Before the Great October Socialist Revolution, healthcare in the Russian Empire was scattered among various departments and charitable organizations, and in cities it was mainly represented by private practitioners. For the entire population of Russia, which in 1913 amounted to 159 million people, there were 28 thousand doctors, that is, on average, two doctors per 10 thousand people. Moreover, most doctors practiced in large cities of the European part of Russia. There were 208 thousand beds in hospitals (1.3 beds per 1000 inhabitants). More than a third of cities at that time did not have hospitals at all.
In terms of sanitary conditions, tsarist Russia was the most disadvantaged country in Europe. Every year, 2 million children died from disease. The average life expectancy at that time did not exceed 32 years. Epidemics of typhus and relapsing fever, cholera and other infectious diseases were frequent occurrences. Preventive medicine was virtually non-existent.
In rural areas, despite all the efforts of the local doctors, the situation was even worse. According to the official data of the Office of the Chief Inspector, in 1909, for every doctor in the rural areas there was an average of 24.5 thousand inhabitants. At the same time, in about a third of the rural areas, a precinct system was not introduced, which led to large losses of time, since doctors had to travel around the villages to each patient.
Immediately after the Great October Socialist Revolution, on December 22, 1917, the Soviet government adopted a decree on the “work insurance program”, which significantly expanded the range of citizens subject to health insurance. Moreover, all insurance costs were fully borne by the entrepreneurs. These measures met with warm support from the working masses, who received access to high-quality and free medical care, but faced a boycott by a significant part of the medical community due to their rejection of the Soviet power and the expectation of its early overthrow, which would lead to the return of the previous orders of work.
The All-Russian Congress of Medical and Sanitary Departments, held on June 15-18, 1918 in Moscow, recognized the need to create the People’s Commissariat of Health, in charge of all medical and sanitary affairs in the Soviet Republic. The first People’s Commissar of Health of the RSFSR was Nikolai Aleksandrovich Semashko, who held this post until 1930. At the congress, in his report N.A. Semashko outlined the principles of the organization of Soviet health care, noted the need to eliminate the former interdepartmental disunity and solve the problems of ensuring the general availability and free of charge medicine, improving the quality of medical care (creating special outpatient clinics and hospitals). The report emphasized the need to combat the raging epidemics (tuberculosis, cholera, malaria, venereal diseases, and the like). Thus, in our country, for the first time in the world, a supreme state body was formed, which united in its jurisdiction all the medical and sanitary health care of the Soviet Republic. The congress laid down the basic principles of Soviet health care. The Council of People’s Commissars of the RSFSR instructed the People’s Commissariat of Health to take emergency measures to combat diseases, providing appropriate funding for this purpose, and ordered it to report twice a week on the progress of the fight against epidemics. In 1918, the Central Commission for Combating Epidemic Diseases was formed. Based on the materials of the work of this commission, a plan for combating epidemics was drawn up and sent out, providing for the deployment of hospital 2 beds, the device and equipment of baths, laundries, disinfection points, registration of morbidity, as well as the broadest sanitary educational work.
The formation of a unified Soviet health care system was not easy. It was necessary to overcome the resistance to the unification of medicine from a number of departments. This especially concerned the merger with the medical unit of the People’s Commissariat of Railways and the Main Military Sanitary Directorate. The new Soviet health care system was created in the conditions of a huge flow of wounded from the fronts of the civil war, as well as a large number of sick and refugees in the context of an acute shortage of doctors and medical personnel, hospitals and medicines. A particular difficulty was that the new Soviet health care system was created for the first time, without any experience in creating such an organization.
In December 1918, the Soviet government approved a decree on the nationalization of pharmacies. A specialized pharmaceutical department was set up in the People’s Commissariat of Health to organize drug care under the new conditions, and pharmaceutical subdivisions were established in health departments under local councils. Gradually, medical specialists began to realize that the Bolshevik Party and the Soviet government, as well as the decisions and decrees they made in the field of health care, were permanent and were consistently implemented. As a result of the measures taken by the Soviet government, high-quality health care became an increasingly guaranteed right for all Soviet workers and the entire population of our country.
