Nursing and the Public Health Legacies of the Russian Revolution

Abstract

The centenary of the October Revolution in 1917 provides a timely opportunity to assess the legacies of that event. I examine the role of the revolution in public health with a focus on nursing, assessing the Imperial Russian health care system, the development of Soviet nursing, and current plans for nursing and public health care in Putin’s Russia. Analyzing nursing shows that there was a great deal of continuity in terms of medical personnel and ideas on how public health care service in Russia should operate. Nursing illuminates some of the complexities of Soviet health care and ideology, particularly the state’s desire to create a socialist form of nursing in theory, despite the strong links with the prerevolutionary past in the form of personnel. This situation changed after the collapse of the Soviet Union, when the new Russian state attempted to sever connections with the past, this time with the Soviet past. But as I show, making a clean break with the past is a difficult and often fraught process.

The centenary of the Russian Revolution has led historians to reassess the impact of that event and its influence on the 20th century. The extent of Soviet “exceptionalism” has been challenged from a number of perspectives, including public health care and nursing. Scholars of Soviet nursing have found more discontinuities than continuity after the revolution. Natalia Lopatina claims that after the October Revolution, “everything was lost,” with the values and professionalism of nursing replaced by a new Soviet system that placed a “negative tendency” in the development of medicine and nursing.¹ According to Lopatina, the coming to power of the Bolsheviks spelled the end for the principles of care and compassion in middle-level medical professions.² Meanwhile, Elizabeth Murray concludes that Soviet nursing was created from an “almost embryonic basis” as a result of the antibourgeois position of the Bolsheviks.³ I contest some of these claims by examining key continuities and discontinuities before and after the revolution, as well as some of the key problems in public health care that confronted the new Soviet state. I outline nursing professionalization before October 1917 and then analyze how nursing was changed by the revolution through a case study of Soviet nursing between 1917 and 1991. Finally, I outline key developments in post-Soviet Russian nursing and discuss the legacies of the October Revolution.

RUSSIAN NURSING BEFORE THE REVOLUTION

Before the revolution, nursing in Russia had developed along lines similar to those in other countries in that it was based primarily on religion and philanthropy. Those responsible for the early development of the nursing profession responded to the awful social conditions around them and organized care for the weak, sick, and vulnerable. The philanthropic and religious origins of nursing expanded in the mid-19th century as a result of a new impetus—that of war. The Crimean War (1853–1855) served as a crucial entrée for many women into the nursing profession, and after this event war acted as a stimulus, drawing larger numbers of women to nursing. Threat of war and epidemics in the late 19th century led to expansion in the number of Sister of Mercy communities in the Russian Empire. Expansion was met with organizational interest on the part of the Red Cross, which became increasingly involved in overseeing the function of the nursing communities.⁴ By the turn of the 20th century, the growing political unrest in the Russian Empire did not go unnoticed by medical workers, including the Sisters of Mercy. The 1905 revolution highlighted the need for change as workers, students, and ethnic minorities protested and called for reform. Yet for nurses, the opportunity for reform did not present itself until after the outbreak of World War I.

The significance of World War I as a catalyst for change in Russia has been the subject of much study in recent years.⁵ The political and social ruptures caused by the outbreak of war and the collapse of the Russian monarchy after the forced abdication of Tsar Nicholas II led to grassroots initiatives. Gradually, the Sisters of Mercy realized that they had greater freedoms and acted upon these. The work of Laurie Stoff has demonstrated the various ways World War I allowed nurses to challenge gender boundaries.⁶ The context of war and upheaval also gave the Sisters of Mercy the opportunity to redraw organizational boundaries within their profession.

But the October Revolution and Bolshevik plans placed restrictions on these freedoms. The reluctance of medical workers, and especially physicians, to join the new, Bolshevik medical union can be understood in light of their ongoing struggle for greater professional autonomy since the 1905 revolution. Physicians had their own differing conceptions of how to shape the medical profession, irrespective of revolution. The same could be said of nurses. A group of Petrograd-based nurses setting up the All-Russian Union of Sisters of Mercy (Vserossiskii Soiuza Sester Miloserdiya) in January 1917 only joined the newly established medical union in 1918 on the understanding that nurses would have a section within this—that never came to pass. Instead, the All-Russian Union of the Sisters of Mercy disbanded in 1918, and its members joined Vsemediksantrud (the All-Russian Union of Medical and Sanitary Workers, later Medsantrud).⁷

