Red Medicine: Socialized Health in Soviet Russia
NOTHING strikes the medical visitor to the U.S.S.R. more than the almost lavish provision of rest homes, convalescent homes, and sanatoria. These are largely concerned with the care of tuberculous patients, though they have been widely extended and are more generally utilized.
Dealing first with tuberculosis, the following official figures are important, as indicating the progress already made in the two chief cities of Russia:
| LUNG TUBERCULOSIS-DEATH RATE PER 100,000 | ||
| Moscow | Leningrad | |
| 1914 | 280 | 300 |
| 1931 | 120 | 130 |
The control of tuberculosis is regulated by a decree concerning Tuberculosis Centres ( June 15, 1929). It is laid down that these centres are social prophylactic institutes for carrying out all antituberculosis measures in the rural districts; and that these centres are organized in the district hospitals. Each has its own definite area of action; and it is laid down that precedence in their organization shall be given where there is a high incidence of tuberculosis, or there are many occupations away from home, or there are State and collective farms. It is also enjoined that working and living conditions favoring tuberculosis shall be specially investigated, that there shall be close cooperation with the area medical officers of health and with maternity and child welfare institutions in the area. The centres are to concern themselves with the giving of prophylactic and social aid to every tuberculous patient, and to select patients to be sent to the various health institutes; and they are required to organize tuberculosis exhibitions or tuberculosis sections in general health exhibitions. For their laboratory work the tuberculosis centres use the hospital of the medical district.
We had many opportunities of seeing to what extent the excellent program set out above is being carried out, and some of our observations are included in the accounts of interviews and visits given below.
In several cities we found that advanced work was being done in the diagnosis of tuberculosis, including the use of the fluoroscope and X-ray. The social arrangements for tuberculous patients were also good, including continued medical supervision after return to work. Furthermore, arrangements are made by the insurance bureau to pay the worker any deficiency in the remuneration for his work caused by his partial incapacity.
Many institutions had divisions for graduated heliotherapy. Children were treated in separate parts of the tuberculosis dispensaries. In Tiflis, for example, all children sent to summer rest places and sanatoria have to pass through the Tuberculosis Institute.
The Commissar of Health of the R.S.F.S.R. gave us figures which illustrate the magnitude of official provision for tuberculosis. There are now 24 tuberculosis dispensaries in Moscow with 226 fulltime physicians. In 1931, 776,000 patients were treated, 90,000 of whom came for the first time. Only 30,000 out of the lastnamed number proved to be tuberculous. All the chief tuberculosis physicians work in these dispensaries.
At the Central Tuberculosis Institute for the R.S.F.S.R. we were received by Dr. Neslin. He described the network of dispensaries in Moscow, each of which has a certain number of beds, with access to further beds in a sanatorium or hospital.
In tuberculosis dispensaries various forms of special treatment are given, including the production of pneumothorax. The first choice in securing institutional treatment is always given to workers. Contacts are watched, especially children, and examinations made every three to six months; for children tuberculin tests and X-rays are employed.
For "open" tuberculosis in towns there is institutional treatment for approximately too per cent of the cases. Before the Revolution there were 350 beds for tuberculosis in the whole of Russia, now 35,000, and in addition some 12,000 beds in day sanatoria and night sanatoria.
These day and night sanatoria are usually attached to a dispensary, and they give provision for many patients who may be working in one of the three or even four shifts of the Soviet factory work. No charge is made for treatment, and the same applies for sanatorium treatment. Most patients have been in a sanatorium.
In the factory dining rooms special diets are arranged for consumives. Very rarely is objection taken by a patient with "open" tuberculosis to removal to a hospital.
All the institutional tuberculosis physicians are wholetime officers. Only a few patients are treated by private physicians, because the tuberculosis dispensary is much better equipped than a private doctor.
There is a trade union comprising doctors and nurses and other members of the tuberculosis staff. As we have noted, the trade unions in Russia differ from those of the American or British type which are based on the
specific craft of the members; in Russia the rule is "one undertaking, one union."
Occasional collisions may arise between the expert and the administrative side of an institution; but generally trade unions facilitate the work of the Soviet organization.
The physician, whether a general or tuberculosis physician, receives a salary which is about two and a half times that of the nurse; but it is less than that of a professional engineer, and not much above that of the teacher. Special salaries are given to exceptional men; but Dr. Neslin explained that this does not raise the problem of capitalism; for in Russia the person who saves money cannot get control over the means of production.
Nursing of tuberculous patients until recently was specialized; now it is combined with that of other patients.
