Health Care

HEALTH CARE. I. Fundamental principles of health care organization. Health care is a system of measures aimed at maintaining the health and working capacity of the population. The concept of health care includes all measures for improving the environment (physical and social), for example: conditions of labor, nutrition, housing, improvement of populated areas, care for providing all types of assistance to the sick, organization of scientific health care institutions, etc. However, the scope and nature of the work of health care bodies differ in different states. Health care is one of those ideological "superstructures" (an expression of K. Marx) that rise upon a specific socio-economic and cultural foundation. The socio-economic structure of society and the level of culture and scientific knowledge associated with it determine both the general state of the matter of protecting the health of the population and its organizational forms. The fundamental tenet of Marxism, that "superstructures" are determined by their "foundation" (the degree of development of productive forces), is fully justified in the matter of health care organization as well. The low degree of development of economy and culture among primitive peoples determined the low organization of health care among them (its almost complete absence). Conversely, the rise of economy and culture among ancient peoples creates the soil for the development of medical organization, in particular for laying the foundation of sanitary organization. The capitalist system creates a medical organization in its own image and likeness. The Soviet system gives birth to Soviet medicine. Thus, each system corresponds to its own characteristic organization of health care. From the point of view of the doctrine of historical materialism, such a connection is indisputable and inevitable. The socio-economic structure of society creates that "environment" which decisively influences both the state of health of the population and its individual classes, and the organization of their health protection. This environment creates that atmosphere of labor and daily life which generates and contributes to the manifestation of numerous diseases, and consequently, to a significant extent, influences the organization of health care. The correlation and position of classes also determine the character of medical organization. In a society where there are classes, class medicine is built; moreover, the ruling classes enjoy the best organization of their health protection; the destitute classes (the working people) are served by a worse medical organization. Thus, three main factors determine the character of medical organization: 1) the class structure of society and the position of individual classes, 2) the general atmosphere of labor and daily life, and 3) the general socio-economic and cultural state of society (in particular, the degree of development of science). From this point of view, the differences between the two currently existing systems of health care—capitalist and Soviet—will be understandable. From this point of view, the contours of the future communist medicine also emerge. Capitalist medicine corresponds to the capitalist organization of society, where the ruling class is the bourgeoisie, and the vast majority of working people are in a state of exploitation, poverty, and misery. In accordance with this, the capitalist organization of health care also develops. It does not at all set as its task the improvement of the working masses; general health-improving measures are carried out only insofar as it is profitable and necessary for the ruling bourgeoisie; care for the protection of the health of the proletariat is carried out insofar as it is necessary to have a labor force; the sick worker is patched up in order to later throw him back into the cycle of exploitation. The organization of health care for the population, i.e., the working people, is not at all set as a full-fledged state task—that is why in no bourgeois country is there a full-fledged, equivalent to all other ministries, ministry of health that would unite in its hands the entire medical organization (even where ministries of health exist, they unite only a part of the medical organization). The possibility of obtaining medical assistance is determined by the same law of buying and selling: whoever has the means "buys" better medical assistance; the destitute person uses low-quality medical assistance or does not have it at all. Bourgeois philanthropy finds the widest application for its activity precisely in the field of health care; therapeutic measures for the working people prevail over preventive ones, which are in an embryonic state; the social "sting" has been torn out of socio-hygienic measures; the capitalist organization distorts socio-preventive work (in the fight against venereal diseases, in the protection of motherhood and infancy, etc.). The creation of a single body managing the entire medical-sanitary matter made it possible to implement one more principle in the construction of the health care matter—the planned nature of this construction. Just as the planned principle distinguishes construction in the Soviet Union from the anarchy prevailing in any capitalist state, so too has the planned principle been introduced into the construction of health care. Capitalist medicine, which has fragmented the medical-sanitary organization among various departments and various organizations (state, philanthropic, private, etc.), cannot implement the planned principle in the construction of health care to the extent that it is implemented by Soviet medicine. The People's Commissariat of Health, which directs the entire medical matter, builds Soviet medicine according to a plan linked with the general plan of economic and cultural construction in the country of the Soviets. The Soviet state considers the protection of the health of the population (the working people) as one of its most important tasks, for the implementation of which an independent People's Commissariat of Health, equal to others, is created, uniting in its hands the entire medical matter in the country; the task of health care is not only the patching up of the sick, but also general health-improving measures [the program of the All-Union Communist Party (Bolsheviks) states: "The All-Union Communist Party (Bolsheviks) bases its activity in the field of health protection of the population primarily on the implementation of broad health-improving and sanitary measures aimed at preventing the development of diseases"]. Medical assistance to the working people is built on the principle of accessibility and free service; almost the entire network of therapeutic-preventive institutions (with the exception of the Red Cross, cooperatives, etc., and a very small private sector) is in the hands of state and local bodies. Socio-preventive institutions are deploying their work as widely as in no bourgeois country; the proletariat in the city, the poorest peasantry in the village (especially collective farms and state farms, farm laborers) are subject to priority and better service. Such are the different principles of the organization of capitalist and Soviet medicine. However, it would be a mistake to think that the nationalization of medical organization is an end in itself and always means, under any conditions, better service for the working population. When deciding the question of the expediency of nationalizing the matter of medical assistance, one must always ask the question: in the hands of which state is the medical matter concentrated? The interests of which class does the given state power represent? From this point of view, the attempt of the tsarist government to concentrate all medical assistance in its hands, tearing it out of the hands of the then city and zemstvo "self-governments" or subjecting them to even greater influence of the central government (the Rein bill, introduced to the IV State Duma), appeared reactionary. Therefore, the zemstvo doctors-Pirogovites were right to decisively protest against this project. From this point of view, on the contrary, those insurance advocates were wrong who, by analogy with the past, objected to the merger of insurance medicine (sick funds) with the Soviet state organization: the opposition of "state" and "workers'" medicine, legitimate in tsarist times, loses all meaning and becomes politically harmful when they want to oppose the "workers'" medicine of the sick funds to the Soviet medicine of the soviets of workers' and peasants' deputies. As great as the difference in the principles of the organization of Soviet and capitalist medicine is, the difference in the methods of work is just as great. In countries of the dictatorship of the bourgeoisie, the ruling classes "take care" of the health of the working people, "patronize" them. In the Soviet state, the working people themselves, "with their own hand," are building socialism. Both economic and cultural construction is carried out with the direct and active participation of the popular masses themselves in the construction. Such is also the method of building the health care matter. "The protection of the health of the working people is the business of the working people themselves"—such is the slogan under which Soviet medicine was born. This participation of the population itself in the matter of protecting its health is expressed in the work of health cells and labor protection commissions at enterprises; in the activity of health care sections of the soviets in cities and villages; in the work of KOTIBs (commissions for the improvement of labor and daily life) at therapeutic-preventive institutions; in the health care campaigns being conducted (weeks of the fight against tuberculosis, the fight against prostitution, weeks of cleanliness, etc.). The organization of health care is also influenced by and reflects the main political tasks set at any given moment in the country. Thus, military interests brought about decisive changes in the organization of health care in all warring countries during the past imperialist war: the dictatorship of military medicine, the restructuring of the entire therapeutic network for the needs of the war, the crisis of the civilian organization—all this was a consequence of military actions.

But even in peacetime, the implementation of specific political tasks is also reflected in the medical-sanitary structure. Thus, the collectivization of agriculture, currently being carried out by the All-Union Communist Party (Bolsheviks) and the Soviet government, sets new tasks before the health care agencies: to create from collective farms and state farms strongholds for the improvement of the countryside. To this end, it is necessary to review and plan for the future the rural network of medical-preventive institutions, to adapt the organizational forms of public initiative to this, etc. The "superstructure" of health care is not only determined by its "foundation" but also changes sensitively depending on the restructuring of the base. Proceeding from these principles and methods of work, Soviet medicine has a different orientation compared to capitalist medicine. As stated, the main orientation of the latter in relation to the working people is the treatment of diseases. The orientation of Soviet medicine is not only to treat, but also (and mainly) to prevent diseases. From what has been said, the contours of communist medicine, which are already emerging at the present time, are clear. This will be prevention par excellence.

