Czechoslovakia

CZECHOSLOVAKIA. Area 140,446 km². Population in 1932 was 14,907,000. Czechoslovakia, which became an independent state in 1918, consists of 5 provinces, of which Bohemia, Moravia, and Silesia were previously part of Austria, while Slovakia and Subcarpathian Rus were part of Hungary. In each of them, Austrian and Hungarian laws and sanitary organizations still remain in force. The first three are wealthy industrial provinces with a predominance of urban population, more cultured and with better healthcare organization, lower morbidity, and mortality. The latter two are the poorest provinces, with a less cultured and poor population, with high birth and death rates, as well as morbidity. The average data relating to all of Czechoslovakia acquire a completely different meaning if they are broken down and considered separately for each of the two halves of Czechoslovakia. In 1930, 25% of the population lived in settlements with a population of less than 2,000 inhabitants. Population movement was expressed by the following figures (per 1,000 inhabitants) (Table 1): Table 1. Years Birth rate Death rate Natural increase 25.08 24.6 23.3 23.3 22.7 21.5 21.0 15.2 15.6 16.0 15.1 14.1 14.4 14.1 9.9 9.0 7.3 8.2 8.6 7.1 6.9. Data on individual provinces for 1933 are given in Table 2. Table 2. Provinces Birth rate Death rate Moravia and Silesia . . . Subcarpathian Rus . . 15.6 17.8 24.8 34.8 13.3 12.5 14.8 18.0. In cities in 1929, the birth rate was 16.2 per 1,000, and in rural areas 24. Emigration from Czechoslovakia is quite strong. In 1923, 34,712 people emigrated (2.49 per 1,000 inhabitants), in 1929—28,166 (1.93), mainly to the USA and France. The excess of women over men is about 8%. Sanitary organization. Before the unification of Czechoslovakia, in Bohemia, Moravia, and Silesia there were two administrative systems—state-wide administration and local autonomous, while Slovakia and Subcarpathian Rus were divided into departments, at the head of which in Slovakia stood a local diet, and in Subcarpathian Rus—a governor. Since 1920, a law on the unification of administrative organization has been gradually implemented, with the division of the entire republic into departments. The whole country is divided into sanitary districts with an average population of 6,000 inhabitants in each. In each district, there is a sanitary physician who is in the state service. In 1930, there were a total of 1,939 such medical posts, of which 1,609 were in settlements with a population of up to 6,000 inhabitants. Many sanitary districts are included in administrative districts. The districts are divided into counties, in which there are also their own county physicians. In large cities, there are local health councils with a physician. All district, county, and city physicians are state officials, paid by the state, and have the right to a pension, although most of them are simultaneously engaged in private practice. Physicians of the city of Prague are excluded from this rule and are in municipal service. In the administration of each of the five provinces, there are several health departments under the leadership of a physician. Healthcare problems common to all of Czechoslovakia are solved by the Ministry of Health and Physical Education (Ministerstvo Zdravotnictvi a telesne vychovy), created in 1918. The ministry is divided into 5 main departments: 1st—sanitary police, control of infectious diseases, supervision of private practitioners, state-employed physicians, pharmacies, hospitals, and research institutes. The State Institute of Health in Prague is also under the jurisdiction of this department. 2nd department manages healthcare in industry, in rural areas, at resorts, and on transport routes. 3rd department: social hygiene, control of tuberculosis, venereal diseases, trachoma, alcoholism, protection of infancy. 4th department: child health protection, physical culture. 5th department: legal. Before the unification of Czechoslovakia, state-employed physicians had to pass a special examination—the physicate, which local physicians did not take. The pay of the former was also higher. Now the conditions of admission and salary rates are unified by the same law of 12/X 1920, and the examination is mandatory for all sanitary physicians. The functions of sanitary physicians are almost everywhere preventive, but in poor provinces, they are also entrusted with curative ones. In addition to the Ministry of Health, there are health departments in other ministries. About 800 physicians are in the service of the Ministry of Railways for the treatment of employees, sanitary education work, etc. Physicians of the same kind are also in the Ministry of Posts and Telegraphs. Under the Ministry of National Defense, there is a special department for the organization of healthcare in the army and for serving war invalids. In the army (150,000 soldiers in peacetime), there are about 400 physicians. Finally, the Ministry of Social Welfare plays an important role in healthcare. Hospital affairs. All hospitals in Czechoslovakia are divided into public and private, and among the latter, there are those assimilated with public ones (having agreed to accept patients at the rate of the Ministry of Health). Public hospitals are maintained at the expense of the state, province, district, county, or city. All patients are divided into three categories: paying, indigent (for whom the relevant administrations pay), and members of insurance societies, for whom insurance funds pay for 52 weeks. In Slovakia and Subcarpathian Rus, the majority of hospitals depend on district administrations. The number of hospitals and beds in 1929 is given in Table 3.

