p The organisation of medical aid for the rural population has some specific features of its own.

p The vast territory of the Soviet Union is distinguished for an enormous variety of geographical, climatic and economic conditions which affect the mode of life of the people, especially in the countryside. We have only to consider the factor of distribution of the population, i. e., its density, the size and grouping of villages, the condition of roads and numerous other factors, to gain some idea of the vastly differing conditions of rural life. It would therefore be wrong to apply the same yardsticks and standards to the organisation of medical aid in the different geographical and economic zones of the country; it would be equally wrong to build only small or only large medical institutions. The approach should be flexible and the solutions variegated.

p But however much the rural areas of the Soviet Union 84 may dilier Ironi each other, they still have certain features in common. One of these features is their size. This factor necessitates the bringing of medical aid closer to the habitation of the rural population.

p This need is met by primary medical aid centres in rural areas, which have the minimum number of beds (2-3) and are run by junior medical workers—surgeons’ assistants, midwives or trained nurses. The premises of such a medical unit usually consist of a few rooms, one where the surgeon’s assistant receives the patients, one (or more) with beds lor normal childbirth, one for recently confined women, one for the medical nurse, etc.

p One of the most important functions of these medical outposts is outpatient aid to the population. In cases when the professional knowledge of the surgeon’s assistant is inadequate he refers his patients to a doctor at the nearest hospital.

p Prophylaxis and improvement in the sanitary and hygienic condition of the village are important functions of these medical units. The surgeons’ assistants, midwives and nurses are obliged to give the rural people health instruction to train some of them to act as voluntary sanitary inspectors and with their assistance to supervise the sanation of the locality.

p Usually these medical units are located in villages where there are village Soviets, i.e., the primary bodies of state power. The units are designed to serve from 300 to 900 people. Consequently, they may administer medical aid to the people not only of the given village, but also, as is most commonly the case, of the nearby ones.

p Considerable importance is still attached to these medical units whose number is quite large—more than 90,000.

p As for qualified medical aid to the rural people, three levels, so to speak, may be distinguished in it. The first level is the divisional hospital.

p As we already noted, the territory of rural areas is divided into medical divisions with a population of from 5,000 to 12,000 in each. A division is served by a divisional hospital with at least 35 beds. At the present moment, it is considered more expedient to have larger divisional hospitals with up to 100 beds, but divisional hospitals with 35-50 beds still prevail in rural areas. Each of these hospitals has both inand outpatient departments. The beds are usually intended for patients with internal, surgical, gynecological and 85 infectious diseases, as well as for parturient women. A divisional hospital requires at least 4-5 doctors—an internist, surgeon, obstetrician and gynecologist, pediatrician and a dentist.

p The head doctor of a divisional hospital and his colleagues are responsible for the administration of medical aid to the entire population of the division, which includes the work of the surgeons’ assistants’ and midwives’ units. On certain days (strictly according to plan) they visit these units and attend to patients. Moreover, they go to these units whenever they are summoned by a surgeon’s assistant, midwife or nurse in charge.

p The second level is the district hospital, the basic medical institution of the district where skilled aid is administered by specialists, including those in the rarer ailments. Today many districts have 2 or 3 hospitals, one of them regarded as the central one and charged with coordinating all public health work in the district.

p Like divisional hospitals, district hospitals also have inpatient departments with departments or wards for patients with internal, surgical, gynecological, otolaryngological, and nervous diseases, a children’s department and maternity wards. Besides, district hospitals have polyclinics. These not only administer medical aid to outpatients of the village in question, but also serve as consultative centres for the other medical institutions of the district, including the divisional hospitals.

p District hospitals usually have 100 or more beds, and are gradually being enlarged. It is intended that the capacity of district hospitals should be increased to 250-400 beds, so that these leading rural medical institutions may provide fully up-to-date, skilled medical aid.

p A centra] district hospital (even when it is the only one in the district) is also the administrative centre of all the public health institutions of the given rural district. Its head doctor is at the same time the head doctor of the district, all its medical workers, including the heads of divisional hospitals and other curative and prophylactic institutions of the district being under his jurisdiction.

p The third level is the regional hospital. This is usually a large hospital with 500 or more beds. It includes a polyclinic, where doctors administer outpatient aid to rural people usually referred to them from district or even directly from divisional hospitals, and an inpatient department with 86 a practically complete “set” of specialised departments, beginning with internal diseases and ending with such narrow specialities as neurosurgery, traumatology, etc.

p Regional hospitals, in their capacity of centres of highlyskilled and specialised medical aid for the rural population, serve as bases for the advanced training of doctors working in the medical institutions of the region, particularly, in divisional and district hospitals, and as a training base for secondary medical schools. In regional cities, which have medical colleges, these hospitals also provide practical training for the students, that is, act as clinical hospitals. Since they have highly-skilled specialists with extensive medical experience on their staffs, regional hospitals are also obliged to render assistance to all the medical institutions of their region. Most regional hospitals have air ambulance stations and it is compulsory for all to have emergency aid departments provided with all the necessary sanitary conveyances not only for transporting specialists to the places where they are to administer urgent aid, but also for bringing in the patients.

p After this brief acquaintance with the structure of Soviet public health system the reader may form the impression that all the different therapeutic and prophylactic institutions in town and country work in isolation, strictly within their territorial bounds. That, however, is not the case. Very often inhabitants of rural areas are treated in city hospitals. This is an inevitable process since the differences between town and country in the USSR are gradually disappearing. This also applies to health protection. The essential differences in the level of medical aid administered to the urban and rural population are also disappearing. While in 1950 the number of hospitalised cases was 15 per 100 town dwellers and 7.7 per 100 country dwellers, in 1970 it was 19.8 and 19.3 respectively, i.e., nearly the same.

p Another expression of this process is the fact that more than 25 per cent of country people are accommodated in town hospitals. We regard this as a very positive phenomenon because the number of doctors and other medical workers is still much larger in towns than in rural areas.

p It is safe to forecast that the enlargement of medical institutions, and especially of district hospitals, and the bringing of hospitals and other forms of medical aid closer to the rural population will make it possible to raise the level 87 of rural medical service to that of medical service in the towns.

p By way of an example we shall describe just one rural district in the Tuva Autonomous Soviet Socialist Republic which forms part of the RSFSR. Before the Revolution this outlying area had, like many others, practically no medical services. Suffice it to say, that in this area there were only two doctors, two very small hospitals, one medical post and one pharmacy. Today the republic has close on 500 doctors, 42 hospitals and polyclinics, 4 specialised dispensaries, 132 medical units and 172 pharmacies.

p The district of the Tuva Republic can be taken as a typical example. The small town of Turan, the district centre, has a central hospital with 100 beds. The hospital has modern equipment and satisfies the needs of the population for skilled medical aid. The hospital and its polyclinic have all the necessary laboratories—clinical, biochemical and bacteriological as well as an X-ray room.

In addition to this central hospital there are several divisional hospitals and 12 medical units in the district. These institutions are particularly necessary in Tuva where the settlements are far apart and there are very few modern roads. When the immediate attention of highly-skilled specialists is necessary patients are either transported by an ambulance to the republican hospital or specialists are brought to the patients. The central hospital provides young doctors (many of them Tuvinians) with a chance to improve their professional skill and increase their knowledge.