Red Medicine: Socialized Health in Soviet Russia

Treatment in Residential and Nonresidential Institutions

NEXT in significance to the fact that every doctor in Soviet Russia is a State official, is a further exceptionally developed feature of Soviet Medicine, namely, the concentration of medical practice in dispensaries, poly-clinics, and hospitals, in which the individual doctor is never an isolated unit, but is in systematic touch with every branch of medicine.

Dispensaries and Polyclinics

In this unified medical organization the next link after the home doctor and the factory doctor is constituted by dispensaries and polyclinics. There is no sharp line of demarcation between these, but usually each dispensary serves the population of a particular district. It is claimed that, by the partial and almost complete "dispensarization" of medical practice, supervision is being exercised over the healthy as well as the sick persons in a district, including not only workers and their families, but the entire population; and that thus the integration of preventive and curative medicine for the community is being reached.

Kazan, with a population of 175,000, has four free dispensaries and five at which some payment is made. These are linked up with a large university clinic.

In Samara, with a population of 172,000, there is a polyclinic in each of its seven districts with additional dispensaries. In Saratov the organization was similar.

In Rostovon-Don we found, as elsewhere, that a doctor at the dispensary is allowed to see only six patients in an hour, even though this often necessitates his working overtime.

In Rostov we inspected The Unitary Dispensary, one of the finest in Russia. It is further described in this chapter, but we may here note one rule of this dispensary, to the effect that every patient treated at the institution must be exhaustively overhauled, passing through all its departments. Furthermore, a nurse visits each patient's home to ascertain domestic and working conditions of life and to arrange for any steps needed for their improvement. Thus there is working in this instanceto some extent in other polyclinicsthat complete integration between medicine on its medical and medicine on its social side which gives the best promise of satisfactory treatment and undelayed return to health and work.

Kharkov has a magnificent polyclinic. Every special branch of medicine is provided for under the same general control, and thus each patient can receive any special skill his case may require. (See also page 238.)

In Leningrad there are eight large polyclinics. We inspected one of them (see page 235), and the remaining seven were stated to be similar to it. This was a most elaborate establishment like those seen in Kharkov and Rostov.

Nonresident institutional treatment for tuberculosis and for venereal diseases and for mothers and their young children may be given at special institutions or may form part of the various polyclinics. The latter arrangement is the most satisfactory from the point of view of securing complete cooperation between the physicians attached to various special branches of medicine. It has already been stated that most confinements in cities occur in maternity hospitals or in maternity wings of general hospitals.

The special arrangements for treating tuberculosis and venereal diseases are described in succeeding chapters.

Domiciliary and factory treatment are linked up with dispensaries and polyclinics, and the chain of medical service is completed in the official hospitals, night, day, and completely residential sanatoria, rest homes, and various forms of physical therapy.

Hospitals

We made many visits to hospitals, some of which are described below. In the cities visited by us, the general standard of hospital treatment appeared to us to be good. We found new hospitals, with the newest and best appliances, and without any evidence of the relative poverty which one would expect in Russia under present circumstances.

Sanatoria and Rest Homes

The same remark applies to convalescent institutions visited by us, though in these there was sometimes a

FIG. 5. Number of persons cared for in rest homes and sanatoria in the Union of Soviet Socialist Republics in 1929-1930, and 1932. The figures for 1932 are estimated.

closer approximation of beds than is desirable. But the astonishing fact is the vast provision of convalescent home and sanatorium accommodation, probably larger in proportion to population than in any other civilized country. This has been facilitated by the previous confiscation of the palaces and palatial homes of pre-Revolution Russia. But the wealth of convalescent accommodation now available is a very hopeful feature in the health prospects of the Russians.

A Polyclinic in Leningrad

The large polyclinic known as the Ambulatorium for Volodarski District in Leningrad includes all branches of medicine and also a training school for nurses.

All workers in the district are treated free. They apply direct to the polyclinic and are not sent by a district doctor. From the clinic the patient is transferred to hospital if this is necessary. There is close cooperation with other districts, and the same doctor sees the patient at the clinic throughout.

One hundred and twentyeight doctors are employed at this polyclinic. These doctors go to the homes of the people when this is necessary. There are no district doctors in the ordinary sense, the patient being expected to go to the doctor at the polyclinic unless he is unable to walk, or there is some other physical reason preventing his attendance. In this case a doctor from the clinic visits him at home.

For industrial purposes the main difficulty, namely, that of overcertification, has disappeared, because of the independent position of the doctor.

The Unitary Dispensary at Rostov

The best example of polyclinic organization and equipment was seen in Rostovon-Don, at the dispensary. The institution so called is the chief polyclinic in the city, admirably equipped in all special departments of medicine, and with a staff in each department which includes the university professors of medicine. Medical students are trained here and are required also to attend at ambulatoria.

There are four dispensaries or ambulatoria attached to the polyclinic, in which ordinary cases are treated. There are also night sanatoria for patients with stomachic diseases, where the patients sleep, are given appropriate food, and from which they go to their daily work. There is a similar institution for nervous cases.

