Health Care Policy and Health Care System in the Soviet Kazakhstan: Historical Essay

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Abstract:

On the exit of Tsars Central Asia including Kazakhstan was plagued with malaria, leprosy, polio, diphtheria, and tuberculosis.[footnoteRef:2] The general mortality rate was 30.2 per 1000 inhabitants and infant mortality rate was 272.0 per 1000 births. In 1913, average life expectancy was under 32.0 years, and 0.4 doctors were available per 10,000 inhabitants in Kazakhstan.[footnoteRef:3] The condition in Russia was not far better and as such soon after October 1917, Communist regime in Moscow established, in June 1918, the People’s Commissariat of Health, a central body for directing the entire health work of the nation under the supervision of Dr. Samashko,[footnoteRef:4] to bring a change in the existing set-up and make health sector modern to combat diseases, as well as for winning the population to the Soviet cause. [2: SaltanatSulaimanova, In the Tracks of Tamerlane: Central Asia’s Path to the 21st Century, Daniel L. Burghart and Theresa Sabonis-Helf (Eds), National Defense University Press, Canada, 2004, p. 224.] [3: A. K. Patnaik, History of Civilizations of Central Asia, Vol. 4, p. 580; Howard M. Lecher, Health Care Policy in Four Nations, USA, 1978, p. 203.] [4: Soviet Communism: A New Civilization, p. 655.]

Introduction:

Soviet medical administrators strongly opposed the traditional practices; fearing the spread of disease was unmanageable for the traditional healer’s whose influence at the local level was far and wide.[footnoteRef:5]Since the Soviets believed that religious practices, povertyand illiteracy played as great a role as microbes in illness the state charged medical professionals with fighting disease not only through the application of scientific knowledge about microbes and vectors but also through a struggle against the social conditions viewed as fundamental to creating an environment in which diseases thrived.[footnoteRef:6] [5: Donald A. Bar & Mark G. Field, “The Current State of Health Care in the Former Soviet Union: Implications for Health Care Policy and Reform”, American Journal of Public Health, Vol. 86, No.3, 1996, pp. 307-308.] [6: Leonard J. Bruce-Chawtt, Malaria Research and Eradication in the USSR, WHO, 1959, pp. 739-740.]

Institutions for Implementing the Healthcare System:

Beginning in 1928, the Soviets intended to facilitate the transformation of the cultural superstructure at a time when industrialisation and collectivisation provided for fundamental changes in the economic substructure.[footnoteRef:7] There was no place in this new order for vestiges of a superstitious, irrational and unscientific past. Traditional healers, who included shamans, mullahs, and folk doctors, found themselves the targets of a vigorous propaganda campaign meant to drive the indigenous population into the hands of the newly trained biomedical doctors, nurses, and midwives.[footnoteRef:8] Beginning with the early 1920’s the Kazakh Ministry of Public Health conducted a large scale medical propaganda campaign, radio programmes, posters, films, lectures, and staged public spectacles on health and hygiene,[footnoteRef:9] that reached the most remote parts of the country.[footnoteRef:10] For the most part, the effort was to persuade the population to distrust traditional healers, even though occasionally the state resorted to coercive methods, such as arrest and imprisonment of Kazakh traditional healers.[footnoteRef:11] The development of biomedical institutions in Kazakhstan, even if it was a clear expression of power and control, was but meant for the health and well-being of potential contributors to the Socialist economy. [7: Paula A. Michaels, The Russian Review, Vol. 59, 2006, p. 163.] [8: WHO, Health care in transition: Kazakhstan, London, 1999, p. 9.] [9: M. A. Bykov, Sanitarnogigienicheskieocherki I zdravookhranenie v raionakhSyr-Dar’inskogookruga, Chimkent, 1931; c.f. Paula A. Michaels, The Russian Review, Vol. 59, p. 167.] [10: It was on account of the policy made in Moscow administered through a centrally organized hierarchical structure, i.e. the republic level to the oblast or city administrations, then to the subordinate rayon level. Since the policy adopted, involved feldsher (paramedic) stations at the village level, district (rayon) and regional (oblast) levels, topped by an assortment of advanced institutions at the national level, where services were in principle, accessible and mostly free to everyone; Mark G. Field, Health Care in Central Asia, pp. 68-70; Paula A. Michaels, Journal of the History of Medicine, Vol.59, p. 318.] [11: Paula A. Michaels, The Russian Review, Vol. 59, p. 160.]

