Medical Service in Other Countries

Mention of the international aspect of positive health problems suggests that we should look at the medical services of other countries. It will be obvious from what has been said that there would be no hope of any international co-operation in dealing with disease if the medical services of other countries were of a lower standard, or less well organized than those of Britain. There are still considerable variations in the training of medical men in different countries, and there will probably always be some discussion as to whether one country’s medical standard is higher than another’s. There are, however, many areas of the earth’s surface in which medical service, even as we know it, is non-existent, and in some countries which consider themselves civilized the number of medical men is so far below the needs of the population that large numbers live and die without adequate medical attention.

There are only two countries in the world, Soviet Russia and New Zealand, where attempts have been made to organize the medical services on a nation-wide basis; in all other countries there is more or less the same mixture of methods and systems as in this country, much of the medical care being in the hands of private individuals or charitable institutions with the State organizing only those parts which private enterprise has left neglected. The rise of the industrial revolution and the realiz­ation that the work of millions of people could be used to make fortunes for the few led at first to a total disregard of the health of the lives of the workers; at a later stage, however, it was realized that this policy was foolish if too many workers, and in particular too many children who were potential workers, died and a certain amount of organization of the medical services to meet this difficulty was therefore carried out. In Germany, for example, there was as early as 1883 a system of health insur­ance, and in many countries, of which the Scandinavian com­munities are perhaps outstanding, the work done in dealing with particular diseases such as tuberculosis led to considerable im­provements. It cannot, however, be claimed that in these matters the medical profession ever gave a lead to the community, and the greatest improvements in the health of the majority of the population were due to changes which they themselves forced on the industrial system by shortening hours and improving wages.

To-day there are four countries whose medical service position is of particular interest. In New Zealand there is on the statute book a Social Security Act which guarantees among other things a complete and free medical service to the whole population. In its primary conception this service was intended to operate very much like the panel system in Great Britain, the doctors being left to work as individuals but to be paid by the State which in this way guaranteed that the service would be free to every citizen. Unfortunately, and for no very clear reasons, the medical profession in so far as it is represented by the British Medical Association in New Zealand refused to operate this scheme; the Government then made what outsiders generally considered a very generous offer to pay to the medical profession as a whole five per cent more than it had ever earned, and to leave the question of how that extra money was to be allocated to the profession itself; but still the doctors, most of whom appeared to be political opponents of the New Zealand Labour Government, refused to operate the scheme even under these favourable conditions; having tried in vain to persuade the profession to negotiate a basis on which the scheme could be operated, the Government has now agreed that when a doctor refuses direct State payment, patients shall continue to pay their doctor as before and that all such payments will be repaid by the State. Other measures introduced include free dispensing and free X-ray diagnosis, but it is not yet clear whether in the end the New Zealand Government will not be compelled, by the resistance of the British Medical Association, to introduce exactly the type of service which some of the doctors feared, a full-time organized service covering the whole of the medical profession. The New Zealand position illustrates more than any other fact that can be quoted the political backwardness of the medical profession, and has led in New Zealand to a feeling that the doctors there were concerned solely with their own financial interests and not with the health of the community.

The second country which presents us with much of interest in medical organization is America. The medical service of the United States has developed on lines somewhat similar to those of Great Britain, but in recent years there has been an enormous amount of interest among the lay population as to the cost and distribution of medical care throughout the United States. Many investigations have revealed that medical care is exceed­ingly costly for most of the population, and that in many areas it is so badly distributed that quite large proportions of the poorer sections of the community are almost without the attention of doctors. These revelations have led to the development of two movements which are likely to revolutionize the whole of medicine in America. On the one hand, the Government has declared its intention and the Roosevelt administration is prepared to spend large sums of money in seeing that hospitals and other forms of medical care are made available in those parts of the country where they are most needed. There has already been a clash between the administration and the American Medical Associa­tion, which, like its New Zealand counterpart, is opposed to any serious change in the form of medical service, as a result of which attempts by the A.M.A. to prevent certain developments have been challenged in the law courts, which decided against the Medical Association.

The second great development is the setting up of organizations for the provision of co-operative medicine; this is a form of medical insurance through which, by the pre-payment of small amounts, medical service in time of sickness is guaranteed; these medical co-operations have sprung up in every part of the United States and are attracting enormous numbers of patients. As a rule the doctors working in this system are full-time salaried officers, and in the best examples of the service the control is generally held equally by the doctors and their patients, all of whom are members of the organization. The importance of this American development is its recognition of three principles:

1. That the risk which all run of needing medical service when they can least afford to pay for it can be made financially easy by co-operation,
2. That the doctors who work in such a service, and who are paid a salary, give as fine a service to their patients as under any other system, and can in many ways work better to the advantage of the sick, and
3. That a medical service to be of any value must be based on the general practitioner who has at his call specialists in other departments.