N. Semashko. P. History of Health Care. A coherent and thoroughly studied history of health care does not yet exist either in the West or in the USSR; a number of works are devoted only to individual stages or episodes in the organization of health care in different countries. These scattered facts, however, reveal an undoubted dependence of the organizational forms of health care of any given epoch on the nature of the economic demands corresponding to it and the interests of the ruling class. At the same time, the content of health care measures is also in close dependence on the level of ideas about the essence of disease and knowledge about the human organism and the laws of its life. In this respect, health care is the practical implementation of discoveries and achievements of technical progress. The triumphant march of science makes health care measures more solid and confident, ensuring their effectiveness. If the progress in the development of urban improvement and the fight against epidemics in the 19th century owes a great deal to the works of Pasteur, Koch, Pettenkofer, and Virchow, then in the foreground stands the fact that it was only the new industrial city that proved capable of implementing scientific discoveries, and the epidemics of the 19th century turned out to be the "lucky star" of health care, while the "Black Death" of the Middle Ages gave only the first glimpses of the organization of health care in Europe. Despite all the importance of precise scientific indications for various health protection initiatives, the state cannot always wait for the final resolution of theoretical disputes in the field of health care, and very often bases it on purely empirical data derived from practical observations and experience. The history of health care up to modern times presents a whole series of convincing examples from which it is evident that even under such conditions, great and lasting successes were achieved in the field of health care. In the development of health care, one can find in almost all periods, along with measures for the preservation and protection of the health of the ruling class, a system of measures for organizing assistance to disadvantaged people who have lost their ability to work due to illness, old age, etc. Very early on, attention is drawn to the fact that such masses represent

HEALTH CARE

identify the foci of diseases even for the wealthy classes, and therefore the authorities strive to neutralize them. State power, as an organization of the ruling class, pays attention to and creates various institutions for health protection to the extent of its own interests and goes as far in this direction as the necessity of the day dictates, and only under appropriate revolutionary pressure is it forced to make greater concessions. One can trace the regularity in the sequential order in which the deployment of medical-sanitary organization proceeds, ensuring, not to mention the representatives of the ruling class, first the army, then the apparatus of civil servants, then—depending on the era—merchants, artisans, and finally workers. At the first weakening of the pressure from the oppressed strata of the population, upon the passing of acute economic and political situations, the government takes back its obligations in the field of health protection, with the exception of the extreme minimum. This basic tendency manifests itself among all peoples at all times. The most ancient monuments have preserved information that, along with providing assistance in case of sudden accidents, injuries, and childbirth, there were also concerns about preserving the health of the entire collective, especially at a relatively high level of pastoral-agricultural economy. In the primitive communal system, there are prescriptions for maintaining the health of all members of the collective, whose physical strength ensures the success of the tribe's economic development and its power in the struggle against hostile tribes. As economic development progresses, as forms of management become more complex, and as the social division of labor and class stratification caused by it emerge, hygienic prescriptions apply only to the ruling classes. These prescriptions were obviously based on an empirical, attentive study of the interaction of man with the surrounding phenomena of nature. The keepers of this knowledge and its further researchers were the elders of the clan, who laid the foundation for the priestly caste, in whose hands the art of healing diseases and prolonging life was concentrated. Priests were the first bearers of the functions of health care, and temples became places for providing assistance to the sick and suffering. An example of a code of hygienic prescriptions is the doctrine of health among the Hindus (Pathapathya), which became part of the Laws of Manu. It sets out in considerable detail the influence of climate and seasons on health, with a temperate climate being considered the healthiest and most favorable for a long life. Attaching special importance to appearance and cleanliness, this doctrine prescribes rising early, brushing teeth, body massage, bathing, neat clothing, the use of an umbrella, clean, ventilated dwellings, haircutting, nail trimming, gymnastic exercises, and healthy food and drink appropriate to the seasons, such as, for example, animal and oily food in winter, and cooling fruits, rice, and barley in summer. Thus, a whole system of strict requirements is revealed, imposed in everyday life and bearing the character of preventive measures against possible diseases, and upon the onset of such, the intensification of the same dietary and general hygienic prescriptions. Another illustration of such a health care system can serve as the so-called Mosaic legislation, in which rules of a dietary and preventive nature are given, concerning cleanliness, sexual life, marriages between relatives, the isolation of not only the sick but even those suspected of disease, the use of utensils, the arrangement of cemeteries, permitted animals for food, etc. A special place is given, in connection with local conditions, to skin diseases and the fight against leprosy. Supervision of these rules, the implementation of isolation, and assistance to the sick were in the hands of the priestly tribe of the Levites. All these prescriptions were obviously borrowed from Egypt, a country that had gone further along the path of economic development and class stratification. By the time of the Mosaic legislation, hygienic prescriptions in Egypt were apparently already the property only of the priestly caste and wealthy Egyptians. Priests were subject to a strict ritual lifestyle, prescribing circumcision, moderation, extreme cleanliness, and proper ablution day and night. There are, however, indications that the hygienic rules of the Hindus were mandatory only for Brahmins. The class character of the health protection system is revealed even more definitely in the Spartan legislation of Lycurgus. Here, the renowned Spartan system extended only to the Spartiates, who conquered the valley of Lacedaemon, whose well-being rested on the labor of the helots, the conquered natives who belonged as common property to the state as a whole. In order for the small victorious people to maintain their power among a sea of the conquered, a system of training and breeding of masters and warriors was created. Physical power and health were the most important tools of the Spartans' superiority over the dying out and degenerating helot-slaves. And indeed, Lycurgus developed in detail this chain of measures for the 'organization of health' of the military aristocracy. First of all, attention was paid to marriage and childbirth. Girls developed physically and were hardened by gymnastics, running, wrestling, and throwing the discus and spear. To overcome feminine softness and effeminacy, youths and girls were present naked at festivities. Healthy newborn children were destined for public upbringing, while the weak were destroyed. All luxury was banished from daily life; the food consumed was simple, without excesses, but nutritious. All education was directed toward providing the ruling class with strong, agile, and fearless warriors, and was in the hands of special ephors. The same ideas about the importance of strengthening and preserving health, starting from early childhood, only for the noblest and strongest, as a guarantee of their future supremacy, are found in the 'Republic' ('Politeia'), a work by Plato, who lived during the period of the collapse of Athens, which had reached a high level of development as a commercial-capitalist state on the eve of the Peloponnesian War. Plato is of the opinion that only the nobility, with its political, scientific, and aesthetic culture, can provide talents who, after careful upbringing, are suitable for holding high positions. Therefore, only future rulers and guardians, the warriors-defenders of the country against external enemies, should receive a good gymnastic education. Only to them should the concern for health protection extend, starting from the choice of spouses, care for the child, up to the hygiene of the environment and the choice of food; the other classes—artisans and slaves—are doomed to base occupations, and their lot is to be physically exhausted and spiritually deformed; Plato completely passes over in silence the regulation of the life of these classes, leaving it to go its own way. In the best case, it is necessary to take care of providing them with treatment in case of disease. Thus, two medicines were outlined, in accordance with the class stratification of society and the interests of the ruling classes. In such a powerful political organism as the Roman state, which conquered world domination thanks to military power, and in which antagonism between peoples and classes boiled, the created health care system bore the same dual character. Rome created institutions for its free population that improved the environment and took care of the health of its legions. From an early period (499 BC), sanitation and concerns about health care became the subject of the administration of special city officials, the aediles, who did not have a medical education. They had to monitor the sale of food products, the construction of buildings, and the water supply. Later, further specialization of the aediles was carried out, and 'curatores alvei et riparum Tiberis', 'curatores aquarum', 'aediles cereales', and overseers of prostitution were singled out. As early as the 6th century BC, in the time of Tarquin, a system of richly branched underground sewer pipes was arranged. The Cloaca Maxima—the main sewer pipe of Rome, which is still used today—dates back to the same time. The ruins of 40 aqueducts, which supplied the city with 300 million gallons of drinking water daily, have remained to this day as the most famous monument of urban improvement among the Romans. However, the magnificent sewage system, the remarkable delivery of water—all this pursued the goal of providing better living conditions only for the ruling classes—those areas where the aristocracy resided. In those quarters where the poor lived, the multi-story houses were, in the full sense, sewers. An achievement of the Roman system of health care organization was also the construction of hospitals, which is directly connected with the organization of medical aid in the army. Doctors with the legions provided only surgical aid and had small infirmaries for the slightly ill. Those who fell ill for a long term were sent home for treatment. Since, over time, the Roman borders expanded ever wider, this became impossible, and military hospitals were founded at the most important strategic points. From military hospitals ('valetudinaria') it was one step to the construction of hospitals to serve the numerous imperial officials and their families, who were abandoned in remote provinces and exposed to the harmful influence of climatic conditions.

