How Socialized Medicine Works in the Soviet Union
FIELD, MARK G.
How Socialized Medicine Works in the Soviet Union by MARK G. FIELD This is the fourth in a series of articles exploring the highly controversial field of medical economics. The first, "Health...
...The Ministry of Health is part of the governmental structure, and the minister has "cabinet" rank in the Council of Ministers...
...By 1940, there were more than 130,000 physicians...
...This bureaucratism, which derives from the very structure of the medical system, affects not only the dispensation of medical care, but also such vital areas as the production of pharmaceuticals and equipment, the placement of medical personnel, and the construction of medical facilities...
...In this respect, it may be worthwhile to cast a retrospective glance at Russia's experiment with socialized medicine over the last forty years...
...The real test, of course, of a medical system and the question the practical man wants answered is that of effectiveness...
...Ten years later, the number had more than trebled...
...And by the same token, the rewards, the status, and the prestige that most of these women physicians can command are similarly low...
...Should he require the services of a physician at home, a request must be made at the same dispensary, and a physician may be sent to his home during the day...
...One of the basic tenets of Soviet political philosophy is that rational planning on a nationwide basis is the only answer to the problems of large scale industrial social systems...
...The first, "Health Insurance for All," by Senator James E. Murray argued the case for a national health insurance program for America...
...There are those, for example, that cater to the needs of pregnant and nursing mothers, called Women's Consultations, and where gynecological as well as obstetrical help may be obtained...
...Where does Ivan Ivanovich fit in all this...
...In 1946, in spite of war losses, the medical contingent numbered over 140,000...
...Considering the large number of physicians in the Soviet Union, where did the Russians get so many people to go into medicine...
...Is it because so many doctors are women, and are better equipped, emotionally, to "mother" patients...
...Medical and public health accomplishments and experience in England, Germany, and even in Russia in the Nineteenth Century were impatiently brushed aside as having contributed little or nothing to the organization of medical services in the Soviet Union...
...But we know the following: taking the 1913 death rate as a base, this rate has been reduced to one-fourth what it was...
...Paul Dudley White, heart specialist for President Eisenhower, to accompany him on a medical mission to the Soviet Union...
...birth rate...
...And they had done it in spite of the opposition which the pre-Revolutionary medical profession allegedly bore to the Bolshevik regime...
...For one thing, there is no college...
...This represents over the last 15 years (including the war years) an average net increment of 10,000 doctors per year...
...Thus, in some industries doctors may be issued temperature minima below which they are forbidden to excuse anyone, in spite of the fact that there are certain illnesses that are not accompanied by fever...
...Unfortunately, the Soviet Union has not released any vital statistics beyond crude birth and death rates...
...While this fear may be exaggerated, and while it may be prompted by considerations other than the preservation of the patient's interests, it is perhaps not quite groundless...
...A. Talbot Rogers, prominent London physician, analyzed the British program in action...
...Concerned as the regime is with maximum productivity, it is liable to be suspicious and jealous of the physician's prerogative of permitting workers to absent themselves on grounds of illness and of abuses such as malingering or bribing to which such a function could lend itself...
...and after ten years or more of service, the salary goes to about 1000-1100 rubles...
...In practice ix may be hampered by lack of equipment and by the large size of the classes admitted to the medical institutes...
...Soviet medical historians, particularly those who wrote in the period immediately preceding Stalin's death, were fond of stating that Soviet mediMARK G. FIELD, medical sociologist on the staff of the Beth Israel Hospital in Boston, has long been a student of Soviet life and institutions...
...Other specialized dispensaries may treat such conditions as cancer, tuberculosis, malaria, or venereal disease...
...Field traveled extensively throughout Russia inspecting hospitals and clinics and interviewing Russians on the operation of socialized medicine...
...One area in which control over the physician is particularly stringent is the delivery of illness certificates to industrial workers...
...During World War II he performed liaison work at the border between the American and Russian zones of occupation in Germany...
