Health Reform in Revolutionary Russia

The Russian Revolution in October 1917 was one of the world shattering events of the twentieth century. Its far-reaching trajectory caused ripples and waves internationally and nationally, pushing aside the old order as it sought to ground the principles and dynamics of the new socialist state.

Changes were both immediate and also aimed at a longer term future – rapidly implemented,deferred,revised and discarded as the force of circumstances demanded on questions of the economy,politics,social and cultural issues,nationalities and minorities and foreign policy within and beyond Europe.

By July 1924 Trotsky was already noting, with some prescience, “what is most surprising is that it seems to be acceptable that the experience of the October Revolution should long since have been relegated to the archives”

One area which deserves more attention is the health planning and reform that the new leadership embarked on in the early years of the revolution. Some academic commentators have remarked that the Health Commissariat had a lower priority compared to some of the other Peoples Commissariats but health reform was certainly on the agenda both before and after October 1917. Assessment of its short-comings and achievements is beyond the scope of this essay but by attempting to chart the direction taken by health reform and policy changes during this period (albeit sketchy, in some places more than others) a condensed analysis can contribute to a greater understanding of this subject and raise questions for further study.

Background …On the Eve of Revolution

Russia’s population in 1914 was estimated at 174 million, a sprawling territorial mass covering nearly one-sixth of the world’s surface. On the threshold of industriaiisation, 80% of the population were peasants and between 1905 and 1917 there were no more than 2 million industrial workers. Only 12.9% of the population lived in urban areas and during the course of the 1st World War the urban population fell by 3%. In Moscow the urban population fell from 1.5 million to 900,000 and in Petrograd the population fell from 2 million to 600,000. These demographic shifts also reflected the effects of famine,hunger, epidemic diseases and the war.

Mortality showed a slight improvement from the late 1890s,estimated at 29.4 per 1000. There was an improvement in the infant mortality rate but it was still high 260 per 1000. Kazan province provides an interesting variation on the infant mortality rate, 161 per 1000 among the Muslim population and 304 for the orthodox Russian population.

The 1926 Census figure for birth rate was 45.6 per 1000, reaching the figure for the prewar level.

Following medical developments in Western Europe there had been some improvement in vaccination and epidemiology. Vaccination against smallpox was compulsory for children from 1885.

An estimated 50% of all births were illegitimate and in 1913 life expectancy was 32 years.

A brief survey of public health on the eve of the outbreak of the 1st World War reveals that medical provision was inadequate. There were not enough universities, a shortage of doctors, lack of government funding and a growing emphasis on community medicine and the social dimensions of public health in rural areas but a continuation of paternalistic curative medicine traditions where private and paying medicine dominated.

In 1912/13 there was a Ministry of Education review of the medical curriculum which upheld an earlier Statute of 1884 conclusion that medical schools were failing to keep up with scientific development and recommended chairs in obstetrics, paediatrics, bacteriology, medical physics and psychiatry. The Statute remained in place until 1917.

Universal health problems across Russia included sexually transmitted diseases such as VD. In 1914 the All Russia League of Struggle Against VD estimated that there were 1.5 million sufferers. 10% of army recruits suffered from TB and in 1908 an estimated 5 to 10% prospective recruits were unfit for military service. Leprosy, trachoma, typhus, plague, smallpox, cholera and malaria were among the recurring epidemics and common infectious diseases. An estimated 2 million children died annually from epidemic diseases.

Per capita spending on health was 91 kopeks. There was one doctor per 5665 persons in eastern regions, 1 hospital bed per 1000 persons and very little or no medical and pharmacy facilities in many rural areas.

In 1913 an estimated 4% of the population of St.Petersburg were alcoholics and a journalist reported that St.Petersburg was “the unhealthiest capital in Europe”.

In 1905 the Ministry of the Interior reported that ” the burial of dead bodies in cemeteries in the major populated centres represents a serious financial burden for the public authorities”.

There had been an increase in women and child labour in Russia since 1905 and by 1914 75% of the workforce in technologically unspecialised factories were women and children. A figure which is unlikely to have changed significantly since 1880, estimated that in Moscow packing factories over 33% of workers had started employment under the age of 12 and 31% between the ages of 12 to 14 years, working the same number of hours as adults.

In 1903 10 factories in Moscow had their own hospitals with between 2 to 26 beds and 274 factories in Moscow had medical personnel on site.

Social Security legislation in 1912 encouraged factories to start up hospital funds with contributions from workers and employers to provide hospital and outpatient treatment for workers and their families. However, there was a paucity of such schemes and the legislation was discontinued after 1914.

Over-crowding and chronic housing shortages provided a breeding ground for insanitary living conditions and a resultant spread of infectious diseases, particularly among children. A typical example of over-crowding in Moscow was a two room flat in a two storey house with eleven apartments, small rooms housing up to eighty people with shared kitchen facilities and a street water tap. Barrack housing arrangements in factories for couples and their children were also common.

The tasks facing the new Bolshevik Government in October 1917, not least in the area of public health, should never be underestimated. The revolutionary turmoil from the beginning of the year, the collapse of the Provisional government, the military situation in the last year of the war, civil war and the allied occupation in some regions (the withdrawal of French, American, British and Japanese allied armies from Russian territory took place between 1919 and 1922), the signing of the Brest-Litovsk peace treaty with Germany in March 1918, refugee and migrant problems, dire food shortages, epidemic outbreaks and famine compounded by economic and social unrest, counter-revolutionary sabotage, bureaucracy, inexperience, shortages in medical personnel, supplies, and facilities, created a vortex of uncertainty, fear, instability, shaking the October revolutionaries to the core as the Bolshevik leadership confronted the harsh challenges ahead of them.

“What we have to deal with here is a communist society, not as it has developed on its own foundations but on the contrary, just as it emerges from capitalist society which is therefore in every respect economically, morally and intellectually still stamped with the birthmarks of the old society from whose womb it came”

(Karl Marx from Critique of the Gotha Programme)

Critical Conditions

From October 1917 and until at least the mid 1920s Russia was on the brink of collapse as the Bolshevik government struggled to establish its authority at home and abroad and began to steady the roots and shoots of the new order. There were a number of critical conditions to contend with, all linked to public health and interwoven to a greater or lesser degree.

The Civil War threw up a Pandora’s box of nearly insurmountable problems. The military situation was desperate: severe shortages of medical supplies, medical staff (particularly trained doctors and nurses), a reliance on charitable bodies such as the Russian Red Cross (and Russian Red Crescent in eastern regions), emergency conscription of medical workers at all levels, requisitioning of food and fuel and chemical supplies for the war front and concomitant refugee and migration problems as the fighting continued (there were an estimated 10 to 15 million refugees in Russian territories in 1917), foreign allied intervention and a reluctant concession to agree to receive foreign aid in face of a devasting famine in 1921.

Dire food shortages, hunger and famine were further exacerbated by the outbreak of several epidemics. Between 1918 to 1922 there were 2.5 million deaths as a result of the typhus epidemic. There was some headway in the control of smallpox resulting in deaths and exposure to the disease reaching one fifth of the pre-war level. Cholera took its deadly toll, preventive measures were rolled out and harsh survival choices were made “adults were sacrificed but a generation was saved”. Incidence of TB remained high, figures for Moscow compared with London were 4.6 per 1000 and 1.8 per 1000 respectively.

Population figures fell by 35 million and were estimated at 139 million in 1921,a direct result of the war, famine and epidemic diseases.

The need for effective sanitary control and hygiene in the army and on the domestic front had to be tackled. Housing shortages and over-crowding were factors which contributed to the growing numbers of homeless and abandoned children.

Military Situation

” the state of the medical services in the 5th army defies description… there are no doctors, no drugs, no hospital trains. The wounded are transported in cattle trucks” …” doctors, hospital trains and drugs are needed”

Trotsky, Chairman of the Military War Council F.A.O. Lenin, Chairman of the Council of Defence; Peoples Commissar of Health; Chief Administration of Sanitary Services April 1919

In 1917 sanitary epidemic control was at pre-war levels. The All Russia Union of Towns and Zemstovs, the Russian Red Cross and the Military Sanitary Department had joined forces to at the outbreak of war in 1914 to assist the war effort. In 1915 the Government’s interdepartmental committee brought together representatives from public health Zemstovs and pharmaceutical companies to address problems: shortage of medical supplies in the army and the need for sanitary trains and beds in infection hospitals for the evacuation of military causalities and sanitary detachment teams for every army corps and the recording of pharmacy supplies.

Basic medical supplies, dressings, drugs, equipment and instruments had hitherto been imported from Germany and proved to be an obstacle later too when the military situation escalated to civil war. There were shortages of vaccines, soaps and disinfectant, analgesics such as morphine,opium,heroin for operating and amputation surgery and iodine for soft tissue wounds. The mortality rate for head and jaw wounds was 10% and there was a 95-100% mortality rate for spinal cord injuries. It was estimated that 80% of deceased soldiers had died from sepsis. The mortality rate for typhus in the army during the first year of the war rose from 10.5% to 16.7% and the rate for soldiers presenting skin disorder problems was at least 10%.