One of the main reasons for the spread of infectious diseases was the very unfavourable sanitary and epidemic state of the country, which was aggravated by the low level of sanitary culture of the population, complicated by the civil war and foreign intervention, together with the economic devastation caused by them. There was also an acute shortage of hygiene items, disinfectants, equipment for disinfection chambers, baths and the like. Among all infectious diseases at that time, the most common were parasitic typhus, especially typhus, from which 1918 to 1922 more than 6 million people fell ill. The total mortality rate among patients with typhus in those years was 6. Malaria was rampant in a number of regions. To organize the fight against epidemics in the very first days of the work of the People’s Commissariat of Health, a sanitary and epidemic department was created in its structure. In 1918, the Central Commission for Combating Epidemic Diseases was formed. Based on the materials of the work of this commission, a plan to combat the epidemic was drawn up and sent out, providing for the deployment of hospital beds, the installation and equipment of baths, laundries, disinfection points, registration of morbidity, as well as the broadest sanitary educational work.
At the insistence of V.I. Lenin, the jurisdiction of the People’s Commissariat of Health included medical insurance, as well as the cost of protecting mothers and babies.
In March 1920, the 2nd All-Russian Congress of Health Departments was held, at which the results of the work done were summed up and further paths for the development of Soviet health care were outlined. By that time, compared with 1913, the number of medical institutions increased by significantly improved preventive treatment of the population, an effective medical assistance at home, first aid stations had been created at enterprises, epidemics had subsided significantly. Let us especially note all this was achieved in the conditions of the civil war that had not yet ended. One of the most important was the decree on the priority servicing of especially hazardous industries.
In 1920-1921, the Sanitary Epidemic Department of the People’s Commissariat of Health carried out a campaign to combat acute gastrointestinal diseases. As part of this campaign, a Water Supply Week was organized to draw attention to the protection of water sources and to take urgent measures to improve them. At the same time, water supply sources were cleaned and 3 repaired. The People’s Commissariat of Health took large-scale measures to combat cholera. Anti-epidemic measures were urgently carried out in cities and towns, at railway stations, at river and sea terminals. The network of hospitals expanded. Old and new medical institutions were provided with inventory, food and medicine. Diet meals were organized for patients. As a result of the measures taken, already in 1922 it was possible to achieve a real decrease in the incidence, and in 1923 the epidemics were practically eliminated.
In 1919 N.A. Semashko presented draft decrees on compulsory smallpox vaccination and on measures to supply relevant medical institutions with the necessary materials and equipment. All decisions on the report of N.A. Semashko and measures were taken immediately.
At that time, mass health education was given serious attention in preventing the spread of infectious diseases. Popular brochures and posters on the fight against typhus and relapsing fever and other infectious diseases were produced. There were also various sanitary “weeks”, “week of fighting typhus” and others. The purpose of these “weeks” was to familiarize the general population with health problems and to involve them in a conscious and active participation in health protection. Thanks to such measures, it was possible to achieve a serious turning point in the fight against epidemics and create conditions for their complete elimination.
After the end of the civil war and the transition to the New Economic Policy, the attention of the People’s Commissariat of Health was drawn to the restoration of old and the creation of new medical institutions, to the implementation of broad preventive measures to improve the health of work and life. Measures were taken to organize tuberculosis and venereal dispensaries, which actively carried out not only therapeutic, but also preventive activities. A wide network of dispensaries for combating occupational diseases was also created. A dispensary examination of workers employed in industries with hazardous working conditions began, with the obligatory registration of such workers and their periodic comprehensive medical examination in order to detect diseases in a timely manner.
The People’s Commissariat of Health developed instructions for organizing workplaces, providing them with the necessary supplies, arranging dwellings and various consumer service establishments. Serious attention was paid to the condition of courtyards, villages, gardens and parks. To further improve the system of medical care and prevention of diseases, a wide network of sanatoriums and rest homes was organized. In the conditions of the civil war, the Soviet government preserved many of the resorts of the Black Sea coast of the Caucasus. After its completion, new resorts and health resorts were built. Already in January 1921, three ambulance trains were sent to Crimea from Petrograd, Moscow and Ivanovo-Voznesensk. In 1920, there were already 22 resorts in operation (in 1919 there were only 5 of them). By the end of 1921, 9 sanatoriums were restored on the southern coast of Crimea, and by the end of the year there were already 23. During 1921-1922, the resorts of the Black Sea coast of the Caucasus opened, and in 1923 – the resorts of Transbaikalia and the Far East. At this time, the number of people receiving treatment at the resorts increased significantly. A network of specialized institutes that studied the health resort business was developed.
