The bourgeois press understandably brushes the question of health under the carpet, but it is a subject which has the greatest of importance, especially for people who are fighting for improved conditions of life, as good health is central, fundamental, to a decent life. In our comparisons of socialist and capitalist societies we should give the example of health, for it is a fact that every single socialist society has a good record on public health, has prioritised health, has made comprehensive health care of the highest quality available to all people, whereas no capitalist country has done this. You only have to look at the situation in the world today to see capitalism’s regard for health. According to official statistics, 40 million people die every year due to starvation-related diseases. There were 5.6 million AIDS-related deaths last year and 33.6 million people are known to be HIV-positive (of these, more than half are under 25 and are expected to die within a decade). Such gigantic problems, yet the amount of money that would be needed in order to provide every single person on the planet with decent basic health care is equivalent to around 3% of the world-wide annual military budget. You can see just how decadent monopoly capitalism has become!
Technology and medical science has progressed so much that, in this day and age, there is no reason why everyone cannot be afforded excellent quality health care. There is no reason why all people cannot enjoy good health. Indeed, this should be considered to be a fundamental human right. Instead we face waiting lists and shortages of doctors and beds.
The questions I have been asked to address are the following: What was the policy of the Soviet state regarding health? What was the USSR’s record on health? How was health care organised in the Soviet Union? What developments were made? In the pages that follow I will attempt to tackle these questions.
Medicine in Pre-Revolutionary Russia
The builders of socialism in the USSR inherited a medical system in an appalling state. There was no central medical body in Russia to co-ordinate health matters, the vast majority of the population lived in extreme poverty, there was a shortage of doctors (in some districts there were as few as 1 doctor per 40,000 of the population) and a huge part of the population had never even received medical care from a doctor. Yet despite all this, there did exist a medical movement in Russia which would provide a basis for the first steps towards a socialist health care system.
The first catalyst for an organised medical system in Russia was Peter I, who set up the first Russian hospitals (in Moscow in 1706 and in St. Petersburg in 1715), using doctors from abroad, and the Academy of Science (in 1724) to train Russian doctors. Catherine II followed the lead of Peter, founding a number of hospitals and the first Russian mental asylum (in 1776). However, Russian medicine was still extremely backward. The tsarist bureaucracy was stifling, and professional health care was rarely available to even propertied peasants, and virtually never to the serfs and the industrial workers.
In 1884, the zemstvo – local government system – was introduced in Russia. The zemstvo was a district assembly designed to deal with local matters, including health. It was controlled by the individual landowners, the bourgeoisie and the propertied peasants, each group carrying one-third of the votes. Zemstvo medicine was the first to bring medical care to the peasants, and was the first to set up networks of medical care in the rural areas. Henry Sigerist, author of ‘Socialised Medicine in the Soviet Union’, describes the zemstvos as "paving the way" for Soviet medicine by creating a network of medical stations all over the country that could be improved and increased in number.
The zemstvo medical system was associated more with good intentions than with good practice. It was badly funded and by far unable to fulfil the task it set itself. The exploiting classes, which held the majority vote, were not willing to contribute in a meaningful way to the public health organisations. The zemstvo doctors were enthusiastic and driven by a passion and concern for the health of the population - they devoted their lives to the service of the people. Had their interest been in money they would have been far more successful as private doctors to the rich in the cities. [As a matter of interest, the great Russian playwright Anton Chekhov was at one time a zemstvo doctor]. One of the foremost zemstvo doctors was the famous N.A. Semashko, who would become the first People’s Commissar of Health of the USSR, and who was one of the leading organisers of what would become the best heath care system in the world.
The attitude of the Bolsheviks to Health
The following was included in the program of the CPSU(B):
"As the basis for its activity in the sphere of protecting people’s health, the Russian Communist Party (Bolsheviks) considers primarily the implementation of extensive health-building and sanitary measures with the object of preventing the incidence of disease. Accordingly, the RCP(B) makes its immediate task:
1 and To carry through resolutely extensive sanitary measures in the interests of the working people, such as:
2 improvement of health conditions in populated places (protection of soil, water air from pollution),
3 organisation of public catering on a scientific and hygienic basis,
4 launching of measures to prevent the outbreak and spread of infectious diseases,
5 creating a code of health legislation.