The policy of Imperial Rome and wars led to a deterioration in the situation of the popular masses, with the lot of those who fell ill and lost their ability to work being particularly difficult. The danger of the spread of epidemics forced the government to take measures to organize medical aid. To attract doctors to Rome, Julius Caesar (102–44 B.C.) granted the rights of citizenship in Rome to all those studying medicine. During the plague epidemic under Antoninus Pius, public doctors, archiateri populares, were appointed to various cities and attached to specific institutions, the main duty of whom was to provide aid to the poor. They were instructed to take on the training of students in the medical art. Their salaries were paid by municipalities (city councils). Later authors mention the spread of hospitals for the poor. Such hospitals were used even by free Romans. In all probability, private institutions of this kind developed into public hospitals receiving subsidies from the government earlier than elsewhere. Public doctors also obviously tended over time to serve the wealthy for a decent remuneration, and in the Code of Justinian, during whose reign there was again a severe plague (533 A.D.), public doctors were again reminded that they must “help with a pure heart, giving preference to the poor over the well-to-do.” The Christian movement that arose during the first emperors, to which the common people and slaves who thirsted for social justice flocked, could not help but take on the functions of helping the disadvantaged and suffering, and first of all, the members of their own community. Until approximately the middle of the 2nd century, Christian communities were built on egalitarian principles. The first positions in Christian communities were diaconal, the competence of which included, first and foremost, the care of the poor and the sick. Julian the Apostate, in his struggle against Christianity, had to resort to the weapons of the Christians and cultivate charity. It goes without saying that as long as Christian communities consisted of the poor, slaves, etc., the charitable activity of the communities was comparatively limited, but as Christians took over temples, wealth, and the property of pagans, more institutions for the poor and sick began to be established. However, as Christianity turned into the dominant religion, the elements of a social movement and the principles of egalitarianism began to evaporate from it. The Church, whose income consisted of tithes, gifts, and bequests, was economically strongly fortified. With the development of medieval structures, the Church became the owner of vast land areas. By the end of the 7th century, it owned a third of all lands in Gaul, and in the 8th century, church land ownership in the Frankish Kingdom was already so significant that the Carolingians carried out the alienation of a significant part of it for state and military purposes. However, such a degeneration of the Church could not but give rise to opposition among ordinary Christians, especially from the working classes (slaves, freedmen, peasants, artisans). This gave impetus to the organization of monastic settlements, which took over and, over the course of a number of centuries, carried out the functions of treating the poor and caring for the destitute. Numerous orders formed in the Middle Ages, such as the Franciscan, Benedictine, and Dominican, set aside premises for the sick in their monasteries. As monasteries also became an integral part of the official Church and monks gradually ceased to be members of production communities and became masters of the labor of others, their social functions also died out. In accordance with the nature of the origin of these functions, they had to be taken over by heretical sects, among which the Beguines and Beghards (Flanders, 11th–12th centuries) and the Lollards (England, 14th century) were especially dedicated to the cause of caring for and helping the sick. In the early days of the spread of Christianity, there were no special hospitals. Only with the passage of time did the clergy begin to turn “xenodochia,” the inns of the East, into shelters under the same name for the sick, the decrepit, widows, and orphans. Funds for their maintenance were obtained from voluntary donations. In 370 A.D., obviously in connection with the consequences of the famine of 368, the Basiliad xenodochium was founded by Bishop Basil at the gates of Caesarea. It consisted of well-appointed houses next to the church, occupying an entire street; they had beds for the sick and weak of all kinds, the care of whom was entrusted to doctors and attendants. Somewhat later, such hospitals appeared in Gaul. By the year 500, a xenodochium had arisen in Lyon, later in Paris, and the still-existing, rebuilt in the 18th century, “Hôtel de Dieu.” In such buildings, premises were concentrated for both the sick and for the care of orphans, the elderly, the blind, and other disadvantaged people. Thus, the medieval system of hospital-almshouses was formed under the aegis of the Church, which sought to consolidate its influence and significance among the popular masses in this way. Due to the fact that the Middle Ages are characterized by the absence of a centralized state power, and the function of organizing health care did not belong to the state as a whole, but was carried out by individual feudal lords; during this period, court medicine for popes, kings, and sovereign princes, and the system of “house doctors” for nobles, the aristocracy, and the wealthy, received special development. The duty of these doctors consisted of supervising food, diet, and protection against diseases. The thought of mainly Arab and Jewish doctors of the early Middle Ages worked in the interests of court medicine. These aspirations are especially clearly expressed, for example, by the Egyptian Jew Isaac ben Solomon Israeli (around 900), who taught that the most important task of doctors is to prevent diseases and that if a disease can be cured equally by food and medicinal means, one should always choose the former. Avicenna, in his “Canon,” devotes Book I of the third section to hygiene and dietetics, in which he sets out the hygiene and dietetics of various ages, especially the child’s organism. Feudal lords were concerned with attracting healers, primarily surgeons, for their retinues, which is especially evident in the era of the Crusades. As cities grew from the 12th century, the function of health care began to enter the sphere of their activities and was reduced primarily to the construction of hospitals, with shelters for cases of illness being arranged for all citizens, and not just for the destitute. Thus, in the rudiments of civil medicine, aid to the sick was combined with the tasks of charity. Wealthy townspeople could secure a place in a hospital for their old age or in the event of an accident by purchasing it. Other circles of the urban population made specific contributions, creating a peculiar type of insurance against illness, accident, and old age. Everyone paid according to their means and received according to their contributions. The appearance of secular authorities in the management of hospital affairs, the involvement of doctors who knew their business, and not dull-witted monks, led to a further step forward in the very organization of hospitals and the management of medical affairs in them. The management of hospitals was carried out by 2 members of the magistrate (Spitalmeister), who had to control the hospitals, which gradually expanded in volume, with the mills, slaughterhouses, and bakeries belonging to them. Later, the management was transferred to city officials. In the 13th century, in Germany, the foundation was laid for hospital work related to the introduction and spread of leprosy. These lazarettos (Lazarus-Krankenhäuser), such as the St. Joachim Hospital in Leipzig, the St. Bartholomew Hospital in Dresden, and others, were not hospitals in the modern sense of the word, since their task was not so much to treat as to isolate the sick. When leprosy began to disappear in the 16th century, these Lazarus-Häuser became shelters for the decrepit, as well as for orphans. The idea of isolating the sick, laid down in the fight against leprosy, had a beneficial effect on the development of measures to combat epidemics. This system so took hold of the minds of medieval doctors that they put forward the necessity of fighting all similar morbid conditions with the same weapons. Therefore, in the 13th century, in addition to leprosy, some other diseases were recognized as infectious, such as: smallpox, fevers with obvious rashes, consumption, granulomatous conjunctivitis, scabies, and erysipelas. The fight against them pushed cities, in addition to building hospitals, to issue mandatory decrees on the prevention of diseases. City authorities from time to time ordered the sick with any of these diseases to be sent outside the city limits; they were forbidden to trade in foodstuffs. The impetus for these regulations was the medical edicts of Frederick II Hohenstaufen, Emperor of the Holy Roman Empire, who began the fight against the feudal lords and the Pope for the consolidation of royal power, a struggle that arose in connection with the growth of new economic relations that dictated the overcoming of the borders of individual seigniories, which hindered the development of merchant capital. In connection with the tasks of state power (according to the concepts of that time) to stand guard over property and well-being, as well as to protect security, the edicts of Frederick II sought first of all to secure the population from ignorant doctors, and from dangerous and low-quality medicines.