During the Civil War the Red Army too was battling with the killer typhus, leaving Lenin to comment in December 1919 “(typhus) may prove a calamity that will prevent our tackling any sort of socialist development” and its alarming effects “laying low our armies”

The death rate among physicians at the war front was up to 70% in eastern regions. Between 1914 to 1920 10,000 doctors conscripted to the army had died in the course of medical duty at the front.

The Civil War’s abnormal death toll weighted 8:1 for civilian and military casualties. The requisitioning of medical supplies by the army further weakened the medical facilities available to the civilian population and there was a perverse competition for chemical fertilisers required for food production, medical supplies and weapons.

A provincial commissar in Ufa in the Bashkir Republic described a war time crisis situation in October 1919 “on average 1000 sick comrades from the Red Army come to Ufa each day of which up to 100 die”. ” many often lie on the floor or directly in the street, in the dirt, without medical help…there are no blankets, no linen and baths…the situation is terrible” ” most of the sanitary personnel are sick but the majority are scattered”

There was ” no transport for carrying the sick…the sick are not disinfected…the hospital is bad…no firewood, entirely without lighting …no water supply”

The US Red Cross relief effort in Siberia during the Civil War documented graphically the work undertaken by medical and sanitary workers and the problems they encountered.

An anti-typhus train operated briefly in Vladivostok and the surrounding territory and was supplied for up to six months in the field. It comprised of 35 cars- for bathing, sterilising clothes, undressing, a boiler car, a tanker and a barber car and was staffed by a mixed crew for US, Swedish, Armenian and Russian medical workers at various levels and Chinese and Czech non medical workers. Its main activity was to wash and bathe those infected and exposed to typhus and to fumigate their clothing. The train had facilities for 350 patients and could shuttle along the railway line from war zones or territories where there was a high incidence of typhus to hospitals where beds were provided for the casualties, including Bolshevik P.O.Ws neglected in Siberian prison camps where the disease was rife.

The US Red Cross also established a hospital at the entrance of Vladivostok harbour, the Russian Island hospital in July 1918 and opened a further 8 hospitals by the end of the year. The Vladivostok Refugee hospital opened in early 1919 in former naval barracks and had up to 250 beds. Primarily for refugee and civilian relief, it dealt with 5500 cases within the first three months of opening and was staffed by US and Russian physicians and mainly US nurses. The US Red Cross also coped with urgent appeals for drugs and other medical supplies from Russian hospitals throughout the civil war period.

In 1919 the Red Army had two primary objectives: to provide medical care for the soldiers by ensuring,for example that there were adequate medical supplies and to maintain sanitary levels to prevent the spread of infectious diseases and to control epidemics. The Military Sanitary Board was now under the control of the Commissariat of Public Health .The Russian Red Cross ran short courses for nurses and sanitary workers,there were more hospital workers, dressing stations, anti-epidemic measures, baths and launderies. Conscription of medical workers was stepped up and an emergency two month training course to recruit assistants for middle medical workers (feldsher assistant physicians, midwives) at the war front with the newly established Proletarian Red Cross playing an active role.

‘the former regime left soviet power a heritage of dirt and desolation in the organization of the military medical service’

`Here everything had to be literally built up again from nothing. Now we have 397,496 beds for patients and 232 fully equipped hospital trains. We have re-introduced such things as bath trains, laundry trains, hospital trains which any European military organization could be proud of…we have a huge well organized highly ramified and centralised authority’

Semashko, Commissar of Public Health

Henry Sigerist, US Professor of History of Medicine, a visitor to Russia in the 1930s considered `the foundations of socialist medicine were laid in the stormy years of civil war’

Soldiers who experienced problems of mental illness were treated by psychiatrists and physicians in field units at the war front, assisted by the Russian Red Cross in the evacuation of casualities to 1st Aid Stations and then via sanitary trains to hospitals.

Russian psychiatrists and physicians placed greater emphasis on psychological and emotional factors when diagnosing mentally ill soldiers, recognising that the horrors of warfare presented an abnormal situation. However, the treatment of mentally ill soldiers was impeded by the obstructive practices of the various agencies involved in providing support to psychiatric casualties at different times including the Russian Red Cross, the Military Sanitary Board, the Union of Psychiatrists, the Refugee Committee and the Department of the Supreme Council of War Invalids resulting in detrimental standards of work. For example figures for the number of psychiatric military casualties recorded by the Union of Psychiatrists was often 10 times higher than those recorded by the army.

Support services provided by the Russian Red Cross for mentally ill soldiers were taken over by the Commissariat of Public Health and in June 1919 the Revolutionary Military Council and the Commissariat of Public Health appointed a psychiatrist/neurologist consultant for the Red Army. Thereafter mentally ill soldiers were to be treated on psychiatric wards in general hospitals where problems were further complicated by an influx refugees,migrants and P.O.Ws.

Psychiatric and general hospitals and clinics struggled to deal with the lack of resources, under-staffing and outbreaks of infectious diseases and patients were often discharged to their families without support.

Food Shortages and Famine

” The food problem forms the basis of all problems and as soon as the military situation improves ever so slightly we must devote as much energy as possible to food work because this is the basis of everything “

(Lenin Dec.1919 address to the All Russia Conference of the Communist Party)

The requisitioning of food and fuel for military purposes had a negative impact on the civilian population under war-time conditions. Peasants withheld grain production as a means of protest and in early 1917 the increase in prices for basic commodities, food products and rents and soaring inflation led to unrest, local strikes and rioting.

Rationing had begun in Moscow — sugar cards were issued in the autumn of 1916 followed by rationing of bread and flour in 1917. There were ” bread cards in Petrograd” and “bakeries were sacked in several parts of the city” (Trotsky). Factory worker committees held meetings on the food supply, prices and the high cost of living. There were 61000 unemployed workers in Moscow and many factory closures. Demonstrations of factory workers in August/September 1917 held up banners which read “we are starving” “our children are starving”. Food shortages were reported in hospitals and there was bread rationing in the army.

In June 1919 Lenin signed a decree on the feeding of children. Children were to be fed first and the age limit for feeding programmes for most needy to receive meals was raised to 16. Communal dining rooms for children opened in factories,schools and at railway stations and some distribution of milk for example for one year old children living in towns though there was dietary deficiency in quantity and quality. In December 1919 there were further increases in food rations on medical grounds and food allocation allowances for large families.

Moscow factory workers spent 50% of their income on food. Bread was a dietary staple representing 55% of workers’ calorific intake and 8% of annual income was spent on tea. From September 1918 onwards there was a nursing mothers ration supplement and special rations for babies up to one year and for infants up to five years though implementation was deferred in areas under the control of the White Army during the Civil War. Efforts were made to guarantee basic food supplies to outlying areas, for example, Turkmenia had 108 milk kitchens by 1920.

The famine of 1921/2 affected 22.5 million people including 7 million children. Grain yield was 52% down on the previous yield,the transport system was inadequate in many parts of the country and the starving population figure was estimated to be 27 million. Regions hardest hit were the Volga (black earth region), Kazan, Samara, Ukraine, Donets Basin, Ufa and Orenburg.

1922 was the ” year of terrible hunger” and the “edge of the abyss” (Trotsky). Government reluctantly agreed that Western European and American famine relief was necessary. US aid (American Relief Administration ARA) was conditional on guaranteed independence for the aid operation and the release of American P.O.W.s. The total aid to Russia comprising of food aid and medicines totalled $61.6 million. The Allies saw Russia as a “hand to mouth affair”.

Newspapers reported on the rising food prices in Petrograd in 1920. Bread was 450 rubles per lb, flour 500/700 rubles per lb, meat 500/600 rubles per lb and butter was 2600/3200 per lb. A female typist received a monthly salary of 32000 rubles with no food ration and a nurse received a monthly salary of 2600 rubles per month and a soldier’s food ration. “Famine was rife in Petrograd” and a journalist observed that food was bartered rather than sold for money. Food shortages and famine conditions also encouraged profiteering. In 1919 the Peoples Commissariat of Food v.Profiteers were 50:50 on the supply of grain to cities but bread prices paid to the State were one ninth of the prices paid to profiteers.

” It is possible to trade in grain and to make a profit out of famine”

(Lenin)

A member of the British Labour Delegation to Russia in 1920, Margaret Bondfield, reported on the food crisis and malnutrition: “(there were) evident signs of illness and under-feeding” Workers were ” unfed, badly clothed and badly shod”

The Commissariat of Public Health reported that the food supply in January 1920 was only 52% of the necessary requirement

Children were prioritised: “on average children are better off than adults” (Bondfield) and ” the State never deviated from its policy of protecting the health of the children” (Le Gros Clark & Brinton commenting on child health in Russia from 1919 to early 1920s). But standards of nutrition were poor. The League of Saving the Children estimated that children received only enough food for 18 to 19 days and the League provided a supplement to the Government’s for children in need (the sick and feeble) which included fruit.

