K. V. MAYSTRAKH THE ORGANIZATION OF PUBLIC HEALTH IN THE USSR

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP81-01043R004200220005-2
• Release Decision: RIPPUB
• Original Classification: K
• Document Page Count: 119
• Document Creation Date: December 27, 2016
• Document Release Date: February 5, 2014
• Sequence Number: 5
• Publication Date: January 1, 1956
• Content Type: REPORT

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K. V. MOSTRAKH
THE ORGANIZATION OF PUBLIC HEALTH
IN THE USSR
MEEGIZ 1956
STAT
STAT
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STAT
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K. V. MAYSTRA1CH
THE ORGANIZATION OF PUBLIC HEALTH
IN THE USSR
Fourth edition
Authorized for use as a textbook in middle grade
medical schools by the Main Inspection on Medi-
cal Education of the Ministry of Health, USSR
STATE PUBLISHING HOUSE
FOR MEDICAL LITERATURE
MEDGIZ - 1956 - MOSCOW'
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TABLE OF CONTENTS
FOREWORD TO THE FOURTH EDITION
Page
CHAPTER 1. PRINCIPLES AND HISTORY OF SOVIET PUBLIC HEALTH
1
Basic Principles of Soviet Public Health
1
The Development of Public Health in Russia and the USSR
11
Public Health in Tsarist Russia
11
The Development of Soviet Public Health
16
The Structure of Public Health Agencies
21
CHAPTER 2. INDICES OF THE PEOPLE'S HEALTH
24
Medical Statistics
24
Derived Values
32
Demographic indices of the People's Health
35
Size and Composition of the Population
35
Movement of Population
36
Morbidity
43
The General Morbidity Rate
44
Recording of Acute Infectious Diseases
48
Recording of Major Non-Epidemic Diseases
49
Computation of Rate of Morbidity with Temporary
Disability
50
Periodic Medical Examinations
53
Statistics on Causes of Death
54
Graphic Representation
54
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Records and Reports of Medical Institutions
Types of Records and Operations Documentation
Medical Reports
CHAPTER 3. ORGANIZATION CV MEDICOPROPHYLACTIC FACILITIES
FOR THE URBAN POPULATION
The Urban Hospital
Hospital Construction
Planning and Construction of the Network of
Medicoprophylactic Institutions
The District Principle of Medical Service
The Clinical Method
Organization of a Polyclinic
Organization of a Hospital
Organization of Dietotherapy
Hospital Records, Reports, and Work Indices
Medical Service to Industrial 'Workers
Medical Units
Medical and Feldsher Stations
The Shop Area Principle
Medical Help in Injuries and Accidents
Periodic Medical Examinations and Clinical Service
Investigation of Rate of-Sickness With Temporary
Disability
A, Single, Overall Hygiene Program
Sanitary-Prophylactic and Antiepidemic Work
55
56
57
58
58
59
60
62
64
67
72
82
83
88
88
89
90
91
92
93
94
95
p.
Organization and Activities of Tuberculosis, Dermato-
venereological and Oncological Clinics
The Campaign Against Tuberculosis
Control of Skin and Venereal Diseases
Control of Malignant Diseases
CHAPTER 4. OMANIZATION OF MEDICAL AND SANITAIWFACILITTFS
FOR THE RURAL POPULATION
The Rural Medical District
The District Hospital
The Feldsher -Midwife Station
Investigation of Morbidity in the District
Organization of District Medical Facilities
Clinical Facilities for the Rural Population
Obstetrical Facilities
Medical Facilities for Village Children
District Sanitary-Antiepidemic Activities.
Propaganda on Hygiene
The Rural Rayon Hospital
The Oblast Hospital
CHAPTER 5. PROTECTION OF THE HEALTH OF WOMEN AND
OBSTETRICAL FACILITIES
WomenIs Consultation Centers
Obstetrical Facilities
The Maternity Hospital
Maternity Hospital Reports and Work Indices
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100
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112
113
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119
121
124
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128
129
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CHAPTER 6. ORGANIZATION OF MEDICOPROPHYLACTIC
FACILITIES FOR CHILDREN
Children's Consultation Centers and Polyclinics
Children's Hospitals
Day Nurseries
Nursery Reports and Work Indices
Children's Homes
CHAPTER 7. THE SANITARY-ANTIEPIDEMIC ORGANIZATION
The Sanitary-Epidemiological Station
Preventive and Routine Sanitation Inspections
Antiepidemic Work
CHAPTER 8. EDUCATION IN HYGIENE
Tasks and Organization of Education in Hygiene
Methods of Hygiene Education
Features of Hygiene Education in. Various Medical
Institutions and Among Different Groups of People
People's Activity in Public Health
CHAPTER 9. PLANNING AND FINANCING OF PUBLIC HEALTH
The Budget of Medical Institutions
Preparation of Individual Estimates
REFERENCES
APPENDICES:
1. Regulations for Rural Feldsher-Midwife Stations
2. Regulations Governing the Rights and Duties of
Feldshers
3. Regulations
14. Regulations
Inspector
S. Report Form for Feldsher-Midwife Stations
Page
133
133
137
139
143
143
145
147
149
'Si
156
156
158
165
167
172
175
177
180
183
189
Governing the Rights and Duties of Midwives 192
for the Assistant to a State Sanitary
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196
198
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FOREWORD TO THE FOURTH EDITION
This edition of the textbook has been substantially revised. Impor-
tant events have taken place in the political and economic life of the
country since the third edition was published eight years ago.
The vast programs of socio-economic and cultural construction set
forth in the post-war five-year plans, the historic decisions of the
party and government regarding the subsequent expansion of heavy
industry and agriculture, and improvements in secondary and higher
education and in the training of cadres have confronted Soviet public
health with new problems.
The directives of the Twentieth Congress of the Communist Party
of the Soviet Union in connection with the Sixth Five-Year plan for
developing the national economy of the USSR from 1956 to 1960, which
represent a new and important step forward in strengthening the social-
ist economy, solving the problems of creating an abundance of consumer
goods, and building a communist society in our country, are making
still greater demands on public health.
Major reforms in different branches of public health instituted
in recent years have fostered the development of new forms and methods
of operations in the various medical institutions.
The amalgamation of outpatient and polyclinic institutions with
hospitals, furnishing the rural population with specialists' services
through strengthening the regional units of the public health organi-
zation, extensive use of the dispensary system for both the urban and
the rural populations, reorganization of medical science and public
health training on the basis of I. P. Pavlov's teachings in physiology,
introduction of new forms of medical reports and new methods of in-
vestigating morbidity of the population -- all these outstanding
achievements and changes of recent years have had to be reflected
in the textbook, with appropriate reworking of certain chapters.
Middle echelon medical personnel, particularly feldshers and
midwives, are playing an important role in Soviet public health,
notably in village feldsher-midwife stations, health rooms in
commercial establishments, and sanitary-epidemiological stations.
It is extremely important to equip these middle echelon medical
personnel with the essential data of public health organization, an
understanding of their tasks, and an ability to evaluate the effective-
ness of their work.
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The content of the textbook conforms to the new curricula of
medical schools of all kinds. Thus, the section on sanitary-anti -
epidemic work has been expanded both in the form of a special chapter
and in the exposition of the tasks confronting all the other divisions
of public health; there is a new chapter on planning and financing;
the section on rural medical services, in which the work of feldshers
and midwives play such an important role, has been enlarged.
Stocktaking, reports, and work indicators of the individual
institutions have been described in terms of the new report forms.
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CHAPTER 1
PRINCIPLES AND HISTORY OF SOVIET PUBLIC HEALTH
Basic Principles of Soviet Public Health
Public health is a system of state and public measures that aims at
preventing and treating diseases, at protecting the health of the
population. It pertains to the political and legal superstructure
resting on the socio-economic base of a society.* The scope, nature
of operation, and organizational forms of public health are determined
both by the level of developaent of its productive forces and by the
working relations existing between them.
The forms and nature of public health vary with changes In the
socio-economic system of a society. Each socio-economic system, whether
slave-owning, feudal, capitalistic, or socialistic, has its own way of
organizing public health, which corresponds to the level of' develop-
ment of its productive forces and status of medical science, and
reflects the prevailing social and economic relations.
In a class society the organization of public health bears a
clearly marked class character and serves .the interests of the ruling
groups. The development of public health in a bourgeois society is
affected by the interests of capitalist production,'which is seriously
injured by the spread of diseases, particularly epidemics, among the
population.
Soviet public health is the highest form of public health and a
qualitatively new stage in its history. It serves the interests of
all the people and is an inseparable part of the Soviet governmental
system and overall building of socialism. In a socialist society
human beings, the builders of socialism, are its most precious capi-
tal. Hence, concern for human beings, for preserving their lives,
health, and work capacity constitutes one of the most important gov-
ernmental obligations of a socialist economy and culture.
*By superstructure is meant the political, legal, religious, artistic,
and philosophical views of a society and the corresponding political,
legal, and other institutions; the base of a society is the economic
system functioning at a given stage in its development.
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The objective of socialist industry, unlike that of capitalist
Industry (to obtain profits), consists of satisfying human material and
cultural wants, which is the principal activity of the Soviet state.
Medical care is a major need of the population.
The progress of Soviet public health depends on party leadership.
The Communist Party and the Soviet Government are ever concerned with
raising 'the people's material and cultural standard of living. The
guiding hand of the party in Soviet public health, as in other branches
of socialistic construction, is felt in the determination of basic
problems and trends as well as in the daily supervision and help
afforded the various health agencies in solving the current problems
facing them at different stages in the development of the national
economy.
The fundamental principles of party policy as regards the protection
of the workers' health are reflected in key party documents and in the
works of the founders of Marxism and Leninism -- Marx, Engels, and
Lenin.
The major decisions of the party and government regarding the
protection of the people's health are landmarks in the history of
Soviet public health. The chief tasks of Soviet public health were de -
fined'in the Communist Party program adopted at the Eighth Congress in
1919.
The program of the Party states:
*The Russian Communist Party (Bolsheviks) regards the execution
of broad measures of health and sanitation aiming at the prevention
of disease as its principal activity in the field of public health.
Accordingly, the Russian Communist Party (Bolsheviks) sets as
Its immediate tasks:
1. The resolute implementation of broad sanitary measures in
behalf of the workers, such as (a) improvement of health conditions
in residential areas (protection of soil, water, and air); (b) estab-
lishment of communal feeding on scientific-hygienic principles;
(c) organization of measures to prevent the outbreak and spread of
contagious diseases; (d) enactment of sanitation legislation.
2. The control of social diseases (tuberculosis, venereal
diseases, alcoholism, etc.).
3. The providing of accessible, free, efficient medical and
pharmaceutical services.*
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Soviet public health is therefore based on the following principles:
development of all public health measures within the framework of a
single state economic plan; free and accessible efficient medical
services; paramount importance of preventive measures recognizing the
decisive significance of social conditions in safeguarding health and
eliminating the source of disease; arousing the general public's
interest in health matters; awareness of the close connection between
public health and progressive medical science and technology.
Governmental control of Soviet public health explains why medical
service is free and accessible, its distinctive feature. In the Soviet
socialist state protection of the peoples health and furnishing them
with therapeutic and prophylactic facilities is taken care of by and
at the expense of the state. During the five years after the war alone
(1945-1950) the state spent about 100 billion rubles on public health.
The 1954 budget allocated 25.3 billion rubles for public health and
physical culture. In 1956 the sum rose to 35 billion rubles.
The rapid expansion of the network of urban and rural medical
institutions, sharp increase in the number of doctors and middle
echelon mechcal personnel, and extension of the medical network into
the remote national oblasts of the Soviet Union brought medical
faciliti-g within easy reach of the people. This is due to the very
nature of the Soviet system. Socialist humanism finds clear expression
in Soviet public health.
The countries of the people's democracies (China, Poland, Czecho-
slovakia, Rumania, Hungary, etc.) have benefited from the Soviet
experience in constructing their own health system.
The Soviet state acknowledges the right of every citizen of the
USSR to obtain not only full medical attention, but also material
assistance during illness, in old age or in invalidism at the expense
of the state. Soviet mothers have the right to obtain the material
assistance of the state during pregnancy, childbirth, and the rearing
of their children. These rights are guaranteed by the Constitution
of the USSR.
Article 120 of the Constitution of the USSR reads *Citizens of
the USSR have the right to financial security in old age as well as in
the event of illness and disability.*
*This right is safeguarded by the broad development of social
insurance of manual and office workers at state expense, free medical
service, and establishment of an extensive network of health resorts
for their benefit.*
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Social insurance, social security in old age, invalidism, and
disability together with free medical service constitute the working
class' greatest gains flawing from the victorious socialist revolution.
They an essential 'Unction in iarroving the nation's health and
In lowering both the sick rate and the death rate.
Soviet social insurance, provided wholly at state expense to all
manual, office, and professional workers, significantly elevates their
material standard of living.
State social insurance pays out allowances for temporary incapacity,
sickness, pregnancy, and childbirth.
Social insurance agencies spend vast sums of money to build
sanatoria, rest homes, pioneer camps, day nurseries, dietetic dining -
rooms, and to promote sports and physical culture.
The USSR social insurance budget is steadily growing. The volume
of state expenditures for social insurance may be judged by the figures
for 1952 When the workers were paid various allowances amounting to
more than 42 billion rubles. Every year state insurance funds pay for
some 3 million workers in sanatoria and rest homes and for more than
5 million children in children's health camps.
Social security agencies spend huge sums from the state budget
on pensions for the elderly.. thereby ensuring them a peaceful, secure
old age.
Soviet
departments
annually by
enterprises
governmental concern is not limited to the activity of
in the Ministry of Health. Billions of rubles are expended
labor unions, social security agencies, and industrial
in order to protect the workers' health.
Governmental control of Societ public health is responsible for
the unity of purpose, tasks, forms and operational methods of medical
establishments. All of them, whether part of the Ministry of Health
system or of other departments, function throughout the country in
accordance with a uniform plan and uniform methods, interlinked and
so designed as to achieve the same objectives -- a reduction in the
death rate of the population, continuous betterment of health, and an
increase in the average life span by ameliorating working and living
conditions.
In the bourgeous countries public health services are scattered
among a host of state, social, private, and philanthropic institue:Ions
and organizations, which are uncoordinated and lacking in uniformity
of plan or method of operation.
The organizational forms of Soviet public health changed at the
various historical phases of the Soviet state, but the unity of Soviet
public health with respect to plan, method of operation and coordination
of Ministry of Health activities with departmental medical services
under a national economic plan has remained intact throughout its
existence.
As socialist construction proceeded and Soviet medicine developed
the People's Commissariat of Public Health discontinued medical services
to individual groups of people. These functions were taken over in the
interests of greater efficiency by appropriate people's commissariats,
which later became ministries, in connection with the expansion of the
network of medical institutions serving these groups. This is how the
medical service of the Ministry of Defense, Ministry of Communications,
and Ministry of Internal Affairs came into being.
However, the existence of such departmental medical services in
no way violates the principle of unity of Soviet public health. The
leading medical agency is the Ministry of Health, USSR. Combining all
aspects of medical activity, it ensures unity and completeness in
providing the urban and rural masses with the needed facilities.
The scientific medical councils, higher medical institutions,
and scientific research institutes headed by the Academy of Medical
Sciences, USSR -- components of the Ministry of Health -- guarantee
that medicine is progressing in the direction of meeting the practical
requirements of public health. The scientific research institutes are
developing the most up-to-date, effective facilities and techniques in
the fields of sanitation and hygiene, diagnostics and therapy and
helping to introduce them into the operation of medical institutions.
Finally, the unity of Soviet public health finds complete expression
in the close combination of therapy and prophylaxis. This unity is
most fully realized in the daily work of the district physician, in
the district structure of medical care, and in the dispensary method
employed by therapeutic and prophylactic institutions.
Another feature of Soviet medicine is the unity of theory and
practice. Flowing from the achievements of socialist economics, the
advances of Soviet public health are inseparably linked with the
development of Soviet medicine, which in our country is founded on
service to the workers.
The health ministries of the USSR and union republics and local
health authorities regard the introduction of the newest and best
techniques of treatment, diagnosis, sanitation and hygiene into the
operations of the entire medical network as their most important task
and a prerequisite to improving the quality of service.
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Soviet public health has at its disposal a variety of ways in
which to communicate the achievements of scientific medicine to all
physicians and middle echelon personnel, namely, periodic all-union
and local meetings of physicians in the various specialties, the medical
press, active members of the public health organization, numerous
scientific and practical conferences. Scientists as well as practical
public health workers participate in these conferences, exchange
experiences and report on major developments in both theoretical and
clinical medicine.
The introduction of new methods of treatment, diagnosis, testing
and approving new drugs is one of the most important assignments of
the scientists connected with the medical councils and scientific
research institutes.
The main specialists affiliated with the health ministries, oblast
and urban health departments -- surgeons, internists, pediatricians,
obstetricians, etc. -- are recognized as playing a big part in this
work. These specialists provide general control and direction of the
various branches of medicine. They help to introduce the latest drugs
and methods of treatment, ensure standardization of lis s by all therapeutic
and prophylactic institutions, and supervise the specialised and advanced
training of medical personnel.
Oblast and rayon hospitals acquaint doctors, feldshers? and mid-
wives with new methods of research and give them practical assistance.
A distinctive feature of Soviet public health as a branch of
state activity is the_fact_that_iLiq_2102E1. The plan for public
health is part ofleollstateecitionamc plan. The planned nature
of public health ensures an even apportionment of funds, sound distri-
bution of medical resources, and organization of the medical network
for maximum efficiency and optimum satisfaction of the people's needs.
It provides for a differentiated approach to the deploying of medical
services in the various krays and ?blasts, enables lagging rayons to
be strengthened, and tends to eliminate the differences between urban
and rural medical facilities.
Soviet public health has for its tasks not only the treatment of
sick people, but also a general improvement in the health and physical
development of the entire population, prolongation of life, lowering
of mortality, elimination of various diseases, chiefly the infectious
ones, a sharp decrease in all the other diseases and, finally, the
creation of sanitary and hygienic conditions to prevent the occurrence
of diseases'. These tasks define the preventive or zaklactic char-
acter of Societ public health.
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Legislation to protect labor, defense of the interests of mothers
and children, social insurance, advancement of the workers' material
welfare, growth of literacy and culture -- all these achievements of
socialism in the USSR create the necessary preconditions, the foundation
of the extensive prophylactic activities of Soviet public health.
W. A. Semashko has pointed out that we must not view prophylaxis as a
narrow, purely bureaucratic function of public health bodies, but as
a broad and deep concern of the Soviet government. Strengthening
health through preventive measures has been the underlying philosophy
of Soviet public health at every stage of its history up to the present
day, a period that is witnessing the transition from socialism to
communisn.
In the Directives of the Twentieth Congress of the Communist
Party of the Soviet Union on the sixth five-year Plan for expanding
the national economy of the USSR it is written: "To ensure the
subsequent development of public health, raise the standard of
prophylactic activities of public health bodies, and improve the
quality of medical service to the population."
The Directives make it necessary "to intensify efforts to pro-
tect labor and prevent illness among manual and office workers as
well as to safeguard the water supplies, atmosphere, and soil from
contamination by industrial waste products."
The prophylactic activities of Soviet public health consist
chiefly of executing public sanitation measures to purify the
external environment. These include safeguarding of the air, soil,
and reservoirs, medical inspection of foodstuffs, housing and communal
construction, and sanitary conditions in industry, school, etc.
Execution of the necessary sanitation measures is provided for by
Soviet labor and sanitation legislation. Responsibility for its
implementation rests with the public health agencies.
The preventive philosophy of Soviet public health finds clear
expression in the organization of obstetrical services and protection
of children's health. All pregnant women are kept under observation
at maternity clinics; children from birth on are observed at children's
clinics; children's hospitals regularly check on the health of chil-
dren in day nurseries, kindergartens, and schools. The health and
physical development of juvenile workers, students at trade schools,
etc., is fully cared for. The prevention of specific diseases is a
very important function of Soviet preventive medicine. This relates
principally to epidemic, acute infectious diseases and elimination of
foci of diseases that have developed.
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ALTASjor role in the prevention of tuberculosis, cancer, and venereal
diseases is played by the appropriate clinics, which aim at early dis-
covery, treatment, and prevention of these diseases by carrying out
individual and communal prophylactic measures.
Clinics also use the preventive approach in treatment. Systematic
clinical observation of various groups (workers, machine operators and
front-rank workers in agriculture, scientists, etc.) permits the early
detection of symptoms of serious, chronic diseases and the institution
of timely treatment. The dispensary system for patients with h,yper-
tensive, ulcerous, cardiovascular and other diseases, timely treatment,
correct layout of work, and imp:VI/Merit of living conditions constitute
the most reliable means of preventing disease or complications arising
from disease as well as conserving the work capacity of sick people. At
the present time all urban and rural medical-therapeutic institutions
lay heavy stress on the clinical method of operation.
The prophylactic theory of Soviet public health is based on
dialectic materialism, on the doctrine of interrelation of organism
and ewtironment.
Bourgeois pseudo-scientists -- the eugenists, Mendelians and
Morganists -- reject the decisive influence of environment, including
social factors, on health.
Relying on the bourgeois idealistic genetics of Mendel, Morgan,
and Weisman, the eugenists attempt to prove that it is not the living
conditions of the people or their environment, but heredity, i.e., the
Innate properties acquired by an organism from its parents, that deter-
mines their physical development and health as well as the occurrence of
various diseases. These pseudo-scientists maintain that heredity is
affected not by the environment, but by genes inherited from parents?
According to these wtheories,? the high death rate, wars, and epidemics
are favorable factors actively conducive to Npurgine mankind of
physically and mentally inferior elements. It is quite apparent that
this reactionary bourgeois usciencelw invoked to defend the interests
of capital, tries to justify capitalist exploitation, imperialistic
wars, racial discrimination, and their pernicious effect on the health
of the workers.
To such outstanding Russian scientists as M. Ya.. Mudrav (1776-
1831), S. P. Botkin (1832-1889), I. M. Sechenov (1829-1905), F. F.
Erisman (1842-1915), and others belongs the historic merit of having
resolved the question of organism-environment interrelations on
materialist grounds. They demonstrated that the development and
qualitative changes of an organism depend on the living conditions.
The great Russian physiologist, I. P. Pavlov, played an exceedingly
important role in working out this problem. He studied the principles
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underlying the development of organisms and the changes induced by
various external and internal stimuli; he elucidated the function of the
nervous system, particularly higher nervous activity, as an instrument
of communication between organism and environment.
I. P. Pavlov demonstrated the capacity of higher nervous activity
to change and improve under the influence of specific environmental
conditions. He showed how much amelioration of living and working
conditions as well as suitable toughening and seducatings the organism
did to fortify health and build resistance to sickness.
The advance of Soviet public health is inseparably associated with
the development of Soviet medicine. The Soviet public health system
combines medical theory and practice to the fullest. At present there
isn't a single branch of therapeutic or prophylactic medicine that is
not directed by a corresponding scientific institute. The Ministry of
Health embraces within its organization more than 250 specialized
central, republic, oblast and kray scientific research institutions in
the various branches of medicine. In addition, all medical schools
conduct research. The Academy of Medical Sciences, USSR, with which
number of leading scientific research institutes are affiliated, was
founded in 1944. It is our supreme scientific research institution
and its purpose is to investigate and solve the most important basic
problems of medicine, ever cognizant of the practical needs of public
health.
The Ministry of Health, USSR, and health ministries of the union
republics have scientific medical councils which plan all the scientific
medical work, analyze the most important discoveries and achievements
in medicine, and facilitate their exploitation and practical application
In public health.
Science has extensively penetrated the practical activities of
medical institutions. Many of the major hospitals, dispensaries,
polyclinics, and sanitary-epidemiological stations are conducting
research programs to broaden their rich daily experience.
Soviet scientists are being increasingly drawn into the practical
work of public health agencies. The achievements of Soviet medicine
have enhanced the practical work of public health, helped to lower the
sick and death rates and raise the health level of the USSR population.
The names of such leading Soviet scientists as I. P. Pavlov, A. I.
Abrikosov, N. N. Anichkov, K. M. Bykov, N. N. Budrenko, N. A. Semashkol,
Z. P. SoloOyev, P. A. Gertsen, M. P. Konchalovskii, A. N. Bakulev,
V. P. Filatov, and many others are well known in the USSR and abroad.
The physiology teachings of I. P. Pavlov have made an exceptional
contribution to the successes of Soviet medicine. I. P. Pavlov's
teachings form the scientific basis of Soviet public health, on his
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materialist principles rest the practical activities of medical insti-
tutions (protective medical regimen, sleep therapy, clinical method of
operation).
The Directives of the Twentieth Congress of the Communist Party of
the Soviet Union pledge the continued advance of medicine, focussing
the efforts of Soviet scientists on finding new techniques of prevention
and treatment.
Experience has shown that success in prevention and treatment
depends on the participation of the population. Attracting the people
to medical and sanitation work is possible only if there is wide
propagation of medical knowledge, i.e., health education.
Health education and organization of independent action on the
part of the people are the chief tools of Soy et public health. Soviet
public health characteristically maintains constant contact with the
masses, encourages vide participation by socially alert groups in
preventive work aimed at lowering the illness rate and traumatism, and
tries to ameliorate the people's sanitary working and living conditions.
NSafeguarding the workers' health is the concern of the worliftrs them-
selves', was used as a slogan when .0.1.z: Soviet public health srvice was
being organized. During its early days and the period of civil mar and
devastation, when the entire population had to be mobilized to combat
epidemics, medical education (the issuance of slogans, posters, leaflets,
discussions, etc.) played a major role in the fulfillment of this task.
The organizational forms of popular action are varied. The
sanitary activists comprise members of the permanent health commissions
of local councils of workers' deputies, sanitary agents, members of
sanitation posts, sanitary combatants and guards of the GS0 (Clot-ay k
sanitarinoi oborone - NBe Ready for Medical Defense* (slogan)37Frrinees
of the Red Cross and Red Crescent Societies, and workers of cooperation
councils organized in medical institutions. The sanitary activists
assist public health organizations in carrying out mass health and
sanitation programs -- vaccination projects, week-long and month-long
campaigns to clean up houses, yards, and reservoirs, etc. They cooperate
with medical workers in organizing lectures and discussions on various
topics of health education.
Since the conducting of educational programs and organization of
public health activists is an obligation of all medical institutions and
individual workers, the specific forms of medical propaganda by the
various institutions will be considered in a separate chapter (Chapter
8).
-10-
1.%
Sanitary activists function under the general guidance and super-
vision of district physicians, health station physicians, feldshers,
and rural midwtves. Day-by-day help and organization of their work is
the direct responsibility of middle echelon medical personnel.
The Development of Public Health in Russia and the USSR
Public Health in Tsarist Russia
The development of capitalism in Russia was accompanied, as in
other countries, by a marked deterioration in the health conditions
of populated areas. The growth of towns due to the expansion and
concentration of capitalist production, the congestion, filth and
misery of the workers' quarters, contamination of the water, air, and
soil by factory wastes -- all these things markedly worsened hygienic
conditions in the cities and raised the sick and death rates.
Physical exhaustion, unemployment, dirt, and crowded housing
conditions, especially in the large cities, facilitated the spread
of tuberculosis, venereal diseases, and alcoholism, which under
capitalism became social diseases. The unlimited work day and total
absence of protective measures resulted in occupational diseases.
"Consumption and other pulmonary diseases are due to the existence
of capital," Karl Marx wrote in. Capital (Vol. 1, chapter 13).
The increase in morbidity and worsening of the health of the
masses directly endangered capitalist production and the fighting
efficiency of bourgeois armies. Epidemics not checked in the workers'
quarters spread to the bourgeois sections, constituting a threat even
to the bourgeoisie. This ultimately compelled them to introduce
various hygienic and antiepidemic measures.
However, the limited, narrow sanitary legislation of bourgeois
countries, which kept clashing with the interests of the entrepreneurs,
landlords, and manufacturers, was not enforced and so had little effect
on the grim working and living conditions of shop and factory workers.
Sanitary laws in capitalist countries cannot eliminate the very factors
(unemployment, hunger, gross exploitation) that cause illness and raise
the death rate. Imperialism and the increasing speed-up of work:
imperialist wars, racial discrimination, simultaneous rise in unemploy-
ment, and uncertainty regarding the future promote mental, cardio-
vascular, and nervous disorders.
In capitalist public health the government's obligation is
restricted for the most part to the organization of a medical inspec-
tion and state sanitation service. The public health bodies deal
purely with individual medical problems, establish general regulations
concerning doctors (issuance of diplomas, determination of right to
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practice medicine, etc.) and only to a limited extent at that. Yet
these countries have a good deal of quackery and medical charlatanry.
Physicians in practice for themselves, private medical organizations,
and various groups generally render medical aid for a fee, as a conse-
quence of which this aid is available only to the well-to-do segments
of the population. There is no plan governing the distribution of
medical institutions or physicians. Unemployment is common among the
- physicians, especially in the large cities. That is why many of them
are compelled to accept work outside their profession.
Medical services provided by the federal government and local bodies
consist largely of mental hospitals and a few municipal hospitals and
polyclinics usually requiring payment too. An insignificant amount of
help is supplied by charitable organizations, hospitalization funds,
and social insurance agencies.
The wealthiest capitalist country, the United States, allocates
negligible funds to safeguard the people's health. A special commission
Investigating public health in the U. S. prior to World War II determined
that &a% of all expenditures on health were paid :by the people, i.e.,
by the patients themselves, 2% by private industry, 5% by charitable
organizations, and only 13% by the government. Due to the vast sums
spent for military purposes in the U. S. allocations for health needs
have been shrinking every year. For example, from 1945-1951 the number
of hospital beds in the U. S. decreased by almost 300,000. In view of
the high costs of treatment it is no wonder that some 50% of the beds
in private hospitals are empty, despite the vast need for them.
All this does not mean, however, that medical science and public
health in modern capitalist countries are lacking in important achieve-
ments. Along with mounting productive capacity, general and sanitary
engineering, and medical achievements, individual branches of medicine
and sanitation have reached a high level in several of these countries.
This is due primarily to sanitary legislation, the execution of various
hygienic and aatiepidemic measures (sanitary and food inspection,
medical planning and municipal responsibility for cleaning streets,
removing garbage, etc., sanitary measures for schools and border
quarantine). As a result, the epidemic sick rate, general and chil-
dren's death rates have declined considerably in several bourgeois
countries.
Notable success has been attained in medical technology, in the
manufacture of medical apparatus, instruments, and drugs. Impressive
achievements have also been registered in hospital construction, the
technical equipment of medical schools, and the elaboration of new
methods of treatment.
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However, neither the high level of medicine and technology nor
the significant achievements in sanitation remove the basic contra-
dictions of bourgeois medicine inherent in the capitalist system.
Expert medical service, as we pointed out above, is available only to
the well-to-do. Therefore, however important this or that medical
achievement in a capitalist countrymay be, it does not become the
property of the masses or promote their general well-being.
* * *
adimentary medical institutions and the first steps in public
health in Muscovite Russia came into being during the 16th - 17th
century, when Ivan the Terrible organized quarantines and patrols
against the plague on the major trade routes. Hospitals and monastery
almshouses were built, the Apothecary Department* set up, medicinal
plants cultivated, pharmacies opened, and the first medical books --
herbals and treatment manuals -- printed. Here too belongs the attempt
made under Czar Alexei Mikhailovich to train Russian doctors for the
army.
The most significant reorganization of medicine and public health
dates from the 18th century. Under Peter the First military hospitals
and infirmaries were built in Moscow, Saint Petersburg, and other cities
in addition to affiliated medical and surgical schools to train doctors,
primarily for the army. A medical department, pharmacies, orphanages,
and foundling homes were organized.
In 1755 the initiative of the great Russian scientist Lomonoscv
led to the establishment of the University of Moscow, the first such
institution in Russia. Its medical faculty was to become the focal
point of Russian medical science as it developed over the years.
Public charity departments organized in 1775 took over operational
responsibility for all the medical institutions, hospitals, orphanages,
foundling homes, etc. This departmental medicine and its bureaucratic
system, together with its venal officials, wretched network of hospitals
and flGod.-pleasing institutions,? survived up to the middle of the 19th
century.
Emancipation from serfdom and the rapid rise of capitalism in
Russia from 1860-1880 required a substantial number of workers for the
shops and factories in the cities and the landed estates in the country.
The high sick and death rates due to the extremely low standards of
sanitation and education as well as the recurrent epidemics were a
WEe highest administrative medical institution of pre-Peter the Great
Russia, which supervised medical workers, the purchase of drugs, etc.
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0
serious threat both to emergent industry and to agriculture. This
situation resulted in the creation of unusual new forms of medical
service -. factory and zemstvo medicine.
Zemstvos local administrative bodies in which representatives
of all the classes (nobilityrbourgeoisie, and peasantry) were supposed
to participate .. were introduced into Russia in 1864 after the
emancipation. In practice, however, only the landlords and kaiak
leaders in the villages were represented. The zemstvo was entrusted
with the responsibility of organizing medical services for the rural
population.
Zemstvo medicine actually did very little. Although it was
supposed to be sfree,91 most of the operational costs fell on the
shoulders of the otax?mingl peasants in the form of zemstvo taxes.
The zemstvo landowners were very loath to allocate funds for medical
facilities. Owing to their sparse distribution, these facilities
were almost Inaccessible, especially to those peasants who had no
horses. Zemstvo expenditures on medicine were negligible (in 1912
some 57 million rubles in 34 provinces, or 66 kopeks per person).
The number of doctors and hospitals were wholly inadequate to meet
the aeeds; so too the sanitation measures. The police regime sup-
pressed all public initiative, making it impossible for doctors to
carry on education in hygiene and enlist the population in the struggle
against disease.
Nevertheless, zemstvo medicine was a significant step forward
from the pre.reform departmental medicine in that it set up a new net-
work of zemstvo hospitals, dispensaries, feldsher and midwife schools,
and a sanitary organization. Zemstvo medicine was a completely original
form of rendering aid to the rural population that was unknown in
Western Europe. The ablest, most advanced elements of the pre-revo-
lutionary intelligentsia went to work in the zemstvo. Prominent zemstvo
physicians evolved the district principles of operation, introduced
registration and investigation of morbidity, and carried out various
statistical studies of the health and physical development of the
peasant and industrial laborers, thereby exposing the pernicious
influence of capitalism on the health of the working people.
This was the work of the founders of Russian medical statistics,
the zemstvo doctors Ye. A. Osipov, V. A. Levitskiy, P. I. Kurkin,
S. M. Bogoslovskiy, F. F. Erisman, A. V. Pogozhev, and others.
From the ranks of zemstvo doctors came a number of bolshevik
doctors who took an active part in building Soviet public health.
These include above all the founder of Soviet public health N. A.
Semashko, his deputy Z. P. Soloveyev, and Drs. I. V. Rusakov, D. I.
Ultyanov, M. F. Viadimirskiy, A. N. Susin,. and others.
Zemstvo doctors constituted the nucleus of the pre-revolutionary
medical profession that merged with the Society of Russian Physicians
in Memory of N. I. Pirogov organized in 1883. At Pirogov and zemstvo
conferences the doctors raised various questions concerning public
health and examined the grave hygienic and economic living conditions
prevalent in Russia at the time.
However, despite the distinguished services of certain individuals,
zemstvo doctors were unable to make a significant contribution to improv-
ing the health of the peasants both because the material resources were
extremely limited and because most of these doctors entertained liberal,
bourgeois views. This also affected the activities of the Pirogov
Society, which in its reports and resolutions during 1905 mirrored the
general revolutionary fervor of the entire liberal intelligentsia and
took a liberal position during the years of reaction, but after the
Great October Socialist Revolution, at the instigation of its officers,
went over to the camp of the enmies of the Soviet regime.
Zemstvo medicine was to be found only in those provinces where
zemstvos were introduced, i.e., in 34 provinces of the European part
of Tzarist Russia. Elsewhere the population was serviced by the insig-
nificant medical network of the Ministry of Internal Affairs. Whereas
the zemstvo provinces averaged one medical district per 710 sq0 km. of
territory and 28,000 persons, the non-zemstvo provinces (Siberia and
Central Asia) averaged one medical district per 2,000 to 13,000 sq km
of territory and 40,000 to 70,000 persons. There was no medical service
at all in the remote regions inhabited by the national minorities.
The situation of the industrial workers was no better. During
the serious cholera epidemic of 1866, the government ordered medical
facilities to be provided for the many workers affected. Accordingly,
every industrialist was required to set up in his factory an infirmary
containing one bed per 100 workers. The original text of the decree
reads that the industrialists could limit themselves to building and
equipping these quarters without actually making doctors available, and
many took advantage of this loophole. These hospitals rendered only
first aid, and workers requiring extended treatment were sent to a city
or zemstvo hospital. But even this meager amount of aid was unavailable
in most factories; in 1907 only 38% of the factories had medical
facilities.
In 1912, when revolutionary fervor was high, the government, under
the pressure of the working masses, passed a law on social insurance,
which required factory owners to furnish first aid and dispensary
facilities; special insurance funds covered hospitalization. These
funds were insignificant and during World War I were virtually termi-
nated. Nevertheless, they played an important role in the revolutionary
movement by serving as a means of legally organizing the working class.
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Some municipal hospitals and other medical institutions were under
the jurisdiction of local administrations (the municipal dumas). How-
ever, except in a few of the larger cities, their effect was slight.
Thus, data on 224 cities from 1912 to 1914 indicate that 35% of them
provided no service at the expense of the local government. In most of
the other cities there were only casualty wards and dispensaries with
general wards. Only a few cities had a public health organization,
which was staffed for the most part merely by one or two doctors.
In 1913 there were all told 142,000 hospital beds in all Russia,
1,230 dispensaries, 19,785 physicians, and no more than 50,000 middle
echelon medical personnel. The peasants in pre-revolutionary Russia
constituted 82% of the total population, but were attended by only
5,000 physicians.- They had just 49,000 hospital beds or 0.44 per 1,000
persons.
Such were the medical facilities available to the masses of Russian
workers and peasants on the eve of the Great October Socialist Revolution.
The Development of Soviet Public Health
The organizational foundations of Soviet public health and its
subsequent development were laid during the preparation and execution
stages of the Great October Socialist Revolution (1917-1918). Soon
after the proletariat seized power in October 1917 the scattered medical
activities of the individual departments were unified by the Council of
Medical Boards; the medical sections of local Councils took charge of
local health affairs; private hospitals, polyclinics and pharmacies were
nationalized.
In July 1918 a resolution of the Council of Peoples Commissars
signed by V. I. Lenin authorized the organization of a Peoples
Commissariat of Public Health to which were transferred all medical
institutions and the direction of medicine and sanitation in the
Soviet republic (Figure 1).
Establishment of the Peoples Commissariat of Health led to the
organizational unity of Soviet public health and to overcoming the
efforts of bureaucratic, particularly insurance, doctors and the
defeated Mensheviks to retain their autonomy and oppose the concept
of a single Soviet medical system. The medical facilities were gradually
amalgamated: all the honorable medical workers dissociated themselves
from the saboteurs and became affiliated with the People's Commissariat
of Health and Soviet medical institutions.
The Soviet government in its early years issued a series of major
decrees to protect the health of the workers: on social insurance, an
maternity and child protection (1917), on nationalization of pharmacies
and medical property, on compulsory vaccination (1918), on the campaign
against typhus (1919), etc.
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From the very beginning Soviet public health participated directly
in the solution of the basic problems confronting the young Soviet
republic. Its most important tasks were to mobilize all medical resources
and facilities during the period of foreign intervention and civil war
(1918-1920) so as to engage the public in the campaign against epidemics
and to service the Red Army.
World War I and subsequent famine and devastation together with
foreign intervention seriously weakened the health of the people, causing
an increase in the number of epidemics, notably typhus and relapsing
fever. V. I. Lenin at the Seventh Congress of the Soviets held In
December 1919 referred to typhus as a threat to the very existence of
the Soviet republic when he urged: "Comrades, all attention to this
problem! Either socialism conquers the lice, or the lice will conquer
socialism"1*
In response to the leader's call, the medical workers under excep-
tionally difficult conditions mounted a fierce attack on epidemics,
carried out extensive educational propaganda, campaigned for cleanli-
ness, set up baths, laundry, and disinfection detachments. They drew
into the battle the entire population -- workers, peasants, and Red Army
men.
The period of transition to peaceful restoration of the national
economy was characterized by the reestablishment and expansion of the
network of medical institutions and by them accessible to both
the urban and the rural populations. Sanatoria and health resorts were
built, home medical care provided, and medical facilities set up in the
regions inhabited by the various nationalities. New types of therapy
and prophylaxis came into wide use at this time: institutions were
founded to protect mothers and children, to control tuberculosis,
venereal diseases, and the remnants of prostitution. Newly organized
consultation centers, clinics, labor dispensaries, night sanatoria, and
venereological detachments carried an extensive medicoprophylactic and
socio -hygienic work. The network of medical institutions, which had
grown in numbers, became firmly established by 1928. Hospital beds
increased by 70,000, doctors by 43,000; rural medical districts almost
doubled.
However, as reconstruction of the national economy got under way
serious inadequacies were noted in the public health system. Despite
major achievements, it lagged far behind the development of the national
economy. It failed to provide differentiated types of medical care for
the various groups of the population, preferential service to workers
in the principal branches of industry, workers in state farms and newly
founded collective farms, nor did it reckon with the fresh dislocation
of economic regions. The historic 18 December 1929 resolution of the
Tr: I. Lenin, Works, vol 30, 4th ed., p 206.
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All-Union Communist Party (Bolsheviks) *On Medical Service to Workers
and Peasants* noted the need for a drastic overhauling of the public
health organizations and suggested ways of doing so.
The years of struggle to industrialize the country and collectivize
agriculture were attended by considerable growth and replanning of the
network of medical institutions to conform to the development of new
economic industrial and agricultural centers. Exceptionally important
were the health stations in industry, which turned into front line
institutions in the cappaign to reduce morbidity and traumatism as well
as to ameliorate the Vorking and living conditions of the people.
The health organization proved to be a major factor. Demands for
medical supervision and control mounted due to the swift growth of cities,
the rise of new, inhabited localities, reconstruction and construction
of new enterprises, development of new branches of industry, mechanization
of agriculture, and inclusion of public nutrition within the scope of the
health apparatus. Sanitary inspection was instituted in 1933 as a function
of the People's Commissariats of Health in the union and autonomous
republics. In 1935 thpeAll-Union State Sanitary Inspection was organized
in the Council of People's Commissars, USSR. In 1936 it became the
People' Commissariat of Health. The post of state sanitary inspector
(for food, industrial, school, and communal sanitation) was set up
together with an extensive network of medical and disinfection stations.
As of 1936 the People's Commissariat of Public Health, USSR, took
over all public health functions in the country. Public Health was
given a big boost in 1936 by ratification of the Constitution of the
USSR, which assured workers the right to rest, medical care at state
expense, and financial security in old age and in the event of loss of
work capacity.
The elimination of unemployment, continuous improvement in the
condition of the workers, and active participation by increasing numbers
of women in social and industrial life raised anew the question of
maternity and children's protection. The 27 June 1936 decision of the
Central Executive Committee and Council of People's Commissars, USSR
to offer greater material and legal assistance to mothers brought about
a substantial rise in the number of maternity beds, women's and children's
consultation centers, kindergartens and day nurseries, as well as greater
financial and legal support for mothers and children. Expansion of the
network of medical institutions to rural areas and improvement of their
facilities were due to a special resolution of the Council of People's
Commissars, USSR, on strengthening rural medical districts.
Public health developed hand in hand with the building of socialism
in the USSR. Medical institutions grew by leaps and bounds. The growth
of Soviet public facilities in the national republics was particularly
-18-
indicative. For example, the number of hospital beds had increased
fifteen times in the Kazakh SSR by 1941, twenty-two times in the Turkmen
SSR, etc. By 1941 there were 661,431 hospital beds in the USSR, 13,512
rural medical districts, and 130,300 physicians, or almost seven times
as many as in 1913.
Advances in Soviet public health based on steady growth of the
country's material well-being and elevation of the cultural level caused
a sharp decline in the sick and death rates in the years preceding
World War II and a marked improvement in the health and physical develop-
ment of the population.
The treacherous attack of the fascist hordes on our country in 1941
subjected the Soviet people to cruel trials and destroyed their peaceful,
constructive work. The war posed a series of new problems for Soviet
public health: providing for the needs of the Soviet Army, expansion
of hospitals, organization of medical aid for wounded and ill soldiers
and officers, organization of medical services for Local Antiaircraft
Defense, etc. In a short time the health agencies set up a chain of
evacuation hospitals with tens of thousands of medical workers.
One of the agencies' principal assignments from the early days of
the war was to protect the favorable situation of the country vis-a-
vis epidemics. The shifting of vast masses of people and destruction
of homes and communal institutions by enemy aircraft made for unhealthy
living conditions and conduced to the rise of infectious diseases. The
strenuous, combined efforts of the local Councils of Workers' Deputies,
public health agencies, and the people themselves helped prevent the
outbreak of epidemics.
As the enemy was driven from the regions they temporarily occupied,
the public health agencies were faced with the problem of reactivating
medical institutions in the liberated areas and organizing facilities
for invalids of the Patriotic War. The fascists destroyed thousands
of hospitals, polyclinics, day nurseries, sanatoria, and other medical
institutions. Even greater was the damage to the people's health.
Overcoming the medical consequences of the war, restoration,
expansion, and substantial improvement in the quality of work of medical
institutions, lowering the neneral and ;nfentious morbidity and mortality
rates -- these were the main tasks confronting the publfc health'agencies
in the postwar years.
During this period various measures were carried out to improve
public health and raise the standard of medical service to the popu-
lation. The most important of these measures was the unification of
hospitals, polyclinics, and other medical institutions, dispensaries
and corresponding hospitals, maternity homes and women's consultation
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centers, children's hospitals, children's polyclinics and consultation
centers. The problem of providing the rural population with specialist
services was solved by building up rural rayon hospitals as centers for
these services and expanding the training of specialist cadres for the
villages. The sanitary-epidemiological service was reorganized.
Improvements were made in the medical care of industrial workers. The
network of medical institutions grew considerably. The number of
hospital beds increased by 60% over the 1940 figure. There are now
300,000 doctors working in the public health system in addition to some
900,000 feldshers, midwives, nurses, etc.
Due to the special attention paid to the training of medical
specialists, the Soviet Union is at present one of the leading countries
in the world in number of doctors per 1,000 persons; several of the
union republics far exceed the foremost capitalist countries in this
respect. During the same period of time the number of rural medical
districts increased by 13%, feldsher - midwife stations by 59.9%.
The advances in public health, continuing improvements in material
welfare, and achievements of medicine resting on the scientific foun-
dations of I. P. Pavlov's physiological teachings helped reduce
morbidity and mortality. The death rate is less than one-third what
it was in 1913. The death rate of children has declined by more than
half in comparison with 1940. In recent years deaths from tuberculosis
have been cut by half, from other infectious diseases by two-thirds.
The natural growth of population in the USSR from 1950-1955 totaled
16,300,000.
The USSR has entered a period of gradual transition from socialism
to communism. The decisions of the Twentieth Congress of the Communist
Party of the Soviet Union contemplate the continued vigorous develop-
ment of all branches of the national economy and a sharp rise in
agricultural production, with consequent major improvement in the
people's material welfare and cultural level.
The directives of the Twentieth Congress of the CPSU concerning
the sixth five-year plan for expanding the national economy of the
USSR chart the future development of public health. They aim at ever
higher standards of preventive work and medical care. The directives
also include measures designed to increase the number of hospital beds
in 1960 by 28% over 1955, places in day nurseries by 44%, places in
kingergartens by 45%, places in sanatoria by 10%, and places in rest
homes by 13% ... enlisting the broad cooperation of the ministries and
departments of the USSR and union republics in building medicopro-
phylactic and children's institutions,n
The Twentieth Congress decided to modernize the medicoprophylactic
institutions by installing up-to-date equipment. Output of the medical
industry is to be stepped up to keep pace..
-20-
The Structure of Public Health Agencies
According to articles 76 and 78 of the Constitution of the USSR,
the Ministry of Health, USSR/is reckoned with the ministries of the
union republics. This means that in addition to the all-union ministry
there are ministries of health in all the union and autonomous republics.
These ministries are directly subordinate to the Council of Ministers
of the several republics.
The Ministry of Health, USSR, provides general guidance and super-
vision through the health ministries of the union and autonomous
republics (Figure 2). Directly-under the Ministry of Health, USSR,
are the Academy of Medical Sciences, various scientific research
institutes, the State Sanitary Inspection Service, and the State
Publishing House for Medical Literature.
The ministries of health of the union republics are responsible
for medicoprophylactic and sanitary-epidemiological services, health
resort facilities, the training of physicians and middle echelon
medical personnel, the manufacture and sale of drugs.
In the union and autonomous republics public health is directed
by ministries of health of the union and autonomous republics, in the
krays and oblasts by kray and oblast ministries of health, in the cities
by municipal departments, and in the rayons by rayon health departments
of the local Soviets of Workers' Deputies.
Health departments form part of the corresponding oblast, kray,
municipal, and rayon executive committee of the Soviet Workers' Deputies
and are subordinate both to the Soviet and to the higher health agency.
Oblast (kray) health departments direct the work of rayon and municipal
health departments, administer all medical institutions under their
direct jurisdiction, supervise the activities of all medical and sanitary
institutions and health resorts of all the departments within the oblast
or kray, organize medical care for the population living in the oblast
(kray), prepare and execute the overall plan of public health for the
oblast, carry out measures to provide advanced training for medical
personnel and raise standards, and direct the middle-echelon medical
and pharmaceutical schools.
