First the concept, then the delegates and finally the journey. This program was originally conceived in the State Department and initiated by President Eisenhower in 1962. The idea was to bring people of similar professions together by conducting visitation in their respective countries to bring a closer alliance, understanding and prospective and, hopefully, to enhance the prospects of peace and the extension of skills in order to make the exposures as humanly profitable as possible. Conceptually then, people who talk rarely fight. People who are knowledgeable do not come to confrontation through ignorance.
1976 was a year in which medicine was one of the exchange professions, and a delegation from Kentucky was one of the groups selected for the exchange.
The group was composed of family practitioners, one internist, one surgeon, one oral surgeon, one obstetrician-gynecologist, one vice president of a university, one hospital board chairman, the chairman of the City-County Board of Health, a vice chairman of a comprehensive health planning council, an assistant dean of a medical school, one President of a large hospital complex, the Chairman of the Board of the American Hospital Association, one emergency room physician, one osteopath, one physician’s wife. Six of the delegates were accompanied by their wives.
The Commissioner of the State Board of Health and a former Governor of the State originally were scheduled to go, but public matters arose in their two instances that precluded their participation.
The basic itinerary was Iron Curtain primarily within the Soviet Union with an excursion to Hungary. In preparation of this, an initial stop in Belgium and Vienna, Austria, was arranged. The last exchange was subsequent to Russia where Yugoslavia was the final destination before home. In each instance, we were given an overview of the medical care systems with exposures to physicians and paramedics, administrators, state authorities and briefings by the U.S. Embassy. The arrangement was from one country with a relatively unfettered medical profession (Belgium) to one completely state controlled- (U.S.S.R.). Therefore, our odyssey began with embarkation from New York; landing in Brussels, proceeding to Budapest, Hungary; then via railway to Vienna, Austria, which is the gateway to the East; then to U.S.S.R., first to Leningrad, then to Moscow emigrating then from Russia to Yugoslavia with a layover in Dubrovnic. These above mentioned cities were our headquarters for site visits to the different clinics, hospitals, administration buildings, embassies, etc.
We departed from New York City of Saturday evening and landed in Brussels, Belgium, after and overnight and comfortable flight. This Sunday was a rest day in order to get over jet lag as well as to prepare for a busy visiting schedule the next two days in Belgium.
The historical city of Brussels is most fascinating and is serving as the NATO headquarters. There is much old and considerable amount that is new. The people appear prosperous, energetic and vibrant. There is much produce and consumer goods and commodities available. The cities and countryside are packed with automobiles. Americans are held in high and friendly esteem and the congeniality of the people was most pleasing. It is easy to communicate in English, although French and German are very common as well.
Our first day we visited into the countryside 35 miles from Brussels to the William Lennox Epileptic Hospital. Its concerns are only with epileptic children up to 18 years of age. It is non-profit and state supported. In-patients are paid for by the Ministry of Health. Outpatients are paid for by the Department of Public Works. The bed capacity is 177 patients and they come from all areas of the country.
On the day of our visit, 164 beds were occupied. Room construction allows for three beds per room, but in difficult cases, sometimes single rooms are arranged. The total staff members are 200, of which 40 are physicians. These are primarily neurologists, pediatric neurologists and psychiatrists. The paramedics are especially trained to work with these youngsters and families, are most dedicated and affectionate with the patient and family population. Much emphasis is placed on diagnosis, and extensive recordkeeping is done. Rehabilitation and training also come in for much emphasis, and they try to make useful research as much as possible. Those patients that are hopeless or have organic disease epilepsy that is totally disabling are eventually transferred to nursing homes of facilities arranged for or by parents.
That afternoon we were taken to a hospital whose name was Clinique St. Pierre. This is a private hospital, modern in design and construction, attractive exterior, with innovative interior. It is the newest hospital in Belgium located in a relatively small town, but with a heavily populated agriculture and manufacturing region 15 miles outside Brussels. There are 55 active physician staff members, 55 percent of the beds are private, 45 percent are paid for by the Belgium Welfare Department and from Mutual Employees Insurance Company. It serves an area of 55,000 population and is affiliated with the University services of the University of Lavarnne. The hospital was constructed in 1973 and hospital stay varies from a few days to several months (usually orthopedic cases). The doctors have offices in the hospital and daily hospital average cost is $61. Doctors are paid $9 for routine out-patient visits and $11 per hospital visitation. The poor are cared for in wards, the for-pay services are in private or semi-private rooms. The full-time active staff doctors are paid for from hospital funds on a negotiated salary basis an average of $35,000 to $40,000 per year.
The for-pay patients are paid for by a mutual insurance which is established by payroll deduction taxes. The retired, indigent and poor are paid for by the Government Ministry of Health. Major and minor procedures are carried out by physicians who are paid per fee schedule negotiated by the Government and insurance company. This type negotiation came from the famous doctor strike of the mid-1960’s. The entire doctor population refused all but emergency care, which lasted 28 days. The Belgium Medical Association is extremely strong, conducts many negotiations with authorities or whatever background and the physicians are the most free in Europe or in any other country we visited. There is no medical audit, tissue committee or peer review system currently in effect. Eighty percent of the doctors have contracted with the Government to accept the negotiated fee schedule. A full-time physician is considered to work 32 hours per week.
All hospital construction, plans or expansions and types of needs are determined by the Minister of Health.
Any patient cannot visit any doctor in the system, but on a private basis may select and negotiate with anyone whom he pleases. Under the system, doctor-patient contracts are controlled by the doctor’s load and the district geography.
