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Y. Lisitsin

__TITLE__ HEALTH PROTECTION IN THE USSR __TEXTFILE_BORN__ 2007-07-29T19:59:56-0700 __TRANSMARKUP__ "Y. Sverdlov" Progress Publishers Moscow [1]

Translated from the Russian by David Myshne

Designed by V. Korolkov

K). PI. JlHCHUHII 3/IPABOOXPAHEHHE B CCCP Ha H-MKC __COPYRIGHT__ First printing 1972
Printed in the Union of Soviet Socialist Republics [2]

CONTENTS

Foreword

Chapter 1. The Soviet Union and Its People ......

Territory. Population ...........

The Economy and Living Conditions .....

Chapter 2. The Great October Revolution and Public Health Public Health in Russia before the October Revolution ..............

Formation of the Soviet Public Health System . The Great Patriotic War ........

Public Health Services in the USSR since 1945 .

Chapter 3. "Health Index" ............

Decrease in Mortality ..........

Decrease in Disease Incidence .......

Improvement in Physical Development ....

Social Homogeneity in the General Health Improvement in the USSR ........

Chapter 4. Basic Principles of the Soviet Health Protection . State Socialist Character of Health ......

Free and Generally Available Medical Aid . . Unified and Planned Public Health .....

Prophylactic Work ...........

Dispensary Service ...........

Divisional Organisation .........

Education in Hygiene and Sanitation .....

Connections Between Medical Science and the Practical Work of Public Health Services . . . Participation of the Population in Public Health Work ................

Chapter ">. Public Health Services ..........

Main Curative anil Prophylactic Institutions. The Problem o( Specialisation .......

Page 5 9 10 33 34 37 41 43 46 46 48 51 54 60 61 62 66 70 72 3

Medical Care for Industrial Workers . Medical Care in the Countryside . Medical (``arc for Women and Children . Sanitary and Kpidciniological Services Health Resorts and Sanaloi iiniis ....

SI S3

N7

Chapter 6. People in White Clowns........

Chapter 7. Health Industry...........

Chapter 8. Medical Science, a Branch of Public Health . Conclusion. "Health Vaccine"..........

98 106 110 120

[4] __ALPHA_LVL1__ FOREWORD

According to official data, in 1970, the Soviet Union had about 700,000 doctors, while the number of persons with a secondary medical education (nurses, technicians and other personnel) exceeded 2 million. Reference books on medical education show that increasingly more doctors and other medical workers are being trained in the USSR with each passing year. For example, more than 30,000 doctors have graduated annually from medical colleges in the last four years. Some foreign readers of this book may wonder why the Soviet Union needs so many physicians and other medical and auxiliary personnel in the health services, since the Soviet Union already has more than a quarter of the total number of the world's doctors and more than half the total number of Europe's doctors, whereas the population of the USSR, which numbered 243.9 million in 1971, constitutes only one-fifteenth of the world's population.

Other facts about public health in the Soviet Union may also seem puzzling. For example, it was reported that in 1969 some 9.5 million people had a rest and received medical treatment at health resorts and in sanatoriums, holiday homes and boarding houses, including more than 7 million industrial and office workers, who received accommodation wholly or partly at the expense of the state or special social insurance funds. This figure appears particularly large, since in many countries sanatoriums and health resorts are too expensive to be afforded by more than a limited part of the population.

The uninformed reader will be astonished by the facts about the improvement of public health in the Soviet Union. They are indeed amazing. In only some 50 odd years, out of which 20 were spent in wars to defend our country's freedom and independence and in restoration of its economy, general and child mortality have decreased severalfold, many formerly widespread infectious and parasitic diseases have been wiped out, and the health of Soviet citizens is on a par with the world's highest standards.

To gain an insight into this and many other questions, those who are interested in Soviet public health and medicine would, of course, do well to see the country for themselves and acquaint themselves with the work of the health services, with the doctors, nurses and other Soviet medical 5 workers. Naturally, no printed matter can take the place of personal impressions, although it can provide answers to many questions.

It is this purpose---to furnish the reader with information on the Soviet health protection system, medical science, the changes that have taken place in public health and the training of doctors and other medical personnel---that this book is meant to fulfil. We hope, moreover, that it will give some idea of the historically unique social experiment carried out in the USSR, the experiment that has transformed the country into one of the world's leading industrial powers with a progressive system of public health services.

At the end of June 1968 a session was held in Moscow of the Supreme Soviet of the USSR---the country's highest body of state power. The session paid special attention to the question of the medical care of the population. The Supreme Soviet of the USSR and, later, the Central Committee of the Communist Party of the Soviet Union and the Council of Ministers of the USSR passed resolutions aimed at further developing and improving medical care and public health services in the USSR. These documents are indicative of the solicitude displayed by the state power for safeguarding and improving the health of all Soviet people and of the importance attached to health protection as a significant branch of the national economy.

``As a result of the construction of a socialist society in the USSR, the consolidation of its economic power, the steady rise in the material and cultural standards of the people and the progress of science, a great deal has been successfully achieved in the preservation and improvement of public health. The socialist principles of health protection---free and universally available skilled medical aid and extensive preventive measures against disease---are being consistently put into effect.'' These words from the resolution of the Supreme Soviet of the USSR can serve as a key to understanding how it was possible to improve the state of public health in so short a period of time.

The Principles of Legislation on Health Protection for the USSR and the Union Republics adopted by the Session of the Supreme Soviet of the USSR held in December 1969, embraced the most important propositions connected with the protection of public health, as a task of the socialist state, and of the whole of socialist society. This document conforms 6 to the spirit of socialist democracy and emphasises the need for the most extensive participation of the population in the public health protection. It is well known that Lenin, whose 100th birthday was celebrated in 1970 by all progressive mankind, attached decisive importance to the participation of the masses of the population in the construction of socialism. Tn his work, 'flic Slate and Revolution, he emphasised that "only socialism will be the beginning of a rapid, genuine, truly mass forward movement, embracing first the majority and then the whole of the population, in all spheres of public and private life.''^^*^^

This legislative act on public health helps to give the entire population a better insight into the public health system and the role of the state and of society in improving the health of the people, it acquaints them with their rights to medical care and the need for active participation in the health protection measures. It is particularly important that the Principles emphasise not only the duty of the state to provide free medical aid to the entire population, but also the duty of each citizen to take care of his own health and be considerate to the health of other members of society. This follows from the duty of each citizen to regard his own health as social property, as society's main wealth.

In addition to extensive factual material and statistics on the development of the public health services and the health of the population, this book also deals with the most important theoretical principles that have made it possible to build a modern health protection system in the USSR.

_-_-_

^^*^^ V. I. Lenin, Collected Works, Vol. 25, p. 472.

[7] ~ [8] __NUMERIC_LVL1__ Chapter 1 __ALPHA_LVL1__ THE SOVIET UNION AND ITS PEOPLE __ALPHA_LVL2__ [introduction.]

Even the reader who is totally uninformed on questions of medicine and public health, must realise that the health of the population and the available medical services are very largely dependent on a country's economy, science and culture. Moreover, many medical specialists working in the developing countries say that the main enemy of the people's health is not so much the causative agents of infectious and parasitic diseases or other direct causes of ailments as the low level of economic development. The position can be stated quite simply: a weak economy is an enemy of health. This thesis could be directly applied to pre-revolutionary Russia. This vast country covering a large part of the world's territory and inhabited by industrious and talented people was dependent on more developed capitalist countries. No wonder, therefore, that the standard of health of its people was considerably lower than that of the people of many other countries.

Although books dealing with public health and medical science do not usually dwell on special problems of economics, welfare, culture and science, we think it to the point to start our narrative about Soviet medicine with at least a brief outline of these problems.

In October 1917 a gunshot from the Cruiser Avrora heralded the beginning of a new era in Russia---the era of socialism. Theses of the Central Committee of the Communist Party of the Soviet Union On the Centenary of the Birth of V. I. Lenin read:

``The Great October Socialist Revolution gave the world an example of how to solve fundamental social problems: the 9 overthrow of the power of the exploiters and the establishment of the dictatorship of the proletariat, the turning of the private property of the bourgeoisie and landlords into public socialist property, the just solution of the agrarian problem in the peasants' favour, the liberation of the dependent peoples from colonial and national oppression, and the creation of the political and economic prerequisites for the building of socialism.''^^*^^

For the first time in history, the new socialist stale upheld (he interests of the working people as its main concern, and provided the necessary economic, social and political conditions to put this idea into practice. The socialist state was built according to the plans and under the leadership of the party that expresses the hopes and aspirations of the industrial workers, peasants and all working people----the Party of Communists headed by V. I. Lenin.

Under the extremely hard conditions of the economic chaos and famine caused by the war, armed foreign intervention and internal counter-revolution the Communist Party and the Soviet Government led the people in their efforts to reconstruct the economy on socialist principles.

To build socialism was neither simple nor easy. The Soviet people were able to build a socialist state only at the cost of privation and rigorous economy.

The following very brief information on the Soviet socialist state should give the reader an idea of the multiformity and complexity of the problems Soviet medicine has to tackle.

__ALPHA_LVL2__ Territory. Population

The Soviet Union covers a vast area on two continentsEurope and Asia. From east to west it stretches for more than 9,000 km and from north to south---for more than 4,500 km. The territory of the USSR is 22.4 million sq. km. which is one-sixth of the earth's surface. Of course such vast spaces include most of the known climatic zones.

The USSR is a multinational socialist state with more than 100 nationalities living in a friendly, fraternal union. It is _-_-_

^^*^^ Lenin's Ideas and Cause Are Immortal. Theses of the Central Committee of the Communist Party of the Soviet Union on the Centenary of the Birth of V. I. Lenin, Moscow, 1970, pp. 17--18.

10 composed of 15 Union Republics. The most typical administrative territorial unit is a region usually having a population of one million or more. Regions are divided into districts with a population of 20,000 to 100,000 or even more.

On January 15, 1970 the population of the USSR numbered 243.9 million. The majority of the population (56 per cent, according to the figures of the 1970 census) lives in towns and urban-type settlements. The rural inhabitants account for 44 per cent of the country's population. These two simple figures evidence the truly immense leap forward made in the country's industrial development. Pre-- revolutionary Russia was characterised by a great predominance ol rural over urban inhabitants; in 1913 the former accounted for 82 per cent of the country's population.

According to the 1968 figures of the Central Statistical Administration, 77.7 per cent of the population are industrial and office workers, 22.27 per cent are collective farmers and co-operative artisans, and only 0.03 per cent are individual peasants and artisans not united in co-operatives.

Socialism has done away with the exploiter classes. In the USSR there are no bourgeois, landowners or private businessmen. There are two friendly classes---workers and collective farmers. The intelligentsia---brain workers---- constitutes a fairly large part of the population and numbers more than 30 million.

The people of the Soviet Union endured the terrible sufferings during the Civil War and the Great Patriotic War against the nazi invaders. Even today, nearly 30 years after the end of the Second World War, it would be hard to find a family that did not lose a dear one. During this war alone the USSR lost at least 20 million people---officers, soldiers and civilians. This ordeal, courageously endured by the Soviet people has unfavourably affected the age and sex composition of the population. It has resulted in a considerable sex disproportion, i.e., in a substantial predominance of women in the population. The 1959 census, the first since the Great Patriotic War, showed that 45 per cent of the population of the Soviet Union were men and 55 per cent were women. This disproportion still persists, although in a somewhat attenuated form. It stands to reason that this unfavourable ratio particularly affected those who at that time were in their prime. Today there are still twice as many women aged 45 and older as there are men oi that age.

11

Pre-revolutionary Russia was characterised by what is called frequent change of generations, caused by a high birthrate (45.5 per 1,000 in 1913), high general mortality (29.1 per 1,000 population) and particularly high child mortality---of 1,000 newborn children 269 died before reaching one year of age. Average life expectancy, which is a comprehensive index of the health of the population and demographic phenomena, was only 32 years for both sexes, in most gubernias (regions) of Russia at the end of the 19th century. Despite the high mortality rate, especially of children, the high birthrate compensated, in large measure, for the human losses caused by disease, injuries and other factors. According to statistics, the population of pre-revolutionary Russia increased at a comparatively high rate; in 1913 it was 16.4 per 1,000.