By the 13th century, there were already a number of universities; the most famous was the School of Salerno; Frederick himself founded several universities. The edict of 1232 provided for special rules for the examination of physicians, surgeons, apothecaries, etc. Medical practice was permitted only after a state examination (this requirement already existed in the 1140 decree of King Roger of Sicily) and after mandatory practice for a year under a well-known experienced physician. Frederick II issued a number of sanitary decrees that included rules for keeping city streets clean, the layout of cemeteries, the prohibition of polluting rivers, the prohibition of certain dirty and dusty industries within city limits, etc. In the very nature of this legislation, one should suspect the influence of the School of Salerno, which drew attention to the disrepair of medieval cities, the hotbeds of epidemics, and even attempted in the well-known poem "Regimen sanitatis" to popularize rules of hygiene (see Sanitary Education). However, these decrees received the weakest response in the cities and countries of medieval Europe. Only a century later, after the terrible "Black Death" of the 14th century, did a certain shift in the field of health care organization emerge. Attention to sanitary measures was paid mainly by Italian cities, in which commercial capital had reached a high level of development, and extensive international trade made them particularly interested in the rapid overcoming of epidemics. Milan and Venice in 1370–74 took the most decisive measures to prevent infected persons from entering the cities, especially those arriving from suspicious localities. The quarantine system gradually spread throughout Europe. Quarantines were accompanied by the complete destruction by fire of all things belonging to the infected. After the plague had claimed 25 million lives in Europe, legislative measures were decided upon. Thus, in 1385 in Nuremberg, it was forbidden to discharge sewage into rivers, to soak hides in them, and to wash laundry on the banks of rivers. In 1388, in England, it was forbidden to pollute rivers and ponds with waste and sewage. However, these measures remained unsuccessful, as they were fundamentally insufficient, disjointed, and issued without any system, and, most importantly, there was no organization to carry out supervision. Only in Italy was a coherent system created. Already in 1348, Venice brought to life a special institution, "Proveditori di sanita," and formed similar sanitary councils in all other Venetian cities. When the plague reappeared in Venice in 1423, it did not prove to be as terrible, because thanks to the existing organization, there were already physicians, medicines, and care, and quarantines were quickly deployed, and hospitals for plague patients were established. This organization became an authority for all of Europe in the matter of health protection, and this period can be considered the starting point for the further development of the medical police system. Under the influence of the lessons of the epidemics, the German Emperor Sigismund II, by a decree of 1426, ordered all imperial cities to hire city "physicians" at their own expense. Their activity was to proceed in the direction of taking measures to combat epidemics, and primarily in the direction of providing for the sick. They were also assigned forensic medical functions and the supervision of practicing physicians, apothecaries, and midwives, as well as the fight against quacks, etc. However, it required the repetition of this decree by the Diet in 1512 for cities to begin hiring "physicians," who thus became organs of medical police. From the middle of the 16th century, the issuance of sanitary decrees by individual cities became more frequent, but due to their still weak influence on the life of the state, these regulations did not have great real significance in terms of improving the health of cities. And throughout the 16th century, Italy continued to stand ahead of all other countries in the development of ideas of sanitary activity in cities, especially in Lombardy. The decline of Italy's economic significance and its loss of political influence entailed a decline in activity in the field of health care. It is characteristic of the health-improving ideas of the Italian figures of that era that at the turn of the 16th and 17th centuries, Campanella attempted to provide in his utopian novel "The City of the Sun" a system for improving the health of the "Solarian" nation. He first of all dwells in detail on the moments of careful selection of spouses to ensure healthy offspring. Children are the property of the whole society, and therefore their upbringing must be public. Campanella covers in detail the tasks of physical education and the labor activity of all citizens, and gives instructions regarding a hygienic lifestyle, the alternation of work and rest, the dietary regimen, etc. As a result of all this, the "Solarians" (children of the sun) do not know such diseases as gout, rheumatism, catarrh, joint pain, colic, bloating, and flatulence: after all, these diseases arise from poor secretion of juices and the development of gases in the body, and the "Solarians" disperse these accumulations of fluids and gases through strictly regulated physical labor. Flatulence and vomiting are considered a disgrace among them; in the opinion of the "Solarians," they are the result of a lack of movement, lazy immobility, intemperance, and overindulgence. They treat consumption with warm baths, milk, staying in the countryside, in a good area, and moderate physical labor. The "Solarians" suffer only from intermittent fever. This description of the principles of health preservation against the backdrop of the life of an ideal state, exceptional in the breadth of its views and the power of its conviction, especially emphasizes the significance that health care must acquire in state activity. The concrete reality, however, presented a sharp contrast to Campanella's ideas. The continuous wars of the 15th, 16th, and half of the 17th centuries moved forward the development of aid to wounded soldiers and primarily entailed successes in military surgery. The famous French surgeon Ambroise Paré built the first military hospital during the siege of Metz in 1575. Near Augsburg, during the Thirty Years' War, Gustavus Adolphus built a military hospital known in Germany. The Thirty Years' War (1618–48) exhausted Germany. Its population partly perished and was partly ruined. The restoration of the country required concerns about raising agriculture, crafts, and trade, and at the same time, the importance of concerns for health protection was appreciated, especially in the Brandenburg Electorate, which began to play a prominent role in Germany from the 17th century. In order to attract the population to new places and settle the swamps, it was necessary to think about draining them and about measures to combat the spread of diseases. The Brandenburg Elector Frederick William, known in history as the "Great Elector," under the pressure of these political and economic requirements, founded a central medical administration in 1685—the Collegium medicum. This college was responsible for supervising the activities of all medical personnel, examining physicians and apothecaries, and controlling the sale of medicines. Subsequently, in 1719, another college was created for the management and organization of the fight against epidemics—the Collegium sanitatis. Corresponding bodies were also created in the lower instances—a physician, or Landphysicus, was attached to each provincial council. In 1794, both colleges were united into one under the name Ober-Collegium, and locally, respectively, Provincial-Collegium medicum et sanitatis. This organization served as a model for the structure of health care bodies in other German countries as well. In many small states, the duties of the Landphysicus were combined with the duties of the personal physician of one or another duke or sovereign prince. It was from the ranks of these Landphysici that the famous Johann Peter Frank emerged, who, in the process of his observations of epidemics and infant mortality, and in his work on training midwives, arrived at the construction of a whole system of measures for health care that the state should take upon itself. They are set forth in his multi-volume work "A System of Complete Medical Police." In it, Frank sketched a carefully developed plan for the organization of aid to pregnant women and infants. Furthermore, he points out measures for the health protection of schoolchildren, growing youth, and especially the importance of physical education. A whole volume is devoted to clarifying the importance of nutrition and housing conditions for health. Finally, much attention is paid to the organization of health care and the establishment of medical education. This first theoretical work, which laid the foundation for hygiene as a science and was published at the turn of the 18th and 19th centuries, already encompassed tasks that went beyond the framework of the internal administration of a police-bureaucratic state, which medical police performed, and transformed health care into an independent branch of social policy. The new industrial society began to carry out these tasks, primarily dictated by the interests of the bourgeoisie, and it was in England. From the 17th century, the keys to economic development passed to the island state, the British Kingdom, where, earlier than anywhere else, the bourgeoisie in the process of its development gave impetus to the development of technology and industry. After the civil wars of the Cromwell era, the devastation in the country led to the unprecedented epidemics of the 1670s, described by Sydenham. All anti-epidemic means and measures provided by the experience of past centuries were put into action, but the thinking of English figures in search of positive measures went much further than the previous era.

Here, new conditions made themselves felt. It is impossible to carry out any rational, correct activity in a certain direction without having precise data regarding one or another sphere of phenomena. Such data can and must be expressed in figures—this is the main conclusion of the well-known English physician and researcher William Petty (1623–87), the father of "political economy" and founder of statistics, who proclaimed that "the welfare of the country must be sought in the productive power of man himself." In the work he released in 1662, "Natural and Political Observations Made upon the Bills of Mortality," he attempts to analyze and establish the patterns of population movement, causes of death, and the influence of diseases and other causes on the productive power of the population. Scattered, random figures give him the opportunity only for cautious, incomplete conclusions, and Petty insists on establishing a system and organizing a state institution for the systematic collection of reliable data. The bourgeoisie approaches the resolution of the tasks of improving the health of the state in a businesslike manner. Several of Petty's friends, members of the Royal Society, led by the astronomer Edmund Halley, become interested in statistics, and at the end of the 17th century, the latter publishes a whole series of data systematically accumulated over many years regarding birth rates and mortality at various ages. Under the influence of English authors, a number of similar studies appear during the 18th century, of which the work of the Prussian pastor Süssmilch is particularly remarkable. The cities of the 18th century were striking in their high mortality: in Dresden, Leipzig, and Haarlem, mortality significantly exceeded the birth rate. In the first half of the 18th century, St. Petersburg was the most fortunate of the European capitals in terms of the level of infant mortality: while 184 infants died per 1,000 births there, 276 died in Berlin, and as many as 320 in London. This unfavorable sanitary situation dictated new principles of Health Care to English figures: the study of the surrounding environment through the accumulation of facts, their registration, provision with sufficient medical personnel, and organized influence on the environment. England, which was continuously waging wars in the 18th century, was especially interested in protecting the health of its army and navy. Here, the principles formulated above were applied for the first time, since only in the army and navy were the sick under competent control and observation, and only there was a real accounting of diseases and health possible. A whole galaxy of naval and military physicians, led by Pringle and Lind, began to implement preventive medicine on a scientific basis. The Scotsman John Pringle (1707–82), a student of Boerhaave, held a prominent post in the British army and, thanks to this, had the opportunity to carry out new reforms. He developed extremely important rules for the hygiene of camps and marches, and worked on issues of preventing putrid infections in hospitals and combating typhus—"jail fever." His contemporary, also a Scotsman, James Lind (1716–94), did an enormous amount for the improvement of the navy and in the field of naval hygiene. He developed issues of combating scurvy, an inevitable and common disease at sea at that time, by introducing a sufficient quantity of fresh vegetables or, in their absence, lemon juice into the sailors' ration. He introduced rules for the prevention of typhus on ships. His work (1757) on the most successful means of protecting the health of sailors became a classic work that had a great influence on the organization of naval sanitary services in other countries. Such were the pioneers of the new preventive direction. The English bourgeoisie, being in a period of its ascending social activity and conquering municipal administrations, put forward a whole series of followers and adherents of Lind, reformers in one or another field of Health Care. It is necessary to mention Howard (1726–90), a humanitarian figure who revolutionized the prison system, and especially Thomas Percival (1720–1804), a Manchester figure who began to energetically carry out reforms in the spirit of Pringle and Lind in the field of civil life and, above all, the improvement of populated areas. During the 18th century, the appearance of England began to change. Thanks to the industrial revolution, a factor that had a global influence, the growth of cities began. The influx of the population