Medicine in Three Societies: A comparison of medical care in the USSR, USA and UK

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The Greater Medical Profession.

About RAND Reports

Education and Training. The Present Dilemmas of Medical Care. Back Matter Pages About this book Introduction This book is a personal testimony of faith in the future and in the progression to better health and a better life. It is the testament of a rough and ready measuring device - a practising physician who sought to compare and contrast three systems of medical care to see what can be distilled from them to help us all in achieving better services for medical care.

Seeking to live longer and in good health we depend on medical, social and welfare services to attain this goal. Yet it is quite obvious that there are limits and dilemmas that prevent anything but an unsatisfactory compromise. The resources that are available cannot meet all the calls. There are some specific provisions designed to promote the limited spread of patient-paid care, the further development of technology and its incorporation into practice, and an emphasis on preventive care.

The proposed changes are quite striking, but as with many previous attempts to improve the lot of the average Soviet citizen, there are many political, economic, and social factors that may limit the success of this latest endeavor. The leadership has made a commitment to increasing the share of the gross national product that goes to health from 3. A second focus is to be a re-emphasis on prevention dispanserizatsia in Russian. Preventive medicine and periodic health examinations have been a cornerstone of official Soviet health policy since the Revolution, although in practice the required physical examinations have been done perfunctorily or not at all.

In contrast to screening methods employed in the United States, which are targeted by age- and disease-specific risk, dispanserizatsia has been a wasteful and unsuccessful program which currently includes such practices as using fluoroscopy as a screening procedure for pulmonary tuberculosis. A fundamental reform, the gradual introduction of private enterprise in the form of cooperatives a Soviet euphemism for private business , is taking place in health care as well as in the general Soviet economy.

Staff-owned medical cooperative clinics and even a recently opened homeopathic hospital [ndE: Homeopathy, acupuncture, and 'tradicional medicine' also existed in the Soviet Union]37 are to rely solely on patient fees to cover operating expenses, drawing no state funds but returning profits to their owners and staff as income.

These will supplement the volume of for-pay medical services already provided in state-owned "self-financing" clinics which receive some state funding but are not privately owned. The process of regulating cooperative clinics has just begun. In late , cooperatives were prohibited from using or paying for the use of state-owned diagnostic equipment39 and, more recently, the government barred cooperatives from many medical activities.

The list of prohibitions includes:. Although legal, moonlighting activity by physicians in the past was heavily taxed and regulated and largely unreported. It provided an estimated six to eight times the volume of services up to now provided in "self-financing" patient paid clinics, and 74 percent of the population acknowledge paying for the services of moonlighting physicians. A system of fee-for-service payment for nurses is being introduced as well.

It is not clear that the government has the means to finance an expansion in health spending. The anti-alcohol campaign, recently de-emphasized, may compromise the government's ability to fund other improvements in health. The entire state budget for health in amounted to just Without better matching of supply and demand than is now achieved, even unlimited funding for health care cannot assure an adequate supply of medical manpower or materials for purchase.

The 1920’s

Even now, funds allocated for health are often returned to the treasury unspent. There is much popular skepticism still expressed privately about perestroika,49 and many Soviets we asked expressed skepticism about the leadership's commitment to reform health care in particular, since the bureaucrats and party bosses, sheltered by a network of exclusive clinics and hospitals, have not suffered the consequences of their mnattention to the public system.

The failure of Gorbachev's first program directed at health, the campaign against alcoholism,8 has increased suspicion that government planners are not capable of organizing successful health care programs. In conclusion, the resolution of the current economic crisis in the Soviet Union will determine its relevance as a world economic power into the twenty-first century.

There is a crisis in the health sector, too; the record of declining health indices, the lack of technological sophistication, and the poor quality of medical care are well known in the West. We have added our own observations about that record and speculate that because of inadequate funding, scant access to Western capital, and constraints placed on the development of alternatives to the state health care system, real improvements in this area may not appear soon.

A year after the announcement of plans to reform the Soviet health care system, Chazov challenged the timidity of the reforms at a special Communist Party conference: "If we the Soviet Government truly want to resolve the problems of health care, we must immediately change the standards by which that care is planned and financed. Field is somewhat less harsh in his critique than Rafferty and Schultz, but he is far from praising its achievements.

American Exceptionalism in the Health Sector

Davis reviews Eberstandt's article on increasing infant mortality in the SU in the 70s. This article challenged the prevailing conceptions that the socialist countries were improving the health of their populations and that they were models for others to imitate. He explains the state of the debate in the initial years:. In the late s the USSR was considered to be a successful and expanding world power, whereas the West was on the defensive e. The objective study of health in the USSR was seriously impeded by the comprehensive and reasonably effective Soviet censorship system.