...There is thus a fear that the doctor either will become a civil servant, or that he will be subject to the control of civil servants, a situation which is held to be prejudicial to "good medicine...
...Usually such work is carried on in conjunction with official or academic responsibilities...
...My impression is that Ivan Ivanovich is satisfied with the medical services at his disposal, and that socialized medicine is one of the most popular aspects of the Soviet regime...
...Much of the heat generated on this problem comes from implications of the fact that in certain cases the patient is unable to pay the doctor on a fee-for-service basis, and that this payment must be made by someone else or some other agency...
...It is there that he sees a doctor, usually a general practitioner, who examines him and decides what shall be done next...
...The birth rate has also declined, but stands, at the present time, slightly above the U.S...
...Furthermore, he is reminded, at every occasion, of how bad things were under the Czarist regime and how lucky he is compared to the workers under capitalism who cannot afford medical care...
...It is usually reserved for those physicians mentioned earlier who have achieved academic distinction...
...The medical system appears to operate at a level below the potential of modern scientific medicine, and yet well enough to satisfy the needs of the system as determined by that system's ruling &ite...
...Should a medical emergency arise at night, or when the neighborhood dispensary is closed, he has the possibility, if he lives in an urban area, of phoning the emergency ambulance service, which must dispatch an ambulance with a doctor to the scene of the emergency...
...He served for a time as a member of the Harvard Refugee Interview Project and went to Germany to interview displaced persons for a number of months...
...And it is held by the organized profession that this someone else, whatever his nature, profession, or position, is bound to have some kind of control over the physician by virtue of his responsibility for the management of the funds involved...
...Essentially, the Ministry is a large service bureaucracy, pyramidal in shape and hierarchical in nature, composed of a series of departments or administrations, each one concerned with one phase of medical services and dependent for its financial and other logistic sustenance on allocations from the state budget...
...Even if we assume that our own physicians are better qualified, or that our equipment, drugs, and facilities enable our doctors to do a better job than their Soviet colleagues (which may be true), it is nonetheless disturbing to contemplate the rate at which doctors are trained in Soviet society—two and one-half times as many as in the United States—and the fact that more than one-fourth of our own residencies and internships are filled by foreign-trained physicians...
...Ministry of Health (and its subordinate units) which is the supreme headquarters for all matters relating directly or indirectly to the prevention of illness and the maintenance of health...
...It is in names like Dostoyevsky, Tolstoy, Chekhov, and many others that one must find what is unique in today's medicine in Russia, and not in Stalin's or Lenin's or even the Party's...
...The third, "Freedom and Security in Denmark," by Max Awner, American author and editor who spent a year in Denmark on a Fulbright Fellowship, examined the workings of the Danish system.—The Editors While no one in America seriously denies that medical attention is a "right" of the individual, not to be withheld on any ground, there is considerable difference of opinion as to how precisely this right ought to be implemented...
...The more affluent members of the population may avail themselves of the services of a private physician...
...This answer lies in vital statistics...
...The Communist Party and its genial leaders had done it all by themselves...
...Whatever the truth of these accusations (and the rewriting of history, medical or otherwise, is not an unknown art in the Soviet Union), they served as a handy pretext for the elimination of the pre-Revolutionary Russian medical associations—thereby destroying the corporate existence of the medical profession—and their replacement by organizations (such as the Union of Medical Workers) which are instruments in the hands of the regime in manipulating the professional actions of the physicians for its own purposes...
...Perhaps, but I would also be inclined to find the answer in another direction: medicine represents a continuation, even under the conditions of Soviet totalitarianism, of the great humanitarian traditions of the Russia of the Nineteenth Century...
...This means that we don't know what the mortality is when we divide the population by age groups, particularly the first year of life, by sex, by city versus the countryside, and so on...
...His book, "Doctor and Patient in Soviet Russia," has just been published by the Harvard University Press...