into cities, which had already begun at the beginning of the 18th century, increased in the second half of the 18th century, and from this time on, the urbanization of the country proceeded progressively and rapidly. In this respect, England is typical, and all other countries only repeated this process as they too were seized by the new economic upheaval. The bourgeoisie replaced the dirty, dark village with a well-maintained city. The improvement of hygienic conditions in the cities of England began from the second half of the 18th century. Westminster was the first to issue an "Improvement Act" (1762), followed by Birmingham (1765), London (1766), and Manchester (1776). Most provincial cities soon followed them. As a result of this act, foul-smelling streams were covered, streets were paved and lit, and the very drainage pipes were improved. Along with these first sanitary measures, there was also the development of anti-epidemic institutions through the establishment, first and foremost, of state control. The port anti-epidemic organization, especially against the plague, had already become so strong that the plague epidemic that broke out in 1709 in Russia, which spread in 1719 to Central Europe and devastated Marseille and Toulon extremely in 1720, did not reach the shores of England. But the achievements in the fight against smallpox, which never disappeared in England during the 18th century, are especially important. The ideas of disease prevention that began to prevail at that time pushed researchers to study the inoculation of smallpox from a sick person with a mild form to a healthy person, which was widely used in the East. During the next half of the 18th century, the use of inoculation spread widely, and it began to be practiced by persons who did not always have a connection to medicine. In such an environment, Jenner's further observations on cowpox took place, which led to the discovery of vaccination. The era of primitive capitalist accumulation was accompanied by the growth of industry and the development of cities, which entailed the rapid proletarianization of the population. Poverty and disease followed on the heels of the industrial revolution for a number of decades. The lengthening of the working day and the massive involvement of women and children in factory labor had the sharpest deteriorating effect on the health of the proletariat. "Capital held its orgies" (Marx). As capitalism developed and large-scale industry appeared, the concentration and organization of the working class grew, which received into its hands a powerful weapon—the revolutionary theory of Marxism. Scattered, spontaneous outbursts, into which protest against inhuman exploitation poured, were directed into the channel of the organized labor movement, led by the revolutionary party of the proletariat. Under the pressure of this movement, the governments of capitalist states were forced to agree to the proclamation of a number of measures to improve the working and living conditions of the proletariat. However, the entire system of Health Care organization during the 19th century was directed toward creating healthy conditions for the existence of the bourgeoisie. If the first reform of Health Care organization, which consisted of its introduction into the state system, was carried out in France, then England was the progenitor of sanitary reforms. In France, in 1802, the first Conseil d'hygiène was created in Paris; a decree of 1805 ordered the introduction of anti-epidemic physicians in every district; in 1822, a supreme medical council was approved under the Ministry of the Interior. All medico-police and sanitary duties were assigned to the administration; departmental sanitary commissions were created under prefects, district ones under sub-prefects, and cantonal ones under mayors. In England, the first measures for the improvement of cities, begun as early as the end of the 18th century, received special development after the bourgeoisie achieved parliamentary reform in its favor in 1832 and the issuance of the Municipal Corporations Act of 1835. The task of the newly created and developing Health Care bodies in England and other states during the 19th century, predominantly within the ministries of the interior, was, in addition to the duties of medical police (see above), mainly the supervision of measures and the improvement of populated areas, the sanitation of the soil, and the protection of water, air, food markets, etc. Having achieved, thanks to the accumulation of capital, a high standard of living that ensured it good housing, abundant nutrition, and the opportunity to invite a private physician in case of illness, the bourgeoisie thereby obtained the conditions for the individual resolution of the tasks of protecting its own health. The only thing that each bourgeois was unable to ensure individually in the field of Health Care was to protect himself from outbreaks of epidemics and from the introduction of contagion, and here he was forced to call upon the state, its resources, and legislative intervention for help. "The mere fear of contagious diseases, which spare not even the 'clean public,' caused no fewer than 10 sanitary police parliamentary acts between 1847 and 1864, and the terrified bourgeoisie of certain cities, such as Liverpool, Glasgow, etc., intervened in this area through their municipalities" (Marx).

The cholera of 1831, and then of 1848, which particularly struck England, showed that an epidemic seizes and strikes with particular force overpopulated, chaotically built-up cities with poor water supply, imperfect sewage disposal, and polluted rivers. Thanks to the lessons of the epidemics on one hand, and under the influence of Chartism, "the strength of which was not so much in theory as in the movement of the masses" on the other, in the 1840s a special commission was created to study the sanitary condition of densely populated cities and towns, the unhealthy consequences of soil, air, and water pollution, and the causes of the enormous mortality of the working class, with the task of developing a series of concrete proposals based on the collected materials to eliminate the discovered shortcomings and to outline a plan for systematic health-improving measures. The activity of this commission led to the issuance in 1848 of the "Nuisances Removal and Diseases Prevention Act." By virtue of this law, in large and populated localities, if the mortality rate exceeded 23 per 1,000, a local Board of Health was established at the request of 10 direct taxpayers. The General Board of Health, created in 1848, appointed inspectors who enjoyed extensive powers, for example, the right to increase taxes for expenses on water supply, sewage, and other health-improving measures. However, all these improvements concerned only bourgeois quarters and led to the creation of new entrepreneurs who took into their own hands the exploitation of water supply, sewage, etc. 20 years after the issuance of the 1848 law, Marx in the first volume of "Capital" could state: "The 'improvements' and urban refinements accompanying the progress of wealth, by means of the demolition of poorly built-up quarters, the construction of palaces for banks, department stores, etc., by means of laying out streets for business dealings and luxurious carriages, the construction of urban railways, etc., rapidly displace the poor into worse and worse, increasingly overpopulated slums." The improvement of the housing conditions of the working class was not provided for by sanitary legislation... The bourgeoisie calmly carried out sanitary reforms, being confident that the workers were too ignorant to know their rights to health, and that "neither the most disgusting dwellings nor the most rotten water will ever serve as a reason for a strike" (Marx). Even less was the bourgeoisie inclined to impose on the state and local self-governments the duties of providing medical aid to sick workers, of fighting infant mortality, of caring for the health of workers' children, etc. The theory of Malthus, prompted by the interests of large landownership, fully suited the aspirations of the industrial bourgeoisie not to feel bound by any concerns for the welfare of the proletarianizing masses. Once, under the action of natural laws, there is always a surplus of population on earth and therefore need, misery, poverty, and lack of rights must always reign upon it, then concerns for the welfare and health of the poor are devoid of any foundation, since they serve only for the preservation of the surplus population and for its increase, and instead of helping the poor, they can only worsen their situation (Malthus). Therefore, the principle of economic freedom "laissez faire, laissez passer" must find its application in the field of health care: let everyone take care of themselves, let them help themselves in a moment of misfortune and disease—all this is a private matter of a private individual. The bourgeoisie does not want to suffer any tax, any coercion on the part of the state. In this regard, aid to the sick is left to the matter of private philanthropy and the church of all denominations. The insignificance of this aid is self-evident. "It is true that a multitude of charitable institutions try to help this trouble, that for example the Manchester Hospital calls itself aid to 22,000 patients a year, but what significance can this have in a city where 3/4 of the population needs medical help during the year. English doctors demand large sums for a visit, and workers are not in a position to pay so much. They are therefore forced to either refuse a doctor altogether or resort to the help of cheap charlatans or quack remedies" (Engels). More qualified workers with high wages, commercial employees, and partly the petty bourgeoisie, in order to ensure medical aid for themselves, following the example of medieval guilds, resorted during the first half of the 19th century to voluntary mutual aid in case of illness through specific contributions. Thus, especially in France, so-called "mutual aid societies" received wide development, in England—"friendly societies" and "workingmen's clubs," in Germany—"free auxiliary funds," etc. The Revolution of 1848 in Germany gave some impetus to the strengthening of these organizations, since by the decree of 1849, local bodies received the right to levy contributions to these funds from entrepreneurs as well. Thus, a significant part of the free-auxiliary funds turned into locally-mandatory ones. English trade unions, after the defeat of Chartism, switched their energy to mutual aid for their members in difficult life situations and in particular to the issuance of benefits in case of illness. Uniting only qualified workers with high wages, the trade unions fell under the influence of the views of the liberal bourgeoisie regarding the complete freedom of contracts between entrepreneurs and workers and the non-interference of the state in these relations, all the more so because the almost 25-year period (after 1848) of the flourishing of English capitalism seemed to confirm the correctness of the liberal principle of administrative nihilism and the "free play" of social forces. Spencer in his work "The Principles of Ethics" preached the theory that "the state has no right to violate the law that everyone must enjoy the good and bad consequences of their own behavior," and a system cannot be allowed in which "the earnings of the higher will be forcibly taken from them to help the lower, and the bad consequences brought upon themselves by the lower will be dumped onto the higher." Spencer warns the bourgeoisie that in the event of the state taking on deep social functions, "the higher earnings provided to the higher by their more successful activity will not only not be placed at their disposal, but a part of it will be taken away by some indirect method in order to increase the smaller earnings of the less diligent or less capable, and, to the extent that this is achieved, the law of equal freedom turns out to be violated." Thereby, state interference in the field of health care was also denied. The course of capitalist development overturned all these theories, as well as the doctrines of free trade as the basis of England's prosperity. From the 1870s, a suspension of the pace of England's industrial development is noted; the competition of the USA and the growing industry of Germany becomes completely evident. In 1873-74, an industrial crisis breaks out. The Conservatives who came to power, led by Disraeli, a representative of heavy industry with protectionist tendencies, introduce a new direction in the sense of strengthening state interference in various areas of public life. Foreseeing inevitable clashes between capitalist states, the Conservative government pays special attention to strengthening the country's security, in particular by somewhat improving the situation of the working class. To Disraeli belongs the famous speech: "Public health is the foundation upon which the happiness of the people and the power of the state rest. The most beautiful country with a cultured and industrious population, with continuously smoking factories and fertile agriculture, in which the arts flourish, where architects erect countless temples and palaces, where a mighty army and navy stand in its defense—this nation must inevitably perish if its population stops growing, if its reserve of vital force falls every year. That is why care for public health is the primary duty of a statesman." The Disraeli ministry was the author of the Public Health Act (1875), the establishment of sanitary boards in cities, urban and rural communities (see Great Britain), as well as laws on workers' housing, by which the improvement of both workers' quarters and their housing conditions was ensured to a certain extent. Subsequent laws of the 1890s were passed against the background of the revival of the labor movement and the influx into it of previously unorganized workers. The 1870s on the continent were marked by the establishment of special bodies for health care and the issuance of sanitary codes in various countries: Germany (1871), Austria (1876), Hungary (1877), Sweden (1879). Before the imperialist war, in almost all European countries, state leadership of health care was under the jurisdiction of internal administration bodies, i.e., ministries of internal affairs, while individual branches of health care were also in other ministries. Usually, health care is managed by a special department, division, or section.