Extra money earned by physicians above and beyond the negotiated salary goes into the hospital for improvements or benefits. General practitioners cannot admit to hospitals, medical specialists do voluntary recertification only. The average hospital stay for all patients is 13 days.
The hospital is run by a board of trustees comprised of seven people elected from the hospital population. They are elected for two-year terms and cannot serve more than six years. They meet once each month. The doctors elect their own representatives to meet with the hospital board.
The general hospital atmosphere would be somewhat comparable to our teaching hospital attitudes. There was a general busyness pervading throughout the hospital, but the doctors did not seem particularly harried. They were most courteous, spent much time with us, and at the conclusion or our conference there, physicians and the hospital administrators had a long cocktail hour in the hospital as a farewell gesture to us.
A large number of the doctors had received their specialty training in the United States and were most familiar with many of our well-known physicians and hospitals.
Our visitation next day was with the Minister of Social Security, Mr. Willy Van de Velde. He was courteous, surrounded by a small staff. Interestingly enough, he responded to all questions without staff input and, despite some rather thorny questions, maintained a cordial, friendly and interested attitude in our delegation.
He explained that their system had grown from past history and the mores of their society in an effort to meet health needs of the people and from mutual negotiations of patients, providers and consumers.
He was appointed to his job in 1964 and serves for life unless convicted of crime or he becomes disabled.
For those who volunteer, the system is compulsory and they remain in the system of a year-to-year basis. It generally covers two-thirds of the country’s total population of ten million. Primarily the people are classified in four categories: (1) workers, (2) miners, (3) seafaring people: (4) independent people (professionals, farmers, prune owners and executives). The State Department and Government cover its own people. The rest are covered by Mutual Insurance Company and all systems together cover 99 percent of the total population.
Of the Mutual Insurance Fund the employers pay the employees’ premiums. This payment includes all sickness, injuries, hardships and unemployment. A separate law covers industrial injuries.
The payment for claims made against the system comes from the National Office of Social Security and the recipients have a card much like a credit card. Physicians also use these at the time a patient is seen. This claim then is filed and the payment is received by the provider.
The cost of the program equals one-sixth of the gross national product and was said by the Minister that this fund is insufficient and the Government must, under separate law, provide for the differences from general tax funds. There are frequent health care crises, both in delivery and construction, and from unexpected events. There are frequent increases in taxes to offset these.
In each instance, except by the indigent and poor, the patient must pay 25 percent of his bill on an out-patient basis, and the Government, under the system, pays for all hospital care.
If a person is unemployed, he cannot receive more than 60 percent unemployment compensation of what his salary was.
Retirement age is 65 for males; 60 for females.
Unemployment starts at 185 days after cessation of the job and there is a sliding scale of unemployment compensation, which begins at 1/45th of annual salary and increases as time progresses to the maximum of 60 percent.
The general tax rates in the country begin at 10 percent for the lowest income people and escalate to 60 percent for those in the highest brackets. A physician’s contract runs for one year at a time and generally the payment from the time of performing a service takes six months.
Observations: The doctors here maintain a firm attitude toward any changing of the system. They wish to make more money. They are satisfied with their abilities to do private practice. About 20 percent of the physicians do this full time.
There seems to be an acceptable mix of private and consumer medical pay coverage, and most of the full-time private practitioners are in the large cities. The system seems to be built on what we would consider American standards. There is no superior advances to be seen in the clinics or hospitals, but they are most willing to hear about new processes that we have in this country and the techniques are acceptable to them provided cost, time and availability of equipment are possible.
The biggest complaint was slowness of construction, high cost of health care system and the anticipation that it will continue to rise into the foreseeable future. The doctors practiced as they saw fit without any interference from either consumers or hospital authorities. There did not seem to be any peer review system and the education and postgraduate education centered around the university hospital complexes. This visit was most interesting and enlightening.
We departed after three days for Budapest, Hungary, where there was a much different population, much different attitudes and a definitely out-dated health care delivery system and with real antique hospitals, clinics and offices. For example, the Semilweiss Hospital, where his original work on antisepsis was developed, was still in operation in Budapest. It is apparent to the knowledgeable that little change from his time has occurred. Startlingly enough, there were large open wards and the crudest of laboratory facilities.
Patients and visitors co-mingle without much restriction. There is a normal number of paramedics available, but there is an obvious shortage of physicians. Hospitals belong to the mayor of the town. Control is totalitarian and he has only to answer to the Minister of Health. The hospital Chief of Staff, always a physician, has great respect, and there is much bowing and scraping by all staff members. The budget and general construction arrangements are arranged through him. He, however, has no input into the medical care delivery. All physicians work for the State, but many see private patients outside their working hours. They negotiated privately with these people. They usually see them in their homes.
A doctor will graduate from medical school in six years from high school completion. Anyone may go to medical school. Entrance is determined by examinations, but most applicants are accepted. There are four medical schools in the country and most of the students are women and 60 percent of the physicians in the country are female. Tuition to medical school is very low--$25 to $50. Medical books are charged to students at one-half price of the cost. They may practice anywhere in the country that they wish only if there is a vacancy and is so determined by the Minister of Health. The professors in charge of each department choose their own staffs independent of any other authority. Residencies last four years, and in all specialties, salary is 4,000 to 5,000 florenz ($200 to $300).
