponding industries in other countries must be so guided as to prevent the cut-throat competition and overproduction now so prevalent.

Towards the first of these ends much has already been done. The various forms of social insurance and pensions for the old and for widows and their children, improved sanitation, protection of food supplies, enforced standards of housing may be instanced. Political equality has been secured at least nominally in most countries. It cannot continue to exist alone; there is needed also a nearer approach, if not to economic equality, at least to a higher standard of living and its security.

Many minds are concentrating on methods for securing an interest of workers in their work equal to that of employers in their profits. The Russian experiment at least shows the necessity of further action in other countries. Capitalism will be judged according to its power to secure active cooperation of all concerned in every kind of industry. A communist has one great advantage over a capitalist country in the fact that there is no waste of effort in rivalry between producers. Capitalist countries must secure similar cooperation if they are to continue to prosper. We were greatly impressed by what we saw in Denmark of commercial cooperation among farmers. Cooperative buying of everything needed on every farm and cooperative selling preceded by standardization of all farm products have led to prosperity and contentment, which is now only disturbed by foreign tariffs.

And this brings us to the final test of the continuance of capitalism. Can the rivalries of production in different countries be reconciled, when these countries are not so situated that they can afford to be absolutely selfcontained?

It was an appreciation of this difficulty which made internationalism an essential part of the policy of Marx and Lenin, and this difficulty explains Russia's incitement to other countries to follow her example!

If capitalist countries cannot agree together as to international trade, and if Russia makes even a partial success of its communist socialism, the rest of the world is likely to experience periods of greater agita-, tion and turmoil besides continuing to suffer from unemployment and its attendant troubles.

Our belief is that capitalism and socialism alike will fail to maintain the position now reached, and that the extremes in the position on either side will of necessity have to be abandoned. Our views were substantially stated in a recent article by a prominent member of the American bar, who has many important connections with banking and large industrial corporations. He says: [Albert G. Milbank in "Socialized Capitalism" in the Survey Graphic, July, 1932]

The progress of socialistic thought in the past twentyfive years, whether it be of the bright red variety finding its expression in Russian Communism, or of the less vivid tones found in other countries, is a factor which intelligent men cannot ignore. It has made its influence felt upon capitalistic thought and action and will continue to affect the thought and action of the world, including those who by temperament and by environment are its most violent opponents.

It is equally true, however, that the Communism of Russia, as preached and practised in 1917 and for some years thereafter, has felt the impact of capitalistic influence. The Union of Soviet Socialist Republics has been borrowing back capitalistic practices which the revolutionary leaders of 1917 spurned and discarded. Those theoristic leaders failed to take into account certain inherent traits of human nature. The individual will refuse to remain a pawn to be moved about at will, whether that will be exercised by a State which unduly suppresses the individual, or by a capitalistic system which unduly ignores its social obligation.

It is high time that we explore the possibility of whether the virtues of the two schools may not be combined into a workable scheme that will provide a better foundation than either one of them alone upon which to build an improved economic and social order.

The Socialization of Medicine

So far our sketchy remarks relate to general policy, with special reference to economics. In some respects there is no sharp line of demarcation between capitalist and socialist communities. There is much socialism in capitalist countries, in the sense of provision, from communal funds, of necessities and amenities of life. Water supplies, sewerage, scavenging, public provision of parks, museums, picture galleries and concerts, and all branches of education are of this nature. So also are the various medical activities of the State and of municipalities in which free provision is made out of taxes. And the various forms of social insurance are in part a policy of State socialism.

We are especially concerned with the socialization of medicinein the sense of the provision of medical aid out of communal funds. In Chapter XXIII are set out the conditions of medical aid which humanity and science demand. In various chapters are stated the chief characteristics of medical aid in the U.S.S.R. The arrangements we have described should be judged on their merits and apart from any preconceions or prejudices as to state socialism. The worst slavery is that of the mind whichwhen right and wrong are not concernedprejudges a social activity according as it fits or does not fit a pet doctrine as to the constitution of society. Happily most countries have refused to be bound in this way, and we are thus the freer to sum up the merits and demerits of Russian medicine as presented in this volume.