Even if Kazakhs reluctantly accepted the new medical system the government did create facilities where after the number of doctors grew from 452 in 1927 to 1,571 in 1937.[footnoteRef:12] Until the founding in 1931 of the V.M. Molotov Kazakh Medical Institute (KazMI), all Kazakh doctors received training outside the republic. Even after the institute was opened, the majority of doctors continued to come from outside the republic, transferred there by the USSR Commissariat for Public Health.[footnoteRef:13] One of KazMI’s primary missions was the creation of a cadre of indigenous medical workers. As of 1931, only 30 to 35% Kazakh physicians served the indigenous population.[footnoteRef:14] Even after KazMI began graduating students in 1935, the number of Kazakh graduates remained quite small in the pre-War years. Kazakhs were more numerous at lower levels of the medical profession, working as nurses, midwives, and physician’s assistants; still they could not serve the population wholly. In 1935 there were 14,604 health workers in Kazakhstan, but among them just 2,015 were Kazakhs i.e, 13.8% of the total number of health workers.[footnoteRef:15] [12: Paula A. Michaels, The Russian Review, Vol. 59, p.165.] [13: “Tsentral’nyiGosudarstvennyi Ark1933-iiu hivRespublikiKazakhstana”, Ed. Kul’turnoestroitel’stvo v Kazakhhstane; c.f. Paula A. Michaels, The Russian Review, Vol. 59, p.165.] [14: “Tsentral’nyiGosudarstvennyi Ark1933-iiu hivRespublikiKazakhstana”, Ed. Kul’turnoestroitel’stvo v Kazakhhstane; c.f. Paula A. Michaels, The Russian Review, Vol. 59, p.165.] [15: David Lane, Ethnic and Class Stratification in Soviet Kazakhstan (1917-1949), Cambridge University Press, Cambridge, 1975, p. 181.]

The number of hospital beds expanded from 3,767 in 1928 to 16,290 in 1941 yet most were concentrated in Slavic urban and industrial areas, and thus were beyond the reach of the region’s indigenous population, which was often served by itinerant medical teams that passed through nomadic and semi-nomadic encampments for a few days or weeks at a time.[footnoteRef:16] Nevertheless in agricultural areas, the state established temporary clinical facilities to servecollective farmers during harvesting and sowing seasons. Among other duties, these young, temporary medical cadres bore responsibility for transmitting health awareness to Kazakhstan’s villages and as such showed positive results as Soviets accomplished their objective of lowering rates of infectious diseases.[footnoteRef:17] [16: Paula A. Michaels, The Russian Review, Vol. 59, pp. 318-322.] [17: Paula A. Michaels, The Russian Review, Vol. 59, pp. 318-322.]

On the occasion of the 25thanniversary of the October Revolution in 1942, numerous public health officials asserted that the Soviets had washed away all the evils of the Tsarist past.[footnoteRef:18] In subsequent decades, dramatic improvements in the field of health were undoubted. By 1960-61, there were 1,620 general hospitals in Kazakhstan with 77,000 hospital beds, 560 polyclinics, 704 health posts, 34 medical and sanitation units, and 3,940 feldsher-midwife posts.[footnoteRef:19] With the great emphasis on preventive medicine some common diseases like malaria, leprosy, polio, tuberculosis and diphtheria including cholera, plague, smallpox, typhus, relapsing fever etc. were brought under certain degree of control by 1960s through widespread preventive measures like mass vaccination and immunization[footnoteRef:20] as the incidence of typhoid was reduced by 80%, diphtheria by 75% and scarlet fever by 55%.[footnoteRef:21] [18: Kazakh Commissar for Public Health claimed that the “The Great October Socialist Revolution transformed the face of old Russia. Colonial exploitation of Kazakhstan, with its darkness, ignorance, and cultural backwardness has disappeared forever.”His deputy, Tleugabylov, enthused that, “casting off the chains of their damnable past, a friendly family of Kazakhs including many others marched hand in hand with the great Russian people along a vast, bright path [to the future].” c.f. Paula A. Michaels, The Russian Review, Vol. 59, p.173.] [19: Medical Services in Central Asia and Kazakhstan, 1963, p.109.] [20: A. K. Patnaik, History of Civilizations of Central Asia, Vol. 6, p. 580.] [21: “The Russian Health care System: Sick in so many ways”, 2007, www.La Russophobe.com]