In South Africa we have an outstanding example of mal­distribution of medical care, combined with a real lack of medical personnel and hospital accommodation. Taking the Union as a whole there is less than one doctor for every five thousand of the population, and the incidence rate of certain preventible diseases is very much higher than for England. When the areas in which the native peoples are mainly crowded are considered separately the position is appalling; medical care is almost non-existent, returned miners spread tuberculosis and venereal disease throughout the community and the hospital beds provided for the natives cannot take more than a fraction of those needing institutional care.

In the last four years there has been a public and professional awakening to the position, and in February 1942, on the motion of Dr. Gluckman, who has strongly condemned the present conditions, the South Africa Government agreed to set up a Medical Commission to study and advise on the best scheme for providing a health service for the Union. The schemes so far suggested nearly all recognize that nothing short of a complete scheme for medical care provided by the State and covering equally both white and native populations is likely to serve; and it is forecast that the example of Soviet medicine may be closely followed.

When we turn to Russia we discover a totally different type of medical service from any other existing in the world, and a totally different attitude towards the provision of health services. This arises from the recognition by the Government of the U.S.S.R. that the people’s health is absolutely essential for the welfare of a nation. Just as they recognize that every citizen of the modern Russian State has a right to a share in all the goods necessary for life which are produced within the State, so health, as Professor Sigerist puts it, ” is one of the goods of life to which man has a right; wherever this concept prevails the logical sequence is to make all measures for the protection and restora­tion of health accessible to all, free of charge; medicine like education is then no longer a trade; it becomes a public function of the State”.

Under these circumstances the State recognizes that if the medical services are to be adequate they must be planned for the nation as a whole. A further recognition is that the prevention of disease is fundamentally a question of providing an environ­ment in which it is possible for the body to remain healthy and to resist disease, and the prevention of disease by environmental means is therefore kept in the foreground of all the health activities of the State. For this reason the control of housing, of industrial conditions, and other important aspects of life comes under the care of the People’s Commissariat for Public Health. Another function of that department is to encourage and look after the communal restaurants which in the Soviet Union have achieved such popularity that they serve twenty million people a day.

As we have said, the recognition that the protection of health is a function of the State leads to the obvious inference that the medical services must be free. It is clear that no service provided by the State is ever really free to the citizens who must in some way or another pay for what they get. In the Soviet Union a large proportion of the cost of the medical services is financed through social insurance which is administered by the trades unions; the remainder of the funds come from the State budget which in Russia consists of the profits made on the industry of the country as a whole. Where the importance of the service being free arises is in the complete separation of the medical services from any question of fee paying; in other words, the relationship between the patient and the doctor and any other medical service is entirely without economic barriers. Whether in health or in sickness every citizen of the Soviet Union has a right to the services of the whole of the medical system of Russia as it exists at any particular moment; in ordinary terms, he has at his disposal the services of a general practitioner who can refer him to any or every type of specialist and specialist service which he considers necessary.

It is worthwhile recording that when the Russian revolution took place, while certain sections of the Russian medical pro­fession were of a standard equal to that of the best of any other country—for example, the physiologist Pavlov was known throughout the world as one of the greatest research workers who ever gained the Nobel prize—the medical services of Russia as a whole were exceedingly backward. In pre-revolutionary Russia there had been an attempt to provide a type of medical service whereby medical stations were set up all over Russia in an effort to provide some medical care for the rural population. In addition there was a system whereby physicians toured certain areas at regular intervals and each saw whatever patients turned up on the particular day on which he visited a village or a town. These methods only touched the fringe of the problem and there were districts in which one physician had to try with very poor equipment to give a medical service to as many as forty thousand inhabitants, and the number of hospitals and proportion of hospital beds to the population was very low indeed. In 1914 the death rate for the whole of Russia was round about thirty per thousand and the infantile mortality per thousand children born in the ten years before the war averaged 244. Many serious epidemic diseases such as cholera, typhoid and typhus ravaged the population continuously. At the end of the 1914-18 war, and by the time the Soviet Union had overcome internal strife and external attack, the whole situation was so bad that it was recognized that the provision of a medical service was one of the most formidable problems the Soviets had to face. In the twenty years that have passed since then the advance has been tre­mendous. In the ten-year plan, which was interrupted by Hitler’s attack on Russia, it was intended to provide hospital beds to the extent of seven or eight per thousand of the population, a figure which, combined with all the other types of provision that are made for the treatment of the people, would have placed Russia on a level with many other European countries. The number of doctors who have been trained in that period in order to cope with these increased facilities has been astonishing, and in 1939 it was estimated that there were one hundred thousand medical students in the various medical schools of Russia. The death rate for the whole population and for infants had by 1937 been reduced to less than half that of pre-war Russia.

