Russia’s 1917 revolution marked not only a political watershed, but also a public health one. Between the two world wars, Russia was transformed from a country with the highest mortality and morbidity rates in Europe, the lowest (relative to population size) number of physicians and other health professionals, and an embryonic pharmaceutical industry into one of the world’s leading centers of medicine and public health, arousing admiration, envy, or censure throughout the world. This quantum leap was a direct result of the Bolshevik Revolution and the combined efforts of the country’s new government and health specialists that included doctors, nurses, and researchers.
The Bolsheviks were idealists and visionaries who dreamed of a new world, and their government was one of the first in the world to recognize the now common ideal of health as both an inalienable human right and a powerful instrument in national development, and to make public health one of its top priorities. Pragmatists and revolutionaries, they spared no effort—and their efforts were often brutal and barbarous—to implement this ideal on the one sixth of the world under their control in the form of universal free access to health services, facilities, and knowledge.
HEALTH PROTECTION
The Bolsheviks created a unique state system of zdravookhranenie (health protection) that integrated into a unified whole everything related to health:
medical practices and institutions,
health research and development,
epidemiological surveillance,
prophylactic measures,
manufacturing and distribution of pharmaceuticals and medical equipment,
specialized education and training,
sanitary infrastructure, and
propaganda.
This system was administered by the People’s Commissariat of Health Protection (Narkomzdrav), a top-level government agency established in July 1918, less than a year after the Bolsheviks had seized power.
Headed by Nikolai Semashko, a trained physician and long-time member of the Bolshevik Party, Narkomzdrav built a hierarchical network of local offices responsible for all the health matters at the level of provinces, regions, cities, and municipalities. Its headquarters in Moscow coordinated, funded, and managed its varied activities throughout the country, which was ravaged by an atrocious civil war, famine, international isolation, and epidemics, and beset by acute shortages of qualified personnel, funds, and supplies.
PRIMACY OF SOCIAL FACTORS AND PREVENTION
Narkomzdrav’s wide-ranging endeavors rested on two ideological pillars. The first was the acknowledgment of the primacy of social factors in defining the health status of individuals and groups—what today is called the “social determinants of health.” The second was the recognition of the primacy of preventive over curative approaches to disease. These two basic ideologies defined the directions and contours of Narkomzdrav’s activities, which include the following:
protection of maternity and infancy,
development of a primary health care system,
mass production of vaccines and sera,
detailed studies of labor and living conditions and occupational hazards,
extensive health propaganda, and
training necessary cadres of health specialists.
From its very inception in 1918, Soviet zdravookhranenie was shaped by local traditions, relevant advances abroad, heated domestic debates, and imperatives of the Soviet political and economic system. It suffered from the pitfalls of overbureaucratization, underfunding, and top-down policy setting and decision making common to state medicine and public health everywhere. It generated innovations, models, and examples to be emulated or avoided, but certainly not ignored, around the world.
CONTENTS OF THE SPECIAL SECTION
In the articles published in this special issue commemorating a centennial of the Bolshevik Revolution, the contributors examine certain illuminating episodes in the history of the Soviet zdravookhranenie, analyze its influence on concurrent public health ideas of influential international players, and consider its legacies in contemporary post-Soviet Russia.
“Propagandizing the Healthy, Communist Life in Early Bolshevik USSR” by Starks (p. 1718) describes the challenges faced by Narkomzdrav in its attempts to introduce the Bolshevik visions of health and disease to the country’s still largely illiterate and ignorant population, who were suspicious of modern medicine, through extensive education and propaganda campaigns. An elaborate poster was produced for the 10th anniversary of the Bolshevik Revolution and celebrated Narkomzdrav’s perceived successes in fulfilling its mission of protecting the health of the people. It serves as a convenient entry and a striking visual aid to Starks’s analysis of the participants, goals, scope, means, targets, and results of these campaigns that spread the message of healthy lifestyles and disease prevention.
In “A Revolutionary Attack on Tobacco,” Starks (p. 1711) details the Narkomzdrav approach to tobacco as a health hazard and the agency’s pioneering efforts to curb its use on a national scale by means of vigorous antismoking campaigns and special smoking-cessation programs. Current economic imperatives, however, have derailed the agency’s attempts to limit tobacco cultivation, production, and sales. Morabia’s editorial (p. 1708) places Starks’s analysis in a broader international context by comparing the Bolsheviks’ and the Nazis’ attitudes toward tobacco.
Grant’s contribution (p. 1725) illuminates an important but little studied part of the Soviet health care system, nursing. It traces the historical development of nursing in Russia and addresses continuities and changes in the social status, training, self-image, numbers, and roles of nurses in the transition from the imperial to the Soviet and then from the Soviet to the post-Soviet systems of health protection.
Rivkin-Fish (p. 1731) examines direct and indirect legacies of Soviet zdravookhranenie in contemporary Russian policies regarding addiction, HIV, and abortion. Her article surveys the preservation of certain Soviet patterns in doctor–patient relations, institutional structures, and ideological strictures in the health system of Putin’s Russia and explores the varying uses of the Soviet past in articulating, validating, and promoting contemporary policies.
In addition to these analytical essays, two “Voices from the Past” articles present the observations and immediate impressions of the Soviet health system by two highly influential Western experts who visited the country after the Bolsheviks had come to power.
The first voice (p. 1740) belongs to Alan Gregg, a high-ranking officer of the Rockefeller Foundation Medical Education Division, and is extracted from a daily journal Gregg kept during his fact-finding trip to Moscow and Leningrad in December 1927, less than a month after the nationwide public celebrations of the 10th anniversary of the revolution. Although his official mandate was limited to exploring possibilities of cooperation between Narkomzdrav and the Rockefeller Foundation in the specific area of medical education, Gregg’s diary provides a panoramic, although necessarily telegraphic, view of Soviet zdravookhranenie. Gregg recorded his conversations with its key figures, ranging from Commissar Semashko and his underlings to the leading lights of Soviet clinical medicine and biomedical research.
The second voice (p. 1736) belongs to Henry E. Sigerist, a leading Swiss American historian of medicine and health system analyst, and comes from his 1937 book Socialized Medicine in the Soviet Union. Sigerist had spent several months in the country two years before, and his book presented his thoughts and analysis of the health care system he had carefully studied and came to admire.
Taken together, the analytical essays and witness testimonies offer an instructive, if somewhat kaleidoscopic, glimpse at the promises, realities, and legacies of a unique experiment in creating an integrated, universally accessible, state-run health system inaugurated by the Bolshevik Revolution a century ago.