The radical changes that have taken place in the country in Soviet times---the creation of a modern industry, the development of culture, science and technology and a sharp rise in the living standards of the population---have greatly altered demographic processes and phenomena. The very pattern of population turnover has changed and is no longer characterised by a frequent change of generations. On the contrary, generations are replaced now at a slow rate. This means that general and child mortality has sharply decreased and life expectancy has grown. According to official data, in 1968 life expectancy was 66 years for men and 74 for women.

Characteristic of the age structure of the Soviet population today is the so-called ageing of the population, which manifests itself in an increased proportion of people aged 60 years or more and a relatively lower proportion of younger people. Whereas, according to the 1939 census, people 60 years old and older accounted for just over six per cent of the population, the 1959 census showed that this figure had grown to 9.3 per cent. The proportion of elderly and old people has increased still further and, as the 1970 census showed, about 11--12 per cent of the population are 60 years old or older.

The population of the Soviet Union is increasing annually by about 3 million. Since the 1959 census it has increased by more than 35 million (as of January 15, 1970).

However, an increasing population is no cause for alarm in the Soviet Union as it often is in countries with a large 12 population but without an adequate economic potential. Both control and family planning, i.e., in the final analysis, measures aimed at curtailing the natural increase in population, have never been encouraged in the USSR. On the contrary, all social policy, since the very first days of Soviet power, has favoured a high natural increase in the population. The content of Soviet demographic policy has always been the same---the encouragement of childbirth and state protection of mothers and young children.

We shall have further cause to dwell on this question and on the system of medical care for women and children, which has contributed much to improving the health of the Soviet population. We shall just note here that the fact that abortions are permitted in the USSR does not mean an attempt to reduce birthrate. It merely gives the women themselves, and their families the right to decide how many children they wish to have.

The Soviet state is interested in increasing the population since everybody in the Soviet Union is guaranteed work and normal conditions of life. The distressing effects of the capitalist economic system---unemployment and poverty among the working people---have long since been abolished in the USSR.

__ALPHA_LVL2__ The Economy and Living Conditions

The October Revolution not only delivered the people of Russia from exploitation and backwardness, but also started the country on the wide road of scientific and technological progress. We need only refer to the figures of the national income (a highly significant economic index) to see the fast rates of Soviet economic development. Between 1913 (before the revolution) and 1970 the national income increased 46 times. In the postwar years the Soviet people effected a speedy restoration of towns and villages which had been distroyed by nazi invaders. They have achieved, to date, an 8-fold increase, as compared to 1940, of the social product and have carried out a technical re-equipment of the national economy. Powerful industry built up in Soviet times has made it possible not only to develop the means of production, but also to produce consumer goods at a fast rate. Industry and agriculture have developed much faster than in economically developed capitalist countries. For example, 13 the average annual rate of increase in industrial output in the USSR hetwcen 19.51 and I96S was 10.4 per cent, whereas in the USA, during the same period, it was 4.5 per cent, in Britain---2.9 per cent, in France---.5.4 per cent, and in the FRG 7.3 per cent.

But the Soviet Union not only has a higher growth rate than most of the economically developed capitalist countries but also a greater absolute industrial output and is second in certain indices only to the USA. For example, in 1970 the USSR produced 740,000 million kwh of electric power, extracted 353 million tons of oil, mined 624 million tons of coal and smelted 85.9 million tons of pig iron and 116 million tons of steel.

By concluding the eighth five-year period successfully, the Soviet people made another step forward to the creation of the material and technological basis of communism. The 24th Congress of the CPSU adopted Directives for the new Five-Year Plan of Economic Development for 1971--1975. The main task of the new five-year period is to achieve another considerable rise in the material and cultural level of the people on the basis of a fast rate of development of social production, its higher efficiency, scientific and technological progress and a rapid rise in labour productivity. The welfare of the people is the primary concern of the Communist Party.

The development of the economy has led to a considerable rise in the living standards of Soviet citizens. Huge sums from the state budget are spent on satisfying the material and cultural needs of the population. The real incomes of workers have increased 8-fold and those of collective farmers 12-fold. Directives of the 24th Congress of the CPSU envisage a further rise in the people's welfare. Between 1971 and 1975 the real incomes of the working people will grow by an average of 30 per cent. Three quarters of this rise will be accounted for by wage rises. The planned wage rises will affect nearly 90 million people. In addition to wage rises social consumption funds will also grow considerably, as was stated in the Report of the Central Committee of the CPSU to the 24th Party Congress. Their volume will be increased by 40 per cent and reach 90,000 million rubles in 1975. These funds will be used to implement a broad social programme. The amounts spent by the state on social and cultural purposes may be judged by the figures of the 1970 USSR state 14 budget; allocations for the above purposes amounted to 56,000 million rubles, which is nearly as much as was spent on the development of industry and agriculture and much more (3 times as much) than was spent on defence. Expenses on social and cultural measures are increasing with each passing year. In addition to the state budget funds, large sums are also allocated to the public consumption funds by state and co-operative institutions. Including these sums the total amount spent on social and cultural purposes in 1970 exceeded 70,000 million rubles.

We have dealt with this question in such detail because a considerable part of the above-mentioned funds are allocated to the development of the public health service in the USSR; this will be dealt with in more detail below.

In 1970 a considerable proportion of all the money spent on social and cultural purposes---more than 21,000 million rubles---was used for social insurance and social maintenance. The larger part of this money goes for various pensions, including old age pensions. In 1970 the total number of pensioners in the Soviet Union was 41.6 million, including 12.3 million collective farmers; 36 million of these were old age pensioners, invalids, etc., and 5 million were former servicemen. According to Soviet law, pensions are granted to men at the age of 60 and to women at the age of 55. Moreover, a large group of the population---workers in difficult trades, women employed in certain enterprises and several other categories of workers---are granted pensions 5-10 years earlier.

The following figures may be cited by way of comparison: in the USA, for example, the pensions for men begin at 65 and for women at 62; in the FRG, the Netherlands and Finland the pension age is 65 for both men and women; in Switzerland it is 67, and in Canada, Ireland and Norway--- 70. In the USSR, besides the comparatively early pension age, old age pensions are between 50 and 100 per cent of a person's working wage. Considerable changes in social insurance and social maintenance are to take place within the next five years. As of July 1971 the minimum old age pension to workers, office employees and collective farmers went up by 50 per cent. Invalidity pensions will be increased, as will those granted on the loss of the breadwinner. The paid leave to take care of a sick child will be enlarged, and the network of old age and invalid homes will be extended.

15

The Soviet system of state pensions, as well as paid leave in cases of temporary disability (illness or injury), looking after a sick child or relative, quarantine, etc., not only contributes to the material welfare of the people, but helps to maintain their health.

It is also important to note that in the USSR the pensions and other allowances are granted entirely from state funds (not.through deductions from personal incomes as is the case in many capitalist countries) and that the state has placed all the funds allocated for social insurance at the disposal of the trade unions which effect their distribution.

If we add up all the gratuities and allowances the people receive from the public consumption funds we lind the total sum to be quite imposing; in 1970 these grants amounted to 262 rubles per head. In addition, the state and the collective farms spend about 150 rubles a year per family on the construction of houses, municipal services, and cultural and medical institutions.

The working hours have been significantly shortened in the USSR and the working conditions improved. Today most of the working people have a 40.7-hour week and most of the industrial enterprises and offices work 5 days a week; this allows the working people to make fuller and better use of the two free days for rest, recreation, and for their cultural development.

The problems of food and modern housing are being successfully solved. Valuable foodstuffs rich in proteins, vitamins

__PARAGRAPH_PAUSE__

Table 1 Consumption of basic foodstuffs (kg per capita, per annum) Foodstuffs 1913 1968 Meat and fat 29 48 Fish and fish products 6.7 14.3 Milk and dairy products (in terms of milk) 154 285 Eggs (in tens) 4.8 14.4 Breadstuffs 200 149 Potatoes 114 131 Vegetables and melons 40 79 Sugar S.I 37.4 16 and other necessary ingredients occupy an ever increasing place in the diet. Increasingly more meat, milk, eggs and sugar arc consumed, and less bread and cereals, which used to be the mainstay of the diet for the majority of Russia's working people (Table 1).

More and more houses are built every year. During the last 10 years half the country's population has been given new dwellings or otherwise improved their living conditions.

In rates of housing construction the USSR has outstripped the economically developed capitalist countries. This is evidenced by the following table.

Table 2 Number of flats built per 1,000 population in 1968 Country Number of Hats USSR Britain USA France Italy 9.4 7.9 7.7 8.3 4.9

We must also remember that in the USSR the rent does not, as a rule, exceed 5 per cent of the wages of industrial and office workers, whereas in capitalist countries it amounts to one-fourth and, not infrequently, one-third of the total personal income of the working family.

Fundamental changes have taken place in Soviet education, science and culture. Illiteracy was wiped out during the first two decades of Soviet power. Science and the arts were brought within the reach of millions of people. During the 1969--1970 school year the higher, general educational and other schools were attended by almost 79 million people.

An extensive network of research institutions uniting hundreds of thousands of scientific workers in all fields of knowledge has been set up in the USSR. The general headquarters of Soviet science is the Academy of Sciences of the USSR. In addition to this central academy there are also socalled branch academies, including the Academy of Medical Sciences of the USSR.

__PRINTERS_P_17_COMMENT__ 2---1065 17

The national policy of the Soviet state provides every opportunity to all peoples within the Soviet Union for the development of science, culture and education. The former outlying, backward districts of tsarist Russia have become prosperous, industrially developed, sovereign republics with an advanced science and culture. Peoples such as the Komis, Mordvinians, Adygeyans, Altaians, Khakasses, etc., who formerly did not even have a written language, now take pride in their doctors, engineers, scientists, writers and artists.

This is just a brief outline of the development of the country's economy and the improvement of the well-being and culture of the Soviet people, but we hope it will be useful for the understanding of the problems tackled by the Soviet public health service, considering the direct dependence between the level of health protection and the country's social conditions.

[18] __NUMERIC_LVL1__ Chapter 2 __ALPHA_LVL1__ THE GREAT OCTOBER REVOLUTION
AND PUBLIC HEALTH __ALPHA_LVL2__ Public Health in Russia before
the October Revolution

Many books have been written on life in pre-revolutionary Russia, and most of them speak about the poverty of the people of this great state.

The low living standards and culture of the people of the multinational Russian Empire could not fail to affect their health. The state of the people's health was such that even government bodies had to admit the grievous condition of the country's health protection and sanitation. The official, interdepartmental commission chaired by Professor G. Y. Rein, a well-known medical scientist, which was specially set up in 1912 to elaborate and submit proposals for reconsidering medical and sanitary legislation, arrived, after a study of public health in the empire, at the following conclusion: "A vast part of Russia has as yet absolutely no provisions for medical aid, the result of which is a distressing sickrate and mortality from communicable diseases, as well as generally very low health standards.'' Even according to the official statement of the State Duma (parliament), Russia was ridden with all possible contagious diseases; almost 20 per cent of workers permanently employed in towns and 28 per cent of temporary workers received no medical aid from the enterprises in which they worked.

Many such facts attesting the highly insanitary living conditions in tsarist Russia could be cited. But the two statements given above are convincing enough evidence of the low health standards and organisation of medical aid in prerevolutionary Russia. Indeed, in 1913, the year most satisfactory, from the point of view of the country's economic development and sanitation, general mortality in Russia was __PRINTERS_P_19_COMMENT__ 2* 19 some 2-2.5 times as high as in the economically developed countries (Britain, USA, Germany, France, etc.). More than one-quarter of children born died of various diseases and abnormalities before reaching one year of age. These were the mean figures. Obviously, there were areas and vast territories with much higher mortality indices; even in Moscow Province, the country's central area, child mortality was as high as 300 per 1,000 newborn.