We are concerned, however, not with the achievements of Soviet medicine but with its structure, but emphatic attention must be paid to the opinion of Professor Sigerist, who has given the medical system of the U.S.S.R. more study than any other outsider, and he says, “Nobody can deny that Soviet medicine in the short period of twenty years, and under most trying circum­stances, has stood the test and has created powerful measures for the protection of the people’s health. It has demonstrated that socialism works in the medical field too and that it works well, even now, in the early beginnings of the Socialist State. It is a system that is full of promise for the future—for a very near future.”

The structure of the Soviet medical system follows the general administrative structure of the country. In order that planning may be complete for the whole State it is controlled on the one hand by the People’s Commissariat of Health, on the other hand by health committees and health nuclei organized in every factory, on every one of the large collective farms, and in every district. The one form of control is the natural outcome of the recognition that health protection is a function of the State, the other is the logical outcome of the principle that the workers themselves must take an active part in the protection of their own health. The system as it now stands is therefore not one forced on either the people of Russia or the medical profession by a particular group or class, but has had the active support and criticism of those interested in the service either as the pur­veyors of medical treatment or as the consumers of medical care.

It will be recollected that Russia takes her present name— the Union of Socialist Soviet Republics—because the adminis­tration is divided up so that local government is carried out by a form of local authorities known as Soviets. Under the con­stitution, each of these Soviets appoints certain committees for certain functions, and one of these must always be con­cerned with the public health. Its duties, as laid down by a decree on January 1st, 1931, are

• To supervise all hospitals and sanitary establishments;
• To take all necessary steps in the organization of sanitary inspection and combating venereal disease;
• To advance the knowledge of personal hygiene and develop physical culture.

In addition it has other duties in relation to social insurance.

There are altogether some seventy thousand such Soviets in Russia apart from the Soviets of the larger cities which function in a slightly different way, not without parallel in the case of an urban district council and a borough council in one of the large cities of this country. The smaller Soviets are linked in districts or Rayons, and each of these has an Inspector of Public Health, a doctor, who is responsible for the entire health work of the district. A large city such as Moscow, which has its own central Soviets and local Soviets, is also divided into districts comparable to the boroughs of London, and each of these also has its own health department and its own Inspector of Public Health. In the very largest districts further sub-divisions may be made, for it is the aim of the system to use units which can reflect the needs of the individual citizen.

The districts or Rayons are further centralized in larger units which we may call regions, and these are in turn under the central administration of each of the Republics through a Commissariat of Public Health. This Commissariat directs and controls the whole of the health work of the Republic, and is concerned therefore with the prevention,, diagnosis and cure of disease. In addition it controls medical education, medical research, and any industries connected with medicine. It should also be noted that while the local health departments are Responsible to the general executive committee in administrative and financial matters, their responsibility in regard to medical and sanitary problems lies entirely with the Commissariat of Public Health; there is, therefore, no interference with purely medical questions by organizations or authorities not directly connected with the medical profession. As a further safeguard it is laid down that the Commissar of Public Health must be medically qualified.

This administrative machinery is concerned with the provision of a complete medical service for every citizen and recognizes the need for health education, the need for health protection in industry, the need for the diagnosis and treatment of disease, and the provision of methods for rehabilitation. As a method of organizing this service the individual, rather than the family, is regarded as the unit to be cared for, and much of the medical service is therefore closely linked with industry. In many factories, in mines, collective farms, and so on, the workers come under the care of the medical profession at a health protection station provided at the place of employment. These stations are respon­sible not only for the health of the individual workers, who are examined before admission to employment, and in many industries at regular intervals, but are also responsible for the factory conditions. They have also to make arrangements for any worker who, although able to carry on at his job, requires special treatment, and the provision of special dietetic dining-rooms is a feature of many factories; so also are the night sanatoria where people who require more than the average rest are treated something like convalescent patients, although they go to work during the day. In the case of incipient tuberculosis this has been a strikingly successful method of dealing with the condition. In addition to the factory health protection stations there are similar centres for those sections of the population who are not in industry. The relatives of workers may elect to be attached either to the factory health station or to the district centre, whichever is most convenient.

The work carried on at these health protection stations is, apart from the periodical health examinations and health propaganda, very similar to the work of the general practitioner in every country. Diagnosis and treatment of disease is done at all of them; those patients who require specialist facilities either of a diagnostic or curative nature are referred from the health protection stations to a district or factory polyclinic. These polyclinics provide a complete specialist and consultative service, including X-rays and laboratories; some of them are very large indeed, especially those connected with a particular industry, and one in Moscow employs nearly four hundred doctors.