At their head stands a government-appointed official, and in German states this is usually not a physician; in those countries where the organization of public health care has been marked by significant successes and encompasses a range of socio-hygienic initiatives, a physician stands at the head of the health care administration. In all countries, with rare exceptions, there is a collegiate advisory body attached to the central organ, consisting of representatives of scientific figures from various branches of medical practice and figures from fields bordering on health care. At the head of this council, almost everywhere, stands a physician, even in those countries where the medical department is headed by a non-physician. In many countries, a scientific research institute exists attached to the central organ as an auxiliary institution for conducting research, testing scientific discoveries, and also for the scientific development of individual questions of the practical activity of health care organs. Local health care organs (the intermediate instance), to which belongs the supervision of the activities of lower-level institutions on the extreme periphery of health care, are included primarily in the composition of internal administration organs, even where the central instance is part of a different ministry. And in this instance, there is very often a collegiate advisory body, which consists primarily of physicians in government service, but which often also includes architects, engineers, pharmacists, and others. The chairmanship of such a council belongs to a person with a medical education. While in the central organ representation of local self-governments is almost everywhere absent, in the intermediate instance their participation is more or less noticeable, and in some countries, such as in Great Britain, where there is no intermediate government instance of health care administration at all, the latter is under the jurisdiction of so-called County councils. The immediate participation of local self-government bodies is, however, ensured almost completely in the peripheral, grassroots organization of health care. Here, the business of health care is in some countries, primarily Anglo-Saxon ones, directly in the hands of health protection commissions, which consist of representatives of the population and have the right not only to initiate but also to implement measures for health protection. For these purposes, they have the right to introduce special taxes or temporary levies for sanitary measures and institutions, and also observe the fulfillment of mandatory regulations and levy fines. These commissions hire medical personnel. And at the level of this instance, there is government supervision, ensuring the implementation of health protection measures on a broad scale. This is for the most part a municipal, community physician (Gemeinde-, Bezirksarzt), who creates a health protection commission under himself from representatives of various groups of the population. At the same time, in the field of health protection, more than in any other field, active participation of the population is necessary, achieved to a significant degree by broad sanitary propaganda among it. (For the organization of health care in individual states, see the corresponding countries, e.g., Belgium, Bulgaria, Great Britain, Germany, etc.) In accordance with the diverse tasks of health care, which touch upon various branches of administration, the legislative acts ensuring them are extremely diverse and almost nowhere are they consolidated into a general and single law. Even in such countries as England, Italy, and Hungary, where an independent sanitary code has been created, alongside it exist other laws having a direct relation to health care, such as labor laws, building codes, the criminal code, etc. In the majority of countries, however, legislation on health protection rests on a large number of individual regulations and clauses scattered across various codes and statutes, which makes their use and application extremely difficult. In Germany, in Switzerland, and in the USA, furthermore, in the individual constituent parts of these states, legislative norms on health protection differ significantly from one another. In recent years, tendencies have been growing to unify basic sanitary requirements and create unified sanitary codes. (Regarding the content and delimitation of sanitary legislation between state-wide and local organs, as well as that affecting international relations, see Sanitary Legislation.) The development of industry, the growth of cities, and in particular the appearance of workers' parties push capitalist governments toward socio-hygienic measures. From this time, activity in the field of health care begins to rely on a scientific base. During the 19th century, science, having received a social mandate from the bourgeoisie for the sanitation of the city created by the growth of industry, was enriched by successes in experimental hygiene and bacteriology (Pettenkofer, Flügge, Koch, and others), which clarified the paths for improving the physical environment. On the other hand, the works of Marx and Engels had even greater significance; they, through their study of the laws of capitalist development and the position of the working class, established that the natural environment acts upon man not directly, but through the mediation of the social environment, and at the same time, the degree and direction of this interaction do not remain constant but change along with how the economic structure and economic forms change with the development of productive forces. Thereby, the role of changing social conditions in the development of the business of health care is established. Revolutionary workers' parties received a program of practical actions regarding the struggle for the improvement of the position of the working class and, consequently, its health. In the struggle with the then-revolutionary German Social Democracy, the "Iron Chancellor" Bismarck, when his attempts to defeat Social Democracy by means of an exceptional law failed, was forced to undertake a series of social reforms. In the imperial message to the Reichstag in 1881, it was pointed out that "the healing of social ills must be sought not exclusively on the path of suppressing social-democratic manifestations, but equally on the path of positive promotion of the welfare of workers," which was to create "greater security and stability of position for those in need of help." Thus were born the laws on insurance in case of disease (1883), etc. Wilhelm II, who pursued an even more frank militaristic policy, solemnly announced that he intended to occupy himself with improving the living conditions of workers and to convene an international conference for the purpose of satisfying the complaints and wishes of workers in general, and not only in relation to the sick, the frail, and the maimed. Thus, the capitalist state was forced to resort to intervention in the matter of providing medical assistance to workers, albeit at the expense of the latter and only partially at the expense of entrepreneurs (see Social Insurance). German legislation of 1890 and subsequent years, caused by the pressure of the working class, entailed for the same reasons analogous initiatives in other countries. And before the war of 1914, it was precisely England that had gone the furthest in the sense of attracting state funds to the matter of medical assistance to workers. In it, from the beginning of the 20th century, a certain revival begins in the activity of trade unions; replacing the temporary national intoxication during the Boer War, at the end of the first decade, a sharp aggravation of the class struggle occurs. Yielding to this pressure, the Liberals (Lloyd George) pass a series of laws seeking to improve the position of the working class, implementing state insurance in case of illness, old age, and unemployment, with the state treasury, entrepreneurs, and the workers themselves participating in the contributions. At the beginning of the 20th century, health care thus significantly expands its content, combining with other social measures (see Labor, Social Insurance), and occupies a prominent place in state activity, while primarily taking the form of preventive measures. This is also facilitated by the circumstance that a whole series of major initiatives in the field of technology and construction reveals the major economic significance of sanitary measures. The digging of the Saint Gotthard Tunnel, accompanied by huge sacrifices of workers who died from ankylostomiasis, pushed toward the finding of such means which, during the digging of the Simplon Tunnel 15 years later, reduced morbidity to negligible figures. Analogous results were obtained during the digging of the Panama Canal, when measures for fighting yellow fever were discovered. Lively trade relations between European countries and other parts of the world entailed, for the purpose of fighting the introduction of epidemics, a whole series of international sanitary conferences, which created sanitary legislation of an international character (see Conventions, International Office of Public Hygiene). Finally, measures for health care also received political significance, contributing to the expansion of the influence of one country or another and the penetration of its capital into semi-colonial countries. Such a goal is pursued, for example, by the activity of the Rockefeller Commission, which zealously planted hospitals, medical colleges, and universities in China from the war of 1914. The Americans developed especially lively activity in this direction after the imperialist war in a number of European countries, especially in France and Czechoslovakia.

