Soviet Medicine: Culture, Practice, and Science

In 1990 Susan Gross Solomon and John F. Hutchinson published Health and Society in Revolutionary Russia(1), an edited volume that has served as a touchstone for scholars of medicine, gender, revolution, culture, professionalization, economics, and state power. Frances L. Bernstein, Christopher Burton, and Dan Healey call to mind this forbearer in the sweep and scope of their Soviet Medicine: Culture, Practice and Science. This is not an accident. Indeed, the volume is dedicated to Solomon, who is also a contributor, and Hutchinson, who passed away unexpectedly in 2002. Bernstein, Burton, and Healey have set a good model for themselves and produced an ambitious and impressive volume building on this foundation as well as expanding into new fields and interpretive frameworks. They do not set off on this task alone, but are joined by an international band of scholars of the history of medicine from Canada, Japan, Russia, the United Kingdom, and the United States.

A symposium at Swansea University in 2005 brought together most of the authors and their essays show the changes of the field in the years since the publication of Solomon and Hutchinson’s volume. As the excellent introduction by Bernstein, Burton, and Healey makes clear, the essays in the volume reflect many of the changes within the field of Russian and Soviet history in that time as well as the moves within medical history during that period. The essays as a whole display increased attention to the question of how medical practitioners worked with or against the state (tsarist and Soviet) as experts, more insight into the political nature of utopian medical planning, new research into the ways medical professionals exercised, gained, or lost authority with revolution or regime change, greater awareness of the experiences of patients outside the metropole, and further scholarship on the post-war period. The introduction is a fantastic resource on its own and should be a helpful to anyone trying to acquaint themselves with the field either as student or instructor.         

The first essay in the volume bridges the revolutions of 1905 and 1917 and their impacts upon the psychiatric profession. Using discussions among psychiatrists at meetings and in print, Irina Sirotkina argues in ‘Toward a Soviet psychiatry: war and the organization of mental health care in revolutionary Russia’ that 1917 exposed the many problems of the profession in terms of organization, funding, image, and personnel. The upheaval of war and civil war left facilities impoverished and patients subject to disease and famine. Many in the profession found themselves more interested in immediate survival than long term liberal ideals of egalitarian, non-hierarchical leadership. In addition, ideals of communal administration were challenged by different-than-expected outcomes from experimental leadership. After October, a mistrust of the public coupled with worries over scant resources and a general image problem within the profession and society led psychiatrists to dovetail their interests with the state, and press for a strong central administration. Sirotkina outlines a group of professionals who did not fight but joined with the state as a source of leadership, resources, and legitimacy

Later essays by Bernstein and Healey similarly explore the effects of the revolution on medical ‘expertise’ and specifically look at how the work of medical professionals contributed to conceptions of a new Soviet person and their sexuality. In ‘Behind the closed door: VD and medical secrecy in early Soviet medicine’, Frances L. Bernstein develops a fascinating tale using the 1927 Lev Semenovich Fridland book Behind the Closed Door: Notes of a Venereal Doctor. The book, censored in the 1930s, did not reappear until 1991. Sensationalistic and provocative, Fridland’s book was unlike other sex pamphlets of the period that courted legitimacy by draining their discussion of all interest. Instead, Fridland’s controversial book used venereal disease as an entrée to discussion of confidentiality and the social duties of doctors following the revolution. While Commissar of Health Semashko argued initially that illness was not a disgrace but a misfortune, the realities for those who had venereal disease (wrongful termination or eviction, etc.) made Soviet doctors reluctantly accept secrecy plus forced treatment and mandatory notification if patients left treatment. As with Sirotkina’s study of psychiatrists, Bernstein finds medical professionals who cooperated with and desired central authority rather than resisting it.

Professional expertise harnessed to the needs of state is at issue in the work of Dan Healey as well. His ‘Defining sexual maturity as the Soviet alternative to an age of consent’ shows how changing concepts of the age of majority were affected by social and cultural context. While under the tsars, girls as young as eleven were considered of age, in the early 1900s new ideas about maturity and the dangers of premature sexual contact emerged and many of these fears resurfaced again after 1917. The Bolsheviks did not fix an age of consent, but instead argued for the use of sexual maturity in courts, thus allowing forensic medical experts into the debate and medicalizing sexual citizenship in Soviet Russia. Experts decided that sexual maturity fluctuated according to the gender, ethnicity, climate, society, culture, and even diet of a subject and used these calculations to buttress long-standing prejudices about people from the south, the degenerative nature of women’s desire, and males as being psychologically and women biologically driven.