Although already the number of sanatorium beds is adequate for "open" cases, this is not regarded as sufficient. Although tuberculosis is being "liquidated," Dr. Neslin expressed the view that for more rapid reduction of this disease the number of beds now available needs to be increased.
At Samara, as elsewhere, we found that tuberculosis is considered specially in relation to industrial conditions. There are six sanatoria for Samara. In some of them treatment by koumiss is practiced. During the last three years the number of tuberculous patients has been halved. There is a night sanatorium at which patients are kept for two months while going to their work daily.
At Tiflis we inspected the splendid new Tuberculosis Institute. Here we visited a class of secondyear students at the medical school connected with the institute. The instruction is given in the Georgian, not the Russian, language. We observed that the students varied considerably in age, as they do in other educational institutions in Russia.
Sometimes tuberculous patients come to the Tiflis Institute independently; but mostly they are referred from the ambulatoria and factories. Children are treated in a part of the institute having a separate entrance and waiting room. All children sent to summer rest places and sanatoria have to be examined at this institution. The other tuberculosis institutions in Georgia are closely related to this central institute.
Attached to the institute is a division for graduated heliotherapy; and a separate block is being built which will be used as a day sanatorium for adult patients.
All school children are screened, and an X-ray photograph is taken in suspicious cases.
We visited one of ten night sanatoria in Moscow. This institution is not intended for any special disease, but for workers needing rest, e.g., cases of neurasthenia, anmmia, etc. Patients are sent commonly by factory doctors.
The institution has accommodation for 39 men or for 36 women. Patients come each day at 4:00 to 5:30 p.m., have a bath, and a change of clothes, are examined by a doctor, and leave the institution next morning. Single rooms are provided.
At Kharkov we visited a sanatorium or preventorium for specially selected children. The selection is made in February and March; the work of the sanatorium begins in May.
During the summer two groups of children are received, each group remaining for forty days. During their stay at the sanatorium the children are periodically examined by medical experts, and some dental and other treatment is given. There are teachers for physical sports, and civic education is given to the children for twenty minutes each day. No payments are received from parents.
There are similar sanatoria throughout the Ukraine, so we were informed. They were initiated nine years ago and form a distinctive feature of the public health administrative machinery in the Ukrainian S.S.R.
Factories are a chief centre of antituberculosis effort. In them instruction is given on precautionary measures against its spread; and in every factory the Workers' Committee discusses keenly the question of who shall be sent to available institutions. We can agree with the opinion expressed to us by a distinguished university professor in Leningrad that perhaps the greatest boon arising from the Revolution is the wide utilization of sanatoria and cure places for the workers. These scarcely existed before the Revolution. Now each worker has a chance to go annually for a fortnight's rest cure at the public cost.
The number of the various rest homes and sanatoria throughout Russia fills one with surprise. Everywhere this provision is available. Even when the worker is not actually ill, he or she appears to be able each year to claim a fortnight's residence in a rest home.
We have already referred in Chapters I and II to the various rest homes and sanatoria which we visited, but further details will be given here. A beautiful palace on the banks of the Neva, in Leningrad, is now used as a home of rest for the fourteenday holiday given to workers, while they are on full pay. No payment is exacted at the home, but to the limit of accommodation all workers can take their holiday in it or in others similarly constituted. We found the magnificent rooms of the palace occupied by workers living amid scenes of vanished private luxury.
In Leningrad also we visited a night sanatorium housed in a palatial suburban house, formerly a private residence. Here also the lavish fittings and decorations remain. This institution has 13o beds. It is intended for early cases of tuberculosis, and 35 women and 35 men are admitted at one time. These go to their work daily, working seven hours each day, return to this institution, bathe, rest for an hour, then have supper, and afterwards consult with the doctor, whom we met.
Exsanatorium patients do not appear to be received in this night sanatorium with a view to continuing under hygienic conditions, nor is there, as yet, any arrangement for giving patients work determined by their medical condition; but an attem is being made to select lighter employment for these workers.
Some of the patients appeared to us to be more in need of protracted continuous treatment in a sanatorium; but presumably this accommodation is not always available.
But the Crimea is the region in which the chief health resorts of Soviet Russia are situated. This arises not solely or directly because of its climatic superiority, but because in it were found the imperial and aristocratic palaces, private mansions, and sanatoria, previously the almost complete monopoly of the welltodo.
We landed from the Black Sea steamer at Yalta, the centre of the health resorts on the Crimean coast. It is a town with some 20,000 inhabitants, sheltered by high mountains, and going back in history to ancient Greek occupation. The morning after our arrival we were met by Dr. S. J. Jacobson, Chief of the Social Insurance Organization for the Crimea region.