In old Russia, as in most economically underdeveloped countries, high mortality was paralleled by a high birthrate (45.5 per 1,000 population in 1913) which resulted in a comparatively large natural increase in population---15--17 per 1,000. At the same time the mean life expectancy was very low---32 years, according to the 1896--97 census.

The poor sanitation also accounted for the high incidence of infectious and parasitic diseases, including those requiring quarantine---cholera, smallpox, plague, typhus and typhoids. According to very incomplete data, more than a million typhus cases were recorded during the 10 years that preceded the First World War. It is but natural that social diseases--- tuberculosis, venereal diseases and alcoholism---should have found a fertile soil for their development. More than 30 persons out of 1,000 applying to physicians during that period were infected with syphilis or gonorrhea. The medical examinations of recruits, young and, one would think, the healthiest people, showed that 50 to 100 per 1,000 had pulmonary tuberculosis.

Infectious diseases annually carried to the grave more than one million adults, while two million children died every year primarily of infectious and parasitic diseases.

It goes without saying that this picture was evidence of the extremely bad living stttndards of the people.

``Thousands and tens of thousands of men and women, who toil all their lives to create wealth for others, perish from starvation and constant malnutrition, die prematurely from diseases caused by horrible working conditions, by wretched housing and overwork.''^^*^^ V. I. Lenin thus determined the social causes of the poverty and diseases of Russia's working people.

Pre-revolutionary literature contains hundreds and perhaps thousands of pages about the really terrible living _-_-_

^^*^^ V. I. Lenin, Collected Works, Vol. 5, p.

20 conditions of the working people. Leaflets put out by revolutionary-minded workers, who called for the overthrow of autocracy, described with wrath and grief the unbearable working conditions in plants and factories, the frequent mutilations, short life span, weak health and poor physical development of the workers. It stands to reason that the working people could not but take action against these inhuman living conditions.

Progressive doctors and other medical workers fought together with the workers and the working-class party for a better life, social justice, freedom and equality of the working people, as well as against their unbearable living conditions and poor health. They demanded more hospitals and medical personnel and bigger government allocations for medical aid to the population. They dreamt of providing free medical aid for all people. Many dedicated doctors went to work in Zemstvo medical institutions, i.e., the few hospitals and dispensaries which were built for peasants in rural areas. But the dedicated doctors and other medical workers were too few to bring about any radical changes in the country's public health system, because this could be done only by a cardinal change in the entire state system of tsarist Russia. By 1913 all the departments of Russia employed just over 28,000 doctors and 46,000 junior medical workers, i.e., there was one doctor per 5,665 population (1.8 doctor and about 3 junior medical workers per 10.000 population). In this respect Russia was in a somewhat better position than the colonial and scmicolonial countries, but lagged far behind the USA and West European countries. Many regions of Russia had no doctors at all, while in a number of outlying national areas there was one doctor per scores of thousands of people. Moreover, the few doctors who worked in the provinces lived in towns so that the rural population was practically deprived of skilled medical aid.

The number of medical institutions was also very small. For example, all Russia's hospitals numbered a total of 208,000 beds or 13 beds per 10,000 population (1913).

The country had scarcely any medical or pharmaceutical industry and no sanitation or epidemiological services; there were very few sanitary inspectors---only a few dozens in all. Another unfavourable factor was the absence of any centralised medical state organisation. Nearly every ministry and every department had its own medical division. Besides, 21 numerous philanthropic, religious and public organisations had their own medical institutions. Even the military medical services were not controlled from a single centre. True, not long before the revolution of 1917 an attempt was made to organise a chief administration of state public health system, a kind of ministry with Professor G. Y. Rein at the head, but this attempt failed.

In analysing the causes of this poor situation in public health and organisation of medical aid in Russia it must be pointed out that not only was it due to the weakness and inadequate development of Russia's economy, but also to the criminally heartless, bureaucratic attitude of the tsarist government to the needs of the working people. Miserably small sums were allocated from the state budget for medical aid; the largest allocations were made in 1913, but even they did not exceed 91 kopeks (in comparable prices) per head the population. Of these sums only 5 kopeks were detailed for sanitation and anti-epidemic measures which required the most attention. Recalling his work as a Zemstvo doctor, A. P. Voskresensky, one of the most experienced physicians of the time, said at one of the medical congresses held after the October Revolution: "Under the curse of tsarism there was only one doctor for every two provincial towns. In the villages there were no doctors at all. It was a mere caricature of medical aid. There was practically no organisation of sanitation. The nobles in Zemstvos feared health education, regarding it as something revolutionary.''^^*^^

The acute shortage of medical personnel could not be made up by the training of doctors, surgeons' assistants and other medical workers because there were far too few higher medical schools. In 1913 Russia had 16 medical colleges, including ten medical faculties in universities, the so-called higher women's courses in some universities, a Military Medical Academy and a psychoneurological institute which, in addition to conducting research, also trained physicians.

These institutions served as the main base for medical research because there were very few special research bodies _-_-_

^^*^^ As was already noted, Zemstvo medical institutions were organisations maintained at the expense of so-called Zemstvo self-government bodies which were like municipalities, but were designed to cater for the rural population. Their functions included maintenance of schools, district hospitals and dispensaries. The Zemstvos were, as a rule, in the hands of the nobility, landlords, and rich peasants (kulaks).

22 and laboratories. There was only one comparatively important research centre---the Institute of Experimental Medicine founded in St. Petersburg (now Leningrad) in 1890. There were also several laboratories and small research centres in the system of the Russian Academy of Sciences.

Despite all this, the works of Russian medical scientists were well known abroad. The schools of professors I. M. Sechenov, S. P. Botkin, I. P. Pavlov, N. Y. Vvedensky, V. M. Bekhterev and many others won world renown.

However, the scientists had no means at their disposal to carry their achievements into effect because they had neither an adequate research base nor enough money. Only a social revolution could ensure fundamental changes in the public health system and medical aid. It was no accident that the Programme of the Russian Social-Democratic Labour Party elaborated by V. I. Lenin and adopted by the Second Congress of this party in 1903 advocated the overthrow of autocracy "to safeguard the working class from physical and moral degeneration, and also to raise its fighting capacity in the struggle for its emancipation. ...''^^*^^

The historical situation made it clear that "outside socialism there is no deliverance of humanity from wars, from hunger, from the destruction of still more millions and millions of human beings".^^**^^

__ALPHA_LVL2__ Formation of the Soviet Public Health System

On the night of October 24 and the early hours of October 25 (November 7, Gregorian calendar) 1917 there was an armed uprising in Petrograd of the city's workers, Baltic Fleet and Petrograd garrison. The victorious Great October Socialist Revolution ushered in a new epoch in the history of man. Soviet power was established and literally at once began to reorganise society on a socialist basis in the interests of the working class and the toiling peasantry. During the very first days of the Revolution the 2nd Congress of Soviets, as the supreme body of state power, adopted the decrees on peace and land. The land, plants and factories, mines, banks and railways became the property of the people. Everything possible was done to improve immediately the _-_-_

^^*^^ V. I. Lenin, Collected Works, Vol. G, p. 30.

^^**^^ Ibid., Vol. 24, p. 37.

23 lot of workers and peasants. The first state enactments included the law On the 8-hour Working Day, the Duration and Distribution of Working Time, the law On Social Insurance, the law On Placing All Medical Institutions under the Jurisdiction of the Workers' Illness Insurance Funds and many other laws which fundamentally altered everything concerned with medicine in the Land of Soviets.

The Communist Party and the Soviet Government devoted a great deal of attention to organising medical aid for the people. V. I. Lenin personally signed nearly 100 decrees on medical aid, illness insurance, etc.

The socialist state of workers and peasants began organising a new public health system. New and unprecedented organisations and institutions of the public health system were set up under the appalling conditions of the Civil War unleashed by counter-revolutionary forces in Russia and complicated by the famine that involved vast territories of the country, and economic dislocation. These were medical and sanitary boards under local government bodies. A Medical and Sanitary Department headed by Doctor M. I. Barsukov was organised under the Revolutionary Military Committee in Petrograd on October 26, 1917, immediately after the armed uprising. This department, which became the first central public health body of the Soviet Republic was charged not only with administering medical aid to the insurgents, but also with reorganising all matters of public health.

Soon, in January 1918, a so-called Council of Medical Boards was organised as the country's supreme public health body by a special government decree. It was thus named because the People's Commissariats (ministries) that were being organised had medical or medical and sanitary boards. The Council of Medical Boards united the work of all of these boards.

It should be noted that at the outset there was no people's commissariat of health. The reason for this was that for some time after the revolution not all the doctors sided conclusively with Soviet power. Some of them failed to grasp the aims of the revolution, did not understand the essence of the democratic reorganisation carried out by the Government and the Communist Party and opposed the undertakings of the young Soviet state.

And only after the first and most representative congress 24 of public health workers---the Congress of Medical and Sanitary Boards---met in June 1918 and passed a special resolution on the expediency of establishing a People's Commissariat of Health was a decree issued and signed by V. I. Lenin. This decree dated July 11, 1918, set up the first, central, state body of public health not only in the Republic of Soviets, but in the world,---the People's Commissariat of Health. N. A. Scmashko, a prominent theoretician and organiser of health protection, was appointed People's Commissar and Z. P. Soioviov his deputy. The first members of the Board of the People's Commissariat of Health included such eminent physicians as V. M. Bonch-Bruyevich (Velichkina), A. P. Golubkov, P. G. Dauge and Y. P. Pervukhin.

A Central Medical and Sanitary Council under the People's Commissariat of Health was established by a government decree, with representatives of various public organisations, as well as of workers, peasants and other sections of the population, taking part in the discussion of questions concerning the development of health protection. A Scientific Medical Council under the chairmanship of Professor L. A. Tarasevich, an outstanding microbiologist, was organised as an advisory body of the People's Commissariat of Health. This council played a notable role in rallying the country's scientific medical forces for the purpose of solving urgent practical problems of public health.

During the same period a number of medical research institutes and laboratories were founded by decision of the Government.

It should be noted that a number of well-known Russian scientists, including V. M. Bekhterev, D. K. Zabolotny, A. N. Sysin, A. N. Bach, P. N. Diatroptov, Y. I. Martsinovsky, N. I. Shaternikov, etc., supported the revolutionary workers and peasants from the first and their tireless work greatly helped the public health bodies of the Republic.

The 8th Congress of the Russian Communist Party ( Bolsheviks) held in March 1919 was of historical importance in the development of health protection in the USSR. The Congress discussed a number of urgent military and agricultural problems and adopted the Party Programme. Elaborated under V. I. Lenin's leadership the Party Programme became the document that determined the main trends of development in all spheres of political, economic and social life, including the sphere of public health. It was the first time in 25 history that a party programme contained a special article on public health. The article defined not only the objectives of health protection, but also the ways and means of achieving these objectives. However, the organisation of a public health system, the construction of medical, sanitary and antiepidemic institutions, and the training of doctors and other medical workers were hampered by the Civil War which had been unleashed by the enemies of socialist state.

The medical personnel of the country had to administer aid to the fighting men of the revolutionary Red Army and organise a nationwide struggle against the epidemics raging in the country. Despite the lack of skilled personnel they managed to mobilise all of the country's forces to stem the spread of epidemic diseases, increase the number of beds in hospitals for wounded and sick fighting men and carry on educational work in sanitation and hygiene among the population. Special commissions were set up in government bodies, the People's Commissariat of Health in particular, to mobilise all resources for the purpose of preventing the spread of epidemic diseases, especially epidemic and recurrent typhus. The decree on compulsory smallpox vaccination was issued in 1919. Urgent measures adopted in connection with it were largely instrumental in stopping the spread of smallpox.

The government decree (September 1922) on sanitary bodies of the Republic was particularly important to the carrying out of antiepidemic and sanitary measures. This decree laid the foundation of the country's sanitary and antiepidemic organisation. The first special state institutions to control current sanitation and antiepidemic measures were founded.