The World War produced significant shifts both in the organization of health care and, especially, in the sense of expanding the scope of duties and rights of health care bodies. On July 27, 1918, a Ministry of Public Health was created in the Austrian Empire. Already after the conclusion of the Treaty of Versailles, similar ministries were created in Czechoslovakia (November 1918) and in Yugoslavia (December 1919). In 1919, England, Poland, and Hungary also embarked on this path (in the latter, it was combined with labor and public improvement issues). In 1920, the French Ministry of Health was created, as well as in Canada and the Union of South Africa. In 1921, a federal ministry was established in the Australian Commonwealth; in December 1921, in Belgium, the Ministry of the Interior was transformed into the Ministry of the Interior and Hygiene. The same reform was carried out in Bulgaria. In China, an independent Ministry of Health was also created, and special medical departments were created in Japan and British India. In a short period from 1918 to 1922, ministries of health or corresponding medical departments were created in 30 countries. In 18 of these countries, only health care functions or those of bordering areas, such as labor and social welfare, were included in the purview of these ministries; in the others, they were combined with other branches of administration (for the structure and activity of health care organizations, see individual countries). The emergence of these ministries was an inevitable consequence of the upheavals of the World War. The fall in the birth rate, the sharp rise in mortality, and the enormous development of infectious diseases, especially in agrarian Slavic countries—which also aroused fears in industrial countries, where tuberculosis and venereal diseases were growing to threatening proportions—all this could not but pose the question of protecting the health of the population in its full breadth. All the successes achieved during the previous decades of the 19th century were reduced almost to nothing. On the other hand, the colossal demands placed by the war on the living resources of the country, which it physically exterminated, in connection with the fact that during army conscriptions it was discovered what a significant number of people were unfit for military service, could not but alarm the ruling classes of capitalist countries. Lloyd George, in one of his speeches, stated: "If we had taken more care of the health of the nation, we could have increased our military forces by at least an extra million people." To an even greater extent, however, such attention of the bourgeoisie to the issues of protecting the health of the nation was dictated by the revolutionary situation that had developed in the period immediately following the Treaty of Versailles in all countries, both the victors and the vanquished. The working masses, bled white by millions of losses on the battlefields, by hundreds of thousands of disabled persons, shaken in the conditions of their existence (housing, nutrition), and having thrown millions of women and adolescents into production, rose menacingly against the true culprits of the world slaughter, the bourgeoisie of their countries. In this situation, capitalist governments found a way out in the creation of ministries of health, the proclamation of social legislation in the field of labor protection, housing construction, the protection of motherhood and infancy, the protection of children's health, and the fight against tuberculosis and venereal diseases. In countries shaken to their foundations, such as Poland, Belgium, and partly Yugoslavia, large material resources were poured in by the American Red Cross and the Rockefeller Commission. However, as the bourgeoisie recovered and, with the help of social democracy, strengthened its state power, it curtailed its social activity in the field of health protection. The Ministry of Health in France fell very quickly; the Pilsudski coup reduced the Ministry of Health to the role of a simple department for reasons of economy. The German government spends millions on international exhibitions and hygiene museums to impress other capitalist states with its successes in the field of hygiene, while ruthlessly striking from its budget appropriations for summer colonies for proletarian children and for the fight against tuberculosis among them. The same policy of reducing appropriations for measures to protect social health is carried out by local self-governments. The capitalist government uses the new state health apparatus to pressure the working class in its own interests. The English Ministry of Health, which is in charge of the care of the sick, carries out systematic pressure on the boards of guardians for the poor, striving to limit the size of benefits and the circle of persons served by them in order to weaken the working class in its economic and political battles with the bourgeoisie, as was the case during the miners' strike in 1926. State participation in housing construction for workers is gradually being curtailed, yielding to the pressure of the interests of private capital. Theories are again being resurrected among bourgeois politicians and even bourgeois hygienists, the most eloquent exponent of which was, in 1910, during the time of the Lloyd George reform, the vice-president of the British Medical Association, James Barr, which boiled down to the following: "Only a degenerate people can allow the government to take care of it from the cradle to the grave. Money goes to money-changers, spendthrifts, and the chronically ill. A free people should not allow an encroachment on its freedom. The law introduces the treatment of tuberculosis. But consumptives, and especially the poor, should not be supported in the interests of natural selection. The state should not help the sick. That is not its business. The sick person is of interest only to his relatives, the doctor, and the apothecary. If the state has extra money, it should be spent so that the strong, healthy, and brave (i.e., the bourgeoisie) live better." The progressive shifts that had been outlined in the matter of social prophylaxis (see Dispensary) are retreating and giving way to the spread of methods of preventive medicine, understood as individual prophylaxis, all kinds of vaccinations, transplants, etc. The health protection system in the country of the dictatorship of the proletariat is built on completely different principles; it proceeds first of all from the basic premise that the health of the working people is a derivative of socio-economic conditions, i.e., it depends on the level of productive forces and social relations. Genuine improvement in the health of the working people is possible only with such a change in social relations that ensures a continuous increase in the standard of living (understood in the broad sense of the word) of the working people. The task of health care is to ensure that a person is all the time under the influence of favorable conditions, under which the interaction of the organism and the environment would neutralize or weaken the pathological deviations of individual organisms and create prerequisites for improving the quality of the race in the future. That is why the system of medicine in the era of the dictatorship of the proletariat provides for a continuous and unified chain of institutions and measures that consistently provide their care to the pregnant woman, the woman in labor, the mother, and the infant. Next come the concerns for the preschooler, the schoolchild, the working adolescent, the pre-conscript, and the Red Army soldier. Professional selection, the fight against occupational hazards, and occupational diseases constitute the next concentration of measures. Since Soviet medicine has to reckon with the concrete fact of high morbidity among the working people as a consequence of the preceding era, it must combine care for the new generation with the fight against diseases arising and existing due to still unfavorable conditions. In both cases, social therapy is not limited only to influencing the individual, but also extends to the environment of labor and everyday life. Soviet medicine (see below) preliminarily studies the level and dynamics of the health of the working people, using dispensary methods of work, and organizes its measures around a central medical-sanitary hub, a differentiated and specialized medical district, which has received the name of "unified dispensary," outpatient association, or polyclinic (see Dispensary, Dispensarization). Alongside all these measures, and as if set apart, stands the system of health-improving influences on the environment in the interests of the entire collective. This includes sanitary protection of housing, food supervision, improvement of populated areas, concerns about water supply, sewage, etc. The unity of organization contributes to the integrity of the measures being carried out, the avoidance of parallelism, and the saving of strength and resources. On the other hand, in the conditions of the development of a planned economy and socialist construction, the unity of the health care cause is ensured through systematic planning. The effectiveness of the measures of Soviet medicine can manifest itself with great force only on the condition of their broad understanding and further branched implementation by the working people themselves. That is why the bodies of Soviet medicine are inseparably linked with the health care sections of the Soviets, medical-sanitary institutions are surrounded by commissions for the improvement of labor and everyday life consisting of representatives of factories, plants, schools, and villages served by a given institution, and the primary medical institutions, brought into the very thick of life, are immersed in a whole network of grassroots bodies of the working people's own initiative (labor protection commissions, health cells in dormitories and houses, school health cells, pioneer sanitary units, etc.).

The initiative of the working people is achieved through the continuous development of episodic and systematic sanitary-educational work (see Sanitary Education). III. History of Health Care in Russia. The period before the Petrine era. The first more or less definite data on the organization of assistance to the sick date back to the period of Kievan Rus after the adoption of Christianity. While individual Slavic tribes, which still retained a tribal structure, resorted in case of illness to the help of their elders, sorcerers, and magi, who treated with herbs, incantations, spells, and simple remedies from the arsenal of folk medicine (see Quackery, Medicine), the situation was different in such centers as Kiev and other trading cities. Here, monasteries (the Kiev Pechersk Lavra) were established with all the functions inherent to early Christianity, i.e., the treatment and care of widows, orphans, the elderly, and the destitute. The circumstance that the first cadres of monks of the Kiev Pechersk Monastery were sent from Mount Athos, where the art of healing had especially flourished since the time of Athanasius, also left a sharp imprint on the activities of the Kievan monasticism. Under the influence of the latter, Grand Prince Vladimir in his statute of 996 determined: "Widows, the destitute, monasteries and their baths, their hospitals and physicians..., all these are given to the holy churches, to the patriarch or metropolitan or bishop in whichever diocese they may be, let him oversee them and provide administration and judgment." According to the church statute of the same time, physicians were free men and were exempted from the operation of general laws and the jurisdiction of secular authority, and were subject to the supreme church court. Yaroslav the Wise (1096) further strengthened the influence of the church in the field of Health Care organization and laid the foundation for church medicine. From the 11th century, various almshouses, hospitals, and cells began to be systematically organized at churches and monasteries, where all kinds of the infirm, wanderers, the sick, lepers, and other kinds of destitute people found shelter. One of the major figures who built the first hospital must be considered Bishop Ephraim of Pereyaslavl. The church, which by that time had already become an essential element of the state apparatus, took upon itself the assistance of people who had fallen out of the social rut and performed functions of