Soviet medicine and the problem of public trust: 1921–1929

The problem of trust in physicians, institutions, and governments is an increasingly important issue in health care. Particularly in the wake of the COVID-19 pandemic, concerns have grown about the well-being and safety of health care workers in the face of public skepticism and animosity.¹ This essay explores a comparable historical moment in the early Soviet Union to consider the political dimensions of trust — both its disruption and repair — between patients and their doctors.

In the years after the Bolshevik Revolution of 1917, the Soviet government launched an unprecedented effort to build a system of universal health care based on socialist principles. The promise of health care for all citizens was greeted as a sign of the regime’s progressiveness, but rising expectations, systemic change, and a generalized “culture of distrust”² destabilized the doctor–patient relationship.

Individuals associated with the new health care system encountered a wary and even violent public. Medical journals during the 1920s regularly featured stories of doctors, nurses, and attendants being treated badly by patients or their families.³ Reflecting the perspective of the medical profession, these accounts promoted an image of doctors as besieged by a distrustful, ill-informed, and frequently armed public. Examples like the husband who threatened to shoot his wife’s surgeon if the procedure was unsuccessful fed into a larger narrative of doctors’ vulnerability and were used to lobby for protections. ⁴ By the mid-1920s, the word “epidemic” was being used by commentators to characterize the level of aggression against physicians.⁵ In response to the threat of violence, medical institutions removed heavy objects from rooms to avoid them being turned into weapons by patients. Some doctors carried guns. Others approached their patients with trepidation. According to 1 practitioner, the first thing that crossed a doctor’s mind when meeting a patient was the fear that the encounter would result in an accusation of malpractice.⁶ In public forums and the medical press, physicians spoke of an “unhealthy” doctor–patient relationship that took a psychological toll and jeopardized their ability to do their job.

A striking example of the tense atmosphere was the 1927 murder of doctor Evgeniia Esterman in Kharkiv, Ukraine. Esterman was shot to death by Neonila Kochetova, a typesetter whose daughter died while under the doctor’s care. Kochetova accused Esterman of misdiagnosing her daughter’s condition and waiting too long to summon a specialist. She reportedly justified her act as a way to keep Esterman from treating (and presumably harming) patients in the future. The ensuing trial, which took place in front of a packed house at the local metalworkers’ club, ended in a guilty verdict and 5-year prison sentence. Responses to these events vividly displayed the rift between doctors and the Soviet public. Kochetova was hailed by some as an avenging hero who stood up to an indifferent and incompetent medical community that mistreated the working class. Government leaders like Chairman Mikhail Kalinin, while criticizing violence as unacceptable, validated the concerns and suspicions of the labouring classes in whose name the revolution had been made. In sharp contrast, physicians reacted with alarm and anger. Esterman’s murder fed their deepening anxieties over a lack of public trust.⁷

Diagnosing and treating the trust gap in early Soviet medicine

Soviet doctors responded from a position of weakness. Their dependence on the state and lack of autonomous professional organizations, compounded by their slow acceptance of the Bolshevik Revolution, constrained them politically. To be sure, they accepted some responsibility for declining public trust, acknowledging insufficiently educated, disinterested, and unprofessional colleagues as contributing to negative perceptions. Fault was also placed on the Soviet press, which physicians accused of focusing on sensational events that painted the medical profession in a bad light.

However, history and culture featured most prominently in their diagnoses of patient mistrust and behaviour. Doctors drew parallels to the mob violence of the 19th-century cholera riots, suggesting that tensions between the public and medical authority predated the Russian Revolution. They attributed the current spate of violence to the population’s lack of understanding of medicine and newfound sense of empowerment. From the perspective of the medical community, Soviet workers and peasants harboured unrealistic expectations of doctors’ power to diagnose and heal. Moreover, the communist regime’s class-based policies in favour of the labouring masses meant that many of their working-class patients expected preferential treatment. As a consequence, poor outcomes, terminal diagnoses, or rude encounters were ascribed to doctors’ incompetence or, even worse, malevolence toward the new “bosses” of the country.⁸