Rayon (urban or rural) health departments are agencies of the
rayon Soviets of Workers' Deputies and are subordinate both to them
and to the higher municipal or oblast department of health. They
direct all public health activity in the rayon, draw up the rayon
public health plan, directly administer all their subordinate medical
institutions, and furnish them with personnel, funds, supplies, and
drugs.
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Rural health departments direct the rural medical districts.
Besides the Ministry of Health, USSR, several other ministries --
Defense, Transport, and Internal affairs -- also provide medical ser-
vices. The special problems confronting these ministries and the
particular conditions affecting their personnel have made it necessary
to transfer responsibility for medical care to the respective ministries.
Ministries engaged in manufacturing and processing food products
have departments charged with exercising sanitary supervision over their
food enterprises, for example, the fish, meat and milk, and foodstuffs
industries.
The medicoprophylactic units of the various ministries do not
impair the unity of the Soviet public health system. All medical
institutions in the USSR are based on the same principle and use the
same methods. Their activities are coordinated under the common plan
for the national economy. The Ministry of Health, USSR, and the health
ministries of the union republics exercise general control over the
operations of the medical and sanitary units of all departments and
organizations.
They settle the basic problems of scientific methods and organi-
zation involved in advancing Soviet public health.
The manufacture and sale of drugs. The manufacture of drugs,
medical supplies, and equipment is chiefly concentrated in the medical
instrument and chemicopharmaceutical enterprises conducted by the
Ministry of Health, USSR.
Some drugs, medical instruments and equipment are manufactured
by other ministries at the order of the Ministry of Health, USSR.
The main Pharmaceutical Administration of the Ministry of Health,
USSR, a self-supporting unit, is in charge of all matters pertaining
to pharmaceutics. The Main Pharmaceutical Administration and its
local agencies operate pharmacies, stores for sanitation and hygiene,
factories (Galenic laboratories, packing departments, instrument repair
shops, and control-analysis laboratories), and organize the sale of
drugs to the public.
The Administration and its subsidiaries engage in the highly
important work of collecting and storing native medicinal plants, in
which the Soviet Union is very rich. Experience has shown that Galenic,
vitamin, endocrine, and other drugs as well as hygienic preparations
(tooth powder, tooth brushes, etc.), can be produced locally at low
cost with simple equipment.
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Soviet pharmacies not only dispense proprietary medicines and drugs
according to prescription, but also spread hygienic information among the
people, publicize new medical and hygienic preparations, and render
first aid. In rural sections, besides pharmacies, there are many drug
stations (branches of near-by pharmacies), which are attached to hospitals,
rural medical dispensaries, and feldsher points in order to make drugs
readily available to the people.
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CHAPTER 2
INDICES OF THE PEOPLE'S HEALTH
Medical Statistics
Soviet public health is organized in accordance with the general
plan fol the development of the national economy and culture. In order
to plan the network and activities of the public health apparatus both
for an entire republic and for an individual medical establishment, it
is necessary to know the size and density of the population to be served
as well as its age, sex, and occupational composition. The preparation
of an effective plan for lowering the sick rate requires data on the
amount and nature of morbidity, i.e., a knowledge of the most prevalent
diseases. Morbidity data provide a prime basis for evaluating the
quality and results of the work both of the public health system as a
whole and of the individual medical institutions.
Medical units or health stations are judged chiefly by the rate of
decrease in traumatism and work incapacity, elimination of occupational
disease, etc. They must therefore systematically calculate morbidity,
traumatism; and occupational diseases among the workers in the enter-
prises with which they are connected.
To organize its work properly, a children's hospital must take into
account all the children living within the area it serves and the indices
of morbidity and mortality of the children in that area. Such a hospital
is judged by the rate of decrease in morbidity and mortality as well as
by the data on physical development of the children. Improvements in
the physical development index -- an increase in the growth rate and
weight gain of newborn infants, school children, draftees, etc. --
testifies to general amelioration of the living conditions of the masses
and to the effectiveness of the health agencies.
The indices of morbidity, mortality, and physical development
reflect the level and condition of health of the people. They are
extremely important to the public health agencies, institution, and
individual medical workers.
Besides these indices, valuable guidance in planning public health
and appraising the medical institutions is furnished by the daily
records and periodic reports submitted by the various health agencies
and medical institutions. Accurate and timely reports constitute a
basic prerequisite to the proper organization of medical facilities.
r.t
?
Reports of the individual institutions and health agencies (rayon
and oblast health departments) serve as a basis for evaluating the
adequacy of the medical cadres, different kinds of facilities, quality
of medical care, and morbidity. Medical service for the coming period
is planned accordingly; appropriate supervision of the operations of
the medical institutions is instituted and checks made an execution of
the work plans. No medical institution could plan its work soundly
without taking cognizance of these data. Every medical worker, regard-
less of where he may be, must know the size, composition, and sick rate
of the population that he serves and be able to analyze and report
effectively on the work of his institution. It is only through up-to-
date familiarity with health conditions of the people in his area that
a medical worker can correctly organize his awn work, concentrating
mainly an the poorer districts, and accurately assess the results of
his efforts.
An investigation of health and analysis of medical institutions
requires use of the statistical method. Data on the numbers, com-
position, and shifts of the population are studied by demo ra hic
statistics. An investigation of morbidity, physical development,
network and activities of medical institutions constitute the research
domain of medical or public health statistics.
The statistical method is employed whenever mass phenomena are
investigated. The function of statistical research is to reveal the
common features and principles underlying the mass of phenomena under
investigation. These features and principles, which are not revealed
when phenomena are studied individually, become apparent when they are
viewed in the mass or in the aggregate and are expressed by a simple
average characterizing the entire body of data.
Individual phenomena within the mass of observations are accidental
and since their presence or absence depends on individual causes, basic
principles cannot be deduced from them. For example, the birth of any
one person is accidental due to a succession of chance circumstances
that might well not have arisen. All women do not have sexual relations,
nor do all women engaging in sexual relations become pregnant, nor do
all pregnancies terminate in births, etc. But the birth rate, as a
mass phenomenon, as a definite number of births per 1,000 of population,
is a rather stable quantity in every country, with only insignificant
variations from year to year. Again, the distribution cif newborn children
by sex (the so-called sexual ratio) cannot be determined, let us say, an
the basis of the data from a single family. In individual families we
may encounter the most varied sex:patterns, e.g., 2 boys and 1 girl,
3 girls and 4 boys, etc. It is only on the basis of an extensive amount
of material embracing tens and thousands of births that we are able to
establish the existence of a definite sexual ratio: 104-106 boys are
born to 100 girls.
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When there is a mass of observations, the varied individual deviations,
so to speak, cancel each other out and the principles underlying the
phenomenon under study emerge in pure form, e.g., the relationship between
the birth rate and general socio-economic conditions.
The constancy (or regularity) of mass phenomena as revealed by the
statistical method depends on the continuing presence of the specific
causes of these phenomena. If they or new factors appear, the
previously observed principles also change. For example, the birth level
characteristic of a given country drops markedly during wartime. The
degree of fatality in connection with emergency surgery (strangulated
hernia, perforated gastric ulcer, etc.) varies directly with the correct-
ness and timeliness of diagnosis, hospitalization, and surgical inter-
vention. Therefore, a sound organization of statistical research and
analysis of the statistical data requires a knowledge of the principles
affecting the object under study, a comprehensive preliminary qualitative
analysis and sound Marxian interpretation of the phenomenon in question,
for statistics, as V. I. Lenin pointed out, does not uncover laws, it
merely illustrates them.
Conclusions drawn from statistics are valid only if they satisfy
a number of conditions.
In order to reveal a fundamental principle statistically, it is
necessary to use a sufficiently large number of observations. Con-
clusions regarding the seriousness of a disease or the effectiveness
of a given drug cannot be drawn from observations of 5 or 10 cases.
Qualitative uniformity of statistical material is a prerequisite
to making a correct analysis. The mean quantity obtained will correctly
characterize the given mass only if it is computed an the basis of
qualitatively similar phenomena. For example, in studying the physical
development of school children it is impossible to compute the average
growth or weight for all students in the first grade. This data will
not be qualitatively uniform: among the first graders there are likely
to be 7-, 8-, and 9-year-olds, boys and girls; the growth and weight of
children vary directly with age and sex, hence the indices of growth,
weight, and size of thorax will be correct only if calculated separately
for the children of each age and sex group. When reporting on the
operations of a hospital, it would be wrong to calculate the index:of
fatalities (the number of deaths per 100 patients) for the hospital as
a whole inasmuch as the hospital may have an infectious section with
relatively higher fatality rate and a maternity section where the
fatality rate is normally-very low and, for practical purposes, should
be regarded as non-existent. Since mean indices for the hospital as a
whole would only confuse the picture of the operations of the various
sections, the fatality index:must be calculated for each section and
within each section for each disease.
Statistical research is conducted in four successive stages: (1)
preparation of a research plan and program, (2) observation - collection
of material, (3) processing -- classification and summarization of the
material, (4) computation of the indices and analysis.
Before starting to collect the material, a research plan and program
is drawn up and a unit of observation along With registration criteria
established. Each individual phenomenon subject to calculation is called
a unit of observation; registration criteria are the data collected for
each case. For example, in studying the morbidity rate of dysentery
each case of dysentery is a unit of observation, while sex, age,
occupation, date of illness, etc., constitute the registration criteria.
The cases are recorded on certain forms, cards, or in statistical
logbooks. Some aspects of institutional operations are recorded in
registers. For example, all hospital patients sign an admissions register
kept in the admissions section. Uniform registration forms used by
hospitals throughout the Soviet Union are approved by the Ministry of
Health, USSR, and are obligatory.
A great many papers used for registration and operational purposes
are filled out by middle echelon medical personnel (patient's daily
record sheets, slips for admission to the physician's office or for
hospitalization, treatment sheets, etc.). As a rule, these workers
fill out the passport part of all the other forms. They do all the
registration work at feldsher-midwife stations, feldsher health stations,
and children's nurseries. It is easy, therefore, to see why it is so
important for middle echelon personnel to be familiar with the various
types of papers required for medical accounting and operations and to
be able to fill out these records and reports accurately.
Most of the registration cards and forms serve a two-fold purpose:
they are operational documents for executing the measures required by
the registrant; collected over a certain period of time, they become
material for statistical processing.
Therefore, these papers must be filled out accurately and handled
with care. Ink must be used and all the questions answered in detail
if the two purposes mentioned above are to be served.
We shall examine later the principal types of record forms when we
analyze the individual health indices.
Observation. Material may be collected in two ways. The first
involves observing and recording each phenomenon as it occurs and
collecting the mass of observations for a certain period of time, say
for a year. This method of current registration is used for investi-
gating the sick, birth, and death rates, and the dynamics of a phenomenon,
that is to say the changes it undergoes with time (e.g., shifts in morbid-
ity or mortality from month to month or from year to year).
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In the second method the entire mass of observations is collected
simultaneously by a census or an inquiry and immediate tabulation of all
the individual phenomena. A one-time census is used to determine the size
and composition of the population, the number and kind of the hospitals,
doctors, middle echelon personnel, etc. A simultaneous medical survey is
used to gather material on the incidence of various diseases in a group
under investigation (trachoma, tuberculosis, intestinal worm invasions)
or on the health of certain groups (draftees, workers). Data on physical
develoment is collected by means of simultaneous anthropometric measure-
ments. This None-time observations method, as it is called, reflects
the condition.or statics of a phenomenon at a given time.
Classification and summarization. Following collection the material
is processed (summed up). Before this work is started, the individual
cards must be checked to see if they have been correctly and completely
filled in. Sometimes omitted information can be readily supplied by
context. For example, even though a card doesn't indicate sex, the name
Mariya makes it obvious that the patient is female. In certain cases
the missing information can be obtained only by referring to the insti-
tution that issued the document and checking its data. If the necessary
basic information cannot be supplied, the card will have to be dis-
regarded. Once the collected material is checked, it will have to be
classified in accordance with basic, qualitatively uniform criteria.
Only if the statistical material is thus correctly classified can we
discover and see in proper perspective the true principles underlying
the phenomenon being studied.
V. I. Lenin in his Development of Capitalism in Russia provided a
classical example of the correct grouping and pertinent analysis of
statistical material. By properly classifying peasant farms in accord-
ance with a number of criteria (rent, use of hired hands, agricultural
equipment, etc.), he uncovered and proved the existence of class
stratification of peasant farms in Russia, i.e., the penetration of
agriculture by capitalism.
In a study of morbidity it is very important to classify patients
by the various age and sex groups, to arrange the various diagnoses of
diseases by classes and groups in accordance with the standard nomen-
clature and classification, etc.
Processing the data consists of tallying the registration criteria
on the cards in conformity with a definite plan and classification
determined by the objective of the investigation.
The data are entered in tables previously prepared so as to
summarize the results. Let us suppose, for example, that our task is
to process data on the acute infectious diseases of children in region
A for 1951. A total of 1,345 children up to 14 years of age were ill.
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We are interested in two things: the kind of diseases and the age
distribution of the children affected. In working up the material we
group separately the most serious or most frequent acute infections --
measles, scarlet fever, diphtheria, whooping cough, and dysentery --
combining all the other diseases in the group 'Others."
The blank summary, arranged in tabular form, will look like this:
Name of disease
Measles
Scarlet fever
Diphtheria
Whooping cough
Number of
cases
IMINOW=1.0
dmp.110WOMI
Name of disease
Dysentery
Others
Number of
cases
m?VM.????????
1???=0.11?11m11
Total
.11.113.1?NM
To fill out the table the cards must be broken down by diagnosis,
each group added up, and the result of the tally inserted on the
corresponding line.
For the material on age of the patients it is necessary to decide
beforehand in what age groups we intend to sort and tabulate the data.
Material grouped by age is usually divided into the following categories:
infant-1 year, younger children from 1-2 years and from 2-3 years,
preschool -- from 4-7 years, school -- from 8-14 years.
Accordingly, we prepare the following table for the summary:
Age
0 - 1 year
1 - 2 years
2 - 3
4 - 7 "
8 - 14 t!
Number of cases
1?111.1?114MdM
Total
M.111?4?11.?
Before arranging the cards by age groups, we must lay out the
material, i.e., determine and mark with a given number (e.g., 1, 2, 3,
4, 5) which of the five age groups each card belongs to. All children
less than 1 year old must be placed in the first group, children from
1 - 2 years in the second, etc. The cards thus marked are sorted into
the five groups, counted, and the tally recorded. The preliminary
marking helps to speed up the work of sorting and counting and prevents
errors.
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Separating and tallying the cards first by diagnosis, then by age,
we obtain the following:
Name of diseases
Measles
Scarlet fever
Diphtheria
Whooping cough
Dysentery
OtheLs
Number of
cas3s
420
135
58
211
207
314
Total 1,345
Age
0-1 year
1-2 years
2-3 years
4-7 years
8-14 years
Total
Number of
cases
294
287
247
329
188
QOM ?.????
1,345
Each table must have a clear heading.
Our tables are called "simple" because they have been prepared
according to a single feature (disease, age).
However, simple tables usually prove inadequate for analysis. We
are interested not only in the distribution of all diseases of children
by individual diagnosis, but also in their distribution by age and the
commonest diseases affecting infants, very-young, pre-school, and
school age children. In order to satisfy our needs we must arrange
the table in such a way as to show both features -- disease and age
combined.
OM. 1??
Statistical tables distinguish a subject and a predicate. The
statistical subject is that which is described by a given table, the
basic feature of the phenomenon under investigation; it is arranged
horizontally in the table. The statistical predicate, which consists
of the various features characteristic of the subject, is arranged
vertically in the table.
In our example the subject is the name of the diseases, the pred-
icate is the age of the patients.
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A composite table will have the following form:
Morbidity of children in region A with acute infectious
diseases in 1951
Age of children
Name of disease
Measles
Scarlet fever
Diphtheria
Whooping cough
Dysentery
Others
Total
0-1 year 1-2 years 2-3 years 4-7years 8-14 years Total
SIMON.
- -
M?????
d=04MM
.M14.0
Mb.=
_
???????
???????
dimir IMO
010.1.
.MOSIM
4.MOMI
WI/DOM
MIP,MP
=10,m.D
???????
.114??
es????
110?11?11.
?????mI.
- -
??=.10 11?????
The material is handled as follows in making a composite table: The
cards are first sorted by subject, in this case by diagnosis of disease.
The number of cards for each disease is noted in the last column "Total."
All the measles cards are then arranged by age groups. The number of
cards for each age group is entered in the corresponding column of the
line "Measles," and so on for the scarlet fever, diphtheria, etc., cards.
Without mixing the cards, the figures are tallied up and checked both
vertically and horizontally.
The filled out composite table will have the following form:
Morbidity of children in region A with acute infectious
diseases in 1951
e of children
Name of disease
Measles
Scarlet fever
Diphtheria
Whopping cough
Dysentery
Others
Total
0-1 year 1-2 years 2-3 years 4-7 years 8-14 years Total
60
90
98
130
42
)120
8
12
19
46
50
135
7
9
lo
20
12
58
47
So
41
Si
22
211
92
62
34
12
7
207
80
64
45
70
55
314
294
287
247
329
188
1,345
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A composite table affords greater possibilities for analysis. It
shows not only that measles, whooping cough, and dysentery are the most
prevalent diseases, constituting together some 2/3 of all the sicknesses,
but also that infants and very young children are the chief sufferers
from dysentery, that measles affects chiefly-very young and preschool
age children, etc.
A table nayte a combination of three or more features. This kind
of table is called "complex? or "composite." Let us suppose for example,
that we want to study cases of diseases not only by age, but by sex.
The table would then look like this:
Morbidity of children in region A with infectious
diseases in 1951
Age and sex
f children
0-1 year 1-2 years 2-3 years
Name of disease M F
Measles
Scarlet fever
Etc.
32 28
4-7 years 8-14 years Total
MF /LIF MF PI FM F
49 41 48 50 64 66 22 20 211 209
Ye. Yee eaello?
Imam. IMMO mem, Yee
=Mee ???
Yoe&
?????? Yee
Me ea nn
- -
*MY YYY YYY
yen YYY ..4006160,0.
If three features are to be combined, the cards are laid out as
follows. The cards sorted by diagnosis of disease are arranged by age
group, then by sex. The column "Total" is filled in after adding up all
the columns marked "Male" and "Female" for all the age groups.
Derived Values
Relative indices. Our tables of actual numbers now enable us to
analyze the material. However, greater accuracy is ensured along with
more opportunities to make statistical comparisons if we do not limit
ourselves to the actual numbers, but use them as a basis for computing
the so-called derived values or indices.
We have already seen from the actual numbers that dysentery chiefly
affects young children. We can show this more precisely if we compute
the proportion of very young children (up to 3 years of age) among all
those suffering from dysentery. Adding the dysentery cases among the
young children (92+62+3)j) to all the dysentery cases, we learn that
young children make up the vast bulk or 90.8% of them(188 ? 100 = 90.8%).
267
This index is called the "extensive index?' or "distribution index."
It shows how the whole (in this instance all the dysentery cases) is
distributed according to its constituent parts (patients by individual
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age groups); it also indicates the proportion of patients in each age
group to the total number of patients. Let us take another example. In
1913, out of 5,800 babies born in region A4 1,235 died during the first
year of life (from 0-1 year of age). In 1937, out of 6,450 babies born
in the same region 890 died during the first year of life. What was
the percentage of infant mortality in 1913 and to what extent did it
decrease in 1937?
In order to answer these questions we compute the child mortality
rates for 1913 and 1937:*
(1) 1,235 . 100 _
4,800 25.7%.
(2) 890 . 100 - 13.8%
6,-450
Thus, the infant mortality rate of 1937 was almost half that of
1913 (a decline of 11.9%).
An "intensive inde>$1 or "frequency indey4 shows the force, frequency,
spread, and intensity of.a phenomenon occurring in a given environment
(here the frequency of deaths among newborn infants).
Errors occasionally result from substituting one index for another,
i.e., from judging the intensity of a phenomenon by an extensive index.
For example, in 1938 a textile factory employing some 1,500 workers had
1,300 cases of sickness of which 265 or 20.4% were influenza cases. In
1939 it had 975 cases of sickness of which 240 or 24.6% were influenza
cases. The proportion of influenza to the total number of sicknesses in
1939 rose by 4.2% as compared with 1938.
Can we draw any conclusions concerning the rise in the influenza
rate for 1939 as compared with 1938 on the basis of the extensive rate?
The answer is no. The proportion of influenza cases in 1939 rose over
that of 1938 because there was an overall decline in the sick rate, and
other sicknesses (gastrointestinal, trauma, etc.) decreased more than
influenza.
In order to determine whether the influenza rate rose or declined
in 1939, it is necessary to compute the number of influenza cases per
100 workers and ascertain the frequency or intensity of influenza among
the workers in 1938 and 1939, i.e., to figure out the intensive index:
(1)
265.100 = 17.7%
1,500
[71Se
(2) 240 . 100
1,500
index of infant mortality is the number of children who die at the
age of 0-1 year per 100 births during a given year.]
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Thus, the influenza rate in 1939 declined by 1.7% below that of
1938.
Average values. Besides relative indices, so-called !average
values! are also computed in statistics. These values are widely employed
in describing physical development, analyzing the work of medical
institutions (average bed occupancy in hospitals, average stay of
patients, etc.). For example, the average growth, average weight,
average size of chest for an entire group is computed on the basis of
anthropometric determinations of growth., weight, size of chest, etc.
Average values correctly characterize the group only if they are
computed for a qualitatively similar group. For example, in appraising
the work of a hospital it would be wrong to compute the average stay of
all the patients as a whole, without distinguishing between the illnesses,
since length of stay in a hospital depends primarily on the nature of
the illness.
The !arithmetic means is very frequently used in statistics. The
simple arithmetic mean is calculated when the number of observations in
all the measurements of the feature under investigation are identical.
Let us suppose that it is necessary to determine the average hospital
stay of 4 patients who were there 18, 17, 15, and 20 days, respectively.
This is done by dividing the number of patients into the total number of
days spent in the hospital by all the patients:
18+17+15+20 _ 17.5 days
4
The number of observations relating to the individual values of the
feature under investigation is more often different, in which case the
!average weighted arithmetic mean! is computed. Let us suppose, for
example that we are required to compute the average stay of patients in
a scarlet fever ward. All told 31 patients were hospitalized as follows:
27 days
28 !
-- 2 patients
__ 4 "
30 *
__ 5
if
32 N
?..-. 10
"
33.'!
--6
1
35 "
_- 3
n
36 "
..... 1
"
Total -- 31 patients
The result is called a 'variational series.' It consists of variants
(v), which are different values of the varying feature, length of stay in
the hospital, and frequency (p), indicating how often the given variant
is encountered. In order to determine the average length of stay, each
variant must be multiplied by the corresponding frequency and the
resultant products added up, thereby yielding the total number of
days spent by all the patients. This number is then divided by the
number of patients.
27 days x 2 = 54 days
x14 - 112
x5 = 150 *
x10 = 320
x6 = 198 N
x3 = 105 ?I
X 1 = 36"
28
N
30
!
32
1
33
"
35
"
36
Total = 975 days
975
= 31.4 days
Accordingly, a patient stayed in the scarlet fever ward an average
of 31.4 days.
The general formula for computing the average weighted value is:
M
? p
where M = weighted average; N = total number of observations; g=
v = variants, p = frequency.
Demographic Indices of the People's Health
Data on the size, composition, and movement of the population relate
to demographic indices.
Size and Composition of the Population
Basic information on the size and composition of the population is
derived from censuses. Western European countries started systematic
census-taking at the end of the 18th century and beginning of the 19th.
Colonial and semi-colonial countries even now do not have an accurate
count of the native population. In Czarist Russia the first and only
general census was taken in 1897.
The organization and processing of censuses in the bourgeois
countries help to conceal the class structure and social class contra-
dictions as well as the true national composition of the population, just
as they did in pre -revolutionary Russia. Grouping by social classes is
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replaced by kind of occupation, which makes it possible to combine both
major entrepreneurs and petty craftsmen; nationality is replaced by
mother tongue or religion, etc. Only censuses in the Soviet Union and
the peoples democracies provide a precise social-demographic picture
of the country.
partial census was taken in the USSR in 1920 and two general
censuses in 1926 and 1939. They revealed that the population had grown
at an extraordinarily rapid rate -- from 147 million in 1926 to 170.6
million in 1939 (Figure 3).
Western Ukraine, Western Byelorussia, and the Baltic republics of
Lithuania, Latvia, and Esthania with a combined population of 23 million
persons were annexed to the USSR in 1939. Thus, the population of the
USSR before the Great Patriotic War exceeded 193 million persons.
Censuses also provide some clues as to the composition of the
population. The 1939 census has given us accurate information about
the age, sex, nationality, and social make-up of the population, about
the literacy, educational level, occupation and family structure of
USSR citizens. This data is necessary for planning public health as a
whole and for the individual types of medical facilities: obstetric,
medicoprophylactic services for children and adults, etc.
Data an the size of the population enable us to compute the index
of population density, i.e., the number of people per sq km of territory.
The USSR is far from being uniform with respect to density. The
greatest concentration is in the western ?blasts, Baltic republics, the
Ukraine, Byelorussia, and the central oblasts of the European area cf
the RSFSR. Siberia, the Central Asian republics, the Extreme North,
and the Far East have very law population density.
Data on population density are Mghly important for the public health
agencies, which take cognizance not only of the size of population but
also of the radius of service when planning the network of medical
institutions.
Movement of Population
Movement of population (births, deaths, movings, etc.), which
alters the numbers as well as the age and sex composition, is of great
medical significance.
Mechanical movement of population. The migration of independent
groups ce people from one region to another or outside a country is
called "mechanical' movement of population.
-36-
Mechanical movement of population is caused by social and economic
conditions. In pre-revolutionary Russia there was a constant shifting
of the male working population from village to city (for extra earnings,
seasonal work), migration from the central regions (e.g., from the
Ukraine) to Siberia, and, finally, substantial emigration abroad. In
Soviet times these spontaneous migrations gave way to planned transfers
of the labor force to newly created and developing industrial and
agricultural centers in the Urals, the Kuznetsk Basin, Siberia, Kazakhstan,
to virgin-soil and long-fallow lands, etc.
Major shifts took place during the war -- evacuation and re-evacuation
of the civilian population, movement of troops, mass transfers to labor
fronts, etc.
Mechanical movement of population has a great effect on a country's
health. When large numbers of people move about, they may spread
infections and import diseases into areas hitherto free from them.
For example, the mass migration of 1914-1922 occasioned by the war and
economic dislocation (hordes of refugees carrying their possessions)
helped to spread typhus and recurrent fever epidemics. It caused the
maleria epidemic of 1923-24 by bringing the disease into areas where
it had been unknown.
Public health agencies must reckon with mechanical movements of
population and take appropriate sanitary measures to prevent the spread
of epidemic diseases.
Despite the vast scale of population movement during the Great
Patriotic War, the public health agencies averted the outbreak of
epidemics by taking timely preventive steps.
Public health agencies must also take into account planned transfers
to new projects, seasonal work (e.g., peat digging, timber cutting),
etc., in order to provide the necessary medical service and facilities
for the new arrivals.
Natural Movement of Population
By the so-called natural movement of population we usually mean
the birth rate and the death rate.
The birth rate and the death rate are computed on the basis of
registration of all births and deaths in special departments of the
Soviets, ZAGS* (Registry of Acts of Civil Status), on special 'act of
birth' and 'act of death* forms.
*Zepis' aktav grazhdanskogo sostoyaniya
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Prior to the Great October Socialist Revolution there was no civil
registration of births, deaths, or marriages in Russia. Churches per-
formed this function using birth and death registers. However, the data
were inaccurate and incomplete.
Birth rate. The index of births is the number of births per 1,000
of population annually. This index, which reflects the rate of births
in the various countries and depends on certain social and economic
factors, is rather stable, changing comparatively slowly over a period
of time. We are entitled, therefore, to talk about countries with a
high, average, or low birth rate. The rate varies from approximately
15 to 50 per 1,000 of population. A law birth rate (15-20) is char-
acteristic of European capitalist countries (France, England, West
Germany, the Scandinavian countries, cf. table below), whereas a higher
rate (20 and above) may noted in non-European agrarian countries.
The rate is higher in rural areas than in urban ones.
The birth rate in capitalist countries (per 1,000 of population)
Country
1901-
1911-
1926-
1936-
1946-
1951
1953
1905
1913
1930
1938
1950
England
Germany (after
28.2
24.2
16.7
14.9
18.0
15.5
15.4
19)46, West
Germany)
34.3
28.1
18.4
19.2
16.5
15.8
15.5
Denmark
29.0
26.3
19.4
18.0
20.6
17.8
17.8
Italy
32.7
31.9
26.8
23.0
21.5
18.5
17.4
Netherlands
31.5
28.1
23.2
20.2
25.9
22.3
21.8
USA
--
25.0
/9.6
17.2
24.2
24.5
24.7
France
21.2
18.8
18.2
14.8
20.9
19.5
18.6
Sweden
26.1
23.6
15.9
14.5
18.2
15.6
15.4
Japan
32.3
34.3
33.7
29.1
30.8
25.4
21.5
Throughout the 19th century (particularly during the latter half)
and the 20th century the birth rate in all the capitalist countries
declined markedly. Especially significant is the wcatastophie drop
that occurs in all countries during wartime, which contributes sub-
stantially to the overall population loss.
A decline in the birth rate is observable everywhere both in
industrial and in agricultural countries concomitant with the develop-
ment there of capitalism, stratification of villages, and growth of
cities. In the 19th century the birth rate among the slower* classes
of bourgeois society -- peasantry and proletariat -- was higher than
among the Nuppeliclasses; however, as capitalism expanded the birth
rate fell sharply even among the peasantry and proletariat. The decline
of births in the capitalist countries at the beginning of the 20th
-38-
?-
?)
century assumed such proportions that bourgeois politicians, economists,
and demographers began an eager search for devices to stimulate a higher
birth rate, especially among those considered the most 'valuable*
segments of society, i.e., the aristocracy, bourgeoisie, and kulak
leadership of the peasants.
The actual extent of the decline in births indicated by the overall
birth index is concealed by changes in the age structure of the pop-
ulation, where as the birth rate goes down and, consequently, the
proportion of children's ages, the proportion of middle ages directly
participating in the birth rate rises. That is why a more accurate
idea of the amount of births is provided by so-called special
coefficient of births or coefficient of fecundity, i.e., the number of
births per 1,000 women of childbearing age (from 15-49 years old).
Bourgeois scientists advance different theories to explain the
decline. Some attribute it to biological causes -- degeneration of
modern "civilized" man or depreciation of the child-bearing function
of women. Others regard it as a result of the corrupting influence of
large cities, increase of venereal diseases, drawing of women into ?
industry, elevation of cultural level, etc.
None of these bourgeois 'theoreticians" is able or willing to admit
that the real reason for the drop in births is inherent in the capi-
talist system itself. The growth of unemployment and impoverishment
of the working class together with stratification of the peasantry
cause the workers' families anxiety and uncertainty regarding the
possibility of rearing and educating their children properly. Even
the moneyed classes do not want many children because they dread having
to divide up their capital among numerous heirs. The low birth rate
of the capitalist countries is the inevitable result, therefore, of
social contradictions, a conscious refusal to have children, i.e., an
artificial regulation of births due to social and economic factors.
The situation is completely different in the USSR and the people's
democracies. The high birth rate of pre-revolutionary Russia was typical
of agrarian countries. The USSR economy expanded and transformed the
country into a first-class industrial power, but the birth rate remained
high.
Motherhood in the USSR is an honorable function of women carefully
safeguarded by the Soviet government. Legislation to protect female
labor, social and legal protection of the interests of mothers and
children, state assistance to pregnant women, unmarried mothers and
mothers of many children, development of an extensive network of medico-
prophylactic and social institutions to serve mothers and children,
bestowal of decorations and medals for motherhood -- all these secure
for Soviet women a peaceful, happy motherhood and are responsible for
making the birth rate of the USSR one of the highest in the world.
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Death rate. The index of deaths is the number of deaths per 1,000
of population annually. The death rate varies within a comparatively
small range, from approximately 8 to 25 per 1,000 of population.
A lower death rate may be noted in the industrial countries (England,
the Scandinavian countries, Denmark) as well as among the white popu-
lation of the United States and some of the British dominions -- Australia
and New Zealand. A high death rate (15% and above) is found chiefly in
agrarian, dependent countries -- in South America and the colonial
countries of Asia and Africa.
A study of the dynamics of mortality in various countries shows
that the death rate ii Western European countries declined appreciably
during the 19th century and at thp beginning of the 20th century. In
most of the capitalist countries the death rate remained stable during
the decade preceding World War II, as it is today (cf. table). The
death rate in the colonial countries is still high.
An analysis of the causes of mortality shows that a high rate
depends largely on the occurrence of epidemics, extensive spread of
acute infectious diseases, and high level of infant mortality.
The decline in the Western European death rate during the latter
half of the 19th century is attributable chiefly to a major drop in
cases of smallpox, plague, cholera, parasitic typhus, and other infections.
A significant factor in the decline of the general mortality index: was
the drop in births, which reduced the proportion of infants in the
population, a group characterized by a high death rate.
The death rate in capitalist countries (per 1,000 persons)
Country
1910-1913
1928-1938
1951
1952
1953
Austria
_-
13.6
12.7
11.8
11.9
England
13.9
12.0
12.5
11.3
11.4
Guatemala
21.3
19.6
24.6
--
Denmark
13.0
11.0
8.8
9.0
8.9
West Berlin
--
--
12.4
13.1
13.0
Spain
22.2
16.4
11.5
9.6
9.6
Italy
19.5
14.1
10.3
10.1
10.0
Norway
13.3
10.4
8.4
8.3
8.3
Portugal
20.9
17.0
12.4
11.8
11.7
US
14.0
11.1
9.7
9.6
9.6
Trieste
--
--
11.3
11.4
11.1
France
18.2
15.7
13.3
12.2
12.8
Chile
31.0
24.4
15.9
13.-8
Sweden
13.9
11.7
9.9
9.6
9.7
Ecuador
--
17.2
17.0
Japan
20.3
17.7
10.1
9.0
9.0
When analyzing mortality we must always bear in mind that the general
mortality index in the capitalist countries used by bourgeois demographers
conceals the social and class differences within the mortality figures
for the various social groups. For example, the death rate in the
proletarian quarters of Western European and American cities is much
higher than that of the bourgeois and aristocratic sections in the same
cities. This difference prevails even in the death rates of the white
and colored populations.
In Tsarist Russia the death rate was high due to the general back-
wardness of the feudal system, the low economic and hygienic level of
the country, and the outbreak of epidemics. During the Soviet regime
the death rate has been declining steadily. The USSR now has an
exceedingly low rate -- 8.9% (Figure 4).
Natural increase ok population. Isolated data on the birth rate
or death rate are not an adequate basis on which to form a balanced
judgment regarding the health of a country. The character of the
natural movement of the population can be determined only by studying
simultaneously the birth and death processes and their interrelationship,
as reflected in the natural increase of population, i.e., the difference
between the birth rate and the death rate.
Three main groups of countries maybe distinguished according to
the type of movement of population and the extent of natural increase
(Figure 5).
(1) Countries with a low death rate and a low birth rate (England,
France, the Scandinavian countries). In spite of the apparently favorable
mortality indices, the birth rate in these countries is low, as a con-
sequence of which the natural increase is slight (5-7 per thousand).
(2) Countries with a high birth rate and a high death rate (the
South American republics, colonial countries). Owing to the high birth
rate the natural increase in these countries is somewhat higher than
in the countries of the first group, but it is not large because of the
high death rate (about 10-12 per thousand). However, in a number of
colonial countries, despite a rather high birth rate, the high epidemicity
results some years in an excess of deaths over births, the so-called
negative natural increase.
It should be noted that at the present time when colonialism is
collapsing the natural movement of population in former colonial countries
(now independent) is marked by a declining death rate.
(3) Socialist countries -- the USSR and people's democracies -- are
characterized by a special kind of natural movement of population. The
USSR birth rate is high, the death rate low, and the natural increase
growing. The natural increase is several times higher than that of all
the western European countries combined.
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In his report to the Twentieth Congress of the Communist Party of
the Soviet Union, N. S. Khrushchev stated that the natural increase of
population in the USSR during the years of the Fifth Five-Year plan
amounted to 16,300,000 persons.
Child mortality. The death rate for the various ages is far from
uniform. If the mortality indices for each age are calculated separately
and represented graphically, the result is a curve resembling an arc
(Figure 6). The peak is reached during the first year of life. It drops
sharply thereafterj but beginning with the 30-40 year age bracket rises
slowly at first and then with increasing speed. Whereas mortality at
advanced ages is due to the normal, physiological processes involved
in the gradual extinction of a generation -- the task of medicine and
public health here is to prolong human life and push forward its present
limits -- mortality among newborn children, whose organisms contain all
the prerequisites for life and continued development, is a phenomenon
of unquestionably pathological nature, and as such, susceptible of
elimination.
The fact that the death rate is highest in infancy, exceeding that
of the population as a whole, and that this index is an exceptionally
Important means of appraising the health of a people led physicians
and demographers to set up a separate infant mortality rate. It is the
number of infants (up to 12 months old) dying annually per 100 births
during the same period.
A more accurate index is obtained by relating the number of children
dying in a given year not to the number of children born in the same
year, but to a total comprising 2/3 of the children born in the given
year and 1/3 of the children born in the preceding year. Of the children
who died, for example, in 1955; some were born in that year, some in 1954.
The infant death rate in the first year of life is also uneven:
the peak is reached during the first month, indeed, during the first
week of the first month.
The infant death rate varies considerably from country to country.
Like the overall death rate of the population, it is lower in the
industrial countries of capitalist Europe and higher in the agrarian
countries. It is exceptionally high in the colonial countries, where
it is 15-20% and more.
The indices of infant mortality vary considerably from social
group to social group. In the city of Berlin, for example, infant
mortality before World War II in the workerst quarters was 3 to times
higher than in the aristocratic and bourgeois sections. It is much
higher among the Negroes (in America) than among the white population,
etc.
-42-
L
40"
Czarist Russia had a high infant mortality rate, but it dropped
sharply after the revolution and is now exceedingly low. A further
decline in the death and sick rates of children continues to be the
major objective of institutions set up to safeguard mothers and children
and of the public health system as a whole.
An analysis of infant mortality shows that the main underlying
factors are the unfavorable and wholly remediable conditions of the
environment where the infant has to live after birth and with which its
still feeble organism cannot cope.
The so.called "neonatal diseases," which are particularly dangerous
for premature babies, and birth traumas contribute heavily to infant
mortality during the first week and first month of life. Infant mortality
can be greatly reduced by protecting pregnant women while at work,
systematic Observation bywcaen's consultation centers, efficient
maternity hospitals, correct and special care of premature children
in maternity hospitals, and special supervision by children's con-
sultation centers after discharge from the maternity hospital.
Another major cause of infant mortality is the gastrointestinal
diseases -. toxic dyspepsia, colitis, and, above all, dysentery.
Gastrointestinal diseases are most dangerous during the transition
period to bottle feeding and in the summertime. These arise from
unsanitary surroundings, slack of breaitfeeding, incorrect and poor
quality bottle feeding, and inadequate anti-dysentery measures. Infant
morbidity and mortality due to gastrointestinal diseases can be sharply
reduced by improving the general living conditions of the population,
large-scale introduction of hygienic practices, and providing babies
with breast milk and good quality nutrition from infant-feeding centers.
Finally, a reduction in morbidity due to children's infections
(measles, scarlet fever, whooping cough, diphtheria, etc.) and pneumonia,
which is another major cause of death, maybe achieved by improving the
quality of infant care and adopting measures to prevent infection both
at home and in such childreOs facilities as day nurseries and con-
sultation centers (Figure 7).
An analysis of the causes of child mortality shows public health
agencies the steps that must be taken if the death rate is to be lowered.
Morbidity
Computation of the morbidity rate, i.e., the amount of disease among
the population, is exceedingly important in studying public health.
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Diseases are diagnosed and reported either when patients come to
medical institutions for treatment or when a group of people are given
medical examinations at the same time (Figure 8).
The purpose of computing the morbidity rate is not only to detect
the presence of disease and the degree of prevalence among the population,
but also to provide public health agencies and medical institutions with
useful information an their current work and enable them to adopt needed
medical and sanitary measures.
The General Morbidity Rate
Russian medical statistics place a top priority on the investigation
of general morbidity. The method of investigating general morbidity on
the basis of data compiled from visits to medical institutions was worked
out by the leading expert of zemstvo medical statistics Ye. A. Osipov
and developed by P. I. Kurkin. The work done by zemstvo sanitary
physicians in studying sickness among mill and factory workers and
peasants is of great practical importance in enabling us to assess the
health of pre-revolutionary Russia.
The study of general morbidity has acquired exceptional significance
in the Soviet Union. Data an the level and composition of general
morbidity are helpful in planning medical facilities and in determining
the number of beds needed for various kinds of patients and the number
of doctors and specialists. Changes in the data make it possible to
evaluate shifts in the health of the population.
Before 1949 general morbidity used to be investigated on the basis
of special statistical studies derived from reports of the initial visits
of patients to medical institutions. Much effort and time was needed to
gather and process this material. Therefore, general morbidity had to
be studied selectively using data from individual cities and inhabited
localities over long intervals of time. This approach, however, was not
very satisfactory. Few public health organs or medical institutions, if
any, were in a position to judge the nature of morbidity for any given
period among the people they were serving and thus they failed to obtain
information needed for their operations.
Introduced in 1949, the present system of continuous computation of
the morbidity rate from medical reports and supplementary modifications
and corrections enhances the usefulness of the computation, accuracy of
diagnostic procedures, and possibility of detecting and registering
specific types of patients.
Under the present system the morbidity rate is computed from slips
and sheets containing confirmed diagnoses attached to all cards for out-
patients. The diagnosis is entered on a sheet by the examining physician
- 414 -
after he has confirmed it. If a patient is treated by several specialists
(internist, neuropathologist, opthalmologist, etc.) in connection with
the same condition (e.g., hypertension), the diagnosis is entered only
once by the first physician who made the diagnosis, and is not repeated
by the other physicians.
Diseases noted in a patient for the first time in his life are
marked an the sheet with a plus (+) sign. These diseases include all
the chronic diseases for which the patient was first treated and all
the acute ones if they recurred, regardless of whether he suffered from
them previously (influenza, trauma, angina, etc.). Chronic diseases
for which the patient was treated in previous years are also entered
on the sheet of confirmed diagnoses when first treated in the given year,
but without the plus sign.
The morbidity rate is computed monthly from the statistical slips
filled out daily by the statistician of the medical institution using
the entries on the sheets of confirmed diagnoses. This type of report
possesses a number of advantages: it is practical since monthly data
on the movement of diseases and on newly arisen diseases make it possible
to compare the sick rate in the regions served by hospitals and medical
districts and ensure that all the sick people are taken into account,
a fact of great importance in planning practical measures.
General morbidity is worked out in accordance with a special nomen-
clature and classification of diseases and causes of death, which are
regularly revised. A uniform nomenclature and classification of diseases
are prerequisite to a statistical investigation of morbidity. It is only
when examining physicians designate the same disease in the same way and
when statisticians include certain kinds of diseases in given classes
and groups that we can compare and analyze the collected material for
various years by oblasts and medical institutions.
The Soviet classification of diseases differs in principle from
the international system in that it attempts to determine the etiology
of diseases and their relation to environmental factors. Diseases
with a common cause or common site are combined in one class, e.g.,
infectious diseases or diseases of the circulatory organs, etc. Within
each class the diseases are divided into more homogeneous groups.
The classification of diseases, which was last revised by the
Ministry of Health, USSR, in 1952, consists of the following 28 classes:
Class I. Infectious diseases.
Group 1. Intestinal (alimentary) infections.
n 2. Blood (transmissible) infections.
3. Airborne droplet infections.
4. Zoonoses.
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Group S.
" 6.
ft 7.
? 8.
Class II.
Group
ft
if
Class III.
Group
if
if
Class IV.
Group
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Wound infections.
Tuberculosis.
Venereal diseases.
Other infectious diseases.
Parasitic diseases.
1. Mycoses (9)*.
2. Helminthic diseases (10).
3. Other parasitic diseases (11).
Traumas.
1. Traumas of non-industrial nature, except intentional or
birth traumas (12).
2. Traumas of industrial nature (13).
3. Intentional traumas (14).
Poisonings.
1. Poisonings of non-industrial nature, except intentional
poisonings (15).
2. Industrial and occupational poisonings (16).
Class V. Industrial and occupational diseases.
Class VI. Vitamin-deficiency diseases.
Class VII. Rheumatism.
Class VIII. Metabolic diseases and allergic disorders.
Group 1. Metabolic diseases (17).
n 2. Allergic disorders (18).
Class DC.
Group
Class X.
Class XI.
Class XII.
Group
Neopolasms.
1. Malignant neoplasms (19).
2. Benign neoplasms (20).
Diseases of the endocrine system.
Diseases of the Hematopoietic system.
Mental disorders.
1. Psychoses (21).
2. Borderline conditions (22).
3. Alcoholism and narcomania (23).
Class XIII. Diseases of the nervous system.
Group 1. Vascular lesions of the brain (24)
Me number in parentheses indicates the order of
classification.
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the group in the overall
Group 2.
3,
if 4.
II 5,
Class XIV.
Class XV.
Group
It
Class XVI.
Class XVII.
Group
ftif
II
Hereditary and familial diseases of the nervous system (25).
Other diseases of the central nervous system (26).
Nerve diseases (27).
Neuroses (28).
Diseases of the visual organs.
Diseases of the ear, throat, and nose (except infectious
and other diseases of certain etiology).
1. Diseases of the ear (29).
2. Diseases of the nasopharynx and pharynx (30).
3. Diseases of the larynx (31).
4. Diseases of the nasal cavity and accessory sinuses (32).
Diseases of the respiratory organs.
Diseases of the circulatory organs.
1. Diseases of the cardiac sac (pericardium) (33).
2. Diseases of the endocardium (34).
3. Diseases of the myocardium (35).
4. Dysfunction of the coronary circulation and after-effects,
except hypertension (36).
5. Hypertension (37).
6. Diseases of the arteries, veins, and lymphatic vessels (38).
Class XVIII.
Diseases of the mouth and teeth.
Class XIX. Diseases of the digestive organs.
Group 1. Diseases of the esophagus, stomach, and duodenum (39).
n 2. Intestinal diseases (40).
" 3. Diseases of the liver and biliary tract (41).
" 4. Other diseases of the digestive organs (42).
Class XX. Diseases of the bones, muscles, and joints.
Class XXI. Diseases of the skin.
Group 1. Pyodermas, except pyodermas of the newborn (43).
n 2. Other skin diseases (44).
Class XXII. Diseases of the kidneys and urinary organs.
Class XXIII. Diseases of the male genital organs (non-venereal).
Class XXIV. Diseases of the female genital organs (non-postnatal and
non-venereal).
Class XXV. Congenital malformations.
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Class XXVI. Diseases of pregnancy, pathology of birth and the postnatal
period.
Group 1. Diseases of pregnancy (45).
" 2. Pathology of birth (46).
3. Diseases of the postnatal period (47).
" 4. Abortion (48).
Clas:. XXVII. Diseases of the newborn (during the first month of life).
Group 1. Birth traumas (49).
" 2. Infectious and septic diseases (50).
if 3. Other diseases of the newborn (Si).
Class XXVIII. Loosely defined or other diseases not included in the
nomenclature.
An analysis of general morbidity shows that its structure remains
more or less constant. Ahead of all the others stand the infectious
diseases (influenza, for the most part) followed by diseases of the
digestive organs, traumas, etc. (Figure 9).
Recording of Acute Infectious Diseases
Acute infectious diseases constitute a special danger to the pop-
ulation since they may spread rapidly and develop into epidemics if
preventive measures are not taken in time.
Elimination of the foci of acute infectious diseases requires
timely action. That is why accurate and prompt recording of these
diseases has such practical significance. This reporting must be
complete and up-to-date, i.e., every case of an acute infection must
be detected and promptly recorded. Heads of health departments and
epidemiologists must have daily summaries of developments in a city or
rayon concerning acute infectious diseases, particularly louse-borne
typhus, typhoid fever, dysentery, etc.
According to law, recording of acute infectious diseases is
compulsory. All doctors or feldshers who come across a case must send
a "special notification" card to the rayon epidemiologist in the rayon
health department. This type of card is sent when any one of the
following diseases is discovered or suspected: typhoid fever, recurrent
typhus, paratyphoid fever, exanthematous fever, measles, scarlet fever,
diphtheria, dysentery, anthrax, tuberculosis, glanders, epidemic cere-
brospinal meningitis, epidemic encephalitis, tularemia, brucellosis,
tetanus, rabies, infectious hepatitis, whooping cough, toxic dyspepsia,
tick-borne typhus, and some others. Exceptionally dangerous infectious
diseases -- smallpox, plague, cholera, and leprosy -- are to be reported
separately.
-48-
On the basis of these "special notification" cards the epidemiologist
verifies the hospitalization of the patient, execution of disinfection and
necessary measures with respect to persons in contact with the patient,
and carries out an epidemiologic investigation.
Data an acute infectious diseases are processed according to the
"special notification" cards by statistical units attached to rayon,
municipal, or oblast sanitary -- epidemiological stations, which forward
monthly reports on infectious diseases to the next higher sanitary --
epidemiological stations.