In every civilized country medicine has become more than half socialized. There is more hospital and institutional treatment of illness (including insanity) than domiciliary treatment. Much domiciliary treatment is partially or entirely a state or municipal service, including the various sickness insurance schemes; and except in Britain and America nearly all hospital treatment is a state service. Even in these two countries it is to a very great extent a state service.

It is unnecessary to detail here the various state services for mothers and their infants, for the poor, for such special diseases as tuberculosis and venereal diseases; but it can be safely affirmed that in all countries west of the U.S.S.R., total official, bulk larger than total private, medical activities.

The position of the U.S.S.R. as already seen is very special. In some essential particulars it has surpassed all other countries in its socialization of medicine. It has removed the doctor almost entirely from the field of monetary competition, and has thus abolished a chief source of inadequate medical service. It has made a gratuitous (that is, statepaid) medical service of an astonishingly complete character promly available for the vast majority of urban populations, a service which is being rapidly extended to rural Russia; and it has given the whole of this service an admirable turn in the direction of social as well as medical preventive measures.

It has constituted a single unit system of medical service for the population, freed from the complications, overlappings, and gaps of western medicine. However, the occurrence of gaps in the service for rural Russia is admitted.

These are great achievements. The new arrangements are far from perfect; but perfection could not be expected after only a dozen years of strenuous organization. But other countries may well envy Soviet Russia's elaborately centralized government in this respect, in that it has been able to brush aside all past complexities and to initiate a nearly universal national medical service on unified lines, untrammeled by such complications as exist in western Europe and America. There are some advantages in starting, as Russia has done, almost from zero point; but the realization of unification and of universality of a satisfactory medical service, available for all who cannot now afford it, should not be beyond the reach of other countries. Almost certainly, however, progress in western countries towards the goal of a national medical service will not follow the exact procedure which Russia is adoing.

To mention only one problem, those countries which remain capitalist will be likely to continue direct weekly payment by the worker in sickness insurance, so far as monetary benefits are concerned; for such direct payments by the future beneficiary give an obvious personal stake in social insurance. It is an open question whether this will continue to hold good for medical benefits.

So far as concerns the medical part of social insurance and the wider problem of a unified medical service, the objects and ideals are those categorically set out in Chapter XXI, to which the reader's attention may once more be drawn.

What Russia has accomplished in its courageously original schemes for the health and social wellbeing of its people constitutes a challenge to other countries. The Reverend Doctor Harry Emerson Fosdick recently [As reported in the New York Herald. Tribune, January 23, 1933.] interpreted the significance of this challenge for one country, when, speaking of communism and in relation to America, he said: "... the only method by which the United States can prevent its adoion is to display equal efforts in a drive for social reform ... those communists in Russia really are on fire with sacrificial and determined zeal, at all costs, even at the cost of ruthless persecution, to build what seems to them a more decent society, and the only way we can ultimately compete with them is to be, at least, equally zealous for social reformation." And he concludes: "What if in the end these atheists in Russia should turn out to care more for building a better social order than we Christians in America do? That is the moral crux of the competition between us."

The issue here is clearly put, subject to an adequately inclusive definition of "a better social order." Can such an order in the fullest sense be created, which does not include recognition of man's spiritual relation to the divine?

Given this more complete definition, the issue is not so unequal as may appear; but the challenge remains: a challenge which western civilization must accept and meet.

(1) Leon Trotsky, My Life, New York, Charles Scribner's Sons, 1930.

(2) In The Man from the Volga, a Life of Lenin. New York, R. Long; R. R. Smith, 1932.

(3) Walter Duranty, in the New York Times, August 24, 1933, comments on the excellent harvest which "will be more than sufficient to cover the nation's food supply for the coming year," and then adds that the food shortage has, however, caused heavy loss of life. He refers to an industrial plant in the North Caucasus, where, although the workers were on bread rations, the death rate during the winter and early spring rose to nearly four times the normal rate. "Among peasants and others not receiving bread rations," he says, "conditions were certainly not better."