For Lenin writing in November 1917 under the heading ” Can the Bolsheviks Retain State Power?”:

“the grain monopoly,bread rationing and labour conscription in the hands of the proletarian state, in the hands of sovereign soviets, will be the most powerful means of accounting and control…means which will provide a force unprecedented in history for setting the state apparatus in motion”

and

” the chief thing is to imbue the oppressed and the working people with confidence in their new strength, to prove to them in practice that they can and must themselves ensure the proper, most strictly regulated and organised distribution of bread, all kinds of food, milk, clothing, housing etc. in the interests of the poor. Unless this is done Russia cannot be saved from collapse and ruin”

Epidemics, lnfectious Diseases and Sanitary Control

Outbreaks of epidemic and infectious diseases were not uncommon in Russia. Towards the end of the nineteenth century infectious diseases, particularly childhood diseases, were the leading cause of death. Measles and Scarlatina were universal with specific epidemics often breaking out in rural areas though they were more widely recorded in cities. In spite of problems such as inferior vaccines, under-trained innoculators and false recordings,there were some improvements. Vaccination against smallpox became compulsory for children in 1885, for railway workers in 1892 and for army recruits in 1899. The cholera epidemic of 1910 killed 100,000 people in Russia but sanitary reform mitigated the outbreak of pandemics between 1905 and 1913.

Lung disease was common in factories and TB was very common in families. Over 16% of medical referrals in 1914 were for infectious diseases and 12% of referrals were for TB alone. By 1915 vaccination against typhus was compulsory in the army and while cholera vaccination was not compulsory in the army it was widely applied but less so among the civilian population.

There was no unified system to control the spread of epidemics. The war relief effort of 1914 when the All Union Town Councils and Zemstovs liaised with the Russian Red Cross and the Military Sanitary Board to evacuate wounded soldiers and distribute vaccines remained in place. In November 1917 there were military and sanitary brigades in factories and 1st aid posts at railway stations. Charitable organisations such as Skoraya Care in Petrograd assisted in the city’s epidemic and sanitary control efforts,evacuating and transporting cholera patients.

In 1918 there were outbreaks of typhus (1918/19), Spanish influenza,cholera and local outbreaks of smallpox. The death rate for typhus was 8 to 10% and higher rates in rural areas. There was a high mortality rate of approximately 50% among doctors treating typhus patients in public hospitals. 14% of doctors were died from typhus in Astrakhan province.

Control measures to combat typhus included the evacuation stations at fixed points along railway lines. Many women were enlisted in the sanitary campaigns, public baths in villages and punitive measures against the unwashed. There was a scarcity of basic of soaps, disinfectants and dressings in hospitals.

A member of the British Labour Delegation to Russia in 1920, Margaret Bondfield reported “all hospital supplies are reduced to virtually nothing”, and considered “the allied policy blockade stands condemned as the cause of many thousands of deaths”.

Figures for typhus casualties for all Russia, including Siberia show a fall in both the number of army and civilian casualties between February 1918 and April 1919. The number of army casualties fell from 66,113 to 16,505 while civilian casualties fell from 389,854 to 158,308. In April 1919 there was further compulsory vaccination against smallpox and health education campaigns and committees in districts, villages, factories, barracks together with numerous poster campaigns. By March 1920 the Commissariat of Public Health’s focus of attention was the health of school age children, especially those suffering from TB.

A Health Statute in 1921 declared “the Communist Party of the Soviet Union will base its public health policy on a comprehensive series of health and sanitary measures designed to prevent the development of disease”. An outbreak of malaria in 1920 prompted the Institute of Tropical Medicine in Moscow to pass a raft of measures to reduce the spread of the disease, establishing compulsory registration of sufferers and those exposed to the disease, malarial stations to provide treatment and clinical and laboratory work. Quinine was distributed duty-free.

There were further epidemic outbreaks between 1921 and 1923: cholera (an estimated 13 million deaths), smallpox, typhus, plague, TB and malaria and strict sanitary control measures to enforce prohibited zones to prevent the spread of diseases. The death rate from cholera and scarlet fever in Petrograd was 89 per 1000, 4 times higher than the pre war level. Overall the death rate doubled and the birth rate fell. The birth rate in rural areas was 22 per 1000 and the birth rate in major towns was 13 per 1000.

The Ufa Bacteriological Institute, based in the Bashkir republic responded to the outbreaks of malaria, cholera and rabies in the region. It produced serums, vaccines and worked on epidemic control, hygiene and sanitation and preventive medicines for smallpox, cholera, diphtheria, typhoid, TB and whooping cough as well as anti dysentery treatment and streptococcus serums and anthrax vaccines, treatment against rabies and vaccines for treating animals (cattle).

There was a shortage of botanicals, insufficient medical supplies and chemicals for the recently nationalised pharmaceutical enterprises. UBI experienced problems of lack of funding, staff shortages, debt, reliance on old stocks, all of which impeded progress.

A bureaucratic misjudgment between UBI, the Commissariat of Public Health and Government pharmacy agency officials contributed to a protracted shortage of quinine stocks which were reduced by 50% at a time of need during an outbreak of malaria in 1923 which affected 10 million people.

The Regional Institute for Microbiology and Epidemiology in South East Russia opened in Saratov in 1919. During epidemic outbreaks its epidemiological teams were sent out to assist affected areas. By 1925 a network of medical observation stations, anti plague laboratories and hospitals covering ten towns organised sanitation programmes led by sanitation and anti plague teams to clean workplaces and workers domestic accommodation, incinerate dwellings, carry out autopsies, organise burials and enforce isolation zones, combat rodents and fleas and run health education campaigns.

From 1923 to 1927 there had been some improvements in the struggle against epidemics. The number of persons affected by smallpox fell from 46 per 1000 to 15 per 1000 and the number of persons affected by malaria fell from 5.7 million to 3.7 million. In 1929 the All Russia Congress of Soviets noted the reduction in the mortality rate from infectious diseases, particularly the infant mortality rate which fell from 273 per 1000 in 1913 to 186 per 1000 in 1922 and 141 per 1000 in 1929/30. There was some regional variation. The infant morality rate per 1000 in 1929 was 131 in Moscow, 106 for Khartov, 178 for Saratov,and 151 for Leningrad.

“On from the struggle against epidemics to the fight for more healthful working and living conditions”. A slogan from the 1920s

In 1930 a Government health document “About the Sanitary Minimum” resolved to increase time and money invested on water supply, sewerage, housing amenities, cleanliness, environmental conditions of domestic properties and in the workplace. A second document published later “About the Battle with Epidemics” suggested that 50% of diseases (infectious, dermatological, digestive) were due to poor public health and in the last 3 years of the first Five Year Plan this would mean that the cost of illness to the economy would be 27 billion rubles.

Housing

The new Bolshevik government grappled with the housing problem throughout the 1920s. Severe housing shortages, over-crowding and generally insanitary living conditions were urgent public health issues.

” we build badly and at great expense” (newspaper report)

” dearth of living quarters is unbearable…dwelling houses remain as a rule uncared for “

(Trotsky)

In pre-revolutionary St. Petersburg floor space per member of a workers family was 33 sq.ft. In Moscow only 28% of buildings had sewerage facilities and the most numerous accommodation available was one room in a basement or one room above street level. There were widespread fuel shortages and problems of water and sanitation pipes freezing up and preventing the supply of water and the carriage of sewage.

All houses with five or more apartments were nationalised in August 1918 in an effort to redistribute property and alleviate problems of homelessness and over-crowding. From 1920s there were more family homes and the experiment of communal amenities was underway — communal kitchens, dining rooms in factories, railways, schools and housing apartments, more creches and nurseries, communal laundries, out-door leisure facilities and cultural spaces. The government building programme to provide more housing got underway by the late 1920s. By the early 1930s there was a fall in housing and sanitation standards. Only 218 out of 508 cities in European Russia had water supply systems and only 23 had sewerage systems and the housing shortfall continued.

Towards a Commissariat of Public Health

A statement put out by Bolshevik health officials in December 1917 cogently explained the government’s position on tackling public health reform:

” the war, economic dislocation and the waste of population and other consequences associated with this have placed before the workers and peasants government the question of struggling on a state-wide scale with morbidity, mortality and the unsanitary living conditions of the broad masses of the population”

” comprehensive sanitary legislation is required regarding water supply, national canalisation and sanitary supervision over commercial and industrial enterprises and residential housing”

“(and for) sanitary inspection for the struggle with morbidity and mortality and in particular with child mortality, TB, syphillis etc. for the struggle with contagious diseases and to provide the population with sanitary and salubrious resorts etc…. it is necessary to take pharmacies out of private hands and transfer them to the public institution of the Soviet government”

Medicines were to be freely available (this was revised later) and there had been earlier plans outlining the organisation of free medical treatment controlled by the workers through sick clubs and extensive social insurance provision to cover work incapacity through illness, injury, old age, occupational disease, maternity, child labour, orphanage and unemployment, self-managed by the workers with the costs on industry.

It was now time to mark out the parameters necessary to establish a coherent policy agenda for health, to take on the responsibilities of managing existing medical services while preparing for incipient change.

In February 1918 the Council of Medical Departments was established in Petrograd to co-ordinate medical work by various departments. But this programme was impeded by an outbreak of typhus, civil war and sabotage.

A centralised unified medical authority was envisaged, capable of providing leadership on public health matters and at the same time enabling some of the tangential tendencies represented by some of the new health commissions to shape policy direction of the central body through broad participation at administration level and offering a degree of autonomy for specialist disciplines and for regional/local agencies.

The Commissariat of Public Health was established in July 1918 and headed by Semashko, a long-standing member of the Bolshevik Party since 1893 with connections to the leadership. Its brief was to provide a single unified soviet medical service, accessible, free of charge and qualified and to encourage worker participation and state obligation to protect the health of workers.