The Soviet state’s limited resources as well as the particularities of the law aggravated the situation. Severe financial constraints during the 1920s deepened the gap between the promises and the reality of universal care. Medical clinics, particularly those in rural areas, were chronically under-funded and frequently lacked medications, equipment, and personnel. Overworked and underpaid doctors spent on average only 10 minutes with each patient.⁸ The brusqueness of such exams reinforced negative perceptions of physicians. Moreover, the legal requirement that doctors respond to virtually any call for medical assistance created additional friction. A carry-over from Tsarist times, this law was the focus of frequent complaints among physicians, who argued that it was abused by patients and exposed doctors to criminal jeopardy.

Efforts to build trust and reduce the sources of tensions between doctors and the public intensified around the middle of the 1920s. A “campaign in defence of the doctor,” launched in 1926, sought to mobilize public opinion in favour of physicians. Focused on education and cultural work, these efforts ranged from improving press coverage of the medical profession to organizing didactic show trials around cases of violence against doctors.^5,9 Most significantly, Soviet authorities strove to improve the climate through “sanitary enlightenment.” They urged physicians to hold conversations within their communities about medicine and the daily lives of doctors. Physicians were also tasked with visiting the homes and workplaces of their patients to strengthen ties and promote salubrious living and working conditions. Such community-based activities were consistent with the ethos of Soviet social medicine.¹⁰ Authorities aimed to foster closer ties and educate citizens about everyone’s roles and obligations in the doctor–patient relationship. Augmenting these longer-term cultural projects, the People’s Commissariat of Health Protection (Narkomzdrav), which administered the health care system in the Russian Soviet Federative Socialist Republic, lobbied successfully to criminalize attacks on medical workers as representatives of the state. Narkomzdrav also issued a series of statutes that clarified the rights and duties of doctors.⁵ Setting out clearer parameters through law and regulation would in theory empower physicians and lessen the misunderstandings that sometimes had violent outcomes.

Looking to the future, Soviet doctors and officials deemed economic development essential for improving medical authority and public trust. The construction of socialism in the Soviet Union, which was in many respects a euphemism for modernization, was expected to create the conditions for the regime to deliver on its promises of truly universal health care. Overcoming scarcities, delays, and other structural barriers, as well as producing better-trained doctors imbued with communist ideals, they hoped, would reduce or eliminate the factors that led to disgruntled and mistrustful patients.

The predicament of Soviet physicians in the 1920s demonstrates the contingent nature of trust in people and institutions. Doctors faced an emboldened population that believed in scientific medicine but was willing to challenge expert authority. Indeed, they were navigating within a society in which distrust was actively promoted by the political leadership and blame for personal setbacks or the socialist system’s failures was routinely ascribed to nefarious actors.² Within this context, doctors’ close association with the state exposed them to frustrations over the health care system’s limitations. Additionally, the background and identity of doctors contributed to patients’ estimations of their trustworthiness. Jewish doctors and those educated before the revolution encountered suspicions inflamed by long-standing anti-Semitism and the regime’s periodic campaigns against class enemies. Most notable for this discussion was the 1929 “doctors’ trial” in Kharkiv. The defendants were accused of promoting Ukrainian nationalism, plotting to poison their communist patients, and exploiting the fundamental trust given to them as healers. The atmosphere of fear created by such proceedings purportedly kept some Soviet citizens from seeking medical care. It also caused rifts among doctors while deepening the mutual estrangement between doctors and patients.¹¹

The trust given to physicians derives from a mix of moral authority and expertise. It reflects social norms and expectations that are shaped by tradition, experience, routines, and other factors that affect reputations and notions of risk.¹² Soviet doctors were therefore in a difficult position after 1917. As members of a society that had been destabilized by the revolution and a political system that vilified professional autonomy, they struggled to shape the discourse of trust. The violence of the 1920s would dissipate over time, but many of the underlying sources of distrust continued to affect the doctor–patient relationship during and after the Soviet Union’s existence.¹³ The case of Soviet doctors is a reminder for us today that earning and keeping trust is a continuous process of negotiation that is only partly controlled by the medical community.