Subsequently, beginning with the government enactment on sanitary bodies of the Republic (February 1927), not only current, but also preventive sanitary control was exercised in the country, by the special sanitary and antiepidemic institutions, the so-called sanitary and antiepidemic stations. The All-Union State Sanitary Inspection was organised.

The primary task after the victorious conclusion of the Civil War was a speedy restoration of the national economy, including the network of medical institutions, disrupted during the war. It was necessary not only to expand this network and increase the number of doctors and other medical workers, but also to make an historically unprecedented leap 26 from backwardness and poor health of the population to a socialist system of health protection which would ensure a rapid improvement of all the indices of social health. The USSR entered a period of reconstruction of the national economy based on industrialisation of the country and collectivisation of agriculture. During this period, while a powerful base was being built for socialism, medical aid to the workers and collective farmers acquired particular importance. A special decision adopted by the Central Committee of the Communist Party in December 1929 not only mapped out definite tasks involved in the solving of this problem, but also defined practical means of its solution. It was precisely during this period that new forms of medical care and new medical institutions were developed. These included primary medical centres at industrial enterprises, administering medical aid to workers on the job. Rational organisation of medical aid made it possible to reduce considerably the sickrate of industrial and office workers and thus to provide the national economy with additional labour power.

Many medical institutions were developed in those years. The principles of the dispensary method were laid down; this method combines both therapeutic and prophylactic work. It will be dealt with in detail below. It is a complex overall service catering to a specific group of the population and involving early and active detection of disease through systematic medical examinations, the summoning of patients to medical institutions, timely and complete treatment, as well as rational employment and improvement of working and living conditions, in accordance with medical indications. This method naturally requires a large number of medical institutions and many specialists. That is why it could not be fully implemented at that time. Only several decades later could the task providing dispensary service for all of the urban and rural population be posed. However, some medical organisations, for example, those of Moscow and Leningrad, tried even at that stage to provide the service for the whole population of their cities.

The system of rural public health was essentially reorganised. The main stress was laid on the organisation and active functioning of rural district hospitals. A large number of doctors and other medical workers was sent to the countryside where appropriate living and working conditions were created for them.

27

It was also at that time that an efficient sysiem ot mother and child protection incorporating an extensive network of children's polyclinics and consultation centres, maternity consultation centres and hospitals was set up.

The Constitution of the Soviet Union adopted in 1936 contained articles which not only declared, but also guaranteed the right of all Soviet citizens, regardless of nationality, religious denomination, social and material status, to rest and material security in old age, as well as in cases of sickness and disability. The Constitution also guaranteed equal rights for men and women and state protection for mother and child.

As a result of important measures aimed at developing the system of Soviet public health, by 1940 the number of doctors increased to 155,000, that of the junior medical personnel, to 472,000, and the number of hospital beds, to 791,000.

The improvements in health protection were particularly noticeable in the former outlying districts of Russia where new modern medical institutions were established and staffed with doctors, nurses and medical technicians of local nationalities. This is evidenced by the following figures: in 1940, as compared with 1913, the number of doctors and hospital beds had increased more than 20-fold in Uzbekistan, nearly 15-fold in Kazakhstan and more than 35-fold in Kirghizia. In the Tajik Republic the number of doctors had increased 45-fold and that of hospital beds 46-fold. In Armenia, Azerbaijan and other republics the number of doctors and hospital beds had increased many times over. Before the outbreak of the Second World War all the Union Republics already had their own medical colleges and schools for junior medical personnel and began to turn out medical scientists. Between 1929 and 1939 twenty-four new medical institutes were set up and began graduating large numbers of medical specialists.

__ALPHA_LVL2__ The Great Patriotic War

The Soviet people suffered bitter trials during the Great Patriotic War against nazi Germany which had treacherously attacked the USSR. The Soviet public health system withstood these trials honourably. All reserves were mobilised for the purpose of organising an efficient system of specialised 28 medical aid as close to the field of battle as possible, evacuation hospitals and medical aid for the people in the rear. Special attention was devoted to providing food and medical care lor women and children. Naturally, all necessary measures were taken to prevent epidemics.

Thanks to these and other urgent measures the spreading of infectious diseases was avoided which saved the lives of hundreds of thousands of servicemen and civilians. For the first time in the history of war on the territory of the Soviet Union, there were no epidemic outbreaks of any appreciable size. The percentage of officers and men returned to the ranks was unusually high---more than 72 per cent of the wounded and 90 per cent of the sick.

A sizeable contribution to the victory over the aggressor was made by medical scientists. It was no accident that during the Great Patriotic War (in 1944) a decision was taken to organise a single medical research centre---the Academy of Medical Sciences of the USSR. Academician N. N. Burdenko, outstanding scientist and Chief Surgeon of the Soviet Army, was elected its first president.

The war inflicted immeasurable losses on the Soviet people. These included 20 million servicemen and civilians killed and millions of mutilated, sick and disabled; 1,710 towns and more than 700,000 villages, 40,000 hospitals, polyclinics, dispensaries, sanitary and antiepidemic centres and other medical institutions were completely or partly destroyed. A tremendous amount of work had to be done to restore the economy ruined by the war. Already the 1946--1950 FiveYear Plan adopted by the Supreme Soviet of the USSR in March 1946 provided not only for restoration of the prewar level of public health, but also for a considerable increase in the number of medical institutions and the size of personnel; the number of hospital beds was to be increased to one million and that of doctors severalfold. The medical and pharmaceutic industries established before the Second World War were to be expanded.

__ALPHA_LVL2__ Public Health Services in the USSR since 1945

By 1950 these objectives of the Five-Year Plan had been attained and the number of medical institutions, hospital beds and doctors exceeded the pre-war number.

The next Five-Year Plan contained provisions for further 29 consolidating and expanding the material and technical base of public health and for enhancing the quality of medical aid by speeding up specialisation.

In 1955, as a result of the successful fulfilment of the five-year plans, the country already had more than 340,000 doctors, close to one million junior medical workers and almost 1,300,000 hospital beds.

The important organisational measures of that period included the unification of dispensaries and polyclinics witli hospitals. Since then (1947--48) the so-called unified hospital consisting of a hospital proper and a polyclinic has become the basic medical institution in the USSR. This has made it possible not only to improve the quality of medical aid, but also to enhance the skills of the physicians.

During the same period the administration of health protection was also reorganised in the countryside. The district public health boards were abolished as the basic administrative bodies in rural areas, and all organisational and economic functions connected with managing public health institutions were transferred to unified district hospitals. The doctor in charge of such a district hospital became the chief physician of the district and was responsible for the work not only of the hospital, as the chief medical institution, but also for that of all the other medical institutions of the district.

Particularly important in improving the health of the population were the decisions of the Party and Government on increasing social aid. The 1956 Session of the USSR Supreme Soviet passed a law on state pensions, which considerably increased the pensions and reduced the pensionable age. At the same time a decision was taken to reduce the workday preceding restdays and holidays by 2 hours; subsequently this decision was followed by the introduction of the 5-day workweek in the majority of enterprises. Also very important to public health were the enactment on increasing maternity leave from 77 to 112 days and other decisions that contributed to raising the living standards of the people and improving public health.

The postwar period has been characterised by increased international activity of Soviet public health workers. It is well-known that the Soviet Union was one of the founders and has been one of the most authoritative members of the World Health Organisation founded after the Second World 30 War. The Soviet medical people have expanded their international contacts. More and more of them are taking part in national and international scientific medical congresses and symposiums.

One of the most important events in the development of Soviet health protection was the 22nd Congress of the Communist Party of the Soviet Union (1961) which adopted a new Programme of the Communist Party in which questions of public health occupied an important place. The public health objectives envisaged in the New Programme logically ensued from those set up by the Party before, the prophylactic trend given first priority. The construction of a substantial material and technical base of public health made it possible to achieve such aims as providing all the population of the towns and countryside with highly-skilled and specialised medical care and dispensary services.

Special importance is now attached to developing specialised medical aid and to establishing large medical treatment and research institutions with up-to-date equipment.

At its session in June 1968 the USSR Supreme Soviet considered the problem of the further development of public health services in the USSR. Concrete measures aimed at attaining the objectives posed were elaborated.

The Decision adopted by the Central Committee of the Communist Party of the Soviet Union and the USSR Council of Ministers on July 5, 1968, On Measures for Further Improving Public Health and Developing Medical Science in the Country gave special attention to further improving the quality of medical aid and health protection. The tasks set include a decrease in general and infectious disease incidence and traumatism, improvement of the living and working conditions, an improvement of general sanitation and of the work of hospitals, and sanitary and prophylactic institutions, and introduction of the latest achievements of medical science and scientific organisation of labour into public health practices. With this end in view, an expansion of the material and technical base of public health is envisaged and the construction of large specialised hospitals and medical centres planned. Interregional and republican centres of most important forms of specialised medical care will be built and further enlargement and modernisation of city and rural hospitals, polyclinics and dispensaries carried out. The sanitary and antiepidemic centres, and also the research 31 institutions, are likewise to be enlarged and provided with up-to-date'equipment. Considerable attention is given to working out long-term plans for developing the most important brandies and trends of medical science (prognosis). The Decision contains provisions for increasing state allocations for medical aid and medical science. Improvement of medical aid, further development of specialisation, the construction of large hospitals and first aid centres, both in towns and rural localities, further expansion in the production of medicines and various medical equipment, such are the main tasks as regards public health posed by the 24th Congress of the Communist Party of the Soviet Union.

[32] __NUMERIC_LVL1__ Chapter 3 __ALPHA_LVL1__ "HEALTH INDEX" __ALPHA_LVL2__ [introduction.]

In the preceding chapters it was shown that, as a result of the rise in the living standards of the Soviet people and the development of culture and the economy, the general health of the people has greatly improved. General and child mortality have sharply decreased, while the average life expectancy has more than doubled. The changes in the health of the Soviet people have been so great that it would not be wrong to speak of a transformation of the type or profile of pathology, i.e., fundamental changes in mortality indices and disease incidence. Whereas before the Great October Socialist Revolution the type or profile of pathology was characterised by a prevalence of infectious diseases, including acute communicable epidemic diseases, i.e., was essentially epidemic, today it may be called nonepidemic. This is to say that infectious and parasitic diseases have been ``superseded'' in the structure of disease incidence and especially of mortality by nonepidemic disorders which usually run a chronic course. It was owing to this and other factors that general and child mortality has gone down, the average life expectancy has increased, and the other health indices and demographic phenomena have changed. In particular, the accelerated change of generations that was observed in pre-revolutionary Russia has given place to a reduced change of generations.

Obviously we need to go into the above processes in greater detail because they are of considerable importance not only in analysing the state of the people's health, but also in evaluating the work of the public health services.

__PRINTERS_P_33_COMMENT__ 3---1065 33 __ALPHA_LVL2__ Decrease in Mortality

It is well known that the frequently used index of general mortality, i.e., the number of deaths per 1,000 population in a year, is not a sufficiently flexible and all-round index of the state of the people's health. Nevertheless, it offers an idea of the changes in the level of health, especially over long periods of time. It is also a very valuable index of the state of health in countries with widespread infectious and parasitic diseases which often have a lethal outcome.

Today most of the economically developed countries have a general mortality index of between 7 and 12. This has also for many years been the stable index of general mortality in the Soviet Union. Moreover, general mortality figures in the Soviet Union during the last few decades reveal a clear tendency towards a decrease. For example, in 1940 the general mortality index was 18, in 1950 it was 9.7, in 1955 it went down to 8.2, while today it is about 7.9. Admittedly, of late (since about 1960) there has been no appreciable decrease in this index, which seems to be due to the influence of various factors, including the process of ageing of the population which is also observed in most economically developed countries. Nevertheless, the general mortality index in the Soviet Union is the lowest among economically developed countries.