6 To combat social diseases – tuberculosis, venereal diseases, alcoholism etc.
7 To make competent medical and pharmaceutical services available to all free of charge."The underlying principles of the medical system put forward by the Bolsheviks were: comprehensive preventive medicine, healthy working and living conditions, social insurance and health education. The trend of Soviet medicine was from the start towards prevention rather than cure. In the words of N.A. Vinogradov, writing in the Soviet book ‘Public Health in the Soviet Union’, "The Soviet state has set itself the aim not merely to cure disease but to prevent it; the state is out to create such living and working conditions as would make the occurrence of illnesses impossible". Such an approach to healthcare is, of course, logical - any child can tell you that prevention is better than cure. However, when the interest of those controlling society is to extract as much profit as possible out of the workers and to provide them with as little as possible in the way of social facilities, living standards which are conducive to good health are simply not an option. And the question is not just economic but also organisational. Under socialism, the whole of society, the people, the government agencies etc. are all fighting towards the same aim - the improvement of the standard of people’s lives – thus making planning and organisation possible. This is not the case in capitalist society.
Putting Theory into Practice
Soon after the revolution of 1917, Russia was plunged into civil war. Epidemics were spreading and the death rate was high. In June 1918 the People’s Commissariat of Health was established and "for the first time in the history of medicine a central body was directing the entire health work of a nation" (Sigerist). The first task was to tackle the epidemics which were rapidly spreading across the country and which were gravely affecting the troops fighting for the young socialist state. At the 7th Congress of Soviets, held in December 1919, Lenin said "…and still a third scourge is moving upon us – the louse, typhus, which is mowing down our troops…Comrades, every attention must be given to this problem. Either the lice will defeat socialism or socialism will defeat the lice!"
In the face of extreme adversity, in the face of a shortage of soap, a shortage of clothing, poor water supply etc., the Commissariat of Public Health embarked upon its most honourable mission on the basis of systematic, planned action. The focus was on improving the network of medical stations, keeping houses in sanitary conditions, providing the population with bathhouses, combating typhus and improving the water supply. In April 1919 vaccination was made compulsory. The effect of this measure was profound: for example in Petrograd the number of smallpox cases fell from 800 a month to 7 a month. It was in this period that the old Russian doctors saw that the Soviet government was the defender of the people and their health, and the majority joined in the struggle for the survival of the socialist state, rather than deserting.
Health education played a very important role in the battle against pestilence. In 1920, 3.8m Red Army soldiers attended lectures and talks on hygiene, and in 1919 and 1920, 5.5m hygiene posters, booklets and leaflets were published for distribution in the army alone. Such health education campaigns were also carried out amongst the population as a whole.
In 1922 the imperialist armies were finally defeated, in large part due to the work of the new nation in improving its health. With the end of the war came a new health slogan: "On from the struggle against epidemics to the fight for healthier working and living conditions."
Although conditions after the Civil War were far from easy, health improved steadily during the years of the New Economic Policy. By 1928, the number of physicians had increased from the pre-war level of 19,785 to 63,219, the allocation for health protection from 128.5m to 660.8m roubles per year, and the number of hospital beds from 175,000 to 225,000 and the number of nursery places from 11,000 to 256,000. But much more rapid progress was achieved under the first Five Year Plan. People tend to think of the Five Year Plans as they are portrayed in bourgeois history books – concerned only with industrial production and in no way linked to the welfare of the people. Nothing could be further from the truth. The Five Year Plans dealt with all aspects of Soviet life: economic, social and cultural. The plans were not imposed from above but based on extensive discussion and data collection by the workers themselves. In health terms, the First Five Year Plan was largely concerned with increasing availability of, and access to, the medical service: more medical stations, more hospital beds, more nurses and more physicians were needed. The plan was based on a full report by the regional health bodies, the hospitals, the farms and the factories on what was required and what was achievable. In the four years it took to complete the first Five Year Plan, the number of doctors increased from 63,000 to 76,000, the number of hospital beds increased by more than half and the number of nursery place increased from 256,000 to 5,750,000. 14 new medical colleges were established, along with 133 new secondary medical schools.