Table 3. Hospitals Number of hospitals Number of beds Beds per 10,000 inhabitants. General........ Psychiatric . . Private....... Children's ....... Tuberculosis . . . 35,451 12,047 4,379 4,036 24.3 8.3 0.6 0.1 2.8. Special psychiatric hospitals and special shelters for women in labor exist only in Bohemia and Moravia; in Slovakia and Subcarpathian Rus, special wards in general hospitals are allocated for these patients. For the transportation of patients, the Red Cross concluded an agreement with the Ministry of National Defense, which granted it the right to use military sanitary vehicles in peacetime. In 1930, the Red Cross had 148 such vehicles, of which 80 were military. In recent years, on the initiative and under the leadership of the Red Cross, "first aid" organizations ("Samaritans") have developed widely, mainly among young people. In 1930, there were 7,112 such organizations with 30,119 members. Infectious diseases. In the last years of the imperialist war (1917-18) in Czechoslovakia, as in neighboring countries, a significant development of epidemics was observed, mainly smallpox, typhus, and typhoid fever. The fight against them, in which Czechoslovakia was greatly helped by American organizations, the improvement of the economic situation, and strict sanitary control at the borders quickly reduced the number of diseases. However, in Slovakia and Subcarpathian Rus, there are still endemic foci of typhus. The incidence of major infectious diseases in recent years was expressed in the following figures (per 100,000 inhabitants) (Table 4): Table *. Name of disease Typhoid fever and paratyphoid Typhus....... Malaria ......... Scarlet fever ....... Diphtheria ........ Influenza .......... Dysentery.......

In Bohemia in 1932, the incidence of typhoid fever was 20.6 per 100,000 inhabitants, in Moravia and Silesia—40.3, in Slovakia—101.7, in Subcarpathian Rus—182.0. Vaccination against scarlet fever and diphtheria is practiced with vaccines manufactured by the State Institute of Health, to which the state provides a subsidy for the manufacture of these vaccines. In 1929, 4,625 children were vaccinated against diphtheria with Ramon's anatoxin. To combat typhoid fever, mobile automotive medical detachments were organized. Smallpox was not observed from 1893 to 1914. During the war, there were serious epidemics brought in from Poland and Russia; since 1921, smallpox has not been observed. Vaccination is mandatory by the law of 1919. The fight against infectious diseases is regulated in Bohemia, Moravia, and Silesia by the Austrian law of April 14, 1913, and in Slovakia and Subcarpathian Rus by the Hungarian law of 1876. All cases of infectious diseases are subject to mandatory registration, and patients must be isolated at home, or if that is not possible, in a hospital.

