Red Medicine: Socialized Health in Soviet Russia
IN THE light of what has already been written we can discuss more fully the leading characteristics of Russian medicine.
Before doing so we should, once more, make it clear that our account brings into relief what is best and what has been most highly developed in Russian cities. In the background there is, as we were repeatedly informed, an inadequate supply of doctors for the needs of the teeming city dwellers and still more for the immense and widely scattered rural population; but the deficiency is being rapidly overcome, and one cannot withhold admiration for what has already been accomplished.
In preceding chapters we have already set out two outstanding characteristics of Russian medicine: First, every doctor, with negligible exceptions, is an official of the State, and second, there is a remarkable concentration of medical practice in coordinated institutions, which ensures that every doctor has ready and daily access to expert and institutional help as it may be needed.
We have already made it clear that monetary motives have almost entirely ceased to operate in medical practice in Soviet Russia. The doctor has been removed from the field of monetary competition. The small and decreasing percentage of private practice with fees may almost be left out of the reckoning, not only because of the general poverty of the population, but more so because public medical provisions in cities are immensely superior to what is possible in private practice, not only in hospital accommodation when needed, but also in the possession of elaborate consultative facilities.
The question at once suggests itself: Can as good medical work be expected in the new circumstances as was secured when a doctor's livelihood depended on his obtaining and retaining the favor of his feepaying patients? The question for the vast majority of patients is academic; for in Russia the masses of the people previously received little or no medical aid, except very inadequately from the medical staffs of hospitals and from the district public assistance medical officers. For this vast majority of the total population the medical care now given is almost incredibly better than it was, both in quality and specialist differentiation and in availability.
The Russian doctors with whom we discussed the question propounded above have no hesitation in giving an affirmative answer. (See, for instance, page 224.) It was even claimed that the removal of the cash nexus from the relationship between the doctor and his patient had greatly increased the doctor's power for good curative and preventive work. This is consistent with the conclusion reached in Medicine and the State. Thus, referring to the doctor's work under English sickness insurance, it is stated (see page 145):
For the conscientious insurance doctor it is a great boon to be able to give satisfactory treatment to the persons on his panel, without regard to a future doctor's bill;
though it was added that under these circumstances
the too complaisant doctor may incur serious moral damage by hasty consultations with his patients and by giving equally hasty and unjudicial medical certificates of inability to work.
The following additional extract from page 250 of the same volume is relevant to this subject:
It is frequently argued that wholetime salaried appointments are destructive of personal initiative and inhibitory to continued effort. This incidentally is a grave and undeserved reflection on present wholetime officers in the medical and in the scholastic professions. The reflection is deserved in individual instances. and these instances in the aggregate may bulk somewhat largely, but in my judgment they form but a small proportion of the total. In these instances security of tenure of office reduces effort and short of this may and sometimes does stereotype and render static present methods of work.
But it cannot be said that intellectual stagnation and moral lethargy, when they occur in officials, are their special possession. With these occasional accompaniments of a too sure livelihood may be compared the medical work of an occasional private medical practitioner in a poor district, his hurried interviews with patients, his too frequent treatment of many patients without diagnosis, the pile of weekly medical journals which one can see unopened on his table, and the inability to attend the meetings of medical societies, still less to cultivate postgraduate work.
The comparison with British insurance experience is apposite so far as concerns avoidance of neglect or of excessive medical visits, one or other of which may arise when a doctor is paid per visit. The comparison is irrelevant to Russian experience in the fact that in Britain the number of patients on an insurance "panel" and, therefore, the doctor's income depend on his personal popularity with his patients. In Russian practice the patient, as a rule, consults the doctor allotted to him, though this rule is not rigid. But in this respect, the position is what it has always been in rural Russia. In Britain also the same position holds good in country villages and for most patients who receive medical aid in hospitals or dispensaries.
Financial motives for efficiency have weight; but in many walks of life they do not determine human conduct, and, as we have seen, good medical service is given in departments of practice in some countries where these motives have disappeared. Professional pride, desire to excel, desire to stand well with one's fellows, count for much in a doctor's mind as in all human minds; and the satisfaction which comes from doing beneficent work, the sheer love of serving and desire to serve the suffering, possess medical hearts at least as much as the hearts of the laity.
Another feature of Soviet medicine, a feature which is perhaps its guiding principle, is that the new service is made available in a special degree to all industrial workers and the poorest of the peasants, and to their families. These form the vast majority of the population. They are given priority of treatment at the various dispensaries and polyclinics and have the first call on hospital beds and on treatment in sanatoria and convalescent homes.