The Commissariat of Public Health was to be “responsible for all matters involving the people’s health and for the establishment of all regulations (pertaining to it) with the aim of improving the health standards of the nation and of abolishing all conditions prejudicial to health ” (Council of Peoples Commissars Article  1 1921)

More immediately the new Commissariat was to take on epidemic control, health education campaign work, to establish workers committees in cities and villages, organise the distribution of soap and sanitary inspection of accommodation, workplaces and public institutions and to establish a network of medical stations. The Medical Division set up by the War Revolutionary Committee in Petrograd gave a further exposition of the party line on health and medical matters:-

1.a determined effort to carry out far reaching public health measures for the benefit of the workers such as

1. sanitation of living places (protection of soil, water, air)
2. establishment of communal feeding along principles of scientific hygiene
3. organisation of medicine to prevent the development and spread of catastrophic diseases
4. health legislation

2.combating of social diseases (TB, VD, alcoholism etc.)

3.the guarantee of qualified health and medical services available without charge to all

There was rapid dissolution of many of the medical bodies established under the Provisional government (All Russia Union of Professional Association of Physicians,the Pirogov Society, Red Cross Commissions) and some departments were transferred to the Commissariat of Public Health e.g Department of Motherhood and Infancy which had previously been under the Social Security Commissariat. There were new Commissions and representative bodies (some re-named) with varying degree of linkage to the new Commissariat, particularly regarding funding matters, e.g. All Russia Federated Union of Medical Workers, Military Sanitary Board, State Institute for Social Hygiene, the Petrograd Skoraya Emergency Care, Psychiatry Commission, TB division.

Although the authority of Commissariat of Public Health was restricted to the Russian Federated States and responsible for bringing all medicine under its control, it functioned like an All- Russia government ministry.

The scale of the policy changes enacted by the New Economic Plan and the 1st Five Year Plan during the 1920s and early 1930s grounded the work of the new Commissariat.

Some achievements were made but many innovative proposals for change were lost through lack of funding, inefficient planning, inexperience, bureaucratic mismanagement, the competitive ethos within and between the various Commissariats and commissions charged with the responsibility for medical services and the wider public health agenda, intransigence from factions within the medical profession more resistant to change, an exhaustive work programme unevenly implemented and the ramifications of the shifts in political power in the Bolshevik Party which had become apparent by the mid 1920s. Critical opposition was summarily dismissed, silenced and courted the risk of retaliatory measures as the dismissal of the more progressive elements of the Moscow Oblast district health department by end of 1920s demonstrated.

The Commissariat of Public Health represented the official face of health planning and reform in Russia throughout this period. Reorganising medical training and facilities, recommending and making changes to the medical curriculum, reversing some of the imbalances in medical services before and after 1917, addressing some of the problems brought about by an on-going shortfall in health sector budgets were vital for securing the longer term future of a viable health service in Russia. These were just some of the hard lines that the Commissariat was expected to operate within.

Human Resources — Medical Training and Education

The recruitment and qualification of the medical workforce formed a continuum of expectation for government health officials from 1917 onwards. It was a target that was for the most part unattainable. There was a shortfall of qualified and experienced medical workers at all levels throughout the 1920s. From the outset the Bolshevik Government was engaged in a balancing act with specialists and experts employed by the old Tsarist regime(many of whom sided with the Provisional Government) and not only in the medical field. Their expertise was necessary for Russia to build up, maintain, and develop its technological and scientific resources in spite of the distortions of a war economy and inter-allied blockading of basic commodities.

” we shall pay the economists, statisticians ,technicians good money…but we shall not give them anything to eat if they are not prepared to work conscientiously and entirely in the interests of the working people”

(Lenin November 1917)

This was a “compromise enforced by objective conditions” which in the first few months of the new government referred to the lack of state funds, no outside support (the stalling of the revolutionary process in Germany), starvation and exhaustion.

Middle Medical Workers

This term refers to nurses, feldsher assistant physicians, dentists, pharmacists, midwives and laboratory technicians. In 1919 one sixth of all middle medical workers were women. Between 1913 to 1926 this category of the medical workforce had increased by 60%.

There was a Russian Pharmacy Society for Mutual Assistance founded in 1895 and the All-Russia Union of Feldshers was founded in 1905. The All —Russia Congress of Nurses Union was founded in 1917. It had established 56 branches within a year and had a membership of 18000. The Medical Sanitary Workers Union was founded in 1820 and by 1923 59% of its members were women.

Middle medical workers were low paid and under-represented in rural areas and they were perceived as representing an off/on threat to the professional status of physicians.  Feldshers were male and female trained assistant physicians with a two or three year work experience in large hospitals. As students they paid for their training but received a salary once they finished and had found a position.

Nurses were designated middle medical workers. “any working woman was taken for a two year training provided she could at least read and write ” (comment on training of nurses in 1922 Le Gros Clark & Brinton). By 1932 nurses enrolled on a three year training programme which included the study of natural science, biology and attendance at some medical classes  but in the early 1920s many women undertook the emergency training courses offered by the Russian Red Cross. The training was a means of recruiting assistants for middle medical workers (primarily feldshers, midwives, sanitary workers and Red Cross nurses) at the war front and was similar to the training offered to assistant nurses in Germany.

The emergency training courses attracted charitable nursing associations such as the Sisters of Mercy who were not formally trained and gained experience through working with seniors in nursing situations. Between 1914 and 1916 the number of the Sisters of Mercy who took up the Red Cross emergency training rose from 4000 to 25000. An All-Union Congress of Russian Sisters of Mercy was founded in 1917 but it was disbanded two years later.

In 1914 there were 109 Red Cross schools of nursing in Russia. Their rapid recruitment programmes provided nurses for military hospitals and flying columns (mobile field units) during the 1st World War and the Civil war that followed. During the Civil War many Russian Red Cross nurses became refugees in Europe as the fighting in Russian territories escalated and there was an attempt to establish a Union of Russian Nurses Abroad. By 1921 there were new schools of nursing in Russia, with different professional standards and a new curriculum. Nurses were expected to join a union but forbidden to strike or to bargain for improved working conditions.

Pharmacists were also designated middle medical workers. Following the nationalisation of pharmacies many pharmacists fled abroad when their premises were seized. Pharmacists were also conscripted for military service during the Civil War. Under the New Economic Plan there were opportunities to lease back former properties and there was some approval for private practice. In 1923 25% of pharmacies were under private practice. In Moscow only ten pharmacy enterprises were state-owned but by 1927 nearly all pharmacies in Moscow were state-owned. Efforts were made to raise the level of training for pharmacists by establishing local pharmacy schools offering a three year training course and study of the root scientific subjects and higher level schools of pharmacy in Moscow, Leningrad, Odessa and other cities.

Doctors were conscripted for military service during both the 1st World War and the Civil War in Russia. They were expected to serve for six months and on demobilisation some doctors refused to take up jobs which fell below rank and profession. The state lacked funds to pay salaries. In Moscow in 1923 there were 5440 physicians, 4190 were state physicians on low salaries often supplemented by private practice and 956 were registered as unemployed. The shortfall in the number of doctors continued. In 1921 it was still just below the level for 1913.

Medical schools were encouraged to show preference in admission procedures towards the children of workers and peasants and the state examination for licence to practice was replaced by a certificate of completion issued by medical schools. A medical workers faculty was established to encourage workers to take up medical training.

By 1930 5% of hospitals, 0.5% hospital beds and 6.4% of out patient clinics were in private practice. In Moscow 17.5% of doctors were in private practice. In Kazan 16% of doctors were in private practice. There was free treatment at a few polyclinics but a fee of between 2 to 4 rubles was charged in some clinics. The fee paying system was controlled by the regional health commisariat or the Russian Red Cross.

Expanding the number of doctors, places in medical schools, changes in the admission criteria, lengthening medical training, fast tracking students for on the job training and directing more medical resources to rural areas were some of the fundamental targets of the first Five Year Plan. There was an increase in the number of medical students from 19,785 in 1913 to 63,162 in 1928 and 76,027 by 1932.

According to the new Commissar of Public Health, Vladimirsky, 90% of all physicians in Russia worked for the State.

Emergency Medical Care

Skoraya Medical Care was revived after 1917. There were 50 stations across several cities by 1927. They were staffed by volunteer and paid physicians and feldshers. They offered basic medical aid to victims of road accidents and accidents in public places, answered emergency call outs and responded to crises such as flood relief and epidemic outbreaks by participating in sanitary control measures and providing transport to evacuate patients. They also ran first aid training courses and in 1932 the Scientific Practical Skoraya Care Institute opened in Leningrad. It ran training courses for physicians on occupational differences in the occurrence of accidents, occupational poisoning,acute abdominal diseases, traumatology and the practical use of splints,dealing with burns and cardiovascular diseases.

Training in Child Health

By 1920s Skoraya Medical Care estimated that 15% of its 1st aid services were used by children under the age of 14 and extended its services to take on paediatric work and to employ paediatricians.

All teachers in schools received expert training in child health, working closely with school doctors. Schools were represented at a municipal level and there were on-going campaigns e.g road safety courses,gardening and growing projects, regular exhibitions and presentations. Health Inspectors were drawn from the pupil-student body and had a monitoring role…airing classrooms, ensuring each child had a handkerchief, keeping health diaries and reports.