Doctors work 44 hours per week, and they must retire at the age of 65. If they are chief of a department of service, however, they may stay until 70 years of age. In talking with private physicians, they stated that on a private basis patients pay about $10 for a physician visit. Family physicians cannot admit to hospitals.
All state hospitals and sanatoriums belong to the Minister of Health and must deal directly with him in all matters, including construction and budget, but he does not determine methods of treatment.
There are 27,000 doctors in Hungary, mostly located in the larger cities.
Five new hospitals were built in Hungary last year, the largest construction program since World War II. In the system, patient health services are paid expense, but the medicines cost them 15% of the expense.
One of the fascinating areas of medical care in Hungary is their enthusiasm for hot water springs and thermal baths. These are quite ancient and some still in operation go back to 4 B.C. and 10 B.C. They are very popular both with doctors and the population, and small local ones are open for general public use.
The large formal ones are maintained and operated by the State. Hungarian physicians recommend thermal baths as a multi-purpose remedy, and many doctors prescribe mud from these hot springs that are so common. After World War II they were found to be slightly radioactive. The more formal ones are arranged for the treatment of rheumatism and arthritis, and there are 400 such baths in the country. Before a patient is admitted to one of the sanitoria, he must be evaluated in a general hospital. There are 286 rheumatologists in the country. This radioactive mud is highly popular for many uses, including skin conditions, infections and among other utilizations is applied directly as vaginal packs to treat pelvic inflammation disease.
Observations: The physicians here give the impression of not being as competent or as well trained as in other countries that we visited. There is a categorical relationship in the medical community, and seniority and status have their privileges.
Automobiles were in abundance. There was a large number of bookstores. Cities showed much signs of industry. There seemed to be plenty of food and clothing available, although it was not stylish by our standards.
There is still moderate suspicion abound in the country. There is rumored to be 25,000 NKVD (Societ Security Policy) in the country.
There is an astonishing amount of restoration and reconstruction of old buildings and castles although there is such obvious need for housing, hospitals and other basic needs of humanity. The people appeared most anxious to be friendly and there were many tourists around in the country. Hungary appears emerging slowly from their yoke.
From Budapest, we departed by train for Vienna, Austria (WEIN). Austria is a country of seven million people, and Vienna has 1.6 million. The train ride was most pleasant and interesting. Trains are very popular, crowded and were composed of two classes—first class and tourist. It is recommended that you not travel tourist if possible.
We were taken through beautiful country where the fields were lush, but methods of farming that were most evident were animal and plow, and not nearly as mechanical as in this country. Most of the homes appeared to be of some vintage although there were areas of new residential complexes and apartment buildings.
The people in the country were well fed and clothed.
At the frontier there was a heavy Army guard on both sides and they performed an extensive search of the train. This gives you a chilly feeling, particularly when they search closely under the seats and in the baggage racks, but they do not search our persons or baggage.
We arrived in the early afternoon in Vienna. It is a beautiful city, rather completely rehabilitated from the devastation of World War II when they were first overrun by the Germans and subsequently by the Russians. Vienna means “Beautiful Wind” and was first established as an old Army camp before the birth of Christ.
Our hotel was across the street form the Grand Opera House. Our first evening after settling in, we were treated to an extraordinarily beautiful experience. In the park two blocks up the street from our hotel, the national orchestra was playing authentic Strauss waltzes in the pavilion and dancers dressed in costumes of the times were dancing beautifully. We ate marvelous pastries, cheese, and drank wine being easily transposed back a full century.
The next day was one of the most memorable. We were taken to the University of Vienna and its hospital. Our guide was Doctor Arthur Kline, a transported American physician graduate of John Hopkins University.
The hospital is the oldest functioning one in the world.
Fourteen of the original medical specialties were founded here, 1500 doctors are trained here yearly, and it can be said with authenticity that this is the birthplace of modern medicine.
The hospital and all its activities were completely sacked in World War II as it was the first pillaged by the German Army and subsequently by the Russians. Four Nobel Peace Prize winners have been housed in its Pathology Department alone.
There is extensive new building going on and two modern departments of psychiatry and pediatrics are currently there and operating. The completely new clinic will eventually cost 30 billion shillings and will have 4,700 total beds. The first hospital was constructed on the site in 1693 as a military hospital and a hospital for the poor. The site was probably selected because the water here contains a laxative salt, and a dipper is still available at a small spring for those of intestinal fortitude, unexcelled bravery and free of any bronchial spasms that might necessitate coughing. In 1778 the facility became the general hospital of the University of Vienna and thus a cradle of the specialties.
There are five surface miles of hospital in the central core of the facility. All people dying in the facility are required by law, still existent, to be autopsied. They do daily three to 24 autopsies and have on file over 100,000 autopsy reports.
The first specialty evolving here was begun in 1783 when the military medical school was founded by Joseph II and was exclusively for the Army (contract this with our own current military school which is taking its first classes). It trained medics and paramedics for emergency and field surgery.
The building is now utilized as the largest medical museum and library in the world with ancient books and manuscripts, many handwritten, going back to ancient Greece.
Joseph II gave the main thrust to the medical care system in Austria. He was the son of Maria Theresa and despite the fact that he was a ruler, his life’s main ambition was to be a physician.
Some of the other specialties founded here with endowed chairs were: 1795-hygiene- Professor Johann Frank. In 1804, the first psychiatric building was constructed and the chair founded in 1818- Professor Fernwald. In 1862 Freud became the professor and his building still stands. It is built circular so there could be no corners and from outside appearance gives the impression of a giant silo.