By now medical facilities were available to all Soviet citizens, and so the Second Five Year Plan concerned itself more with improving the quality of the health care administered. One of the principal tasks was to improve medical education and hence to improve the standard of physicians. New medical and scientific research institutes were established, among them being the enormous Institute of Experimental Medicine, on the initiative of Stalin, Molotov, Voroshilov and A.M.Gorky. Health education among the workers and peasants continued to form a central part of the fight to improve health. S.M. Manton, a British scientist who visited the USSR in 1951, gives a useful account of the widespread health education in the USSR in her book ‘The Soviet Union Today’. She notes that: all doctors were obliged to spend at least 8 hours of every month teaching preventive medicine and answering the questions of the public in places such as parks, lecture rooms and health centres; education in preventive medicine and hygiene was carried out thoroughly in schools; posters and pamphlets were to be found all over the Soviet Union, in different types of institutions, giving instruction on basic health care.
By the end of the Second Five Year Plan, the foundations for a socialist health system characterised by excellence had been cemented. The health system of the USSR was far and away the best in the world.
How was Health care organised in the USSR?
In the Soviet Union, the health programme was administered in the most democratic way, and, like everything in the Soviet Union, its administration had the form of a "triangle with a very broad base". The base of this triangle was formed by the thousands upon thousands of committees which existed in every factory, every farm, every place of work. These committees co-operated with the local doctors in order to give feedback and improve services; they made sure that the workers’ social insurance funds were spent in the most appropriate way; they controlled the hygienic conditions of their place of work and the nurseries; and they organised health education in the workplace. Elected representatives from the workplace would be involved in the next highest form of organisation – the Soviets. The Soviets were responsible for the supervision of all hospitals and sanitary establishments, sanitary inspections, wider organisation of education in personal hygiene and so on. The next highest form of organisation was the rayon/district, of which there were around 3,000 in the USSR. In each district there was a Health department, headed by a Rayon Inspector of Public Health, who was held responsible for the entire health work of the district, The Health Departments controlled, inspected and advised all medical institutions in the district. At the apex of the pyramid stood the Commissariat of Health, which was advised by the various scientific research institutions.
By organising the health system in such a way, the entire population was involved directly, and hence felt very strongly about improving the health of the nation. Habits and attitudes of the people changed dramatically from the pre-revolutionary days. Sigerist describes some of his experiences in 1936:
"The habits of the Russian people have been changed radically in a very short time. The cities are spotlessly clean, and the foreigner soon learns that cigarette butts are not supposed to be thrown on the street but into special cans placed at every corner. I remember a long railroad ride from Moscow to Kazan during which the conductor came to clean my compartment every two hours, which was more often than I liked. When I asked her to let me sleep in peace, she said ‘Well, citizen, I have to clean the compartment because the inspector may come in at any station, and the car must be kept as clean as it was when we left Moscow – but I will do it without disturbing you.’ No visitor is allowed to go into food factories, medical institutions, or nurseries without sterilised gown and cap. Such regulations may sometimes seem exaggerated, but they are part of a great educational programme, and far-reaching results cannot be expected unless there are strict rules which must be followed literally."Ever-increasing spending on health resulted in continually-improving services. By 1937 there were 132,000 doctors in the USSR, as compared to 2,000 in tsarist Russia. The difference was most marked in the non-Russian republics. In Azerbaijan there were, by 1941, 2,500 doctors, whereas before the revolution there had been 291. In Tajikistan there had been only 13 physicians. By 1941 there were 372. In tsarist Russia there were 9 child and maternity welfare centres. In 1938 there were 4,384. Kindergartens, nurseries, rest homes for mother and child – all of these were built. By the time the 2nd 5-year plan had been completed, hospitals, hygiene institutes and health centres were to be found all over the USSR. All types of treatment – hospital treatment, physiotherapy, radiotherapy, sanatorium cures, dental treatment, maternity services and so on – were available to Soviet people free of charge. Sanitary Commissions were organised in apartment homes. The members of these commissions had been elected by the local population and were trained in special Hygiene Education Centres. The public health budget of the USSR in 1937 was approximately 75 times that of Russia in 1913. The per capita expenditure for medical purposes in 1913 was just 90 kopecks. By 1937 it had increased to 60 roubles.