Physical education, food hygiene and First Aid were on the school curriculum and there were regular medical examinations of school children.

Medical Education ….Curriculum Changes

Teaching and research in public health changed after 1917. By 1920s there was an emphasis on Social Hygiene. It was taken up as a discipline in medical schools, accepted as a research field in specialised government institutes and agencies and guaranteed the support of the Commissariat of Public Health. Social Hygiene was also disapproved of in traditional medical circles and had to compete for sponsorship from the Commissariat of Public Health. Social Hygiene was the “study of the influence of economic and social factors on the incidence of disease and on the ways to make the population healthy” (Semashko, Commissar of Public Health)

In 1919 the Commission for Reform of Education and medical institutions in Petrograd produced a report recommending community and social hygiene, sanitary statistics, epidemiology, schools and professional social hygiene to be an integral part of hygiene courses. In 1923 the State Institute for Social Hygiene opened.

However, the Commissariat of Public Health did not have the sole jurisdiction over physicians. From 1922 to 1930 administration and funding for medical education was the responsibility of the Commissariat of Education which supervised the admission of students, curriculum and training and the budget for higher professional and technical education, which was 50% below the level for 1913. Social Hygiene was not seen as an academically rigorous discipline and its inter-disciplinary and integrated approach was not approved in some medical departments. Students saw it as a low-funded area. For example in 1924 only 6.1% of female students and 5.2% of male students indicated a preference for Social Hygiene at the Leningrad Medical Institute. Social Hygiene competed with other medical and non medical disciplines for funding and sponsorship from the Commissariat.

By the late 1920s research priorities had changed and there was an emphasis on occupational illnesses and occupational injury and areas such as housing and nutrition were no longer on the agenda.

In 1930 medical faculties were split off from universities as separate institutes and the responsibilty for medical training was transferred from the Commissariat of Education to the Commissariat of Public-Health and divided into three core areas: curative prophylactic; sanitation prophylactic (social hygiene was now a part of this area) and protection of mothers and children. The State Institute for Social Hygiene was renamed the Institute of Organisation of Health Care and Hygiene and there was no longer analysis of health and diseases and by the mid 1930s no longer social statistical research work.

Economics of Health Spending

Official data shows there was a broad increase in health spending in the mid 1920s. Between 1923/4 and 1926/7 spending on medical services increased from 140.2 million rubles to 384.9 million rubles. However, from about 1926 the cost-cutting thrust of economic policies led to a reduction in the budget of the Commissariat of Public Health. While overall spending continued to increase (410.5 million rubles by the end of the decade),there was only a negligible increase in per capita spending – 3.82 rubles in 1926/7 and 3.94 rubles in 1928/9.

There was a deterioration in the provision of medical services. Many hospitals and out-patient clinics refused to offer assistance. Long queues and over-crowding in treatment areas, food shortages in hospitals, low wages for medical staff and lack of funding undermined construction and repair programmes (e.g in Moscow the spending on new construction for 1926/7 was 7.4 million rubles but in 1928/9 it was 5.2 million rubles) and the allocation of social insurance continued to be a source of conflict between the trades unions and the Commissariat of Public Health.

There were marked differences between the health spending provision for insured and uninsured workers and peasants in urban and rural areas as the mini table for below indicates:-

Year 1927/8

% of pop.     % of health budget

• insured                    16.7     78.2
• uninsured              83.3     21.8
• urban insured                    71.3
• rural insured                       6.9
• urban uninsured                 7.1
• rural uninsured                 14.7

In 1929 the government economic planning agency, Gosplan USSR, projected health spending to be 16% of total government budget, a 5.6% increase in the number of hospital beds and a 6.9% increase in the number of doctors but once again there was only a slight increase in per capita spending,around 2%. There were further re-adjustments to the 1st Five Year Plan in face of growing economic difficulties. While average wages for medical staff had increased they remained at pre-1917 level whereas the industrial labour force had seen wage level rises of 150%. Doctors were directed to take on multiple posts at the workplace, a workload increase of 33%.

Poor harvests, disruption to food supplies, food rationing (between 1930/1932 food rationing was extended from 26 million people to 40 million people) a fall in real wages and the standard of living in urban areas, pressure on welfare organisations to safeguard existing levels of consumption migration problems and the beginnings of collectivisation contributed to a climate of uncertainty and insecurity. There was also a rise in the mortality rate in rural areas.

The health spending target was reduced from 490.5 million rubles to 477.9 million rubles and medical assistance for the social insurance fund was reduced from a proposed target of 177.7 million rubles to 151 million rubles. The final projection for health sector spending was 20% of the total government budget, much less than had been expected and there was now pressure on local councils to make up the shortfall in government expenditure. The Commissariat of Public Health was criticised for implementing changes too slowly and for failing to incorporate the proletarian class line sufficiently.

1929/1930 was seen as the great turnabout in health sector planning. Yet there was a fall in actual investment in health services from 2.4% to 0.8% .The health sector planning target fulfillment rate was 35.4%, lower than any other sector of the economy. Wages levels fell from 91% of national average to 87% of national average between 1928 to 1932. There was an increase in the number of women employed in the health sector (from 64.6% in 1929 to 70.2% in 1932).

The new direction of government-led health planning focused on occupational health and economic productivity and a bias towards insured workers valued for their contribution to the economy. During the New Economic Plan there was registration of industrial injuries in 1922 and occupational poisoning in 1924 and regular workplace medical examinations. By the late 1920s there was more attention to industrial hygiene factors- reducing occupational diseases, accidents at work, morbidity linked to loss of work capacity. The funding deficit in health sector spending had a direct effect on access and distribution of medical services and even accounting for regional and local differences,uneven provision resulted in persistent inequalities.

Medical Facilities and Medical Treatment

Hospital Buildings (further information needed)

• hospitals under the imperialist regime
• zemstov municipal hospitals
• old and new style hospitals after 1917
• dispensaries and out-patients clinics
• military hospitals (army and navy) – asylums
• maternity hospitals and foundling hospitals
• requisition of properties for medical use
• physical links between hospitals and universities

” former hospitals for the rich are now devoted primarily for the workers” (Red Medicine ref.1932)

The shortage of medical facilities, the requisitioning of medical supplies for the war effort and the disparities in provision between cities and villages, old buildings in a state of disrepair, insanitation and under-funding were familiar problems before and after October 1917.

In 1913 there were 5300 hospitals and 1 doctor to 5665 persons. Only 10% of mentally ill patients were treated in hospital in 1914 and by 1918 this figure had halved to 5%. There were no medical facilities or pharmacies in many areas and no state —run sanitation or anti-epidemic services. In some eastern regions the doctor/population ratio was 0.2 to 0.7 per 10,000. There was no state obstetrics service before 1917.

To rectify or even ameliorate this situation was an impossible challenge but it was taken up and there were shoots of progress in some areas overtime.

The number of hospital beds increased from the pre war level to the late 1920s. In 1928 there were:

• 158,514 hospital beds in urban areas and 59,230 hospital beds in rural areas
• 5,673 medical centre beds in urban areas and 7,531 medical centre beds in rural areas
• 18,241 maternity beds in urban areas and 9,097 maternity beds in rural areas

The dispensarisation model was preferred in many medical and specialist practices in urban and rural areas. It combined a broader understanding of social factors and medical matters in diagnosis and prescribing treatment. It involved extensive record ­keeping, collecting medical and social statistics and regular medical examination of target groups of patients.

In the 1920s 60% of health spending was directed towards preventive methods of treatment. The first state rest home for workers was opened in May 1920 and in 1925 the first health resort for agricultural workers was opened in Yalta.

Life Expectancy had reached 44 years by 1926.

Nationalisation of pharmaceutical businesses had started before 1917. German pharmaceutical enterprises in Moscow were nationalised and new pharmaceutical companies were opened. There was also an increase in production of some chemicals (e.g agricultural fertilisers) often sparked by necessity as a response to the shortages caused by import restrictions from Germany. Russian pharmacists were prepared to break patents in order to obtain essential medicines. In December 1917 the Bolsheviks nationalised pharmacies and took over pharmaceutical factories. There were many problems including an unsupervised trade in medicines and an increase in drug abuse. Nationalisation was not a uniform process. Workers and local commissariats controlled 32 pharmaceutical enterprises in Moscow and shortages of basic commodities and medical supplies continued. An estimated 35 products had to be imported to fulfill production targets. Medical instruments and x-ray and laboratory equipment were not up to standard, storage of materials was inadequate in some areas. There was a lack of funding, profiteering and high costs for raw materials. There were divisions between pharmaceutical and chemical industries resulting in compartmentalisation and inflexibility.

Under the New Economic Plan there was greater availability of basic commodities and some market economy features, including re-privatisation, but the government retained control particularly over pharmaceutical factories and there was a “continuing medicaments famine”. By 1928 70% of all pharmaceuticals and 88% of drugs were produced nationally. There were some improvements in research and development though there was still a reliance on foreign expertise. There was some domestic production of medical equipment such as dentist chairs and drills.

Dental services were sparse. In 1926 less than 56% of the population of the Ukraine had received treatment at a dental practice.

Between 1928 and 1932 2000 new hospitals were built in Russia.