A study of the dynamics of acute infectious diseases in the USSR
shows that execution of planned measures to control epidemic diseases
together with simultaneous elevation of the general economic, cultural,
and hygienic standards of the broad masses has resulted in a significant
decline of infectious diseases in the USSR -- louse-borne typhus,
typhoid fever, etc. Such diseases as plague, cholera, and smallpox
have been completely wiped out, malaria almost so.
Recording of Major Non-Epidemic Diseases
Recording of major non-epidemic diseases, which gravely affect the
health of the population because of their severity and danger to persons
close to patients suffering from these diseases and to their descendants,
is next in importance. The following must be reported: tuberculosis
(in the active stage), syphilis, gonorrhea, soft chancre, trachoma,
trichophytosis, favus, and malignant neopolasms. To control these
diseases Soviet public health has set up a network of specialized
institutions (anti-tuberculosis, dermato-venereological, trachomatous,
and oncological scientific research institutes and clinics). These
institutions are required to study methods of preventing and treating
the corresponding diseases and to process statistical data relating to
shifts in the morbidity rate.
The above-mentioned major non-epidemic diseases are recorded by
doctors in all medicoprophylactic institutions. A notice is prepared
for each new case or an entry made on a special register sent to the
appropriate clinic. In addition, open tuberculosis or infectious forms
of syphilis are recorded on the same kind of "special notification" cards
used for the acute infectious diseases.
Data on patients suspected of having malignant neopolasms or actually
suffering from them are sent directly to an oncological clinic.
Tuberculosis, syphilis, and trachoma were known in pre-revolutionary
Russia as social diseases -- and are still called that in bourgeois
countries -- because their prevalence is due mainly to the social and
economic conditions of the working people. Tuberculosis is a disease of
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poor peasants, of people working in damp cellars, stuffy, crowded shops,
the result of unrestrained exploitation. The spread of syphilis and
other venereal diseases, particularly in large cities, is a clear indi-
cation of the social contradictions of capitalism: alcoholism, prosti-
tution, disorderly sex life, and destruction of the bourgeois family.
Syphilis introduced by the white colonizers has led to the extinction of
several native peoples in the colonial countries (e.g.. the African
possessions Madagascar).
In the USSR, tuberculosis and syphilis no longer have a social
pathological character. Amelioration of the people's working and living
conditions, the extensive network of specialized anti-tuberculous and
anti-syphilitic institutions, and widespread hygienic education have
resulted in a sharp drop in the tuberculosis and venereal disease rates.
Trachoma too has been almost completely wiped out in the USSR. A
further decrease in tuberculosis and the venereal diseases and the total
eradication of trachoma are among the principal public health objectives.
Computation of Rate of Morbidity with Temporary Disability
Computation of the rate of morbidity with temporary disability is
also a continuous and compulsory task. It is done on the basis of
disability certificates and covers wage earners (manual and office
workers in industrial establishments, institutions, state farms, machine
and tractor stations, etc.).
A disability certificate is both an official document confirming
the validity of a person's absence from work and a pecuniary document
according to which an allowance is to be paid for temporary incapacity.
All this ensures accuracy in reporting. Every completed certificate is
sent for formal registration and payment to the enterprise or institution
where it is recorded by the medical unit or health station of the enter-
prise or dispensary by place of residence. These certificates serve as
the basis for the current computation of the amount of sickness among
workers in the enterprise by the various departments. Data an all the
cases and number of days of disability are processed every month and a
monthly report submitted that notes the diseases most frequently en-
countered as well as the number of cases and days of disability connected
with pregnancy and child birth (cf. form 3-1). Later on, the statistical
divisions of oblast committees and the Central Committee of Trade Unions
organize the data on morbidity by the various branches of industry.
These data are summarized and processed in the All-Union Central Council
of Trade Unions.
In computing disability it is not so much the number of cases as the
number of work days lost that is of significance. Hence, sickness with
temporary disability is judged on the basis of these three indices:
(1) number of cases per 100 insured persons; (2) number of days of
-So-
disability per 100 insured persons; (3) average length of disability
(determined by dividing the number of days of disability by the number
of cases). These indices are computed for a certain period of time
(year, quarter, month).
Illnesses with disability involving the absence of a substantial
number of manual and office workers from their jobs adversely affects
fulfillment of the industrial plan and results in the trade unions'
spending large sums from their insurance funds. Consequently, a reduction
of morbidity with disability has vast significance for the national
economy and constitutes a major objective of the medical organizations
serving industry.
Form 3-1
REPORT ON TEMPORARY DISABILITY
Based on disability certificates
No. of Types of temporary workreleases
cases
Acc. to 1. Influenza
initial 2. Angina
certifi- 3. Abscesses, phlegmons, paronychias
cates 4. Acute and chronic rheumatic diseases, incl.
rheumatic heart diseases
S. Pulmonary tuberculosis
6. Carbuncles, furuncles, hidradenitis
7. Industrial accidents with loss of work
capacity of 1-3 days, more than 3
working days
8. Household injuries (contusions, wounds,
burns, acute poisonings, etc.)
9. Acute gastrointestinal diseases (acute
gastritis, gastroenteritis, colitis)
10. Diseases of female genital organs (diseases
of the uterus and adnexa uteri)
11. Cardiac diseases
12. Neuralgias, neuritic and radiculitic diseases
13. Gastric and duodenal ulcers
14. Pneumonia
15. Hypertension
16. Bronchitic diseases
17. Other diseases
18. Total of all diseases (lines 1-17)
The same per 100 workers
19. Leave for treatment at sanatoria or health
resorts
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No. of
days
Acc. to
initial
certifi-
cates and
extensions
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20. Abortions
21. Care of patients and quarantine
22. Total minus pregnancies and births (total of
lines 18, 190 20, 21) - the same per 100 workers
23. From the total number of cases and number of
days mentioned in line 22, not liable to pay-
ment
24. Transfer to other work due to illness
25. Pregnancy and maternity leave
(Date) (year)
Physician responsible for filling out disability certifi-
cates
Chairman, Factory and Plant Installation and Assembly Committee
It is necessary to know the causes of disability in order to carry
out concrete measures for reducing sickness with temporary disability.
A comparison of data on the composition of morbidity with temporary
disability in the 1930's (the beginning of the reconstruction period)
with recent data shows that substantial changes occurred in morbidity
during this time. Among the principal causes of disability in the 19301s
were influenza, angina, gastrointestinal diseases, industrial injuries,
impetiginous diseases of the skin and subcutaneous tissue (pyodermas,
furuncles, phlegmons, etc.).
Morbidity among the workers during this period clearly showed the
effect of the various unfavorable industrial factors. However, the
extensive effort of recent years to improve living and working conditions,
particularly the vast amount of capital investments on hygiene and safety
engineering, and to mechanize laborious industrial processes caused a
sharp decrease in occupational illness, injuries, poisonings, etc.
The structure of morbidity with temporary disability is now scarcely
distinguishable from the pattern of general morbidity for the corres-
ponding age group. Among the acute infections, influenza and angina,
accounting for almost 1/4 of all disability cases, warrant special
attention. A large percentage of cases, especially costly in respect
to the number of days of disability, is made up of various chronic
diseases of the heart, blood vessels, nervous system, digestive organs
and everyday injuries.
All this points to the need of uncovering and eliminating the un-
favorable industrial factors still existing. It also calls for even
greater efforts to improve household conditions (proper organization of
nutrition, rest, sleep), promote physical culture and sports of all kinds,
combat alcoholism and other injurious habits of everyday life, which are
responsible for many chronic diseases.
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?
Most illnesses with attendant disability (70-75% of the cases) are
due to influenza, including inflammation of the upper respiratory tract,
anginal acute and chronic gastrointestinal diseases, household and
industrial injuries, diseases of the nervous system (radiculitis,
neuritis, etc.) and the cardiovascular system.
In addition to the mean indices per 100 workers, calculation of the
proportion of sick persons is extremely important in an investigation
either of morbidity with temporary disability or of general morbidity.
We know from experience that among the total mass of workers a certain
number never become ill, a substantial number are ill once or twice a
year, and only an insignificant number are ill five or more times a
year (Figure 11). However, this small percentage of "persons who are
sick frequently or for a long period of time" are responsible for the
greatest number of days lost through disability. Therefore, it is
essential to identify the specific individuals who are ailing before
effective measures can be devised to solve the problem.
Periodic Medical Examinations
Besides reports based on visits to doctors and medical institutions,
periodic medical examinations serve to show the prevalence of various
-diseases among the population. These examinations are given to such
large and well defined groups as children (in nurseries, kindergartens
and childrents homes, schools), juvenile workers, students in factory,
mill, and trade schools, workers in shops and in different occupations,
draftees, physical culturists, etc. They reveal the level of physical
development and general health, the presence of diseases, chiefly in
the form of pathological changes in the various internal organs and
systems, and the early stages of chronic diseases.
Periodic medical examinations are widely used in the USSR for
odispensarizationn [panel medicine], i.e., for the purpose of early
diagnosis of, for example, tuberculosis, cancer, cardiovascular and
occupational diseases, timely treatment, preventing the further spread
of disease, and systematic care of patients.
Specific preventive medical examinations are also used in con-
nection with field studies of the population undertaken to ascertain the
incidence of certain diseases, e.g., trachoma, malaria, and goiter, at
the different focal points.
The data on physical development constitute a major index of health.
Physical development is determined by anthropometric studies of such
basic indices as growth, weight, circumference of chest, lung capacity,
muscular strength, and fat deposits in children (newborn, pre-school,
school), draftees, juvenile workers, and physical culturists.
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Mass medical observations repeated from year to year make it
possible to evaluate changes in physical development and, conse-
quently, in the health of major population groups. Improved living
conditions compared with those prevailing in pre-revolutionary times,
better hygiene in the schools, and wide-scale promotion of sports and
physical culture have notably advanced the physical development of
school children. For example, 10-year-old boys are 4 cm taller and
1.6 kg heavier than pre-revolutionary youngsters; girls of the same
age are 5.9 cm taller and 3 kg heavier.
Statistics on Causes of Death
Statistics on the causes of death are important in investigating
the incidence of various diseases. The data are worked up fran entries
on acts of death prepared by the Registry of Acts of Civil Status
from medical death certificates. These statistics, which relate, for
the most part, to the urban population, show the prevalence of serious
diseases that result in death. The pattern differs in countries with
high and law death rates. When the general and infant mortality rates
are high, acute infectious diseases, acute gastrointestinal diseases,
and tuberculosis are the leading causes of death. When the general and
infant mortality rates are low and average life expectancy is increasing,
the proportion of middle and old age diseases, which affect the respir-
atory and circulatory organs, metabolism, cancer, etc, rises.
The extent and seriousness of the various diseases are determined
by computing three basic indices: (1) index of morbidity -- number of
persons sick per 1,000, 10,000, or 100,000 of population annually; (2)
index of fatality -- number of persons dying per 100 sick persons; (3)
index of mortality -- number of persons dying from a given disease per
10,000 (or 100,000) of population. The level of mortality from a given
disease depends both on how widespread (level of morbidity) and on how
serious (level of fatality) it is.
Graphic Representation
Statistical data are more effectively presented and more readily
absorbed when they are shown in the form of diagrams. Line and plane
(columnar and circular) figures are the commonest of these devices.
A line diagram is produced by two lines: at the bottom -- a
horizontal line (abscissa); at the left end -- a line perpendicular
to it (ordinate). A zero is placed at the point where the two lines
intersect. Along the horizontal line, beginning with 0, equal segments
are narked off, which represent, for example, time (days, months, years)
or age (0-1 year, 1-2 years, 2-3 years, etc.), etc. Along the vertical
line, going up from 0, segments representing the quantity of the
phenomenon under investigation are marked off on a definite scale
(number of beds, diseases, death, etc.).
- 54 -
The divisions are in centimeters or millimeters. A definite
numerical expression of the phenomenon being described corresponds to
one division of the vertical line. Against each division of the hori-
zontal line is placed a point at the height corresponding to a quantity
of the given phenomenon. The Points are then joined together by lines
(curves) showing changes of the phenomenon in time, by age groups, etc.
In cases where several phenomena are shown on a single line diagram, the
lines are distinguished by different colors or hachures.
Line diagrams are commonly used to represent the dynamics of a
phenomenon in time (cf.Figure 5). A temperature curve is a typical
example.
A columnar diagram is made up of columns whose height corresponds
to the size of the numbers being represented. Precision of scale is
maintained, just as in the linear diagram, by drawing a vertical line on
the left on which the scale of the phenomenam in question is indicated.
The width of the columns as well as the distance between them must be
uniform. Columnar diagrams usually represent the statics of a phenomenon
(cf. Figure 7).
A circular or sectorial diagram is used to represent the composition
or structure of some phenomenon expressed in extensive indices (e.g.,
structure of morbidity). In a circular diagram the area of the circle
is taken at 100. Individual segments in percentages represent the con-
stituent parts of the given phenomenon.
Records and Reports of Medical Institutions
The statistics of medical institutions constitute an important part
of health statistics. Each medical institution keeps records of its
work and makes reports covering a certain period of time.
Institutions of the sane type are required to keep uniform records
-- the so-called "local records and operations documentation." For the
sake of uniformity of data and ease of comparison, all forms of docu-
mentation must be approved by the Ministry of Health, USSR. The
Ministry also devises forms and determines when they are to be submitted,
subject to the approval of the Central Statistical Administration.
Reports of the individual medical institutions are included in the
system of state reports submitted by the Ministry of Health, USSR, and
its local organizations to the Central Statistical Administration and
its local agencies.
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Types of Records and Operations Documentation
The variety of medical institutions calls for different forms
reflecting the nature of their work. The records of the individual
actions taken are kept in such a way that the resultant data can be
easily tabulated. The method of entering the items is determined by
the particular form, which contains lines for each aspect of the
operation that is to be recorded.
Two main types of local record keeping may be distinguished.
The first type is individual documentation in which the data or
actions refer to individuals. There are separate blanks for each
patient, e.g., the history of illness, in which are noted personal
details (age, sex, occupation, previous diseases, condition on admission,
subsequent examination, and discharge from the hospital, etc.) and the
therapeutic and other measures prescribed for him. History of births
(in maternity hospitals or departments), development of children (in
nurseries, children's homes), slip for examination by doctor, etc. are
examples of individual documentation.
Entries for individuals may also be made in an appropriate book.
For example, hospitals maintain a so-called admissions register where
they enter the names of patients in order of admission, place of
residence, date, name of the person Who made the diagnosis, etc.
Individual records make it possible to note the various circum-
stances subject to registration and the pertinent actions taken, i.e.,
they are primarily of operational significance. These cards, collected
and tabulated for a given period of time, provide material for statis-
tical studies of mass phenomena or the activities of medical institutions.
For example, a special notification of a patient with an infectious
disease alerts the authorities concerned. The cards tabulated by inhabited
areas, age, sex, month, etc., indicate changes in epidemiological
morbidity and the pattern, reveal sources of epidemics, etc. Temporary
disability certificates serve as a basis for payment by insurance
agencies. When collected for a certain period of time and processed
in accordance with some program, they reveal the composition and pattern
of morbidity with temporary disability among workers in a given enter-
prise of branch of industry.
The second type of documentation consists of journals, registers,
and daybooks. An example is the daybook of a hospital. Separate
columns indicate for each day the number of beds, number of old and
new patients by departments,etc. The same principle governs treatment
sheets, daybooks of clinics and health stations, and registries of
obstetric assistance rendered in homes. The elements subject to
recording naturally-vary with the activities of the institution. The
-56-
1.
principal elements for a hospital are: beds patients by diagnosis; in
the X-ray room -- radioscopy, photographs; in the infant-feeding center
-- the portions issued, etc.
Thus, the daybook (journal) is a document by means of which one
can trace day by day the various operations of a medical institution.
Maintenance of the daybook is the responsibility of middle-echelon
personnel.
Medical Reports
The daily entries in daybooks, journals, registers, etc, constitute
the basis on which medical institutions compile their reports for a
given period of time. They then submit them to higher organizations
(rayon, city, oblast health departments).
The reports have to be made on established forms. They help the
institution's director to check and Pnalyze the work done, justify
measures taken or plans proposed for the next year. Reports in the hands
of the higher health agencies provide material for city, rayon, oblast,
and republic health plans and make it possible to verify the quality of
work done by the institutions and the extent to which the plans have
been carried out for the accounting period.
Reports contain information on only the most important operations
of an institution. They must, therefore, be frief and include data
pertinent to the aims mentioned above.
The passport section of the medical renort of a medicoprophylactic
institution contains information on the location and type of institution,
constituent parts (structure), i.e., the kind of departments and rooms
it has (X-ray and physiotherapy rooms, laboratories and other medical
and diagnostic units, pharmacies, disinfection apparatus, morgue, etc.).
Information is also furnished on the staff, i.e., the number of positions
(doctors, middle echelon and junior medical personnel, and others working
In the institution). The number of positions budgeted in the staffing
pattern, the number of positions actually filledland the persons currently
in the position are mentioned. In addition, there are data on the work
of the main divisions of the institutions (polyclinic, inpatient depart-
ment), morbidity of the population, composition of patients by diagnoses,
results of treatment.
The passport section of the report is uniform for all medical and
hygienic institutions, but the other sections are specific for the given
type.
The principal reports and evaluation criteria of each type of
institution will be discussed in the chapter dealing with its work as
a whole.
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CHAPTER 3
ORGANIZATION OF MEDICOPROPHYLACTIC
PACIL1TIES FOR THt URBAN POPULATION
The Urban Hospital
A network of institutions, chiefly-hospitals, furnishes medico-
prophylactic service to the people of the Soviet Union.
Until recently hospitals offered only inpatient facilities (beds),
but not outpatient service or assistance at home, which were provided
by independent dispensaries and polyclinics. In 1947 the entire medical
system was radically reorganized by a decree of the Council of Ministers,
USSR. The various independent hospitals, dispensaries, and polyclinics
were amalgamated into single institutions called hospitals.
The amalgamation of hospitals, dispensaries, and polyclinics had
vast theoretical and practical significance. It substantially improved
the quality of medical service and made it more accessible to the people,
strengthened the district principle of organization, provided favorable
conditions for raising the qualifications of physicians, especially in
outpatient polyclinics, and gave them the opportunity to work in in-
patient departments.
Unification was extended to other institutions as well, e.g.,
tuberculosis, dermato-venereological, and oncological clinics, which
were combined with the corresponding hospitals, maternity homes with
women's consultation centers, children's hospitals with children's
consultation centers and polyclinics.
Of utmost importance in implementing the policy of amalgamation
of hospitals and polyclinics was order no.870 of the Ministry of Health,
USSR, dated 21 November 1949, which regulated the organizational frame-
work, approved the norms of service, and standardized nomenclature and
the categories of medical institutions. In accordance with this order,
city, oblast, rayon, and district hospitals are the standard medico-
prophylactic institutions furnishing the urban and rural populations
with all kinds of service. These hospitals are called *general! since
they include inpatient and polyclinic facilities for all the branches of
medicine. There are, in addition, specialized hospitals -- tuberculosis,
infectious, psychoneurological, etc.
Patients with these and other diseases are also served by a chain
of specialized clinics (tuberculosis, dermato-venereologicall oncological,
etc.). Industrial establishments have medical units with inpatient and
polyclinic facilities, doctor and feldsher health stations. Feldsher-
midwife stations are to be found in the rural areas.
- 58 -
Hospital Construction
Hospitals are the oldest type of medical institution known. Even
in ancient Rome there were military hospitals and hospitals for slaves
(valetudinaria). During the Middle Ages -- the feudal era -- hospitals
were built by monasteries; they 4ere used to take care of the poor, the
sick, and the crippled, serving as a means of religious propaganda.
Lazarettes came into existence (initially "Asylums for lepers in the
name of St. Lazarus") somewhat later. They were followed by military
hospitals which arose at the same time as regular armies.
Hospitals long retained the character of charitable institutions
for indigent patients. Owing to the low level of hygiene, poor quality
of treatment and care of patients, not to mention the high mortality
rate, these institutions were extremely-unpopular with the people.
With the rise of cities, development of public health, and progress in
clinical medicine the modern well-built and equipped hospitals gradually
came into existence.
The first hospitals or asylums for children and elderly people
were built as far back as the 10th - 11th century (Kiev Russia), or earlier
than in some western European countries. In Muscovy Russia the mon-
asteries were the first to offer hospital facilities. The first secular
hospital was erected in Moscow in the middle of the 17th century. More
significant were the hospitals (originally military, then urban) in
Russia going back to the 18th century. Zemstvo hospitals were built
in conjunction with zemstvo medicine.
Types of hospital construction changed with the rise of general
and sanitary engineering and advances in medicine. At first the hos-
pitals were centralized in a single building containing large, frequently
communicating wards and dark central corridors. The one building in-
cluded both the main and the secondary facilities. This layout along
with improper organization and incorrect conception of how infectious
diseases spread caused an enormous number of intrahospital infections
such as sepsis and hospital gangrene with extensive mortality.
Awareness of the fact that infections spread by contact and that
isolation is essential for prevention led to the so-called pavilion
or decentralized type of construction in which the hospital consists
of a series of small, detached, one- or two-story buildings (pavilions).
This style of architecture provides a separate pavilion for each
infectious disease, thus helping to lower intrahospital infections.
However, there are a number of disadvantages: need of large tracts of
land, costliness and complexity of operation and management, awkward-
ness in moving patients, food, linens, medicines, etc.
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As technical facilities (laboratories, X-ray and physiotherapy
rooms) were steadily perfected, it became increasingly difficult to use
the therapeutic and diagnostic apparatus in the pavilion system. That
is why rayon and rural district hospitals, which tend to occupy large
areas, are now built on a somewhat different principle. Although they
too have ane- and two-story buildings, all the major facilities are
usually concentrated in the main building. Separate structures on the
grounds house maternity and infectious disease departments, dispensaries,
polyclinics, and auxiliary installations (kitchen, laundry, etc.).
Large-panel construction is featured in key industrial centers.
The inpatient and all the auxiliary departments are normally contained
within a single 3 ? 5 story building. The inpatient department consists
of several sections, each of which accommodates several 25 - 35 bed
wards, an area for toilets, baths, and washrooms, another for snack bar,
payroll unit, staff roam. Separate entrances and exits, doors, and
partitions in the corridors make it possible to isolate any section in
case intrahospital infections develop (Figure 12). The problem involved
in transporting patients, personnel, and food in multistoried hospitals
is solved by elevators.
However, it is still recommended that the infectious departments
of hospitals be housed in separate buildings.
Planning and Construction of the Network of
Medicoprophylactic Institutions
In planning hospitals and determining the number of beds and
facilities required by the various medical specialties, account is
taken of the locality, its economic, industrial, and political signi-
ficance, size and density of the population, and structure of morbidity.
Order no. 870 of the Ministry of Health, USSR, dated 21 November
1949, sets forth the composition (structure) of beds by individual
specialties (cf. table) in relation to the size of the inhabited area
to be served and the number of beds (62 82 10 per 1,000 of population).
Most in demand are general medical, surgical, maternity, infectious
and pediatric beds. This is due, on the one hand, to the predominance
of general medical patients and, on the other, to the need for maximum
hospitalization by parturient women, infectious and surgical patients,
particularly emergency cases. Beds in these four specialties must be
made available, therefore, even in the smallest city hospital. The
larger the hospital, the better the diagnostic equipment and the more
numerous the specialists in narrower fields such as neurology, tuber-
culosis, oncology, urology, etc.
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-61-
8
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E-4
in parentheses are included in the figures for the principal specialties
*Appendix to Ministry of Health, USSR order no. 870, 21 November 1949
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The modern hospital consists of an inpatient department, polyclinic, and
appropriate therapeutic and diagnostic facilities with which to serve the
people an its premises or in their homes (Figure 13). I
The territory served by city and rayon hospitals is divided into
medical districts.
Besides general hospitals with their children's divisions, medico..
prophylactic facilities for children are provided by children's hospitals
combined with children's consultation centers and polyclinics. These
hospitals too are organized on the district-territorial principle.
A highly developed network of clinics, Which also operate an the
district-territorial principle, supplements the general hospitals.
The territorial principle of serving the people by place of residence
is reinforced by the industrial principle of aiding workers on the job.
In workers" settlements and major residential areas built around
industrial enterprises these principles more or less coincide since the
medical facilities are available to manual and office workers and their
families both at place of work and at home. However, the workers of a
given enterprise may sometimes be scattered throughout a city so that
setting up special facilities to take care of them at their place of
work is particularly important.
Medicosanitary units have been set up in major plants and factories
to provide all types of care closely related to production and to study
work conditions so as to devise preventive and sanitary measures. They
combine a polyclinic, inpatient department, night sanatorium, and other
installatioKis.
Smaller enterprises, particularly if they are remote from the
territorial medical institutions, have their own health stations, some-
times private dispensaries and polyclinics.
Finally, workers in small plants that have no medical units of
their own use the facilities of the medicoprophylactic institutions
serving their area.
The District Principle of Medical Service
The so-called district principle is the basis on which are organized
the operations of city hospiTals, tuberculosis clinics, children's
hospitals, and maternity hospitals. Each district physician (general
practitioner, phthisiologist, pediatrician, obstetrician-gynecologist)
attends a fixed number of people in his district, thereby eliminating
the lack of personal responsibility in medical care.
-62-
4
The district physician is completely responsible for the health of
the people entrusted to him. He not only treats patients, but also
observes hygienic conditions in his district, detects diseases in their
early stages, prevents the development of foci of infections, uncovers
sources of contamination, and introduces prophylactic hygienic measures.
The district principle enables the physician to know his district
well -- the hygienic conditions, composition of population, working and
living conditions.
The district physician is the personal physician of the patients and
their families. Prolonged, systematic observation of the people enables
him to individualize treatments most effectively, prevent complications
of disease, and help to improve the living conditions and management of
his patients.
With the active assistance of the district nurse the physician also
directs the sanitary and prophylactic work in his district. He must
study the prevailing conditions, uncover the foci of epidemic diseases
and take timely measures to liquidate them, discover, report, and treat
carriers of bacilli, and carry out antiepidemic inoculations.
Education in hygiene -- conducted in the hospital as well as directly
among the people -- constitutes a major activity of the district physician.
Success in implementing a sanitar program requires the cooperation of an
active group of sanitary workers.
Some cities try to create single urban districts in which a general
practitioner, pediatrician, and obstetrician-gynecologist serve the same
people. This system has the advantage of permitting all the physicians
to coordinate their work and carry out comprehensive sanitary measures.
The Ministry of Health, USSR, has based the standard structure and
norms of an urban medical district on a population of 4,000 persons,
approximately one-fourth of whom are children up to 14 years of age.
ltr. ch. 8 for the kinds of groups and methods of operation.
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Model structure of a typical urban medical district
with a population of 4,000**
Specialty
For one medical district
No. of hospital Approximate distribution
physicians by of hospital beds by
specialties specialties
Internal medicine
2.0
10.0
Pediatrics
1.25
5.4
Surgery
0.9
7.6
Obstetrics and gynecology
1.0
7.2
Ophthalmology
0.25
1.0
Otolaryngology
0.2
0.6
Neurology
0.25
0.8
Phthisiology
0.6
4.2
Dermatovenereology
o.4
1.6
Total
6.85
38.4
44*Appendix to Ministry of Health, USSR order no. 870, 21 November 1949
The shop district principle underlies the care of workers. The
shop district physician treats workers in the various shops, studying
working conditions and at the same time executing hygienic measures.
To sum up, district physicians are concerned both with therapy
and with prophylaxis (sanitary, antiepidemic, sanitary-educational),
as they endeavor to improve working and living conditions and prevent
disease (Figure 14).
The Clinical Method
The district principle enables hospitals and district physicians
to use the clinical method, thereby reflecting the preventive trend in
medicine.
The clinical method involves systematic observation of the health
of the people concerned and the early detection and treatment of diseases.
It is used as a means of carrying out measures to improve the living
and working conditions of the patients and to prevent the further
spread of diseases, especially to those close to them. Thus, the
clinical method contributes to the successful implementation of a
fundamental principle of Soviet public health, i.e., preventive medical
care. It is the most advanced modus operandi of all medical institutions.
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The clinical method is employed above all by district physicians.
Persons suffering from the following diseases are required to visit a
clinic: pulmonary tuberculosis, rheumatic heart disease, hypertension,
coronary insufficiency, nephritis, gastric or duodenal ulcer, achylia
gastrica, chronic dysentery, and diabetes mellitus. In some rayons,
depending on the character of the local pathology, even patients with
such diseases as malaria, brucellosis, etc., may be kept under obser-
vation at a clinic.
The clinical method is concerned chiefly with the early detection
of disease (functional disorders are most readily curable), systematic
treatment, investigation of the causes of disease, and elimination of
harmful environment factors. As such, it fully meets the conditions
for fighting diseases as laid down by the great Russian physiologist
I. P. Pavlov, who wrote: NIsnit it a fact that the causes of a disease
are generally stealthy and begin to act in the organism of a patient
before he becomes the object of medical attention? A knowledge of
causes is naturally the very heart of medicine. First, only by knowing
the cause can one effectively combat it. Second, and even more important,
it can be prevented from acting upon or invading the organism. Only by
knowing all the causes of disease can the medicine of the present by
transformed into the medicine of the future, i.e., into hygiene in the
broad sense of the word.n*
The register of patients eligible for clinical observation may be
somewhat enlarged or contracted depending on local conditions and
medical resources.
Besides district physicians a variety of specialists (obstetrician-
gynecologists, surgeons, neuropathologists, etc.) come to the clinics.
Each doctor has a separate list of patients with clinical appointments
already scheduled.
Patients obtain clinical treatment either on the basis of prophylactic
medical examinations or when they come to hospitals for medical assistance.
Periodic prophylactic examinations are given to certain groups of people
subject to clinical control (children, students, juvenile workers, workers,
persons handling injurious substances, women over 35 -- for early
diagnosis of cancer and precancerous diseases of the female sex organs).
These examinations are the principal means of detecting tuberculosis,
cancer, etc. in the early stages.
It is obvious that proper examination and timely diagnosis require
a careful and thorough study of every case, essential laboratory tests,
X-rays, etc. Organization of these examinations requires good prep-
aration and publicity to ensure that all the persons concerned are
included.
*I. P. Pavlov, Collected Works, vol II, Moscow-Leningrad, 1946, p 358.
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Special attention must be paid to improving the methods of choosing
patients for clinical observation that are now followed by city hospitals.
Analysis of the case history of a patient (say with stomach cancer)
frequently reveals that he came under the clinic's scrutiny in the late
stages of the disease because the physician who was treating him ignored
or minimized his complaints and failed to make the necessary tests. A
careful, alert examination of a patient on his first visit will usually
result in the timely diagnosis of a disease.
The most important feature of the clinical method is systematic
observation of the patients along with execution of comprehensive
therapeutic and preventive measures. These are determined only after
a careful study of the working and living conditions of the people.
The effectiveness of the entire system depends precisely on this
investigation, which is the most laborious aspect of the job, requiring
great persistence, care, and attentiveness on the part of the medical
workers.
Chiefs of general medical departments of hospitals supervise and
direct the clinics, while district physicians are in charge of actual
clinical documentation. The principle form used is the medical card
(a clinical case history) that must be carefully filled out each time
the patient is examined. The information includes the results of the
examination, analysis, treatment prescribed, recommendations for work
arrangements, and data on subsequent observations.
In addition, a clinical card is filled out for each patient, which
serves to verify the patient's visits to the doctor. The clinical card
contains brief passport information on the patient, notes instances of
disability, describes his appearance, states the time of the next
appointment with the doctor. The other side of the card is used for
notations on the main therapeutic measures taken (hospitalization,
sanatorium treatment, work arrangements, etc.).
An individual program of therapeutic and hygienic measures is
prepared for each person to be kept under clinical observation. It
includes examination dates, laboratory and other tests, results of
consultation with specialists, sanitary inspection of living and work-
ing conditions, etc.
Rayon sanitary-epidemiological stations (doctors and assistants
to sanitary doctors) take part in investigating the patients' living
and working conditions as well as working out proper corrective measures
and checking to see that they are carried out.
Clinical cards must be checked no less than once a month to
determine whether or not the patients are keeping their appointments.
If they are not kept, the doctor is summoned through the district nurse,
who is required to visit such patients at their homes to find out the
reason for their non-appearance.
-66-
A major indication of the quality of clinical care is the changes
It may have brought about in the health of the patients. A so-called
epicrisis is entered once a year in the case history of each patient
to evaluate these changes. It includes a brief subjective account of
the patient's condition, data from objective tests, therapeutic and
prophylactic measures taken, modification in working conditions. The
epicrisis is prepared by the attending physician and signed by the head
of the division or chief physician of the hospital. Data on temporary
disability constitute an extremely important indication of the effective-
ness of the clinical method.
Organization of a Polyclinic
A hospital cannot function properly without an efficiently organized
polyclinic. A polyclinic provides the widest range of medical aid,
which is furnished patients either in the hospital or at their homes.
The early and correct diagnosis of disease, treatment, timely
hospitalization, execution of necessary therapeutic and prophylactic
measures in behalf of the patients and those who come into contact with
them -- all these depend on the way the polyclinic is organized and on
the calibre of the physicians working there.
Registration. The method of admitting patients to a polyclinic
is exceedingly important. It must therefore be organized in such a
way that the patient does not stay too long with the doctor; nor should
he have to spend much time waiting to be taken or giving information.
It is no less important that the admitting physician's time be effi-
ciently utilized.. Be should not be reauired to wait for patients,
search for and f91 out papers, or do minor administrative work that
could easily-be handled by middle echelon personnel.
In order to avoid waiting in line at the admissions office, appoint-
ments are generally made both in person and by telephone. The precise
time is set with due regard for the capacity of the various consultation
rooms. Subsequent appointments are made directly-by the attending
physician who notes the time on a slip handed to the patient. The
admissions office fills out a medical card, which is passed on to all
the departments and rooms visited by the patient. Some departments
(e.g., tuberculosis, venereological, dental, pediatric) have their
own form of registration and case history. Case histories are kept
in the admissions office where they are filed by district, street, and
house number.
The work of middle echelon medical personnel in a polyclinic. These
persons have major responsibilities in a polyclinic.
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Each department has a head nurse charged with directing the nurses
and seeing to it that hygienic standards are observed in her area. She
is responsible for providing the consultation room with medical and other
supplies. The head nurse of a surgical, gynecological, etc., department
is required to sterilize dressings, to maintain and store the medical
instruments and apparatus.
Nurses in gynecological, surgical, otological, physiotherapy, and
some other rooms carry out certain therapeutic procedures under a
physician's direction.
Sometimes nurses administer emergency first aid to patients in
polyclinics.
The district nurse plays an exceptionally important role as chief
assistant to the district physician in all his therapeutic, sanitary,
and prophylactic work.
The nurse in a polyclinic gets the doctor's consultation room
ready for the patients, obtains beforehand case histories from the
admissions office and analyses, photographs, etc., from the laboratory
or X-ray room. When required, she takes the temperature of the patients
or does anything else the doctor may order. She prepares slips for the
next appointment, fills out medical certificates, etc.
The hard working district nurse executes the physician's instructions
in the homes of patients, carries out such preventive sanitary and anti-
epidemic measures as inoculations, epidemiological tests, disinfection
of foci of disease, and, when there are indications for it, takes the
temperature of persons who have been in contact with sick persons. She
helps in hygiene education and works with volunteer groups.
Assistance at home. Providing assistance at home is an important
hospital Ainctiono It must be reliable and prompt, i.e., all house calls
must be made on the same day.
It is the district physician who makes the house calls. Each visit
lasts an average of 30 minutes. The physician must see to it that the
patients are systematically observed and given careful, thorough
clinicodiagnostic tests. He himself sets the time for a subsequent
visit without waiting to be called again. When the patient has to be
hospitalized, the physician makes the necessary arrangements.
A patient at home must be given skilled, specialized treatment.
Thus, when the case warrants it, the distrist physician calls in appro-
priate specialists for consultation.
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Chiefs of general medical departments of hospitals supervise the
work of district physicians. They must systematically review the case
histories of patients confined at home and personally visit all those
suffering from a protracted disease, especially-when the diagnosis is
unconfirmed. They are required to take all steps leading to the earliest
possible recovery.
Proper care of patients is an exceedingly important element in
treatment. It is the district nurse's duty to visit the patients and
carry out the doctor's orders.
Sanitary -prophylactic work in the district. Besides therapy, a
hospital conducts planned sanitary-prophylactic and antiepidemic
activities (prophylactic vaccination, control of bacilli carriers --
detection and treatment of such persons) and education in hygiene.
A major part of a hospital's antiepidemic work is the effort to
control dysentery and other intestinal infections. Special units to
handle these diseases have been set up in a number of polyclinics.
The entire medical staff of a hospital is drawn into its educational
and prophylactic programs.
Each hospital is required to have a plan of sanitary and anti-
epidemic work in the rayon both for the population as a whole and for
individual sectors (industries, schools, hotels, etc.). The plan is
seasonal and specific, varying with the morbidity of the rayon and the
hygienic conditions prevailing in the different industries, schools,
and hotels. The hospital plan is part of the master plan of the rayon
sanitary-epidemiological station and is carried out under its direction.
Medical workers rely on volunteer sanitary workers. The district
physician organizes a group of these men and women, trains them, and
guides their activities in connection with his systematic propaganda
in the field of hygiene.
The district physician and nurse are familiar with the sanitary
condition of the apartment and house in which the patient lives. They
discuss with him and his family subjects pertaining to hygiene and
advise them on how to take care of sick people, on proper maintenance
of the apartment, personal hygiene, nutrition and rest. This is a
useful, easily grasped method of teaching hygiene.
Sanitary and prophylactic work must be pursued systematically,
for which special time must be set aside. It is the most important
task of district medical personnel who are charged with the duty of
*Cf. ch. 8 for the kinds of groups and methods of operation.
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detecting in time and liquidating acute infectious diseases (Figure
15). They must immediately seek the help of the area sanitary-
epidemiological station and their voluntary sanitary workers in correct-
ing any unsanitary conditions they may find that are conducive to the
outbreak and spread of disease.
As soon as a doctor or feldsher discovers a person with an infectious
disease, he must promptly arrange for his hospitalization and take
emergency antiepidemic measures at the patient's bedside and among
those near him in order to try to prevent the disease from spreading.
The doctor or feldsher must instruct the family on how to handle the
patient's dejecta, clothing, and dishes, how to disinfect his room and
possessions, and later check to see that all these things are done.
Examination of ability to work. Physicians who treat people in
hospitals or polyclinics are authorized to issue temporary disability
certificates. These physicians (occasionally feldshers) are confronted
every day with the necessity of determining whether the people coming
to them for medical help are able to work. They must take into con-
sideration both the condition of the patients and the kind of job they
have. If they are deemed incapable of working, they are issued disa-
bility certificates. Every wage earner, manual or office worker, in a
manufacturing plant, institution, state farm, or machine and tractor
station is entitled to such a certificate when ill.
According to the social insurance law, every worker who has
completed his or her probationary period has the right to obtain funds
from social insurance for the period of illness, pregnancy, or child-
birth. These funds come from mandatory deductions from wages and are
handled by the unions. The social insurance wage fund is grooting year
by year due to the steady rise in the number of manual and white
collar workers. A substantial part of this fund goes for payments on
disability certificates.
All medical personnel are responsible for the proper issuance
and filling out of these certificates, checking on execution of the
doctor's instructions by the patients, detecting malingering and
abuses. A high degree of alertness is required in the struggle to
decrease morbidity.
The doctor or feldsher must be very careful when issuing a disa-
bility certificate to verify inability to work and to determine how
long it is likely to continue. He first authorizes leave for a short
period of time (3 days) which can be extended, if necessary, after
further examination of the patient. In the case of a protracted ill-
ness (more than 6 months), an extension is approved by a medical
advisory commission.
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A feldsher has the right to issue a medical certificate only if he
treats patients independently. The district physician validates medical
certificates given out by the feldsher.
Temporary disability certificates continue in force until the
patients are able to resume work. In chronic, protracted illnesses, the
patients are officially invalidated -- temporarily or permanently. A
medical-labor examination commission determines the various classes of
disability.
Disability certificates are extremely important documents. Accord-
ingly, hospitals register them in special books and guard them like money.
Hospital management, organization of personnel. Patients in a
hospitai or polycliniciare --ended by a single group of physicians.
Each district physician is required to work in a hospital and polyclinic
or to work in a hospital and make house visits.
The head physician directs the hospital and is in sole charge of
all the medical and financial activities. He is responsible for admin-
istration, proper and effective treatment of patients, and competence of
the hospital personnel. He systematically visits and checks on the work
of the departments and the condition of the various patients.
In major hospitals and polyclinics the departments are directed by
chiefs who are skilled specialists in the corresponding branches of
medicine. A department chief in a hospital visits the patients daily,
consults with staff physicians, checks on diagnosis and treatment,
directs all medical and scientific work in the department and corres-
ponding division of the clinic, discusses autopsy findings with the staff
physicians and cases of erroneous diagnosis, observes autopsies of
patients in the departments who have died, discharges patients who have
recovered, reviews and signs epicrises.
Staff physicians are in direct charge of treating and observing
patients. District physicians working at the same time in a hospital
and polyclinic or working in a hospital and making house visits must
have a carefully planned schedule so that they can render maximum
service during a 6-hour working day in the hospital, clinic, or homes
of patients.
District physicians now follow the familiar two-member team system
whereby one is in the hospital or clinic and the other is working in
the hospital or making house calls. The latter spends the first part
of the day (from 9 to 12) in the hospital and then calls on patients
in their homes.
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It is more difficult to draw up a schedule for a physician in a
polyclinic since he has to work in the hospital early in the day and then
be available in the polyclinic for the convenience of patients who may
come in at different hours. The following schedule is practicable:
Day of week Hours Place of work
Monday
Thursday
Tuesday
Friday
Wednesday
Saturday
9:00 - 12:00
12:00 - 15:30
9:00 - 12:30
12:30 - 15:30
12:00 - 15:00
15:00 - 18:30
Hospital
Polyclinic
Polyclinic
Hospital
Hospital
Polyclinic
Physicians in the other specialties more or less follow the same
type of schedule. Sometimes when it would be inconvenient for surgeons,
pediatricians, etc., to be assigned to the hospital and polyclinic at
the same time, the physicians work alternately in both places for 3
or 4 months at a time.
Organization of a Hospital
A staff physician spends 3 hours a day in the hospital and,
depending on his specialty, takes care of 3 to 6 patients. He visits
and examines his patients daily, issues orders, keeps the case history
up to date, talks with the department chief or invited consultants. Be
directs the middle echelon personnel, instructs them in the care of
patients, hygiene, and technical matters when required. While visiting
patients, the physician checks to see whether the nurses are carrying
out his instructions correctly and punctually.
All hospitals require morning and evening visits to patients by
the staff physicians on duty. Special attention is paid to postoperative
and newly admitted patients as well as those in a serious condition.
A very important factor in maintaining the continuity of a hospital's
work is round-the-clock duty. Many hospitals have so-called often-
minutersn in which all the house physicians, head physician, and
administrator participate. At these sessions the physician going off
night duty reports briefly on developments over night, condition of the
serious patients, newly admitted patients, discipline among the service
personnel and patients. Here too are discussed the problems of the
coming day.
Organization of middle echelon personnel. Middle echelon personnel
include: a head nurse (one per division), ward manager (assistant to
the head nurse of a division), ward nurses, operating room nurses,
dietetic nurses, etc. Middle echelon personnel also work in auxiliary
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clinicodiagnostic divisions (as masseurs, anesthetists, X-ray technicians,
laboratory assistants, disinfectors, etc.), in maternity departments
(midwives), in district and rayon hospitals (feldshers).
There is a head nurse in every hospital and department with more
than 35 beds. She checks on hygienic conditions and housekeeping details
of the department. She is responsible for medical and maintenance
supplies and linens, and personally carries out. special instructions
for certain patients as issued by the doctor.
The head nurse supervises all the middle echelon and junior personnel
in the department. She gives out assignments, enforces discipline,
teaches them proper patient care, various therapeutic procedures, and
checks on their work. She prepares menus for special diets and super-
vises their preparation in the kitchen, requisitions medicines, and
distributes them among the ward nurses. The head nurse also compiles
information an the admission and discharge of patients, intrahospital
diseases, etc.
Departments with more than 50 beds provide assistance for the head
nurse in the person of a ward manager who is in charge of the linens,
supplies, and equipment of the division.
The ward nurse is directly responsible for the actual care of the
patients, their hygiene, change of bed-clothes, baths, hair-cutting, etc.
Weak and seriously ill patients require special attention as regards
feeding, washing, and preventing bedsores.
The ward nurse carries out the doctor's instructions. She admin-
isters medicines, carries out prescribed procedures (applies compresses,
mustard plasters, cupping glasses, enemas, injections, etc.), takes the
temperature, delivers material for laboratory analysis, keeps up the
patients' charts, prepares patients for the doctor, and helps him during
examinations.
The ward nurse plays an extremely important part in curing the
patients, for frequently the quality of care they receive is as important
as skilled medical help. The physician has much less to do with the
patient than the nurses who keep them under constant observation. Other
factors in recovery are adequate sleep, the patient's impression of his
condition, food, proper drugs taken an time, and various therapeutic
procedures.
The patients must take the medicines prescribed for them every
day at the same time in the presence of the nurse. It is not permitted
that the day's supply be left with the patients an the understanding
that they are to help themselves. The different medical procedures
must also be carried out at set times (therapeutic baths, enemas,
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injections, etc.). Occasionally patients refuse to take their medicine
or submit to the procedures. The nurse has to reason with such patients
and persuade them to do as the, doctor ordered. The food too must be
served at fixed times. A patient may not eat if he has a poor appetite
or the food is not prepared according to his taste. The nurse must
explain to him the importance of proper diet in successful treatment.
Since she is responsible for feeding the patients and carrying out the
doctor's orders, she should carefully observe the patients every day,
and see to it that the doctor is obeyed. Accordingly, she must be
familiar with each patient's disease and the significance of the treat-
ment prescribed.
The entire staff should be self-controlled and tactful where the
patient is concerned. He must be constantly assured that his condition
Is curable and required to conduct himself in restrained and orderly
fashion. Under no circumstances, however, are his complaints to be
ridiculed as exaggerated or unfounded.
The nurse instructs the orderlies on the rules for cleaning the
wards and corridors since dust and food particles attract flies, which
transmit various infectious diseases. The wards, corridors, and utility
rooms must be spotless. The nurse must see to it that the dust is
moistened before sweeping and that the orderlies promptly remove the
dishes after the patients finish eating. The wards are to be ventilated
regularly and the dust carefully wiped off the furniture. The wards
must always be clean and pleasant.
The nurse should realize that often the health, indeed the very
life, of her patients depends on the quality of care they are given.
She is required to be particularly attentive to a seriously ill or
postoperative patient, reporting promptly any unfavorable changes so
that he can be given necessary help in time. Uttering words of comfort
and encouragement, patiently listening to his complaints and fears, and
satisfying his requests do much to influence his mood and often the
course of illness.
A disinterested attitude toward one's work is generally inadmissible
for Soviet workers. It is particularly intolerable for personnel in
medical institutions. The nurse should always be friendly, calm, self-
controlled, and neatly dressed, for appearance markedly affects the
patients and inspires them with confidence. She must love her work,
do her duty conscientiously and skillfully, thereby achieving her full
potential as a medical worker.
Hundreds and thousands of our Soviet nurses, feldshers, and phy-
sicians showed themselves to be models of valor and self-sacrifice in the
Great Patriotic War, saving soldiers under enemy fire as they selflessly
tended the sick and wounded. All our medical workers should pattern
themselves after these heroes.
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The two-member or three-member system has a definite bearing on the
quality of patient care.
Many hospitals operate on the three-member system,i.e., three persons
serve the patient: doctor, nurse, and orderly. The nurse merely takes
the temperature and administers the medicines, whereas the actual care
of the patient -- toilet, dressing, change of bedding, feeding, etc. --
is left to the orderly along with the cleaning chores, bringing of bed-
pan, and serving of food. This arrangement often fails to come up to
minimum hygienic standards. Yet all the elements of patient care are
important and require the skilled medical training that only a trained
nurse possesses. Thus, in our better hospitals, particularly those for
children, the two-member system is now in vogue and patient care is
entirely in the hands of the nurse. The orderly does only the cleaning,
brings the bedpan, and generally assists the nurse. Even where circum-
stances prevent installation of the two-member system, the ward nurse's
work must be organized in such a way that she spends the bulk of her time
directly attending the patients. She must be relieved as much as possible
from purely administrative tasks. For example, a special orderly should
be used an errands between the clinical divisions and the laboratory.
The nurse's working space should be right in the ward or, if she is
handling several wards, in the corridor between them.
In children's hospitals mothers, with the authorization of depart-
ment chiefs, are permitted to take care of their children, provided they
adhere closely to hospital routine and the established rules for nursing
patients.
A hospital cannot operate efficiently without proper organization
of shifts or scheduling of personnel. Even now there are instances
where the nurse and orderly work around the clock and then have two or
three days off. The patient sees a new nurse every day. Since the
nurse sees her patients once in three or four days, she cannot keep
them under continuous observation. The result is impersonality in
treatment and care, which for all practical purposes relieves the
personnel of individual responsibility for the condition of the patient.
Moreover, the long, unbroken period of duty is so fatiguing that towards
the end efficiency and, with it, quality of care drop sharply.
That is why the triple-shift or double-shift has come into operation.