In 1804, a Department of Forensic Medicine and the first Department of Pathology was established with Professor Rokantansky.
In 1807, Obstetrics- Professor Boaz. In 1812, Ophthalmology- Doctor Baer, professor.
In 1846, Dermatology was founded- Professor Hebra. Of the first 2,000 patients to the department, 1800 had scabies.
In 1867- Surgery with Professor Billroth. He wanted to be a concert pianist, but his mother insisted on his becoming a doctor. He maintained a lifelong enthusiasm for music, and he was a close friend of Johannes Brahm and played many Brahm’s compositions in his home before they were performed on stage. He was a very large man with giant hands. He started the first intensive care unit and insisted on close post-operative follow-up. Those people on whom he personally operated, he carried off the table to the bed.
In 1868, Urology, Professor VonVittel. He was the inventor of the cystoscope, and it is still on display in the museum along with the next five models.
It should be pointed out that Semilweiss was here during this very productive period beginning in 1847.
1876- Eye, Ear, Nose and Throat was established under Professor Purlitzer (1,000 American physicians trained in this clinic in the early days).
In 1882 Neurological surgery was established under Professor Gussenauber (Doctor Cushing worked here and wrote his memoirs of Vienna when training here).
Other specialties founded first here included: Social Medicine (public health) – 1180.
Gynecology – 1890 – Professor Wertheim.
First emergency room and trauma department – 1895. Other areas of specialization founded here were the first chair of pediatrics – Pirquet, and the first Department of Orthopedics - -Professor Lorenz. In 1897, the first chair of radiology was Professor Guide Holzknecht. A physicist, Professor Roentgen, worked with him in the development of this department. The first angiography was performed here in 1896 and the films are still on display for viewing.
In the calmer days in medical specialties training, the usual time spent by physicians on-site was three months. From there they returned to their respective home towns, usually declaring their individual specialties and training from the University of Vienna. The two most recent areas of specialization are radioisotopes and medical computer science. They are both the largest in Europe and are 15 years old. The Center of Computer Science started in the early 60’s and their largest computer installation was donated in 1965 by IBM. Doctor James Miller, President of the University of Louisville, was a consultant in this installation.
During World War II the Russians were instructed to take the stored treasures of the University of Vienna back to Russia, but they were saved by the Professor of Pathology, who stacked bodies of those killed in front of a door in the basement of the Pathology Department which lead to a storage room where the books, manuscripts and other valuables survived.
In addition to its many other things, the hospital had the oldest and largest anatomical wax museum in the world that was begun in 1760 and finished in 1783. The materials were brought from Florence, Italy, by overland mule train. They were made from beeswax. The museum consists of six rooms of perfect wax specimens, 1,092 in number. All are life-size and in perfect condition. Medical students in those days learned their anatomy from them because of the limited number of bodies available for study. The medical school today had 1200 students, 70 percent are male and 30 percent are female.
The new pediatric hospital has 220 beds. The original pediatric bed unit was founded by Escherichi of Escherichi Coli Fame.
The wage scale for physicians is about 25 percent less than in the United States. There is compulsory health insurance for all employed persons and service professions.
Seventy-five percent of the population is included, and about 75 percent of the doctors participate. Those who do not participate mostly are specialists. Private health insurance costs about $40 a month. There are 50 hospitals in Vienna of which 20 take private patients. The health system is directed by the Ministry of Health. The Minister of Health is currently a woman and an M.D.
At the afternoon embassy briefing, it was stated, among other things, that the people are generally contented with the current Government.
The people of Austria are sympathetic to the West and particularly the United States, but maintain well-reserved caution toward the East because they are its doorway. Of each person with whom we talked and particularly with out sponsor, he stated there was hostility and denunciation of the Russians.
We concluded our visit in Austria by touring through the Vienna Woods, which are most spectacular and beautiful. There were also visits to galleries, castles, including the Schoenburn. It was noted by all of us that the cost of food and clothing was high in Austria, but the people were well fed and stylish. There was plenty of food, clothing and other human items available in the stores, and there were tourists present from all over the world.
As we departed from Austria, Doctor Kline’s resounding admonition rang in our ears. He said, “Despite all the greatness in this country and the rebirth that you see here, none of it compares with the greatness and the humanness of medical care in the United States. Why do the politicians keep insisting on substituting an inferior system and profession. It is important for you doctors not to let it happen, and you must not let it happen because everyone, everywhere will suffer. The true epitome of health care today resides foremost above anywhere else in the United States.”
We left Vienna in mid-afternoon aboard an Aeroflot plane departing to Moscow where we changed planes to continue on to Leningrad. Externally and internally the plane was by modern standards the usual appearing jet, but perhaps somewhat more drab on the inside than those to which we have become accustomed. The stewardesses were friendly and spoke fluent English. There was scrutiny of baggage by the Austrian authorities as we left. In flight, there was food service, which was a heavy amount—giant size sandwich of bread and sausages. Of course there was plenty of vodka and Austrian beer.
We were later to find that Russian beer was not of great quality. There was also French brandy aboard, soft drinks, coffee and tea.
We landed in Moscow in the early evening for a stop-over before enplaning for Leningrad for our first Soviet visit. Here we ran into scheduling difficulties and were seven hours late departing Moscow to Leningrad. During this time we were monitored and well organized and fed inside the terminal building.