An account of a trip to Russia in 1932 in the book ‘Red Medicine’ gives a brief description of medical services on the ground. Treatment for ‘ordinary illnesses’ was domiciliary, at home but usually by medical staff at in the workplace. Patients could be referred to dispensaries,polyclinics and night sanitatoria in the district or to hospitals as appropriate. There was free medical treatment for workers and peasants and “for the rest the desire is to serve all gratuitously…thus in a dispensary an intellectual will have to wait until all the workers have been treated”. In Rostov the average number of consultations between doctor and patients was six per hour.

There were many specialist services. In 1914 there were 12 bacteriological institutes in Russia,mainly in large cities. By 1937 there were 37 institutes (25 were new) and some were based in the outlying regions e.g the Regional Institute for Microbiology and Epidemiology in South East Russia based in Saratov.

The Roentgen Institute in Khartov in the Ukraine opened in 1931. It was a specialist cancer treatment facility with a laboratory which designed and made x-ray apparatus for the whole country. 98000 cases of cancer and allied conditions were treated. There were 87 research workers, 20 professors, specialist medical staff —surgeons, physicians, gynaecologists) and facilities included chemical, physiology, bacteriology experimental treatment laboratories. There was also early diagnosis treatment and on-going health education campaigns.

Before 1917 psychiatry in Russia was moving towards a more decentralised approach to medical care — smaller hospitals (10 to 20 beds), out-patient clinics, some collaboration with private practice and collective control in the running of asylums i.e. staff to elect the head physician/director of a psychiatric hospital and greater public involvement to foster an interest in mental illness.

Psychiatrists complained about the lack of funding and over­work as they were expected to deal with general medical issues and problems relating to epidemic and infectious diseases (e.g sexually transmitted diseases such as VD and syphilis). They were also expected to provide forensic evidence to the courts, conduct autopsies, medical certification, witness corporal punishment and attend executions. There were problems of the police referring an increasing number of prisoners to psychiatric facilities, particularly after the 1905 February Revolution when there was an influx of political prisoners. Psychiatrists opposed the use of manacles and irons to restrain prisoners in psychiatric hospitals and even after legislation in 1909 on insane prisoners, the onus was on psychiatrists to provide certification to state that such restraints were detrimental to a patient’s health.

In October 1917 the Psychiatry Commission was established under the authority of the Commissariat of Public Health and psychiatrists were given a more decisive role in the running of hospitals. They could choose to elect a non-medical person to be the head of the hospital and there are examples when manual workers were elected to this position, a metal worker,a cook and a warden. There were problems of disorganised management and bureaucracy. Before 1917 local zemstovs provided two-thirds of the funding for psychiatric services and a third of the funding was provided by government. After 1918 the state provided 50% of the budget for psychiatric services and by 1919 the state assumed total funding of the budget. Local soviets set up psychiatric sections and there were criticisms from psychiatrists that the sections lacked experience and were not in touch with the services on the ground. Famine and epidemic outbreaks in the early 1920s overwhelmed the psychiatric services in some areas and more problems erupted in the hospitals- the spread of infectious diseases,absconding patients and staff, an increase in the number of suicides, insanitary conditions . A government official commented “the hospital’s horrid state resembles that of a military prison”.

Social Insurance and Social Welfare

” citizens of the USSR have the right to material security in old age as well as in the event of sickness and loss of capacity to work…ensured by the wide development of social insurance of workers and employees at the expense of the State,free medical aid and the provision of a a wide network of health resorts for the use of the toilers”. (Article 120 Constitution 1936)

In 1903 the Bolshevik Party programme highlighted the fundamental rights of workers to minimum social security provision,guaranteed by the state and managed by themselves. Emphasising the importance of optimal working conditions they proposed:-

• an eight hour working day,
• 42 rest days,
• prohibition of nightwork (except in those areas of production where it was necessary)
• a ban on children under the age of 16 working,
• a six hour working day for children,
• prohibition of women working in areas harmful to their bodies,
• 10 weeks maternity leave on full pay,
• creches,
• state supervision in industry,
• free medicines and sick pay.

Against the background of social and economic unrest, it is not surprising that the Duma and the Provisional Government introduced social insurance legislation to redress some of the demands of striking workers and militants in the armed forces. The Law passed in June 1917 extended social insurance provision to 25% of blue and white collar workers in key industries (mining, metallurgy, urban and river transport) i.e. to 3 million out of 18 million workers. Factory sick funds were to provide disability benefit for 12 weeks and assistance thereafter was to be provided by mutual assistance funds which did not cover medical expenses. Employers would finance two-fifths of the scheme and workers would contribute three-fifths. Further legislation in July 1917 extended this provision. Accident insurance cover was extended to 13 weeks, sickness benefit was payable for six months at two-thirds of wage/salary, maternity leave was increased to 8 weeks with 25% of wages for 20 weeks. There was a shift from factory-based funds to regional funds,managed by the workers and financed by the employers at a rate of 2% of wages. Some categories of workers were excluded from the legislation, namely government workers,railway workers and agricultural workers.

In October 1917 the Peoples Commissariat of Labour announced a broad and comprehensive list of benefits to be covered by social insurance funds- accident and sickness, health care, maternity leave, unemployment,disability and widow’s pension for industrial and agricultural workers. Funding was to be provided by employers. But there were problems of implementation from the outset. There were no state funds to support the legislation and employers were economically too hard pressed to make consistent contributions. By December 1917 there were restrictions on sickness, disability,maternity benefits and medical treatment for the families of the insured to be available to wage earners only.

There was no single, centralised social insurance system. Social insurance was organised according to needs identified by regional and provincial insurance funds and financed by the state. The main difficulties were employers failing to make the required contributions and the ensuing funding crisis faced by welfare organisations who in turn became indebted to those in need of help.

By October 1918 insurance cover was extended to peasants and social insurance was re-organised as a five-tier sickness and accident benefit scheme along with unemployment and maternity benefits and healthcare and medical treatment. The health insurance funds were now responsible for managing benefits and became effectively social security funds under the authority of the Social Security and Labour department of the People’s Commissariat of Labour. When the health insurance funds were unable to make payments workers received payment in kind that was not enough to feed themselves and their family and peasants often received no assistance at all except in times of famine.

During the NEP period there was no improvement in employers making regular contributions to the insurance fund. There was a return to more restrictive practices in qualification for benefits and a preference for the rights of insured workers. The State Reserve Fund was expected to cope with emergencies such as famine and the outbreak of epidemic diseases.

In 1923 employers were paying only 10% of their contributions and it was estimated that by then no more than 29% of workers were receiving social security payments. Furthermore there were discrepancies in the rates of benefits paid out by provincial and district funds. There were attempts to exact employer contributions through extortion. In Moscow between 1923/4 there was an improvement in employers making contributions (up to 93.7% in July 1924) but the steady increase in numbers claiming benefits soon left the insurance fund in deficit and no benefits were paid at all.

Regional funds were required to make a 10% payment to Central Administration and the Peoples Commissariat of Health and these two authorities then set up reserve funds to redistribute funds locally as needed. Official statistics suggest that there was some improvement in the administration of social insurance by 1924. There was an 80% increase in the number of employers making contributions. More workers were receiving benefits, including holiday pay and there were some increases in the rates for disability benefits.

But the drop in contributions to insurance funds in industrial areas presented a desperate situation where funds sought outside finance to keep themselves afloat. Government response was to pressurize local funds through regional offices to maintain contributions to the Reserve Fund and in 1925 a Supreme Council was established to direct and supervise local funds. Social security funds were to be considered as long term loans to support industrial development and were diverted to the State Bank.

These measures had a negative effect on the unemployed who were seen as not making a contribution to industrialisation. 60% names of unemployed were removed from the unemployment register and the unemployed were required to register at the labour exchange within three months of losing their jobs.

In 1924/5 there was a 50% rise in the number of industrial accidents, mainly in the mining industry. Temporary disability benefits were inadequate and on site medical services were unable to deal with illnesses in the workforce. In Odessa the social insurance fund could not guarantee disability benefits to metal worker most of whom suffered from lead poisoning and respiratory diseases. In Donbass the fund was unable to make more than minimal pay outs and miners received hardly any medical care, clinic facillities were insanitary and in a state of disrepair, there was no heating and makeshift dressings were used. The death rate for Donbass miners was 2.9 per 1000 in 1932 as compared to 2.6 per 1000 between 1906 and 1913.

In August 1926 social security legislation was passed to ensure that funds were used for the specific purpose they were set up for and further legislation aimed at raising the disability pension to 40% of wages in districts and villages. Mutual assistance committees and workers co-operatives were established to support disabled peasants. By 1927 there was government backing for disabled war veterans to be seen as a special category for social security purposes,separate from disabled workers.

The unemployed were divided into skilled and unskilled categories and generally seen as second-class claimants, receiving a lower rate of benefit and directed to workfare schemes (handicraft trade workshops and farmwork). The number of vagrants increased – women, homeless young people, sick and starving people surviving through theft and prostitution.

This situation was not ameliorated by the 1st Five Year Plan. Benefits were suspended for the unemployed who did not live in urban areas or join a union and only 50% of the unemployed received benefit payments and the rate of payment was dependent on where they lived. 25% of the unemployed received payment of between 15% to 35% of wages for family members.