In a conversation on social insurance in Russia he stated as its chief objects: (1) the emphasizing of prophylaxis in medical treatment, and (2) the organization and development of increasing numbers of sanatoria and rest houses. Already the number of these institutions is several times greater than before the Revolution.
The chief aim is to help workers, and in accordance with present needs 90 per cent of those helped must be workers in the heavy industries. Technicians are included in this preferential treatment.
In medical work in the Crimea the chief aim is to obtain full advantage of its. special climatic healing powers; and from this point of view, said Dr. Jacobson, it is being found desirable to develop sanatoria about 1,700 feet above sea level. Those formerly built were on the sea level.
In addition to the insurance sanatoria and homes, there are similar (perhaps not equally good) institutions administered by the Commissariats of Health. There is agreement between the two, patients being sent from a central bureau. Actual fusion of the two sets of institutions is contemplated. Patients are sent to the Crimea from all parts of the U.S.S.R. Advanced cases are seldom sent to these distant sanatoria. When an insured patient is under treatment he receives full wages, is treated free, and special help is given before he leaves home.
On the Crimean coast there are more beds for the noninsured than for the insured.
At least half the cost of maintenance of workers in sanatoria and homes of rest appears to come from public health funds, said Dr. Jacobson, the insurance funds not sufficing for all applicants.
A select committee decides on patients to be sent from the heavy industries. The local tuberculosis dispensary organization is utilized in deciding on cases.
Night, and day, sanatoria for workers are relatively little developed in the Crimea. Pulmonary cavitation cases are specially trained in photographic and other light industries. Some work has been done in occupational therapy. There is no difficulty in selling goods produced.
Each patient on returning home is handed a copy of the history of his illness, and this and his record card he takes with him to his local dispensary.
There are few special children's sanatoria in the Crimea. It has been found necessary to concentrate first on the workers themselves. These are a main source of infection to others.
Cases of tuberculosis, even in children, are always treated separately from other illnesses.
We visited Dolossy, a large sanatorium in the mountains above Yalta, at an altitude of about 1,600 feet. This is magnificently situated and organized. In winter it has about 300 patients, in summer 480. In admitting patients special precautions are taken against the introduction of extraneous infection; all crockery and spoons, etc., are sterilized after each meal; sputa are cremated.
The funds for building and equipping the sanatorium were derived from social insurance. Each patient costs 6 rubles a day for maintenance.
Touch is kept with patients who have left the institution, the records of factories and other work places and of tuberculosis dispensaries being available for this purpose.
We next visited Livadia, the former Crimean residence of Tsar Alexander III, a magnificent building, with many subsidiary houses. The palace and other buildings now house from 1,300 to 1,500 workers from various parts of Russia, sent here for a fortnight's or, longer rest cure. It is in fact a vast convalescent home, with added facilities for patients needing special care. It is intended for workers sent by both insurance and public health authorities.
We were accompanied by Dr. Karpenko, the Director for State Sanatoria in the Crimea, who explained the working of the rest cures. They are under centralized direction from Moscow. The patients who are sent here are workers on collective farms who are not insured, also insured persons who are not ill enough or for whom beds are not available under the insurance scheme. These must buy their own traveling tickets and are required also to be members of a trade union.
The workers admitted to Livadia in the summer are chiefly "shock brigade" workers from factories; in the winter patients from collective farms preponderate. Thus Livadia has become a "peasants' palace."
Usually patients stay six weeks in Livadia. They come in groups from various areas, and these groups enjoy a certain amount of autonomous management. Discipline is found to be easy among the hard workers sent here.
On our visit to Livadia we had interesting discussions with its staff, including especially the medical superintendent. He was most emphatic in his preference for the new regime, and had no doubt that, although his remuneration was lower than formerly, he had much greater influence for good now that all financial considerations between him and his patients had ceased. Furthermore, he had no doubt that his interest in each patient as an individual had increased ; and regarded it as certain that this feeling would continue, because the young were being sedulously educated in the principles of socialism, which meant that personal welfare was to be sought through communal welfare.
Finally, we may quote from a distinguished woman professor of histology in Moscow. She is over sixty years old, came from a wealthy family, and had been engaged in revolutionary activities during the Tsarist period. As evidence of progress made, she instanced the gigantic growth of rest homes and sanatoria to which, she said, a great majority of the proletariat go for a fortnight each year. Before the Revolution the proletariat did not count; now they count for everything. They had suffered most from the old bourgeoisie, and in her view it was right that they should receive the first and chief benefit of the new regime. It is they who form the vanguard of socialism and are building it up, and theirs must be the first benefit.