Child mortality has decreased even faster in the Soviet Union. Whereas, as was noted above, before 1917, 269 children per 1,000 newborn died before reaching one year of age in Russia, today the Soviet Union has a very low index of child mortality. The rate at which this index has decreased is particularly important in characterising the state of general health. In 1940 the index of child mortality had dropped to 182, remaining, as we see, very high; ten years later, in 1950, it was already down to 81; in another 5 years it dropped to 60; by 1960 it came down to 35 and in 1970 it was 25. It follows that in the years of Soviet power it decreased to less than one-tenth of the pre-revolutionary and to less than one-seventh of the 1940 figure.

As a result of such sharp changes in the mortality rate including the considerable decrease in such a particularly inert index as pre-natal mortality (stillbirth and child 34 mortality in the first week of life),^^*^^ the average life expectancy has appreciably increased and is now, we have already seen, 70--71 years for both sexes or 74 years for women and 66 for men. It should also be noted that the average life expectancy has increased quite rapidly since 1917. In 1926--27 it was 44 years for both sexes and in 1958--59, 69 years.

Despite the considerably diminished birthrate in the USSR---from 45.5 in 1913 and 31.2 in 1940 to 17.4 in 1970--- the country has retained a relatively high natural increase in population owing to the appreciable decrease in mortality. During the last 5 years the increase has ranged from 9.2 to 11 per 1,000 population. The following table represents the main demographic indices in the USSR.

Table 3 Birthrate, mortality and natural increase in population Per 1,000 population Children dying Years before reaching one year of age Birthrate Mortality Natural increase per 1,000 newborn 1913 45.5 29.1 16.4 269 1940 31.2 18.0 13.2 182 1950 26.7 9.7 17.0 81 1960 24.9 7.1 17.8 35 1970 17.4 8.2 9.2 25

Such are some of the general indices of the state of the people's health and some demographic phenomena. However, they cannot furnish a complete idea of the changes in the state of the people's health in the Soviet Union. The mere mortality indices are not so significant as the structure of mortality, i.e., the share of different causes of death, especially the major ones.

As is the case in most economically developed countries, the major causes of mortality in the Soviet Union today are chronic, nonepidemic diseases, primarily cardiovascular _-_-_

^^*^^ In most economically developed countries this index is 18--20 per 1,000 newborn. In the USSR the index of pre-natal mortality does not exceed this figure; moreover, according to specially conducted research, in a number of towns, particularly newly-built since the October Revolution, pre-natal mortality is lower, its index ranging from 11 to 14.

35 disorders and malignant neoplasms. The two aforesaid groups of diseases alone account for half and even more of all the deaths. For example, according to the data of recent years, diseases of the circulatory system and vascular diseases of the central nervous system are responsible for 44--45 per cent of all the deaths, while malignant neoplasms cause 18--19 per cent of the deaths. These mortality figures, especially those for cardiovascular diseases are quite high, although they are somewhat lower than in other economically developed countries. Soviet statisticians note a relative increase in mortality caused by the two groups of diseases in recent years, but there would be no increase in deaths from cardiovascular diseases, were it not for the changes that have taken place in the age and sex structure of the population. This factor emphasises once again the significance of the changes in demographic phenomena, especially that of the ageing of the population. This tendency towards ageing of the population can also be observed in the proportional mortality coefficients which have recently come into practice. These coefficients indicate the share of deaths at a certain age in relation to all mortality. Most commonly it is the age of 50 years and older that is taken and the corresponding proportional mortality coefficient is calculated, this coefficient in most economically developed countries now amounting to 80 and more per cent. In other words, more than three-quarters of the entire population die at the age of 50 years and older. But even if we take the mortality rate among people 70 years of age and older, which in Russia in 1910 was only 8 per cent of the total mortality, in 1960 it was already 32 per cent.

In considering other causes of death it should be noted that they are more or less the same in most economically developed countries; the cardiovascular diseases and malignant tumours are followed by traumas, influenza, pneumonia, diseases of metabolism, including diabetes mellitus, diseases of the liver, tuberculosis and inborn developmental defects, etc. The share of infectious and parasitic diseases, including tuberculosis, in the mortality structure is usually 1-4 per cent.

The situation is closely similar in the Soviet Union, where in the mortality structure cardiovascular diseases and malignant tumours are followed by traumas, respiratory diseases, diseases of the newborn, diseases of the digestive organs and, lastly, infectious diseases, including tuberculosis.

36 __ALPHA_LVL2__ Decrease in Disease Incidence

The data on the structure of mortality causes in some measure reflect the situation with regard to disease incidence, i.e., the prevalence of various diseases among the population as a whole or in its different groups.

In view of the difficulties of taking stock of all disease incidence we shall confine ourselves to some information on general disease incidence. Compared with 1926--28, when mass investigations into the general disease incidence were carried out, this highly significant and most important index of the state of the people's health has now decreased by more than 50 per cent. Obviously, the most important reason for this reduction was a sharp decrease in the occurrence of infectious and parasitic diseases which were the main causes of death in the not so distant past. The decrease in the prevalence of infectious diseases, and especially those which were responsible for extensive early mortality among children, is evidenced by the following few figures: in 1966, as compared to 1940 the mortality rate among urban children under one year of age went down in the case of diphtheria by 402 times, in the case of scarlet fever by 347 times, __PARAGRAPH_PAUSE__ Table 4 Infectious Diseases Incidence (per 100,000 population) in 1940--68 Disease 1940 I960 1965 1966 1967 1968 Typhoid fever and paratyphoids A1? Bx and C 62 22 11 12 10 10 Scarlet fever 129 313 230 297 254 211 Diphtheria 91 25 2 1.3 1.1 0.9 Whooping cough 232 259 82 63 49 50 Tetanus 1.1 0.6 0.6 0.5 0.4 Poliomyelitis (acute) ' 0 . 7 3.3 0.13 0.12 0.06 0.05 Measles 605 972 923 750 769 664 Infectious hepatitis (Botkin's disease) 239 204 00 158 156 Epidemic typhus (in-- cluding Brill's disease) 25 2.9 1.6 1.5 1.4 1.3 Malaria 1,637 0.17 0.14 0.13 0.11 0.4 37 __PARAGRAPH_CONT__ whooping cough---139 times, tuberculosis---77 times, measles---70 times, toxic dyspepsia, gastroenteritis and colitis--- 38 times, dysentery---20 times and pneumonia----7 times. An idea of the disease incidence is furnished by Table 4.

Considerable success in wiping out a number of widespread and acutely contagious diseases was achieved in the USSR because of social-economic and medical reforms. As late as 1922 more than 76,000 cases of smallpox were recorded on the territory of the USSR. By 1936 smallpox had been eradicated through compulsory vaccination, begun after the Government had issued a special decree in 1919. Close to 1,400,000 cases of typhus were recorded on the territory of the USSR in 1922, whereas in 1940 there were only occasional cases of the disease. In 1940 the incidence of typhoid fever decreased to less than one-third of its 1922 level. Besides smallpox, other serious diseases such as plague and relapsing fever have been wiped out. Control of malaria in the Soviet Union was an outstanding achievement; no less significant was the practical eradication of trachoma in the RSFSR and many other parts of the country.

The incidence of diphtheria and other infectious children's diseases has decreased sharply in recent years; poliomyelitis, which was still very dangerous in the 1950s, has now been almost completely controlled. Only 120 cases of this disease were recorded in 1968. The following figures may give some idea of the fast rate of decrease of the incidence of infectious diseases in the USSR: in 6 years since 1960 the incidence of poliomyelitis decreased by 98 per cent, of diphtheria, by 97 per cent, of tularemia (which had gone down to 0.1 per cent of the 1940 level) by another 76 per cent, of tetanus, by 52 per cent and of brucellosis, by 61.5 per cent, etc.

Viral diseases, especially influenza, are still widespread. Influenza, angina and other catarrhal diseases come high on the list of disease incidence in the USSR, as they do in many economically developed countries. In this respect the structure of disease incidence does not coincide with that of mortality where, as was noted above, the major part is played by nonepidemic diseases.

In the Soviet Union the general disease incidence is studied mainly by means of an analysis of the people's requests for treatment at medical institutions. Most of these calls, it has been shown, are connected with influenza, angina 38 and upper respiratory catarrh. These disorders hold first place in the structure of general disease incidence in the Soviet Union. They are followed by various traumas. Next in importance in the structure of general disease incidence, are ear, nose and throat diseases, especially chronic otitides, gastrointestinal diseases (gastritides, colitides, gastric and duodenal ulcers) and eye diseases (primarily conjunctivitides). After these come various cardiovascular disorders. The above diseases usually account for 70--80 per cent of the general disease incidence.

The foregoing list indicates the approximate succession in the prevalence of diseases revealed mainly by the requests for treatment at medical institutions. According to specialists who study the prevalence of diseases among different groups of the population, a somewhat different pattern of diseases is observed among the people living in the countryside. For example, an extensive study of the disease incidence among the rural population carried out by workers of the All-Union Research Institute of Social Hygiene and Public Health Organisation, has shown influenza, catarrh, angina and a number of other disorders, mainly of an infectious character to be on top of the list in the countryside. The second place is held by diseases of the digestive organs, oral cavity and teeth, the third place, by diseases of the heart and blood vessels, the fourth, by traumas and the fifth, by respiratory diseases.

Naturally, people do not always seek medical aid, especially in cases of chronic disease; to reveal these cases, researchers have to resort to such methods as the examination of groups of the population by teams of specialists and the careful study of each case by experts. Such examinations lead to the detection of quite a large number of disorders which require medical aid. For example, a study conducted under the supervision of Professor I. D. Bogatyryov revealed 500 cases of protracted diseases per ] ,000 of population, a figure amounting to one-third of all the people's requests for medical aid at medical institutions. It follows that all recorded cases of disease may be figuratively compared with an iceberg, its above-water part being the cases of disease revealed when the people request help at medical institutions and its under-water part being the diseases, mainly chronic for which people do not ask for medical aid. The task of the researcher is to study the whole 39 iceberg, in order to reveal genuine picture of the people's health.

According to reports of Soviet statisticians, the general disease incidence of different groups of the population ranges from 1,100 to 1,400 cases per 1,000 population in a year. In analysing these seemingly high figures we must take into account the fact that with the development of the public health services the number of recorded diseases increases. This may result in an erroneous impression of an increasing rate of disease incidence. Actually, however, the incidence of disease in the USSR, especially that of infectious and parasitic diseases, has considerably decreased compared with the 1920s.

And, although studies of the general incidence of disease are still the most complex and difficult part of medical statistics, on the basis of several random studies, we may judge of the generally high incidence of disease in capitalist countries. For example, according to official figures published in the USA,^^*^^ 223 cases of acute diseases were recorded per 100 population in 1962, more than two-thirds of these cases having an infectious character (infectious and parasitic diseases, influenza, upper respiratory catarrh, etc.). One extensive random study conducted in the USA (in 1961--1962) revealed a large figure---401,851,000 cases of disease in a year, of which 49,123,000 cases was of infectious and parasitic diseases, and 230,805,000 of upper respiratory diseases, including influenza.^^**^^

One of the most important problems of public health services in many economically developed capitalist countries are mental diseases which show a distinct upward trend. In the USA mental health is now considered problem No. 1 of public health. The incidence of mental diseases (all cases, including those newly recorded) in most capitalist countries has been estimated by a number of prominent authorities at between 40 and 150 cases per 1,000 population.

In the USSR, as in a number of other socialist countries, the problem of mental diseases is not so acute. Moreover, according to several studies conducted in recent years, the incidence of some mental disorders is tending to decrease.

_-_-_

^^*^^ Statistical Abstract of the United Slates 1963, Washington, 1963.

^^**^^ Acute Conditions, Incidence and Associated Disability. United States, July 1961-June 1962. Vital and Health Statistics, U.S. Department of Health, Education and Welfare, Washington, May, 1963.