There is a special venereal disease centre for treatment, with a branch at the polyclinic.

Recently a department has been opened for the treatment of alcoholics, with arrangements for antialcoholic addresses, in the giving of which the People's Committee help.

Dr. Rubinstein, the director of The Unitary Dispensary, explained the working of each section and subsequently presented us with a set of the interesting educational diagrams and cartoons which were found in the waiting rooms and in some consulting rooms.

At this polyclinic about 1,800 patients are treated daily. All diseases are treated, including formerly tuberculosis; but for this disease it has been found more convenient to use the tuberculosis sections of the clinic chiefly for consultation in difficult cases sent from other institutions.

All the documents relating to the patient are collected and kept. Thus a tuberculous patient is treated with complete medical knowledge of his condition. During the last three years, we were told, a Tuberculosis Care Committee had been meeting every ten days. In this committee are included the patient's doctor at the polyclinic, and the doctor from the ambulatorium who knows the conditions of his daily work. The future conditions of the patient's working are determined, the deficiency in his wage created by his partial inability being paid by the insurance bureau. He remains under the supervision of the ambulatorium doctor and of the doctor at the factory where he works. Workers take great interest in this branch of health work and in the committees of workmen concerned in it.

Every child patient is examined with a fluoroscope, and in selected cases an X-ray photograph is preserved. Contacts are examined.

The polyclinic serves a section of the city having a population of some 25,000. Its area is divided into twelve subdistricts, each of which has a doctor allotted to it. He has charge of about 2,100 people. He may live where he likes, not necessarily in the district allotted to him. He is an employee of the dispensary of his district and spends part of each day working there. He may also be the school doctor for the school in his subdistrict. He has sanitary supervision of those living in his area, and gives addresses on health problems to the people.

But this district doctor, although he may be described as the family doctor for those living in his area, is not in sole possession of the field. The children attend a Children's Centre for advice and treatment, and the children's doctor from the centre visits them when visits are called for.

The Third Labor Polyclinic, in Kharkov

In Kharkov we visited The Third Labor Polyclinic, a magnificent new building. In the following brief descriion of it we have utilized a handsome volume giving full details, issued jointly by the People's Commissar of Health of the Ukrainian Socialist Soviet Republic and the chairman of the City Soviet. The prefatory statement of this volume is significant. It claims that "Soviet medicine is social and prophylactic in character"; and that "like the whole State, Soviet medicine is built up and directed by the workers themselves."

This particular polyclinic is situated in a workers' district and is intended primarily to give gratuitous medical aid in the factories of Kharkov.

The polyclinic is a great multiform dispensary, serving some 40,000 workers and their families. It is controlled by the Department of Health of the Kharkov City Soviet and is supported out of insurance funds. . The new building consists of four floors. On the ground floor are placed the Roentgen diagnostic and therapeutic offices, the registry, committee room for employees, their dining hall, and various other offices.

The first floor comprises surgical, urological, and orthopedic departments, a chemical and bacteriological laboratory, a dispensary for children under four years old, offices for the physicians, for inquiry, and for receion.

The second floor has a therapeutic department and a special department for the treatment of workers in dangerous industries, a department for consultations on physical culture, a psychoneurological dispensary, a dispensary for antinarcotic treatment, a dispensary for prenatal and gynecological care and for consultation on questions of sex and marriage, a department for electric and lightradiating treatments, and a hall for corrective gymnastics.

On the third floor is the ophthalmic department and the department for ear, nose, and throat diseases, an inhalatorium, a sanitary consultation, a dental department, and a dispensary for young children.

There are in addition four old pavilions, a tuberculosis dispensary, a venereological department, a dietetic dispensary, a milkfood kitchen, a dietetic dining hall, a pharmacy, and diagnostic wards with ninety beds and physiotherapeutic wards with sixty beds.

The above enumeration gives only an imperfect idea of the elaboration and completeness of the arrangements for every branch of medical or hygienic need; nor does it express the completeness of the arrangements for cooperation between these various special departments for the benefit of patients.

The Third Labor Polyclinic is admirably equipped for research as well as for clinical work; and in order to make use of the valuable material for research passing through the polyclinic, an institute for special researches is maintained there.

Near this new polyclinic are the immense new Tractor Works employing some 16,000 workers. This plant has a separate but similar polyclinic and a hospital of its own with four hundred beds.

The Therapeutic Hospital at Rostov

The Therapeutic Hospital at Rostov is a general hospital of 1,200 beds, having many separate departments, including provisions for hydropathic, X-ray treatment for cancer, thermotherapy, etc. The hospital has its own power station supplying hot water and steam to every room. The ambulance for the district in which this splendid hospital is situated is lodged in the hospital grounds.

At the time of our visit fiftysix of the eightyeight children in the hospital were accompanied by their mothers.

If a child develops a cough, a glass screen is at once placed on each side of its bed.