Here we met our Intourist guide who remained with us throughout our entire stay in Russia. She was intelligent, a schoolteacher originally who found that tourist work was more interesting and also better paying. Her husband was a movie film producer and seemed to travel about the country a good deal. With our seven-hour delay departure, we landed in Leningrad after midnight and had the pleasure of exposure to the so-called “White Night.” This is a climatic feature that occurs in late spring and early summer for a three-month period. It seems as if you are walking around in broad daylight, and is bright enough that you can read large print.
We were bussed from the airport to the hotel arriving at the Neva River about 2:00 a.m. This was poor timing as all the 56 drawbridges were up. This happens always when the river is not frozen to allow commercial shipping to pass under the bridges when there is minimal street traffic. The timing is from approximately 1:00 to 4:00 a.m. Until the last boat is through, one waits on the side of the river. The rest of the time the drawbridges are down and the boats wait beyond the bridges for this particular delineated period of time.
To reward our patience, we were parked on the street beside the Winter Palace.
Several noted the large number of pedestrians walking about the streets even though it was at such an early hour. This appeared not to be unusual, and we observed throughout our stay there seemed to be no fear of trauma in the street or other crimes.
A brief review of history will help here. Leningrad was selected as Peter the Great’s capital in 1712 and he intended to make it as modern as any European city. It could now be assigned the title of the Museum of Russia in contrast to Moscow, which could be described as the metropolitan city of Russia.
The first abortive revolution started here in 1905 when Czar Nicholas II soldiers massacred scores of workers who were demonstrating outside the Winter Palace.
Lenin became closely associated with the revolution at this time and maintained so throughout the incurring political events. It was here during World War I in 1918 that he returned, being brought from Germany in a sealed train and landing at the now so-called Leningrad’s Finland Station where he began his subsequent triumph leadership of the revolution. This occurred on November 6 and 7 and established the current Soviet power.
During World War II Leningrad withstood the assault of 43 German and 22 Finish Divisions composed of about a million men. The city was bombarded by 107,000 bombs, 250,000 shells, and was battered by 2,000 heavy field guns, 1,500 tanks and 1,200 aircraft. The siege lasted 1,000 days and was much longer and more severe and devastating than that of Stalingrad. One million people alone died of starvation. In the last 30 years, it has risen from its ashes to a triumphantly stirring city.
Leningrad is nourished by the Neva River, which is only 50 miles long and flows from Leningrad’s Lake Lagoda to the Gulf of Finland.
Many extraordinary fascinating historical things are to be seen, including the Summer and Winter Palaces, the Battleship Aurora, from which the first shot was fired signaling the beginning of the Revolution on November 6 and 7. It is now a museum and is anchored directly across the inlet from our hotel.
Cathedral of Peter and Paul, University of Leningrad, which was Lenin’s college. Pau Lou’s Institute is also located here, and some of his experiments are on display along with his stuffed dogs and demonstrations that typified his work.
The city, other than the restored historic places of which some are mentioned above, generally appears quite drab. The people themselves appear somewhat downcast and downtrodden.
It is to be remembered that the USSR is not one nation, but a large continent of a very diverse population. Pure Russians compose only about one-half of the total people of 250,000,000. By official count, there are 104 nationalities, 120 different languages, and 53 republics, autonomous regions or national areas. Each has a different lifestyle and a distinctive character to its people. There is, in addition, a vast difference between rural life and city life. The language alone is a most formidable barrier for outsiders, and the people, especially the older people, seem to have a beware feeling for the tourist. There is a pervasive, subdued, almost expressionless quality to the people and extends even to the landscape and scenery in general.
Strikingly, in contrast, in different attitude from these are Leningrad’s Summer and Winter Palaces, the Peter and Paul Cathedral, Moscow’s Kremlin and St. Basel’s Church, which have a fairytale, wonder-like appearance. Russian churches are now ornaments of the past and now serve as museums. All of these seem suspended in time and disconnected from today’s pressures.
Our primary Leningrad medical person exposure was to the Chief of Administration of Leningrad’s Public Health Committee. He was not a physician, but was striking in appearance, spoke fluent English and obviously anxious to present the best possible picture to us. We met the man in the auditorium of one of the medical schools of Leningrad. There are a total of three in the city. Along with this there are nine paramedic training schools. The medical school and the auditorium itself was hard to believe and none in this country to my knowledge would even approach its antiquity, it having not even rudimentary elements of a modern day building. All of the people, however, in attendance, which consisted mainly of aids and supportive staff were cordial and friendly and extended every possible courtesy and help. The exposure was concluded by a visit through the library and historical part of the medical school where we ran into a most verbose recluse that seemed to be harbored for no particularly identifiable reason in the confines of this library and museum area. When he was turned on, however, he droned endlessly and we finally had to depart, and as far as is known he may still be going through his litany of what has happened and is apparently to happen in his place of wonder.
From our meeting with the Chief Administrator, we found that the annual budget for health of Leningrad is 200 million rubels, which is used for hospitals, clinics and industrial clinics associated with large manufacturing enterprises. It does not include however, monies for research institutes.
There are 22,000 doctors in Leningrad, 75,000 paramedics. Per ratio, there are 72 doctors per 10,000 people. This is better, it was explained to us, than any other Russian city. There are 27 research institutes in Leningrad, but despite our repeated request, we were not invited to visit any of them. This was also true of the hospitals. In discussing this in Moscow with some who would know, it was explained that their hospitals are about the same vintage and style and development as the medical school that we met in and they were embarrassed to show them to foreigners. There is some modern construction underway, however.