40

In the USSR the incidence of mental diseases among both urban and rural population is only one-third or even onequarter of that registered in several economically developed capitalist countries. This essential difference in mental health is hard to explain; it requires special studies. At any rate, it is clear that the explanation must be sought mainly in the fundamental differences in the social conditions and in the social policy pursued by the socialist state which is aimed at ensuring the well-being of the people and care of their health.

This chapter is entitled the "Health Index''. For people familiar with medical statistics these words signify a definite index of the state of health, representing' the percentage of people who never fell ill in the course of a year. Obviously, this coefficient is one of the most vivid indices of social health, although it has not as yet been widely used in scientific literature. In the Soviet Union this coefficient is used increasingly more often, particularly in characterising the state of health in children. According to a number of studies conducted in recent years, the "health index" is constantly rising. A special study carried out in Moscow in 1953 showed the "health index" of children in the first year of life to be about 14 per cent. Recent studies have yielded a much higher index. In one of these studies conducted in the city of Kaluga (1964--1966) the "health Index" was found to be 26.9 per cent, which means that in this city one-fourth of all the children under one year of age were never ill.

The "health index" is also used increasingly more often to determine the state of health of adults. For example, a study of the health of the workers in a number of Moscow factories (1965 and 1966) revealed that in the course of a whole year, between 25 and 30 per cent or even more of the workers never called at medical institutions.

The "health index" is important not only as a precise statistical index, but also as a symbol of the magnificent improvements achieved in the state of Soviet public health.

__ALPHA_LVL2__ Improvement in Physical Development

Considering the health of the population is a concept which embraces not only mortality and disease incidence, but also physical development. Numerous studies conducted 41 in the Soviet Union at different times attest an all-round improvement in the physical development of children, adolescents and other age groups of the population. Especially valuable are the studies that make it possible to compare the anthropometric data obtained at different periods in the same parts of the country. The following are the results of one of these studies. According to F. F. Erisman, a prominent Russian scientist who studied the physical development of adolescents in Glukhovo, a small workers' settlement near Moscow, in 1880 the height of 15-year-old boys averaged 141 cm, while, according to G. P. Salnikova et al., Soviet researchers who studied the physical development of adolescents in the same settlement 82 years later, in 1962, the height of 15-year-old boys already averaged 162 cm. During that period they had thus ``grown'' 21 cm taller. According to Erisman, the boys outstripped the girls in height only at the age of 16, according to Salnikova---at 14. Contrariwise, according to Erisman, the girls outstripped the boys in height at 12 years of age, according to Salnikova---at 10.

Similar data may be cited with respect to other parameters ---weight, chest girth, etc. It seems to us, however, that the few facts cited above are enough to show the considerable improvement in the physical development of children and adolescents. Even if we take shorter periods of time we can observe an appreciable improvement in all parameters of physical development, and not only in the central parts of the country, but also in outlying districts with rigorous natural conditions. For example, studies conducted beyond the polar circle, in Murmansk, in 1964, showed that 15-- yearold boys were 12.31 cm and girls of the same age 12.7 cm taller than in 1947; during the same period the boys of this age had ``gained'' in weight 8.35 kg and the girls 11.4 kg. Analogous figures were furnished by a study of the physical development of children and adolescents in the city of Norilsk and other parts of the Soviet Far North.

The increase in the major parameters of physical development in children and adolescents during a comparatively short period of time has been so appreciable both in the USSR and abroad that it is referred to as the acceleration phenomenon. More and more studies are now being devoted to this phenomenon and increasingly more hypotheses are being advanced to explain it.

42

Without dwelling on this problem in detail (for it needs special consideration) we should like to mention that, according to most studies of the physical development of the Soviet people, there are no essential differences relating to financial position or social status. All groups of the population--- workers (both industrial and office) and peasants, wherever they may live, show clear signs of improved physical development.

No such conclusion can be made as regards a number of capitalist countries where the effects of the difference in the social status can be observed in the physical development of the population.

__ALPHA_LVL2__ Social Homogeneity
in the General Health
Improvement in the USSR

Medical scientists from several countries, including the USA have had to admit that differences in the state of mental health follow a distinct social pattern. Studies of foreign scientists have revealed considerable differences in the occurrence of mental diseases among representatives of different "social classes" (bourgeois researchers refer in this way to groups of the population with differing incomes). For example, studies on the mental health of the population conducted in Baltimore, New York and other cities have brought to light an essential difference in the mental health of the ^so-called first (richest) and fifth (poorest) "social classes'', the incidence of mental diseases being 7 or 8 times as high in the latter category as in the former. According to the study of the population of Chicago carried out as late as the end of the 1930s, the incidence of psychosis among the poor was 362 per 100,000 population and only 55.4 among the rich. A similar study conducted in Baltimore in the 1940s and 1950s, revealed that the rich were found to give 302 cases of psychosis per 100,000 people and the poor 653 cases. Researchers at Cornell University (USA) have discovered mental disorders in 13 per cent of the examined people from the so-called "lower classes" and in 3.6 per cent of the "upper classes''.

A similar picture is observed as regards other diseases. For example, in the USA and other capitalist countries the 43 incidence of acute diseases is 50 per cent higher among the unemployed and those living on relief than it is among families with annual incomes of 3,000 dollars and more, and the incidence of chronic disease is most 100 per cent higher among the former.''^^*^^

A study of child mortality in France has shown that it is higher where the parents belong to the lower 'social class''. In families belonging to the "upper class it was 17 per 1 000 children born alive, while in families belonging to the "lower classes" (unskilled workers, etc.) the figure was 61 per 1,000.

Similar data have been recorded in Great Britain where child mortality in families of the "lower classes" is 2-3 times as high as it is in those belonging to the upper social classes.''

In the USSR there are no such sharp social distinctions in the health of the population. The numerous statistical studies, including those conducted with due regard lor the effects of the living conditions (work, income, housing, rest and recreation, etc.), reveal no great distinctions in the state of health of the different social groupings. This does not mean of course, that there is no difference whatsoever in the general health and its various indices depending on various occupational factors, material well-being, cultural level etc. But this difference is not so great as it is in capitalist countries. It is not so essential and, therefore, allows us to assume a social homogeneity of the peoples health in the Soviet Union, while the health in most capitalist countries, including economically developed ones, is characterised by sharp social distinctions. This phenomenon is very important because it testifies in favour of the social and economic system of the Soviet Union.

Further evidence of the advantages of socialist society are the faster rates of improvement of the mam indices ol the people's health in the USSR as compared even with the economically developed capitalist countries.

The following table gives some idea of the changes in some of the health indices in the USSR and a number of economically developed capitalist countries.

_-_-_

^^*^^ F. H. Landis and P. K. Hatt. Population Problems. A Cultural Interpretation. N.Y., 1954, pp. 143--144.

44 Table 5 Changes in the indices of general and child mortality, and of average life expectancy in the USSR and some capitalist countries during the last 50--60 years^^*^^ USSR USA Britain France Index 1913 1906 1910 1906 1910 1966 1910 1966 General mortality per 1,000 population 29.1 7.3 15.0 9.5 13.5 11.7 17.7 10.7 Decreased during the aforesaid period to 25 per cent to 63 per cent to 86 per cent to 60 per cent Child mortality (per 1 ,000 born alive) 2G9 26.1 86^^**^^ 23.4 105.0 19.0 111.0 21.8 Decreased during the aforesaid period to 9 per cent to 27 per cent to 18 percent to 19 per cent Average life ex-- pectancy 32^^***^^ 70 --- 70 48 71 47 71 Increased during the aforesaid period by 1 18 per by 48 per by 47 per cent cent cent _-_-_

^^*^^ Supplement to the Third Report on the World Health Situation, 1965--1906. WHO. Geneva, 1968, and national reference books.

^^**^^ Data for 1920.

^^***^^ Data for 1896--189S.

[45] __NUMERIC_LVL1__ Chapter 4 __ALPHA_LVL1__ BASIC PRINCIPLES OF THE SOVIET HEALTH
PROTECTION __ALPHA_LVL2__ State Socialist Character of Public Health

In the Soviet Union health protection is regarded as one of the most fundamental functions of the state on a par with guaranteeing the citizens the right to work, rest and education. In the USSR public health is based on an extensive system of social, economic and medical measures carried out by state and public organisations. This chapter will deal with the most important principles of socialist health protection.

The Programme of the Communist Party of the Soviet Union adopted by the 22nd Congress reads: "The socialist state is the only state which undertakes to protect and continuously improve the health of the whole population. This is provided for by a system of socio-economic and medical measures.''^^*^^

These lines are not a mere political declaration, for every word in them is confirmed by the practical activities of all public health services and institutions of the USSR. But the readers who are familiar with public health in other countries, especially Great Britain, may argue that these countries, too, have, for a comparatively long time, also had a state or governmental public health service, for which reason one may not justifiably speak of state health protection in the Soviet Union as a unique phenomenon. However, such reasoning is disproved upon closer acquaintance with Soviet reality.

When we speak of the state character of public health in the USSR we imply not only the activities of public _-_-_

^^*^^ The Road to Communism, Moscow, p. 542.

46 health bodies and institutions, not only those of the medical services, but emphasise that all links of the socialist state system, including the public health services, take part in caring for and improving the health of all the people. Herein lies the profound significance of the above-quoted words from the Programme of the Communist Party of the Soviet Union.

The state character of public health in the USSR is an expression of socialist democracy which, unlike bourgeois democracy, not only declares the rights of the people, but also guarantees their realisation. It is the socialist state that fulfils the function of implementing the fundamental democratic, social rights of the Soviet people. It was the socialist state that assumed immediately after the Great October Socialist Revolution, the responsibility of caring for and improving the health of the people, and built up the most extensive system of public health with free, generally available and highly-skilled medical aid.

As was already stated above, immediately after the armed uprising in October 1917 the Revolutionary Government of the Soviet Republic issued several decrees (laws) aimed at organising public health services.

These decrees laid the foundation for Soviet, socialist health protection. In the summer of 1918, when the first congress of medical and sanitary boards was convened, the basic organisational principles of the new system of Soviet public health were already clearly defined, namely, free, generally available and planned medical aid, a single system of state public health and extensive participation of the people in sanitation and health protection. This was discussed at the congress by N. A. Semashko and Z. P. Soloviov, the leaders of the first state central public health body---the People's Commissariat of Health. The principles of organisation of the public health service formulated in those years still retain their significance, the most important of them being, as was already noted, its state character.

State health protection, considered as one of the functions of the socialist state, as its duty to ensure each Soviet citizen's right to health, also means that the health of each citizen is regarded not only as his personal affair, but as public property as well. In this sense the state care for the health of the people, i.e., the state character of public health, is opposed to the principles of the private capitalist system 47 which proclaims medical business to be a most important principle in relations between physician and patient and the main principle of the public health policy as it is pursued in capitalist countries. It is well known, for example, that the leaders of the American Medical Association, one of the largest corporated organisations in the USA, have repeatedly declared that the basic principle of public health in their country is the responsibility ol the individual for his own health and that of his dependents.

What, in concrete terms, does the state character of health protection in the USSR mean? What functions and duties of the state and its public health system are included in this conception?

__ALPHA_LVL2__ Free and Generally Available Medical Aid

When we speak of the state character of public health we mean, in the first place, that medical aid is administered to the entire urban and rural population regardless of social, political, racial and all other factors. This, in its turn, implies that the medical aid is free and that the state provides for the population a sufficient number of medical institutions and skilled medical personnel.

Free and generally available medical aid is ensured by state allocations for public health. The funds provided by the state budget of the USSR for medical aid and the development of public health institutions are growing every year. Table 6 gives some idea of the USSR state budget outlays for public health.