In addition to these works that look towards issues of expertise and professionalism, the volume also includes pieces that conceive of tsarist and Soviet medical care in the context of imperial policy. Dmitry Mikhel’s ‘Fighting plague in Southeast European Russia, 1917–1925: a case study in early Soviet medicine’ conceives of plague policy as an imperial policy of social control and political order and details the transmission of pre-revolutionary specialists into post-revolutionary anti-plague measures. Conceptions of the colonial other weave through the policies of both states as plague is conceived of as a threat from East to West that even after the bacteriological revolution is blamed on the dangers that the East – and especially the movement and culture of the ‘Kirghiz‘ – brought to the doorsteps of European Russia. Mikhel details the anxieties of authorities, which occasioned policies for the enlightenment of the population and its surveillance.

Susan Gross Solomon’s essay ’Foreign expertise on Russian terrain: Max Kuczynski on the Kirghiz Steppe, 1923–4’ recounts conceptions of the ’Kirghiz’ but from the vantage point of German medical expeditions to Russian regions in the 1920s. Solomon focuses on the work of Max Kuczynski who journeyed to the steppe where he attempted to develop new field of ‘ethnopathology’ with which he hoped to bring greater focus on social factors in disease. Kuczynski argued that medical research had much to learn from the field as well as the laboratory, and Solomon deftly analyzes the ways in which field research can be part of or separate from their area of study. Solomon argues that Kuczysnki remained isolated from the Soviet interpretations outlined by Mikhel of the backwardness and danger of the ‘Kirghiz‘ to instead develop a more nuanced interpretation than the simple binary of civilized/uncivilized in conception of disease among nomads.

As with Solomon’s essay, international connections between medical experts emerge in the work of Michael Z. David. David shows in his ‘Vaccination against tuberculosis with BCG: a study of innovation in Soviet Public Health, 1925–1941’ the connections with the French that energized the Soviet campaign to vaccinate with Bacilles Calmette Guerin (BCG). Tuberculosis, perhaps the leading cause of disease between 1890 and 1940, was a scourge in Russia. The vaccination campaign, dependent upon international trust and ties with the French, began in the 1920s. When a financing mechanism and earmarked funds developed in the mid-1930s, the program expanded exponentially. By 1960 the program was enormous, with 15.2 million children vaccinated and almost universal coverage of the population achieved. Regional problems – supply, training, personnel, and cooperation problems – showed the difference that the enthusiasm or intransigence of local medical professionals could make to the implementation of central directives. In this case, David highlights the innovative and proactive work of professionals in protecting the health of their populations.

Several essays follow the current interests of the profession in the post-war years by addressing professionalization against the backdrop of late Stalinism. Marina Sorokina highlights the work of Soviet medical and forensic experts on the international stage in ‘Between power and experts: Soviet Doctors examine Katyn’. Using accounts of the Soviet Katyn’Commission, sent in 1944 to investigate the Katyn’massacre site and buttress claims that the Germans not Soviets had committed mass murder, Sorokina concludes that while the NKVD and NKGB controlled the commission, physicians experienced and responded to Stalinist power in complicated ways. Experts were important to the Soviet public face in the post-war period, and even though all the investigators were loyal communists there was a negotiation between expert and state as they attempted to complete their work according to professional standards with the degree of doubt typical of their fields. When such hedging or doubt was not acceptable, experts were ‘corrected’ and professional standards aligned with state directives.

The troubles of medical personnel dealing with another outgrowth of Stalinist policy – the post-war famine – grounds ‘Medical expertise and the 1946–47 famine: the identification and treatment of a state-induced illness’ by Veniamin F. Zima. Chronic malnutrition struck roughly 60 million people in 1946–7 in the territories of Russia, Ukraine, and Moldavia with a typhus epidemic following. Not only was help to victims stalled by a lack of aid, but also problematic, argues Zima, was the complicity of physicians in the limitation on communication about famine and slow government responses. In particular, he details the elaboration of Alimentary Toxic Aleukia (ATA also known as ‘drunken bread’) and mass outbreaks of the disease in 1946 as malnourished people sought out unharvested grain in fields under snow and fell prey to the illness caused by bad grain. In a typical bit of Soviet irony, the government created both the famine and the expertise to diagnose the illnesses that famine created.