Twenty-four-hour tours of middle echelon personnel are permitted only
in emergency hospitals, first aid and health stations. It is desirable
that inpatient departments of hospitals schedule the same nurses for
the morning, day, and night shifts, rotating them at fairly long inter-
vals (no less than every other month). Here is an example of a good
schedule for nurses: the morning shift works from 0800 to 1430, the
day shift from 1400 to 2030, the night shift from 2000 to 0830, with
30-minute overlap between shifts for ease of communication. In a two-
shift system middle echelon and junior personnel may not work more than
12 hours continuously.
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Night nurses substitute for the regular nurses on their days off
since 10 times a month they do not work the full amount of hours.
Orderlies working 12-hour shifts change at 8 o'clock in the morning
and 8 o'clock in the evening. It is undesirable for the day shift to
arrive earlier because the noise would disturb the sleep of the patients.
Administrators and staff must strive incessantly to raise the
calibre of middle echelon personnel. Training of nurses, feldshers,
and midwives does not end in medical school, it merely begins there.
Every worker should be tireless in efforts to improve himself by reading
medical literature and mastering new techniques in the examination,
treatment, and care of patients. Large hospitals systematically hold
conferences for nurses to exchange experiences. All feldshers and nurses
should be familiar with the methods of determining blood groups, applying
plaster casts, making splints, transfusing blood, taking X-rays, etc.
Physicians teach the medical workers in hospitals.
Method of admitting and discharging ketients. A person is generally
sent to the hospital by the district physician who examined him in a
polyclinic or at home; in emergencies he is brought to the hospital in
an ambulance. Upon arrival he is examined in the admissions department
by the physician on duty who determines where he is to go. He is then
carefully washed, given clean hospital clothing, has his hair cut and
possessions disinfected.
The admissions department also administers first aid to all persons
brought there regardless of whether they are hospitalized or not. Bence,
the department must have the essential splints, oxygen apparatus, band-
ages, and medicines.
The admissions department registers incoming patients and the
number of available beds, gives information to relatives of patients,
and handles discharge slips. It fills out the passport section of an
incoming patient's case history, i.e., the part containing significant
personal details, and also enters the information in its journal.
Patients hospitalized by a polyclinic bring along their medical
card (outpatient). Other patients are given a hospitalization slip,
which is kept with the case history.
The case history includes salient data an earlier diseases, the
condition of the patient's organs, and a detailed anamnesis of the sick-
ness that led to his being hospitalized. This information is helpful
In making a diagnosis and prognosis as well as in individualizing
treatment.
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The patient must be given a complete clinical examination without
undue delay, generally within the first three days of admission to the
hospital so that diagnosis can be made and treatment begun as quickly
as possible. Effective and timely treatment depends an the diagnosis,
which in turn is based on a thorough examination utilizing all necessary
clinicalplaboratory, and X-ray facilities. The case history includes
the polyclinic's diagnosis, diagnosis of the hospital that admits the
patient, and final clinical diagnosis, which constitutes the basis of
treatment. It also contains notations of associated diseases, compli-
cations, outcome, and recovery of ability to work.
Into the case history go day-by-day details on the patient's
health, medicines and procedures prescribed, routine to be followed,
diet, laboratory analyses and X-rays, conclusions of consultants, and,
if operated on, the nature and results of the surgery. When the patient
is discharged, an epicrisis of the disease is prepared and entered into
the case history and outpatient card, which are returned to the poly-
clinic together with instructions for follow-up.
Case histories are not only extremely important as far as treat-
ment of the individual patient and the course of disease are concerned,
but they provide essential data for evaluating the clinical effective-
ness of the treatment, surgery, etc. They are also used in forensic
medical inquiries. That is why medical personnel must be unusually
careful in maintaining and safeguarding the case histories. The ward
nurse remains in charge of them until the patient is discharged, after
which they go into the hospital's files.
After the admissions department performs the necessary sanitation
measures, the patient proceeds in the company of an orderly, or is
carried on a stretcher, to a ward depending on the nature of the
disease. The distribution of patients is particularly important in
contagious hospitals. It is also desirable to segregate patients
awaiting surgery, patients recovering from surgical operation, etc.
This system makes it possible to set up in the various wards a common
routine for all the patients, thus facilitating the task of attending
them. Patients in a serious, postoperative condition must be kept in
small wards or private rooms so that they can receive individual care.
Patients are discharged after recovery or upon transfer to another
hospital. Those suffering from chronic incurable illnesses may be
sent home whenever there is no exacerbation of the condition. Dis-
charges are authorized by the attending physician and confirmed by the
department chief. A special card is filled out for each discharged
patient. These cards constitute the basis for determining the morbidity
rate of hospitalized patients. Following discharge the patients come
under the active observation of the polyclinic where, should it prove to
be necessary, they receive additional treatment.
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In the event of death, the hospital notifies the patient's closest
relative and issues a death certificate. An autopsy is performed if
the hospital has the appropriate facilities. Significant pathologico-
anatomical data are noted in the case history. Autopsies are of major
significance in raising the quality of medicine. They make it possible
to check on the correctness and timeliness of the attending physician's
diagnosis as well as his methods of treatment. They are useful in
scientific evaluation of clinical material and in forensic medicine.
Both the attending physician and department chief are required to be
present at the autopsy.
Protective measures in hospitals. Successful therapy depends in
large measure on the way a hospital organizes and executes protective
measures. Modern Soviet hospital practice is based an I. P. Pavlov's
teachings regarding protective inhibition, unity and integrity of the
organisml mental and physical unity, and cortico-visceral laws con-
cerning the origin of disease.
Pavlov determined experimentally that the higher nervous activity
of man, indeed all the organism's reactions, are entirely the result
of interaction between the internal and external environments. The
works of Pavlov and his students an experimental neuroses showed that,
due to the unity and integrity of the organism, psychic traumas or
emotional shocks cause diseases to develop in the autonomic nervous
system and impair the activity of various organs.
Establishment of the close connection between various organic
diseases and the cerebral cortex is of exceptional importance in
practical medicine, for it opens the way to therapy by acting on the
central nervous system.
I. P. Pavlov also proved that for man words, (the second signaling
system) like any other external environmental factor, are a powerful,
tangible stimulant, sometimes extraordinarily so.
Finally, Pavlov elaborated a set of views on the significance of
the inhibitory processes arising in the cerebral cortex as a defensive
mechanism, a nnormal weapon in the physiological struggle against the
pathogenic agent.n
The fundamental aim of the protectice measures of a hospital,
polyclinic, or sanatorium is to create for their patients such external
conditions as will sustain their morale and neural and mental tonus,
bringing them actively into the therapeutic process. The patients must
be shielded from the many kinds of unpleasant emotions and fears (of
examinations, operations, or outcome of treatment) that so often beset
them.
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The environment of a hospital embraces the general layout, setup
of wards, routine, and conduct of personnel. A cold, official manner
or whiteness throughout the wards frequently depresses the patients,
especially children. The wards and other areas (corridors, dining room)
must have a pleasant, livable appearance, with walls in warm colors,
flowers, pictures in the halls, clean curtains on the windows, floor
mats, armchairs for convalescents, shades on the lamps, good linens,
pajamas. All these things add to comfort without violating sanitary
regulations.
The patients are benefited if the hospittl's rules regarding
quiet are observed. The personnel need not whisper, but they should
avoid loud talk, unnecessary noise, slamming of doors, etc. Similarly,
the groans of people in operating rooms ought not reach the ears of
patients in the wards.
It is very important for patients to have a long, sound sleep.
We know that I. P. Pavlov attached a great deal of importance to sleep
as an inhibitor of cerebral cortex activity. This is the basis for
the principle of sleep therapy vhich is applied in several diseases.
Workers in the MaRarovsk hospital, Kiev Oblast, who pioneered in
introducing protective measures into hospital practice have developed
various techniques of inducing conditioned reflex sleep through the
use of different, monotonous sound and light stimuli.
However, normal physiological sleep is essential in any disease.
Therefore, for 9 hours (from 2200 to 0700) there should be complete
quiet: changing of personnel, cleaning, temperature taking, etc.,
should all start after 7 a.m.
An adequate system of night-lights in the wards and shaded lamps
near the patients' beds permit the personnel on duty to answer calls
and observe the seriously ill without disturbing the others.
Here is an example of the way a typical day is organized in a
hospital:
0700 - 0800
0800 - 0830
0830-- 0900
0900 - 1300
1300 - 1400
1400 - 1600
1600 - 1700
1700 - 1730
2000
2200
-- taking of temperature, toilet, cleaning
breakfast
-- visit of house physician
therapeutic and diagnostic activities; visit of
division chief; consultation of specialists
dinner
rest, nap
taking temperature; carrying out of doctor's
instructions
-- evening tea
supper
sleep
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The proper organization of feeding the patients -- arrangements and
appetite appeal -- require a great deal of attention. Pavlov emphasized
the role of mental stimulation of the secretory nerves of the stomach,
without Which lithe amount of juice needed to start digestion cannot be
obtained.? It is more important, he believed, than the chemical stimu-
lation resulting from the direct effect of food on the mucous membrane
of the stomach.
Some hospitals concentrate almost
of the food, being largely indifferent
taste. Proper assimilation of food is
many diseases it is the most essential
entirely on the chemical composition
to methods of preparation and
highly important; in fact, in
part of the therapy.
The patients must have something to occupy their leisure hours,
especially in the evening. Left to themselves, they are likely to
become moody about their illness and discuss it with others in the
ward.
Hospitals should have a library with a well chosen collection of
books, table games, etc. They should also devise simple work therapy:
for women -- knitting and embroidery. In warm weather patients,
depending on their condition, might well be permitted to work in the
garden (digging and loosening the soil, arranging flower-beds, seeding,
watering, weeding, laying out and clearing paths, planting shrubs).
In winter some might even clear away the snow. Work therapy must be
adjusted, of course, to the individual patient in accordance with the
doctor's advice. Patients should be given the opportunity to stay in
the fresh air -- walking for ambulatory cases, lounging on the veranda
for those who must recline.
A final, vital ingredient in the protective practices of hospitals
is proper attitude on the part of the personnel, which goes far toward
preventing iatrogenic diseases, i.e., conditions that arise from
thoughtless words and remarks negatively affecting the minds of a
patient. Doctors and middle echelon personnel should always bear in
mind that they are not only healers, but also the patient's source of
hope for recovery. That is why psychology plays such an important role
in the treatment of various diseases. Depending an their personality,
patients are more or less nervous and apprehensive about their health.
They are likely to take thoughtless "wounding" words to heart and the
ensuing suspicion and agitation lead to the development of iatrogenic
disease. In talking with patients, every word must be weighed. One
should not refer to their condition when they are present. In no cir-
cumstances are they to be given any information from their case history
or relevant papers, since these may upset them and cause much suffering.
On the other hand, soothing and encouraging words imbue even the most
seriously ill patients with the hope of a favorable outcome and strengthen
the organism's defensive powers. Explaining to patients in simple terns
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the nature of their illness and the treatment employed will further
contribute to their recovery. Upon discharge patients should be given
a detailed description e the program of work, diet, and rest prescribed
for them. Education in hygiene is a mandatory part of the protective
measures of a hospital.
Words serve as a basis for psychoprophylaxis, and preparation of
patients for surgery and for painless childbirth.
These protective practices are not limited, naturally, to the
inpatient department of hospitals. They are equally necessary in poly-
clinics, sanatoria, and other medical institutions. Elimination of long
lines, courtesy, use of psychology along with other therapeutic devices,
explanation of sanitary problems in the prevention and cure of certain
diseases, personal and differentiated hygiene are no less essential in
polyclinics than in hospitals.
Control of infections in hospitals. The concentration of a large
number of patients, including those with infectious diseases, is conducive,
in the absence of appropriate prophylactic measures, to the spread of
infections both among patients in the hospital and among the surrounding
population. In order to prevent this spread, sewage, mucous, and excreta
must be disinfected prior to discharge into sewer pipes or cesspools
with chlorinated lime or lysol. All the solid wastes, used bandages,
cotton, etc., must be burned, and the patients' possessions carefully
disinfected. Linens, especially of infectious patients, must be soaked
in disinfectants before being sent to the laundry and their dishes
scalded and washed thoroughly. Objects used in taking care of these
patients must be disinfected each time -- so too stretchers, wheel
chairs etc.
A number of precautions are taken to prevent the entrance of
infections into hospitals, especially contagious hospitals. Only one
patient may be admitted at a time to the examination room of the
admissions department. The physician makes the diagnosis, ascertains
the so-called epidemiological anamnesis, i.e., any previous infections,
whether there was contact with other infectious patients, and directs
him to the appropriate department where he is placed in a general ward,
cubicle, or isolation ward. The examination room is carefully dis-
infected after each patient; the medical personnel change their gowns
and wash their hands.
Contagious hospitals are equipped with complete-isolation and
semi-isolation cubicles. Admissions departments are frequently laid
out with these partitioned-off sections.
Complete-isolation cubicles are wholly isolated ane-bed or two-
bed rooms with separate entrance for the patient on the outside and
lock [compartment] from the corridor for the medical personnel. They
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contain a bed, bath, wash-stand, and bedpan for each patient who also
has his awn dishes and medical equipment for as long as he is in the
hospital. Food is passed to him through a special small window.
Before entering the cubicle, the medical personnel wash their
hands and put on a special gown which they remove after leaving, and
then once again wash their hands. This is to prevent their transmitting
infection as they moveto another cubicle or to the general ward.
Poorly trained or undisciplined personnel can play a major role
in spreading infections either within the hospital or among the popu-
lation. The rules of asepsis, therefore, must be carefully heeded by
all concerned. On coming to work they put on hospital dress.
A shower before and after work is desirable. Carriers of bacilli as
well as those with a member of the family sick at home with an infectious
disease are not allowed to work in a hospital. Medical personnel must
carefully washtheir hands after coming into contact with a patient's
excreta.
Every infectious department should have its own personnel, since
passage from one department to another is not permitted.
The training of medical personnel includes a detailed acquaintance
with the nature of infectious diseases, sources and paths by which they
spread. Constant efforts must be made to improve their skills.
Hospitals must keep careful records of intrahospital infections,
for these are one of the most significant indices of poor quality of
work.
Organization of Dietotherapy
Physician-dietitians in large hospitals or nurse-dietitians in
small institutions are in charge of therapeutic nutrition. Proper diet
is vital in therapy and, as such, warrants special attention. Appearance
of the food and the way it is served are important factors. Relatives
and friends of the patients must be watched lest they bring in items
against the doctor's instructions that may be harmful to them.
Specialists in dietotherapy establish certain standards, prepare
the menus, and devise the general feeding routine for the hospital.
They are responsible for sanitary conditions in the kitchen, auxiliary
and storage areas and for the observance of hygienic regulations by
kitchen helpers. The latter are required to have regular monthly medical
examinations. Persons with infectious diseases or bacilli carriers,
especially typhoid and dysentery, are not allowed to work in the kitchen.
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The taste and nutritional qualities of the food, hence its ready
digestion by the patients, depend not only on the manner of preparation,
but also on the way it is served and the conditions under which it is
eaten. Frequently the food spills on the way, gets cold, or loses its
taste and nutritional qualities due to standing too long. That is why
particular attention should be paid to delivering food to the various
departments of the hospital and to the possibility of warming it up when
It gets there.
The ward nurse and dietitian must supervise the serving of food,
be present in the wards while the patients are eating, and feed those
incapable of doing so themselves. Institutions that have no waitresses
usually have orderlies do this job.
In order to improve the diet of patients, many hospitals have
their own farms worked by the staff with the help of local Councils and
public health agencies. These farms are to be considered a supplemental
source of food as well as a means of work therapy. It has been shown
both in psychiatric hospitals, where physically healthy persons may stay
for a long time, and in general hospitals that fresh air and light
physical activity (strictly controlled) are beneficial to a number of
patients.
Every rural hospital can have its own farm. Rayon and district
hospitals can generally use adjacent land for gardening purposes.
Hospitals and other medicoprophylactic institutions are helped to
improve their service to the people by social organizations and coop-
erative groups.
Hosita2_:.UIecor&tsandWorkIndices
Periodic statistical reports make it possible to judge the amount
and quality of -work a hospital does and the efficiency with which it
uses the beds available.
The main types of documents used by the polyclinical department
of hospitals are: medical card (outpatient), physician's daily work
sheet in the outpatient division, and admission slip to the physician's
office. Polyclinical reports are compiled from these and other records,
For the inpatient department the most important records are the
admissions register, refusals of hospitalization by the admissions
division, and case histories.
The patient traffic and utilization of available beds are cal-
culated from the daily report sheets and the composite lists based on
them. The data make up that part of the hospital report which deals with
bed utilization, kind of patients hospitalized, length and outcome of
treatment.
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A register of infectious diseases is also maintained in which are
noted all cases of acute infectious diseases detected in the hospital
(excluding the patients hospitalized for a given infection) regardless
of whether the patients became infected while in the hospital or prior
to their admission.
These and other records are used for the hospital's annual statistical
report, which is submitted to the rayon or city health department that
has jurisdiction over it.
The report includes information on the work of the polyclinic and
inpatient departments.
The passport section of the report mentions the type of hospital,
equipment, number of industries in its area, affiliated health stations,
and number of medical districts.
The report mentions the staff, number of positions occupied by
doctors, middle echelon and junior medical personnel, work and work
load of physicians in the hospital, polyclinic, and in homes.
In 1954 the Ministry of Health, USSR, introduced a new form of
annual hospital report which reflects not only the totality of the
hospital's activities, but also the morbidity and mortality rates of
the population served by it. The various indices characterizing the
hospital's work are calculated from these data, the most important being
those relating to the population's health.
The morbidity rate is based an confirmed diagnoses, with only those
sicknesses tallied that were discovered the first time in the patients.
The number of fatal cases both in the hospital and in homes are cal-
culated for each illness, thereby making it possible to judge the extent
and timeliness of hospitalization in the givenrayon or district.
The report goes into considerable detail on clinical check-ups,
emergency aid, and hospitalization.
The second section of the report is used to calculate the most
important indices of the polyclinic's work:
(a) observation of the district rinci le in the ..1 clinical work
of the dis riot 2hEi2ima ratio o the number ?I patients admit ed
in their district to the total number of patients received by the
district physician);
(b) observation of the district rinci le in attendin tients
at home (ratio o the number of visits by physicians o e patien s
In theirdistrict to the total number of house calls. The higher the
percentage, the better organized the work of the polyclinic -- 70 to
75% or more is considered a good index);
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? ? -
(c) determination of .r..ortion of visits made ? inhabitants of
rural areas ratio o the number of visits by rural resi ents to the
total number of visits. This index shows the extent of medical aid
obtained by rural residents in urban hospitals).
Another section of the report yields information on the volume of
clinical service (ratio of the number of patients under clinical
observation to the total number of patients with given nosologic types
of diseases). It permits assessment of the action taken with respect
to the clinic's patients (percentage of individuals hospitalized, sent
to sanatoria, recommended for other work, placed on the permanent dis-
ability list, etc.).
The section of the report bearing on inpatient service reflects
both the quantitative side of the hospital's work, for example, utili-
zation of available beds and movement of patients, and the quality of
its therapeutic and diagnostic facilities. The report classifies patients
by type of disease, length of time and results of therapy, surgery
performed by principal kinds of operations and anesthetics used, and
post-operative complications. A special section deals with emergency
surgery, mentioning the time the patient was brought to the hospital
and when the operation was performed.
A hospital report contains a chart with columns representing the
number of beds planned and the number of beds actually available.
Estimated beds are those due to be made available during the year and
for which allocations have been made. These estimates are the basis
for financing the institution. Actually available beds are those for
which space, personnel, bed clothes and linens have been physically
provided, that is to say, completely ready for the patients. These
two figures determine the extent to which the hospital has utilized
its beds. For example, in a hospital with 200 planned beds and an
average of 180 actually available, the plan has been fulfilled by
180 x100
200 9w..
The hospital workload is usually measured in so-called "bed days."
The planned number of bed days, or planned use of hospital capacity,
is determined by multiplying the number of planned beds by the average
number of days of bed occupancy projected for the year. For example,
in a hospital with 200 planned beds and average number of days of bed
occupancy per year 340, the number of planned bed days will be 200 x
340 = 68,000 bed days.
The number of s actuall s t in bed is noted in the report in
the column "Number of days spent in bed by all patients." The figure
is derived from the daybook by adding up the number of patients present
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at 9 a.m. every day. For example, on 1 January there were 15 patients,
2 January - 16, 3 January - 12, or a total of 15 4- 16 12 = 43 bed
days.
The average length of bed occuyancy or bed utilization is determined
from the number of days the patients spent in bed. This is done by
dividing the number of beds actually available into the number of days
the beds were occupied. For example, in a hospital with 65,410 bed days
and 190 beds actually available, each bed was occupied an average of
344.3 days during the year: _.61_41.2.- 314J4 1
190
The beds cannot be occupied every one of the 365 days in a year.
Some of them have to be repaired or periodically disinfected, patients
are changed, and often beds are empty due to unskilful arrangements.
The Ministry of Health, USSR, has set the norm of bed occupancy
in urban and rural hospitals at no lower than 340 and 310 days a year,
respectively. Failure to maintain this standard is indicative of poor
management.
It may happen, however, that the utilization index shows a number
of days in excess of 365. Suppose that a hospital has 20 beds all
actually available and occupied. One or two patients are brought in
whose condition warrants hospitalization. They are placed in award
or corridor on reserve beds or in the duty room, etc. These beds are
not included in the estimates, nor is their number stated in the report,
but the time spent by the patients in these beds is added to the number
of bed days. When this happens often, the utilization index will exceed
365 days a year, indicating that the hospital is overcrowded.
The annual report also permits a determination of the average number
of days spent by a patient in the hospital, i.e., index of length of
stay in bed. This is calculated by dividing the nraer of patients
attended (the number of patients attended is the total number of patients
who were admitted, discharged, and died during the report period) into
the number of days spent in bed by the patients. For example, in a
hospital that had 65,410 bed days and treated 4,088 patients, the
average length of stay was derived from 65,410 = 16, i.e., a patient
4,088
spent an average of 16 days in bed.
The so-called bed turn-over, or average number of patients in the
beds for a year, is closely related to the above-mentioned index.. For
example, during a given year 4,088 patients entered a hospital that had
180 beds available. Thus, the beds were turned over, so to speak,
Lan7times, i.e., an average of 22.7 patients occupied each bed
. 22.
1b0
during the year.
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rT
All these indices serve to measure the extent of bed utilization.
The rate of bed turn-aver varies with the length of time a patient stays
in bed, which in turn varies with the nature of the illness. For example,
the average length of stay in contagious hospitals is 17 or 18 days, the
shortest 7 or 8 days in maternity beds, the longest in psychiatric
hospitals, tuberculosis departments, particularly by patients with bane
tuberculosis.
Although the length of stay is generally determined by the nature
and course of the illness, a decrease in length of stay and, consequently,
increase in bed turn-over largely depend on the accuracy of diagnosis,
timeliness of hospitalizations care and treatment given by the hospital.
New and more effective therapeutic methods are sharply reducing the
duration of illnesses, e.g., pneumonia, through use of the sulfanilimides
and penicillin. Length of hospitalization may be shortened by early
diagnosis, timely admission to hospital, use of various kinds of exam-
inations and analyses in the clinic, that is, even before the patient is
hospitalized.
An important qualitative measure of a hospital2s work is the
mortality index the ratio of the number of patients dying to the number
o patients leaving the hospital (discharged dead), expressed in a
percentage. For example, in a hospital which during the year had 4,088
patients of whom 143 dieds the coefficient or index of mortality is
143 x 100
3?5%.
This index is computed for each department and for the individual
illnesses. A decrease in mortality from various illnesses or after
surgery is undoubtedly a major indication of effectiveness of treatment.
For example, the use of antidiphtheria serum reduced deaths from
diphtheria from 35.1% in 1892 to 4% in 1936; the sulfanilimides and
penicillin decreased the pneumonia mortality rate many times.
The quality of diagnoses is determined by the degree of coincidence
(polyclinic and hospitals hospital and pathologicoanatomical). Data on
results of treatment, postoperative complications, duration of treatment
for the different categories of patients also go into the composition of
the qualitative Indices.
The quality of emergency surgery is evaluated from the speed with
which patients are admitted to the hospital after the onset of illness
and the amount of time required to perform the operations after admission,
measured in hours.
The reDort presents in detail an account of the hospital's surgery,
permitting the results in each group of patients to be evaluated, post-
operative complications elucidated, etc. The higher the percentage of
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patients brought early to the hospital (up to 6 hours after onset of
illness), the better the ambulance service and the higher the quality
of diagnosis by the district physicians. Cases where patients are
brought in 24 hours after the onset of illness must be regarded as
gross defects in hospital organization.
Analysis of patients requiring emergency aid (percentage of patients
operated on, fatalities among surgical and medical patients) shows
convincingly that timely hospitalization and surgery are major factors
in the recovery of patients.
All medical workers must be familiar with the quantitative and
qualitative indices of hospital work and discuss them at their con-
ferences, for they constitute the foundation of hospital planning.
Medical Service to Industrial Workers
Industrial workers are served by a network of special establishments
in addition to the regular medical institutions providing aid at their
homes. These establishments are extremely important in that they bring
medical aid within easy reach of the workers, make it possible for
doctors to study industrial conditions and discover the causes of
morbidity and traumatism. They also enable the doctors to plan and
carry out, jointly with management and union officials, hygienic,
prophylactic, and therapeutic measures to lower the sick rate and
improve working conditions in a given enterprise. Medical units are
organized in all major industries.
Medical Units
A medical unit is a complex of therapeutic and prophylactic
facilities affording the manual and office workers of a given enter-
prise all types of medical care. This is the so-called closed medical
unit. Sometimes it also serves members of the workers' families and
other people living in the area, in which case it is called an open
medical unit (Figure 16).
Combining all the medical facilities in an enterprise makes it
possible to improve the quality of medical service, adapt it closely
to the working conditions of that enterprise, and carry out comprehensive
medicoprophylactic measures.
The medical unit is organically connected with the enterprise and,
like the other units, helps to fulfill the overall industrial plan.
The chief of the medical unit is directly under the jurisdiction
of the head of the rayon health department or, in large enterprises,
the head of the city or oblast health department.
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?re7;
Medical units arose during the Great Patriotic War in defense
plants. The development of a powerful defense industry under war con-
ditions employing hundreds of thousands of new workers, chiefly women
and adolescents, confronted public health agencies with special problems.
When the war ended, medical units were organized in other branches of
industry with more than 3,000 workers, and in some with lesser numbers,
e.g., coal and iron (over 1,500 workers), mining and chemical (1,000 or
more workers).
Medical units provide all types of specialized therapy in a poly-
clinic or hospital. They carry on hygienic and preventive work in the
shops. Large plants organize as a part of their medical unit feldsher
stations in various shops to provide first aid along with hygienic and
safety advice.
Medical and Feldsher Stations
Plants with 1,000 or more workers have medical stations, those with
400 to 1,000 workers have feldsher stations. Sometimes health stations
are set up even when there are fewer workers. These health stations are
usually part of the urban hospitals. Small plants lacking their own
health station are served by the rayon or urban hospital of their area,
which appoints a special doctor for this purpose.
The basic task of medical units and health stations is to reduce
morbidity and traumatism, make medical aid accessible to the workers,
improve living and working conditions by executing comprehensive
sanitary and prophylactic measures, and to observe and check on
execution of laws relating to industrial hygiene.
Since the health station is a direct part of the plant, it con-
centrates its activities on the prevailing morbidity and hygienic
conditions, working closely with the management, union, and workerst
organizations. It is set right in the plant and maintains daily super-
vision over sanitary conditions, provides first aid for injuries and
acute illnesses, and, with appropriate indications, prescribes treat-
ment in a sanatorium for those who need it, special diet, etc. (Figure
17).
The expenses involved in maintaining and equipping the health
station is shared by public health agencies and industrial organizations.
The plants provide space, maintenance equipment, transportation; they
pay for public utilities and the salaries of technical personnel. The
public health agencies supply the medical personnel, apparatus, and
medicines. These agencies carry out improvement programs in plants
through the health stations.
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Besides public health agencies, industrial ministries, factory
managements, and trade unions also spend money on medical facilities.
According to a decree of the Council of Ministers, USSR, ministries
and departments in constructing new plants or renovating and enlarging
old ones must at the same time provide medical facilities, day nurseries,
and living quarters for medical personnel. These are the norms: for
plants numbering over 10,000 workers -- a hospital with 12 beds per 1,000
workers and a polyclinic to handle 150,000 visits a year; 5,000 to
10,000 workers -- a hospital with 75 beds and a polyclinic to handle
75,000 visits a year; 2,000 to 5,000 workers -- a hospital with 50 beds
and a polyclinic to handle 50,000 visits a year; 800 to 2,000 workers --
a medical health station; 300 to 800 workers -- a feldsher station.
Nurseries attached to plants must be built with 12 places per
1,000 female workers.
Plant managers and unions are required to build sanatoria, night
sanatoria (prophylactoria), nurseries, dietary dining rooms, rooms for
personal hygiene of the female employees.
The directives of the 20th congress of the Communist Party of the
Soviet Union oblige the appropriate ministries and departments "to
improve industrial hygiene and safety arrangements in industrial plants,
particularly in mines, hot shops, and in plants injurious to the health
of the workers, exploiting for this purpose the latest achievements
of science and engineering."
The Shop Area Principle
Physicians of medical units serve the enterprises in accordance
with the shop area principle. The shop area physician, a general
practioner, attends the workers of one or more shops depending on the
number of persons.
The shop area physician works in a polyclinic, hospital, and shop.
He must be in the shop no less than 9 hours a week where he studies the
working conditions, becomes familiar with the technical processes, dis-
covers unfavorable environmental factors that may cause sickness or
injury and takes an active part in efforts to overcome them. Since he
is acquainted with the working conditions of the various types of
workers in his shop, he is in a better position than anyone else to
judge the work capabilities of the ill and correctly solve problems
related to layout of work (Figure 18).
In accordance with the shop area principle, besides the general
practitioner a number of specialists also work in the health unit,
chiefly surgeons, obstetrician-gynecologists, and dermatovenereologists.
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These physicians too study the causes of injuries, the effect of working
conditions on women, particularly pregnant women, and seek ways of pre-
venting injuries and pyodermic diseases.
The medical unit affords the manual and office workers of the plant
all kinds of polyclinical services, including hospitalization, if there
are facilities for it. If not, the unit makes arrangements in hospitals
of the open medical network. If the employees live in a workers1 settle-
ment, the medical unit will make house calls even on members of the
family. It is important for the shop area physician to keep in touch
with the local district medical officer who normally makes the house
calls.
The medical unit spends a good deal of time in organizing help for
injuries, carrying out periodic medical examinations and keeping various
groups of workers under clinical observation.
Medical Help in Injuries and Accidents
Proper, timely help in injuries depends largely on the available
first aid facilities mandatory at all plants.
First aid facilities must be provided as long as the plant is
operating. The quality of service for the night shifts must not be
permitted to decline. It is important that first aid be decentralized
as much as possible, i.e., brought close to where injuries are likely
to occur. Feldsher stations have been set up for this purpose in very
large shops. Elsewhere there should be present in every shift and crew
individuals capable of rendering aid until the doctor comes. These
individuals may be members of the Red Cross or Red Crescent who have
passed the "Be Ready for Medical Defense" tests, specially trained team
leaders, middle echelon or junior technicians, etc. Every shift should
have a medical post of workers instructed in the principles of first
aid and capable of taking charge of the medicines, splints, and stretchers.
Effective organization of traumatologic aid requires that the workers
be instructed in the principles of self-aid and mutual aid. Accordingly,
those who man the medical posts are systematically taught safety engi-
neering, how to apply splints, sterile bandages, and tourniquets, how to
move injured persons, etc. The crew foreman may also be the organizer
and director of first aid. The foremen have medical kits which are
periodically checked by feldshers. Persons who work alone should be
taught self-aid and provided with individual packets of sterile bandages.
All these arrangements make it possible to give first aid right
where injuries occur and have the victims brought safely to the health
station or medical unit, an extremely important factor in subsequent
treatment, particularly in preventing complications.
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The teaching of self-aid and mutual aid is especially important
where the workers are off by themselves or in small groups quite a
distance from one another and from the medical station (in mines, lumber
camps, or in fields driving tractors or combines, etc.).
Feldsher health stations handle minor injuries. For serious
. injuries they merely render first aid before bringing the victims to
the polyclinic of the medical unit. Polyclinics have their awn surgeons
and specialists in trauma and they provide additional outpatient treat-
ment as required.
In order to render first aid for injuries and poisonings the
feldsher health station must be supplied with all the necessary medicines
and equipment.
Sterile bandages and careful sterilization of instruments are
required for the proper treatment of wounds. The head of the station
must always keep in mind that the timeliness and quality of first aid
affect both the duration and course of the condition, the patient's
ability to resume work, and sometimes even his life.
The surgeon of the medical unit or hospital is in charge of all
traumatologic help. His duties include checking on the quality of
service, competence of the staff, availability and condition of the
instruments, dressings, medicines, etc.
In order to study the causes of injuries and their prevention,
workers in the medical unit and ,health stations together with safety
engineers and the factory commfttee's representative an the commission
for labor protection take part in investigations of accidents as well
as check on the implementation of safety measures.
The health station also gives first aid in acute illnesses and
sends the patients to the polyclinic for further treatment. The staff
executes the doctor's orders regarding injections, dressings, simple
physiotherapy, etc.
Periodic Medical Examinations and Clinical Service
Medical units, particularly shop area physicians, emphasize periodic
medical check-ups. They examine all job applicants in order to bar those
for whom work in the given plant or occupation is contraindicated. The
personnel office does not have the right to hire anyone without a
certificate from the shop physician of the medical unit or health
station.
Adolescents as well as workers coming in contact with toxic sub-
stances are examined at regular intervals set by special order or
instructions of the Ministry of Health, USSR. The purpose of these
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examinations is to uncover occupational diseases as soon as possible,
institute timely treatment, diet, change to other workland alter when
necessary working arrangements. The orders for each occupation provide
that specialists participate in the examinations, which may include
laboratory analyses and X-rays.
Specialists of the medical unit also conduct specific mass medical
examinations to uncover cases of tuberculosis, cancer, and other diseases.
Workers with these conditions are then directed to the clinic of the
medical unit or to an appropriate dispensary for treatment and systematic
observation.
Most of the medical duties in the clinic and all the paper work
are concentrated in the hands of the shop physicians. These keep under
observation groups of healthy manual and office personnel (the most
valuable producers) as well as sick workers in accordance with instructions
of the Ministry of Health, USSR. All young people under 18 years of age
are also subject to clinical observation by a special section of the
medical unit or, if there is no such section, by the shop area physician.
An individual program of treatment is drawn up for each clinical
patient. Systematic observation, use of different kinds of treatment,
hospitalization when required, sanatorium or health resort therapy,
and alteration of working arrangements are the most important measures
that may be taken.
Results of the clinical method are evaluated from the number of
measures taken, the patient's condition, and, above all, from the number
of cases and days of disability.
Investi ation of Rate of Sickness with Te
? ?
Disabilit
Personnel of the medical unit, primarily the shop physician and
health station chiefs, must be thoroughly familiar with the amount of
sickness accompanied by temporary disability prevailing in a given shop
and in the plant as a whole. The plan for therapeutic and hygienic
measures is based on an analysis of morbidity by the medical unit and
health stations.
The level and changes of morbidity are judged from the results of
the therapeutic and prophylactic work done by the staffs of the medical
unit and health station.
Under the present system each completed disability certificate to
be submitted for payment is recorded by the medical unit in a special
book and an the worker's personal medical card. This enables the shop
the forms and methods of the clinical approach, cf. Chapter 3,
"The Clinical Method."
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physician to follow up systematically every case of illness involving
disability. The data compiled for a certain period of time (month,
quarter, year) indicate changes in morbidity throughout the plant. The
data are also entered monthly an form 3-1 by the factory-plant committee.
Statistical processing of the data on morbidity includes all dis-
ability certificates, both those subject and those not subject to payment
In the given month. Account is taken not of the calendar days, but of
the number of work days. The number of workers in a plant is taken for
the purpose of computing the intensive indices per 100 workers from the
first number for the current month.
The shop physician supplements the monthly report on form 3-1 with
details on sex:, age, occupation, and breakdown of the group of *other*
illnesses.
Every injury is noted in a special book, which facilitates the task
of analyzing the pertinent material and ascertaining the circumstances,
operations, units, benches, groups of workers most prone to injury, and
the nature of the injuries.
Recording each illness with temporary disability on the individual
worker's card is important because sick:persons can be put on record and
frequent and chronic sufferers detected. They can then be sent to a
clinic, sanatorium, or health resort, etc.
A Single Overall Hygiene Program
Following its analysis of the sanitary conditions in the plant,
extent and nature of morbidity and traumatism, the medical unit works
out jointly with the plant management and union a single, overall hygiene
program. The program specifies the time allotted for implementation
of the measures and designates those responsible (management, union,
medical institution). The program is discussed by all the interested
parties and signed by the director of the company, head of the medical
unit, and representative of the factory-plant committee.
The program outlines safety measures, improvements in ventilation
and illumination, hygienic conditions and layout, and in the everyday
services for which the management is primarily responsible.
The union vigorously cooperates in providing sanatorium-health
resort facilities and processing applications for rest home accommodations.
It also helps to organize groups of sanitary activists.*
fen and women workers displaying special interest in public health --
translator's note.]
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4
The program contemplates measures to control individual diseases
and injuries, improve medicopropbylactic service and hygiene education,
train sanitary activists and guide their leaders.
Sanitary-Prophylactic and Antiepidemic Work
Sanitary-antiepidemic work occupies a major portion of the time of
the medical unit, particularly the shop area physician and his staff.
The unit and health station are the champions of the sanitary and anti-
epidemic measures of the health agencies in the given plant.
Every day the medical workers inspect sanitary conditions in the
shops, snack bars, dining-halls, showers, and toilets. From time to
time they even visit workers' settlements, homes, and stores.
All activities relating to industrial hygiene are carried on under
the direction of the industrial sanitation physician. Inspection of
the sanitary condition of the non-working areas is conducted in cooper-
ation with the city sanitation physician of the sanitary-epidemiological
station. In plants where there is no industrial sanitation physician,
the shop physician helped by the nurse inspects the shops, ventilation,
illumination, issuance of special protective clothing, the condition of
protective devices, and enforces safety measures, etc.
The medical unit makes suggestions to the management regarding
hazards and sees to it that the necessary steps are taken to eliminate
them.
The entire staff of the health station is engaged in sanitary-
prophylactic work. Each member has a specific area which he checks on
daily, e.g., shop, dining hall, homes, store, bakery, etc.
Daily checks by the heads of health stations are important to
ensure the successful implementation of the sanitary measures planned.
The staff of the medical unit in their sanitary-prophylactic work
rely on various groups -- insurance delegates, sanitary posts in shops
and homes, communal sanitation representatives and cooperation councils.
The sanitary-antiepidemiological program includes preventive
vaccinations, detection and cure of bacilli carriers, recording of all
cases of acute infectious diseases, education in hygiene (talks, lectures,
articles in wall newspapers, speeches at conferences, radio discussions)
and work with the sanitation activists (organization of a local Red
Cross group, preparation for taking *Be Ready for Medical Defense*
tests, etc.).*
*On the forms and methods of operation of sanitation activists cf.
Chapter 8.
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3
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The medical unit must maintain very close contact with the manage-
ment and party and communal organizations. It must systemically acquaint
them and the public health agencies with the morbidity, traumatism,
and sanitary conditions prevailing at the company.
Organization and Activities of Tuberculosis, Dermato
Venereological, and Oncological clinics
The USSR medicoprophylactic network includes special institutions
which concentrate on combatting tuberculosis, cancer, and venereal
diseases. The organization of work and methods of prevention and
treatment used by these facilities are due to the unusual course and
prevalence of the diseases.
In Tsarist Russia tuberculosis and syphilis were social diseases
largely caused by social and economic factors. To control them is one
of the main responsibilities assigned by the Party to Soviet public
health.
Tuberculosis, the venereal diseases, and cancer are serious con-
ditions requiring prolonged treatment and constant observation. The
first two, moreover, constitute a great danger for persons close to the
patient, particularly members of his family. Cancer and .tuberculosis
can be effectively treated only when they are diagnosed early, often a
very difficult task, which requires appropriate medical organization and
methods of operation. That is why special facilities in the form of
clinics have had to be created (Figure 19).
The clinical method is at present the core of all Soviet medical
practice. It was first applied to tuberculosis and the venereal diseases.
The network of clinics founded in the earliest years of Soviet public
health has now been expanded to the point where they are to be found in
every city. In recent years oncological clinics have come into existence
to cope with cancer.
In addition to the above-mentioned, the USSR also has special
trachoma and goiter clinics in areas where these two diseases are
prevalent, psychoneurological clinics for nervous and mental diseases,
and medico-physical culture clinics to check on physical culture
activities and sports, which are popular all over the country.
Until recently clinics offered medical and preventive services
only for ambulatory-patients and their families. After the hospitals
and polyclinics were merged, however, inpatient facilities were made
available to the clinics, thus expanding their scope.
Oblast and kray clinics are centers for organization and methods.
They are responsible for recording shifts in tuberculosis, venereal
diseases, and cancer morbidity, guiding the local clinics and the
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general oblast network, and training medical personnel in new diagnostic
and therapeutic techniques.
Clinics carry on abroad program of hygiene education, featuring
exhibits, lectures, reports, posters, and leaflets.
Some clinics (e.g. tuberculosis) have subsidiaries -- night and day
sanatoria, dietetic dining rooms, healthful areas.
The clinical method requires above all active efforts to detect
diseases in the earliest stages when frequently even the patients them-
selves are unaware of them and thus do not seek medical assistance. Early
diagnosis of tuberculosis, cancer, and other diseases is the concern of
all physicians. The district physician of a hospital or medical unit
who observes sick people daily must be particularly alert to their
complaints and arrange for all those with suspicious symptoms of a serious
disease to have a special examination. Surgeons and gynecologists are
among those doctors with increasing responsibility for making timely
diagnoses.
Diseases may be detected in their early stages by periodic medical
examinations of various population groups (school children, adolescent
workers, different occupational and age groups). These examinations are
conducted by clinics, polyclinics, hospitals, health stations, and
school physicians. Once tuberculosis or a venereal disease has been
diagnosed and registered, the clinic examines the patient's family and
those living with him.
The staff follows up to see if all the patients visit the clinic
as suggested and, if not, calls them to ascertain the reason. Thus,
the clinic provides systematic treatment and observation, a main pre-
requisite to the effective control of these diseases. Besides detecting
and treating diseases, sending patients to a polyclinic, hospital,
sanatorium, forest school or healthful area, the clinic makes heavy
use of visiting nurses to improve the working and living conditions of
sick people.
The visiting nurse system is an integral part of the clinical
operation. The nurses inspect the homes of patients, uncover the
unfavorable sanitary aspects, and give advice on how to overcome them.
Through regional councils, factory committees, and plant managers, they
seek to improve both the living and working conditions of the patients,
for example, by assignment to lighter work, suggestions for proper diet,
and, sometimes, by offering material assistance. These nurses become
acquainted with the relatives and friends of the patients, arrange for
them to be examined in the clinics explain how to prevent diseases and
how to take care of sick people.
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Since clinics are closely connected both with the general medical
network and with communal organizations, factories, and institutions, they
can go beyond individual prophylaxis to executing broad sanitary measures
affecting the people as a whole in manufacturing establishments, residential
areas, schools, and restaurants.
A distinctive feature of Soviet clinics is the maximum cooperation
they receive in their sanitation activities from factory managers, councils,
unions, and other communal organizations.
The Campaign against Tuberculosis
?
The campaign against tuberculosis, which, like other social diseases,
is a legacy of capitalism, has been one of the principal tasks of Soviet
public health from the moment it was organized. It achieved great success
during the years that socialism has been built. The tuberculosis
mortality rate in 1941 was 2-1/2 times below that in 1913, while the
morbidity rate was one-third the 1913 figure.
The deprivations suffered by the people of the USSR during the
Great Patriotic War and the deterioration of sanitary conditions could
not but be reflected in a certain rise in the tuberculosis morbidity
and mortality rates. Therefore, in the early part of the war the
government was greatly concerned with helping the tuberculous patients
and enlarging the network of specialized clinics. According to a decree
of the Council of People's Commissars, additional beds were made available
in hospitals and night sanatoria. Special dietetic dining rooms were
set up for tuberculous patients who were given supplemental rations.
Child patients were assigned sanitary quarters in nurseries and kinder-
gartens.
In addition to the regular medicoprophylactic facilities, a special
network has been set up to control tuberculosis: institutes and clinics,
hospitals, night and day sanatoria, forest schools, divisions and
sections within medical units, and polyclinic departments of urban
hospitals.
The essence of the struggle against the disease is early detection.
Some cases are diagnosed during a visit to the doctor for other con-
ditions. It is necessary to pay special attention not only to those
inwhon tuberculosis has been found, but to those suffering from
influenza, subfebrile temperature, etc.
A most useful method of control is periodic examination of large
groups of the population -- children of all ages in children's insti-
tutions (centers, nurseries, kindergartens, regular and trade schools),
juvenile workers, youths of pre-military age, and draftees, workers in
various industries, employees in children's or in public food establish-
ments, etc.
-98-
Various diagnostic techniques are used in preventive medical
examinations ?X-rays, tuberculin tests (in children), laboratory
analyses of sputum. Fluorography a modern method of X-raying the
lungs that. makes it possible to examine over 100 persons an hour -- is
very helpful in expediting and facilitating diagnosis.
All patients in hospitals, regardless of the nature of their ill-
ness, pregnant women coming to maternity centers, etc., are required to
have a clinical examination for tuberculosis, which includes a chest
X-ray. It is also compulsory to examine persons who come into contact
with tuberculous patients whether at home or at work.
Medical workers must always keep in mind that tuberculosis is to
be handled like the dangerous infectious disease that it is: elimination
of the foci of infection, sanitary measures, compulsory hospitalization
of all those infected, examination of persons in contact with them,
current and final disinfection of the apartment, etc. The sanitary-
epidemiological station must be drawn into this task. Special notification
cards must be Sent to the appropriate agency for all confirmed cases of
open forms of tuberculosis.
Preventive measures include an extensive campaign of hygiene
education, issuance of literature, vaccination of all newborn children
in maternity hospitals, revaccination of preschool and school children,
and improvement of working and living conditions.
Special attention should be paid to the work arrangements of tuber-
culous employees in factories, who are forbidden to work on night shifts
or overtime. They can be transferred to work involving few hours per
day, with the difference in wages made up by social insurance.
Medical institutions must keep tuberculous patients under constant
observation so that changes in their condition can be noted and thera-
peutic and prophylactic measures promptly taken. Of exceptional impor-
tance is improvement in their living conditions and retraining them in
personal hygiene habits. Here the visiting nurses of the clinics play
a major role.
Physicians in health stations and medical units together with
phthisiologists, plant managers, and unions must have an overall plan
for antituberculosis propaganda among the employees and for providing
the individual sufferers with the medicopropbylactic care they need.
The general rise in standard of living, expansion of facilities,
and introduction of effective drugs (streptomycin, phthivazide
[isonicotinic acid hydrazide derivative] PASA, etc.) have resulted in
a sharp decrease in tuberculosis morbidity.
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Control of Skin and Venereal Diseases
Soviet public health has made considerable progress in controlling
skin and venereal diseases. The morbidity rate dropped sharply after
the Great October Socialist Revolution due to elimination of the main
factors contributing to their spread -- unemployment and prostitution --
in broad network of venereological institutions in cities, sending of
thousands of special venereological teams, especially in the early
days of the socialist regime, to rural areas and outlying districts to
combat syphilis, the scourge of Tsarist Russia, not to mention elevation
of the people's cultural level and the extensive hygiene propaganda.
In 1941 the syphilis rate was one-tenth that in 1913, the 1941 gonorrhea
rate one-fifth that in 1913.
Venereal diseases are combatted by special venereological clinics,
teams, departments in hospitals, and the general medical network.
Skin diseases remain a major problem. Particularly-widespread
are pyudermas and fungus infections like trichophytosis and favus. The
prevention and treatment of these conditions, which arise chiefly-because
of unfavorable working conditions ("microtraumas," chemical irritants)
and unsanitary living conditions, require the clinical approach.
Skin and Venereolo ical clinics and scientific research institutes
are medical establishments and at the same time scientific centers for
the organization of medicoprophylactic measures to combat skin and
venereal diseases in the oblast or kray. They report and process data
on the morbidity rate, train and improve the skill of personnel, and
cooperate with other medical organizations.
Effective control of skin and venereal diseases requires timely
diagnosis and discovery of the sources of infection, compulsory and
complete course of treatment, elimination of the foci of new cases,
mandatory hospitalization of all patients with infectious forms of
syphilis -- all organized by the clinics.
The nature of venereal infections, which leads certain patients
to conceal both the disease itself and the source, requires a great
deal of tact and persistence on the part of medical workers, partic-
ularly the visiting nurses, to induce them to come for medical exam-
ination and systematic treatment. No less prudence and tact are needed
to persuade those in contact with the patients (family and friends) to
submit to an examination.
Some patients do not continue their treatments to the end due to
the rather frequent disappearance of subjective feelings of pain. It
is therefore incumbent upon all medical workers to see to it that
treatment is systematically continued until complete recover. In
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certain cases Soviet law provides for compulsory examination, treatment,
and criminal punishment for those who refuse treatment.