Our attention was drawn to the experience that the children, in the cubicles are not fretful. For convalescent children there is a charming playroom and a balcony leading from this.

Preschool children and school children are sent to this hospital for special examination in its tuberculosis department. The fluoroscope is employed in each case, but as a rule X-ray photographs are not taken.

Open cases of tuberculosis are sent to a special hospital.

The doors of the part of the hospital in which seic cases are treated are kept locked to ensure complete separation from the rest of the hospital.

The Hospital for Railway Employees in Tiflis

At Tiflis we visited the Hospital for Railway Employees. This is a splendidly equipped institution with five hundred beds, intended for all grades of railway employees in the State. Its existence shows that within the State system of medical attendance special arrangements can be made for those engaged in a particular occupation. Evidently if this separate provision of hospitals according to occupation were to become general there might be danger of redundant effort and of rivalry in standard of provision.

This particular hospital was splendidly organized. We were especially interested in its obstetric and gynecological divisions. The staff for these two divisions is kept strictly separate. In the obstetric division there are special rooms for confinement. Then the patients are put in a general ward, and the infants in another ward in strict isolation. Each infant is brought to its mother for breastfeeding and then taken back to the infants' ward. Any febrile patient is at once isolated.

The patients confined in this institution have previously attended at a prenatal consultation centre, and the record of their condition comes with them to the hospital. Women are brought by ambulance at the beginning of labor. When complications indicate the need, they are sent to hospital before labor begins.

The hospital midwife delivers each mother, but a doctor supervises.

Integration of Institutional and Noninstitutional Treatment

The integration of the practice of medicine within and without institutions may be illustrated by the experience related to us by an American citizen, formerly secretary of a public welfare society in a New York county, who for seven weeks had been an instructor in English under the Soviet Government in Moscow. He fell ill with tonsillitis, followed by acute rheumatism and pleurisy. As a Soviet worker he was attended at home by the Soviet doctor of his district. This district doctor was expected to be familiar with the sanitary conditions as well as the personal welfare of his patients. The American's progress not being satisfactory, he was sent to a hospital, and there he was treated in the general ward as a worker, although he had been a worker for only seven weeks.

He found the treatment in the hospital satisfactory, and, apart from the quality of the food, general arrangements were good. Nursing was fairly good. He was in the hospital for six weeks, and the feature of his treatment was that his case, like others, was regarded as a consilium, i.e., a subject for expert consultations, every collateral medical help being invoked. The hospital treatment was gratuitous.

After leaving the hospital he was under the care of the district doctor again for a month; but specialist aid was still available when circumstances called for it.

He was then sent for protracted treatment at a sanatorium on the Russian Riviera, where the charge was 222 rubles for a month's residential treatment. It appears that all workmen must pay for this special sanatorium treatment, the trade union being expected to defray the cost when necessary.

The American's relation to the system of state insurance is interesting. When the district doctor first diagnosed his illness, he filled in a certificate which authorized him to obtain monetary aid to a limit of fifty rubles for emergency expenses. He was ill altogether for ten weeks, and during this time was paid half his salary as a teacher. Had he been a member of a trade union he would, he stated, have received his full salary.

He considers that he was treated exactly as a Russian worker would have been, and that his nationality did not give him special attention. The case is an example of almost complete integration of medicine, with an almost ideal absence of redundance or deficiency of service, and with exact linking up of domiciliary and institutional, including expert, services.

We were informed that complete strangers, including foreigners, would be admitted to hospitals without distinction, except that when in any community skilled services are not adequate, the peasant and worker must be served first, all others being served to the extent possible. This is defended on the ground that workers are producers and must always take first place.

Further Data on Institutions

In Russia the care of the lyingin woman is almost universally arranged in special hospitals in its cities, and largely also in rural districts.

The rapidly increasing number of beds in hospitals is shown below. In institutional treatment must be included the outpatient treatment given in factories, dispensaries, and the various general and special clinics and polyclinics. Patients are expected to go to these for treatment, and are only treated at home when they are unable to travel or when traveling would be detrimental.

The following statistics indicating the increasing amount of institutional treatment and of other expert facilities for diagnosis and treatment are derived from the Soviet Culture Review, Nos. 7-9, 1932.

*Figures for 1931 are preliminary and those for 1932 estimated.

In the same period the number of rural medical districts in the R.S.F.S.R. has increased from 4,667 to 7,962.

These figures are rightly quoted as triumphs of the Five Year Plan, as are also the following figures, which deal with special public health organization:

We regret that in the above tables figures giving statistical comparison with the pre-Revolution period are absent. In the following table is given a comparison between 1913 and 1926 or 1927 for the R.S.F.S.R.:

*There appears to be a discrepancy between this total for 1926 and the total of beds in towns and villages for 1927-28 in the table on page 244.

In another part of the same medical report the following table is given which further shows the rapid progress of medical provisions when 1927-8 is compared with 1932. In each instance the provision in the earlier year is given as 100 and that in 1932 in proportion to this.

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