The nationalization of medicine under the Soviet administration, including the organization of a public health service, was entrusted, after the Revolution, to Dr. N. A. Semashko, the first Commissar of Public Health in Soviet Russia. His descriion of the medical organization of Tsarist Russia includes a statement that it
possessed all the characteristics of the capitalistic state; a better service for those who were rich, an inferior one for the poor; practically no preventive medicine; no special care for the poor; sanatoria, etc., the monopoly of the rich.
It is noteworthy that already by 1931 there were in Russia 724,000 beds in convalescent homes and sanatoria for the poorer population.
But although priority and preference are given to workers, treatment is not withheld from those who do not come within the category of workers. It was difficult for us to get into touch with nonworkers (for definition of these see page 80) and to ascertain personal experiences; but this general statement is at least approximately correct. As stated by the Commissar of Health of the R.S.F.S.R. in the interview we had with him (see page 221), the desire is to serve all gratuitously, but the first call necessarily is for the manual workers. Thus at a dispensary an intellectual will wait until the workers have been treated.
In other matters the lot of the nonworker appears to be less happy; he is not likely to have a ration ticket; he cannot buy advantageously at the official stores; he cannot obtain the cheap tickets for the theatre, opera, and motion pictures which are accorded to trade unionists.(1) His position in sickness insurance is indicated later.
The nonworker's position as regards medical aid is anomalous. He may be poorer than the worker; but, unlike him, he cannot demand the best medical treatment. However, so far as we could ascertain, he usually receives it.
Some nonworkers still employ official doctors privately in their free time. But, as we have said, private practice probably does not amount to 10 per cent of total medical work in Russia.
An important feature of Soviet medicine is that there is practically only one channel through which it flows. In each republic there is a unit national system for the entire population. The fact that, in theory at least, kulaks and other "nonworkers" receive only such treatment as is available after workers' needs have been satisfied does not alter this main fact.
In the main also the treatment of disease is entirely gratuitous to those receiving it. Its cost is defrayed by governmental funds, which are derived chiefly from the pursuit of its monopolistic industries.
There are minor exceptions to the rule of gratuitous treatment, as for instance in the induction of abortion (see page 181), and in obtaining accommodation at sanatoria (see page 242). At some clinics and sometimes in hospitals partial payment is required.
In Soviet Russia the treatment of disease has been institutionalized more completely than in any other country, clinics and other nonresidential institutions being included in this statement. The tendency to institutionalization of medical treatment is seen in all countries, the extent to which it has advanced depending in large measure though not entirely on the financial resources of each country. Given adequate funds, the urge in this direction appears to be overwhelming. The reasons for this need not be discussed here; they are fully considered in Medicine and the State.
While this section of the present volume was being written we received the final report of the Committee on the Costs of Medical Care, which had completed a fiveyear study in America. This report enumerates the present maladjustments in the provisions for medical care in America, such as:
(1.) Uneven distribution in the costs of medical care among families.
(2.) Acute shortage of physicians and hospitals in certain rural areas.
(3.) General shortage of convalescent facilities.
(4.) General shortage of dentists to meet the real needs of the people.
(5.) Inadequacy of personnel and financial support among official health agencies.
(6.) Inability of many patients to obtain nursing
services because of cost; actual shortage of
nurses trained in obstetrics and public health;
a surplus of privateduty nurses, considering
present inability of people to employ them.
(7.) Extensive use of inferior types of treatment and
widespread selfmedication.
(8.) Low net incomes of many physicians, dentists, and nurses.
(9.) Insufficient utilization of preventive procedures.
(10.) Inability of many people to differentiate accurately between good and poor medical service.
It is convenient to compare these findings with what we found in the great towns of Soviet Russia. For convenience the headings have been numbered.
(1.) In Russia for four fifths of the population in cities and a majority in rural districts the uneven distribution of the costs of medical care has disappeared. It has not disappeared for the dwindling remnant of the "deprived classes," nor entirely for independent brain workers outside any organization, together with their families; but these depend in the main on the same official system of medical care as that given to the manual workers and peasants and to the members of any of the various social organizations.
(2.) There still exists a great shortage of physicians and of. hospitals in rural districts both in the United States and the U.S.S.R., but in the latter country the disadvantages are immensely greater, owing to the deficiency of roads and other facilities for travel.
(3.) In the United States there is a general shortage of convalescent facilities. Russia is exceptionally well provided in this respect; though owing to its vast area its rest homes and sanatoria are unequally distributed.
(4.) As regards shortage of dentists, undoubtedly this is much greater in the U.S.S.R. than in the United States; though we have no exact figures on this point.
(5.) In the United States as in other capitalist countries the financial support received by official medical agencies is quite unequal to their real and urgent requirements for good work; furthermore this support is very unequally distributed, some communities having a fairly complete organization, at any rate in some branches of medical work, while in other communities all medical work is being restricted.