As a result of the social insurance system whereby all workers and peasants contributed a certain percentage of their earnings to the social insurance fund, ALL aspects of health care were free – not like in England, where you have to pay for prescriptions, for dental care, for physiotherapy, for osteopathy, and where the national health service is so badly funded that you cannot expect decent health care from it.
Private medicine in the USSR was never banned, but withered away, since people had a free service of equally good, if not better, quality.
The material basis for bad health was got rid of. In the capitalist world, the main source of disease is poverty. It is well documented that the poor suffer considerably worse health than the rich. Pappas et al (1993) report that, in 1986, Americans with a yearly income of less than $9,000 had a death rate 3-7 times higher than those earning $25,000 or more.
The British General Household Survey of 1989, in a study of thousands of people, showed the existence of long-term illness to be twice as high for unskilled manual workers as for professionals such a doctors and lawyers, and surely a comparison taking into account the vast army of unemployed would produce even more frightening results. These statistics are no coincidence, nor are they indicative of some kind of genetic weakness of poor people. They merely highlight the fact that the working class is forced into living conditions which are not conducive to good health. If you are short of money, you are forced to live in poor accommodation. The council does not clean your streets, and you’re lucky if your rubbish is taken away even on a weekly basis. Heating is expensive, so you must compromise your health in order to keep the bills low; healthy food is expensive; warm clothing is expensive; hot water is expensive; cleaning products are expensive; exercise is expensive; treatment is expensive; the air is polluted; the streets are dirty; the buses and trains are rarely cleaned and are hence a breeding ground for disease. It is little wonder that the nation’s health is so bad.
"In the USSR… unemployment, destitution and poverty have been permanently done away with on the basis of the abolition of the exploitation of man by man. In a remarkably short period of time the socialist state has succeeded in raising the material and cultural level of the entire population enormously, thereby laying a firm foundation for successful work in the field of public health"
(Professor N. Propper-Grashchenkov, Assistant People’s Commissar of Public Health, in an article entitled ‘Public Health Protection’).
The Soviet Union wiped out slums and provided both town and country with water mains, sewer systems and electricity. In addition to this, the quality and quantity of the foods available were increased beyond all recognition. The output of the food industry in the USSR in 1938 was approximately 6 times the output of the food industry of Tsarist Russia in 1913. Nutritious food was made available to the entire population, and its production and consumption increased constantly. Over the period of the second Five Year Plan, consumption by workers of fruits and berries increased three-fold, consumption of ham, bacon and other cured meats increased five-fold, and consumption of eggs increased two-fold. In 1938 the per capita consumption of protein was over 100g per day, compared with 35g in Germany. The national payroll in 1938 was three times what it was even in 1932.
Not only this. Research over the last few decades has proved that, in addition to material factors, psychological factors are a major cause of illness. There has been found to be a direct link between stress, especially stress over which a person has no control, and immune function. Of course the workers, with the conditions they face, suffer the greatest stress, and this affects their health. It has also been demonstrated that there is a definite link between levels of control and health. Researcher such as Kobasa et al (1979) show that those who feel themselves to have little control over their lives, even when adjusting for other influencing factors, suffer from worse health. Under capitalism, the small minority, the bourgeoisie, is in control, and the life of the average worker is in the hands of the ruling class. The USSR, by putting control in the hands of the proletariat, by allowing the necessities of life to be supplied plentifully, and by providing decent leisure facilities, was able to improve peoples’ psychological as well as material conditions, and hence further improve health.