The measures that were taken in Kazakhstan were so concrete that the health status of the people showed a lot of improvements. Mortality rates, both infant and general, dropped sharply, the expectation of life correspondingly rose and the general health of the population improved largely, reducing the rate of infant mortality, by opening new children’s hospitals and clinics and by increasing the number of pediatrician’s. Women and infant mortality rate declined substantially. For example, between 1940 and 1960, there was a fivefold drop in infant deaths in Kazakhstan. The general life expectancy reached 43 years in 1942, and nearly 70 years at the time of disintegration of Soviet Union as compared to 32 in 1913.[footnoteRef:22] The birth rate was comparably high, 36 per 1000 population, in 1960, 40% above the all Union average. It was the aim of authorities that all confinements should take place in hospital conditions and new maternity homes were constantly being opened to make this possible. There were 11,000 maternity beds and 410 kolkhoz maternity homes, more than 500 women’s and children’s clinics including 196 in rural areas and 11,500 beds in children’s hospitals and more than 1,700 children’s doctors in Kazakhstan in 1961.[footnoteRef:23] In addition all the kolkhozes were being encouraged to build their own maternity homes.[footnoteRef:24] [22: Medical Services in Central Asia and Kazakhstan, p.123; A. K. Patnaik, History of Civilizations of Central Asia, Vol. 6, p. 580; WHO, Regional Office for Europe, 2007, www.who.com.] [23: Women’s consultation centers, maternity homes, health stations at factories and offices, midwife and gynecological institutes and so on were mainly for expectant mothers, and were able to handle all the births in the country; Soviet Communism: A New Civilization, pp. 670-674; USSR: Questions and Answers, 1917-1967, p. 322; Rising Infant Mortality in the U.S.S.R. in the 1970s, Washington, 1980; Ethnocultural Identity and Induced Abortion in Kazakhstan, p.319.] [24: Medical Services in Central Asia and Kazakhstan, p. 124.]

Achievements in Healthcare System:

The result was that the infant mortality dropped almost five times in the years between 1940 and 1960 even though the death rate of new-born babies, particularly premature ones, was still high.[footnoteRef:25] General mortality declined by 71% and infant mortality by 90% at the close of 1960s.[footnoteRef:26]While in 1937 the death rate in the USSR in general was 40% below the death rate in Russia in 1913 and was constantly being reduced implying a much higher life expectancy, on the other hand the birth rate increased constantly. Even just from 1936 to 1937 the birth rate increased by 18%.[footnoteRef:27] In spite of the growth in population the authorities and health ministries of the republics in the Union took measures to provide substantial infrastructural facilities to measure the health standards of the people. It was therefore mandatory for the entire adult population, to undergo a compulsory medical check-up once every two years. As an example; 104.4 million people were examined by the doctors throughout the Soviet Union in 1965 alone.[footnoteRef:28] [25: Examining the reason for this the Health Minister of Kazakhstan remarked in 1961 that a survey was done in 1960 only 78.6% of new-born babies had been visited by doctors in the first three days after discharge from the maternity home; Medical Services in Central Asia and Kazakhstan, p. 124.] [26: The consultation centres looked after children in the area up to age of three. They regularly examined the both healthy and sick children in specialized departments and at home and taught mothers how to protect their children’s health, vaccinate children against smallpox, tuberculosis, diphtheria, polio, etc. and supervised the work of the infant- feeding centers where mothers received supplementary food for their babies. Children after reached the age of three were constantly looked after by the district clinic up to the age of 14, or until they finished school. Due to these efforts, with the passage of time Soviet children became stronger, taller, and healthier; USSR: Questions and Answers, 1917-1967, p. 323.] [27: N. A. Abdurakhimova, History of Civilizations of Central Asia, Vol. 6, ChahryarAdle (President),UNESCO, Paris, 2005, pp. 139-140.] [28: Between 1926 and 1959 there was an 8.5 times increase in the number of medical personnel for the USSR as a whole, but as for the Central Asia and Kazakhstan is concerned the increase was 21 times; “Chislennost, Sostav I Razmeshcheniye SSSR”, Moscow, 1961; “Kazakhstan Press (KP)”, 19.05.1961; c.f. Medical Services in Central Asia and Kazakhstan, p.37; A K. Patnaik, History of Civilizations of Central Asia, Vol. 6, p. 580; Health Care Policy in Four Nations, p. 203.]