By 1928/9 budget cuts in the Commissariat of Public Health and the conflicting views held by the Commissariat officials and trades unions in the allocation of social insurance funds in favour of insured workers created further divisiveness. Although wages had increased and there were more insured workers and Old Age Pensions were introduced in May 1929, there were further restrictions on disability and maternity benefits and a permanent suspension of unemployment benefit.

In September 1933 the responsibility for social security was transferred to the trades unions who were in favour of wage differentials and fought largely on behalf of insured workers. They controlled social insurance cover for workers and their families including access to medical care- free general and specialist treatment until 1935.

” The social security law must be the tool of the proletarian class;if must serve the interests of the proletariat and be directed against our enemies”

Disability

(also see under Social Insurance)

” the patriotic nightmare of the war invalids.

An enormous number of wounded from the hospitals of the capital­legless,armless,bandaged — advanced upon the Tauride Palace. Those who could not walk were carried in automobile trucks…”

Banners read “war to the end”

(Trotsky’s description of the war veterans marching in support of war in 1917)

Official figures for March 1921 estimated that health insurance funds had used up available resources to make 775000 wooden arms and legs for disabled soldiers. In 1929 to 1932 the disabled population in Russia was made up of 43% war veterans, 32% industrially injured and the remainder through accidents and disability at birth. In 1926 there were 15 blind persons per 10,000 population and societies for the blind and for the deaf and dumb.

Provision for the disabled at state level was organised through Commissariats for Invalid Welfare and social insurance funds which were responsible for social security benefits and pensions. There were welfare co-operatives, mutual aid societies and re-training programmes organised by the state and charitable societies there were also homes for the disabled. The aim of these homes was to encourage the disabled to become self-sufficient by engaging in handicraft and trade workshops. In 1926 there were up to 21000 disabled people in homes.

Post 1917 Dealing with the Dead…Cemeteries & Funerals

” Petrograd was burying the victims of the February Revolution… 800,000 people filed past the grave…everybody went to the funeral, both those who had fought side by side with the victims, those who had held them back from battle, very likely also those who had killed them and above all, those who had stood aside from the fighting…red coffins carried on the shoulders of (fathers) and soldiers streamed from the workers districts to Mars Field” (Trotsky)

The spiralling cost of funerals and the need for prompt burial in times of epidemic outbreaks to reduce the risk of spreading disease were just two of the problems that the new Bolshevik Government had to deal with under the remit for public health and social welfare. In December 1918 cemeteries and coffin-making businesses were nationalised.

“distinction by rank whether they apply to the place of burial or to the style of the funeral will be annihilated”

Grave diggers were now public employees with production quota to adhere to — two full size graves or four smaller ones, suitable for children, to be dug daily. There were three sizes for coffins, one style and fixed prices and there mass production of wreaths and colour paper. Problems of bribery and bureaucracy between grave diggers and local government officials held up funeral arrangements and there was also a problem of delays in the burials. In 1920 cemetery inspectors in Petrograd discovered 241 unburied bodies.

Cremation was forbidden by the Russian Orthodox Church but discussions were underway in Moscow and a cremation sub­committee was formed in 1919. In 1920 there were cremations of the unclaimed dead in Petrograd and in 1927 the first crematorium opened in Moscow.

There was discussion at municipal level about the re-use of old cemeteries as parks and leisure spaces.

Under the NEP there was some re-privatisation of cemeteries and funerals but local soviets were responsible for maintaining registers of births,marriages and deaths.

Social Issues

There were many social problems requiring some input by medical services and local soviets which were tackled with varying degrees of success — sometimes as half measures and retrospective responses rather than a chart of progress– through legislation, preventive treatment methods with the aid of mutual assistance societies and other charitable bodies and subject to financial constraints.

Abortarias were established in many cities to provide medically safe and specialist facilities. There were restrictions on the criteria for abortions and by 1924 only where pregnancy put the life of the woman and/or the unborn child at risk. Abortion was legalised in Russia in 1926. Funding for medical facilities was inadequate and fees were charged (not in excess of 40 rubles). There were health education campaigns against abortion and agencies to promote healthy pregnancies — advice and consultation centres for women linked to the workplace and the State Institute for Maternal and Infant Welfare. There was also concern about the effect of abortion on the birth rate. By 1935 abortions were only permitted on medical grounds and only within the first three months of pregnancy and six months between a first abortion and a second abortion. In 1936 abortion was prohibited with a medical exemption for women whose life would be endangered if pregnancy continued.

Abandoned and homeless children were part of the growing number of vagrants in Russia during the 1920s, which included an estimated number of 360,000 homeless young people. There was a shift away from charitable bodies to state departments and commissions to deal with this problem.

The Family Code in 1918 prohibited adoption in an effort to reduce child labour exploitation particularly in rural areas. There was a ten­fold increase in the number of children in care between 1917 and 1920/21 and 3000 homes for orphans under local government control and also the boarding out of children. In 1920 budgetary constraints put pressure on local councils to provide social security assistance and there was dual funding arrangements between the Commissariat of Public Health and the Commissariat of Culture to support local initiatives. There were campaigns to promote the health and welfare of children e.g Children’s Days and A Week for the Protection of the Children. The Friend of the Children was a voluntary group providing assistance for homeless children. Between 1913 and 1926 the death rate for children under 10 years was halved from 24 per 1000 to 12 per 1000.

Before 1917 alcoholism was seen as a contributory factor in mental illness, alcohol psychosis,to be treated by psychiatrists.

It was estimated that 50% of mentally ill soldiers during the 1904/5 Russo-Sino War were alcoholics and there were always a large number of alcoholics in mental institutions. Alcohol consumption in 1909 was 11 bottles per capita per year.

In 1920 dealing with alcoholics and the preventive treatment measures for alcoholism were at the centre of a research row for funding and research direction between the Social Hygiene lobby and medical departments. The Council of Peoples Commissars decided in favour of the medicalisation of alcoholism and preventive treatment by neuropsychiatrists and other specialised institutions while the Commissariat of Public Health lobbied on behalf of the Social Hygienists represented by the State Institute for Social Hygiene to cover the social aspects of the problem. Alcoholics were also treated in medical centres- prophylactoriums organised by local government under the authority of the Commissariat of Public Health.

Prostitution was dealt with at a local level under the Commissariat of Public Health. In 1922 special councils were convened to discuss the issue and to decided on what steps they needed to take. Unemployment and underemployment among women were seen as major causal factors linked to prostitution. In 1923 two thirds of women were unemployed. Local councils set up handicraft co­operatives in an attempt to provide alternative employment for prostitutes. In 1925 medical treatment centres — prophylactoriums – were established in all large cities to treat prostitutes and any infected women. For example, in 1926 there were two centres in Moscow which treated 128 women and in 1929 there were five centres which treated 600 women.

Before 1917 there were between 25000 and 30000 prostitutes in Moscow. In 1928 a survey by members of the prophylactorium board in the city estimated that the number of prostitutes in Moscow was 3000. Prophylactoriums also provided residential facilities and work programmes for young women with special needs and without family support, caught up in prostitution.

There were campaigns to close brothels and social welfare organisations, the police and the courts were involved in dealing with some of the secondary problems,often crime-related,commonly associated with prostitution — violence and abuse,drug-taking and theft.

Women were over-represented in the growing number of vagrants in Russia in the mid 1920s.Many vagrants fell in to prostitution as a means of survival.

TB Vaccination Programme –  A Work in Progress

In many ways the Bolshevik vaccination programme against TB represents a work in progress during the early years of the revolution. There were frustrations due to lack of funding for research work which limited the effectivenes of the programme but, in all, this was one of the more positive achievements of health development, an – example of good medical practice largely supported by the government, the medical profession and the wider population outside the medical field.

TB and typhus were priority diseases for control and development of treatment strategies. The official figure for the pulmonary TB death rate in Russia at the beginning of the century was 4 per 1000, much higher than the 1.7 per 1000 rate for England for example. It was a common disease among factory workers and the children of factory workers, particularly those engaged .in factory work. This is a graphic description of a post mortem report of a young match worker:

“His stomach was empty. His lung tissue was feeble and flabby and covered with many purulent tumors and both (of) his heart ventricles had coagulated blood”

The cause of death was stated as a tuberculated haemorrhage of the brain.

The All Russia League for the Struggle Against TB was set up in 1909 and disbanded in 1918. TB was recognised as a specialist area for medical research and in Russia there were TB dispensaries along the lines of the Paris model with a focus on medical, social, economic, environmental and laboratory -related issues an example of the Social Hygiene approach in practice. The Commissariat of Public Health established a TB Commission in 1919 and there was a journal to publish research findings from 1923.

In France researchers Calmette and Guerin had been trialling the BCG vaccine in cases of TB among young people. They had developed the TB vaccine from living no-virulent bovine bacilli in 1921 and by 1924 the BCG preventive vaccine was introduced and tested on children. The following year, Tarasevich, a Russian physician brought back serum of the BCG vaccine from the Pasteur Institute in Paris. Tarasevich was the director of the Institute of Control of Serums and Vaccines in Russia from 1918 to 1927. The vaccine was used in the Ukraine in 1925 and the first child was vaccinated in Moscow in 1926.