...I often was told, when I visited industrial enterprises, that the physicians who were taking care of the workers received about half as much pay as well-qualified workers...
...Medical care becomes progressively more primitive as one moves to the countryside...
...If was then that Dr...
...This dispensary constitutes his port of entry, so to speak, into the medical system...
...The structure of Soviet medical education is somewhat different from the American...
...Planning necessitates control over available resources in manpower and materiel, and their allocation, in a manner deemed most appropriate to the needs at hand...
...Beyond statistical indices of birth and mortality, one must rely on qualitative evidence to determine how well the system of medical care works...
...after five years of experience this is raised to about 800 rubles...
...It has surrounded this function, as it has many other medical functions, with elaborate bureaucratic safeguards which often introduce into the medical process considerations which are essentially non-medical, and destructive of the patient-doctor relationship...
...Usually it is the state (whether at the local, state, or federal level) which is the only agency capable and willing to underwrite medical care for those who cannot afford it...
...Thus most medical services are made available to Ivan Ivanovich at no direct cost to him...
...Field started gathering materials for a sociological study of the medical profession in Soviet society...
...From the testimony of former Soviet citizens, from eyewitness information gathered during a trip to the Soviet Union last summer, from casual conversations with Soviet persons in the course of the trip, and from a reading of Meditsinski Rabotnik, the house organ of the Ministry of Health (where no punches are pulled), one gathers the impression of a system that operates more on a quantitative than qualitative basis, and which is often plagued by a disease that also affects most other areas of the Soviet system: bureaucratism with its byproducts of indifference, inertia, and depersonalization...
...In the medical field, this control rests squarely with the U.S.S.R...
...He may be sent to work, or back home, or to a specialist or to a hospital...
...Thus medicine has become a woman's profession, exactly in the same way as elementary and secondary school teaching has become a woman's profession in this country...
...It is a mass operation, oriented to satisfying the needs of the regime rather than the personal requirements of Ivan Ivanovich...
...And in the ten years that followed the cessation of hostilities, the number of doctors doubled: Soviet statistics indicate that early in 1956 there were 330,000 civilian physicians in the Soviet Union, or about 16 doctors per 10,000 of the population, a figure considerably higher than our own 13.3...
...The Ministry could be described as the "Ford" of the Soviet medical world in that it is a self-contained vertical organization which not only directs the dispensation of medical care to the population, but also trains its own personnel, places them into medical jobs (forcibly if necessary), manufactures the drugs and medical instruments it needs, directs medical research, supervises the construction of medical installations, establishes treatments and procedures which then become standard for the whole country, administers public health and preventive medicine, inspects health conditions in industry, transportation, and food handling establishments, provides dental care and hundreds of other related medical and preventive services...
...Finally, I would like to conclude with an impression that I gathered while visiting medical installations in the Soviet Union: I was struck by the kindness, the gentleness with which patients were handled by the staff...
...But the number of physicians in private practice is small, and I doubt that any of them lives by private practice alone...
...The best and most comprehensive medical systems are found in the urban areas, particularly in the large cities...
...Thus, according to published statistics, the Soviet crude death rate is slightly lower than the United States at the present time...
...According to Soviet historians, the organized pre-Revolutionary medical profession not only refused to cooperate with the new regime but did something which was even graver: it refused, in some instances, to give medical help to wounded Red Army soldiers and workers who were fighting for the Bolsheviks...
...Compared to this the beginning physician earns around 600 to 700 rubles a month...
...Specialists, physicians who have advanced medical degrees, and those who carry administrative responsibilities earn somewhat higher salaries...
...As a state employee, the Soviet physician is expected to go where he is ordered to go and to do what he is asked to do...
...Indeed, he firmly believes that the government "gives" him this medical care (as stipulated by Article 120 of the Constitution), not realizing that he pays for these services rather heavily through the so-called turnover tax which is added to the price of most basic commodities, and which is essentially regressive, since it affects the poorer person more than the richer...