Results of the Health care in the USSR
I would like to conclude by quoting some of the direct results of the USSR’s attention to health care:
· By 1938, the 21 years of Soviet rule had brought about a 50% reduction in child mortality rate.
· The height of the average Soviet child in 1938 was one and a quarter inches greater than that of the average child in tsarist Russia.
· The weight of the average Soviet child was eleven and a half pounds greater in 1937 than in 1925.
· The chest expansion of the average Soviet child in 1938 was roughly 1 inch greater than that of the average child in tsarist Russia.
· Incidence of tuberculosis decreased 83% under Soviet rule up till 1938 and continued to decrease.
· Cases of syphilis decreased 90% by 1938 and continued to decrease.
· The death rate in 1937 in the USSR was 40% below the death rate in Russia in 1913 (implying a much higher life expectancy)
· The birth rate increased constantly. Even just from 1936 to 1937 the birth rate increased by 18%. In Leningrad the natural increases in population increased from 5.3 per 1000 in 1913 to 18.6 per 1000 in 1937.
· Reported cases of sickness and accidents decreased consistently.
Such figures provide absolute proof of the benefits of socialism to peoples’ health, even though they really only reflect 10 years of socialist construction. I have not had the time or material to cover much of the period after the second world war (this shall be done at a later date), but the period from 1945 to 1953 certainly saw massive improvements in the peoples’ health in the USSR.
Even by the mid-thirties, health care in the USSR far outstripped the health care in the western world. The report of the Administrator of the United States Federal Security Agency, published in 1948, showed that a sixth of the US population suffered from chronic ailments, 200,000 children were afflicted with epilepsy, 175,000 had tuberculosis and 500,000 were in need of surgical or orthopaedic treatment. However, decent medical care remained out of reach for a large part of the population. This situation has still now seen very little improvement. It is estimated that in the US, the richest country in the world, 40 million people are without health care because they cannot afford the health insurance. Those who do have health care (mainly in the form of Health Maintenance Organisation (HMO) schemes provided for employees) find the quality of the health care afforded to them to be wholly inadequate. In a recent survey conducted by the OECD, 61% of respondents said that the HMO care plans have decreased time being spent by the doctors with the patients; 63% said that HMO schemes made it harder for sick people to see specialists; and 50% said that there is now a decreased quality of health care for the sick.
In Britain, the situation within the NHS goes from bad to worse. The number of hospital beds has fallen from 194.000 to 103,000 over the last decade and the number of doctors per 1,000 head of population has fallen below three. Horror stories such as that of the man, whose cancer operation was cancelled four times and whose condition subsequently became inoperable, are becoming commonplace. Even Lord Winston, New Labour’s favourite doctor, felt compelled to speak out (only to be put under severe pressure from the Downing Street spin doctors). He said that Labour’s reorganisation of the health service was very bad, and that medical care had been made "deeply unsatisfactory for a lot of people".
The dismantling of the NHS and its gradual transformation towards privatisation are in line with monopoly capital’s policy of dismantling the welfare state. Imperialist competition is driving each of the powers to level wages and social conditions to the lowest denominator. The same dismantling of the welfare state is happening in all imperialist countries, and, by and large, it is social democratic administrations who have been brought in to do the dirty work (this dismantling is presented by governments as positive change – David Blunkett, Labour’s Education Secretary, is on record speaking of the welfare state as "undermining self-reliance"!).
Meanwhile health care in socialist countries has continues to improve by leaps and bounds. Today’s world leaders in health are Cuba and the Democratic People’s Republic of Korea. It is in these countries that the people enjoy the world’s best health care and where the greatest innovations in medical science are being made. Examples of the extraordinary contributions made by Cuba in the field of medical science include the discovery of vaccines for dengue fever, hepatitis B and meningitis B; the development of policosanol – a medicine derived from sugar cane which lowers cholesterol and treats lipid disorders); and the development of advanced monoclonal antibodies for the treatment of cancer.