In 1925, in the report of the People’s Commissariat of Health N.A. Semashko reported on the successes achieved in Soviet medicine. By this time, mortality had dropped significantly. In particular, infant mortality under one year of age decreased from an average of 27.6% in 1913 to 13.7%. The incidence of massive infections dropped sharply. There was a rapid growth of various kinds of medical institutions, especially treatment and prevention, as well as institutions for the protection of mothers and infants. At the same time, the backlog of rural health care and the need for measures to improve it were noted.
In May 1927, the sixth congress of health departments was held in Moscow, which summed up the results of what the health authorities had done over 10 years. At this congress N.A. Semashko, in his report on the state of health care and its tasks, noted the following significant successes of Soviet medicine, expressed in a decrease in morbidity and mortality from infectious diseases by 20%, an increase in the number of hospital beds by 40% compared to 1913, as well as in a significant increase in the number of outpatient clinics and prenatal clinics.
Heading the People’s Commissariat of Health of the RSFSR, N.A. Semashko developed the theoretical foundations of the organization of Soviet medicine, which formed the basis for the activities and further development of health care in our country. In accordance with the theoretical developments of N.A. Semashko, from the first years of Soviet power in our country, a fundamentally completely new health care system was formed, which was named the Semashko system. Thanks to this system, during the Great Patriotic War, the Soviet soldier for the first time in the history of wars did not experience the massive spread of epidemics of infectious diseases. All outbreaks of infectious diseases at the front and in the rear, despite the difficulties of wartime, were immediately suppressed by the concerted actions of Soviet doctors. In the future, it was the Semashko system that was able to prevent the spread of the epidemic of smallpox imported from India in 1959, and in 1969 to quickly cope with the outbreak of cholera in Astrakhan and Odessa. Until recently, while the Semashko system continued to operate, we seemed to have the idea that in our country there could be epidemics of infectious diseases with numerous victims. It is no coincidence that at the post-war elections to the British Parliament, one of the slogans of the Labour Party was “Let’s create a health care system as in the USSR”.
The restoration of capitalism in our country and especially the “market” reforms of the 1990s dealt a tangible blow to the Semashko system, although they could not destroy it immediately. The attack on free health care began to develop especially actively with the arrival of “effective managers” – medical businessmen – in Russian medicine. In order to discredit the Soviet health care system, these businessmen launched a number of myths about the initial inferiority and ineffectiveness of Soviet medicine. The underpinnings of these myths were stagnation in society and, in particular, in Soviet health care in the 1960-70’s, when the restoration of capitalism in our country had already become a fact and state-monopoly capitalism prevailed in the Soviet Union, which bourgeois propaganda invariably presented as socialism and even “developed socialism”, first in order to protect against class proletarian criticism, and during the years of “Gorbachev’s” Perestroika in the form of open anti-communist slander. At this time, there was a systematic decrease in the allocated budgetary funds for medicine, and by the end of the 1980’s, the financing of Soviet medicine no longer exceeded 40% of the need. It was then, in the heat of perestroika psychosis, that they started talking about “the need to reform the Soviet health care system.”
As an alternative to the existing Semashko system, Western “models” of “budgetary insurance medicine” were proposed. In the early 1990s, a system of compulsory health insurance (CHI) was introduced throughout Russia. Part of the funding had to come from the budget, the other – from the health insurance funds, to which the “employers” were required to deduct payments in the amount of 3.6% of the payroll (another item of deductions from the employee’s income). Recall that in the 1990’s, production itself was in a state of systematic crisis, accompanied by massive unemployment, long delays in wages, “grey” wages in envelopes, and the like, which led to a sharp reduction in the balance of budgetary funding for health care. Systematic underfunding, which led to a sharp reduction in the volume of free medical care, as well as to a 5 massive outflow, due to low salaries, of doctors from hospitals and clinics, and, finally, to discredit the CHI system itself.
At the same time, the country launched the promotion and introduction of voluntary health insurance (VHI), that is, already openly paid medical care. (Note that the CHI system was also, in fact, paid, since it was financed through deductions from workers’ wages.) All this was just the beginning of the offensive of “effective managers” on the Semashko system, which, despite the comprehensive and widespread introduction of paid medicine, has not yet been completely destroyed. And if in our country the victims of the coronavirus epidemic are not the most frightening compared to the “developed capitalist countries” (for example, the United States and Great Britain), then we owe this to the not yet destroyed remnants of the Soviet health care system – the Semashko system.
Proletarskaya Gazeta, May 2021.
Translated from the Russian by Polina Brik.
to return to the April 2022 index.