The October Revolution received a mixed reaction among nurses. The autobiography of one nurse, P. S. Stepanova, written during the ideologically conservative late 1960s, provides a glimpse of nurses during the revolutionary period.⁸ On the outbreak of World War I Stepanova wanted to become a Sister of Mercy. Through her own efforts at studying she was eventually accepted as a nurse in an infirmary in 1916, where she was based during the February Revolution. Stepanova became drawn to politics and the Bolsheviks in the summer of 1918.⁹ Her introduction to them came via her friendship with a communist nurse, Vlasova, when they worked together in Petrograd’s Mechnikov hospital. From this point on, she became involved in political events and attended party meetings in the Vyborg district. Stepanova’s involvement did not bring her much popularity in the hospital though; she claimed she and Vlasova were “persecuted,” with some medical workers there boycotting the two Bolsheviks and even “spat in their faces,” saying that they were “dishonouring” the title of medics. Stepanova’s account illuminates how two different worlds of Bolshevik and non-Bolshevik collided in the hospital. But there were also those medical workers remaining in hospitals and clinics who simply tried to weather the storm; their skills and experience were, after all, desperately needed in the health crisis unfolding across Russia from 1918 through 1922.

THE DEVELOPMENT OF SOVIET NURSING AND PUBLIC HEALTH

Nursing experiences of the revolution varied considerably. Nurses such as Stepanova and Vlasova supported the Bolsheviks and their revolutionary agenda. Some nurses who did not support the Bolsheviks formed part of the White emigration; others remained and continued working in the newly emerging public health care system.¹⁰ The conditions of civil war and famine required a vast army of medical workers, but the profession became increasingly unattractive. First, nursing was still associated with religion and philanthropy, and, second, there were high mortality rates among medical workers during the civil war years.¹¹ Recruitment consequently became a central feature of Soviet nursing, with nursing school directors under pressure to draw and maintain student numbers.

The recruitment drives by and large worked; the difficulty more often lay in retaining students. Soviet era statistics indicate that middle medical workers certainly increased in number. In 1913 there were 46 000 middle medical workers; in 1950 this had increased to 719 400; and in 1975 there were 2 515 100 middle medical workers in the Soviet Union.¹² The tremendous growth was understood to signify progress and the expansion of the health care system—a sign that socialism met the medical needs of its citizens. Yet these figures belie certain problems. The first was that middle medical workers included feldshers, midwives, and other types of medical workers that were often considered more prestigious than nurses. The other difficulty was that nursing and middle medical education sometimes functioned as a back door to the medical institute. Competition for places in medical institutes meant that becoming a nurse was the first step to becoming a physician.¹³ These distinctly Soviet problems proved difficult to rectify, although not for want of trying.

One of the reasons for the specific problems associated with Soviet nursing relates to the immediate postrevolutionary years, when the Commissariat of Public Health attempted to make a clean break with the past by creating medical workers whose work would be grounded in science. After 1926, the Sisters of Mercy were officially known as “medical sisters,” but they remained subordinate to the physician and without a keen sense of professional identity. For much of the early Soviet period there remained a lack of clarity about the exact role of nurses, especially when compared with the function of other middle or junior medical workers.¹⁴ There was little doubt that the Bolsheviks were eager to modernize and innovate, and nursing was no exception. The effort to establish an American hospital in Moscow in the mid-1920s is an example of how the Soviet government explored different ways of changing public health care, of making it both modern and socialist.¹⁵ However, much of the innovations intended for nursing, particularly molding nurses into scientific workers, increasing their pay, and improving working and living conditions, ended up as limited reforms.

To be sure, the revolution became the driving force for seeking new methods and means of improving people’s lives; this was the utopian modus operandi of the early Soviet years. In real terms, this meant that new nursing profiles were developed to meet the public health needs of Soviet citizens (and indeed many of these, such as the visiting nurse, remain today). In addition to specialized nurse training for hospitals and clinics, visiting health nurses and kindergarten nurses emerged in the 1920s and 1930s. Alongside these were nurses with specialist training for working in the countryside and in factories and, in the late 1930s, nurses with specific military training, such as parachuting.¹⁶ In this sense the sheer range of Soviet nurse training and their functions diverged considerably from the prerevolutionary period.