The BCG Commission of the Sanitary Medical Council under the Commissariat of Public Health was trialling, supplying and experimenting with the vaccine, initially in Moscow, concentrating on children in homes with an active TB patient. The work was expanded to other cities in 1927 — Kazan, Leningrad, Rostov and Saratov where requisite medical facilities were already in place such as a TB dispensary,a bacteriological institute and maternity clinics. The programme targeted high risk children and new born babies where parents had requested the vaccine. Manufacture of the vaccine was done locally and maternity clinics were directed to co-operate with local health planning agencies and the dispensary model methods of multi-factor approach, recording and analysing statistics, prescribing treatment with a focus on target groups under review were followed.

However there was a limited take up of the vaccination programme. In June 1928 56 children had been vaccinated in Saratov, 52 in Kazan, 26 in Moscow, 10 in Rostov and no children were vaccinated in Leningrad. In 1929 in spite of government support and very little opposition,there were no funds to implement a mass programme of vaccination. The medical elite strongly backed the dispensary model for TB vaccination work but the emphasis was still on high risk children rather than new born babies. Between 1928 and 1931 a Moscow study of 310 vaccinated children and 154 non-vaccinated children found that the TB mortality rate for vaccinated children was significantly lower than the mortality rate for non-vaccinated children, 0.6 % and 1.9% respectively. In 1930 Togunov, a female bacteriologist presented her findings on the BCG vaccine for TB and concluded it was both safe and effective. On a cautionary note, policy and planning changes in the direction in public health by 1930 placed less priority on the TB vaccination programme and led to a rise in TB related mortality. This was mitigated by more widespread vaccination against TB from the mid 1930s. In 1934 the TB vaccination programme was 0.1% of the total budget for health sector spending and finance for the programme was supported by the TB Fund from 1935. Between 1926 and 1934 the BCG vaccination rate for children in Russia had more than doubled.

Conclusion

Article 23

” endeavour to secure and maintain fair and humane conditions of labour for men,women and children”

Article 25 (ref. to supporting charitable organisations such as the Red Cross)

” having as purposes the improvement of health,the prevention of disease and the mitigation of suffering throughout the world”

from the Constitution of the League of Nations.

At the height of the Civil War in Russia the allies were thrashing out the terms of the Treaty of Versailles and fulminating against the spectre of revolution and Bolshevism.

Without the prospect of international support on the horizon, the revolutionary government in Russia was literally fighting a war on several fronts — its economy laid bare by war weariness,epidemic outbreaks,famine and near starvation conditions. The severity of the death toll alone was enough to drive the government to the verge of collapse. lt set out the rudiments of redistribution by seizing property,requisitioning food and fuel supplies and through rapid nationalisation. It dismantled the legislative and administrative apparatus of the Provisional Government and embarked on a radical re-organisation of the economic and social infrastructure both ideologically and politically e.g the conflict with the Russian Orthodox Church and confiscation of church properties and the State Administration of Public Health Administration’s policy in 1921 to recruit more working class students (from families of workers and peasants) to enrol in medical schools to train as doctors.

There was no cohesive strategy nor any fundamental root and branch changes in the sphere of public health reform. There were radical departures in policy direction. During the first few years there was frequent compromise in many areas,intermittent opposition and objectives were constantly revised in order to address those needs demanding most urgent attention,both proactively and reactively. Throughout the 1920s key health indices rarely exceeded and often fell short of pre war levels.

Neither should the building up of an edifice of bureaucracy, buttressed by the various Peoples Commissariats, be seen as a preconceived masterplan. Power struggles were played out at all levels — central state departments, regions and provinces, districts and villages, in factories and on farms.

The grand planks of state planning in the 1920s, the New Economic Plan and the 1st Five Year Plan marked a fundamental break with the past, major changes in policy direction and affected the ethos of the government. Health initiatives and reforms were dependent on these developments. The harsh realities of the high costs of achieving even limited goals tempered earlier optimism. There was a loss of autonomy, more centralised planning, a growing intolerance of critical opposition to government policies within government circles and a back-tracking on earlier pledges affirming the potential of broader popular participation and support.

In part this can be balanced out by the demonstrable and unwavering commitment to laying the foundations of a socialist state evident throughout the first phase of revolutionary government.

Only the people themselves can save themselves and the country. We appeal to the people.

All power to the Soviets!

All power to the people!

All land to the people!

On with an immediate, honest, democratic peace!

On with the Constituent Assembly!

Lenin October 1917

READING REFERENCES

• Lenin Selected Writings
• Trotsky The History of the Russian Revolution

1920s

• Margaret Bondfield Papers. GB Delegation to Russia 1920

1930s

• Red Medicine. Socialised Health in Soviet Russia Sir Arthur Newsholme & John Adams Kingsbury (Heineman 1934)
• Men,Medicine and Food in USSR Le Gros Clark & N.Brinton (Lawrence & Wishart 1936)

1940s

• Health and Medicine in the Soviet Union Eva Black (pamphlet 1941)
• Health and Medicine in the Soviet Union H.Sigerist & J.Older (Citadel Press 1947)

1960s

• The System of Public Health Service in USSR Ministry of Health, Moscow (booklet 1967)
• The Soviet Achievement J.P.Nettl (Thames & Hudson 1967)
• The Soviet People and their Society from 1917 to the Present P. Sollin (Pall Mall Press 1969)

1970s

• Russia Enters the 20th Century 1894-1917 Ed. Katov et al (Temple Smith, London 1970)
• The Soviet Health Service. A Comparative and Historical Study G. Hyde (Lawrence & Wishart 1974)
• The Russian Revolution and the Soviet State 1917-1921 Documents M.McCauley (Macmillan 1975)
• Urban Emergency Medical Service in the City of Leningrad M.A. Messel (US Dept of Health Education & Welfare Public Health Service 1975)
• Health Care in the Soviet Union and Eastern Union M. Kaser (Croom Helm 1976)

1980s

• Moscow Workers and the 1917 Revolution D. Koenker (Princeton University Press 1981)
• Russia in the Age of Modernisation and Revolution 1881-1917 H. Rogger (Longman 1983)

1990s

• Health and Society in Revolutionary Russia Ed. Solomon & Hutchinson (Bloomington 1990)
• Politics and Public Health in Revolutionary Russia 1880-1918 J.Hutchinson (John Hopkins University Press 1990)
• Alexander II and the Modernisation cf Russia W.E. Mosse (IB Tauris & Co. Ltd. London 1992)
• Society and Politics in the Russian Revolution R.Service (SSEES 1992)
• Russia’s Great Reforms 1855- 1881 Ed. B. Eklof et al (Indiana University Press 1994)
• Russia Under the Bolshevik Regime R. Pipes (Harvill Press 1997)
• Critical Companion to the Russian Revolution 1919-1921 Ed. E. Azton et al (Arnold 1997)
• Night of Stone. Death and Memory in Russia C. Merridale (Granta Books 2000)
• The Soviet Pharmaceutical Business During the First Two Decades M.Schaeffer Conroy (American University Studies Series 2006)
• The Versailles Settlement. Peace-Making After the 1st World War A.Sharp (Palgrave Macmillan 2nd edition 2008)
• Medicine,Culture,Practice and Science, Ed.Bernstein, Burton & Healy (Northern Illinois University Press 2010)
• Nurses of All Nations.History of the International Council of Nurses B.L.Brush & J. E. Lynaugh (pub. Lippincott)
• Containing Trauma. Nursing in the 1st World War C.E. Hallett (Manchester University Press 2009)
• 1st World War Nursing. New Perspectives Hallett & Fell (Routledge 2013)
• Veiled Warriors. Allied Nursing in the 1st World War C.E. Hallett 2014

Journals

• Social History of Medicine: The Limits of Government Patronage of Sciences. Social Hygiene and the Soviet State 1920-1930, Susan Gross Solomon 1990
• Mortality in Late Tsarist Russia. A Reconnaisance K. David Patterson 1995
• Gendered Dis/ability. Perspectives on the Treatment of Psychiatric Casualities in Russia’s Early 20th Century Wars Laura L. Phillips 2007
• Social History: Russia’s Factory Children.State,Society and the Law 1880-1917 review by J. Humphries 2011
• Popular Perceptions of Soviet Politics in 1920s. Disenchantment of the Dreamers. review by Storella 2013
• Spanish History of Medicine Society: Sanitary Trains and Epidemic Control. The US Red Cross in Siberia During the Russian Civil War
• Clifford M.Foust 1992
• Kritika: Workers,Revolution and Stalinism D.Shearer 2011
• International Review of Social History:Bolshevism, Stalinism and Social Welfare 1917-1936 D. Caroli 2003

New Frontiers in Medicine

In spite of the poor state of healthcare in Russia, there are some signs of promise. State-sponsored research into the mental health treatment of Russian soldiers has yielded some unique findings. Take, for example, the anxiolytic supplement Phenibut, which was first synthesized at the A. I. Herzen Leningrad Pedagogical Institute (USSR) by Professor Vsevolod Perekalin’s team and tested at the Institute of Experimental Medicine, USSR Academy of Medical Sciences.

Since its discovery and synthesis, Phenibut, marketed as Noofen made its way from the lab and into outer space; it is included in the standard medical kit of every space-bound cosmonaut. Phenibut earned its place in space thanks to its ability to calm the mind without side effects of drowsiness, lethargy, or fatigue.