099-1.jpg __CAPTION__ The first months of the
revolution. Free food for the
children 099-2.jpg Table 6 Allocations for public health Years Sums allocated by the state budget in millions of rubles Expenditures per capita (in comparable prices) (in rubles) 1913 14.5 0.91 1940 860.0 4.70 1955 3,490.6 17.22 1960 4,759.0 22.60 1965 6,610.7 28.59 1966 6,997.0 29.86 1967 7,350.0 31.22 48 __CAPTION__ The Great Patriotic War of
1941--194.5. First aid in
hattie __CAPTION__ In a field hospital during the
fighting for the liberation of
Novgorod in 1944 099-3.jpg 099-4.jpg 099-5.jpg __CAPTION__ An operation in progress.
Town hospital in Nurck
(Tajikistan) __CAPTION__ Preparations lor an
operation in a pressure chamber __CAPTION__ The Sanatorium Ukraina
Miskhor, the Crimea 099-6.jpg __CAPTION__ Workers of the U/lovaya
Engineering Works (Tula
Region) resting and receiving
medical treatment in the
prophylactorium ol the works 099-7.jpg 099-8.jpg 099-9.jpg __CAPTION__ Sanitary inspectors making
a thorough check on working
conditions at industrial
enterprises __CAPTION__ Physical exercises at work 099-10.jpg __CAPTION__ A new fangothcrapeutic centre
built in the Donetsk Region
at the expense of the Coal
Trust for miners and
members of their families 099-11.jpg 099-12.jpg __CAPTION__ The workers of the Saratov
Chemical Works have their
own polyclinic 099-13.jpg __CAPTION__ S. Zubarcva, divisional
doctor of Polyclinic No. 40 in
Babushkin, a new Moscow
residential district

In 1972 the state allocations for public health and physical culture exceeded 9,700 million rubles. Not only are the absolute allocations for public health increasing, but also their share in the state budget has increased.

In addition to the above appropriations medical institutions receive large sums of money from their lunds from various industrial enterprises, collective farms, co-operatives and other establishments. These sums exceed, in tot, 1,000 million rubles a year.

No small part of the funds allocated for social maintenance and social insurance is also used for health protection. These allocations exceeded 21,000 million rubles annually in recent years. They were spent among other things on allowances for temporary disablement, quarantine and to working mothers caring for their sick children, on grants to pregnant women for maternity leave, on the maintenance of sanatoriums, kindergartens, creches and Young Pioneers' camps, etc. Taken together the share of all expenditures on public health defrayed by the social consumption funds reaches 25 per cent of these funds.

Besides the aforesaid expenditures on public health we must also take into consideration the considerable state expenditure on the development of medical science and medical education, which are not included in the public health and physical culture item, but come under science and education in the state budget.

The situation is different in a number of capitalist countries where only a comparatively small part of the cost of health protection is defrayed by the state budget. In these countries the working people pay the bulk of the expenses on medical aid. The personal expenditure of U.S. citizens on medical treatment exceeds two-thirds of all the funds used for health protection. Despite all attempts to introduce various systems of public aid, including the so-called Medicare and Medicaid systems, the patients or their families have to pay large sums of money to medical institutions or medical personnel for the aid rendered. Suffice it to say that, according to official data, the price of one day's hospitalisation in the USA now exceeds 50 dollars, a visit to a general practitioner costs 6 to 10 dollars, the expenses on obstetric aid range from 150 to 400 dollars, the price of filling a tooth is 5 to 10 dollars, etc. Even U.S. presidents have repeatedly referred to the exorbitant "cost of health''.

__PRINTERS_P_49_COMMENT__ 4---1065 49

The general availability of medical aid in the USSR is also ensured by the extensive material and technical base of public health and medical science. Had not a sufficient number of hospitals, polyclinics, dispensaries, research institutions, medical schools, etc., been built under the Soviet Government, the general availability of medical aid, as a clear expression of the state's responsibility for public health, would have been an empty phrase.

We have already noted that before the October Revolution Russia was at the bottom of the list as regards the number of medical institutions and medical personnel. For example, in 1913 the country had 13 hospital beds per 10,000 population. In the outlying national districts there were either no hospitals at all or there were very few, and only in the towns. Thus on the territory of the present-day Republics of Turkmenia, Uzbekistan, Kirghizia and Kazakhstan there were no more than 1-3 hospital beds per 10,000 population and only 28,100 doctors, that is, 1.8 per 10,000 population. The bulk of the rural population had practically no skilled medical aid at all.

According to the 1970 figures, the USSR had 26,500 various hospitals with a total of 2,663,300 beds, i.e., 109.2 beds per 10,000 population. Soviet Union is now one of the world's leading countries in providing hospital accommodation. As regards the so-called somatic beds, i.e., hospitals for the treatment of all patients, except mental cases, the Soviet Union is ahead of the USA, Great Britain, France and other economically developed countries.

A veritable army of doctors has been trained in the country in Soviet times; in 1970 it numbered nearly 675,000, i.e., 27.6 per 10,000 or one per 400 population. The USSR has more doctors than any other country in the world.

The number of medical workers with a secondary medical education (nurses, technicians and surgeons' assistants) has also increased severalfold. Today this number exceeds 2 million.

Particularly great changes in health protection have taken place in Russia's former outlying national regions. For example, in the Uzbek SSR the number of doctors increased from 139 in 1913 to 21,100 in 1968. In Kirghizia the number of doctors increased from 21 in 1913 to 5,700 in 1968, in Turkmenia (during the same period)---from 70 to 4,400 and in the Tajik SSR---from 19 to 4,300.

50

At the present time even the remotest towns and villages in all the republics have their own hospitals, polyclinics, dispensaries, pharmacies and oilier medical institutions which administer highly-skilled medical aid. Table 7 presents some of the main indices of the development of health protection, i.e., figures attesting the building up and expansion of the material and technical base of the public health system.

Table 7 Number of doctors and hospital beds (at the end oi the year) 1913 1940 1950 I960 1965 1970 Number of doctors of all specialities, in thousands 28.1 155.3 265.0 431.7 554.2 679 Number of doctors per 10,000 population 1.8 7.9 14. G 20.0 23.9 27.6 Number of hospital beds in thousands 208 791 1,011 1,739 2,226 2,663.3 Number of hospital beds per 10,000 popu-- lation 13 40.2 56 80.5 96 109.2 __ALPHA_LVL2__ Unified and Planned Public Health

The concept of the state character of public health also includes the idea of a unified public health system.

The unity of public health in the USSR means that the country has a single system of medical services subordinated to a single central body---the USSR Ministry of Health. All public health institutions---from the smallest medical agencies supervised by surgeons' assistants and midwives, and district hospitals in rural districts, to the largest city hospitals and research institutes---are under the jurisdiction of the USSR Ministry of Health which controls the activities of all these services and plans all measures connected with health protection in the country. In the USSR there are also so-called departmental public health services, i.e., medical institutions administratively subordinated to other ministries, such as, for example, the Ministry of Transport, the Ministry of 51 Waterways, the Ministry of Civil Aviation, and other central bodies. However, all medical institutions, regardless of their departmental subordination, have to be guided by the instructions of the USSR Ministry of Health with respect to the discharge of their direct medical functions. The Ministry of Health is thus the single co-ordinating and controlling centre.

Every republic has its own ministry of health which oversees all health protection work in the republic. In regional and territorial centres public health problems are dealt with by public health boards which are departments of the corresponding executive committees of Soviets. While subordinated to the local Soviets, the public health institutions in the districts and regions are also guided in their activities by the instructions of the ministries of public health. It follows that in the activities and management of the public health bodies and institutions the principle of centralisation is combined with that of decentralisation and these two principles not only do not contradict each other, but, on the contrary, presuppose the unity of the public health system in the USSR as its distinctive feature. This viewpoint is correct also because the unity of Soviet public health must be conceived in a much broader sense than that of mere administration and management, because it means a unity of purpose, practical methods and general doctrines by which all medical personnel is guided in its multifarious health protection activities.

Thus public health in the USSR is managed along two lines---the line of public health bodies and institutions under the jurisdiction of the USSR Ministry of Health and the line of state power of which the USSR Supreme Soviet is the highest legislative body and the USSR Council of Ministers is the highest executive body. As has already been noted, the Ministry of Health discharges its administrative functions through the system of health ministries of the Union Republics and their subordinate regional, territorial and city boards of health, district departments of health of large cities and head doctors of central district hospitals in the countryside. The public health bodies are, in their turn, controlled by corresponding bodies of state power. Local public health bodies and their subordinate institutions are, as a rule, run on local budgets, i.e., receive their allocations from the state budget. The ministries of health (of the USSR 52 and the Union and Autonomous Republics) are accountable to the corresponding councils of ministers.

The state character of health protection in the USSR is also expressed in the planned development of all its services. The planned development of public health means that it is subject to the laws of planned development of the entire system of the USSR national economy. Planned development also makes it possible to avoid disproportions between health protection and the other branches ol the national economy.

Like all the other branches of the single national economy of the USSR, health protection is being developed on the basis of state plans. There are current plans (for one year) and long-term plans determining further development of health protection as regards most important indices, such as improvement of the people's health, expansion and improvement of medical institutions, training of medical personnel, production of medical goods, etc. The five-year plans for the development of the national economy and consequently, five-year plans for the development of public health have become a tradition. All the boards of health---from the district, i.e., small, rural hospital to the USSR Ministry of Health---take part in drawing up both the current and longterm plans. The general trend of the plan for the development of the national economy in the nearest future is elaborated by the State Planning Commission of the USSR. After approval by a session of the USSR Supreme Soviet the plan becomes law. For example, the law for all medical people of the Soviet Union, as well as for the organisations and institutions having anything to do with public health, during the past five years was the 1966--1970 Plan for the Development of Public Health.

The 24th Congress of the CPSU summed up the fulfilment of the Eighth Five-Year Plan of Economic Development for 1966--1970 and adopted Directives for the next five years (1971--1975). Between 1966 and 1970 more than 440.000 beds were added to the country's hospital fund. Today there are 10 beds per every 1,000 of the population. The number of doctors of all specialities grew to almost 700.000. During this period the production of the medical and pharmaceutical industries was greatly raised, and the number of hospitals, polyclinics, sanatoriums, holiday-homes, health-resort boarding houses and sports facilities greatly increased.

53

Particular importance is attached to the further development of specialised medical aid in order to improve the quality of medical service. In accordance with this, large hospitals with various well-equipped departments are being built, specialised offices in polyclinics are being organised, dispensaries set up, physiotherapeutic services expanded, and other measures envisaged. The plan also determines the most important, urgent and practically necessary long-term trends of medical research, and provides the required means, research institutions and specialists.

Such are some of the concrete expressions of the state character of health protection in the USSR, which are inseparably connected with its other features, above all with prophylactic work.

__ALPHA_LVL2__ Prophylactic Work

Prophylactic (preventive) work is regarded as the most important part in health protection in the USSR. This is natural, since more than 50 years of Soviet medical experience have confirmed the old truth, known even to the physicians of antiquity, that an ounce of prevention is worth a pound of cure. But the great medical men of the past--- Hippocrates, Galen, Sushruta, Asclepiades, Geratsi and many others---though they stressed the role of prevention, could not, of course, imagine that a time would come when the prevention of disease would be an efficient and most important instrument in caring for the health of a whole country. Even the outstanding physicians of the 19th century, including well-known Russian scientists, could go no farther than appeal to the public to devote more attention to prophylactic measures. They saw the future of medicine in an all-- inclusive prophylaxis practised not only by individual doctors, but also by the entire system of public health. "The future belongs to preventive medicine,'' stated the celebrated Russian surgeon N. I. Pirogov. G. A. Zakharyin, one of the most eminent internists of the 19th century, said that "only hygiene can prove victorious against the diseases of the masses''; by hygiene he meant preventive medicine in the broadest sense of the term. It would seem that such statements and appeals should have had their effect as public health services developed and the nature of many infectious 54 diseases which at that time constituted a primary public health problem discovered. But with the social and political system of pre-revolutionary Russia prophylaxis could not develop to the level of nation-wide, state measures, and the matter stopped at individual prophylactic measures. It should be added that prophylaxis has not become a state function in any of the capitalist countries to this day.