All cases of syphilis in its infectious stage must be entered on
special notification cards which are sent in sealed packages to the
rayon or city health department within 24 hours of detection.
Individuals who handle food or who work in such everyday service
establishments as barbershops and baths, children's institutions, or
any place engaged in detection of venereal or contagious skin diseases
are required to submit to regular medical examinations.
Education plays a key role in the prevention of these diseases.
The clinics cooperate with health agencies and medical units, issue
general educational literature and materials on methods of handling
patients. They facilities to enable physicians in health
stations, medical units, and city hospitals to increase their skill
in diagnosis and treatment.
Control of Malignant Diseases
The campaign against cancer is now being intensively waged in the
USSR. Besides searching for an effective cure, the main problem is
early diagnosis of cancer and so-called precancerous conditions.
Internists, surgeons, gynecologists, and otoloaryngologists are needed
as well as qualified general practitioners, feldshers? and midwives,
who must be made "cancer conscious."
The most reliable method of early detection of cancer and pre-
cancerous conditions is the preventive examination of persons over 40,
(introduced in 1948) by physicians attached to health stations, indus-
trial medical units, urban and rural hospitals, and women's consultation
centers.
Persons found to have precancerous diseases (e.g., achylia gastrica?
erosion of the uterine cervix) or suspected of having cancer are placed
under clinical observation and given appropriate treatment.
Experience has confirmed the value of mass medical examinations.
Among the 23 million persons in cities and villages examined between
1948 and 1952 .11% (24,000 persons) and 0.99% (more than 200,000 persons)
were found to have cancer and precancerous conditions, respectively.
Re-examinations showed a sharp reduction in the number of persons with
inoperable malignancies, the disappearance of neglected cancers of the
skin, lip, breast, and uterine cervix. The extensive propaganda on
initial symptoms of the disease and the need of prompt visits to the
doctor is an important factor in the struggle against cancer, since
the early signs occasion no discomfort and are thus frequently ignored.
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Ctcological clinics and stations, consulting rooms or departments
in large hospitals make up the special network organized by the Soviet
Union to control cancer. The key element is the clinic, which makes
early diagnosis and provides skilled treatment -- surgical and X-ray --
for patients sent there by city, oblast, and republic medical institutions.
The clinic is well equipped with various X-ray and radium diagnostic and
therapeutic machines, a laboratory to make biopsies, and other facilities.
The oncological clinic has an inpatient department for observing
and treating patients and accommodations for those coming from the oblast
for examination or ambulatory treatment. This clinic is a center for
organization and methods of combatting cancerous diseases in the oblast?
kray, or republic. It seeks to enhance the skills of the physicians,
processes statistical data on morbidity and mortality, and plans propa-
ganda among the masses.
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C:HAPTER 4
ORGANIZATION as MEDICAL AND SANITARY FACILITIES
FOR THE RURAL POPULATION
The fundamental tasks of Soviet public health in the rural areas
are: to provide free, readily available skilled and specialized medical
assistance on the same principles as those for the urban population and
to introduce large-scale measures to improve sanitary conditions. How-
ever, the peculiarities of agriculture and the unusual working and
living conditions of the rural population, the way in which new places
are settled, and the geographic dispersion of the inhabited areas have
required Soviet public health to devise and apply special administrative
forms and methods of operation for the countryside.
Zemstvo medicine was the first to create rural health facilities
in prerevolutionary Russia. Prior to the rise of the zemstvos there
was virtually no medical assistance available to the Russian village.
The advent of zemstvo medicine is inextricably bound up with the
development of capitalism in agriculture. During the 50 years of its
existence zemstvo medicine built a network of institutions and
elaborated ways of organizing medical and sanitary facilities for the
farm population. Medical districts came into being with dispensaries
and hospitals, stations with feldshers and midwives trained in zemstvo
schools. Some of the district and provincial zemstvo hospitals were
outstanding for their time.
In sum., elucidation of the principles underlying the proper organ-
ization of medical facilities and sanitary-statistical investigations
of morbidity and physical development of the rural population carried
out by prominent zemstvo physicians constitute the major achievements
of prerevolutionary Russian medicine.
However, despite the persistence and keen desire of the leading
physicians to improve the quality of service, the practical results
of their work were insignificant. The Tsarist autocracy and its
administrative arbitrariness were an insuperable obstacle. The
doctors' efforts ran athwart the prevalent economic and political
conditions and thus received no cooperation from the authorities.
Expenditures for medical assistance, especially sanitary measures,
were negligible. Soviet public health thus inherited a meager set
of poorly organized and equipped facilities, accessible to compara-
tively small numbers of people and directed by general practitioners
and feldshers. Only 64% of the medical districts had small hospitals,
the other districts providing only outpatient service.
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The history of rural health in the USSR corresponds to the main
stages of development of the national economy. During the years of
civil war and intervention and the subsequent period of reconstruction
Soviet public health was primarily faced with the task of restoring and
normalizing the rural medical facilities destroyed by the war.
Along with restoration and expansion of the rural medical dis-
tricts, new types of installations came into being -- tuberculosis
clinics and stations, stations to combat trachoma, skin and venereal
diseavs, day nurseries, women's and children's consultation centers;
there was also a good deal of hygiene propaganda. By the end of the
reconstruction period the number of rural medical districts had almost
doubled from 4,300 in 1913 to 7,531 in 1928. The number of doctors
rose from 4,975 in 1913 to 10,941 in 1928.
The mass collectivization of peasant farms, which began in 1929
under the guidance of the Communist Party and Soviet Government,marked
a turning point in the history of rural public health. The system of
collective farms destroyed once and for all the factors responsible
for stratifying and impoverishing millions of peasants. It created the
conditions for economic growth in the village and for systematic ele-
vation of the cultural and material level of the peasants, thereby
producing new and favorable circumstances for the development of public
health.
The 'Model Regulations for a Collective Farm," which formulates
the principles for organizing agricultural work and managing farms,
confronted farm leaders with the task of "raising the cultural level
of members of the collective farm, introducing newspapers, books, radio,
movies, clubs, libraries, reading rooms, baths, and barbershops." It
also required them 'to provide light, clean lodgings in the field., to
improve streets in the villages, to plant various kinds of trees,
particularly fruit trees, and to help collective farmers to improve
their houses and make them more attractive.'
The 'Model Regulations for a Collective Farm" provide for the
material support of farmers in sickness, old age, .arid disability.
Women are relieved of work before and after childbirth, while con-
tinuing to receive half of their average earnings.
Public health was not able immediately to deal with the new prob-
lems and demands posed by the collective farm. village. The historic
decree of the Central Committee of the All-Union Communist Party (B)
of 18 December 1929 'On Medical Facilities for Workers and Peasants'
noted the wide gap between public health and the needs and tempo of the
rapidly developing national economy, including agriculture, and showed
haw to overcome it. The Party's decision initiated the reconstruction
of rural medicine. Additional facilities were erected in convenient
locations to keep pace with the progress of collectivization and the
emergence of new economic centers. Between 1928 and 1941 the number
of rural medical districts and doctors rose from 7,531 to 13,500 and
from 10,941 to 19,992, respectively. During the same period feldsher
and midwife stations increased more than tenfold (from 3,113 in 1928
to 34,511 in 1941).
The work of rural medical districts is based on the seasonal and
organizational peculiarities of farming. It takes cognizance of the
special problems of those living in field camps during the summer, first
aid, and prevention of injuries due to the mechanization of agriculture.
The mass use of women in agriculture required more day nurseries, at
first seasonal, then permanent.
The reorganization of public health was legalized by the decree of
the Council of People's Commissars 'On Strengthening the Rural Medical
Districts,' which set forth measures to organize and equip these dis-
tricts and.to improve the working conditions of the physicians. It
outlined the course of rural public health for the entire period to
follow.
By way of implementing this decree, the People's Commissariat of
Health, USSR, in June 1938 issued 'Regulations for Rural Medical Dis-
tricts,' which defined precisely their tasks and the direction they were
to take. Each district was assigned a jurisdictional area covering all
the populated places, collective farms, state farms, machine and tractor
stations, shops, local factories, etc. The limits of the districts were
then determined by oblast health departments and approved by the people's
commissariats of health of the union republics in accordance with the
size of population, number of populated places, etc. This permitted a
more efficient utilization of medical resources and facilities.
Feldsher and midwife stations underwent substantial changes in
method of operation. Formerly they werelargely autonomous and had
little to do with the medical districts as they provided primitive
medical care and introduced prophylactic measures only sporadically.
However, the 'Regulations' incorporated them into the respective medical
districts. .
Through integrating all the medical facilities located on its
territory (feldsher and midwife stations, collective farm maternity
hospitals, day nurseries, etc.) the rural medical district became the
center of all village medical activities.
During the years of the Great Patriotic War rural public health
was assigned the crucial task of maintaining the medical facilities
and existing level of service, which it executed with distinction. The
network of institutions located on non-occupied territory, so far from
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shrinking actually expanded, the number of districts increasing from
13,512 in 101 to 14,746 in 1946. The rural medical districts com-
pletely proved their value under the difficult war conditions, which
Involved mass shifts of the population (evacuation and re-evacuation),
transportation and economic dislocations, shortage of medical personnel
and drugs.
The districts disinfected incoming groups of people, systematically
inspected inhabitations where infectious diseases were noted, detected
people with fevers and kept under observation those with whom they had
contact, and tried to hospitalize every one with an infectious disease
within a day or two after it was discovered. The sanitary activists
rendered major assistance to the medical districts in this work.
The post of rayon pediatrician was set up during the war in rural
rayons and a visiting nurse added to the staff of the medical district
in order to improve child care. The number of day nurseries, children's
consultation centers, and milk kitchens increased substantially. Many
seasonal nurseries became permanent and not a few collective farms
built orphanages.
A new form of independent activity on the part of the people
developed during the war nursing units of the Red Cross and Red
Crescent. The nurses, who were recruited from the local population
and trained by the Red Cross, became the principal assistants of rural
doctors and feldshers.
Rural public health after the war developed side by side with
agriculture. Progress was achieved not only in expanding facilities,
but also in training more competent physicians and in providing the
services of specialists. The center of these activities was the rayon
hospital.
The decisions of the 19th Congress of the Communist Party of the
Soviet Union and the 1953 and 1954 Plenums regarding further strengthen-
ing of the organization and economy of collective and state farms,
growth and consolidation of machine and tractor stations, and develop-
ment of virgin and unused lands made new demands on rayon and rural
public health agencies and institutions. Their main tasks today are
to achieve a further decrease in the sick rate of farm workers, help
them to raise their productivity, and reduce disability.
Medical personnel must aim at bringing about a healthier way of
life for all, steadily reducing the number of infectious diseases,
improving methods of diagnosis nid treatment, providing better medico-
prophylactic facilities for children, and promoting among the masses,
chiefly the youthsph,ysical culture and sports. These will be accom-
plished by building new medicoprophylactic and pharmaceutical facilities,
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especially in rayons where virgin and unused lands are being developed,
filling vacancies for doctors and middle echelon personnel in rural
medical institutions, and equipping these institutions with therapeutic
and diagnostic equipment and laboratories.
The Rural Medical District
The District Hospital
The jurisdictional area of a rural medical district includes the
various inhabited places, collective and state farms, machine and
tractor stations, local factories, etc., situated on its territory.
The accessibility of medical aid is determined not only by the
number of doctors and middle echelon personnel, but also by the juris-
dictional range, condition of roads, transportation facilities, and,
above all, by the location of the medical establishments. The principal
institution is the rural district hospital, which is located as centrally
as possible In the most populated area (Figure 20).
On the periphery of the district are found feldsher -midwife stations,
health units (in state farms, lumber and peat camps), day nurseries,
and collective farm maternity hospitals. These are built with due regard
for the location and size of populated areas as well as for the economy
of the district. First and foremost, facilities must be provided for
the manual and white collar employees of major machine and tractor
stations (which are now becoming the technical and economic centers
of agricultural production) and workers in state and collective farms
living at a considerable distance from the hospital. The various
institutions mentioned above are part of the rural medical district and
subordinate to the district hospital. They function In accordance with
the overall district plan and are directed by the chief physician of
the district hospital.
Due to substantial variations in the density of population and
geographic and economic conditions prevailing within the oblasts of the
USSR, the jurisdictional area and population size of the rayon rural
medical districts differ greatly among themselves. There are, for
example, five categories of rural district hospitals.
Rural hospitals of the highest (first) category are rated at 50
beds. They must have specialized beds for medicine surgery, obstetrics,
pediatrics, infectious diseases, and tuberculosis. The outpatient
department matches these specialties. The hospitals are usually well
equipped with therapeutic and diagnostic apparatus, laboratory, physio-
therapy room, and, not infrequently, X-ray facilities. These hospitals
are scarcely to be distinguished from their urban counterparts in
quality of service.
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Rural hospitals of the lowest (fifth) category are rated at 10
beds divided into beds for infectious diseases and beds for maternity
cases since these are emergencies which every hospital must be prepared
to handle. This type of hospital must have two physicians -- one a
general practioner, the other a surgeon.
Rural medical hospitals operate in accordance with the district
principle and have the following functions:
Reduction of morbidity, mortality, and invalidism;
Prevention and timely suppression of acute infectious diseases;
Execution of medicopraphylactic measures to protect the health
of mothers and children;
(d) Execution of medicoprophylactic measures to control tuber-
culosis, skin and venereal diseases, malaria, malignancies, and locally
prevalent diseases such as trachoma, tularemia, and brucellosis;
(e) Clinical observation of the health of various groups of the
population;
(f) Inspection of sanitary conditions in residential, industrial,
and public areas;
(g) Providing of medical facilities for workers in collective and
state farms and machine and tractor stations during the sowing and
harvesting seasons;
(h) Elevation of the hygienic level of the population;
(i) Organization of independent activities by the people in
connection with public health problems.
The rural district hospital carries out its program with the help
of all the medical personnel and institutions located within its jurls
diction, the most important being the feldsher-midwife stations.
The Feldsher-Midwife Station
Feldsher-midwife stations have been set up as a compment of rural
public health in order to render medical assistance more accessible to
the people where district hospitals have a large area to cover and the
population is fairly small. They are usually located on the outskirts
of medical districts in the mostteavity populated places farthest away
from the district hospitals. If a machine and tract= station or a
large collective farm is more than 3 to 5 km from a hospital, a
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feldsher -midwife station is opened up. A district usually has several
stations, one per village Soviet (an average of 4 stations), which pays
for the cost out of its own budget.
Two middle echelon medical workers -- a feldsher and a midwife
(Figure 21) -- rnun. the station. There are still a feu feldsher or mid-
wife stations (with a single employee), but these are gradually being
reorganized into feldsher -midwife units.
The feldsher offers emergency medical assistance, in his office
or at the patient's home, until the doctor comes. The early detection
and isolation of persons suffering from acute infectious diseases is
extremely important.
Nhere a doctor or consultation is required, the feldsher sends the
patient to the district hospital or discusses the case with a doctor
when the patient comes to the feldsher-oldwife station. The station
Is equipped with the necessary instruments, bandages, and medicines.
The station may have several beds for women in labor and for
patients with infectious diseases as well as a pharmacy for selling
patent medicines and hygienic supplies, which is managed by the
feldsher. These pharmacies are a means of raising the health level
of the rural population.
The feldsher is largely independent. Be has the right not only
to treat patients and write out prescriptions, but also to issue disa-
bility certificates (for a period of up to 3 days) to manual and office
workers in collective farms, machine and tractor stations, and other
state institutions. This pert of the feldsher's work, as indeed the
entire operation of the feldsher -midwife station, is supervised by a
physician from the district hospital through systematic on-the-spot
visits.
Feldsher-midwife stations play a major role in sanitary-anti-
epidemic work. Their closeness to the people enables them to detect
promptly persons with or suspected of having contagious diseases and
to arrange for their immediate isolation, which, as we know, is the
most important prerequisite for eradicating the focus of an epidemic.
These stations are also useful in providing obstetrical assistance,
keeping pregnant women and breast-fed infants under clinical obser-
vation, and carrying out sanitary-prophylactic plans (which will be
discussed in the appropriate sections).
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Invest/ ation of Morbidity in the District
The rural medical district plans its medicoprophylactic and sanitary-
antiepidemiologic work on the basis of investigations of the sanitary
conditions and the amount of sickness prevalent in the district.
A variety of sources are used to investigate morbidity. Regis-
tration of acute infectious diseases from special notification cards
filled out by the physician or feldsher who first made the diagnosis is
highly important in that it permits the execution of emergency measures
to cope with the diseases, observe those in contact with patients, dis-
infect the foci, and impose a quarantine. A study of morbidity is needed
before a program of preventive vaccinations, detection and treatment of
bacillus carriers, hygiene propaganda, etc., can be devised.
District hospitals also maintain records of individual patients
suffering from tuberculosis, malaria, trachoma, skin and venereal dis-
eases. The data is considered in the overall program of medicoprophylactic
measures both for the patients themselves and for relatives and friends
whom they maybe endangering.
Recent years have witnessed many changes in the method of studying
the general morbidity of the farm population. The new record forms and
hospital reports introduced in 1949 have made it possible to investigate
the general morbidity of the entire district on the basis of patients'
visits for medical help.
The annual hospital report describes the composition of the patients
diagnosed by doctors either in the clinic or at their homes. The data
covering 32 of the most prevalent diseases permit the doctors to assess
the morbidity of the population and plan appropriate therapeutic and
prophylactic measures (selection of patients for clinical, hospital, or
sanatorium treatment, work arrangements, educational propaganda, etc.).
As a result of recent innovations in the technical and economic
aspects of agriculture and the growth of machine and tractor stations
and collective farms, the investigation of morbidity with temporary
disability (from disability certificates registered in local unions)
has acquired considerable importance.
Morbidity is calculated monthly from form 3-1, which is similar
to that used by the health stations and medical units of industrial
enterprisesb An analysis of morbidity with temporary disability reveals
the pattern of illness, duration of disability, the number of cases and
days of disability per 100 workers, and its seasonal nature.
The productivity of collective farm labor has been increased by
the systematic issuance of certificates to sick workers requiring their
release from work. There is now one form for everybody. These
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"Certificates of Temporary Release from Work on Account of Illness," as
they are called, maybe issued by a district hospital or feldsher-mid-
wife station, which retains the stubs (control slips). The latter
provide the materials for investigating disability of collective farm
workers by disease, sex, age, job, duration and seasonality of illness.
Organization of District Medical Facilities
-The rural population is served by feldsher-midwife stations, dis-
trict, rayon, and oblast hospitals, which reflect the special features
of rural medicine (Figure 22).
The main jab of feldsher-miduife stations located in outlying parts
of the district is to provide emergency aid and to make timely diagnoses
of persons with acute infections and to arrange for their isolation.
They provide outpatient treatment within the limits of the feldshers
competence and rights. The stations carry out the doctor's orders
regarding, for example, injections, cupping glasses, infusions, massages,
and physiotherapy.
The regulations governing the rural district hospital provide for
regular visits by its physicians to feldsher-midwife stations for the
purpose of checking their work, consultation with patients, and conduct-
ing of educational propaganda (decree no. 992, Ministry of Health, USSR,
4 December 1950).
Prior to the arrival of the doctor, the feldsher and midwife summon
to the station the patients wham the doctor is to examine. The physician
should schedule his visits in advance so that people in remote areas can
see him without having to make a special trip to the hospital. In
addition, the physician is required to make house calls for sudden
serious illnesses, injuries, complications in births, etc.
The feldsher also examines patients in the hospital and at their
homes, which is reflected separately in the reports of the district
hospital. However, his role here is secondary. The chief physician
of a rural district hospital must organize the work in such a way that
the physicians carry the main load, with the feldshers acting only in
case they are absent, sick, or there is an unusually large number of
patients. Thus, the ratio of patients handled by the doctors and
feldshers to the total number coming to the hospital is an important
indication of the quality of medical aid rendered by the hospital.
Visiting hours in the clinic must be scheduled for times that are
maximally convenient for collective farmers. For example, 8 to 9 o'clock
in the morning might be satisfactory in the fall and winter months, but
at hours before or after work in the field or during the dinner break
during the busy months of planting and harvesting.
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In most of the district hospitals the patients receive general
treatment. However, medical and diagnostic services have been improving
from year to year as the hospitals acquire new laboratories and apparatus.
The doctors are develoning increasing skill in employing the latest
techniques of research and therapy. The district hospitals have thus
been converted into excellent medical institutions capable of rendering
essential medical service to ever larger ntmbers of people.
To provide expert medical assistance, hospitals and clinics must
have advanced therapeutic and diagnostic equipment, specialists of
various kinds, and specialized beds. This kind of service is afforded
chiefly by rayon and oblast hospitals to farm workers sent there by the
district physicians.
The organization of specialized assistance to the rural population
will be considered in the section dealing with the rayon and oblast
hospitals.
Clinical Facilities for the Rural Population
The expansion of clinics in recent years has been a major step
forward in raising the quality of rural medical care. The clinical
approach became possible as a consequence of the development of
agriculture since the war. It was first tried in the Chudnov rayon,
Zhitomir oblast, Ukrainian SSR, whence it quickly spread to many
rayons of the Russian, Byelorussian, Ukrainian, and other republics.
The success of the clinical method depends primarily on sound
preparation and organization. The district physicians are the most
important element. They draw up the local plan of clinical check-ups
in accordance with the rayon master plan. The local plan must be
approved by the village Soviet and managers of the collective farms,
machine and tractor stations, and state farms. Their active support
is necessary in order that all the eligible workers receive medical
examinations and the doctors have the necessary facilities. The
cooperation of the soviet and managers is particularly important If
hygienic improvements are to be carried out and special arrangements
made to suit the needs of sick workers and those under clinical obser-
vation. The scope of the investigation and quotas of persons to be
included are determined by the district physicians in accordance with
local conditions and resources.
The Ministry of Health, USSR, has issued instructions that top
priority for clinical observation be given to skilled workers (drivers
of combines and tractors), students in schools for mechanized agri-
culture, administrative personnel of machine and tractor stations and
state farms, collective farm workers, outstanding farmers and animal
breeders, and youths from 15 to 18 years old. These persons are given
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medical checkups at least once or twice a year including, wherever
possible, chest X-rays. These check-ups result in the discovery of
persons who need various kinds of treatment, further observation, or
special work arrangements. Besides healthy individuals, the clinical
approach is applied to those suffering from tuberculosis, hypertension,
ulcers, etc.
The rayon hospital provides guidance an clinical organization and
methods, sends specialists when needed to take part in the medical
check-cps, conducts more detailed examinations, and gives specialized
treatment jointly with the district physicians. The feldshers are
required to take part in this work. They actively assist in the pre-
liminary choice of patients to be given check-ups, compile lists of
workers in collective farms, state farms, and machine and tractor
stations who are eligible for clinical observation, and execute the
doctors' orders. The feldshers play an important role in investigating
the working and living conditions of those under clinical observation
and seeing to it that their recommendations are carried out.
Effective examination of ability to work and the solution of
problems related to work arrangements for sick persons are possible
only when medical workers carefully study agricultural production in
all its branches.*
Obstetrical Facilities
One of the main problems in organizing rural obstetrical facilities
is to make this most important form of medical aid maximally accessible
to pregnant women. We have enough beds to take care of all women in
labor, but experience has shown that the beds are used as a rule only
when they are no more than 5 km away from the womens' homes. Since the
district hospital usually has a larger service radius it is easy to
understand why feldsher-midwife stations and collective farm maternity
hospitals are so important.
Rural localities have comparatively few special women's and children's
consultation centers, so the feldsher-midwife stations and district
hospitals perform their functions. The stations are required to keep
a record of all pregnant women on their territory and to arrange for
them to be kept under systematic clinical observation. Midwives must
teach pregnant women hygiene, child care, including proper feeding and
prevention of infectious diseases. The midwives also follow up to see
that the collective farm regulations are implemented with respect to
releasing the women from work before and after childbirth, with reten-
tion of half their earnings for the days worked during the preceding years.
7a. Chapter 3, section *The Clinical Methodo'l for the forms and methods
of organization.
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Midwives and other district medical personnel have the important
task of carrying on propaganda against abortions.
Midwives are responsible for helping all pregnant women to achieve
full term, normal births. Births should preferably take place in a
district hospital, but this is possible only when it is close to where
the women live. If not, normal cases should be handled either in the
feldsher-midwife station or in the collective farm maternity hospital.
If for same reason this proves to he impossible, the midwife must assist
In the woman's home. Every case of birth at home without a midwife in
attendance is to be regarded as evidence of unsatisfactory obstetrical
arrangements and, above all, poor organization of the feldsher-midwife
stations since there are enough of these stations to take care of all
women in childbirth.
Through continuous observation of pregnant women the midwife is
in a position to detect or suspect the presence of a disease or patho-
logical condition. In this event she must send the patient to a physi-
cian or have him see her during his next visit to the feldsher-midwife
station. The midwife will also have to arrange for her hospitalization,
shortly before she gives birth, in the district or rayon hospital.
All pregnant women living in a village where a district hospital
is located or in the center of a rayon or adjacent populated area are
directly served by district or rayon hospitals. The maternity-beds in
district and rayon hospitals are used, therefore, largely by women living
nearby.
Collective farm maternity hospitals, which have come into existence
in the USSR due to the collectivization of agriculture, constitute a
great achievement of the collective farm system. The farm sets aside
place for the hospital, provides fuel and food for the women, and
assians a woman to do the cooking and cleaning. These hospitals have
2 or 3 beds and are intended for normal births with a midwife in attend-
ance (Figure 23). Should there by any complications during labor, the
midwife must immediately summon a physician from the district or rayon
hospital.
Collective farm maternity hospitals are built to enable women to
give birth under more sanitary conditions than prevail in their own
homes. Bence, medical workers should fully support the construction
of hospitals throughout the collective farm network.
Of great value to mothers and infants is postnatal care which is
also afforded by the midwife or physician from the district hospital.
The midwife visits the mother at home during the first 9 days after
birth. Thereafter the mother and child come to the district hospital
or feldsher-midwife station.
Medical Facilities for Village Children
All district institutions provide medical services for children.
Every rural rayon hospital has a childrents department or separate beds
in the medical department. Its polyclinic also treats children's dis-
eases. There is a rayon pediatrician in every rayon center who normally
serves as head of the children's department in the rayon hospital. He
also directs the rural medical district's efforts to reduce the children's
morbidity and mortality rates, helps to organize seasonal day nurseries
and trains their supervisors.
Visits to infants is an important factor in preventing diseases.
The midwife of a feldsher-midwife station or special nurse from the dis-
trict hospital has the task of instructing mothers in the proper care
and feeding of their children.
Particular days and hours are scheduled for mothers and infants to
visit the hospital in order to prevent healthy children from having con-
tact with sick ones coming for treatment because children are known to
be highly susceptible to infections. It is best, however, for a child
with fever to be treated at home by a physician or feldsher.
Much of the rural medical districts' preventive work is taken up
with systematic inspection of hygienic conditions in children's insti-
tutions (schools, children's homes, day nurseries), periodic medical
check-ups, treatment of ailing youngsters, and vaccinations against
diphtheria, dysentery, tuberculosis, and measles as planned by the
rayon sanitary-epidemiologic station.
Temporary day nurseries are required by the special circumstances
of agriculture. At the height of the season they accommodate several
million children. District medical workers assist the managers of
collective farms in choosing a suitable place and equipping it, fur-
nishing proper food, and ensuring adequate hygienic conditions.
Before entering the nurseries, all children are given a medical
examination to exclude those with contagious diseases. While in the
nurseries the children are given check-ups from time to time. As a
rule, medically untrained farm women work with the children in the
nurseries. Although they are given some instruction during the winter
by the supervisors, they require daily guidance.
District Sanitary-Antiepidemic Activities.
Propaganda on Hygiene
Preventive and antiepidemic work is the most important function
of a rural medical district. Considerable progress has been made in
lowering the morbidity rate, especially of infectious diseases.
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Collectivization of agriculture, technical advances, and elevation
of the material and cultural level of the farmers have been largely
responsible for improving sanitary conditions in populated areas.
During the years following the war there was a tremendous amount
of residential and industrial construction. The five-year-plans
provided for the rebuilding of thousands of villages in the western
rayons of the USSR that had been burned and destroyed by the German
invaders. Construction is still going forward all over the country.
New state farms and machine and tractor stations are being set up an
hitherto undeveloped lands.
The rural medical district under the direction of the rayon sani-
tary-epidemiolog/c station makes preventive sanitary surveys of plans
for the layout ahd distribution of residential zones, animal raising
farms, cattle yards, industrial plants, waterworks, and the landscaping
of streets and yards. The district also inspects routinely farmsteads,
restaurants, schools, day nurseries, barbershops, dairies, sources of
water supply, etc. The various areas subject to sanitary inspection
are assigned by the district to individual medical officers. The latter
are required to arrange for the building of baths and disinfection
chambers, and to check to see that they are in continuous operation.
The officers maintain close contact with village soviets and collective
farm managers.
The position of sanitary feldsher has been set up in many district
hospitals to increase their efficiency in sanitary. work. This feldsher
inspects hygienic conditions in populated areas, machine and tractor
stations, collective farms, state farms, and factories within the
jurisdictional area of the district hospital to which he is attached.
He carries out systematic preventive antiepidemic measures, epidemiologic
investigations, and eliminates epidemic foci. At the orders of the rayon
sanitary-epidemiologic station, the sanitary feldsher checks to see
whether the managers of the machine and tractor stations, collective,
and state farms have implemented the overall plans for sanitary improve-
ments. He works directly under the chief physician of the district
hospital. and chief physician of the rayon sanitary-epidemiologic station.
At present due to the steady mechanization of agriculture it is
becoming increasingly important to better the working and living con-
ditions of machine operators and farm workers. Appropriate measures
must be devised after carefully investigating the farms and machine
and tractor stations, work arrangements of the drivers, causes of
accidents, and skin and other diseases directly related to agriculture.
The program drawn up must include instructions for managers on haw to
overcome any defects noted. Specialists of the rayon sanitary-epi-
demiologic station directly supervise and participate in this work.
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Systematic inspection of sanitation in inhabited areas and the other
places mentioned above is essential to prevent the outbreak of epidemics.
The antiepidemic program of the district must also include specific
measures to deal with individual infectious diseases. For example, in
connection with intestinal infections, it is vital to protect the water
supply, build and correctly maintain toilets, remove and decontaminate
impurities, combat flies, observe personal hygiene, and discover and
treat bacillus carriers.
To combat malaria, it is necessary to drain swamps and destroy
mosquitoes, report and treat all cases of the disease, and in the fall
provide treatment against recurrence of the disease in individuals who
have already had it, etc.
SOMB of these measures cannot be effectively implemented by the
district medical workers alone. The community as a whole together with
the local soviets, farm and machine and tractor station managers must
do their share.
Active imunization of the people by vaccination is carried out
in accordance with the sanitary-epidemiological station's plan. The
carriers of dysentery, typhoid, etc., are reported, treated, and, in
the case of those working in dairy farms, children's institutions,
restaurants, or other places where food is handled, transferred to
other jobs.
In order to eradicate foci of infection, it is necessary that
timely epidemiological checks be made, that people in contact with
those suffering from infectious diseases be kept under observation,
and that disinfection of the area and prophylactic vaccinations be
carried out. All patients with infectious diseases must be isolated
and transported to the hospital or promptly treated in their homes.
A highly important function of rural medical institutions is to
provide care during the sowing and harvesting campaigns. The staff
makes preparations in the winter long before the field chores begin.
It is responsible for insuring adequate sanitation in the field camps.
The plans must include the following measures: (a) sound location for
the camps and construction; (b) sanitary arrangements -- for showers,
dining halls, pure drinking water and food; (c) sanitary disposal of
garbage and sewage (by burning or burial in special pits); (d) opening
of seasonal nurseries and children's playgrounds; (e) training of
nursery workers, cooks for brigade dining halls, etc. These tasks
are largely-performed by middle echelon personnel -- feldshers, mid-
wives, and nurses.
Due to increasing mechanization the prevention of injuries and
proper organization of first aid under field conditions are extremely
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important. Medical personnel must be familiar with the causes of injuries
and conditions of agricultural work and together with the farm and machine
and tractor station managers try to eliminate the causes.
The farmhands must be taught the elements of personal hygiene and
safety arrangements as a means of accident and disease prevention. They
also need to know self-aid and mutual aid. This information can be
imparted in one-year training courses for farm leaders, in crop and
zootechnical courses, etc.
First aid facilities must be set up as close to the porkers in the
field as possible, thereby helping to prevent skin infections and com-
plications in injuries. During the season the feldsher and nurse must
come to the fields daily-both to render first aid and to carry out pro-
phylactic measures.
The principles of first aid should be taught in the winter to
leaders of field teams and drivers of tractors and combines who work
at considerable distances from medical stations. If provided with first-
aid kits, they can help themselves or others in case of injury.
Before work in the fields begins, persons with malaria are treated
for possible recurrence, steps taken to give other jobs to farmers found
during a medical examination to be suffering from a disease, and work
conditions rendered sanitary.
Sanitary posts are organized from among workers of the various
brigades in order to administer first aid. They are taught the basic
principles and supplied with medicines, bandages, and stretchers.
There are different kinds of sanitation activists (health workers)
in the villages -- sanitation representatives, members of sanitary
posts, active members of the Red Cross and Red Crescent. The organi-
zation, training, and direction of these activists are carried out by
rayon medical institutions (rayon sanitary-epidemiological station),
rayon committees of the Red Cross and Red Crescent, and district medical
workers.
Besides those in field camps, sanitary posts are set up in machine
and tractor stations, state farms, collective farms, schools, and hostels.
Their job is to give first aid before the doctor comes, carry on hygiene
propaganda, and check on sanitary conditions in the places where they
work.
Rural sanitation representatives constitute a multimillion man army
of aides to medical workers. Selected from among the literate, leading
collective farmers or other agricultural workers, they help to carry
out general hygienic, antiepidemic measures.
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Hyoiene propaganda which is the obligation of every medical insti-
tution, physician, feldsher, midwife, and nurse carry on, is particularly
important in rural areas because of the prevalent superstitions, pre-
judices, and unhygienic practices and traditions. The program is
extremely varied. Depending on the pattern of morbidity, it necessarily
deals with infections and other diseases, the health of mothers and
children, accident prevention, alcoholism., sports, and physical culture.
The campaign must be waged not only within the walls of medical insti-
tutions, but also at great distances -- in field camps, hostels, clubs,
reading rooms, and libraries.*
The Rural Rayon Hospital
The rural rayon hospital is the main center of specialized medical
assistance for the farm population. According to the regulations of
the Ministry of Health, USSR (decree no. 369, 15 September 19).i7), the
rural rayon hospital (with outpatient department or polyclinic) is the
only medical institution furnishing specialized services on both an
inpatient and an outpatient basis. It also supervises the district
hospitals jointly with the rayon sanitary-epidemiological station.
The rayon hospital is required to devise and execute antiepidemic and
medicoprophylactic measures aimed at decreasing the rayon's morbidity
rate and combatting tuberculosis, cancer, skin and venereal diseases,
etc. (Figure 24).
The structure, and staffing pattern setup by the Ministry of
Health, USSR, for rural rayon hospitals (decree no. 278, 27 March 1952)
provides for five categories of these hospitals -- 150, 100, 75, 50,
and 25 beds -- depending on the size of population and area of juris-
diction.
A rayon hospital maintains inpatient facilities with specialized
departments or wards (in small hospitals) and polyclinics for the
different branches of medicine. As a minimum each hospital has depart-
ments for medical, surgical, maternity, and infectious disease cases,
wards for children and tuberculous patients, and the appropriate number
of staff physicians who also work in the polyclinic. The polyclinic of
a rayon hospital must have a dental section. The hospital generally
has X-ray and physiotherapy rooms along with a diagnostic laboratory.
Patients living in a district within the jurisdiction of a rayon
hospital are accepted directly by the hospital. Patients living in other
districts, however, are referred to the rayon hospital by physicians
of district hospitals or other medical institutions within the rayon.
n% Chapter 8 for the methods of hygiene education and the work of
sanitary activists.
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District physicians send patients to the rayon hospital when they cannot
be given specialized treatment locally or when they require consultation,
X-ray or laboratory services.
Specialists in the rayon hospital are widely-used in clinics through-
out the rayon.
Combining the main types of specialized medicoprophylactic facilities,
the rural rayon hospital is the rayon center both for information on
organization and methods and for direction of the rayon's medical work.
The latter is effected in different ways, the most useful being direct,
personal, systematic contacts between specialists of the rayon hospital
and district medical workers. The specialists regularly-visit the
districts, meet with patients, sometimes perform operations or other
specialized procedures in the local hospitals, and introduce new techni-
ques of research and therapy.
The rayon hospital strives to increase the competence of district
physicians by organizing regular conferences in the hospital on various
scientific, practical, and clinicodiagnostic topics. Depending on its
size, the hospital may provide facilities and advanced training for
district physicians temporarily released from their regular work by the
oblast health department. It plays a particularly important role in
developing the skills of middle echelon personnel -- the feldshers,
midwives, and nurses. For example, several rayons in the Moscow oblast
use the following time-tried method of training these people. According
to the plan worked out by the chief physician of the rayon hospital
jointly with the head of the rayon health department, two or three
feldshers or midwives come to the rayon hospital for one month (1101.
class hours), while their places are taken for this period of time by
probationary nurses from the hospital. Thus, although rural medical
workers may be studying full time while an temporary leave, there is
no break in the medical care of the population.
Another approach, involving only release from work, requires
the rural medical workers to spend an entire working day once a week in
the rayon hospital, returning in the evening to their duty station.
This cycle lasts for 5 or 6 months (a total of 144 class hours). The
chief physician of the hospital organizes the courses and assigns the
students to various physicians on the staff, enabling them to spend a
certain number of hours in each department of the hospital.
Large, well equipped rayon hospitals can also help district hos-
pitals to train laboratory technicians, physiotherapy, dietary, and
surgical nurses.
The facilities, courses, and conferences set up for middle echelon
personnel greatly contribute to the growth of their knowledge and skills.
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The Oblast Hospital
The most advanced forms of therapeutic and diagnostic service is
furnished the rural population by oblast hospitals, tuberculosis,
oncological, and other clinics.
The oblast (kray, republic) hospital, which is found in every
oblast (kray, renUblic), is the leading medical institution. It
often houses the clinics of medical institutes, which further improves
the quality of its therapeutic and diagnostic work. The most prominent
specialists of the oblast (surgeons, internists, pediatricians, obste-
trician-gynecologists, etc.) usually work here.
The oblast hospital has departments in all the clinical specialties,
X-ray rooms (diagnostic and therapeutic), diagnostic, serologic, and
biochemical laboratories, electrocardiography room, and pathologic? -
anatomical department.
The oblast hospital also has polyclinic facilities to match the
inpatient departments.
In some cities the oblast hospital functions both as an oblast
center and as a municipal hospital. However, its main task is to
furnish the rural population of the oblast with specialized medical
services. Patients living in rural medical districts are referred
to the oblast hospital by the rayon or directly by the district
hospital if a definitive diagnosis cannot be made locally, if there
is need of further clinical investigation or consultation with or
treatment by a urologist, neurosurgeon, otolaryngologist, ophthal-
mologist, etc. Special accommodations are provided for patients who
come from remote rayons for consultation or specialized outpatient
treatment.
The services of oblast specialists are available not only in the
oblast hospital, but locally in the rayon and rural medical district.
These physicians make trips there and carry on a great variety of
therapeutic and teaching work. They meet with patients, instruct
district and rayon physicians in, the latest techniques of research
and treatment, help local specialists to organize clinical check-ups,
arrange conferences on scientific and practical subjects, etc.
Besides the scheduled visits of specialists, the oblast hospital
offers emergency aid by means of the ambulances and airplanes it has
at its disposal. The planes are used to bring patients from outlying
districts when local assistance is insufficient.
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The oblast hospital is also responsible for helping public health
agencies and rural medical institutions in matters related to methods,
organization, and advanced training of physicians and middle echelon
personnel. The assumption of these duties marks a qualitatively new
stage in the development of oblast hospitals, which are now required to:
(a) Study the condition and structure of the medical facilities
furnished by rayon and district hospitals, to produce and analyze
statistics an sickness in the oblast, to study the pathology-of the
kravj
(b) Schedule visits to the rayons of the oblast by special-
ists for the purpose of organizing scientific and practical conferences,
consulting with local health departments on methods and organization,
and assisting hospital physicians to raise the quality of medicoprophy-
lactic work;
(c) Consult on problems related to the organization and structure
of hospital and extrahospital assistance;
(d) Analyze the work of rayon and district hospitals and present
the results to those concerned, submit to the oblast health depart-
ment proposals for improving medical and sanitary services and lowering
the morbidity and mortality rates.
The cabinet for organization and methods found in every oblast
hospital is the chief organizer and participant in this work.
Another highly important function of the oblast hospital is to
train specialists and improve the skills of doctors and middle echelon
personnel. It is responsible for the so-called primary specialized
training of young physicians and the routine work of enhancing their
skills.
This training assumes various forms, as elaborated over the years.
Facilities are provided for physicians to spend from 3 to 6 months in
the oblast hospital on leave from their regular jobs studying various
aspects of clinical and diagnostic work. Or they may take courses one
day a week while continuing their regular work. The physicians may
attend conferences on scientific and practical problems held in the
oblast center or in the rayons and towns of the oblast (rayon and
interrayon conferences) where oblast specialists read papers and give
lectures.
Of equal practical significance in satisfying the needs of rayon
and district hospitals is the training of middle echelon personnel. The
oblast hospital gives specialized and advanced courses to laboratory and
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X-ray technicians, surgical nurses, nurses for X-ray, physiotherapy.,
and electrocardiograph rooms. It gives instruction in nutrition,
medical physical culture, massage, etc.
Other oblast institutions (tuberculosis, venereological, oncological
and other clinics, sanitary-epidemiologic stations, etc.) carry on
similar work.
Training programs for middle echelon personnel are also made avail-
able locally. For example, the N. F. Vladimirskii Scientific Research
Clinical Institute of the Moscow Oblast, which functions as an oblast
hospital, systematically schedules trips to rayon centers by its special-
ists to set up theoretical and practical courses in accordance with a
certain program. These courses may also be taken by technicians from
the neighboring rayons.
The combined efforts of all three elements making up the USSR net-
work of medicoprophylactic institutions -- district, rayon, and oblast --
make it possible at this stage in the development of medicine to furnish
comprehensive and expert medical service to the toilers in rural economy
of our country.
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alAPTER 5
PROTECTION CF THE HEALTH OF WOMEN AND
OBSTETRICAL FACILITIES
As a result of the Great October Socialist Revolution, the USSR
was the first camxtry in the world to grant women equal rights with men.
Article 122 of the USSR. Constitution not only secures for women the
right to work, rest, and education, but also guarantees their use of
these rights: "Women are afforded equal rights with men to work, pay-
ment for work, rest, social insurance, and education, state protection
of the interests of mothers and children, state aid to mothers of large
families and to Unmarried mothers, leave with pay during pregnancy,
maternity hospitals, day nurseries, and kindergartens."
The Soviet system of protecting mothers and children includes not
only medical institutions, but also laws to regulate woments labor,
the work of pregnant women and nursing mothers, social and legal services
to safeguard marriage, the family, and. guardianship. Then too there are
the trade unions and other social organizations which are concerned with
helping women to rear their children.
The wiping out of unemployment, the use of women in all branches
of the national economy and culture, and the unrestricted right to take
up any profession or specialty have created the preconditions for women
to enjoy an independent and secure life while bringing up their children.
The state systemically passes laws to encourage mothers and protect
children. In recognition of its responsibility, the government by decree
of the Central Executive Committee and Council of Peoplets Commissars,
USSR (27 June 1936) increased the amount of financial aid available for
the. education of children, gave grants to mothers of many
considerably expanded the network of day nurseries, maternity hospitals,
and kindergartens, stiffened criminal penalties for nonpayment of
alimony, and changed the laws on divorce to strengthen the Soviet
family.
The socialist government's concern for mothers and children found
clear expression in the order of the Presidiun of the Supreme Soviet,
USSR, 8 July 1944 "On Increasing State Aid to Pregnant Women, Mothers
of Many-Children and Unmarried Mothers, Strengthening the Protection of
Mothers and Children and On Awarding the Honorary Title "Mother-Heroine"
and. Establishing the Order "Honor of Motherhood" and the Medal "Medal .
of Motherhood." In accordance with this decree, issued during the
Great Patriotic War, the goverrraent appropriated vast additional sums
of money to aid mothers of many children and unmarried mothers, to
expand the network of medical institutions, and increase the privileges
-1214
of pregnant women and mothers. "Concern for children and mothers and
for strengthening the family," this decree states, "has always been a
main objective of the Soviet government."
The Twentieth Congress of the Communist Party of the Soviet Union
paid a great deal of attention to problems concerning the education of
children. The decision to increase by 1960 the number of places in day
nurseries by 44% and in kindergartens by 45% provides a good start in
the enormous task of providing education in state nurseries and kinder-
gartens for all children of nursery and preschool age whose parents
want it.*
The decision of the Twentieth Congress "to improve the working and
living conditions of working women" was clearly reflected in the Order
of the Presidium of the Supreme Soviet, USSR, 26 March 1956, "On
Extending Pregnancy and Maternity Leave" from 77 to 112 calendar days.
Due to elevation of the material and cultural level of workers,
protection of female labor, and activity of medical institutions caring
for mothers and children, the morbidity and death rates of women and
children in the USSR dropped sharply as compared with the prerevolutionary
level. In 1913 Tsarist Russia had only 19 day nurseries with 550 beds
and a few consultation centers with a total of 6,800 maternity beds
capable of accommodating only about 4% of all women in childbirth. The
network of medical institutions began to expand rapidly only after the
Great October Socialist Revolution. The most important components are
the women's consultation centers, children's hospitals with children's
consultation centers and polyclinics, and day nurseries.
Order no. 870 of the Ministry of Health, USSR, resulted in the
merger from 1949 on of maternity hospitals and woments consultation
centers and in the setting up of gynecological departments in maternity
hospitals. After unification the maternity hospital became a general
institution providing women with all kinds of obstetrical and gynecologi-
cal help -- outpatient (polyclinic, woments consultation center) and
Inpatient, The maternity hospital works on the district principle.
A city district hospital has 1 obstetrician-gynecologist and 7.2 maternity
beds per 4,000 of population. Depending on the size of population and
jurisdictional area maternity hospitals have 150, 120, 100, 80, 60, 40,
or 20 beds.
In addition to the specialized hospitals, the maternity departments
of general city and rayon hospitals also furnish obstetrical and
gynecological services.
TT: S. Khrushchev3 Report to the Central Committee, Communist Party of
the Soviet Union, 20th Congress of the Party, State Publishing House
for Political Literature [Gospolitizdatb 1956, p 96.
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Woments Consultation Centers
A woman is kept under Observation by a consultation center from the
time she becomes pregnant until she gives birth. The center teaches her
hygiene and gives her whatever medical aid she may. require during
pregnancy and after she gives birth. It prepares her for motherhood
and instructs her in infant care.
Consultation centers in maternity hospitals serve women in their
homes. In addition, medical units provide comparable facilities for
working women at their place of work.
Observation of pregnant women. The center must try to reach every
pregnant woman in the rayon. Accordingly, it has to be in close touch
with the people. Through mass propaganda in homes, farms and factories,
the staff explains.to women the need of coming to the center.
Health stations and industrial medical units play an important
role in explaining the work of consultation centers and urging pregnant
women:to visit them. The centers issue medical certificates for preg-
nancy and childbirth, pregnancy certificates for release from overtime
work, etc.
A healthy woman during normal pregnancy visits the consultation
center 6 to 8 times, or an average of once a month. If for some reason
she fails to keep her appointments, the center seeks to find out the
reason by sending a visiting nurse or a midwife to the woman's home.
It is particularly important for a woman to try to come to the
center during the first three months of pregnancy, thus permitting a
determination to be made of the term. This is necessary in connection
with pregnancy leave and to make an early diagnosis and institute prompt
treatment for any pathological condition that maybe present. Working
women have leave beginning 56 days before and ending 56 days after child-
birth. In the case of abnormal childbirth or the birth of two or more
babies, postnatal leave is extended to 70 calendar days.
The consultation center is judged by such factors as the month in
whio4 pregnant women first come under observation, the number of sUbse-
quera:visits, the services extended to the women, and the results of
pregnancy with respect to the nutber ending in normal, full term babies.
The center maintains a continuous check by gynecological examination,
measurement of blood pressure, urine and blood analyses, Wasserman
reaction, etc. Women found to be suffering from diseases of the internal
organs or other conditions are referred for treatment to the appropriate
specialists in the rayon or city hospital. Special attention is paid
to women suffering from tuberculosis or venereal disease. They are sent
as a rule to tuberculosis or venereological clinics for registration and
treatment.
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All the information derived from medical examinations, laboratory
tests, and the doctors' conclusions are entered into the case history
and on the personal card of the pregnant woman. The card goes to the
maternity hospital when she is admitted.
'yglene education. The center must teach pregnant women essential
hygierii-d-halfs and methods of infant care. For this purpose it arranges
private talks, public lectures and exhibits, distributes books and
pamphlets, and sets up a "school for motherso with aVell defined
program of studies.