In the case of mortality rates, during —71 the Soviet Union published the infant mortality rate but not perinatal, neonatal, and post-neonatal rates , the crude death rate, age-specific death rates, and life expectancy at birth in its annual statistical yearbook, Narodnoe Khozyaistvo SSSR there were no electronic databases in those days. Maternal death rates quite high were published only sporadically in specialist journals.

In response to the deterioration in the health situation, the USSR ceased publication of life expectancy after , infant mortality after and age-specific death rates after Soviet specialists used a unique and misleading methodology to calculate infant mortality high risk live births were excluded from consideration , which underestimated the actual rate by Although demographic and health specialists in the Soviet Union produced thousands of studies in Russian and other USSR languages on the health situation, and a number of these scholars were first rate, their access to accurate statistics was restricted by the government and the censorship system state control of all publications limited their ability to call attention to serious problems and prohibited them from suggesting that there were systemic causes of any difficulties.


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Soviet-Western academic cooperation was extremely difficult. Studies by Western specialists were constrained by the facts that few of them possessed knowledge of Russian language and that the Soviet Union published only a small amount of information in Western languages.

All WHO publications related to health in the USSR were either prepared by Soviet specialists or vetted by Soviet authorities, and contained even less critical analysis than that found in Russian language sources. Official Soviet books on health published in foreign languages provided some useful basic information, but essentially were propaganda documents. Certain anomalies had arisen, notably rising mortality rates, that posed questions about the prevailing paradigm, but no crisis was perceived to exist in it and there was little pressure for a paradigm shift.

Over the next several years the general findings that mortality really had risen in the USSR and that serious health problems existed there became widely accepted in the West and a component of a new paradigm that interpreted the Soviet Union as a failing system.

However, several serious articles challenged our analyses. In the first half of the s there was a tightening of Soviet censorship in the health field in an attempt to keep a lid on the story of deteriorating health. The official attitude toward our findings was quite critical and several Soviet publications took issue with them.

The Russian Epidemiological Crisis as Mirrored by Mortality Trends

At the unofficial level, there was considerable interest in our work and Murray and I received some favourable feedback during our trips to the USSR. Following Gorbachev's accession to power in the Communist Party line changed substantially. The official publication of mortality and life expectancy statistics resumed, reforms were introduced to correct problems in the health sphere, and mortality rates temporarily declined.

McKee presents a similar view. Regarding lif expectancy, a figure summarises trends from to the end of the SU:. Source: Kumo The increase in life expectancy in the 80s was, according to the author, to Gorbachev's anti-alcohol campaign. We can make the comparison clearer by using the same countries that back in had the same GDP per capita as the Soviet Union,.

Source: World Bank.

The 1920’s

Source: World bank. Spain did better. The US is there for comparison. But in the period depicted here, stagnation ensured that all those countries ended up surpassing Russia. Russia was not the Soviet Union, but roughly half of the SU population was there. In the Soviet Union medical services were provided for free, and in terms of quantitative indicators such as the number of doctors, nurses, and hospital beds, the level of medical care was superior to that of developed nations. This much is widely known, and can also be seen in official statistics from the Soviet era Levin, ; Kotryarskaya, ; Cromley and Craumer, , In , during the Soviet era, there were 3.

In the same year in the U. Even in , Russia had 4. He then says that the rise in mortality rates were not due to worsening healthcare or increases in pollution, but to increased levels of alcoholism. However, he doesn't cite much evidence to support these claims. For healthcare, he says that it's not plausible that heealthcare deteriorated if there was economic growth until the 80s, and that in , Japan was able to import 10 million vaccines for polio from the SU.

This is inconsistent with the picture the other researchers show, both qualitatively and quantitatively: even if there was growth, healthcare spending went down. And then, it is possible for quality to go down as spending is constant.

click Data for year olds cannot rule out the hypothesis that this growth rates were just continuations of the trends present in the Russian Empire. Source: Brainerd While the Soviet experiment of the twentieth century clearly failed and in countless ways harmed the lives of Soviet citizens, the record of Soviet health achievement prior to remains impressive. The first provide previous estimates. This confirms the rising trends present in the Russian Empire, therefore giving more plausibility to the thesis that height increase in the early SU was a continuation of previous trends.


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In a recent review of heights and their relation to health, by Steckel mentions work by Komlos , who argues that improvements in health in Russia as measured by height were not particularly good, not only after , but even before, in comparison with Mexico, Philippines, Spain, Chile or Jamaica. In , Mark G. Field published some brief notes as part of a conference report about the quality of life in the Soviet Union.

Every disease is. The Soviet healthcare system heavily underperformed most of the countries that we can use as meaningful comparators. Relative to other countries that began from the same situation o poverty as the SU, its performance wasn't better than the systems of those countries.

FAQ Policy. About this book This collection compares Russian and Soviet medical workers — physicians, psychiatrists and nurses, and examines them within an international framework that challenges traditional Western conceptions of professionalism and professionalization through exploring how these ideas developed amongst medical workers in Russia and the Soviet Union.

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