To create high health standards Kazakhstan had more than 13,000 doctors and 53,000 feldshers, midwives and nurses by the year 1961.[footnoteRef:29]That means there was one doctor for every 859 inhabitants. There were 23.8 physicians per 10,000 inhabitants in 1970 and 38.3 in 1981 in the entire Soviet Union as compared to 1.5 physicians per 10,000 inhabitants in 1913 in Russia.[footnoteRef:30] The ratio of doctors in Kazakhstan was not the least as there were 21.8 in 1971 and it rose to 38.7 in 1988 doctors for 10,000 inhabitants.[footnoteRef:31] It was a huge accomplishment as compared to 0.4 doctors per 10,000 populations in pre-Soviet days. Since by then education standards had also risen and medical education was well received by the Kazakh population more so by females, therefore by the 1970s about three fourths of the total number of doctors in Kazakhstan was female.[footnoteRef:32] By organizing the health system in such a way, the entire population was involved directly, and hence felt very strongly about improving the health of the nation.[footnoteRef:33] Accordingly habits and attitudes of the people changed dramatically from the pre- Soviet days not only in Kazakhstan but throughout the Union.[footnoteRef:34] [29: “Chislennost, Sostav I Razmeshcheniye SSSR”, Moscow, 1961; “Kazakhstan Press (KP)”, 19.05.1961; c.f. Medical Services in Central Asia and Kazakhstan, p.37; A K. Patnaik, History of Civilizations of Central Asia, p. 580; Health Care Policy in Four Nations, p. 203.] [30: SankarBasu, Culture and Civilization of the USSR, New Delhi, 1985, p. 120.] [31: A K. Patnaik, History of Civilizations of Central Asia, Vol. IV, p. 58] [32: Bejoy Kumar Sinha, The New Man in Soviet Union, New Delhi, 1971, p.185.] [33: It was pointed out that in 1956, 1.3 percent of the entire population of the Soviet Union including Kazakhstan worked in one way or another in the field of public health; Elizabeth Brainerd, “Reassessing the Standard of Living in the Soviet Union: An Analysis Using Archival and Anthropometric Data”, The Journal of Economic History, Vol. 70, No. 1, 2010, pp. 83-99.] [34: Sigerist (a prominent scholar of the time) describes some of his experiences in 1936: “The habits of the Soviet people have changed radically in a very short time. The cities are spotlessly clean, and the foreigner soon learns that cigarette butts are not supposed to be thrown on the street but into special cans placed at every corner. I remember a long railroad ride from Moscow to Kazan during which the conductor came to clean my compartment every two hours, which was more often than I liked. When I asked her to let me sleep in peace, she said ‘Well, citizen, I have to clean the compartment because the inspector may come in at any station, and the car must be kept as clean as it was when we left Moscow – but I will do it without disturbing you.’ No visitor is allowed to go into food factories, medical institutions, or nurseries without sterilized gown and cap. Such regulations may sometimes seem exaggerated, but they are part of great educational programmes and far-reaching results cannot be expected unless there are strict rules which must be followed literally”; “The Russian Healthcare System: Sick in so many ways”, www.LaRussophobe.com]

Health thus became a force of unity wherein Soviet accomplishments succeeded tremendously with every passing day, providing equal opportunities to the diversified populations across Kazakhstan without any ethnic divisions. All Kazakh population thus reached to almost western standards of living in just 70 years even if there were still shortfalls in many areas. The benefits that came to Kazakhs in social sector were felt more around the end of the World War II as till then they resented the moves of Soviets unsuccessfully and therefore, Slavs got benefited, as was found in case of supervisions and higher jobs that were occupied by them because of their accepting the programmes launched in education, health, industry, etc.

Conclusion:

Soviet education and health thus were guarantee to unify not only sexes but also all nationalities to serve the purpose the Soviet leadership desired for them and in the process all of them got better material status after reaching to about 100% literacy levels and attaining better health status. This was not a mean achievement for both Kazakhs and Russians to transfer from below 10% to absolute figures, both for men and women, in a period of just fifty years and attain for themselves gains in all works of life. Soviet education and health provided no opportunities for dividing the diversified nationalities and wherever these existed, those were on political grounds or else because of management skills of the Communist leadership that grew and enlarged in all walks as dictators and as supervisors to keep an eye and check the lives of the people.

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Health Care Policy and Health Care System in the Soviet Kazakhstan: Historical Essay

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