Exhibits constitute a form of hygiene propaganda that should be
set up in every consultation center. They can be made up of posters,
sketches, and slogans illustrating such things as infants' clothing,
objects used in the care of infants, a properly built bed, etc. The
workers of the center aided by volunteers can easily prepare these
materials,
A major task of the momants consultation center is to reduce the
number of illegal abortions. Believing that it is up to the woman her-
self to decide whether or not she wants to become a mother, the govern-
ment withdrew its prohibition against abortions. According to the
Decree of the Presidium of the Supreme Soviet, USSR, 23 November 19552
an abortion may be performed -- but only in a hospital -- on any woman
who requests it upon the order of a consultation center or hospital
physician. Abortion is prohibited when the woman's health would be
endangered thereby (e.g., in the case of an acute infectious disease
or inflammation of the sexual organs, etc.).
Consultation centers must try to reduce the number of abortions
by propaganda, increasing the amount of social and legal assistance
available to mothers, and teaching the use of contraceptives. Women
must be told by the staff that abortions, even when performed in
hospitals, may affect their health adversely.
Abortions performed outside of hospitals, whether by doctors or by
other individuals, are strictly forbidden and punishable by criminal
penalties.
Soclig-taid legal services. The consultation center also concerns
Itself with the legal rights and interests of mothers and children.
It therefore has on its staff lawyers to advise mothers haw to get
allowances for having many children, pensions, and social insurance.
The lawyers help in matters pertaining to labor protection, transfers
when needed to other jobs, and leave, and represent them in court.
They arrange for placement of children in nurseries and kindergartens
to make the everyday life of mothers easier. The social and legal
staff maintains liaison with factory and plant committees, industrial
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managers, institutions of various kinds, hostels, etc., to effect
Improvements in the material conditions of the women for whom they are
responsible. They are particularly concerned about unmarried mothers
and women whose financial, home, and family circumstances are unusually
difficult.
The social and legal staff relies heavily on visiting nurses and
midwives who encourage women to come to the center, observe than system-
atically, investigate their working and home conditions, teach hygienic
practices and infant care, check on whether the women are following the
doctors, instructions.
Women are visited for social as well as for medical reasons,
particularly those in unusually difficult financial straits, unmarried
mothers, and mothers who have given birth for the first time. The
nurse is very sympathetic and becomes the friend and advisor of. these
women.
The visiting nurse plays an important role in persuading women to
undergo preventive medical examinations.
Gynecological facilities. Women are given post-partum care by
being kept under clinical observation and treated for whatever con-
ditions may be troubling them either on an inpatient or outpatient
basis. no consultation center records gynecological diseases diagnosed
and registered in its rayon. Cancer and precancerous conditions of the
sexual organs have come in for a good deal of attention in recent
years. Accordingly, the maternity hospital conducts mass prophylactic
examinations of working women and housewives over 35 years of age. Those
Lamborn a malignancy is found are promptly hospitalized for radical
treatment. Those suffering from precancerous diseases are treated and
kept under observation by the consultation center.
Obstetrical Facilities
Obstetrical facilities are the next link in the chain of services
to pregnant women. Women in cities and workers' settlements today are
hospitalized when about to give birth. In the villages, however, births
to some extent still take place at home with medical assistance (of
midwives). The increasing nu,r1ler of maternity beds in the country,
particularly in collective farm maternity hospitals, is providing
hospital facilities for ever larger numbers of women. In outlying
districts and certain rural areas it is still possible to find a hand-
ful of women not making use of these facilities even though they are
readily available. This is principally due to the fact that the medical
institutions, consultation centers, midwives, and district workers are
not carrying out effective educational work to induce women to go to the
hospital. A contributing factor is the poor distribution of maternity
beds.
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The specific, frequently emergency character of obstetrical assist-
ance makes it imperative that it be maximally accessible to the popu-
lation.
The Maternity Hospital
A maternity hospital must satisfy the same general requirements
as a regular hospital, and it functions in more or less the same way.
-t has a department for normal births and a department for women with
fever (doubtful). Each department has its own reception and admissions
unit, lying-in unit (labor, delivery and operating rooms), postnatal
wards and wards for the neWborn babies. In addition, there is an iso-
lation area with separate entrance and facilities for women suffering
from puerperal septic diseases. In a snail maternity hospitals where
it is impossible to construct a self-contained section for these women,
the institution is required to provide special wards that are fairly
isolated from the other areas. The maternity hospital may also have
an observation department or wards for women with pathological con-
ditions and a gynecological department (Figure 25).
Prevention of infections. The physiological processes of birth
heighten the susceptibility of parturient women to infections. It is
very important therefore that all the rules of hygiene be strictly
observed in a maternity hospital. Each woman applying for admission
is questioned and given a preliminary superficial examination after
which she is sent to the examining room of either the normal or doubt-
ful department. To the latter come all women with a temperature
above 37.50 and an undiagnosed infection, women having a miscarriage,
women suffering from syphilis or gonorrhea or a contagious skin dis-
ease (favus, scabies), etc.
In the examining room a midwife looks over the women and takes
whatever measurements are required. The women are given a special
antiseptic treatment before being admitted to the labor room. In
order to prevent infection all the rules of hygiene must be carefully
observed with respect to the person of the women, their beds, and
everything with which they may come into contact. They are provided
with individual bedpans and other necessities. It is absolutely for-
bidden to visit women while they are in the maternity hospital.
In the event of complications or a disease arising inside the
hospital the women are transferred to the doubtful or septic depart-
ment. Mothers are generally moved with their babies in order to
effect the maximum isolation of sick women from healthy women.
Women may not be discharged from the hospital until they (and
their babies) are completely well, usually 8 or 9 days after a normal
delivery with no ensuing complications. The hospital shows its con-
cern to the very end, as it permits no mother to leave unless there'is
someone to take her home. If not, the hospital provides an escort.
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Care of women in childbirth. A satisfactory outcome depends largely
on the care given the women, timely treatment, and prevention of com-
plications. Women's consultation centers play a major role in ensuring
normal pregnancy and birth. If pathological conditions are detected,
the women are promptly hospitalized. The merger of consultation centers
and maternity homes has provided for close cooperation in keeping the
women under continuous operation.
Of great significance in deliveries is the now widely used method
of painless birth through psychoprophylactic preparation of the parturient
women, which is based on the principles of Pavlovian physiology. This
preparation is begun by the consultation center during the final weeks
of pregnancy and continues in the hospital right up to the time of
delivery. It consists not only of the physician's private talks with
the women individually, but also the hospital background -- quiet,
relaxation, concern and encouragement on the pert of the staff to
inspire confidence in a happy outcome, etc.
Care of the newborn. Maternity hospitals set aside children's
rooms for the newborn. This not only protects them against infections
through maintenance of adequate hygiene, but also affords mothers the
quiet they need. The infants are taken care of by the pediatrician and
special nurses.
The maternity hospital is responsible for the life and health both
of mothers and of their babies. It is a well known fact that most of
the infants who die before they are a year old do so during the first
few days after birth, i.e., while they are in the hospital. The reason
is that the act of birth involves an abrupt transition from the intra-
utrine enviroment to the outer world to which the young organism is
not yet adapted.
The care accorded infants, particularly in preventing infections,
is a decisive factor in keeping them alive. For example, antituber-
culosis vaccination of the newborn is now compulsory.
Premature infants must be kept in a special nursery and handled
with extreme care. The experience of our better hospitals has shown
that with good care infants weighing as little as 900 to 1,000 g. can
survive.
Most deaths of the newborn result from pneumonia, asphyxiation,
hemorrhages due to birth traumas, and septic diseases. Thus, proper
care includes maintaining a constant temperature of between 22 and 240
in the wards, individual heating of the cribs of prematurely born
infants, prevention of asphyxiation by high pillows and the use of
oxygen, frequent feeding (7 or 8 times in 24 hours) the first time
through a tube, and, finally, prevention of infections. The newborn
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must not be allowed to touch one another. Those attending them are
required to wear sterile masks and strictly observe all the rules ofl
hygiene pertaining to the care of the newborn.
Birth injuries are a major cause of deaths. They can be largely
avoided by carefully watching the mother during delivery.
Statistics show that the mortality rate differs markedly from
hospital to hospital. This is undoubtedly due to the differing standards
of care given the babies.
The maternity hospital notifies the children's consultation center
of every birth, giving the date, name, and address, and special instructions
if the child was born prematurely, is sick, a twin, etc.
Since childbirth is a normal physiological act, every death of a
woman or infant must be regarded as an extraordinary event. An autopsy
must be performed to ascertain the cause, and the case thoroughly dis-
cussed at medical conferences. The causesof death of women in labor are
noted in reports. Deaths from puerperal infection or umbilical sepsis
are intolerable. These testify to poor organization and violation of the
rules of asepsis by the maternity hospital in question.
Maternity Hospital Reports and Work Indices
A maternity hospital submits an annual report to the rayon (city)
health department containing a passport part and sections dealing with
the activity of the consultation center, inpatient department, and
auxiliary services.
The passport part gives a detailed picture of the structure of the
institution, its staff and equipment. In the section of activities of
the consultation center mention is made of the number of pregnant women
served, abortions, and gynecological diseases. Visits to middle echelon
personnel as well as to doctors are tabulated.
The report presents a complete analysis of the pregnant women, when
they first came for assistance, and the outcome of the pregnancies. It
cites the number of gynecological diseases detected in the area served
by the consultation center, and the results of prophylactic examinations.
The section on hospital activity analyzes the use of the available
beds and composition of the patients. Data on complications in child-
birth, post-partum diseases, surgery, and diseases of the newborn are
given in detail. This information is helpful in evaluating the scope
and quality of the maternity hospital's work. The following are the
basic indices of the consultation center and inpatient department:
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(a) Visits to consultation centers -- The average number of visits
per pregnant woman before and after delivery (calculated by dividing
the total number of visits before and after delivery by the total number
of women who gave birth during the period under review);
(b) Time of visits by pregnant women to the consultation center --
ratio of the number of women up to 3 months pregnant coming under
observation to the total number of pregnant women registered;
(c) Time of maternity leave -- ratio of the number of pregnant
women who gave birth 11 or more days earlier or later than the regular
term to the total number of pregnant women who received maternity leave;
(d) Extent of hospitalization of gynecological patients -- ratio
of the number of patients hospitalized for each disease to the number
of diseases registered;
(e) Results of prophylactic medical examinations -- ratio of the
number of women with gynecological diseases or malignancies to the total
number of women examined.
These are some of the qualitative indices used in evaluating the
work of the inpatient department:
(a) Freauency of complications during childbirth and post-partum
diseases -- ratio of the number of dRferent complications and diseases
to the total number of babies delivered (special attention must be paid
to cases involving hemorrhage, laceration of the perineum and uterus,
genitourinary and intestinal-vaginal fistulas, and septic diseases);
(b) Morbidity of the newborn -- ratio of the number of individual
diseases of the newborn to the total number of babies born alive;
(c) Mortality of mothers -- ratio of the number of women dying to
the number of babies delivered;
(d) Mortality of babies -- ratio of the number of babies dying to
the number born alive;
(e) Percentage of _premature babies among full-term babies -- ratio
of the number of premature babies born alive to the total number of babies
born alive;
(f) Percentage of stillborn babies -- ratio of the number of still-
born babies to the total number of babies born.
Such indices are computed for the gynecological department as:
fatality rate, average term of bed occupancy, amount of surgery for the
various gynecological diseases.
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CHAPTER 6
ORGANIZATION OF MEDICUROPHYLACTIC FACILITIES FOR CHILDREN
Medicoprophylactic facilities for children are furnished by childrenis
hospitals with children's consultation center and polyclinic, the
children's department of a general hospital, children's sanatoria, etc.
The children's hospital is the principal institution (Figure 26). In
its absence the children's consultation center and polyclinic are combined
with the children's department of a general hospital. The merger of con-
sultation centers, polyclinics, and hospitals has made it possible to
organize services for children in accordance with the so-called single
pediatrician system. Prior to the merger there were consultation centers
for children up to 3 years old and separate polyclinics for children from
4 to 14 years old, an arrangement that satisfied neither the doctors nor
the people. For example, if two children of different ages in the same
family were ill with the same disease, say measles, they were treated
by two physicians from different institutions (consultation center and
polyclinic) who frequently acted independently of one another even though
the situation called for uniform therapeutic and prophylactic measures.
The amalgamated children's hospitals now operate on the district
principle within the framework of a single standard urban district
served by a pediatrician (medical rating of 1.25). This district
pediatrician treats children of all ages, from birth to 14 years. In
a district of 4,000 population there are about 1,000 children, of whom
one fourth are 3 years old and younger. The pediatrician is assisted
by one or two nurces who work in the consultation center as well as come
to the homes of the children.
This physician normally works under the so-called three-link system
(hospital - polyclinic - home). Where the district has a great many
children or is sparsely settled, the preferred method is alternation,
i.e., one pediatrician works for a few months only in the district
(polyclinic, house visits) while another works in the hospital. Then
they exchange places.
Children's Consultation Centers and Polyclinics
The merger of consultation centers and polyclinics with hospitals
and the organization of care for all children in the district under
a single pediatrician should not obscure the vital role of the con-
sultation center.
The center is essentially a clinic for infants and young children
who are kept under observation from the minute they are born until they
are three years old. Since centers are found all over the USSR, they
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embrace the entire younger generation and are the Major element in the
campaign to lower the sick and death rates of children. Through propa-
ganda they increase the people's knowledge of health and develop good
hygienic habits While coMbatting deeply rooted prejudices and customs
(baby's pacifier, keeping children too warmly dressed, fear of fresh
air especially in the winter, additional food during weaning, unsanitary
conditions at home, etc.).
The consultation center is responsible for the health and life of
every child under its supervision. Hence, the basic indices of its
work are the sick and death rates of the children it serves.
In order to reach all the children, the center must have accurate
information about every birth in the rayon. It is the duty of maternity
hospitals to send the pertinent data to the center every day.
After a physician examines a child and familiarizes himself with
the sanitary conditions prevailing in its environment, the physician
draws up an individualized plan. The first visit to a newborn infant
must be made by the physician in the child's home. Visits are made
systematically throughout its first year of life.
Infants cannot be properly raised by medical advice given to mothers
in the consultation center alone. Mothers have to be given practical
instruction in child care and actual help at home. In addition, the
child's health must be systematically observed and efforts made to see
that the doctor's orders are carried out and that the mother visits the
center regularly. This work is the responsibility of visiting nurses.
These nurses are chosen from among the most experienced and compe-
tent nurses who love their work. They are the principal assistants of
the district pediatricians and make home visits as assigned. Each visit
and the work done is recorded on a special form for the information of
the physician.
The consultation center is especially concerned with women who have
given birth for the first time, women whose home circumstances are diffi-
cult, sickly children, twins, or prematurely born infants. The visiting
nurse is required to see them as often as possible beginning right after
birth until things become normal again.
It is highly desirable for the nurse to visit a future mother even
before the baby is born so that she can start to train her early in
infant care and call an her the first day she returns from the hospital.
Close liaison between the children's consultation center and the
women's consultation center ensures that all concerned are informed about
every woman in the final stage of pregnancy.
Efforts must be made to persuade mothers and children to come to the
center regularly. An infant should be brought there at least twice a
month for the first 3 months after it is born, once a month during the
next 9 months, and once every 3 months thereafter. If the infant is
not brought to the center, the visiting nurse must find out the reason
why. The center weighs and examines the child, prescribes the diet
according to age and condition, and gives preventive inoculations.
The center usually has an infant-feeding station or distribution
point to furnish milk and other baby food. There are also some stations
to collect breast milk for children whose mothers are unable to supply
their own due to illness.
As described above, consultation centers carry out extensive
educational programs on the care of children, prevention of diseases,
etc., as pert of their normal activities. The children's and women's
centers have legal advisers to protect the interests of mothers and
children. The same social and legal staff may serve both centers at
the same time.
A center combines treatment and prevention, thereby enabling the
same physician and nurse to keep healthy and ailing children under
continuous Observation.
Efforts are generally made to provide separate arrangements for
handling the younger and older children. If circumstances permit, it
is advisable for the younger children to visit the consultation center,
the older childrm to visit the polyclinic. If a district pediatrician
has to treat children of all ages in the same place, separate waiting
rooms should be set aside for the two groups. Neither the center nor
the polyclinic should allow healthy childrea to come into contact with
sick children due to the danger of infection. Healthy children must
be examined in different rooms (with separate entrances) from those
set aside for sick children. Before being allowed into the waiting
room$ all children, including the healthy ones, are screened by the
nurse on duty who examines the mucous membranes of the nose and throat
and the skin, takes the temperature, and inquires of the mother whether
anyone at home has an infectious disease.
In departments for sick children, all the patients likewise pass
through a "filter." Children suspected of having an infection are kept
in isolation rooms where they are examined by a physician, after which
the rooms are disinfected. Even in small consultation centers and
polyclinics not equipped with roams especially constructed for the
purpose, the children must pass through the "filter!' one at a time.
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Children should be examined at home by a physician rather than come
to a consultation center or polyclinic if they an acute infectious
disease, high temperature: severe intestinal disease, or if they
had contact with individuals suffering from an infectious disease.
The center provides a sick child with all kinds of specialized
help including, when necessary, home visits by an otolaryngologist,
ophthalmologist, surgeon, etc. Whether at home or in the clinic, the
child is cared for by the same district pediatrician and the same
district nurse.
When he discovers an acute infectious disease, the physician sets
up a quarantine and hospitalizes the child. Together with the nurse
he gives the necessary instructions to the members of the family,
notifies the school, kindergarten, or nursery authorities as the case
may be. The apartment of the sick child is disinfected and a special
notification sent to the rayon epidemiologist.
Children's consultation centers and polyclinics carry out programs
of preventive inoculations against diphtheria, dysentery, typhoid fever,
measles, and the appropriate vaccination for children who may have con-
tact with sick persons. The district pediatrician is required to be on
the alert for carriers of bacilli so that they may be isolated and
treated.
The consultation center maintains a history for each child in
which pertinent information is recorded on its physical development,
sicknesses, inoculations, etc.
The district pediatrician keeps under clinical observation older
children who have had infectious diseases as well as those suffering
from rheumatism, malaria, and tuberculosis.
The children's polyclinic draws up a general health plan for its
rayon including: clinical observation of preschool and school children
and working youths, selection of children for placement in sanatoria
and health resorts, supervision of physical culture activities in the
rayon and medical check-up of physical development, mass prophylactic
inoculations, health campaigns, inspection of hygienic conditions in
schools, kindergartens, and nurseries, improvement of home conditions,
hygiene propaganda among the children, parents, and teachers.
In small towns and villages that have no special children's
facilities, children and adolescents are handled by the general medical
network. Almost every city and rayon hospital has a children's depart-
ment and pediatric facilities. If not, the regular physician takes
over, but he examines the adults and children separately at different
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hours. The general network also undertakes mass prophylactic medical
examinations of school children, vaccinations, inspection of sanitary
conditions in schools, pioneer camps, etc.
Children's Hospitals
Children's hospitals must meet the same general requirements as
regular hospitals, as set forth in the chapter ?The City Hospita1.14
But they have certain features of their own due.to the child organism
and the kind of diseases affecting it. It should be noted that almost
half of all the youngsters in hospitals are suffering from a contagious
disease (measles, scarlet fever, diphtheria, dysentery). Thus, the
problem of preventing intrahospital infections and the quality of care
afforded the young patients are of primary importance.
Infants are usually kept in special nurseries. Mothers remain in
the hospital if they are breast-feeding their children.
Control of intrahospital infections starts from the moment a child
is admitted. The admissions division makes a detailed epidemiological
anamnesis regarding previous infections, vaccinations, possible contact
with infected children in school, nursery, or at home. Depending on
the data, the child is placed either in a general or an isolation ward.
He is disinfected along with all the objects he may have touched.
Children's hospitals for infectious diseases have special wards
with a partitioned space for each child.
The departments of a hospital must be isolated from one another,
with separate entrances and permanent personnel who are not allowed to
go from department to department. Each department has its own supplies,
linens, dishes, toys, etc.
In the partitioned wards the various items like toys or thermometer
are assigned to the individual patients. In the general wards they must
be disinfected when passed an from one child to another.
An important factor in controlling intrahospital infections is the
behavior of the staff, which must maintain strict discipline.
Sick children require special care, their recovery frequently
depending on it. In children's hospitals nurses have this responsibility.
They must be efficient, precise in their work, and faithful in carrying
out the doctor's instructions.
Nurses must be alert and promptly report any changes in the children's
condition to the doctor. Diet is important, hence both nurses and physi-
cians must observe how the children eat and, if they refuse, find out the
reasons why. Very small or weak children must be fed by the nurses.
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I.
Nurses in charge of sick children have to be exceptionally pleasant
and attentive since many children find the hospital and separation from
their parents unbearable. The children must he distracted and enter-
tained.
Convalescent children need a program of study and play. Thus,
many children's hospitals have special teachers on their staff.
Childrents Hospital Reports and Work Indices. The annual report
of a children's hospital goes into full detail an all aspects of its
medical and prophylactic activities.
The report includes among other things the number of children
under observation by the center by the various age groups (up to 1,
1 to 2, 2 to 3), children discharged and dead, visits by physicians
and nurses to newborn infants (during the first 3 days after the
mothers left the maternity hospital, children with a positive Pirquet
reaction, local forms of tuberculosis, rickets, and chronic alimentary
disorders (hypotrophy). These data are used to appraise the quality,
regularity, and effectiveness of the institution's medicoprophylactic
services.
Consultation centers and polyclinics stress prophylactic inocu-
lations (against smallpox, diphtheria, and tuberculosis) and treat-
ment for worms. The report mentions the number of children subject
to vaccination, revaccination, and examination for worms as well as
the number actually revaccinated and treated for worms.
A detailed analysis is made of the results of check-ups of
kindergarten and school children. Note is taken of the number of
children suffering from tuberculosis, rheumatism, cardiovascular
disturbances, decrease in acuity of hearing or sight, and speech
disorders. The report also describes the prophylactic work of the
dental clinic.
Visits by children to the polyclinic and home visits by the
staff are recorded separately. Cases of infectious diseases and
hospitalization are given special attention.
Other sections of the report present data, just as reports of
other hospitals do, on the number of patients who recovered or died
and the number of bed-days. There is emphasis an intrahospital
infections and refusals of admission to the hospital.
The section "Composition of Patients and Outcome of Treatment"
lists the diseases for which the majority of children were hospi-
talized (acute childhood infections, tuberculosis, rheumatism,
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pneumonia, dyspepsia, etc.). In each category the figures are broken
down into those for children up to one year old and those for children
from one to two years old.
The report makes it possible to calculate the principal indices
characterizing the quality of work of a children's hospital:
(a) Extent of visits to newborn infants -- ratio of the number of
visits by doctors and nurses to the total number of infants up to one
month old under observation by the center;
(b) Regularity of observation of children up to two years old --
ratio of the number of children up to two years old under systematic
observation by the center to the total number of children of the same
age living in the jurisdictional area of the center;
(c) Fulfillment of the plan of prophylactic inoculations -- ratio
of the number of vaccinated and revaccinated children to the total
number subject to vaccination and revaccination;
(d) Inclusiveness of medical examinations -- ratio of the number
of kindergarten and school children examined to the total number attend-
ing the kindergartens and schools served by the hospital;
(e) Completeness in hospitalizing children with acute infectious
diseases -- ratio of the number of hospitalized children to the total
number sick;
(f) Timeliness of hospitalization -- ratio of the number of patients
hospitalized during the first three days of illness to the total number
hospitalized;
(g) Deaths of children by individual diseases (separately for
children up to one year old, from one to two, and older, separately
for children dying at home and in the hospital) -- ratio of the number
of children dying in each group to the total number of diseases
registered.
The number of older children is calculated by subtracting the number
of children up to one year old and from one to two years old from the
total number of children (column "Total").
Day Nurseries
Day-nurseries are educational institutions for children ranging
from 2 months to 3 years in age. They enable mothers to work and at
the same time participate in the economic, cultural, social, and
political life of the country. Their growth is closely related to the
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expansion of the national economy and the increasing use of women in
Industry. The nurseries are both medical and social institutions in the
development of Which various government departments and trade unions are
keenly interested. Therefore, economic organizations, certain ministries,
unions, collective farms, social insurance agencies, and, of course,
parents share in the construction and maintenance of these centers.
Nurseries are built by the ministries concerned at plants employing
a large number of women -- 12 places per 100 female workers. Manage-
ment and supervision are in the hands of public health agencies regard-
less of the department that may have jurisdictional or financial res-
ponsibility.
Types of nurseries. Nurseries are of seasonal or permanent char-
acter. The former are set up in rural communities during the summer,
thereby enabling the mothers of young children to participate in the
field work. Priority is given to thr t...hildren of working mothers of
large families, unmarried mothers, and disabled veterans of the Patriotic
War.
Nurseries differ in organization and length of time the children
remain there: day - up to 10 hours; extended day - up to 12 or 14 hours;
round-the-clock. Shift nurseries are available for the children of
women working in the day and night shifts. There are also rayon
nurseries, which take care of children where the women live. Nurseries
for breastfed children are necessarily near the women's place of work
so that they can regularly come to their children during special breaks.
Nurseries may have places for 120, 100, 80, 60, 45, or 20 children.
The larger buildings (80 places and over) are directed by
the smaller ones by middle echelon medical personnel trained for the job.
In addition, the staff may include a physician (full or part time,
depending on the size of the institution).
Organization of work. All children must be examined by a con-
sultation center physician before they are admitted to a nursery. Those
suffering from an acute infectious disease, gonorrhea, syphilis, trachoma,
or tuberculosis in a contagious form are not accepted.
The visiting nurse or senior nurse of the nursery is required to
visit the home of a child placed in the nursery in order to determine
the absence of infectious diseases in the child's family or among those
living with him in the same place.
The children are segregated by age groups, 18 to 20 older children,
15 to 17 younger children. Each group is supervised by a nurse and
maid. The number of age groups varies with the number of children. In
a nursery with four groups, the first has infants up to 9 months old;
the second -"sliders," i.e., children from 10 months to 1 year and 2
months old; the third - children from 1 year and 2 months to 2 years
old; the fourth - children from 2 to 3 years old. When the children
are few, they are divided into two groups: younger (unable to walk)
and older (able to walk). Each group should have a separate section
and entrance.
Nurseries have the following areas: dressing, reception, children's
rooms with at least 2.25 square meters of space per child, play, sleep-
ing, isolation, veranda for naps in the open air, toilets, kitchen,
laundry, storeroom.
The work involves setting up a routine for each age group, feeding
and teaching the children, providing medical care, and preventing
infections. The nursery director and physician are responsible for
the medical care and hygiene. A teacher is in charge of the educational
activities. A group nurse and maid do the actual supervising of the
children.
The length of time the children spend in the nursery depends on
their mothers' hours of work. However, when a shift ends late in the
evening, the children remain overnight so that they may have their
normal sleep from 9 p.m. to 6 a.m.
Feeding the children. This is an extremely important part of the
nursery's work. Efforts must be made to continue breast feeding as
long as possible -- at least 5 or 5-1/2 months.
Soviet law requires nursing mothers to be released from their jobs
every 3-1/2 hours for half an hour to feed their infants. Space is
provided for this purpose in the reception room of the nursery where
they may wash their hands and put on a robe before starting.
Children an a mixed diet get additional food from the nursery to
take home.
Older children are fed according to a menu prepared every ten days
by the physician, nursery director, and cook, with size of portion
determined by the Ministry of Health, USSR, for the various age groups.
Proper physical development and weight gain constitute an important
index of correct nutrition. All children must therefore be weighed
frequently and those who are underweight given special attention.
Improvement of the nutrition of children in nurseries, just as in
hospitals, depends largely on the initiative of the staff. Planting
a garden of vitamin-rich plants (hip-bearing roses, black currants,
spinach, blueberries, and others) serving of vitamin-rich drinks, etc.,
are among the things that can be done in this direction.
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Sickly children, those with rickets or tuberculosis are given
special handling -- extra food, naps in the open air, and treatment*
Medical care of children in nurseries. The children are system-
atically observed by a doctor or feldsher or midwife (in the country).
They are examined before admission and during their stay, the older
at least once a month, the younger at least twice a month. All
pertinent health data (physical and mental development, nutrition)
are noted in each child's history. The nurse is responsible for day-
by-day Observation. She records her impressions and reports to the
doctor When he visits the nursery. On each visit the doctor or feldsher
must check on the sanitary conditions and quality of the food.
A sick child is treated, depending on where he lives, by either
the nursery or consultation center physician. Children with dyspepsia,
conjunctivitis, stomatitis, pyodermatitis, furunculosis, etc., are
allowed to remain in the nursery provided they are kept in the isolation
area, which must be away from all the others and have its own equipment
and toilets. Permitting these children to remain in the nursery saves
a considerable number of work days for the mothers who would otherwise
have to be released from their jobs to take care of them.
Prevention of infections. The prevention of infectious diseases
is an important function of the day nursery. Unfortunately, cases of
intranursery infections are still fairly common. They constitute the
main reason why nurseries are closed for a long time and their beds
unoccupied. Newly admitted children and their families are carefully
examined to prevent their introducing infections.
The nurse examines the children every morning on arrival. She
checks the mucous membrane of the mouth and throat, takes the tempera-
ture, and, when undressing the children, inspects the skin for rashes.
Those suffering from an infectious disease or suspected of having one
are promptly sent home. If a child gets sick while in the nursery, he
is kept in the isolation area until the doctor comes.
The nursery keeps in close touch with the consultation center.
The center must immediately inform the nursery of every child with an
infectious disease and of those close to the child. Bacteriophage
treatment and vaccinations against smallpox, diphtheria, and measles
are given in the nursery.
A group is quarantined when one of its members is found to have
an infectious disease. Children in this group are not allowed to
have contact with other children. A quarantine may be set up in a
nursery for children with whooping cough, chickenpox, or mumps.
Children with loose stools or chronic dysentery should also be kept
apart. The quarantine system is important because it relieves working
mothers of the need to nurse their sick children and thus saves them
considerable time.
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If medical personnel in nurseries are careful to observe all the
rules of hygiene and conduct an effective educational program among
mothers, the children can be wholly safeguarded from infections.
The medical personnel too must be regularly examined. No one
should be permitted to work in a nursery if he has an active case of
tuberculosis, venereal disease, trachoma, a contagious skin disease
like scabies, or is a carrier of bacilli (typhoid, dysentery, .diphtheria).
Nursery Reports and Work Indices
The work of ?a nursery is measured by the extent to which the avail-
able beds are used. The number of days the children occupied the beds
as well as the number of days missed, together with the reasons therefor,
are noted in the daily journal. Information an the movement of the
children is obtained from the admission records. A tabulation is made
of the number of children admitted during the period under review, the
number departing with the reasons therefor, and the number remaining at
the end of the period. The most important indices of a nursery's work
are:
(a) Use of nursery places -- ratio of the number of children on the
rolls to the number of p aces in the institution;
(b) Use of nursery capacity -- ratio of the number of days the
children used the beds to the planned number of bed days multiplied by
100.
The quality of a nursery's work is also evaluated from an analysis
of the children's physical development, morbidity rate, the number of
days the children were Absent and the reasons therefor. Such reasons
as illness or intranursery quarantine testify to poor care on the part
of the medical personnel and inadequacies in prophylactic measures.
Children's Homes
Children's homes provide accommodations for orphans, children who
have lost touch with their parents, children of unmarried mothers who,
in accordance with the Decree of the Presidium of the Supreme Soviet,
USSR, 1 July 1944, are entitled, in case of need, to place their children
in these institutions, and children of sick mothers.
Children remain in these homes until they are 3 years old when they
are released either to their parents or foster parents, or for adoption,
or for transfer to preschool homes maintained by the Ministry of Edu-
cation.
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The sanitary requirements, construction, maintenance, and organi-
zation of children's homes are largely the same as for nurseries. How-
ever, since the youngsters in these homes are isolated from the conditions
and influences of the normal environment and have no family, their
psychological, physical, and educational development calls for special
attention.
It is very important that infants up to 6 months old be provided
with breast milk, a main factor in the effort to control mortality in
children's home go Milk may be obtained from wet nurses or from maternity
hospitals and cansultation centers.
To control infectious diseases, aside from the measures mentioned
in connection with day nurseries, children's homes are required to keep
newly admitted children in quarantine until it is ascertained that they
are not introducing infections. Any child suffering from an infection
is promptly sent to the hospital. The homes provide isolation areas
for sick children not requiring hospitalization.
All the children are regularly examined by a pediatrician.
CHAPTER 7
THE SANITARY-ANTIEPIDEMIC ORGANIZATION
The tasks of the sanitary-antiepidemic organization are determined
by the fact that Soviet public health is governmental in character and
preventive in emphasis. Sanitary measures are designed to improve the
natural environment along with the living and working conditions of the
masses whose active cooperation is required.
The health of the population is affected by unfavorable environ-
mental factors. For example, the existence of swamps contributes to
the spread of malaria. Negative macroclimatic and microclimatic con-
ditions favor influenza and diseases of the upper respiratory tract.
Incorrect nutrition, lack of hygiene, and poor food give rise to
gastrointestinal disorders. Unhygienic working and living conditions
are a source of skin infections, injuries in industry and at home.
These examples can be multiplied at will. Unfortunately, the part
played by the individual environmental factors in causing disease has
not yet been fully elucidated. It is the prime responsibility of
Soviet medicine to investigate in detail the role of the environment
in inducing cardiovascular, endocrine, and metabolic diseases, cancer,
etc., for only a knowledge of the etiology of diseases can lead to the
development of effective methods of preventing them. Consequently,
the successful control of sickness requires above all improvement of
sanitary conditions in industry and at home, better nutrition, and
elevation of the hygienic level of the masses.
Certain agencies have the job of guiding, planning, and coordi-
nating all sanitary-antiepidemic measures in the USSR. Their practical
work is closely associated with advances made by the science of hygiene
in studying the influence of the environment on the human organism and
setting up hygienic requirements and standards accordingly.
Sanitary-prophylactic work impinges on every aspect of life, every
branch of the national economy. It would be impossible to lower the
sick rate and raise industrial productivity without it. Proper sani-
tary arrangements in factories and farms are essential for the progress
of our country, particularly in this period of transition from socialism
to communism.
Advances in socialist industrialization, the building of new and
rebuilding of old cities, the growth of urban organization, automation
of labor in industry and agriculture, widening prosperity and elevation
of the general cultural level of the Soviet people have created the
necessary prerequisites for improving the health of our people.
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However, improvements in sanitation and control of epidemics do
not come about spontaneously. They are effected by state control and
supervision, legislation, and establishment of compulsory norms and
requirements based on scientific knowledge. '
The directives of the 20th Congress of the Communist Party of
the Soviet Union regarding the 6th five-year plan conceded the necessity
of "improving labor protection and disease prevention for manual and
office workers in industry and safeguarding the water, air, and soil
from pollution by industrial emissions."
USSR legislation on sanitation provides for compulsory standards
in the layout and construction of cities, factories, homes, medical
institutions, schools, etc. It sets up norms for the installation of
utilities in populated areas and factories, the sale of food products,
antiepidemic measures, etc.
It is the duty of every manager of a factory, machine and tractor
station, collective or state farm, school principal, teacher, etc., to
concern himself with sanitation. Compliance with the pertinent regu-
lations is as necessary for individuals as it is for institutions and
organizations. Medical personnel have the chief responsibility for
directing and checking on these matters. They are required to keep
administrators and teachers informed of developments and to explain to
them the significance of various measures proposed.
The inspection of water, air, and food involves the use of special
methods and trained people -- sanitary physicians and feldshers.
Success in this field depends largely on extensive propaganda and
enlisting the active support of the population. While all medical
Institutions, doctors, and middle echelon personnel take certain steps
to cope with different diseases, overall direction of the work rests
with the sanitary-antiepidemic organization.
Tsarist Russia had no single state-wide sanitary organization
and no sanitary code. The government passed laws from time to time
of police character to deal with certain epidemics. Local ordinances
were haphazard, issued as a rule in connection with extraordinary
events such as a cholera epidemic or famine. Only 20 zemstvo provinces
had a health organization, which was staffed with an insignificant
number of physicians (only 257 in 1913). From the meager sums set
aside for medical services in prerevolutionary Russia (20 kopecks per
person in 1910), only 5 kopecks per person were spent on sanitation.
Although the zemstvo health organization is entitled to credit for its
contribution to the development of sanitation (organized records on
epidemic morbidity, introduction of vaccination, statistics relevant
to the working and living conditions of the laboring and peasant
classes), its scope and practical accomplishments were slight.
- 146 -
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An extensive network of sanitary-antiepidemic institutions came
into existence during the years of socialist construction. Its most
important element is the sanitary-epidemiological stations of which
we now have approximately 6,000.
The SanitarrEpidemiological Station
The sanitary-epidemiological station carries on all the sanitary-
antiepidemic work within its area of jurisdiction including direction,
coordination, and inspection of the sanitary-antiepidemic activities
of the other medical institutions. Each station consists of a sanitary-
epidemiological division, sanitary-bacteriological laboratory, and
disinfecting division (Figure 27). The sanitary-epidemiological division
is made up of a sanitary section and an antiepidemic section. The
sanitary-bacteriological laboratory has sections dealing with housing
and communal sanitation, food hygiene, and bacteriological problems.
The disinfecting division has a unit engaged in antiepidemic disinfection
work.
Sometimes, if local conditions warrant, the station may have a
parasitological division, which directs antimalarial and anthelmintic
work as well as the activities designed to control measles, rabies, and
brucellosis.
The laboratories of stations in large industrial cities have
industrial-sanitary divisions.
Sanitary-epidemiological stations in the republics, oblasts, krays,
and some cities (those under republic jurisdiction) have sections
specializing in preventive sanitary inspection.
Sanitary-epidemiological stations are responsible both to local
public health bodies and to the superior stations or agencies of the
sanitary-antiepidemic service.
Sanitary-epidemiological stations register all cases of contagious,
parasitic, and helminthic diseases, food and industrial poisonings, and
occupational diseases. They conduct epidemiological investigations,
arrange for the transportation and hospitalization of people with
contagious diseases, inspect foci of infection, check on implementation
of antiepidemic measures by the various medical institutions.
The disinfecting division carries out temporary and permanent dis-
infection of focal areas of disease, prophylactic disinfection, dis-
infestation, deratization, and the appropriate treatment of persons
who have come into contact with those suffering from a contagious dis-
ease and disinfection of their things.
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The station conducts educational programs among the people designed
to increase their knowledge and develop hygienic habits. It also
organizes and trains sanitation activists.
Staffing Pattern of Medical and Administrative Personnel for
a Rayon (okrug) Sanitary-epidemiological Station
Position
I. SANITARY-EPIDEMIOLCGICAL DIVISION
Sanitation physician for residential-
communal sanitation
Sanitation physician for school sanitation
Sanitation physician for food hygiene
Physician-epidemiologist
Assistant to sanitation physician
Assistant to epidemiologist
Instructor in hygiene propaganda
Medical statistician
II. LABORATORY
Director of laboratory - sanitation
physician or physician-epidemiologist
Physician-bacteriologist
Laboratory technician
Laboratory technician-bacteriologist
Attendant
III. DISINFECTION DIVISION
Director of division - assistant to the
epidemiologist 1
Attendpn+ 1
Disinfection instructor in focal disinfectionl
Disinfection instructor in fl disinfection 4
Disinfection instructor in room disinfection 2
Total 32
Category for a rayon with
a population of
more from up to
than 30,000 30,000
60,000 to
- 60,000
11 III
1
1
??????
IMAM
1 1
2 1
6 3
3 3 2
1 1
2 1 1.
OMMAIIM
NOW
2
OMPION
1. 1 1
1
2 1
1 1
1 1
On OW
IMP NO
1
NOON.
IV. ADMINISTRATIVE-CLERICAL PERSONNEL
Chief physician
Secretary-typist
Office manager
Senior book-keeper
Total
1
J.1
1
14
1
1
1
3
1
??????
41.1=
1
Vote: if the station has a sanitation inspector, the staffing pattern
includes an additional disinfection instructor and two disinfectors.
The station provides expert advice on problems in hygiene and
epidemiology, cooperates with all the medical institutions in its dis-
trict, and conducts advanced courses for medical personnel.
A sanitary-epidemiological council serves as an advisory body
an scientific methods to the head physician of the sanitary-epidemiological
station.
The oblast, city, and rayon sanitary-epidemiological stations differ
somewhat from one another. Each type is divided into three categories
depending on the size of population served, number of inhabited places,
and kinds of establishments in the area. The division of sanitary-
epidemiological stations into types and categories determines both
their structure and staffing pattern.
Preventive and Routine Sanitation Inspections
Preventive sanitation inspection ensures conformity with sanitary
standards in the planning and building of industrial plants, public
utilities and hydraulic works, health resorts, schools, etc.
Our country is now engaged in a major construction effort both in
industrial and undeveloped regions. In the building or rebuilding of
large cities or small inhabited localities the opinion of the sanitation
physician must be as authoritative as the architects. Construction
Plans and methods for inhabited areas must meet sanitary requirements
with respect to water supply, baths, laundries, and personal service
shopss protection against pollution of the air of residential sections
and homes by industrial emissions, streets and sidewalks, landscaping,
and garbage disposal. This inspection is carried out by sanitary-
epidemiological administrations of the ministries of health of the union
republics and divisions of preventive sanitation inspection of the
republic, oblast, and city sanitary-epidemiological stations.
The stations have specialists an the different types of inspection
required. There are state sanitation inspectors to check on the plans
for populated places, safeguards against air pollution, industrial
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hygiene, protection of reservoirs, water supply and sewerage, food
hygiene, and sanitary conditions in schools. They cooperate with
architects, engineers, designers; and builders in the planning stage
of new projects (choice of place, layout, drawing up of the designs)
and While the construction is in process.
Routine sanitary inspection of establishments in actual operation
(factories, public buildings, schools, etc.) is the responsibility of
sanitation physicians and their assistants in the several divisions of
sanitary-epidaniological stations -- residential and communal, food,
industrial, and school.
The residential and communal division inspects sanitary conditions
In its jurisdictional area (city, settlement), individual homes and
public buildings. It is charged with keeping the city clean, safe-
guarding water supplies by establishing sanitary protection zones for
the water pipes and maintaining a systematic laboratory check on water
purity, processing of sewage, safeguarding the air, inspecting sanitary
conditions in water works, sewers, baths, barber shops. Following
systematic observation, it requests the managements concerned to con-
form to the sanitary code and it follows up to see that the necessary
corrective measures are taken.
The food sanitation section inspects all places engaged in the
manufacture, sale, storage, consumption, and transportation of food
(processing plants, meat packing plants, slaughter houses, dairies,
markets, restaurants, snack bars). The staff checks on the quality of
the food and acts to prevent food poisoning.
As part of the five-year plans, the giants of the food industry --
meat, fish, canning, refrigeration, bread -- grew swiftly to meet the
needs of the people and the responsibilities of the food inspection
agencies of the government mounted accordingly. The ministries engaged
in the manufacture of food products created special services to check
an sanitary conditions in the various industries. They work closely
with and are supervised by the sanitary-epidemiological administrations
of the health ministries of the union republics and the local sanitary-
epidemiological stations. Inspection of poorly equipped plants is
especially important.
Individuals suffering from infectious diseases or who are carriers
of bacilli constitute a great danger to the public if they are employed
in food plants, water works, bath houses, barber shops, etc. Soviet
law therefore requires that all workers in these establishments be
examined every month and be certified as free from the carrier state.
The others must be removed from their jobs and not allowed to return
until they receive authorization to do so by a sanitary physician.
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The sanitary-epidemiological station registers all food poisonings
and toxic infections. Each such case must be carefully investigated to
determine the source of the infection and appropriate measures taken
against it.
The Industrial-sanitarydivision routinely inspects sanitary con-
ditions in factories and aaherence by their managers to established
standards with respect to ventilation, light, control of dust, humidity,
temperature, noise, and other harmful factors. The industrial sanitary
physician and his assistants see to it that workers are issued special
protective outer garments and safety equipment when necessary and that
the doctor of the medical unit or health statian'instructs new workers
and foremen in the principles of hygiene. The division also registers
and investigates the causes of industrial poisonings and diseases.
The sanitary-epidemiological station inspects schools, kinder-
gartens, outpatient departments for children in hospitals, gymnasiums,
Young Pioneer camps and other youth organizations. It is concerned with
proper heating, ventilation, illumination, cleaning, etc., and ensuring
that the directors and teachers maintain sanitary standards, correct
the defects, and instruct the younger generation in proper hygienic
habits.
The sanitary physician sets down his conclusions on the sanitary
conditions of the various establishments he has inspected (together
with laboratory analyses and other data) in a special journal kept at
each place.
Soviet legislation empowers the sanitary-epidemiological agencies
to protect the health of the workers and enforce observance of the sani-
tary norms and regulations promulgated by the state. The sanitary
physician reports failures on the part of management to comply with his
requests. In the event of continued refusal, the head of the station
has the right to impose a fine, prohibit the use of or confiscate the
product in question, and even to close the place and bring those guilty
to court.
Antiepidemic Work
Antiepidemic work constitutes one of the most important activities
of Soviet public health.
It is a well-knomn fact that there were many major epidemics in
Tsarist Russia. Soviet public health has had to wage a fierce, allaut
struggle against this legacy before achieving its great success in
eradicating such terrible diseases as cholera, smallpox, plague, and
malaria (as a mass disease) and in reducing the number of cases of
exanthematous, typhoid fever, scarlet fever, diphtheria, etc.
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Epidemics may be controlled or prevented by general hygienic
measures and by special antiepidemic measures -- improving sanitation
in inhabited areas, laying sewers and water pipes, timely cleaning up
of cities, building baths and laundries, introducing hygienic practices
in food handling, etc.
The battle against infectious diseases is a major national problem
that requires enormous effort not only by public health agencies and
institutions but also by other Soviet organizations. Hence, the govern-
ment wages antimalaria, antituberculosis, and antitularemia, etc.
campaigns in accordance with a single, overall plan. Three main elemants
are involved in dealing with acute infectious diseases: (1) medico-
prophylactic measures aimed at early detection, rendering harmless or
destroying the sources of infection (plus isolation of those suffering
from such diseases and treatment of carriers of bacilli); (2) measures
to eliminate the factors facilitating the transmission and spread of
infections (disinfection, general sanitary measures, etc.); (3) measures
to prevent healthy people from contracting these diseases (try immunizing
them).
Malaria is a good example of this approach. All patients are
registered and systematically treated. Medicine is administered in the
spring to prevent recurrences. Preventive treatment is instituted for
those in danger of infection. Since malaria is transmitted by the
Anopheles mosquito, steps are taken to destroy the insectts breeding
places. Petrolization, dusting of reservoirs by airplane, and swamp
drainage projects are executed not only by antimalarial stations of
public health agencies or sanitary-epidemiological stations, but also,
in accordance with the government plan, by different departments and
ministries and, lastly, by the people themselves.
Prophylactic vaccination is an extremely important method of
preventing infectious diseases. As the science of medicine advances
(microbiology, immunology), the number of infections that may be
prevented by increases. In the USSR vaccination against
smallpox is compulsory for all children up to one year old and revac-
cination when the children are 4 to 5, lo to 11, and 18 to 20 years
old. Children are vaccinated against diphtheria before they are 8.
Workers in food plants, railroads, medical institutions, seasonal
workers, migrants, and others when there are epidemiological indi-
cations for it, are vaccinated against typhoid fever, paratyphoid,
and dysentery. Vaccinations against tetanus, rabies, and measles
when there are indications for it, tuberculosis, etc., are very
common. Specific prophylaxis is a major weapon in the battle against
germ diseases. More than 100 million persons are vaccinated against
various diseases (other than smallpox) annually in the USSR.
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Another vital factor in curbing infectious diseases is effective
organization of antiepidemic work. The disease must be detected and
accurately diagnosed as early as possible and patients promptly-hos-
pitalized." A special notification must be sent immediately to the
epidemiologist of the local sanitary-epidemiological station who will
start an investigation to discover and decontaminate the source of the
disease.
Carriers of bacilli play a big role in spreading germ diseases.
Those who have had these diseases or who have been in contact with
infected persons must be examined to determine whether they are carry-
ing the bacilli. Every medical institution is required to register all
carriers of typhoid, dysentery, and diphtheria. It must also register
persons suffering from malaria and report on bacteriophage therapy for
chronic cases and treatment to prevent recurrences.
Success in sanitary and antiepidemic work depends to a considerable
extent an active participation by the people. The nature of the dis-
eases, methods by which they spread, and measures of individual and
group prophylaxis must be explained to them. It is obvious that the
vigorous support of all urban and rural hospitals and clinics is like-
wise needed. Early diagnosis, hospitalization of the sick, and vac-
cination are their contribution.
The sanitary-epidemiological station plans and executes antiepidemic
measures in the city. But in the country this work devolves upon the
district physician aided by the sanitary feldsher and all other dis-
trict medical personnel.
There are several tens of thousands of sanitary feldshers through-
out the USSR. Their task is to check on the implementation of suggestions
and decisions of sanitary-epidemiological agencies, make routine inspec-
tions, report on violations. They do much of the paper work, including
preparation of the periodic reports and writing up in legal form the
sanitary physician's decisions on the levying of fines.
Sanitation feldshers are also responsible for obtaining samples of
suspicious food products, water, or soil for laboratory examination.
At times they may be required to make very simple investigations an the
spot and report on their findings.
Sanitation feldshers are charged with the task of disinfecting foci
of epidemics. They whatever method may seem appropriate and later
check an the effectiveness of any disinfection or disinfestation they
may have carried out.
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Under certain circumstances the feldshers may' temporarily substitute
for physicians with all the rights of the latter.