...In the summer of 1956 he was asked by Dr...
...Private practice has never been forbidden in the Soviet Union, but it is not, by far, the most common type...
...This, of course, enables the Ministry of Health to move its physicians around for the "good of the service," and to have the kind of control over the dispensation of medical services that would be unheard of not only in a country like the United States but even in such countries like England, which have "socialized medicine," where the physician is not an employee of the state in the true sense of the word...
...In addition^ the general medical facilities such as neighborhood dispensaries and hospitals, there also exists a network of specialized facilities...
...cal organization was something unique, and realized through the wisdom and foresight of Lenin and Stalin...
...In most cases the Soviet physician, whether he is a professor and member of the Academy of Medical Sciences, or a country doctor working in a remote area of Siberia, is an employee of that administration—the Ministry of Health, a medical bureaucracy the size of which and the scope of whose activities stagger the imagination of those accustomed to the more atomistic and unorganized system of medical care as they are found in the West, and particularly in this country...
...He is in most cases assigned to a neighborhood dispensary or, should he work for a large industrial enterprise, to the dispensary maintained by that enterprise for its employees...
...The second, by Dr...
...It is true, of course, that in some instances his medical care is likely to be complicated by its bureaucratic nature, and that delays, red tape, unavailability of certain services, and "indifferent behavior" are not infrequent...
...The answer is simple enough: they trained women doctors...
...The latter might easily earn in the vicinity of 2000 rubles a month ($200...
...It is the introduction of a third party which is seen as a threat to the sanctity and confidentiality of the patient-doctor relationship...
...It seemed to me that the medical area, the hospital even more than the dispensary, was a sort of sanctuary from the harsh realities and the excessive demands that the regime makes of the population...
...Parallel to the elimination of the medical corporation as a self-governing body and as a potential locus of independent power which it would not tolerate, the regime proceeded to build its own medical administration...
...after completing ten years of schooling the student is ready, at 17 or 18, to enter professional training at a medical institute...
...The problem is relieved, to some extent, by the feldsher, or physician's assistant, a sort of highly trained nurse, usually of peasant background, who provides a great deal, if not the majority, of routine medical services in the countryside...
...Even with its high overall ratio of doctors to the population, the Soviet Union is suffering from a shortage of physicians in the countryside...
...Since half of the population lives on the land, this is a serious problem...
...As befits the work of a bureaucrat, the Soviet doctor sees his every professional action limited and guided by the bureaucratic standards or norms which his employing organization issue in a steady stream...
...Physicians are usually posted to rural assignments immediately at the end of their medical course for a period of three to five years, but few remain there beyond that time, and many manage to evade such assignments through bureaucratic manipulations and pull...
...While the Soviet medical profession has lost its status of a free corporation, it has increased considerably in size from the time the Bolsheviks seized power...
...Since the Bolshevik revolution, the proportion of women doctors to the total medical profession has increased almost eight fold: at the present time, 76 per cent of all Russian doctors are women...
...Basically and theoretically there is little that differentiates the Soviet from the American medical curriculum except for the emphasis on the study of Marx-ism-Leninism, to which about as much time is devoted as to anatomy...
...The course lasts six years so that the first two years correspond loosely to our two-year pre-medical course...
...This medical education, on paper at least, appears as thorough and comprehensive as ours...
...In other words, does it work...
...There was a respect for the "sick" which I often find missing in our more aseptic and better equipped hospitals...
...And yet these are experiences which are not unknown to Ivan Ivanovich (he encounters them in all -areas of Soviet life), and he accepts them as being part of life in the Soviet Union...
...Thus, with the exception of a few highly placed doctors, the Soviet physician ranks not only very low relative to his or her American counterpart, but also low in the hierarchy of Soviet wages, and almost at the bottom of the hierarchy of professional salaries...
...There were about 20,000 physicians on the eve of the Revolution in the whole of Imperial Russia...
Vol. 22 • March 1958 • No. 3