In the U.S.S.R., in the rural sections, which include more than four fifths of the total population, medical provision both of institutional and noninstitutional treatment remains deficient. Inadequacy of a much less serious character continues in many rural parts in the United States. In the Russian cities visited by.us, excellent medical treatment is available, especially for workers, and this treatment is almost completely integrated, so that no form of treatment is lacking. Gaps have been filled up, except to some extent in dental treatment. This unification of medical practice means an absence of redundant effort.
(6.) The deficiency of nursing services found in the United States is shared by many countries. In Russia it is immensely more serious than in western countries, owing both to deficient numbers and inadequate training. The fact, however, that the treatment of disease in Russia is chiefly institutional probably reduces the suffering from inadequate nursing.
(7.) Selfmedication, except with herbs and the like, is likely to be exceptional in the U.S.S.R. Drugs are almost fabulously dear and scarce.
(8.) As to incomes of physicians it is difficult to find a basis of comparison of the two countries. In 1929, that is, virtually before the depression began, the net income for one half of all American physicians in private practice was less than $3,800. For one third it was less than $2,500; for 18 per cent it was below $1,500. Probably $3,800 could purchase a higher standard of living in America in 1929 than is possible in Russia today for the best paid doctors, but it is doubtful if the earnings of many Russian doctors have a purchasing power lower than $1,500 represents in America.
(9.) In insufficient utilization of preventive measures all civilized countries stand condemned. The U.S.S.R. is still behind other countries which began preventive work much earlier and probably from an initially higher level. But as to factory medical work and the work of the dispensaries and polyclinics, we were impressed by the extent to which each patient was regarded as a member of the community as well as an individual, and by the extent to which his treatment was directed to the group of which he was a member. Instances of this have been given in the preceding pages.
(10.) The inability of the majority of the public to distinguish between good and poor medical services is a universal characteristic. It will become less marked as biology and science generally are taught. Meanwhile a question obtrudes itself, even though one wishes it did not: Is not this inability to distinguish between good and poor medical care likely to be more hurtful to patients and to the public when the doctor is remunerated on a fee basis than when he has no concern with the cost of the treatment he is privileged to give? The answer must, we think, lean towards the system begun in the U.S.S.R., although, as yet, it is being incompletely carried out.
In some prefatory remarks we assumed that the medical arrangements seen by us in the U.S.S.R. were the best which it possesses. Even so they showed some imperfections and varying degrees of completeness. They sometimes illustrated, furthermore, the risk which all highly organized medical units experience of "running to excessive specialism." The U.S.S.R. arrangements may also be regarded by many as open to the accusation of lack of the "human touch" which is regarded as the saving grace and overwhelming merit of private medical practice in western countries. We saw no evidence of this, and we do not regard it as a necessary consequence of officially organized medical practice. Furthermore, if one has to choose between the unaided sympathetic family doctor of average skill and the Russian system of a chain of dispensaries, polyclinics, hospitals, and sanatoria when well run, the latter is preferable for a large proportion of total cases; and it does not necessarily mean the loss of the "human touch."
Our imperfect review of medicine in the U.S.S.R. shows that it has great merits, even in its present incompleteness. True, it has the faults of youth and beginnings; and it has the supreme fault, common to the U.S.S.R. and other countries, of not being fully available, without discrimination, for the entire population. But even in this respect it differs from other countries; for the excluded section of the population is a small nonproletarian minority, and these are only partially excluded. On the other hand, in most western countries, including the United States, the very poor and the wealthy can obtain the best possible treatment at home, in the consultation rooms of experts, or in the general and special hospitals, but there remains a large part of the total population for whom this provision is beyond their means and is not adequately forthcoming from charity or from public funds. The varying provisions of medical insurance in different countries modify this statement; but even when allowance is made for the provision made in insurance schemes in any of the western countries the average medical service available is less complete and, as far as we can judge, somewhat less satisfactory than the provision sampled by us which is made for industrial workers in the cities of Soviet Russia.
The Soviet service has the great merit that the direct payment of fees has ceased, and with it has ceased the burning problem of the relation between the private and the public practice of medicine, which in capitalist countries is always with us.
The further salient features of this service gratuitous provision for all the medical needs of the proletariat at the expense of the State, and the coordination, apparently without gaps or overlapping, between the various portions of the national medical servicemust commend themselves to the physician and the hygienist.
(1) Usually at least half of the tickets at these places of entertainment are supplied at halfprice to trade unions and factories. This is one of the conditions of the subsidy from the Commissariat of Education (Maurice Dobb in Soviet Russia and the World. London, Sidgwick & Judson, 1932).