The work of the sanitary-antiepidemic organization is bolstered
by the existence in almost every kray and oblast of an institute of
epidemiology and microbiology and hygiene, which conducts extensive
theoretical and practical research and manufactures sera and vaccines.
The sanitary and antiepidemic program of a sanitary.epidemiological
station is planned on an overall basis. It includes a complex of
essential measures for the individual establishments to he inspected
and for prophylaxis (each disease separately) that are to be carried out
by the station itself, medicoprophylactic institutions, and other organ-
izations. The plan must be complete and detailed specifying the decisions
to be implemented by the local executive committee of the Soviet of
Workers" Deputies, e.g., the decree an spring cleaning of yards; the
section dealing with laboratory control of.water supplies should list
the wells and hydrants from which samples of water are to be drawn,
kind of investigations, times, names of officials in charge, etc.
The main guarantee of a plan's effectiveness is systematic
follow-up. This supervision is the responsibility chiefly of the
sanitary-epidemiological station and constitutes its day-by-day work.
Its reports contain information on staff and equipment, all kinds of
routine and preventive inspections, antiepidemic measures carried out
(hospitalization or evacuation of people with acute infectious dis-
eases, results of epidemiological studies, disinfecting activities),
bacteriological and serological analyses, steps taken to deal with the
individual diseases, administrative sanctions applied (e.g., fines)
and the results.
The effectiveness and quality of a station's work Can be appraised
from the data on sanitary conditions and establishments in its juris-
dictional area, morbidity rate of the population, etc. The chief
indices ares
(a) Coii.eteness and time of hos italizino persons with infectious
diseases -- ratio of the number of patients hosPltalized between the 1st
and 3rd days, on the 4th day, etc., from onset of the disease to the
total number of patients registered (separately for each disease);
(b) Quality of epidemiological investigations -- ratio of the
number of investigations and sources of infection discovered to the
total number of diseases registered (separately for each disease);
(c) Time of carrying out final disinfection -- ratio of the number
of final disinfections carried out simultaneously with hospitalization
(up to 12 hours and more than 12 hours from the time of hospitalization)
to all the orders for disinfection executed;
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Anong the indices characterizing the quality of routine sanitary
inspections are:.
(a) lementatian of the
of indivi buildings and esta
places actually inspected to the
according to the plan;
et
..19
lan with respect to routine inspection
lishments -- ratio of the number of
number ot places subject to inspection
(b) Effectiveness of sanitation inspection -- ratio of the number
of places with sanitation violations removed to the total number of places
inspected in which violations were noted;
(c) Implementation of the plan with res ct to medical examination
of persons subject to examfnation -- ratio of the number of persons
actually examined to the number of persons subject to examination
(separately for each group).
A number of other indices can be calculated in the same way.
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r
CHAPTER 8
EDUCATION IN HYGIENE
Tasks and Organization of Education in Hygiene
Education in hygiene is a fundamental part of Soviet public health
and the duty of every medical institution and worker, physician, feld-
sher, midwife, and nurse.
Improvement of the masses' working and living conditions, prevention
of disease, fortifying of health and physical developeent, teaching of
hygienic practices in the home and at work -- with the peoples' active
cooperation -- are the principal tasks and ultimate goal of public health.
Education in hygiene is an integral part of communist teachings
and, as such, must be on a high ideological and cultural level and
based on the findings of progressive medicine. The high ideological
and scientific level, spreading of knowledge about the structure and
functioning of the body, and the causes of disease help to develop
a materialist world outlook, liquidate remnants of the past in the
consciousness of the people, and root out surviving harmful prejudices
and superstitions.
Education familiarizes the people with the problems of Soviet
public health, organization of medical facilities, and the achievements
of Soviet medicine.
Education in hygiena is not the sole responsibility of public
health agencies and institutions. Schools, clubs, libraries, social
organizations also participate in the work.
Education carried on within the walls of hospitals and at patients'
homes is of utmost importance. Sick persons usually show a great deal
of interest in their diseases and listen attentively to doctors and
other medical personnel. The teachings of I. P. Pavlov an the unity and
integrity of the human organism, on the interaction of the first and
second signaling systems, and the predominant role of the central
nervous system explain why the words of medical personnel are potentially
of great importance in hastening the recovery of sick people.
Lectures and chats on hygiene must be readily intelligible, per-
suasive in form of presentation and optimistic in content.
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Since propaganda is incumbent on every medical institution and
sanitary..epidemiological station, the directors are required to plan
and supervise this aspect of the work of their staffs, which is scheduled
during regular working hours. The content of the lectures and informal
talks, which are given in factories, hostels, collective farms, schools,
and hospitals, is determined primarily by the nature of the institution,
the practical problems it has to face, the type of patients, and morbidity
of the population.
Public education through lectures, 'teports delivered in clubs,
houses of culture, and large auditoriums) is organized and carried out
by personnel of the Houses of Hygiene Education, which have lecture
bureaus of trained speakers (Figure 28).
Besides lectures, the Houses employ other devices such as sta-
tionary and mobile exhibits, films, local newspapers, and radio broad-
casts. They organize courses and circles for citizens particularly
interested in hygiene (sanitary activists). As sources of guidance
and methods, the Houses have appropriate facilities: stationary
exhibits, movie and lecture halls, libraries and reading rooms, shops
to make visual aids, storerooms for literature and visual aids.
There are rayon, oblast, city and republic Houses. The Central
Scientific Research Institute for Education in Hygiene is the USSR
Center for scientific knowledge and methods.
General organizational guidance, the planning of facilities and
staff is handled by the hygiene education division of the sanitary-
epidemiological administration of the Ministry of Health, USSR, and
the corresponding divisions (or inspectors) in the health ministries
of the Union republics. In oblast, city, and rayon health departments
this work is the responsibility of the local House of Hygiene Education
(Figure 29). Should the city or rayon center have no House, this
function is performed by the sanitarr.epidemiological station, which
has a special instructor on its staff for this purpose (feldsher or
physician's assistant). In oblast and republic stations a physician
specializing in hygiene education assumes the task.
Major medical institutions have a cabinet for hygiene education
or inspector (physician or middle echelon worker) to provide guidance.
The inspector of hygiene education in a hospital organizes the
work inside the institution (among the patients, relatives, and visitors)
and among the people within its jurisdiction. He draws up plans assisted
by the House of Hygiene Education or the sanitary-epidemiological
station, keeps records, helps his staff to obtain instructional mate-
rials and aids for displays in the building, issues wall newspapers and
bulletins, etc.
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A record is kept of the lectures, talks, and courses given in a
"Register of Work in Hygiene Education." Entries are made on the basis
of passes presented at the place of the lecture, talk, or course, or by
written statements of the speakers. These entries provide the information
used to compile the periodic reports.
Methods of Hygiene Education
In carrying an his educational work, the hygienist appeals directly
to the sensory organs of man, to the first signaling system (e.g., by
showing posters, sketches, slides, movies -- the visual method), and to
the second signaling system by using the written and oral word which,
as I. P. Pavlov put it, is the "second signal, the signal of signals."
All human mental processes are based on the close interrelation-
ship between the first and second signaling systems. Since the processes
of perception are bound up with those of thought, it would be incorrect
to regard them wholly in terms of their influence on the first or second
signaling system. Actually, any method of hygiene propaganda works an
both. In practice, a combined approach is frequently used, thereby
increasing the impact, comprehensibility, and, consequently, effective-
ness of the message.
Hygiene propaganda uses oral, written, and visual techniques. The
first includes lectures, reports, conversations, oral readings, evenings
of questions and answers, and radio broadcasts. Books, pamphlets,
brochures, booklets, slogans, wall newspapers, blackboards of questions
and answers comprise the written approach. Visual materials are posters,
slides, photographs, models, plastic molds, films, displays, and theatrical
productions.
The oral method is the commonest and perhaps most effective because
the material can be very specific with due regard for the peculiarities
of the time and place of delivery.
There are formal lectures, chats with patients in a clinic, at
home, in a hospital, advice to mothers entering children in day nurseries,
conversations with people during sanitation and epidemiological investi-
gations. The lecture form is suited to large audiences where much
material has to be set forth and the complexity of the subject requires
particularly logical and systematic presentation.
Talks usually fall to the lot of middle echelon personnel. The
listeners are drawn into the discussion and full use made of their
experience, knowledge, and ideas. The speaker, however, retains the
leading role; the participants raise questions, express doubts, and
object, thereby affording him an opportunity to explain the material
more clearly and to convince the skeptics.
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?
In order to be an effective speaker a medical worker must constantly
strive to deepen his medical, political, and general knowledge. He
should keep abreast of current events, read the newspapers, study the
culture and way of life of the local population, and systematically read
technical and belle-lettristic literature.
For his talk to be interesting and intelligible, the speaker must
first become familiar with his audiences, their intellectual level, and
learn what things concern him. It is recommended that he base his talk
an concrete material drawn from the records of his institution, cite
examples from the life of the group wham he is addressing (the workers
in a factory, state farm, inhabitants of a district, etc.), and quote
from his literary readings.
All talks, lectures, and reports require serious preparation. This
includes the writing out of an outline and a summary, the former con-
sisting of brief notes, figures, newspaper items, literary quotations,
etc.
Here is a rough outline for a talk on "Influenza and Hew to Deal
with It:
1. Influenza - very common disease.
2. Influenza - not a mild disease.
3. Ways of transmitting it (concept of droplet infections).
4. Prevention.
The outline can be even more detailed:
1. Influenza - very common disease.
2. Influenza - not a mild diseases
(a) harm to the state;
(b) harm to the patient.
3. Ways of transmitting it (concept of droplet infections).
4. Prevention of influenza:
(a) conduct of patients;
(b) hardening the organism;
(c) preventive vaccination.
Here is a typical summary of a talk on the same subject:
1. Influenza - very common disease;
In one factory out of 100 cases involving disability 32 were
due to influenza.
2. Influenza - no mild disease:
(a) harm to the state.
In 1954 the factory Yrasnaya Zarya suffered a loss of
almost one million rubles due to underproduction resulting
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from the disease. Approximately one-half of all disburse-
ments from social insurance funds were for disability
certificates issued in connection with the disease.
(b) harm to the individual.
Possible complications: bronchitis, pneumonia, pleurisy,
pulmonary abscess, lung gangrene, aggravation of tuberculosis,
otitis media, frontitis, damage to the heart or nervous
system.
3. Nays of transmitting influenza (concept of droplet infections).
Sprays from the mouth are ejected in conversation to a distance
of 1 meter and up to 3 meters in coughing or sneezing. Large
droplets remain in the air for half an hour to an hour, small
droplets up to five hours.
4. Prevention of influenza and complications.
Early-visit to the doctor and faithful obedience to his orders.
(a) behavior of sick persons.
They must cover their mouth and nose with a handkerchief
when coughing or sneezing. Nursing mothers must wear a
gauze mask over their mouth and nose. The beds must be
partitioned off by a screen. No one should be allowed to
use a patient's dishes, towel, etc.
(b) Hardening.
Taking the sick rate for influenza in a naval school in
Leningard for first year students at 100, the figures show
that as they became more hardened the number of cases
dropped for 2nd year students to 86, 3rd year students to
52, 4th year students to 42, and 5th year students to 19.
A summary contains three parts: introduction, body, and conclusion.
The purpose of the introduction is to acquaint the listeners with the
subject and its importance and to arouse their interest in it. The body
contains the basic factual material, proofs for various contentions,
analysis of the question from all sides. The conclusion briefly re-
capitulates the main points and calls for action.
Presentation of the material may start with a specific example and
then go on to a generalization, or vice versa. In speaking before a mass
audience it is usually preferable to begin with something concrete and
familiar to everybody. There are various ways of enhancing the effect.
A simple gesture, apt comparison or literary quotation often clarifies
an idea. Special visual aids (posters, charts, slides, etc.) help to
illustrate and make the talk more vivid. These aids should be quite
large, with a minimum of text. Some lecturers use small photographs,
medical preparations, etc., to be passed from listener to listener.
The main objection to this kind of demonstration is that it distracts
the listeners from the lecture proper.
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The
(1)
(2)
(3)
(4)
(5)
following rules should be kept in mind when preparing a summary:
Separate, numbered pages are used;
The text is written on one side of the page;
Every item, every sentence begins with a new line;
The main ideas are given numbers, the others letters;
The writing should be large and legible, and in ink;
(6) Particularly important passages are underlined in colored
pencil or marked in some other way;
(7) Numbers and quotations are written down or noted with "cf.
appendix,* "cf. book,* *cf. page*;
(8) If visual aids are to be employed, the time they are to be
shown is noted at the appropriate places.
The first two or three sentences of the speech should be written
down or committed to memory. However, the text as a whole should not
be read since this kills the living word. The language should be in
the simple colloquial style, avoiding foreign words and technical terms.
Heavy use should be made of proverbs, comparisons, and examples.
A very effective exploitation of the spoken word is in the form
of an address at meetings of one kind or another. The medical worker
should take advantage of every opportunity to speak before workers or
collective farmers, the content being related to items on the agenda and
based an local material. The speech should include specific suggestions.
Chats with sick persons require exceptionally careful preparation.
One must be on guard against the possibility of wounding or frightening
them. The talks or lectures should be optimistic in tone, inspiring the
patients with faith in the treatment and favorable outcome of the dis-
ease. At the same time they should teach them how to take care of them-
selves, to practice hygiene in their daily lives, and to eat according
to the principles of sound nutrition.
Evenings of questions and answers on medical subjects are extremely
popular. These programs, at which various specialists answer the
questions of the listeners, are very lively and attract a large audience.
The people are notified about forthcoming programs over the radio, in
the newspapers, or by posters.
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The printed word has a number of features which make it more
accessible and convenient for the people.
It is useful to recommend additional reading material. This may
be done:
(a) at a clinic, where the patient maybe referred to literature
about his disease;
(b) by a wall or factory newspaper or library reading room posting
a list of suggested books and articles for further reading;
(c) at the end of each talk or lecture;
(d) in hospitals and clinics by posters or display cases.
In addition, booklets, pamphlets, and brochures may be distributed
to the population.
A good way of using printed materials is that of reading aloud -- a
lively and interesting form of hygiene education. Its value lies in the
fact that it increases the number of people to whom the written mord may
be made accessible. Before starting to read from a text, it is desirable
to introduce it by mentioning the name of the author and the subject. It
is necessary to read slowly, expressively, and loudly.
It is recommended that the reading of a popular scientific piece
be interrupted by questions, additions, explanations, and checks to see
whether the listeners understand the meaning. These digressions also
provide brief breaks. However, there should be no such interruptions
in the case of reading from a piece of literature because they would
destroy the mood.
Medical workers discuss public health problems in the press,
particularly local newspapers. The material should be of topical
interest, concrete, and of practical concern. Liveliness and brevity
should characterize the style of writing. Here are various ways of
presenting the same subject in a newspaper:
I. Don't Forget Hygiene!
Hygiene is a science dealing with health. Whoever wants to be
healthy must meet the requirements of this science.
One of the most important hygienic habits is the mashing of hands
before eating.
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S.
During the course of a day a person's hands get very dirty. It
is a question not only of the dirt that one can see, but also of the
invisible dirt. It is enough to shake hands with a friend at work, to
turn the knob of a door, to hold money or some other object that was
held by another, for a great many invisible microbes to fall on your
hands. These microbes may include the disease-causing kind. From
your hands they can travel to your food, and from the food into your
internal organs.
Protect yourself against infectious diseases!
Wash your hands before eating!
2. Remember
When you go into the dining hall, remember where you were today
and what you did.
You rode in the trolley, you met some friends in the street, you
walked into the office of a factory, you spoke an the telephone, you
paid your union dues. This means that you held the handrail of the
trolley, a door knob, money, telephone receiver, shook the hands of
your friends.
Remember all this and you will realize how many germs from different
things might have come into contact with your hands! Remember that this
is the way disease-causing germs spread!
Always remember to wash your hands before eating!
3. Save a Second - Lose a Month
While observing sanitary conditions in our dining room I noticed
that some of the workers didn't wash their hands.
I went over to a friend of mine, Misha Karasev.
"May I ask you a question?"
"Certainly."
"Will you answer truthfully?"
"Of courser
"Did you wash your hands before eating?"
Misha was silent a moment, then said:
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*To tell you the truth, I didn't."
"And why didn't you?"
Then Misha got wound up trying to prove that he was a good worker,
anxious to save every minute he could, so he had no time to wash his
hands.
"You saved a minute," I said, "but if you get typhoid or dysentery,
which are transmitted by dirty hands, you'll lose a month or more. Is
it worth the risk?"
Comrades, those of you who don't wash your hands before eating,
think this over very carefully! A little later I'll come back to see
how you're getting an with washing your hands in the dining room.
The first example is not very good. It is rather dry and theoretical.
The second is more lively and interesting, and more closely connected
with the dining room. The third is the most concrete. In describing
her conversation with Misha, the medical worker breaks down his unsound
arguments. The title is arresting: "Save a Minute -Lose a Month."
It isn't only medical workers who write an public health matters
in the newspapers. The sanitation activists also exploit this medium
as a weapon in the struggle to raise the health level of the people.
Medical workers help by suggesting topics and making contacts for them
with the papers.
Activists hang up slogans and posters in hospitals, clubs, reading
rooms, factories, and apartment houses.
An interesting kind of hygiene education is the "question boxr
and "answer board* (advice by mail). Questions are written on pieces
of paper and deposited in a box resting on a small piece of plywood or
cardboard (about 75 x 100 cm). The answers are soon posted on the
bulletin board. The answer board" is intended to be read by a great
many people. The.answers must be serious, detailed, fairly simple,
and include references to sources of additional information.
Posters are the commonest forms of visual aids. They are of two
kinds. The "agitation* poster deals with a narrow theme that is to be
widely popularized. The "propaganda" poster usually has several pictures
and a good deal of explanatory text;.the colors are more restful. There
are also posters combining both approaches. Photographs too are of
value in that they enable medical workers to make extensive use of
local material.
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For exhibits, "health corners," *answer boards," and wall newspapers
photographs provide.clear documentary.evidence of Soviet activityl:,
instituticlls, and achievements. Clever captions greatly enhance their
usefulness.
Exhibits usually propagandize the growth of the public health
budget, network of medical institutions, staff, lowered sick rate, etc.
Popularization of the statistical data is greatly aided by the use of
graphs.* It is often necessary to enliven a graph. This is most easily
done by adding an appropriate illustration or photograph.
In addition to such flat objects as posters, illustrations, photo -
graphs, slides, diagrams, charts, etc., considerable use is maae of
three-dimensional models, dioramas, plastic molds, and natural prep-
arations.
A very simple display or "health corner" is readily put together
by middle echelon personnel from a few posters or photographs, pictures
of scientists, slogans, local material in the form of charts, wall
newspaper, and literature. Such exhibits can be mounted on cardboard
and easily moved from place to place.
Moving pictures are an excellent means of carrying an visual agi-
tation and propaganda. Medical workers should try to get local groups
sponsoring films to include some on health topics.
Local radio stations can also be used, especially for brief lectures.
A good type of speaker is the citizen actively interested in public
health (he should describe his experiences). Radio talks should be
prepared on the assumption that the audience is likely to be highly
diversified, consisting of adults and children, healthy and sick people.
The language must be simple, with the main ideas repeated to ensure
full comprehension.
Features of Hygiene Education in Various Medical Institutions
and Among Different Groups of People
Hygiene propaganda is one of the duties of the sanitary-epidemio-
logical station along with its routine inspections and antiepidemic
activities.
Workers must be familiar with the elements of industrial hygiene,
the different ways of improving working conditions (mechanization of
time-consuming processes, control of dust, gases, and noise), personal
*Ion graphs, cf. chapter 2.
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hygiene, etc. It is particularly important to reach employees in food
processing plants, water works and other public utilities. This should
be done through regular courses and lectures or reports.
For the population as a whole the station should arrange for
lectures and informal talks on sanitary conditions at home, removal
of garbage, the importance of planting trees and shrubs.
Mothers should be taught at inoculation centers the significance
of vaccination, disinfection, and early hospitalization of persons
with contagious diseases. Appropriate stories should be placed in
factory newspapers and wall newspapers for recreation rooms and propa-
ganda centers, booklets issued, posters and slogans displayed.
The approach to children is adapted to the age level. Nursery
and pre-school age youngsters are taught hygienic habits and instilled
with a positive attitude toward cleanliness and water and a negative
attitude toward filth, slovenliness, and untidiness. They should grow
accustomed to fresh air, adopt good food and sleep habits. Useful
pedagogic devices are games (e.g., bathing dolls, washing handker-
chiefs, etc.), picture books, stories. In school the students acquire
knowledge of how to take care of their health along with new hygienic
habits. This is all elementary for the lower grades, but in the upper
grades the youngsters study human anatomy and physiology along with
various problems in hygiene, take courses in DGS0 and GS0 ["Be Ready
for Medical Defense"] circles, read pertinent literature.
In handling patients in a polyclinic or hospital, it is necessary
to be aware of the psychological problems involved and to show great
interest in their disease and anxieties. Here hygiene education assumes
a psychotherapeutic character as it strives to gratify the patients'
curiosity about their condition and at the same time relieve their
anxieties, inspiring them with confidence in the treatment they are
getting and in a favorable outcome of the disease. The approach will
vary with the circumstances. In a polyclinic, for example, the work
can be performed in the physician's office, waiting room, or regis-
tration section. The physician's office is a good place for individual
and group talks. The waiting room lends itself to displays, wall
newspapers, and remarks by medical personnel. The registration section
might well pass out reading materials. Clubs, reading rooms, and
propaganda centers should arrange for movies, exhibits, and plays in
addition to lectures.
Hygiene education among the rural population is of exceptional
importance, for it can help raise the productivity of farm laborers
and their general cultural level along with improving their working
and living conditions. The main things to be emphasized are improve-
ment of sanitary conditions in the state or collective farm, machine
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and tractor station, and homes, personal hygiene, inculcation of health-
ful habits in children, antialcoholism, and control of infectious dis-
eases. The nature of agriculture requires the expenditure of much effort
to explain how to avoid injuries and skin diseases, how to render first
aid in case of accidents and acute infectious diseases. Any educational
program for a rural medical district must take cognizance. of the seasonal
character of farming and the various diseases associated with it.
The propaganda of a feldsher-midwife station is coordinated with
the work of the local Soviet and social organizations and approved by
the chief physician of the district hospital. The station's program
consists chiefly of talks, distribution of literature, lectures in
clubs of collective farms, and local radio broadcasts.
The place in which the talks are given is determined by the subject
and audience: in farm maternity hospitals and nursery schools - with
mothers; in schools - with students and teachers; in field camps - with
workers in collective and state farms, machine and tractor stations; in
feldsher-midwife stations - with pregnant women and patients, lessons
for sanitary activists.
Rural hygiene education stresses the training of activists. The
program of a feldsher-midwife station includes: (1) organization and
training of sanitary activists; (2) scheduling of the propaganda work;
(3) arranging of mobile exhibits, health boards, supplying of reading
and recreation rooms and collective farm clubs with literature. The
station selects, trains, and appoints public sanitation representatives
to collective farms, machine and tractor stations, schools, and hostels.
It also teaches farm workers how to render first aid to themselves and
to others and trains "Be Ready for Medical Defense" leaders.
People's Activity in Public Health
The people share in the work of public health agencies and medical
Institutions. This activity is a principle of Soviet public health
whose success would be impossible without it. The people's interest
in public health and understanding of its importance combined with their
energetic participation guarantee continuing improvement in the quality
of the service rendered. The organization of medical facilities is one
of the major tasks of the Soviets of Workers' Deputies.
The Soviets are aided by 2ermanent commissions for public health,
which are made up of elected representatives, deputies who unite around
themselves a large group of medical men. Members of these commissions
together with sanitation activists check daily on sanitary conditions
in cities, workers' settlements, and rural localities. They inspect
water supplies, landscaping, conditions in medical institutions and
in manufacturing, trade, and food companies. They report on the results
at executive sessions of the Soviets of Workers' Deputies, which then
take whatever action may be appropriate.
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The Red Cross and Red Crescent are of great help in public health.
They do a good deal of vork amorg the peoples particularly in spreading
knowledge of medicine and hygiene in. GS0 groups ("Be Ready for Medical
Defense of the USSR" Gotov k sanitarnoi oboroneSSSR), sanitary squads,
EGSO groups ("Be ReadyoredicalDsedgornovBu k sanitarnoi
oborone) in schools. They enlist the help of sanitary activists in
behalf of various public health programs.
The Minister of Health, USSR, issued a special order On the Joint
iork of Public Health Agencies with the Red Cross and the Red Crescent,'
30 October 1954, no. 218), making it the duty of all directors of
oblast, kray, rayon, and city health departments, and hospitals to
cooperate personally with the Red Cross and the Red Crescent and help
them to organize mass training of the population in the GS0 and EGSO,
set up sanitary posts, sanitary squads, and sanitary representatives,
and persuade members to become blood donors. Accordingly, the directors
are required to assign the sanitation squads, posts, sanitation repre-
sentatives to the nearest health stations, dispensaries, polyclinics,
medical districts, feldsher-midwife stations, and sanitary-epidemio-
logical stations. The directors are also required to give the sanitation
activists daily guidance. The latter are also used by medicoprophylactic
institutions in connection with mass sanitary improvements.
The work of these public spirited citizens in the preventive phases
of public health is very varied.
In factories they help medical workers to check on observance of
sanitary norms and regulations for the maintenance of shops, food,
administrative, and residential areas, cultural and welfare facilities,
and industrial safety devices. They spread knowledge of general and
personal hygiene along with methods of preventing sickness and accidents.
Activists organize health lectures and talks, give first aid in emer-
gencies, and transport injured persons to the medical station. They
are under the direction of the head of a medical unit of health station,
shop physicians, or physicians of a polyclinic, hospital, or sanitary-
epidemiological station.
In rural localities the activists help medical workers to educate
the people on the prevention of agricultural traumatism and infectious
diseases (mass prophylactic examinations, inoculations, disinfection,
notification of acute infectious diseases, etc.). They check on sanitary
conditions in field camps, yards, and houses, dining rooms, stores,
sources of water, etc. They interest the people in village planning,
organize health lectures and talks, render first aid in case of accidents,
transport the injured to the feldsher station or rural district hospital
(outpatient department). They are under the supervision of a sanitary-
epidemiological station, district physician, or feldsher.
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In schools id-other educational institutions the activists assist
medicirioersonnel in spreading propaganda on the rules of personal hygiene
and see to it that they are obeyed, check on sanitary conditions in the
class rooms, food areas, shops, gymnasiums, cloak rooms, toilets, and
yards, calling the attention of the school doctor (or nurse) to violations.
They organize health lectures and talks by medical personnel, render
first aid in accidents. They are under the direction of medical workers
In the rural district, sanitary-epidemiological station, school physician,
or nurse.
In institutions and private homes sanitary activists help medical
workers to check an sani ary conditions and report violations to the
health agencies. They cooperate in the execution of measures designed
to prevent the spread of infectious diseases (detection, vaccination),
participate in the organization and supervision of disinfection. They
give warning of all cases of acute infectious diseases, organize health
lectures and talks by medical workers, render first aid in accidents,
help victims of accidents and those suddenly becoming ill to get to the
hospital. They are under the supervision of a sanitary-epidemiological
station or district physician.
Sanitation activists must serve as an example to the people. They
should take part in meetings of workers, farmers, and students on health
problems and see to it that sanitation is given full consideration in
socialist commitments and agreements as well as in plans for industrial
improvements.
Sanitation representatives are chosen at general meetings of manual
and ofIrce empioyees, and collective farmers from among those literate
persons who are most actively interested in public health problems. They
give an account of their work to the group that chose them.
Efforts should be made to have sanitation representatives in every
populated area and on every collective farm.
Sanitation posts are organized in factories, collective and state
farms, machine and tractor stations, workers' quarters, schools, and
institutions. They are manned by active members of the Red Cross and
Red Crescent and have some medical training (they have earned the GS0
or am emblem). The sanitation posts render first aid in the case
of accidents in shops, field camps, or schools. They are equipped with
stretchers, medicines, and bandages. They also check on sanitary con-
ditions in their plants or institutions.
Insurance delegates are active members of trade unions working
in close cooperation with the medical staff of industrial enterprises.
They see to it that sick workers get the medical attention they need,
that medical certificates are correctly used, and that sick persons
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obey the doctor's orders. They help to take care of patients who live
by themselves. The work of these delegates is a factor in lowering the
industrial sick rate.
Assistance councils consisting of representatives of,;6iffice and
manual workers in factories and various kinds of institutions take an
active part in the work of medicoprophylactic institutions. In
accordance with the regulations approved by the All-Union Central
Council of Trade Unions and the Ministry of Health, USSR, these councils
discuss the programs of the institutions, help to work out ways of
improving medical service, decreasing and preventing sickness, especially
that involving temporary disability, organizing medical aid at homey
health propaganda, antiepidemic measures, and sanitary inspections, etc.
If sanitation activists are to function efficiently, they must be properly
trained and systematically supervised by medical personnel. The latter
can ensure high calibre people by:
(1) Participating in the election of activists (selecting candidates,
being present and speaking at general meetings). A group of activists is
usually formed once a year, but medical workers must study and choose
people to help them throughout the year. Sometimes a future activist
may be encountered in a hospital or polyclinic and his interest subse-
quently strengthened when a former patient is elected to a public post.
It is also possible to meet potential sanitary representatives in GS0
societies or in hygiene courses for tractor drivers, milkmaids, collective
farm cooks, etc.
(2) Training activists. The persons chosen take special courses
depending on the group they are in. Those attending classes with
insurance delegates study industrial hygiene and methods of lowering
the sick and accident rates. Sanitation posts practice first aids etc.
These courses are given without interrupting regular work. In the
country classes are held in farms and machine and tractor stations if
a physician or feldsher is available to provide the instruction.
(3) Maintaining contact with the activists. Medical workers must
keep in cOEFEFEE touch with their activists (to pass out assignments,
exercise supervision).
(4) Check an the activists' work. If it turns out that certain
activists do poor work, send in no reports, or fail to develop, the
appropriate organization (e.g., collective farm management) is asked
to give them a hearing. Those who do not justify public trust are
relieved of their duties.
(5) the activists' Every effort should
be made to---.ctivistsitiStrenghentithority. In their lectures,
reports, and informal talks medical workers must refer to the activists
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as performing useful and respectable work possessing national significance.
The press and wall newspapers are required to carry accounts of their
activities. Their authority is enhanced when newspaper articles on
health questions are signed jointly by a medical worker and an activist,
or only the latter.
(6) Encouraging activists. By directly supervising their work,
medical personnel income acquainted with the ablest of these public-
minded citizens. Health departments, business concerns, and collective
farms are authorized to reward those Who have done outstanding work.
They may be officially thanked on behalf of the rayon health department
or executive committee of the rayon Soviet. Another form of encourage-
ment for good work is publication of accounts of activists' experiences
in newspapers (with mention of their names) or even in special booklets.
Certain oblasts and rayons are famous for the brilliant way they
managed to enlist mass participation in public health activities. For
example, in Geokchai (Azerbaijan SSR) and Rogacheva (Byelorussian SSR)
the people did an exceptionally fine job in cleaning up inhabited places
and homes, building baths and toilets, decontaminating wells, planting
trees and shrubs, etc. In Zhitomir (Ukrainian SSR) the people were of
great help to the public health agencies in reconstructing the network
of medical institutions destroyed by the fascist invaders.
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CHAPTER 9
PLANNING AND FINANCING CF PUBLIC HEALTH
A distinguishing feature of Soviet public health as a branch of
governmental activity is its planned character. The national economy
is developing in the USSR not haphazardly, as in the capitalist countries,
but systematically.
The party and government plan the national economy, scientificially
applying the objective economic laws of socialist development. The
importance of planning is set forth in article 11 of the Constitution
of the USSR: *The economic life of the USSR is determined and directed
by the state economic plan in the interests of increasing the people's
wealth, ensuring a steady rise in the workers' material and cultural
levels, and strengthening the USSR's independence and defensive capac-
ities."
National economic planning is possible only when all the tools
and means of production belong to the people. In a capitalistic society,
which relies on private property, planning on a state-wide scale is
impossible. National planning, as practiced in the USSR and the
countries that have chosen the road to socialism, it must be emphasized,
is one of the major advantages that socialism possesses over capitalism.
All branches of the economy and culture in our country, including
public health, are developing in accordance with a single, overall
state plan.
Planning embraces the most important aspects of public health
work; distribution of material resources, personnel, medical facilities,
equipment, etc., with a view to ensuring their utilization in the
most efficient way possible.
Sound planning of the facilities and programs of medical institutes
helps to solve general problems involving state policy and to promote
industrial expansion. For example, the swift growth of public health
in the union republics was an expression of the national policy of
the Soviet government aimed at developing to the maximum the economy
and culture of the formerly backward national regions of Tsarist Russia
and raising them to the level of the leading Soviet republics.
The most important problem in recent years -- exploitation of
undeveloped lands and the creation of well equipped and staffed
collective farms and machine and tractor stations -- has required
appropriate action by public health agencies to provide the necessary
high quality medical facilities and personnel. Many other examples
could be cited.
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The advantages of socialized public health are clearly revealed by
comparing it with the medical system existing in the capitalistic
countries, e.g., the United States. Although this country has a large
number of hospital beds and physicians, it turns out, as the chief
medical inspector wrote in the Journal of the American Medical Associ-
ation, that in 1947 40% of the rural areas of the country had no hospitals,
that there were no physicians at all serving in 81 regions, while the
bulk of the profession flooded the large cities in the hope of creating
a well paying private practice.
The planned character of Soviet public health makes it possible
to organize medical facilities in various populated places, krays, and
oblasts according to the nature and importance of the local economy,
climatological and geographical features, and distribution of the
population.
Data on the age, sex, and occupational compositicn of the popu-
lation as well as on the morbidity rate are essential since this
information determines the requirements for the different kinds of
medical aid.
Directives of the party and government and orders of the Ministry
of Health relating to the individual ()blasts, rayons, or to medical
services for various groups, e.g., the workers in certain branches of
industry or juvenile workers, are taken into account in drawing up the
plans.
A comprehensive program for public health expansion includes the
following interrelated elements: (a) network of institutions, (b)
medical staff, (c) data an the number of workers and wage funds,
(d) construction and equipment of facilities, (e) supplies, e.g.,
linens, fuel, (f) finances (budget).
Plans are drawn up for one year, five years, sometimes longer.
The annual budget estimates of the individual medical institutions
are the most important of all. They are combined with those of the
rayon and city, which are merged in turn with the oblast, republic,
and all-USSR estimates.
Certain elements are used to characterize the size, structure,
staff, and program of every health facility. For a hospital they are:
number of beds by specialties, number of positions for doctors and
middle echelon personnel, number of consultation rooms in the poly-
clinic, and various activities. In the case of a sanitary-epidemio-
logical station it is necessary to know the number of laboratory
analyses, number of establishments in its jurisdictional area subject
to sanitary inspection and control, etc.
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Estimates for the coming year are based on the work done during
the first half of the current year, anticipated accomplishments for the
entire year, and reports of the preceding year. For example, the over-
loading of doctors' or feldshers' offices with patients in violation
of the norms -- possibly due to an increase in the number of people
served -- suggests the need of adding more medical positions. A low
Index of average bed occupancy by patients with certain diseases when
all those suffering from these diseases were hospitalized suggests the
possibility of transferring some of the beds to other departments. On
the other hand, a very high index of bed occupancy (more than 3)40 days
a year), especially when some sick persons could not be accommodated
and there were deaths at home, would justify an increase in the number
of beds for certain departments.
An effort should be made to adhere to the typical structure and
staffing pattern established by the Ministry of Health, USSR, for the
given type of institution. The figures should be arranged in chart
form. A completed table for a rayon hospital will look something
like this:
Principal indices of a hospital's Beds
work
Total number of beds
Including:
medical
surgical
maternity
children's
others
1954
(report) plan
1955 1956
comple- (plan)
tion ex-
pected
70 70 72 75
20
17
10
5
18
20
18
12
8
12
Number of days beds occupied a .
year 335 330
Number of bed-days for the year 23,450 23,100
Number of outpatient visits 95,400 96,000
Number of medical positions 16 16
etc.
I.'
18
12
8
12
23
20
12
8
12
348 340
25,056 25,500
96,200 96,500
16.5 18
The concluding or financial section contains the institution's
estimates of the amount of money needed to carry out the plan.
The budget includes only beds actually available for use, i.e.,
not merely beds as such, as specified in the estimates, but ready for
the patients with linens and other necessities. The average number of
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beds per annum is the usual basis for calculation. supposing that in a
certain hospital the number of beds in the general medical department
was increased from 20 on January 1st to 26 on July 1st, the average
number of beds for that year would have been 21: i.e.:
20 beds x 6 months = 120 bed months
26 beds x 6 months = 156 bed months
276 bed months
276 bed months = 23 beds
12 months
The norms established by the Ministry of Health, USSR, are applied
in calculating the number of bed days. Hospital beds cannot be used
every day in the year since some of them have to be repaired, disinfected,
etc. Hence, public health agencies estimate an average occupancy of
340 days for city hospitals and at least 310 days for rural hospitcls.
The planned number of bed days for 23 medical beds would be 340 days
23 beds = 7,020 bed days.
The number of doctors and middle echelon personnel required is
ascertained from the prevailing norms. For example, a general practitioner
sees 5 persons an hour, a surgeon 10 persons, an opthalmologist 8 persons,
etc. A doctor is allotted 30 minutes for each home visit, a district
nurse 40 minutes.
The Budget of Medical Institutions
redical institutions are supported by the state. In the 11=1
unlike the capitalistic countries, due to the socialistic economy and
socialistic ownership of the means of production, the entire national
income belongs to the workers. The bulk of the income goes for further
expansion of socialistic production and for satisfaction of the people's
every day and cultural needs.
The national economy and cultural upbuilding of the USSR n.e
financed by the state budget, which is approved every year by the
Supreme Soviet 0: the USSR. The state budget is the basic financial
plan of the country, providing for its revenues and expenditures for
the coming year.
In contrast to the capitalistic countries, where most of the revenue
comes from taxes and levies on the population, the major portion of the
USSR budget (87% in 195)4) is made up of income from the socialistic
economy (turnover tax, deductions from profits, etc.).
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Taxes and levies as well as state loans constitute an insignificant
percentage of the income (11.1% in 195)4.), all of which is returned to
the people in the form of allocations for cultural services, payments
for winnings in state lotteries, etc. In addition, the workers receive
substantial sums from state social insurance funds.
Expenditures are another item in which the USSR state budget
differs radically from that in the capitalistic countries. In these
countries the budget is used to enslave the workers and progressively
lower their standard of living, whereas in the USSR the budget reflects
the basic economic law of socialism, which aims at maximum satisfaction
of the steadily growing material and cultural needs of society as a
Whole. The budget in capitalistic countries is fundamentally military
in preparation for a new world war. For example, American military
expenditures make up about 80% of the total budget, with scarcely 1%
devoted to public health. On the other hand, the picture in the USSR
is completely different in that state expenditures on social and
cultural affairs keep on rising from year to year. In 1954 they were
25% of the total, or 141 billion rubles, in 1955 they were 147 billion
rubles. Some 35 billion rubles were allocated in 1956 for public
health and physical culture, 53.6 billion rubles for social insurance,
social security, and grants for unmarried mothers and mothers of large
families.
The USSR state budget is a composite of the union, republic, and
local budgets. The union budget, as prepared by the Council of Ministers,
USSR, finances the most important sectors of the national economy, defense,
and major social and cultural measures. Local Soviets of Workers'
Deputies draw up their own budgets -- oblast (kray), rayon, city, and
village.
Each organization or project is financed by its own budget. The
major institutions (Academy of Medical Sciences, scientific research
institutes, etc.) are covered by the union budget, hospitals and clinics
serving an oblast or rayon by the oblast or rayon budget (Figure 30).
The individual estimates for each hospital, nursery, sanitary-epidemio-
logical station, etc., in the rayon are added together to make up the
budget of the rayon public health department, which determines the
standards to be met. The composite total is then studied and approved
by the rayon executive committee of the Soviet of Workers' Deputies.
Feldsher-midwife stations are financed by the village budget.
The city budget takes care of the city hospitals, nurseries, and health
stations under the jurisdiction of the health department.
The composite rayon budget is a total of the village, city, and
rayon estimates.
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The composite oblast budget consists of the rayon, city, and oblast
estimates.
Most of the medical institutions are under the jurisdiction of the
local soviets so that the bulk of expenditures on public health is
covered by local budgets.
Preparation of Individual Estimates
The individual estimates of an institution are the list of expendi-
tures by separate items needed to support the institution and its work
for the coming year. They are based on certain indices which define the
scope of its activities, normal outlays for food, medicines, and repairs,
staffing pattern, and wage scale. In addition, they include the instruc-
tions of the next higher public health agency and the projected allocations
and expenditures for the current year.
Institution budgets, which follow the form approved by the Ministry
of Finance, USSR, are arranged by item and work index. A hospital
budget, for example, will contain the following:
Item 1 - salaries.
Item 2 - social insurance payments.
Item 3 - clerical and administrative expenses.
Item IL - business and official trips.
Item 5 - expenses for educational purposes and scientific research,
acquisition of library books.
Item 9 - costs of feeding the patients.
Item 10 - procurement of medicines and dressings.
Item 12 - capital investment for equipment and supplies.
Item 14 - procurement of soft goods.
Item 16 - major repairs to buildings and installations.
Item 18 - other expenses.
Items 1 to 10 represent the regular recurrent expenses incorporated
in the estimates of every institution. Items 12, 14, and 16 represent
occasional expenses.
Item 1 (salaries) covers all the workers of the institution in
accordance with the existing staffing pattern and official pay scale.
It includes the salary of substitutes when the regular personnel are
absent.
Item 2 provides payments for state social insurance from the
salaries specified in item 1. In the case of medical workers the
payments are 5.9% of the annual wage fund.
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Item 3 takes care of clerical and office expenses, postage,
telegraph, and telephone costs along with maintenance (heat, light,
water, rent, transportation, laundry, etc.).
All these expenses must be based on sound calculations and pre-
vailing standards for the various items.
The estimates must mention the place, type of heating, number of
automobiles, amount of linens to be laundered, etc.
Item 4 states the number of projected trips, length of time,
transportation, food, and lodging costs in accordance with established
standards. Besides official trips, the item covers attendance of
doctors and middle echelon personnel at courses, meetings, and scientific
conferences.
Item 5 is particularly important for medical schools and scientific
research institutes since it covers expenses for both theoretical studies
and practical work. It also covers the acquisition of books and period-
icals for libraries.
Item 9 is a major element in hospital budgets. Food expenses are
calculated per bed-day in accordance with the established norms. They
will differ, of course, from department to department. In the maternity,
children's, and tuberculosis departments the norms are somewhat higher
than in the others, and the estimates for each type of bed are calculated
separately. The total food costs are obtained by multiplying the norms
for feeding one patient a day by the planned number of bed-days.
Item 10 covers expenses for the procurement of drugs, dressings,
small medical instruments, disinfectants, X-ray film, etc. The expenses
are calculated at the rate of one bed-day for a hospital and one medical
visit for a polyclinic. The estimates are necessarily based on the
norms established by the health department as well as on the estimates
and actual disbursements of the past year.
Items 12 and 14 provide for one-time capital investments to acquire
medical equipment, apparatus, furniture, linens, clothing, bed necessities,
etc. In justifying this item, it is necessary to list the available
equipment and supplies, the number and kind of objects it is proposed to
acquire along with the cost of each according to state prices.
Item 16 deals with expenses for major repairs (justified on technical
grounds) estimated by a construction organization or by an engineer or
builder invited by the institution. Appended to the figures is a break-
down of the necessary work together with the costs.
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Item 18 (other expenses) includes expenses for cultural and educational
propaganda among patients and for other things connected with hospital care.
The budget of a sanitary-epidemiological station is prepared in the
same way.
Item 1 (salaries) is based on the established staffing pattern for
sanitary-epidemiological stations and the appropriate pay scale.
Item 5 (scientific research) can include, in addition to the above-
mentioned, expenses for scientific missions, procurement and maintenance
of experimental animals, chemical reagents, laboratory vessels, etc.
Item 9 (costs of feeding patients) is naturally not in the budget
of sanitary institutions.
Item 10 (procurement of medicines) includes bacteriological pre-
parations, drugs, disinfectants, payments for blood donors.
Item 14 provides for the procurement of linens (robes, towels)
and special protective clothing in accordance with established norms.
The preparation of other items in the estimates for a sanitary
institution does not differ in principle from the preparation of estimates
for other medical institutions. However, in case of an epidemic requiring
extraordinary measures, a supplemental request is made (in item 18).
The figures are prepared by an accountant, checked, signed by the
head of the institution, and submitted for approval to the health depart-
ment exercising jurisdiction over the institution.
The estimates approved by the health department director are the
financial plan governing the operation of the institution. The latter
does not have the right to make any changes thereafter or to transfer
funds from one item to another.
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REFERENCES
General Problems
Organization of Public Health
Semashko, N. A., Izbrannyye proizvedeniya [Selected writings] Medgiz, 1954
Solovlyev, Z. P., Voprosy zdravookhraneniya [Problems in public health],
Moscow, 1940
Batkis, G. A., Organizatsiya zdravookhraneniya [Organization of public
health] Medgiz, 1948
Maistrakh, K. V. and Rodov, Ya. I., Posobiye k prakticheskim zanyatiyam
po organizatsii zdravookhraneniya [Aids for practical lessons in
organization of public health] Medgiz, 1955
Alsip= tablits nOrganizatsiya zdravookhraneniya,? red. K. V. Maistrakh
[Picture book "Organization of public health,1! ed. K. V. Maistrakh],
Meduchposobiye, 1952
Zhurnaly: ?Felldsher i akusherkaIN nMeditsinskaya sestran [Periodicals:
?Feldsher and Midwife," "Nurse")
CHAPTER 1
Vinogradov, N. A., Osnovnyye printsipy sovetskogo zdravookhraneniya
[Basic principles of Soviet public health] Medgiz, 1954
Barsukov, M. I., Velikaya OktyabrIskaya sottialisticheskaya revolyutsiya
i organisatsiya sovetskogo zdravookhraneniya [The Great October
Socialist Revolution and the organization of Soviet public health]
Medgiz, 1951
Bakulev, A. N., Zabota sovetskogo gosudarstva o zdorovlye trudyashchikhsya
[Soviet government concern for the workers! health] Profizdat, 1954
Petrov, B. D., Profilaktika - okhrana zdrovlya zdorovykh [Prophylaxis --
protection of the health of the healthy] Medgiz, 1954
CHAPTER 2
Kozlov, P. M., Sanitarnaya statistika [Health statistics] Medgiz, 1949
Sadvokasova, Ye. A., Teoriya i metodika sanitarno-statisticheskogo
issledovaniya [Theory and methods of research in health statistics]
Medgiz, 1954
Khotsyanov, L. K. and Annareiskayal A. I., Metodicheskiye ukazaniya
po provedeniyu ucheta, razrabotki i analiza zabolevayemosti s
vremennoi utratoi trudoscosobnosti [Methods of recording, processing,
and analyzing morbidity mith temporary disability] Medgiz, 1954
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?.!
?
CHAPTER 3
Gorodskaya bollnitsa? sb pod red. N. A. Semashko [The city hospital,
a collection edited by N. A. Semashko] Medgiz, 1949
Vinogradov, P. A., Podollnyil S. A., and Rostotskii, I. B., Metodika
obsledovaniya gorodskikh bollnits [Methods of inspecting city
hospitals ]Medgiz, 1954
Podollnyi, S. A., Organisatsiya raboty poliklinik gorodskikh bollnits
[Organization of work in the polyclinics of city hospitals] Medgiz,
1955
Timko, I. M., Osnovnyye printsipy mediRD-sanitarnogo obsluzhivaniya
rabochikh promyshlennykh predpriyatii [Basic principles in medical
examinations of industrial workers) Medgiz, 1954
Maistrakh, K. V., Dispansernyi metod raboty lechebno-profilakticheskikh
uchrezhdenii [The clinical method in medicoprophylactic institutions]
Medgiz, 1955
CHAPTER )4
RostotskiiII. B., Oblastnaya bollnitsa [The oblast hospital] Medgiz, 1954
Lekarev, L. G., Sillskii vrachebnyi uchastok [The rural medical district]
Medgiz, 1949
Konstantinov, G. F. and Bychkov, I. Ya., Felldshersko-akusherskii punkt
na sele [The village feldsher-midwife station] Medgiz, 1954
CHAPTER 5 AND 6
Gosudarstvennaya okhrana pray materi i rebenka v SSSR. Spravochnik
dlya meditsinskikh rabotnikov, izd. Instituta sanitarnogo prosvesh -
cheniya. [State protection of the rights of mothers and children in
the USSR. A reference book for medical workers, published by the
Institute of Hygiene Education]
Manannikova, V. V., Okhrana zdorov!ya materi i rebenka v SSSR [Protection
of the health of mothers and children in the USSR] Medgiz, 1955
CHAPTER 7
Sbornik vazhneishikh ofitsiallnykh materialov po sanitarno-epidemiolo-
gicheskim voprosam, pod red. T. Ye. Boldyreva [Collection of the most
important official papers on sanitary-epidemiological problems, ed.
by T. Ye. Boldyrev] Medgiz, 1949
Sanitarno-epidemiologicheskaya stantsia, pod red. V. M. Zhdanova [The
sanitary-epidemiological station, ed. by V. M. Zhdanov]. Vol. 1,
Medgiz, 1952; vol. 2, Medgiz, 1953
Bychkov, I. Ya., Pravovyye osnovy deyatellnosti sanitarnykh organov
[Legal bases for the activities of health agencies] Medgiz11954
Veber, L. G., Osnovnyye etapy razvitiya sanitarno-epidemiologicheskoi
sluzhby v SSSR, yeyo struktura i zadachi [Principal stages in the
development of the sanitary-epidemiological service, its structure
and tasks] Medgiz, 1955
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CHAPTER 8
Sokolov, I. S. and Trakhtman, Ye. N., Organisatsiya i metodika sanitarno-
prosvetiteltnoi raboty, uchebnik dlya felldsherskikh shkol [Organization
and methods of health education, a textbook for feldsher schools]
Medgiz, 1951
Zabolotskaya,L.P., Sanitarnoye prosveshcheniye v gorodskoi boltnitse
[Health education in a city hospital] Medgiz, 1951
Shangin, N. I., Sanitarno-prosvetiteltnaya rabota gorodskoi sanitarno-
epidemiologicheskoi stantsiilizd. Instituta sanitarnogo prosveshcheniya
[Health education in a city sanitary-epidemiological station, published
by the Institute of Hygiene Education] Moscow, 1953
Sanitarnoye prosveshcheniye, rukavodstvo dlya vrachei, izd. Instituta
sanitarnogo prosveshcheniya [Health education, a guide for physicians,
published by the Institute of Hygiene Education] Moscow, 1954
CHAPTER 9
Rozenfeltd, I. I., Osnovy i metodika planirovaniya zdravookhraneniya
[Principles and methods of planning public health] Medgiz, 1954
Kachalov, S. F., Sostavleniye smety raskhodov meditsinskikh uchrezhdenii
[Preparation of budget estimates of medical institutions] Medgiz,
1955
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APPENDICES
Appendix 1
Regulations for Rural Feldsher-Midwife Stations
Approved by the Ministry of Health, USSR
31 December 1954
1. "Feldsher-midwife station!' is the name of a public health unit
which submits its own budget estimates and is located in a rural locality.