Soviet literature and scholarship certainly promoted the idea that the revolution represented a great shift in public health. This applies especially to nursing, which had been closely associated with religion and philanthropy before the revolution. The first commissar of public health, Nikolai Semashko, was quick to note that the Sisters of Mercy from the Imperial period were not the same as the Soviet medical sister (medsestra), or nurse.¹⁷ In his 1942 article, “Sister,” Semashko wrote that Imperial Sisters of Mercy were “locked up like nuns” to be “kind of heart,” and that many women from the nobility joined these communities to “expiate their lives as half prostitutes and adventurers.” These women were “dirty” until they became nurses who devoted their entire lives to looking after the sick and injured. Political and ideological motivations meant that in the early Soviet period, clear boundaries were drawn between the Imperial and Soviet systems of public health care. Soviet nurses were to be medical and scientific workers as well as cultural workers educated in Marxism–Leninism.

Ideological training became a part of the nursing program, and nurses were expected to be educated to a cultural and technical level sufficient to meet the needs of Soviet workers. New nursing schools were established, nursing became incorporated into medical technikumy (polytechnical colleges) in the 1930s, and new curricula were designed to reflect the changing needs of the state. These needs included inoculation training for epidemics such as typhus during the civil war period, prenatal care in the 1920s and 1930s, and blood transfusion training under the threat of war at the end of the 1930s. Many of the changes in the structure and content of nursing education were as much reflections of wider state-level shifts initiated in the bureaucracies as they were responses to requirements on the ground level.¹⁸ Further reforms in the structure and organization of medical education occurred in 1953 and 1963 in an effort to streamline medical workers and move toward training nurses in larger hospitals.

The state’s reactive tendencies, present since the revolution and civil war years, meant that long-term strategic goals often became subordinate to addressing short-terms problems. This certainly affected the development of nursing during the Soviet period, which was subject to frequent reforms. The public health care system suffered from myriad problems, including lack of resources, underqualified personnel, and lack of prestige. Soviet health care also suffered from a lack of access to Western technology and knowledge after World War II, although this isolation had eased by the late 1950s.¹⁹ Health care services certainly expanded and improved after the revolution, but low wages continued to harm the medical profession and levels of care and expertise varied across the Soviet Union.

Although historians of Russian and Soviet nursing such as Lopatina might argue that the Bolsheviks’ coming to power altered the course of Russian nursing—which was supposedly destined to follow the Western path until the October Revolution—the situation was much more complex on the ground. It should not be seen as given that the Bolshevik seizure of power ultimately determined the fate of Russian nursing. Rather, the system of nursing that developed in Russia and the Soviet Union was the result of a much wider set of circumstances, both within and outside Russia. These circumstances culminated in an approach to nursing care that was both Russian and Soviet. The process that resulted in this system was a long and fragmented one, beginning even before the outbreak of World War I and continuing throughout the Soviet period.

LEGACIES OF THE REVOLUTION

One of the primary long-term obstacles for nursing created by the October Revolution was the lack of knowledge exchange between nurses in the Soviet Union and in Western, capitalist countries. It was not until after the collapse of the communist state that nurses began to fully develop international links. Although such links were limited before the revolution, from the 1930s on restrictions became more pronounced. Making connections with nursing colleagues abroad was greatly facilitated by the establishment of the Russian Association of Nurses in 1992. For the first time since 1917, nurses had their own dedicated professional body.

In the post-Soviet sphere, nurses have been more engaged with colleagues in other countries. There has been greater international dialogue since the Russian Association of Nurses joined the European forum for national nursing and midwifery associations in 1998. And in 2005, the Russian Association of Nurses joined the International Council of Nurses—the first time in history that Russian nurses were part of this professional body.²⁰ The increasingly outward facing direction of Russian nursing organization in the post-Soviet years has permitted the examination of problems from a wider lens. Issues are now considered that confront the nursing profession globally (a trend reflected in the historiography of the revolution) as are problems inherited from the socialist system.

Despite the many difficulties faced in the 1990s, it is important to note that the Soviet experience was not completely erased from Russian nursing. There are clear continuities that include personnel and publications, and one could argue that these have helped to anchor the profession. One of the key nursing publications, Meditsinskaia sestra (launched in 1942 and featuring Semashko), remains a significant professional publication and continues to discuss issues faced by nurses working in the Soviet Union—professional practice, theory, nursing education, and the history of the profession (it also includes a new section on nursing abroad).²¹ A range of professional journals and the Russian Nurses Association have provided nurses with a clear sense of direction and a mouthpiece that were absent under the socialist system. This has placed nurses in a better position to deal with issues and work toward advancing their profession.