Most research and research institute construction occurs in Moscow and occasionally there is one in one of the other major cities, such as Odessa. It was stated these research institutes in Leningrad, however, do maintain close contact to research groups in the United States in accordance with an agreement established by Vice President Nixon in 1962.
There are three major institutes in Leningrad training specialists, and one which trains family doctors. There is one also that trains pediatricians and one that trains epidemiologists (public health doctors).
Public health departments for the country are administered by the Government, and the chief administrators are not necessarily physicians and commonly are not.
There is also one institute for refresher courses for physicians, and they are required to do this once every three years. This may extend up to a six-month visitation period.
If a family doctor, after a refresher course, wishes, he may become a specialist in an area of his selection.
Entry to the medical system for care is interesting to hear about. It begins by first going to an outpatient clinic for examination or assistance. These are usually cared for by felchers or two-year medical graduates most all of whom are women and would be about the equivalent of our registered nurses in education. It is to be remembered at the outset, however, that all medical people can extend up the ladder form the lowest rung if they show aptitude, efficiency and energy, can ascend up to the highest level, which is a specialist physician. One stairstep is used to build another.
The outpatient clinics are in each district. They do not provide hospital beds. They are, however, assigned auto buses with skillful personnel to deal with emergencies. They can also render help inside the cars and can take you to a hospital if necessary. All cars are radio-equipped and usually in the larger cities are within 10 to 15 minutes reach.
The second stage if the outpatient clinic is not sufficient is the so-called polyclinic where there is more extensive diagnosis and treatment available. One of these services 50,000 to 70,000 population, and the medics from here may also see patients in the home. They do not deal with emergencies, but do deal with routine illnesses and chronic cases.
Children under 14 years of age have special pediatric polyclinics, one for each 25,000 people.
Obstetric clinics for expectant mothers have physicians and midwives see the patient two times a month and have a 56-day pre-partum and 56-day post-partum leave of absence from their work. The average stay in the hospital for a delivery varies from 11 to 13 days.
Special diseases have their own clinics, such as tuberculosis, cancer, psychiatric and venereal disease. After the polyclinic, the more acute or severe diseases found are then forwarded to the general hospital. This can only be done at the direction of a doctor. There are 145 hospitals or in-patient bed centers in Leningrad. There are 125 beds for each 10,000 people. Each hospital has 600 to 800 beds and are multi-purpose type. The smallest hospitals in the country are in the rural areas and vary from 20 to 25 beds. No surgery or acute treatment is done here.
All medical care is rendered at “no cost” to the patient or family. The patient may also get paid sick leave and the amount depends on percentage of the salary according to length of previous employment. After eight years of employment, they get 100 percent of pay. Before then pay usually starts at about 50 percent depending on the skill of the worker.
It was said there was a moderate shortage of paramedics, such as nurses, assistant nurses, lab technicians, etc.
Nurses, after three years of training, may transcend into higher institutes and become research people or physicians. One of the large problems in Russia today, as described to us, including Leningrad, is air and water pollution. A city, at the direction of the Minister of Health of the city, can close mills that are the worst polluters. Managers may also be transferred or changed if they do not respond to environmental urging.
All health care is administered in the country by the Minstry of Health. The chief administrators are of high political rank and very few are physicians.
Senior citizens, people with no relatives, and people with social inabilities are administered through a separate system that is directed by the Ministry of Social Security.
To enter medical school in Russia, one must take competitive examinations in chemistry, physics, biology and literature. For each 15 or 20 who take the exam, one is accepted. Special credit to the acceptance is extended to ex-service men, applicants from rural areas and people who have previous medical education or experience. The director of the medical school is permitted to make certain allowances in the selection of his classes.
Only doctors are allowed to administer hospitals, and there are no hospital administrators in Russia. The physicians who do administer the hospitals are given two or three months special training for this.
Dentists are trained for five years post high school diploma; family doctors for six years; specialists eight to ten years according to the specialty.
If a patient wishes to get medicine on his own without going through the system, he must pay total cost. All patients must pay for glasses and false teeth. These are relatively cheap.
Medical malpractice in Russia is determined by peer judgment. There are no lawyers involved. If guilty, the convicted one is sent back for more training or schooling. If a specialist, he may be demoted to a family practitioner or be sent to a smaller area or institute. There may also be issued a public citation condemning the action.
If there is criminal conduct involved, however, this is sent to the Court Authorities and handled in the judiciary system and not by physicians. Here they may be fined or given penal servitude. If a patient has been found to be done wrong, he is refunded from the institute where the incident happened and this is taken from their budget.
There are no mandatory autopsies in Russia except for those cases of sudden death. In these cases, all are mandatory.
There is no compulsory age of retirement for physicians. If the physician continued to work after 65 he gets both his usual pay plus his pension entitlement. Pay levels start at $150 a month with the top specialists receiving approximately $1,000 a month. Some extra bonuses for teaching is allowed. The pay scale is generally increased by length of service, type of specialty or area of service. There are also extra bonuses given for rural area practice and for those is less desirable areas. It was said one of the more severe problems in Russia is getting physicians to go to rural areas or areas of severe climate, such as Siberia.
Physicians serving in the military have their own pay scale.
Radiologists in Russia may retire at 45 because of the special health hazards involved. Seventy percent of the doctors in Russia are female, 80 percent of the felchers are female.
None of the top administrators or chairmen of the departments that we met, with the exception of gastroenterology at one major hospital, were female.