As early as the 1920s Z. P. Soloviov, an eminent theoretician and organiser of the public health service in the USSR, emphasised that the main difference between Soviet medicine and that of the capitalist countries is that the latter cannot embark on the path of prevention without thereby infringing upon the very foundations of the capitalist system.

In emphasising the importance of the social, state system in the development of prophylactic work it should be noted that prevention does not mean merely measures of individual sanitary and technical protection like, for example, in preparation of a surgeon's hands before an operation. Z. P. Soloviov, N. A. Semashko and other theoreticians and organisers of the Soviet public health service, who elaborated the theory of prophylaxis as the main line of development of Soviet medicine, often had to explain this to a number of well-known clinicists of their time, who reduced prophylaxis to mere technical cleanliness.

Nor should be prophylactic trend be identified with broader medical measures of controlling a number of infectious diseases, although this is still the way in which prophylaxis is conceived by the medical people and hygienists in capitalist countries. It was for this reason that all measures for controlling infectious diseases, including campaigns for vaccinations, were long since given the name of prophylactic or preventive medicine, as opposed to curative medicine. It is well known, that despite this enlarged concept of prophylaxis, medical treatment of diseases is still divorced from prophylactic medicine in many capitalist countries and is handled mainly by general practitioners. Even in Great Britain, where there is a state public health service, there is a gap between the organisation of prophylactic service and medical aid. Progressive medical workers are worried about this gap. At the 16th World Health Assembly the need for closely integrating prophylactic and clinical medicine came under special discussion. Doctor A. Shousha, 55 a prominent public health worker, emphasised in his report the urgent need for doctors to study the social aspects of medicine. He said that a modern physician had to be a social worker capable of making a "social diagnosis" and administering "social therapy''. He also assigned an important role to preventive measures understood as extensive social prophylaxis.

H. E. Sigerist, an outstanding medical theoretician and historian, has repeatedly insisted on the necessity of broadly conceived prophylactic measures. He maintains the aim of medicine is social and future doctors must need be social physicians. He highly appraised the development of prophylactic work in the USSR (he made two special visits to the Soviet Union in order to study the public health system). In his books dealing with public health in the Soviet Union he wrote: "And I have come to the conclusion that a new period in the history of medicine has been inaugurated in the Soviet Union. All that had previously been achieved in 5,000 years of world medicine represents only the first epoch, that of curative medicine. Now a new era, that of preventive medicine has come of age and passed the stiffest test that could be devised.''^^*^^

It follows that the prophylactic trend in health protection could not be implemented in pre-revolutionary Russia, nor can it be implemented even in developed capitalist countries today, because the most that can be achieved there is separate hygienic measures, including campaigns for vaccination and sanitation of the external environment. The prophylactic trend, as the basis of public health in the USSR, is the aggregate of social-economic and medical measures aimed at preventing disease and, zvhat is even more important, at eliminating the causes of disease. The overall prophylactic measures coincide with the work of remaking man's environment, changing the conditions of life so as to guarantee people joyous labour, valuable rest and recreation, strengthen the people's health and ensure them a long, active life, the work of improving the well-being of the people, raising their material and cultural standards and promoting the harmonious development of their physical and spiritual faculties. The prophylactic trend in health protection is, _-_-_

^^*^^ H. K Sigerist. Medicine and Public Health in Ilia Soviet Union. New York, 1907, p. 299.

56 consequently, regarded as an expression of the basic economic laws of socialism, i.e., the maximum satisfaction of the growing material and spiritual needs of the working people.

It stands to reason that this conception of prophylactic work is untenable unless the public health system is made an inseparable part of the state system. In other words, the prophylactic trend is impossible where health protection does not have a state character, where the state is not concerned about or responsible for the health of its citizens.

The section on public health in the Programme of the Communist Party adopted back in 1919 at its 8th Congress emphasised the importance of developing the prophylactic trend in health protection. It read: "As the basis of its activities in public health the Russian Communist Party proposes to carry out primarily extensive hygienic and sanitary measures aimed at preventing disease.''^^*^^

The special importance of prophylactic work is emphasised in the Programme of the Communist Party of the Soviet Union adopted by its 22nd Congress. The Programme states that the socialist state works to improve the health of the people by social-economic and medical measures aimed at preventing and decisively reducing the incidence of disease.

Consequently, the prophylactic trend as the basis of health protection in the USSR, is expressed in social-economic measures carried out by the state with the aim of improving the conditions of life, work and recreation, raising the living standards and spiritual level of the people, as well as in specific medical measures of prophylaxis. There is no need to dwell in detail on the social-economic measures carried out by the state, on the social policy aimed at improving the well-being and furthering the cultural development of the Soviet people, because this was treated in sufficient detail in the preceding chapters. It is perfectly clear that all measures connected with social maintenance, social insurance, improvement of the material conditions, diet, housing, increased incomes, elc., have a most favourable effect on the health of the people. Moreover, these measures carried out by the state serve as the necessary background for the _-_-_

^^*^^ 7 he Communist Parly of llie Soviet Union in the Resolutions anil Decisions of the Congresses, Conferences and Plenums of Its Central Committee. Part I, 19.">4, p. 42!). In Russian.

57 implementation of the prophylactic trend in health protection.

While it is hardly feasible to dwell in detail on all the measures that make up the prophylactic work of medical institutions, we feel it necessary to emphasise certain aspects of medical prophylaxis which are compulsory for all the medical institutions of the USSR regardless of their purpose and constitution. It is no accident that hospitals, polyclinics, dispensaries, so-called medical and sanitary centres at industrial enterprises, etc., are referred to as therapeutic and prophylactic institutions, which emphasises the most important aspect of prophylaxis in the USSR---the synthesis of curative, sanitary and hygienic activities.

The idea that it is necessary to introduce prophylactic principles into all forms of medical activity is gradually winning over the minds of our foreign colleagues. It also finds expression in the activities of medical international organisations, including the World Health Organisation. Thus in considering the role of the modern hospital in public health services one committee of experts came to the conclusion that "in hospitals prophylaxis must keep abreast with the development of the curative services in various specialities . .. , the hospital cannot be an isolated institution, but must be a part of a social and medical organisation concerned both with treatment and prevention''.

The members of the Committee of Experts of the World Health Organisation examining the question of teaching pathology stated that "prophylaxis may and must permeate all activities in the field of medicine''.

Prevention work is the duty and daily concern of all medical institutions in the USSR, whether a hospital, a polyclinic, a dispensary, or a sanitary-epidemiological centre, etc. It is therefore impossible to list briefly the most important forms of direct prophylactic work. It includes enforcement of hygienic norms at industrial enterprises, and in daily life in town and country, checking the observance of state sanitary legislation on labour protection, and against pollution of atmospheric air, soil, water reservoirs, and foodstuffs, mass and individual prophylactic inoculations and many other sanitary, hygienic and antiepiclemic measures.

The following example gives some idea of the concrete sanitary and hygienic functions of some medical institutions. 58 Soviet scientists-hygienists, physiologists, toxicologists, etc.--- have established the maximum permissible concentrations of various substances in the soil and air, beyond which they may prove harmful to health. These maximum permissible concentrations are legislatively established as legal limits which may not be exceeded. Such maximum permissible concentrations have been established in the Soviet Union for more than 70 substances that pollute atmospheric air and close to 100 substances which pollute water. Moreover, maximum permissible concentrations have been established for a number of substances or radiations at industrial enterprises. For example, for people employed at enterprises of the atomic industry or working on X-ray installations, which are not safe from the point of view of irradiation, the level of irradiation has been established at 5 rem/year. Maximum permissible concentrations have been established for more than 230 radioisotopes which may find their way into the air and water.

These limits established in the Soviet Union with due regard for international experience are, as a rule, much lower than those accepted in the USA and a number of other capitalist countries. For example, in the USA a concentration of 100 mg/m^^3^^ of lead is allowed in the air of industrial enterprises, while in the USSR the maximum permissible concentration of lead is 10 mg/m^^3^^. In the air of inhabited localities the maximum permissible concentration of lead in the USSR is 0.7 mg/m^^3^^. This concentration is even somewhat lower than the safe concentration, which is 1 mg/m^^3^^. Scientists have demonstrated that a concentration of 2-5 mg/m^^3^^ of mercury in the air causes a number of disturbances in the health and behaviour of experimental animals and leads to an accumulation of this metal in their bodies. Taking this factor into consideration the maximum permissible concentration of mercury in the air in the USSR has been set at 0.3 mg/m^^3^^.

Without dwelling in greater detail on this most important question connected with the protection and sanitation of the environment, since medical people are familiar with these activities, we should only like to note that in the USSR preventive vaccination for a number of diseases is compulsory and is administered by medical workers under control of sanitation agencies and institutions. Thus sanitation laws cover all aspects of prophylactic activity.

59 __ALPHA_LVL2__ Dispensary Service

At the dawn of Soviet power N. A. Semashko referred to the dispensary service as the most important method of achieving the synthesis of prevention with treatment. The dispensary service is now in operation in hospitals, polyclinics and other curative and prophylactic institutions.

On the surface, the dispensary observation seems to consist in the application of routine medical measures. However, the dispensary service, if it is to be practised on a really all-embracing scope, requires vast resources and a large number of doctors and other medical personnel; it implies a considerable additional expenditure of effort and money. That is why not all Soviet people as yet come within the reach of the dispensary service, especially if we consider that not only sick people, but also healthy ones come within its scope.

The dispensary service is now administered to large contingents of the population---children and adolescents, school pupils, students of secondary specialised and higher schools, office and industrial workers of a number of industries, especially at industrial enterprises with harmful working conditions, war invalids, athletes, scientists, people of a number of agricultural occupations, pregnant women, etc. In addition to the foregoing categories, evervone in town and country suffering from one of the specified group of diseases is subject to dispensary observation regardless of occupation. This group includes tuberculosis, all tumour, cardiovascular disorders (coronary disease, heart failures, hypertensive vascular disease, rheumatic infections, thrombophlebitides, varicose veins and other vascular lesions, etc.), gastric and duodenal ulcers, nephritis, diabetes mellitus, certain liver diseases, mental disorders, fungus and other skin diseases, etc. It follows that the number of people subject to dispensary observation is very large (according to some authors, it comprises nearly 100 per cent of the children and not less than 20 per cent of the healthy adult urban population, not counting the patients suffering from one of the above-listed diseases).

What, then, is this dispensary service which, as was noted above, does not include any unusual, unknown measures? The dispensary service comprises a complex of various diagnostic, curative, prophylactic proper and social 60 functions. These include active systematic observation, detection ol early Jonns of disease^^1^^, timely treatment, and prophylactic measures aimed at preventing the onset or development of diseases, including the transfer of patients to other, more suitable work and a change in their living and working conditions. Active observation, which we regard as the leading feature of the dispensary service, implies that doctors and other medical workers visit the patients, summon them for consultation to medical institutions, keep strict records and control of the systematic examinations and implementation of the requisite preventive curative measures.

__ALPHA_LVL2__ Divisional Organisation

The synthesis of curative and prophylactic principles manifests itself not only in the dispensary service, but also in the divisional organisation of administering aid to the people. This organisation is employed throughout the Soviet Union. It means that both towns and countryside are divided into medical divisions with no more than 4,000 people (3,000 adults and 1,000 children) per division in towns and usually somewhat more in the countryside. At industrial enterprises there are so-called shop divisions, which means that the doctors employed at a particular enterprise administer medical aid to a certain number of workers in definite shops or other departments of the enterprise. Shop divisions differ in size, depending on the working conditions, from 600 to 2,000 workers. According to the norms adopted in the USSR, each urban territorial division must have at least 6 doctors, including two so-called divisional internists and a pediatrician; each division is also served by surgeons, obstetricians, gynecologists, neuropathologists and other specialists. The divisional doctors visit the patients at their homes or receive them in polyclinics, i.e., outside the hospitals where the main laboratory services arc concentrated and doctors of all specialities are employed. Most of the home visits are made by divisional internists and pediatricians who discharge the functions of home or family doctors since they are familiar with the living conditions and state of health of each of their patients. In com