The polyclinics and health protection stations provide the centres from which domiciliary visits are arranged. All patients are expected to attend at the centre if possible, and appoint­ments are made in every case; those who are unable to attend have only to telephone to the clinic, when a doctor will be sent to visit at the house of the sick person; that doctor can then arrange for admission to hospital, having only to report to a central bureau for all arrangements for the removal of the patient to be completed by the clinic staff.

Particular stress on the need for convalescent treatment and other forms of health restoration is made in the Soviet system. There are very large numbers of sanatoria and rest homes, many of the latter being in the southern parts of Russia where the climate is sub-tropical. These sanatoria and rest houses are an integral part of the medical system, and are therefore available to all patients whose doctor regards them as likely to benefit from a period of rest in such a place.

The provision of drugs and chemicals for a medical service for a country with a population approaching two hundred millions is obviously of great importance, and the Commissariat for Public Health controls the whole production of drugs in Russia, and all medicines are dispensed by State pharmacies attached to the hospitals and clinics. No patent medicines as we know them are permitted, although permission may be obtained for the sale of proprietary medicines from outside Russia which the profession recognizes are of value.

All medical workers of every type and of every grade are employed and paid by the State. Medical education is open to anyone having the necessary ability, and scholarships cover the cost of living as well as the cost of tuition. The doctors employed in any district or factory health station have their share in the control of the service of which they are a part, and are encouraged to regard themselves as part of the team appointed by the State to ensure the maximum health for all.

Before leaving this subject we should mention that special care is taken of the mother and of the child in Russia, and that ill-health is not allowed to interfere with the right of every citizen to a sufficient share in those things necessary for health; in other words, all workers are guaranteed maintenance, and there is security in old age. The care of the child begins, as it is everywhere recognized it ought, in the ante-natal clinic, and as so many Russian mothers are employed in factories there is a compulsory thirty-five days leave on full pay before confinement. Particular care is taken of the pregnant mother in every way, even to the provision of preferential treatment in queueing up for buses. After a child is born the mother has a further twenty-eight days leave from work on full pay, and may then return to work. In order that she may do so, factory creches and nurseries are available everywhere, and millions of Russian children normally spend part of their life in such a nursery under constant medical supervision. It is regarded as an important psychological contribution to the future development of the Soviet State that so many children are being brought up under conditions in which, from the very start, they have to take their part in co-operating with their equals in every way.

There is no gap, as there is in this country, in the medical service provided for children, for in addition to school inspection they can be seen at any time either at the ordinary health station or at special polyclinics.

To summarize the Russian system is very difficult, but from the patients’ point of view it amounts to this. There is provided for every citizen a health protection station, in relation either to his employment, or his place of living, at which he can- attend whether in health or in sickness for medical examination; from this place he can obtain the services of a general practitioner who has at his command a full consultative service, with ready admission to hospital and to other facilities. His health is looked after, both as an individual and, by the close examination of his factory conditions made by the health services, as one of an industrial group.

From the doctor’s point of view the system operates so that he is a full-time servant of the State, drawing his salary from public funds. Whether he functions as a general practitioner, or as a specialist, he will be one of a team with a definite job to protect the health of the people in a given area, or industry, and will have ample opportunity both for advancement, for study, and for recreation. The system recognizes the possibility of any doctor taking up a new branch of medicine and becoming a specialist in it, and recognizes the possibility of lower grade medical workers, such as technicians, studying and qualifying in medicine.

In addition the State recognizes that research in medicine is of the utmost importance to the future health of the people of Russia, and every opportunity is given to all doctors to carry on individual research. The State has established large research institutes, staffed by whole-time research workers, engaged in trying to find a solution both to the general problems of medicine and to those of particular importance to Russia. The work done in these institutes, like the whole of the Russian medical service, is capable of being planned in every detail, but every effort is made to allow full freedom for those whose work or particular ability leads them to investigate problems that are not part of the general plan. The world has already had some advantage from this research in these Russian institutes, for much of the modern work on blood transfusion, and on the preservation of blood in various forms, has its origin in Soviet Russia.

When Hitler attacked the Soviet Union the medical services had only just begun to work out the steps of the ten-years’ plan which it was hoped would produce a medical service in every part of Russia that would bear comparison with that existing in almost every other country. The war against Hitler obviously destroys all possibility of that plan being fulfilled, but cannot alter the lessons which the Soviet system has already given us, namely, that it is possible to organize medical services as a whole, to prove to a people that the efficiency of the service and not the pleasantness or other attribute of the individual doctor is the important thing in modern medicine, and to demonstrate that once the protection of health has been recognized as a function of the State, and a medical service has been provided free for every citizen, the health both of the individual and of the nation can be improved in a way that would have been impossible in a backward country like Russia, under the old system, in any imaginable period of time.