We toured about the city of Leningrad looking at various sites, and frequently went past hospitals, but they were wretched in appearance and may have survived the siege of Leningrad during World War II. We would have preferred more physician exposure in Leningrad, but it was not to be, but it was felt we had exposure to understand the circumstances well enough.
From Leningrad on to Moscow. The plane both to Leningrad and back was considerably different from the one we traveled from Vienna to Moscow. These are jet planes, but they are small, there is very little leg room, the seats are most uncomfortable with straight backs, the food was of a considerably more course variety—it came in a small sack composed of a small sandwich heavily laden with butter, cheese, and again, some strong Russian sausage. It was noted that some of our delegation seemed to drink larger quantities of vodka during the meal on these two flights than during any other meal service. We landed at the same field in Moscow. Curiously enough flying in or out of Moscow you never pass over the city. The terminals are located approximately 25 miles out.
We travel after landing by bus into the city, and one is immediately aware of the giant construction of apartment houses which must house thousands. One’s mind can only hopefully speculate the plumbing, laundry and hygienic conditions that must exist under these circumstances.
Apartments are small one and two rooms mostly. There is no doubt much togetherness. Furnishings are the most simple type and throughout the entire city you see no private houses.
Moscow is a much more vibrant city than Leningrad. Many cars are on the street, more than was anticipated. Sidewalks are quite crowded and people use the public transportation subways and buses extensively.
Our hotel was the Rossiya. This is on a corner from the Red Square and just up the street form St. Basels. It is Europe’s and probably the world’s largest hotel with accommodation for 6,000 people. It is generally rated first-class and was completed in 1967. There was minimal room service available, has a reasonably efficient staff present, a constant rather drab moderately obese lady present on each floor to keep an eye on the comings and goings. Special note to this hotel is the fact that it was the first to add a service charge of five percent to insure promptness. It is giant in size requiring a considerable period of time to walk around, and it would be described as equivalent to the coverage of approximately four average city blocks. There is minimal television in the rooms, but there was radio present, for which there is a selection of six stations which played various news, music or propaganda programs ceasing at 10:00 in the evening.
When traveling in Russia, in tourist (soviet tourist bureau) make the selection of the hotels in which you stay, and you only find out once you get to your place of landing which one. We were most fortunate that ours were of the best, The Rossiya, being right by Red Square and very close to the Kremlin.
Our first day of recuperation was Sunday. We spent it walking around Red Square looking at the walls of the Kremlin, St. Basel’s Cathedral, and Lenin’s tomb. Just behind this in an inconspicuous blocks in the wall lay the remains of Stalin. His name was not mentioned by anyone throughout our entire stay, except when we inquisitive Americans asked. He was not spoken of kindly and it was interesting to note also that Kruschev was spoken of as a clown.
The ordinary street people were silently apparently unnoticing of our presence and made no particular overture to become acquainted with several rare exceptions. One was a schoolteacher from Siberia who brought her son in to be introduced to Americans. Both spoke excellent English. We also were encountered on a subway when asking for directions by a lady who spoke English and went considerably out of her way to guide us back to the hotel. She concluded our brief exposure to her by saying, “It makes me feel so wonderful just to touch your hands”. One of our physicians offered her a ballpoint pen, and much to his astonishment, she gave him a much better one plus some other souvenirs of Russia as an expression of good will. After this she quickly disappeared into the crowd surging up the street.
After a stroll through the Kremlin the next day we went inside to view the treasures of Russia. Their magnitude and great wealth along with its sheer beauty and fabulousness leaves one exhausted by their enormous value. It is easy to conclude the Czars personally lived more luxuriously perhaps than anyone. One of our delegation stated after viewing the palaces, castles and adornments of the wealth of the Czar, “That these places were the cradles of communism.” This statement could easily be accepted without debate.
The features of the Kremlin have been described many times over and need not be a part of this venture. There are armed guards around the place, and the areas where you can and can’t go are well marked. There few officious loudmouths about the place that try to herd you around unduly. Walking about the city was permissible and as far as we know no one paid particular attention. Pedestrians are warned that traffic moves from left to right, and that you cross streets only where there is either stripes or arrows and at green lights, making use the underpasses available. Drivers are not allowed to use their horns. That makes for some rather fast footwork on occasion.
One day of our tour was spent at the Exhibition on Economic Achievements of the USSR. Here a display of the technical achievements of Russia were in open exhibition.
Pavilions are built in the architectural style of different Soviet Republics and the large buildings are devoted to different branches of agriculture, industry and science, including space achievements. There is a demonstration of astronauts in flight, mechanical hearts, and various scientific achievements in all areas, much too numerous to mention, but a most grandiose presentation. You could easily spend days here. Medicine was one of the many scientific achievements on display.
Our biggest single medical day of exposure to health care and to physicians came on a day’s visit to City Hospital Number 52, where we were the guests of the Chief-of-Staff, Dr. Ivan Zachepin. As in all things Russian, this was a giant installation built in 1966 and described as the newest hospital in Moscow. It had 5,000 rooms, arranged in six different buildings. Each building housed a particular area of specialty care, laboratory or special project facilities. We traveled about the wards, through the lab and operating rooms.