Social diseases. Czechoslovakia is one of the countries in Europe most affected by tuberculosis. Tuberculosis is especially widespread in Slovakia and Subcarpathian Rus. Tuberculosis is the main cause of death in Czechoslovakia. Mortality from tuberculosis was 193.5 per 100,000 inhabitants in 1923-24. The fight against tuberculosis is conducted almost exclusively by the Masaryk League Against Tuberculosis, which the state subsidizes for the organization of Calmette vaccinations. In 1923, there were 143 local anti-tuberculosis organizations in Czechoslovakia belonging to the league, but in Slovakia and Subcarpathian Rus there are almost no such organizations, and the fight is conducted there by social hygiene dispensaries (in 1931, there were 15 such dispensaries in Subcarpathian Rus). In 1931, there were 224 dispensaries, 180 of which belonged to the aforementioned league. Venereal diseases are very common, although they have been declining in recent years. Thus, the number of syphilis cases decreased from 137 per 100,000 inhabitants in 1921 to 68 in 1926, gonorrhea from 248 in 1921 to 221 in 1926, and soft chancre from 51 in 1921 to 15 in 1926. According to the law of August 22, 1923, the treatment of syphilitics is mandatory and free. Under the Ministry of Health, there is a special Council for Combating Venereal Diseases, as well as a special department in the National Council of Social Hygiene. In addition, two public organizations, one Czech and one German, are fighting venereal diseases. In 1931, there were 30 venereal dispensaries in Czechoslovakia conducting exclusively preventive work, although in Slovakia and Subcarpathian Rus, treatment is also provided in the dispensaries. Trachoma is very common; there are large endemic foci in Slovakia and Subcarpathian Rus. Its incidence is decreasing very slowly. The incidence of trachoma in Czechoslovakia in 1932 was 11.2 per 100,000 inhabitants. By law, in Bohemia, Moravia, and Silesia, local authorities must conduct the fight against trachoma themselves, while in Slovakia and Subcarpathian Rus, the state conducts the fight. In Slovakia, since 1927, the fight has taken on a broad character; mass examinations of the population were carried out, mobile medical detachments were organized for villages, and 10 main dispensaries and 14 auxiliary ones were opened. In total, in 1929, there were 38 main dispensaries and 65 auxiliary ones with 34 doctors. In 1929, the state spent 950,000 crowns on the fight against trachoma. Malaria is now encountered very rarely: in 1929, only 431 cases and one death were registered, in 1932 - 557 cases and 2 deaths, in 1933 - 1,517 cases (of which 1,311 were in Subcarpathian Rus). Maternity and infant protection is organized unsatisfactorily. Infant and maternal mortality are high compared to neighboring countries. Infant mortality in 1932 was 137.7 per 1,000 births. Among illegitimate children, mortality is especially high. Thus, in 1927 it was 210.8 per 1,000 births, in 1928 - 200.9, in 1929 - 206.1. Infant mortality is especially high in Slovakia (in 1931 - 163.0 per 1,000 and in 1932 - 169.9) and in Subcarpathian Rus (in 1931 - 171.3 and in 1932 - 190.5). Child protection depends on the Ministry of Social Welfare, which carries it out through special committees in the provinces. In Slovakia and Subcarpathian Rus, the government was forced to establish special departments for child protection, depending directly on the ministry. In 1929, there were 23 maternity protection centers, and in 1931 there were 1,100 child preventive consultations. Maternity insurance is mandatory under the Austrian law of 1888 for all industrial workers, and in 1919 it was extended to all wage earners. A pregnant woman has the right to leave for 6 weeks before and 6 weeks after childbirth, and during this time she receives an allowance in the amount of ²/₃ of her earnings. Treatment and obstetric care for the insured are free. Medical-sanitary supervision in schools is not established by law but is organized in many large cities. In Prague, it has existed since 1904 and is entrusted to 14 school doctors, as well as school nurses. Following the type of the Prague school-medical inspection, it is also organized in other cities. Health resort business. Czechoslovakia is one of the richest countries in Europe in terms of health resorts, both in variety and in quantity (Karlsbad, Franzensbad, Jáchymov, Marienbad, the Tatras, etc.). Resorts belong either to local communes, or to the state, or to private societies. The state owns 7 large resorts. Supervision of resorts is entrusted to a special sanitary inspection, which is not unified for the whole country. Labor protection depends on the Ministry of Labor, but sickness insurance and medical assistance to war invalids are entrusted to the Ministry of Social Welfare. The Labor Inspectorate, created by the law of July 17, 1883, also depends on this latter ministry. Bureaus of inspectors numbering about 25 are scattered throughout the territory of Czechoslovakia. The functions of labor inspectors are very broad: supervision of labor safety and compliance with sanitary rules in factories, plants, and workers' housing, compliance with laws on the protection of the labor of women and children, on the 8-hour working day, and on weekly