Administratively, it is under the jurisdiction of the agency supplying
its funds, but as far as its medicosanitary work is concerned, it is
responsible to the rural district hospital (outpatient department) or
rayon hospital (if the station is in its area).
2. A feldsher-midwife station is opened or closed by the rayon
health department by agreement with the oblast (krgy) health department
and health ministry of an autonomous or union (having no oblast division)
republic.
3. A feldsher -midwife station is set up to serve the population of
a rural soviet in a village, machine and tractor station, state farm,
or lumbering establishment inhabited by 300 to 800 persons, provided
that there is no rural district hospital or rural district clinic within
a radius of 4 or 5 kilometers.
4. The staffing pattern of a feldsher-midwife station typically
consists of 1 feldsher, 1 midwife, and 1 (female) orderly.
5. The head of a feldsher-midwife station is a feldsher (or
feldsher-midwife) who has completed his (her) middle grade medical
education. The midwife of the station must have completed specialized
middle grade medical education. The rayon health department appoints
and dismisses the head of a feldsher-midwife station and the midwife.
6. The head of a feldsher-midwife station maintains records and
submits reports in the established form and at fixed times to the
chief phys5cian of the rural district hospital (outpatient department).
Be appends to the report an explanatory memorandum with an
analysis of the statistical data an morbidity, directing attention to
the reasons for the various diseases (traumatism, infectious diseases,
angina, etc.).
Copies of the reports must be kept on file at the station
until they are delivered to the archives after a certain period of time.
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7. A feldsher-midwife station affixes to the various documents
that it issues a circular seal and stamp with its name on it.
8. A feldsher-midwife station must have adequate quarters -- at
least 3 rooms -- and be furnished in accordance with the table of equip-
ment approved by the Ministry of Health, USSR.
9. It may happen that a collective farm maternity hospital is built
in the villages served by a feldsher-midwife station. In that event, if
there were no need for a special midwife, the midwife of the feldsher-
midwife station would be required to work at the same time in the maternity
hospital.
10. The midwife of a feldsher-midwife station is administratively
subordinate to the head of the station. The actual direction of her
work is provided by the chief physician of the district hospital (out-
patient department) or obstetrician-gynecologist of the rayon hospital.
If a feldsher-midwife station has a maternity section, the mid-
wife does her practical work in accordance with the regulations for a
collective farm maternity hospital.
11. The head of a feldsher-midwife station prepares jointly with
the midwife a quarterly work program for the station, submitting it for
approval to the chief physician of the rural district hospital (out-
patient department) or rayon hospital.
12. The head of a feldsher-midwife station and the midwife of a
feldsher-midwife station shall systematically endeavor to increase their
scientific skills and political knowledge. At regular intervals the
rayon health department shall arrange for them to take advanced courses
or specialized training in a rayon or district hospital. They shall
also participate actively in conferences of medical workers.
13. The head of a feldsher-midwife station has the right to prescribe
from the dispensary any drugs that may be needed, including poisons and
potent preparations, in doses not to exceed the maximums established by
the Pharmacopoeia. The feldsher accounts for and stores group A and
group B drugs in accordance with the rules and instructions of the
Ministry of Health, USSR, and under the supervision of the chief physician
of the district hospital (outpatient department).
14. A dispensary of the second group may be organized in a feldsher-
midwife station located in a village where there is no dispensary in
accordance with the regulations for dispensaries approved by the Ministry
of Health, USSR.
184
In this case the head of the feldsher-midwife station shall at
the same time manage the dispensary and discharge the duties specified
in the regulations for dispensaries.
15. The head of a feldsher -midwife station has the right to issue
information on birth certificates, inoculation records, and certificates
of death at home, if he treated and observed the patients while they were
alive.
16. The head of a feldsher -midwife station has the right:
(a) to issue to members of collective farms certificates
releasing them from work for temporary disability, the period not to
exceed 3 days; extensions may be authorized only by a physician in the
rural district hospital (outpatient department), rayon hospital, dis-
pensary, etc.;
(b) to issue medical certificates in accordance with prevailing
instructions for issuance of these certificates to insured persons, pro-
vided that the feldsher who manages the station has been included by the
oblast (kray) health department (ministry of health of an autonomous
republic, Ministry of Health, USSR, in republics having no oblast
division) on the list of feldshers authorized to issue medical certifi-
cates, together with an indication of the period for which his authority
is valid.
17. The feldsher of a feldsher-midwife station and the midwife have
the right to issue certificates releasing women from work for pregnancy
and childbirth if a village or rayon hospital (outpatient department) is
located at a considerable distance or in emergencies.
Duties of the Head of a Feldsher -Midwife Station
With Respect to Medicoprophylactic Work
18. The feldsher (or feldsher -midwife) of a feldsher -midwife
station provides the population of his district with free medical help
and in emergencies he assists sick people living outside his juris-
diction. He discharges the following functions:
(a) To examine people at the station and in their homes, to
render first aid in acute diseases and accidents (wounds, bleeding,
poisoning, etc.) and then summon a physician or send the ill person to
a district or rayon hospital (outpatient department) depending on his
condition; in certain cases he accompanies the patient himself;
(b) to send as early as possible to a district hospital (out-
patient department) patients whose condition has not been definitely
diagnosed and those requiring medical attention;
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a
(c) to select and prepare for consultation with the visiting
physician of a district or rayon hospital cases presenting complex
problems;
(d) to treat (under a physician's supervision) patients with
trachoma, skin and venereal disease, tuberculosis, and cancer; to uncover
the sources of infection and examine individuals in contact with the
patients;
(e) to participate actively in clinical check-ups of the
population living within the jurisdiction of his station, to select
groups for examination by a physician; to maintain continuing observation
and check on the correct application of recommendations for working con-
ditions; to carry out improvements in sanitation ordered by a physician;
to carry out propaganda among the people on the purpose and problems of
planned improvements in working and living conditions and on the role of
collective farmers and the managers of collective farms, machine and
tractor stations, state farms, factories, etc.; to see to it that persons
subject to clinical check-ups appear on time at the appropriate medical
institution; jointly with the midwife to assist the managers of collective
farms, machine and tractor stations, state farms, and various enter-
prises (lumbering, peat digging, etc.) in rearranging the work of pregnant
women, nursing mothers, juvenile workers, and disabled veterans, to check
on their working, living, and recreational conditions;
(f) to give medical examinations to children in day nurseries,
kindergartens, children's homes, and schools if these institutions do
not have their own medical staff;
(g) to work actively with public spirited citizens interested
in public health and with the local Red Cross (Red Crescent) in their
efforts to set up sanitary posts in the brigades and teams of collective
farms, machine and tractor stations, state farms, lumbering and peat
digging camps, etc.
(h) to carry out all the medicoprophylactic, sanitary-anti-
epidemic, and sanitary-educational work assigned to him in accordance
with the plan approved by the chief physician of the district (out-
patient department) or rayon hospital.
Principal Duties of the Midwife of a Feldsher-Midwife Station
19. The midwife of a feldsher-midwife station discharges the
following functions:
(a) to discover among the people living within the jurisdiction
of the station all pregnant women as early as possible in their pregnancy'
to observe their condition and carry out all the medical and preventive
measures to ensure a favorable course and outcome of the pregnancy;
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(b) to establish the term of pregnancy; to issue to collective
farm women certificates for release from work before and after child-
birth in accordance with the Model Regulations for a Collective Farm.
(c) to see to it that every women in childbirth obtains
medical help by bringing them to the feldsher-midwife station or 'collec-
tive farm maternity home, or sending them to the district or rayon
hospital, or helping women to give birth at Mame in the event that
they cannot be accommodated in a hospital;
(d) to observe the condition of new mothers at home following
discharge from the hospital or after giving birth at home;
(e) to observe the health and development of children during
their first year of life, paying special attention to the newborn and
physically-weak infants;
(f) to discover women with gynecological diseases and refer
them to a physician or treat them in accordance with a physician's
instructions;
(g) to maintain the type of records established for tb;
obstetrical-gynecological service of feldsher-midwife stations, to
submit reports on her work to the head of the feldsher-midwife station;
(h) to conduct propaganda on problems pertaining to health
protection for mothers and children;
(0 in the event that the midwife is absent, the head of the
station is required to perform the duties outlined above;
(j) the head of a feldsher-midwife station has the right to
ask the midwife to handle any medicoprophylactic task that may be
assigned to the station as long as it is within her normal working day
and range of experience.
On Sanitary-Antiepidemic and Sanitary-Educational Work
20. The head of a feldsher -midwife station together with the mid-
wife is required under the direction of the chief physician of a rural
district hospital:
(a) to execute planned sanitary-antiepidemic measures in
collective farms, machine and tractor stations, state farms, peat
digging, and lumbering camps; to check on the cleaning up of inhabited
places; to make the round of farmhouses; to check on sanitary con-
ditions in schools, day nurseries, kindergartens, children's field
camps; to carry out prophylactic inoculations of children and adults as
specified in the plan of the rayon health department;
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(b) to discover and register persons suffering from malaria, to
provide treatment and prophylactic chemotherapy;
(c) to carry out anthelminthic measures, anamnestic examinations
of individuals groups of people for taeniasis, diphyllobothriasis,
ascariasis by questions concerning parasites or segments of them
(the inspection of proglottids is compulsory), sending them, when necessary,
for laboratory analysis to a district or rayon hospital; to register all
those found to be suffering from these conditions and give them vermifuge
treatment; to institute measures aimed at eradicating the eggs of the
worms;
(d) to notify the chief physician of a rural, rayon or district
hospital and the rayon sanitary-epidemiological station of every case of
infectious disease;
(e) to execute sanitary-antiepidemiological measures to eradicate
the focus and prevent the spread of infectious diseases; to keep under
observation those in contact with people suffering from these diseases;
to conduct propaganda, etc.;
(f) to report to the rayon sanitary-epidemiological station
establishments with unsatisfactory sanitary conditions and all violations
of the sanitary code by the managers of collective or state farms,
village soviets, machine and tractor stations, lumbering, and peat
digging camps, and by the administrators of schools, kindergartens, and
nurseries, etc.
21. In accordance with the plan approved by the chief physician of
the district hospital (outpatient department), the head and midwife of
a feldsher-midwife station conduct systematic health propaganda among
the population by means of reports, newspaper articles, talks in read-
ing rooms, schools, hostels, and field camps. This educational activity
is to be regarded as an inseparable part of their medicoprophylactic
work.
22. Successful implementation of the sanitary-antiepidemic and
hygienic measures requires the head and midwife of a feldsher-midwife
station to enlist the cooperation of local organizations and active
members of the Red Cross, ralying in their day-by-day work on the
village soviet's commission for the improvement of living conditions.
The Female Attendant of a Feldsher-Midwife Station
23. The attendant of the station must be a woman at least 18 years
of age who can read fairly well, preferably one with work experience in
a public health agency.
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24. The institution financing the feldsher-midwife station appoints
and dismisses the attendant on the recommendation of the station head.
25. The attendant is supervised by the head and midwife of a
feldsher-midwife station.
26. The duties of the attendant are:
(a) to keep the station clean and neat, to take care of the
furnace;
(b) to obtain pieces of equipment and medicines when needed;
(c) to assist the medical workers in handling and taking care
of patients, obstetrical and other work not requiring special education.
Appendix 2
Regulations Governing the Rights and Duties of Feldshers
(Women Feldshers, Feldsher -Midwives)
Approved by Order of the Ministry of
Health, USSR, no. 343, 6 June 1946
I. In accordance with the decisions of the Council of People's
Commissars, the title of feldsher (woman feldsher, feldsher -midwife)
is assigned to individuals who have completed feldsher school and
obtained the diploma signifying completion of the feldsher or feldsher-
midwife school or who have passed the examinations without attending
the lectures of a feldsher or feldsher -midwife school.
II. Feldshers (women feldshers, feldsher -midwives) train for work
in:
1. Independent feldsher or feldsher-midwife stations where with-
out supervision they render inpatient, consultative, and outpatient aid,
make house calls, and carry an sanitary-prophylactic work.
2. City and rayon hospitals and clinics where they work under
the direction of physicians.
3. Executing measures to combat and eradicate infectious diseases,
performing necessary prophylactic inoculations (in accordance with the
special instructions of the Ministry of Health, USSR), inspecting schools,
kindergartens, and day nurseries.
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III. In the absence of a physician, a feldsher (woman feldsher)
who has completed his (her) medical education and has had at least
three years of practical experience may substitute for the physician
in the health unit of a factory, clinic, or small hospital (up to 10
beds) provided that arrangements are made for consultation with a
physician in the nearest hospital; he (she) may take temporary charge
of a rural medical district or substitute for the district physician
during his absence.
IV. Feldshers (women feldshers, feldsher-midwives) in hospitals
and elsewhere have the right -- both independently and under the super-
vision of a physician -- to perform the following medical procedures:
1. Minor surgery: (a) opening of superficial abscesses and
phlegmons; (b) removal of foreign bodies not requiring complex methods
and not involving destruction of substantial amounts of tissue; (c)
making skin sutures and ligatures to check bleeding (in wounds and
incisions) with observance of all the rules of asepsis; (d) venipuncture,
taking of blood from a vein, phlebotomy by means of venipuncture;
(e) subcutaneous, intramuscular, and intravenous injection of medical
preparations and solutions (physiological saline, Ringer's, glucose);
(f) taking of blood for a Wasserman, Widal, or Weil-Felix test and for
the malarial plasmodium; (g) determination of blood groups; (h) appli-
cation of tourniquets; (i) reduction of simple dislocations, application
of ambulatory splints for fractures (simple and compound), and fixation
bandages for fractures and dislocations; (j) application of plaster
casts; (k) application of adhesive extension for fractures; (1) use of
ethyl chloride and novocain for local anesthesia; (m) tamponing for
nasal and uterine bleeding; (n) simple extractions of teeth.
2. Catheterization and irrigation of the urinary bladder with
a soft catheter.
3. Application of dry and wet cupping glasses, leeches, mustard
plasters, compresses, and poultices.
4. Irrigation of the stomach, enemas (cleansing, siphon, medicated,
nutrient), insertion of colonic tubes.
5. Examination of the urine for albumin, examination of the blood
for the ESR and hemoglobin.
6. Taking of throat and nasal smears.
7. Performing physiotherapeutic procedures as ordered by a doctor
(Minin, quartz, and Sollux lamps, dry-air baths, etc., massage, and
gymnastics.
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8. All types of conservative treatment for eye, ear, nose, and
throat diseases: irrigation, lubrication, instillation, application
of salves, removal of superficial foreign bodies, scarification of
the conjunctiva, application of dressings.
9. Doing obstetrical work in the absence of a midwife: (a) normal
deliveries, (b) opening of the amniotic sac, (c) resuscitation of the
fetus in asphyxiation, (d) use of Crede's method in the postpartum
period, (e) manual detachment of the placenta, (f) digital removal of
a miscarried fetus, (hemorrhage), (g) suturing of first and second
degree perineal lacerations, (h) anesthetization in childbirth in
accordance with the instructions of the Ministry of Health, USSR.
10. Rendering first aid in accidents (injuries, poisonings,
drownings, hangings, etc.)
11. Carrying out independently all types of disinfection.
12. Inspecting in his district sanitary conditions in food estab-
lishments, baths, showers, water supplies, and making appropriate reports,
bringing deficiencies to the attention of the state sanitation inspector.
13. Carrying out health propaganda among the people.
V. Feldshers (women feldshers and feldsher -midwives) may, in
addition to the procedures enumerated above, do other work under the
direct supervision of a physician, such as: (1) assisting during
operations; (2) taking X-rays of fractures and dislocations; (3)
performing duodenal probes; (4) performing blood transfusions; (5)
administering inhalation anesthesia; (6) injecting anesthetics
intravenously and rectally; (7) inserting a bougie into the urethra;
(8) using a tampon to check hemorrhage.
Note: Physicians may not authorize feldshers to perform any
surgery other than that specified in this section.
VI. Feldshers in charge of independent medical units, temporarily
directing medical districts, or substituting for doctors during their
absence have the right to prescribe from the dispensary over their
own signature any drugs required by the patients, including poisons
or potent substances, in doses not exceeding the maximum for a single
dose stipulated by the Ministry of Health regulations.
All other feldshers in an emergency-have the right to
prescribe drugs from the dispensary over their own signature, but
no poisons or potent substances except:
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(f)
(9)
silver nitrate in no higher than a 2% solution;
mercury bichloride solution no higher than 1:1,000;
caffeine and its salts;
opium tincture no more than 5.0 per prescription;
stypticin;
ergot extract or ergot fluidextract;
santomin tablets.
XIV. After 5 years of service feldshers are entitled to two months
of advanced training at their main place of work with full pay.
XV. Feldshers are liable to disciplinary action -- or, under
certain circumstances, criminal punishment in accordance with the
criminal code of the union republics -- for administering improper
treatment, negligence, or carelessness in discharging their official
duties, or for failure to use the rights conferred by section IV of
these regulations in cases threatening the lives of their patients
or for performing unauthorized medical functions.
Appendix 3
Regulations Governing the Rights and Duties of Midwives
Approved by order no. 343 of the
Ministry of Health, USSR, 6 June
1946
I. In accordance with the decrees of the USSR 00n the Training
of Middle Echelon Personnel, Dentists, and Pharmacists" and l'On Improving
the Training of Middle Echelon Personnelln the title of "midwife" is
reserved for those persons who have completed midwife school and
received a diploma or who have passed the examinations of a midwife
school without attending the lectures.
II. The midwife's functions consist of:
1. Performing obstetrical duties under the supervision of a
physician in a city or rayon obstetrical-gynecological institution
(maternity hospital, maternity department in a general hospital,
women's consultation center, obstetrical-gynecological room in a
factory, etc.).
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2. Rendering independent obstetrical aid in a collective farm
maternity hospital, consultation center, or an a traveling basis within
the district.
3. Making visits to homes and factories.
III. In her actual work a midwife must:
1. Diagnose normal and pathological pregnancies, term of pregnancies,
and establish the period of maternity leave in a collective farm maternity
hospital, midwife station, health station, or consultation center.
2. Distinguish between a normal and pathological course in births
and be capable of handling births and the postnatal period.
3. Use gynecological methods of studying and diagnosing women's
diseases as a basis of prompt referral to a physician; know the rules
concerning indications for termination of pregnancy and sending the
women to the hospital as early as possible.
4. Use conservative methods of treating gynecological diseases,
including physiotherapy (under the direction of a physician).
S. Keep a diary of clinical observations of ill women and women
in childbirth in a collective farm hospital or midwife station; take
the temperature and graph it, take the weight, pulse, respiration,
measure the pelvis, blood pressure, etc.; report obstetrical-gyneco-
logical diseases on statistical forms.
6. Consult with a physician and do other things required to
prevent complications in pregnancy.
7. Know the methods of caring for newborn and breast-fed infants,
feeding techniques, organization of supplemental feeding, and decanting
of breast milk; use methods of preventing inclusion conjunctivitis in
infants and puerperal sepsis; render first aid to a sick infant; prevent
and treat the diseases of infants.
8. Carry out hygienic measures and propaganda in behalf of feminine
hygiene, protection of mothers and children.
9. Carry out disinfection procedures in maternity hospitals and
in the homes of women in childbirth (cleans mothers and babies during
postnatal visits).
10. Isolate patients, carry out disinfection and disinfestation
measures in homes and medical institutions; know the epidemiology and
prophylaxis of the commonest infectious diseases (measles, scarlet
fever, diphtheria).
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11. Know the main types of narcotics and anesthetics and methods
of using them.
12. Apply all the necessary rules of asepsis and antisepsis in her
routine work; store and sterilize (in an autoclave) surgical instruments,
dressingsA and articles used in caring for patients; prepare sutural
material.
13. Make surgical dressings, help the physician in obstetrical-
gynecological operations and intravenous infusions; make venipunctures
and laboratory tests (determination of blood groups, analysis of the
urine for albumin, analysis of the blood for hemoglobin and the ESR).
14. Make subcutaneous injections, catheterization; use cupping
glasses, compresses, leeches, enemas (simple, medicated, nutrient),
douche, irrigation.
15. Know the dosage of the principal drugs, including those with
potent action, rules for storing and accounting for medicines, methods
of using them; compound the main drugs and solutions of antiseptic
preparations; easily read, copy, and write prescriptions on the
instructions of a physician.
16. Make beds with due regard for the individual
the patients; know the methods of moving them.
17. Know the methods of taking care of the skin,
and throat, particularly of children.
circumstances of
ears, mouth, nose,
18. Observe the junior medical personnel assigned to her and guide
their work.
19. In a case requiring emergency medical assistance, the midwife
is obliged to arrange for transportation of the patient to the nearest
hospital or clinic, or if this is impossible, to make an urgent request
for a physician from the nearest medical district, rendering first aid
until he comes.
IV. In emergencies requiring obstetrical or gynecological assistance
and where a physician is not available, the midwife has the right and
is obliged to:
1. Resuscitate the fetus in asphyxiation.
2. Open the amniotic sac if the indications call for it.
3. Use manual means in pelvic presentations.
-194-
it.
period.
S.
6.
7.
Use modern methods of removing the placenta in the postnatal
Manually investigate the uterine cavity and remove the placenta.
Insert a tampon in the vagina.
Suture first or second degree perineal lacerations.
8. Use Stroganoff's method in eclampsia, magnesium therapy,
venesection in massive doses, provide the patient with complete rest.
9. Use approved methods of treatment for shock (injections of
morphine or pantopon, intravenous infusions of glucose with strophanthin,
etc.).
10. Investigate manually the uterine cavity in atonic hemorrhage,
inject pituitrin, apply angiopressure to the abdominal aorta; use
Kocher's forceps in case of uterine laceration, promptly summoning
medical help.
11. In cases of bleeding or placenta previa, promptly send the
patients to a hospital or call a doctor, using in exceptional cases
Villet-Ivanov's method.
12. Make early diagnosis of extrauterine pregnancies, give treat-
ment for shock, use Trendelenburg's position, provide rest,and give
medical aid.
13. Use anesthesia in births in accordance with the instructions
of the Ministry of Health, USSR.
14. Prescribe from the dispensary over her own signature any drugs
necessary for emergency treatment, using the dosage established by the
instructions of the Ministry of Health, USSR; store and account for
medical preparations.
V. Midwives with middle grade medical education who have shown
themselves in their work to have adequate theoretical and practical
training are permitted to instruct students of middle grade medical
schools in practical subjects.
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-195-
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Appendix 4
Regulations for the Assistant to a State Sanitation
Inspector (Sanitation Physician)
Approved by the All-Union State
Sanitation Inspection Service,
People's Commissariat of Public
Health, 20 March 1940
1. The assistant to a state sanitation inspector (sanitation
physician) is a person of middle grade medical education trained to
perform the following tasks:
a. To inspect all establishments in a populated area under
the supervision of a sanitation physician;
b. To execute individual assignments made by the sanitation
physician (collect materials on the spot relating to the sanitary con-
ditions in an establishment and transfer the data to a card, check on
execution of requests made by the sanitation physician, make edpiemio-
logical investigation of cases of infectious diseases);
c. To carry out independently all types of disinfection and
disinfestation, using whatever methods may seem appropriate, and to
check on the effectiveness of the disinfection and disinfestation;
d. To conduct hygiene propaganda among the people, encouraging
independent activity;
e. To draw up reports of sanitary inspections;
f. To do clerical work, including the keeping of all types of
sanitary-epidemic records, under the supervision of the sanitation
physician;
g. To obtain samples if there are appropriate sanitary or
epidemic indications and send them to the laboratory for analysis,
and, whenever, required, to make simple an-the-spot investigations,
duly reporting on the results.
2. The assistant to the state sanitation inspector (sanitation
physician) inspects minor food enterprises, shower rooms, washstands,
etc., making notes in the sanitation journal an all inadequacies observed
for the information of the state sanitation inspector (sanitation
physician):
-196-
\,
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a. He describes sanitary conditions in small places and reports
on sanitation violations; the sanitation physician himself is required
to describe the major manufacturing, food, and communal establishments;
b. On the instructions of the sanitation physician he care-
fully collects samples of food products, water, soil, etc., for analysis
by experts;
c. He checks on execution of the proposals and decisions of the
sanitary-epidemiological station regarding the closing down of places,
removal from circulation or destruction of products, sanitary measures
in factories, communal buildings, etc.;
d. He checks on the availability of baths, showers, washstands,
etc., and their condition, disinfection equipment, and the taking of
medical examinations by individuals who are required to do so;
e. He officially registers the decisions of the sanitation
physician regarding the levying of fines, prepares the text, records,
and follows up on the course of the decisions.
3. The assistant to the state sanitation inspector (sanitation
physician) receives an identification card containing his photograph
and the signatures of the chairman of the rayon executive committee
and rayon sanitary-epidemiological station plus a list of the establish-
ments (in the rayon, city, or district) assigned to him for inspection
and a statement that he has the right of direct access for this purpose
and is authorized to take samples for analysis by experts.
4. The state sanitation inspector (sanitation physician) is
required to give his assistants systematic instruction on the regulations
covering the places they are assigned to inspect.
5. The sanitary-epidemiological station of an autonomous republic,
kray, or oblast is responsible for advanced training of the assistants
by arranging for them to take appropriate courses.
6. The assistant to the state sanitation inspector (sanitation
physician) works according to a plan approved by the sanitation physician?
the execution of which must be checked at least once every ten days.
- 197 -
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USSR
Ministry of Health
Budget
Name of institution
Oblast (kray), ASSR
Inhabited locality
Appendix
Public health, report form no. 14
Approved by the Central Statistical
Administration, USSR, 13 July 1954, No.323
Report submitted to the rayon health
department through the rural district
hospital (clinic) for the year beginning
January 5 by feldsher -midwife stations,
feldsher stations, midwife stations,
collective farm maternity hospitals
REPORT FORM FOR
FELDSHER-MIDWIFE STATIONS
FOR 195
p rayon
(write in name and postal address)
Feldsher -midwife station, feldsher station, midwife station, collective
farm maternity hospital (underline); permanent, seasonal (underline)
The station is located in a state farm, machine and tractor station,
collective farm, forestry station, lumber camp, peat bog (underline)
The station (collective farm maternity hospital) serves
inhabited localities collective farms
(number)
Transportation, no transportation (underline); kind
Hydraulic hose, no hydraulic hose (underline)
Authorized positions 1
Filled 2
I. STAFFING PATTERN*
Total no. of
positions at
end of year
under review
1
(number)
Including
(write in)
Feldshers
(feldsher- Midwives
midwives)
2 3
Junior
medical
personnel
It
*Data compiled an the basis of the staffing pattern filed with fiscal
agencier,
-198-
outpatient department
total no.
of visits
plus visits
by pregnant
women
II. SERVICE TO PATIENTS*
Patients treated
at home
total
incl. visits
total
incl. those
no.of
of nurses
no.of
involving no
visits
babies
deliv-
subsequent
hospitalization
to child- to
ran nant
women &
new
mothers
ered
of new mothers
2 3 It 5 6
*Including visits in connection with babies delivered at home.
At end of year under review
no. of children up to 1 year old (11 months, 29 days)
11 ff " from 1 to 3 years old (2 years, 11 months, 29 days)
Number of pregnant women registered during year
Circulation of "feldsher -midwife station report"
III. HOSPITAL ACTIVITY
No. of beds at Incl. those In year under review Total no. of
end of year of new bed-days for
under review mothers patients patients died all patients
(actually avail- admitted dis-
able those charged
undergoing
repair)
1 2
3 It 5
No. of parturient women admitted
parturient women and new mothers
6
; total of bed-days for all
; babies delivered
No. of deaths among pregnant, parturient women, new mothers
Cause of death:
(a) hemorrhage (b) eclampsia
Born alive , incl. premature babies 1 stillborn babies
No. of infant deaths
incl. premature infants
- 199 -
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IV. REFERRALS TO CONSULTATION CENTERS AND HOSPITALS
No. of pregnant
women referred
to consultation
centers
1
Number sent to hospitals
pregnant women
2
new mothers with postnatal
complications
3 4
V. HYGIENE PROPAGANDA
No. of talks delivered
No. of public health inspectors
as part of an approved program
incl. those who attended seminars
VI. NUMBER OF PATIENTS WITH TRACHOMA
No. of cases of trachoma newly No.of patients regis-
diagnosed during the year tered at the end of
the year
1st stage 2nd stage 3d stage 1st stage 2nd stage 3d stage
Total no. of
patients 1 1
incl.children:
up to 6 yrs.
old inclu-
sive 2
from 7 to 14
yrs. old
inclusive 3
195
2
3
6
, director
- 200 -
Declassified in Part - Sanitized Copy Approved for Release
?
FIGURES
DECREE
The Council of People's Commissars at its session of July 11th
decided:
1. To establish a People's Commissariat of Health to be assigned
the direction of all medical institutions in the R.S.S.F.R. for the
purpose of unifying all affairs pertaining to medicine and sanitation
in the country.
2. To transfer to the People's Commissariat of Health all the
activities and facilities of the Council of Medical Boards.
3. To charge the People's Commissariat of Health with responsi-
bility for unifying the activities of all the medical departments
attached to all the Commissariats and to direct their work henceforth
until complete unification is effected.
4. To make the following temporary appointments to the Board of
the Commissariat of Health pending confirmation by the Central Executive
Committee: comrades Semashko, acting People's Commissar, Solovlyev,
deputy, Dauge, Golubkov Bonch-Bruyevich, Pervukin, members.
V. Ullyanov (Lenin) [signed], Chairman, Council of People's
Commissars
Bonch-Bruvevich [signed], Executive Director, Council of
People's Commissars
Pervukhin [signed] Secretary of Council
Moscow, the Kremlin
July 11, 1918
Figure 1. Decree of the Council of People's Commissars establishing the
People's Commissariat of Health.
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6
Declassified in Part - Sanitized Copy Approved for Release ? 50-Yr 2014/02/05: CIA-RDP81-01043R004200220005-2
HUSSRSupreme
Soviet
Council of Ministers
Supreme
--Soviet
RSFSR
Ministry of
Health
USSR
Council of Ministers
RSFSR
Supreme
Soviet
ASSR
Ministry of
Health
RSFSR
Council of Ministers
ASSR
Oblast
(kray)
Soviet of
Workers'
Deputies
1
Ministry of
Health
ASSR
Executive
Committee
Municipal
Soviet of
Workers' Deputies
1
dmIr dm+ mal?
Ministry of
Defense
Oblast (kray)
Department of
Health
Main
Military Medicine
Administration
Executive
Committee
Rayon
--Soviet of
Workers' Deputies
Municipal Depart-
ment of Health
Executive
Committee
Rayon Depart-
ment of Health
Ministry of
Internal
Affairs
Medical
Department
Ministry of
Transport
Main Sanitary
Inspection
Administration
Ministry of
Foodstuffs
Industry
Medical
Service
? -
Figure 2. Administration of medicine and sanitation in the USSR.
,16
Figure 3. Size of population in Russia and in the USSR
(in millions)
OnNmo moimomM.ms. ommip
Figure 4. The death rate in the USSR and the capitalist
countries (per 1,000 of population)
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Declassified in Part - Sanitized Copy Approved for Release ? 50-Yr 2014/02/05 CIA-RDP81-01043R004200220005-2
19
15'
17'
15
Up to 3 years
Up to 1 year
19012
1.905e
1905z.
1.910 a
1935a.
1945212532
19502.
100%
AY%
Belgium England
France Sweden
19492 19502 1.9.5i. 19322
Germany Italy
(after 1946 West Germany)
Figure 5. The natural increase of population in capitalist
countries (per 1,000 of population) by five-year
periods from 1901 to 1953.
Pneumonia
Dysentery
Other diseases
Figure 7. Rate and causes of mortality of infants (according
to the Moscow consultation centers and polyclinics
compared with 1949, taken for 100)
nprlassified in Part - Sanitized Copy Approved for Release ? 50-Yr 2014/02/05 ? CIA-RDP81-01043R004200220005-2
Declassified in Part - Sanitized Copy Approved for Release ? 50-Yr 2014/02/05: CIA-RDP81-01043R004200220005-2
Morbidity rate
according to data
from medical
eNaminations
Morbidity rate
of hospitalized
cases
Card of person
subject to periodic
medical
examinations
Tuberculosis, venereal
disease, cancer
morbidity rates
e ica car or
slip for regis-
tration of con-
firmed diagnoses.
Reports of medi-
cal institutions
Causes of death
?ospi is
charge card
113,4
105,8
2W
113,9
113,8
106,1
111111111111111111111111111111
88,8
843
58,3
!!!1.11)111111111111/111111
notice of patient
with active tuber-
culosis, venereal
disease, cancer
? 0 ?O*15*?%'? *0*
Medical death
certificate
Epidemic morbidity
rate
special notice oi
patient with acute
infectious disease
ing industrial
traumatism with
loss of work
capacity
Figure 8. Outline of an investigation of morbidity.
1.926z
Acute infectious diseases
Traumas and poisonings
Diseases of the skin and subcutaneous
cellular tissue (including parasitic diseases)
Diseases of the digestive organs
Diseases of the respiratory organs
Diseases of the visual organs
Diseases of the nervous system
Chronic infectious diseases
Diseases of the circulatory organs
Diseases of the bones, joints, and muscles
Diseases of the auditory organs
Diseases of the urinary organs
Other diseases
Figure 9. The pattern of morbidity in Moscow.
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Declassified in Part - Sanitized Copy Approved for Release ? 50-Yr 2014/02/05 CIA-RDP81-01043R004200220005-2
Structure of morbidity among workers with temporary
disability at N. chemical plant (on the left) and
N. textile factory (on the right). The number of
cases of illness per 100 workers is shown here.
Figure 11. Number of cases of temporary disability among
individual groups of workers at N. factory.
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Declassified in Part - Sanitized Copy Approved for Release ? 50-Yr 2014/02/05: CIA-RDP81-01043R004200220005-2
HOSPITAL ADMINISTRATION
Chief physician
Administrative assistant
to chief physician
f
Inpatient
Admissions depti
Wards:
il
Deputy chief physician
Vo'. the polyclinic
11
IMedical section
Medical control
commission
Departments:
medical
surgical
pediatric
Polyclinic
Registry
Offites:
iatricians
Diagnostic section
Autopsy room
,4w
Physiotherapy
room
AdminIstrative section
rAccounting
gterilizaion
room
?
'MI Wien r Laundr-71
Storage
Figure 13. Structure of a city hospital.
ITam enance
cxi
4-)
.14
C14
0
0
IC
9.4
4-I
1:1)
4-)
Head of medical
sanitary-prophylactic work
medicoprophylactic work
af 0
104? 0
0
C.4
P, 0
w -P
w c.)
o) $4
g "4
0 4-)
ofo m
? *1-4
cd
loom
?
.-411
O 1 W
?) E
,4 0
0 .0
$4 P.
0
4? -)
W
o t4
4-3
7:)
44) .14
ommsirevaimb,,
Declassified in Part - Sanitized Copy Approved for Release @ 50-Yr 2014/02/05: CIA-RDP81-01043R004200220005-2
Outline of work of a district physician.
Declassified in Part - Sanitized Copy Approved for Release ? 50-Yr 2014/02/05: CIA-RDP81-01043R004200220005-2
District physician of a city hospital
Medicoprophylactic work
District nurse
LAssisting he physician in
examining patients in the
polyclinic
Executing the physician's
instructions in the homes
of patients
Keeping medical records
Assisting the physician
in clinical examinations
Sanitary -antiepidemic work
0 Performing vaccinations
Carrying out epidemiological
investigations
Doing routine disinfection
work
*-
Assisting the physician
in propaganda work and
directing sanitary
activists
Figure 15. Outline of work of a district nurse.
Medical unit chief
Shop health stations
Feldsher stations in
FZU schools and RU FZO
[industrial training
and trade schools]
.I:Assistant for epidemiological work
Sanitary-epidemiological
laboratory
Feldsher stations with
living quarters and isolation
area
.1?11Mil??????????
Day and nIght tuberculosis
sanatorium
Hospital with polyclinic
Medical departments and
consulting rooms for
all specialties
Auxiliary depart-
ments and con-
sulting rooms
RecoraTand statistics of ice
Consultation room
for juveniles
?
Health propaganda office
Sanatorium-health resort
selection commission
Women's hygiene
Room
?Day nurseries
Medical consultafion
commission
li.
Infant-feeding
center
--F7indergarteni
Medical-ancf-labor
examination
commission
ono orium
Figure 16. Structure of a medical unit in an industrial enterprise.
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Declassified in Part - Sanitized Copy Approved for Release ? 50-Yr 2014/02/05: CIA-RDP81-01043R004200220005-2
City (rayon) hospital, polyclinic
The factory Administration,
unions and other organizations
City (rayon) sanitary-
epidemiological station
Medical health station
Medicoprophylactic work
First aid in
accidents and
sudden ill-
nesses
Clinical exam-
ination of
Individual
groups of
workers
Periodic med-
ical check-ups
of workers
Organization of
sanatorium -
health resort
selection
Execution of Processing of
several med- data on mor-
ical measures bidity and
and procedures traumatism
1
Sanitary -antiepidemic work
Preventive an
routine in-
spection of
sanitary con-
ditions in the
factory
Sanitary
inspection of
non-work areas
(dining rooms,
snack bars,
showersletc.)
Execution of
antiepidemic
measures
J
Hygiene propa-
ganda, organi-
zation of
sanitary acti-
vists and work
with them
Instructing of
workers in
self-aid and
mutual aid
Supervision
of shop health
stations
Elaboration and execution of a single, overall
program of health improvement measures
Figure 17. Outline of work of a medical health station in a factory.
flo acci ri rt
Medical unit
Head of the general medical division
Shop area physician (general practitioner
Shop area
4 Execution of improvements
in the shop
Prophylactic inoculations
4 Measures to lower morbidity
and traumatism
-11 Aid in accidents and sudden
illnesses
1
Hospital
Treatment of patients
Consultation on patients
with specialists
Hygiene propaganda
Training of sanitary
activists and guidance
of their work
Polyclinic
(-1
Treatment
of
patients
{Consulta-
tion on
patients
with spec-
ialists
Selection of
patients for
sanatorium-
health resort
treatment
Examination
by experts of
ability to
work and work
arrangements
of sick persons
Clinical
observation
of groups
of workers
Periodic med-
ical check-
ups
Investigation of morbidity and traumatism, participation
in execution of health improvement measures
Figure 18. Outline of work of a shop area physician.
Coov Approvedf r Release ? 50-Yr 2014/02/05 ? CIA-RDP81-01043R004200220005-2
Registry
-h
7:1
(D
CD
(D
City (rayon) health department
Assistance council
tUberculousl oncologicall dermatovenereological) etc.
Chief physician
Cabinet for organi-
zation and methods
Admissions department
Departments:
npatient dept.
.. _
liagnostic
- _
pulmonary
tubercu-
losis of
adults
_
pediatric
.
,
bone
tuber-
culosis
1
laryngo-
logical
.
for surgery
for X-ray '4for
combined
therapy
treatment
r
r
skin
venereal
Oncolo-
gical
clinic
Dermatoven-
ereological
clinic
Polyclinic
Tubercu-
losis
clinic
Statistical
office
? 'Waiting room
Consulting rooms:
,
pulmonary
pediatric
bone
laryngo-
tubercu-
losis of
tuber-
culosis
logical
adults
r
_ .
'surgical
gynecolo-
otolaryn-
medical
radio-
gical
gological
therapeutic
-
x-ray rooms
. .
admission of skin and
venereal patients
admission of urolog-
ical patients
women
children
menli women
children
men
Figure 19. Structure of a clinic in the USSR.
Pysiotherapy roomS.:t
?
uorvezpiEBso
Co
O Ct.
M
O cr
0 H.
4
o Co
(0
1-?? b???
H.
0
P.R
FA
c+
P.
(s;
co
(I)
Imo. ? - 1111,
MN.
41?1,
0
cr
re4Idso4 qopq.sw
Declassified in Part - Sanitized Copy Approved for Release ? 50-Yr 2014/02/05 CIA-RDP81-01043R004200220005-2
?,.
Rural district
hospital
LRural Soviet of
Workers/ Deputies
Feldsher-midwife station
Sanitary-antiepidemic work
Routine sanitary inspection
T.
Uncovering and treatment
of epidemic foci
Antimalarial and
anthelminthic measures
Organization of
sanitary activists
and work with them
Medicoprophylactic work
Clinical
service
Selection
of patient
for the
physician
Help at home
for acute
illnesses
Participation
in clinical
observation
Pharmacy
J
Hygiene
propaganda
IObstetrics. Medicoprophylactic
assistance to children
Observation
of pregnant
and partur-
ient women
Observation of
children up to
1 yr. old
Mistance fo
gparturient
women and
new mothers
lieclical Cfie-Ok-
ups in nurseries
and schools
Collective farm
maternity hospital
_If
Figure 21. Outline of work of a rural feldsher -midwife station.
no acci ri in Prf Coov Approv
?
Oblast (kray) health department
Oblast (kray) clinics:
talerculcus, dermato-
venereological, onco-
logical, etc.
Oblast (kray)
hospitals
Rayon hospital
Oblast (kray) scientific
research institutes
Rayon health [ Oblast
sanitary-
department epidemiological tio
Rural medical districts
Rayon sanitary-epi-
demiological station
1Jr
Administrative jurisdiction
- - - Guidance on organization and methods
Figure 22. Medicoprophylactic facilities for the rural population.
d for Release ? 50-Yr 2014/02/05 ? CIA-RDP81-01043R004200220005-2
Structure of a collective farm maternity hospital.
0
1-6
M
cn
eme.:11
1-4 C) I?I
0 0^ P
m
m m m
0.11 0
m m
1-?
0
0
T?
(A
0
TE-4Eu-qs0d
quemqaedap quoiTeduT
He
431Aos eacTIIA
regIdsoti loTalsTp TE
Chief sanitation
physician
Rayon sanitary-
epidemiological
station
Sani- Lab- Dis-
tary ora- in-
anti- to- fec-
epi- ry tion
demic de-
de- part-
part- ment
ment
Souse 6f ygrene
education
Pharmacy
RAYON HEALTH DEPARTMENT
npatient dept.
Wards:
medical
JLLc1 -ii
irymecre
IrretTICTIr=
infectious
rx-ra,y
Rayon hospital i
Chief physician
Departments:
medical
surgical
gynecological
pediatric
infectious
Laboratory
Polyclinic
Consulting rooms:
finternists
&Coln 1...4
=TA
E=71
'ehildrerfis con-
sult.ctr. & inft.
feeding sta.
.114.?
Physiotherapy
room
Maternity hospital
inpatient dept.
woments cons.cent.
?
Childrents home
3
Day nurseries
11
0
EJ
Rural medical districts .
o Feldsher-midwife stations o 0
Figure 24. Organization of public health in a rural rayon.
?
Rayon tuberculosis
clinic
Rayon dermatovenereo-
logical clinic
Medical health
stations
Feldsher aid
S tations
CD
0
CD
=14.
CD
-o
CD
(I)
CD
CD
0
CD
6,
7:1
CD
CD
CD
CD
?
01
0
c-5
cn
0
-o
co
cb
cio
?
Lponsultation center
iRegistry
Sick
children
department
Waiting
room
legal
staff
e=12cam==0
Physician
office
office
Visiting nurse
service for
breast-fed
Infants
Infant-
feeding
center
Isolation
ward
7.47317di?Ti
tribution
station
Breast milk
decantation
station
House
calls
ilork in the district'
Nurseries,
infants'
home
rChildren s hospital
fInpatient dept.
--
Admissions
department
Wards for
younger
children
Wards for
older
children
Diagnostic
division
a
Polyclinic Consulting rooms:
IOffice of
district
pediatricians
Isolation ward 1
Isurgical j
tolaryngological
ophthalmological
neurological and
psychiatric
r euma o ogicaf
Work in the distric
?
ma ar a ogical and
helminthological
House
ClInical
calls
check-up:
of child.,
ren
1 dermatolovical
Kinder
Schools
Igarten
MOO..
defective speech
Laboratory
X-ray room
4
Children's home
Physiotherapy
room
Figure 26. Structure of a children's hospital
Declassified in Part - Sanitized Copy Approved for Release ? 50-Yr 2014/02/05: CIA-RDP81-01043R004200220005-2
Women's consult.
center
11 Regist
aiting room
Consulting rooms:
obstetric-gyne-
cological
4.
I---
dental
venereal
socio-legal
Maternity hospital
Obstetrical department
First dept.
.(clean)
dmissions section
)Lying-in section 1_
[Post-natal section I_
lurseries for new-
orn infants
IDepartment ?or
pathological preg-
nancies
Second dept.
(isolation area)
- Admissions section
-I Lying-in section
4 Post-natal section I
Arseiles eor new-
born infants
Venereal depart-
ment
Diagnostic division
-..i_Gynecological dept.
Laboratory
X-ray room
House calls
Work in th
district
Phys lot erapy room
z
Figure 25. Structure of a maternity hospital.
Visiting service I
for pregnant women'
-
surgica Conservative
ii
methods of
treatment
en a
rtUberculosis
npriassified in Part - Sanitized COPY Approved for Release
50-Yr 2014/02/05: CIA-RDP81-01043R004200220005-2
Z-9000ZZOOZ17001?1701-0-1-8dCll-V10
Rayon sanitary-epidemiological station, 1st category
Chief physician
Sanitary-antiepidemic
division
Sanitation
physician
for resi-
dential-
communal
sanitation
-Sanitation
physician
for food
sanitation
comgar
Assistants
to sani-
tation
physicians
411???????
Instructor
in hygiene
propaganda
'13hysi. c fan ?
r epiem-
?
ogi st
I.
I I
tinnalion
physician
for school
sanitation
1..
II
Medical
statisti-
cian
Assistants
to epidemi.
ologist
Laboratory
Directing physician
pm=mnlysician-epiaemiologist
Laboratory technician in
residential-communal
sanitation
Laboratory technician in
food sanitation
Laboraory technician in
bacteriology
Attendant
I_ Sanitary-epidem-
iological council
Disinfection division_ 1
Directing feldsher
Disinfect-
ion in-
structor
in room
sanitation
Figure 27. Structure of a rayon sanitary-epidemiological station.
attendant
Disinfect-
ion in-
structor
in focal
disinfect-
ion
Disinfector
for focal-
disinfection
Structure of a House of Hygiene Education
qaulaceo spotnali
naaanq a.m433l
a
Jo asnoH .To ao4oaam
uoT4uonpg auaT
Declassified in Part - Sanitized Copy Approved for Release
50-Yr 2014/02/05: CIA-RDP81-01043R004200220005-2
Declassified in Part - Sanitized Copy Approved for Release ? 50-Yr 2014/02/05: CIA-RDP81-01043R004200220005-2
Ministry of Health, USSR
Division of hygiene
education
Ministry of Health, SSR
Inspector of hygiene
education
Republic House of
hygiene education
Rayon health
department
Rayon house of
hygiene education
Republic, oblast (kray),
city sanitary-epidemio-
logical station
Medical institutions
Cabinet for hygiene education
or hygiene education organizer
Rayon sanitary-epidemio-
logical station
Instructor in hygiene
enrntinn
Figure 29. Hygiene education agencies and institutions.
Medicoprophylactic institutions and measures
Medicoprophylactic assistance to children
Institutions and measures to combat tuberculosis
Obstetrics
Hygiene propaganda institutions and measures
Medical schools and middle grade institutions,
scientific research institutes
Other
Figure 30. Structure of the public health budget (1949).
GPO 877555
Declassified in Part - Sanitized Copy Approved for Release ? 50-Yr 2014/02/05: CIA-RDP81-01043R004200220005-2