It is possible to make the following observations. The physicians were most cordial, cooperative, friendly and were anxious to talk with us. All of them had been trained, with few exceptions, in the Soviet Union and one can perceive immediately that one of the great losses to health care in Russia is the inbreeding and lack of international exposure and training at worldwide institutes that would immediately enhance their care. Most of the equipment, even at this new hospital, is well outdated, some even pre World War II. Much to our astonishment in the operating rooms we saw open beaker decanters being used for intravenous fluids. When empty, another open beaker was used to replenish the one that was directly tubed into the patient.
The anesthesia machines were quite ancient and were General Electric models. It appeared to be a 1950 model.
The general hygiene of the entire hospital would not pass any ordinary public health standards in this country. The operating rooms were atrociously dirty. Using this as the standard of cleanliness, the condition of the toilets in the hospital will not even be described. Patients here seemed to be quite servile in the presence of physicians.
A few medical interesting features, usual stay of non-operative duodenal ulcers for a routine hospital admission averaged 42 days. The old original sippy regimes were still used in treating the ulcers and computer analysis of automated lab studies were not in evidence. General discussion of health care in the country was similar dialogue as Leningrad.
They do take great pride of their research in cardiac surgery and described some of their heroes along with our own Doctor DeBakey who had visited the hospital some ten years before.
The staff mentioned that they got most of our current medical journals and read them avidly.
It was impressive to find out in Russia the subconscious mind is denied and the Pavlovian Theory is held. Man is responsible for his own deeds and can be retrained or redirected.
Throughout all our visitation to medical facilities in Russia, it was obvious that there is a commonness and friendliness within the profession of physicians. If it is true for arts and music, it is equally shared in the medical world family. One could continue almost ceaselessly, the description of construction, services, facilities, pharmacies, hospitals, clinics, but the general above description gives a gross coverage of health care may seem derogatory, but it must be pointed out that this is the best they have ever had and far superior to that of any other government. There is an anxious desire on the part of doctors to improve and enhance the system and modernize it. When asked the greatest problem, it was said there is not enough money.
They have a severe problem getting enough doctors and other medical people interested in medicine. It was felt that our restriction from many of the facilities was because they are not yet approaching ours in either modernization, construction or adequateness. One concludes rapidly in reviewing all the different systems that money is a large problem. There is a shortage of specialty trained people and of people wishing to enter the profession. There is a severe distribution problem in all the countries, and especially so in the Soviet Union. Despite all these disadvantages, however, the people in Russia today undoubtedly have better health care than ever before.
The procedure for financing a U.S.S.R. hospital is interesting. The institution is given at the beginning of the year a lump sum of money which is to carry them throughout the year. This assumption of allocations is established by the Ministry of Health. It is presumed there is some dialogue on arriving at a figure although the administrator of a hospital in Moscow indicated they had had no increases in their budgetary allocation in the last five years. It is a common saying amongst Russians, “Do not get sick in the early part of the year, but wait until the last month or two when surpluses have to be expended in order to re-establish the budget for the next year.” The grounds of the hospital are only vaguely landscaped. There were screened-in porches with cast holes and there were some other obvious deterioration of the structures which had been left unattended or unrepaired for many months. No doubt these all have some budgetary connotations too.
After our stay in Moscow, we then embarked by Yugoslav Airlines for Belgrade, then on the Dubrovnic on the Adriatic Coast. This is a superbly beautiful place, and it was apparently included in the itinerary as a balance for our previous brusque schedule of large geographic coverage and of multi-system exposures. It is definitely one of the divinely scenic areas of the world. Yugoslavs are vibrant, gay and happy people and show callous disregard of the Russians. They feel they have little in common with them, and indeed, and analysis of their system would be called more Capitalism than Communism. Citizens are allowed to come and go in Yugoslavia as they wish, including outside the country.
The old city of Dubrovnic is the best maintained ancient city in the world and seeing it, it is easy to understand. One extra exposure here was that the oldest continuously operating apothecary in the world located inside the confines of the old city. It was begun in 1343. Around the corner from it was another which had been operating since 1410. Some of the original old jars and other instruments were on display.
After a three-day visit up and down the Adriatic Coast, including a look into Elizabeth Taylor’s private apartment, being maintained in one of the resort areas, we returned to Dubrovnic, embarked to Rome, back to New York and Louisville.
Summary: Health care systems all have their problems. The universal one is money. Personnel distribution is a perpetual problem. Motivating people to become physicians and health care people is an unsolved health problem.
No system, facilities, or care area that we saw would be comparable to what is present in the United States. Considering cost analysis, health care delivery here is still relatively inexpensive in contrast to the quality of the product received, the number of things that are available, and the opportunities to maintain one’s health care in an independent statue for the profession and the patient. These are irredeemable features, and it would be a tragic loss if they are ever transgressed. They cannot be enhanced by Government, or less expensively done by Government. It can be concluded rapidly, after seeing multiple systems, that once politics have seized control of medical care, it is no longer a priority item and it becomes a budgetary hardship to the government. Health care then takes a second-rate position, depending on priority assignments from the people who direct the Government.
One cannot leave Russia, however, without being depressed to think that a small number of people, less than 500, are autocratically in charge of the country, composed of 250 million people that they hold in bondage and servitude, not even allowing to leave their own borders. They only travel about their own country with some amount of supervision from state authorities.
It portrays the lesson always taught by history, “You will run the Government, or it will run you.”
May it ever be our lot in this country that we have the freedom given by our abilities to pursue what we wish in an unfettered state and to reach the epitomes such as we wish to claim for ourselves without handicapping interference of bureaucracy, and the forced servility of personality brought about by the sword of state held by pernicious hands.