The under-researched demographic and environmental crises of the late Soviet period serve as backdrop to the essays of Mie Nakachi, Donald Filtzer, and Christopher Burton. All move forward from the pioneering 1992 work Ecocide in the USSR: Health and Nature under Siege by Christopher Davis and Murray Feshbach.(2) In Mie Nakachi’s ‘”Abortion is killing us”: women’s medicine and the dilemmas for postwar doctors in the Soviet Union, 1944–48’, debates among medical professionals and statistical information are used to discuss the conundrum that while abortion is outlawed in 1936 the number of registered terminations rises every year until abortion is re-legalized in 1955. Nakachi explains this not just as women’s pursuit of illegal abortions, but also as the ambivalent response of medical professionals to the surveillance and enforcement of the law. Doctors worry that the law and pressure for strict surveillance resulted in fewer women seeing doctors thus many medical professionals ignored the official line and instead provided care according to patient need as defined by patients according to their own social, economic, and cultural concepts. Even in the face of the demographic crisis after the war, doctors argued against surveillance and for professional secrecy and prophylactic care.

Donald Filtzer’s essay, ‘The political economy of water supply under late Stalinism’, teems with tales of the dangers of industrial and environmental pollution. Filtzer uses the files of the State Sanitary Inspectorate on water supply to discuss public health and the quality of life in the post-war period. Filtzer focuses on areas outside of wartime occupation including the central industrial, Ural, and Western Siberia regions and details how water and sewarage supply remained grossly inadequate. Most areas pumped untreated filth from industry and people into water supplies that then served industries and people of that region or downriver. Water treatment was inadequate to the increasing pollution. Filtzer contextualizes Stalinist water policy by comparing it to the systems of 19th-century Germany and Britain, but he notes that the Soviets had more advanced technology and knowledge available. Thus, for Filtzer the question becomes not backwardness but priorities. He argues that poor planning created industrial growth that was self-negating as it endangered the labor pool. While capitalist systems might similarly endanger their workers, he notes that they had a ready pool for replacement while the Soviets did not.

Christopher Burton’s ‘Destalinization as detoxification? The expert debate on industrial toxins under Khrushchev’ brings together the demographic, environmental, and professionalization issues of the post-war era in a discussion of the field of ‘communal hygiene’.  Rooted in 19th-century public health and rising up especially in the 1930s with the shift away from social hygiene, communal hygiene became very important to Soviet ideas of pollution control. Guided by the concepts of self-cleansing and maximum concentrations of toxins, the result was near direct release of industrial waste into water and a faith in the dilution of these materials negating the danger. After 1953, challenges to the theory become part of the public debate as biologists, icthyologists, and inspectors attack the science and regulation of the existing system. While a massive change does not follow, the debate does show the precedents for the post-Chernobyl environmental movement and how professionals responded to the Stalinist industrial push and subsequent thaw.

The final essay of the volume brings the patient voice in more strongly than any of the previous pieces. In ‘White coats and tea with raspberry jam: caring for sick children in late Soviet Russia’ Catriona Kelly continues to mine the extensive collection of oral histories she has gathered with aid from the Leverhulme Trust to detail how Soviet citizens recall their childhoods and relationships to power, the state, and in this case, medical authorities. Kelly documents an overwhelmingly positive attitude towards medical authorities in her records. Even though some subjects remember an occasionally difficult relationship with a specific practitioner, overall those interviewed recalled medical professionals as kind and interested in the care of children. This was a manifestation, for most, of a state that was nurturing in its use of power, if harsh, at times in its application.

Overall the essays create a satisfying and cohesive work. Many of the essays serve as superb encapsulations of the issues addressed in the authors’ larger works. The editors did an excellent job of bringing the essays together as references are made back and forth throughout the volume. Additionally, they should be commended for exercising strong control over the length of each study. Each essay weighs in at a lean 15 pages or so, making these the perfect size for upper-level undergraduate classes or even nice to pair for a day of discussion. Of course, such limitations did cut into the contextualization – both in Russian and world history – of several of the pieces, but instructors who choose to adopt these for class use could easily solve this. Bernstein, Burton, and Healey, along with the fine collection of scholars assembled here, have paid brilliant tribute to the earlier work of Solomon and Hutchinson. The book should be on the shelves of all specialists in Russian and Soviet history as well as those who work in comparative public health.

Notes

1. Health and Society in Revolutionary Russia, ed. Susan Gross Solomon and John F. Hutchinson (Bloomington, IN, 1990).Back to (1)
2. Christopher Davis and Murray Feshbach, Ecocide in the USSR: Health and Nature under Siege (New York, NY, 1992).Back to (2)

The editors are delighted to accept this review and have no further comment.