One of these issues—and one of the key characteristics of Soviet health care—was its feminization, although this can hardly be attributed only to the revolution. (The Russian Empire had the highest number of women physicians in Europe by 1910.²²) In the Soviet period, women continued to proliferate in the health care professions (both in medicine and nursing), and after World War II, women constituted more than three quarters of the medical profession.²³ The legacy of Soviet public health care is consequently also connected to the Soviet legacy of gender relations. In her edited volume Gender, State and Society in Soviet and Post-Soviet Russia, Sarah Ashwin wrote that the Soviet state “promoted and institutionalized a distinctive ‘gender order’” that was being “reformulated” in the late 1990s at the end of the Boris Yeltsin era and the rise of Vladimir Putin.²⁴ One clear example of this was the introduction of “maternity capital” in January 2007, a scheme devised to encourage families to have more than one child by providing entitlements to second- and third-time mothers.²⁵ Such reformulations are not unusual (another is the reinstatement of the Get Ready for Labor and Defense norm, introduced first in 1931 and again in 2014).

If gender and the role of women in Soviet society represented a cornerstone of Soviet policy from the moment of the October Revolution, then so too did religion, or more specifically the antireligious campaigns of the 1920s and 1960s. A key feature of the post-Soviet nursing landscape has been the rise of the Russian Orthodox Church and the official return of the Sisters of Mercy. This almost gives the sense that Russian nursing has come full circle since the revolution, with charity and Christian service drawing some women to becoming Sisters of Mercy. In the 1990s, Sister of Mercy communities were again established in Russia after an absence of 70 years. In November 2010, the Syndodal Department for Charitable and Social Services established the Association of Sisters of Mercy.²⁶ As in the prerevolutionary years, spirituality and the church play a key role in the professional and personal lives of these Sisters of Mercy. Now, nurses and Sisters of Mercy coexist in Russia.

The transition from one system to another was not easy, and a persistent problem was the shortage of nurses and drawing younger people to the profession. One senior nurse, Liudmilla Fedorovna Silkina, identified and wrote about this issue in 1997. Silkina, who had more than 30 years of nursing experience at that time, advocated greater propaganda to recruit new students to the profession.²⁷ Her Soviet experience proved useful when she used the Day of the Young Specialists to mobilize her colleagues and draw young people to the profession (the hospital attracted 32 students as a result of the campaign). She also urged nurses to remain in the nursing profession, rather than leave it to become a doctor, a practice that had been rife during the Soviet period. Similar concerns with the shortage of nurses were expressed by the vice-president of the Saint Petersburg regional branch of the Association of Nurses in Russia in 2009. M. R. Tsutsunava was particularly worried about the demographic imbalance among middle medical workers.

More than 40% of these cadres were older than 50 years; the proportion of young was 7.4%.²⁸ Moscow experienced a similar problem: 65% of orderlies were older than 50 years, and 25% were older than 60 years. The problem did not stem from the transition to the market economy or to recent trends. The roots of the issue, Tsutsunava claimed, lay in the Soviet past—1983, to be precise. She traced the problem back to N. V. El’shtein’s monograph Dialogue on Medicine (Dialog o meditsine), which warned about the unattractive nature of the nursing profession.²⁹ Tsutsunava recognized that there was a global crisis in the nursing profession but indicated that internal Russian problems, such as weak administrative support, needed to be addressed. Indeed, large-scale efforts were taken to improve the profession, and at the All-Russian Congress of medical workers in St. Petersburg in December 2008, a new program for developing nursing in Russia from 2009 to 2014 was ratified. The main purpose of this was to introduce changes that would modernize Russian nursing and public health care more generally.³⁰

The Russian government appears to be struggling with many of the same problems that confronted its Soviet predecessor—underqualified personnel, substandard medical care, a shortage of doctors and nurses willing to work in rural areas, and low salaries. Some of these problems were inherited from the late Imperial period, when the health care services were still in the process of modernizing and professionalizing. When the Bolsheviks grabbed the reins of power in 1917, they set about solving some of the problems in public health care, some of which were the result of years of war and some of which were more systemic. But the Soviet system of public health care, which I have exemplified in my study of nursing, proved that change and innovation were difficult in the face of ideological dogma or lack of resources. Time will soon tell if the current Russian government’s policies can successfully overcome the public health care obstacles that the revolution and socialist system could not.