rest, which is mandatory for a duration of at least 32 hours. Inspectors also observe working conditions at home, check work regulations in factories, wage payments, the training of apprentices, participate in negotiations between workers and entrepreneurs (in case of strikes, etc.), and in the development of collective agreements. They also determine the risk percentage when concluding accident insurance policies. Labor inspectors are engineers, not doctors; the scope of their activities is excessively large compared to their number. Besides them, local sanitary and medical doctors of districts, provinces, etc., also monitor the hygiene of workers' housing and factories. The law on the 8-hour working day was introduced by the law of December 19, 1918. Accident insurance for workers is mandatory under the Austrian law of 1887 for all persons employed in industry. Disability insurance is mandatory under the 1906 law for all employees in industry and trade; in 1924 it was extended to all manual laborers, and in 1925 to all working people, including artisans and craftsmen. The same laws and for the same categories established old-age and death insurance. According to the 1921 law, unemployment benefits were introduced for all wage earners. Compulsory sickness insurance was introduced in 1924. In each administrative district, there is an insurance society, which all persons whose insurance is mandatory by law must join. The insurance premium is paid half by the entrepreneur and half by the insured. The premium is 5% of wages during the first 5 years, 4.5% during the next 5, and then 4%. The state adds a total of 180 million crowns annually. According to the amount of the premium, workers are divided into 4 categories by earnings (14 crowns per day, from 14 to 22, from 22 to 28.5, and over 28.5 crowns). In addition to district societies, the law allows the formation of special societies for certain types of industry and miners, as well as mutual insurance societies. Insurance societies form federations, and each federation belongs to a political party and thus is a powerful tool in the hands of this party. Insurance societies provide the insured with medical assistance and pay sickness benefits in the amount of ²/₃ of earnings, starting from the 4th day of illness and within the limits of the funds available to the society. In the event of the death of the insured, the family receives a benefit of at least 150 crowns. All members of the family are insured, including children under 16, parents, brothers, and sisters of the insured, if the latter live under the same roof and are not insured separately. Insurance societies conclude agreements with doctors for treatment but also have their own doctors. If necessary, free medical assistance can be replaced by treatment in a hospital. Sickness insurance is mandatory for all wage earners, regardless of their earnings. In case of loss of ability to work due to an accident, the pension cannot exceed ²/₃ of the victim's earnings. In case of permanent disability due to illness or accident, the pension is calculated as follows: a part depending on the category and earnings of the victim, and a part depending on the period during which he paid insurance premiums. The disability pension is equal to the old-age pension. It consists of a basic amount—a minimum of 500 crowns per year, to which ¹/₅ of the amounts paid by the insured in the form of premiums is added each year. To be eligible for a pension, the insured is required to have a period of at least 150 weeks—about 4 years—of work. For those with large families, the pension is increased. Agricultural workers are also insured against illness—in 1929 there were about 450,000 of them insured. In total, there are over 7 million insured in Czechoslovakia, i.e., more than half of the population, and in cities, it is actually 90%. The healthcare budget is divided among three ministries and does not change much from year to year. The national healthcare budget for 1929 was expressed in crowns: expenses 144,771,872 and income 31,874,866. The main expenditure items of the Ministry of Health were as follows: Public hospitals, etc. . . .

36,351,289 Fight against social diseases . .

2,500,000 Subsidies for the construction of hospitals . .

2,200,000. In the provinces, districts, and counties, cities, etc., there is a local health budget, about which there is no precise data. Medical personnel. The course at the medical faculty lasts about 5 1/2 years. Only those who have completed the course at one of the Czechoslovak medical faculties and are Czechoslovak citizens have the right to practice in Czechoslovakia. Medical practice, as well as the rights and duties of medical chambers, are regulated by the law of June 28, 1929. In 1929, the following number of medical personnel were registered (see Table 5). Midwives are required to have a special diploma; there are 5 schools for them in large cities with a course of 5 to 6 months. In 1919, two schools for paramedical personnel were founded, but their training is insufficient, wages are low, and the recruitment of nurses is difficult. Therefore, patient care in hospitals is concentrated in the hands of nuns. There are very few orderlies and disinfectors. In Prague, there is a special school for them.

A. Rubakh