charity. In the field of medical assistance, it did not stray very far from folk medicine. Church medicine was intended only for the destitute and the "base people," who received free assistance and care here. "And the construction of baths and physicians and hospitals—free treatment for all who come." The church received funds for this activity in the form of a special tithe ("Russkaya Pravda"), designated for the benefit of the poor, orphans, and the sick. Princes, for themselves and for the service of their retinue, used secular physicians brought in from abroad (Greece, Western Europe), who appeared with the army. Thus were formed "domestic," court medicine for the needs of feudal lords—appanage princes, about the activities of which there is no detailed information whatsoever, and church medicine for the destitute and disadvantaged, which existed throughout the entire period of the appanage-veche system and the Tatar yoke, right up to the formation of the Moscow Tsardom. This era abounded with continuous pestilences and famines, recurring regularly every decade, but history has not preserved a single monument testifying to sanitary measures of a broad nature. Only as the Moscow princes, who overthrew the Tatar yoke, came to the fore, and then in the person of the Moscow tsars and especially Ivan IV (the Terrible), who waged a decisive struggle against the feudal boyars, did shifts in the field of Health Care begin to emerge. Ivan IV relied on the zemshchina, submitting to the policy of merchant capital and the interests of the townspeople and merchants; he pursued a policy of conquest and, pushing toward the seacoasts (White and Baltic Seas), entered into trade relations with England. These connections, on the one hand, required concern for the improvement of harbors and the fight against the introduction of epidemics. On the other hand, continuous wars brought forward the need to have medical assistance with the troops. Striving to consolidate his supreme power and undermine the influence of the church, Ivan the Terrible took measures to recruit foreign physicians into his service, primarily from England and partly from France. At the Stoglav Council, he rejected the church's desire to continue to retain the matter of caring for the sick and widows by obtaining funds for opening new almshouses and hospitals at churches and monasteries. On the contrary, the intention of Ivan IV to open state hospitals dates back to 1550, which reflects a further desire to break old institutions. But if, in the direction of serving the urban population, these plans remained only plans, then for the service of the court, the tsar's entourage, and the army, the first royal pharmacy was created in Moscow. In 1588, the first Russian medical book appeared in manuscript. In 1592, a border station was established in Russia for the first time to prevent infectious diseases. The attention paid during this reign to issues of medical organization is also explained to a significant degree by the outbreaks of pestilence in Novgorod, Pskov, and Smolensk. Boris Godunov, under the influence of the same reasons and the need to care for the health of the army, which was to a significant extent mercenary, took further steps to increase the number of physicians in Russia. According to the testimony of Margeret, who served under Boris Godunov, the latter created the Apothecary Chancery, which oversaw physicians and pharmacies. However, in view of the singularity of this assertion and the Time of Troubles, which stifled the initiatives of the Apothecary Chancery, if it was indeed created, the development of the activities of the Apothecary Chancery should be attributed to the reign of Tsar Mikhail Fyodorovich. Under him, the Apothecary Chancery had as its task, besides ensuring primarily the health of the royal family and the closest boyars, also the organization of medical assistance to the army, for which field pharmacies were established and regimental physicians were regularly sent to the army. In the materials of the Apothecary Chancery, there are many regulations in the field of caring for soldiers wounded on the battlefield, "on providing certain meritorious civil officials with the means for the restoration and continuation of health" (Richter). The Apothecary Chancery even sent special physicians to remote provinces for the treatment of meritorious boyars. There are isolated measures in the field of charity as well, but it still remained in the hands of the church. The Apothecary Chancery also set as its task the training of medical personnel. The government obliged foreign physicians to teach Russian students the medical craft "with all diligence and concealing nothing." After five years of training and successfully passing an examination at the Apothecary Chancery, a physician's diploma was issued. Foreign physicians invited from abroad, although appointed to positions by the Apothecary Chancery, first passed an examination at the Ambassadorial Chancery. Pharmacies were also subordinate to the latter, obviously in view of the fact that medications were predominantly imported. Thus, during the 16th century, there were three centers that oversaw the organization of Health Care: the church, the Ambassadorial Chancery, and the Apothecary Chancery. Under Tsar Alexei Mikhailovich (1670), the Apothecary Chancery was already charged with the duty "to apply effort toward the general health of the citizens and the prevention of the spread of contagious diseases." These measures were the result of the development of epidemics in the country in connection with the wars being waged (with Poland). By this time, trade relations with the West, especially with England, had also developed strongly, and the interests of trade required, following the model of Western Europe, decisive measures to combat the danger of the introduction of epidemics into other countries. Such outbreaks, on the one hand, occurred in 1654 in Moscow, and in 1665 it became necessary to "ban trade with England" due to the terrible plague epidemic of 1665-66 in London. Strict quarantines were introduced, and the Arkhangelsk harbor was closed to trade. Decrees were issued to the Arkhangelsk and Novgorod governors regarding the inspection of arriving foreigners—not only the English, but also the Dutch, Hamburgers, and Lübeckers—the interrogation of them, and the seizure of goods. Thus, for the first time, anti-epidemic measures were implemented in Russia on a state scale and by a state body. However, all concern for the "general health of the citizens" was limited only to patrols and quarantines. An attempt, the beginning of which dates back to the time of Ivan IV, to take into its own hands the construction of hospitals and the care of the poor and to oppose the secular authority to the authority of the church was made by the successor of Alexei Mikhailovich, Fyodor Alexeyevich. By this time, as a result of long-term wars (with Poland, Sweden, Turkey), a large group of disabled and elderly soldiers had already formed, for whose care the government itself, which was increasingly in need of an army, had to take care. It is not surprising, therefore, that in 1682 the Apothecary Chancery was ordered by a royal decree to discuss the issue of creating a hospital and an almshouse. The hospital had the task "to provide the truly poor patient with the means to heal his ailment in the hospital, and to assign those suffering from an incurable disease and earning their livelihood from the compassion of their fellow men to an almshouse until death." However, almshouses were intended mainly

"for the poor and retired soldiers, who, being maimed in the Tsar's service, could no longer feed themselves. These almshouses were to serve as a lifelong and quiet refuge for wounded warriors." In the hospital, "truly destitute patients" enjoyed free treatment and food, whereas serfs and household servants could not use state maintenance. However, the Apothecary Chancery was instructed to work out conditions for the admission of these people to the hospital with payment for treatment and food. The creation of the hospital was also motivated by the need to provide young doctors with a practical field for perfecting their medical art. Characteristic of the Tsarist power's offensive against the patriarch are not only the transfer of these institutions to the jurisdiction of the Apothecary Chancery, but also the allocation for their financing of funds belonging to and collected by the church, namely: the estates of the former Archbishops of Arkhangelsk in the Moscow, Kashira, Klin, and Borovsk districts, as well as "all the money which, by the prompting of philanthropy, is placed in the collection boxes of Moscow churches." The Muscovite state also experienced a great need for craftsmen and artisans, the invitation of whom from abroad was very expensive; forced to resort to strengthening serfdom by distributing votchinas and estates, it made an attempt to create cadres of these craftsmen from foundlings and beggar children. This explains the decree on the plan for the Foundling Home, where young poor people, "especially the children of beggars who begged for alms on the streets," were to be accepted and trained in crafts. To this end, arithmetic, architecture, painting, geometry, artillery, and the following crafts were to be taught at the school attached to the Foundling Home: cloth-making, goldsmithing, watchmaking, and gunsmithing. Such were the demands of the era, and the Apothecary Chancery, as a special authorized body, expanded the scope of its activities in connection with the current needs of state power. The period before the fall of serfdom. Peter I, who stubbornly and boldly carried out his reforms, constantly fighting his way in wars to the seas, to a free outlet for the country's raw material wealth to Europe, had as his primary support the "new army" and a young fleet with foreign officers. Therefore, he first of all deepened the initiatives of his predecessors regarding the care of the health of soldiers and sailors. In his Military and Naval Regulations, borrowed from the Dutch, much attention was paid to measures for maintaining and protecting the health of troops both in peacetime and on campaign, in barracks and in camps. Interesting is the instruction written by Peter I himself to the army that set out on a campaign to Persia (1722) regarding protection against diseases. In this instruction, he indicates how soldiers should be protected in a hot climate and which fruits should not be eaten; to avoid sunstroke, soldiers were forbidden to go out during the day without a hat and to remain in places where nothing protects from the sun. Officers were ordered to set an example for the soldiers; violation of the law threatened them with loss of rank and severe punishment. The same needs of military requirements dictated the organization of well-appointed medical institutions for the army. In 1706, a military hospital was founded in Moscow under chief physician Bidloo. In 1712, it was ordered to create invalid hospitals for elderly warriors and almshouses for the maimed in Moscow, St. Petersburg, Kiev, Yekaterinburg, and Revel, and the almshouses themselves were transferred from the hands of the clergy to the police. In 1718, hospitals were established in St. Petersburg: the Land and Naval hospitals, on the Vyborg side. All these initiatives were dictated, in the words of Peter himself, by the necessity that "every exhausted person who has served should find help and rest, which he had not had until now." At these hospitals and in Moscow, surgical schools were established for the study of medicine, which were later transformed into the Medico-Surgical Academy. Thus, under Peter, the military medical department was tangibly defined and organized, however, not within the bowels of the Military Collegium, but within a single body, the same Apothecary Chancery, renamed in 1707 to the Medical Chancery, which in 1712 was transferred to St. Petersburg. This new body, which united all branches of medical and sanitary affairs (pharmacies were transferred to it from the Ambassadorial Chancery), launched the widest activity in close accordance with all of Peter's transformations. The measures of the Medical Chancery took on a special scope when it was headed by Peter I's personal physician, the talented Scotsman Erskine, who was the first to be elevated to the rank of archiater. His position consisted of managing the entire medical department in Russia, in commanding and supervising doctors, surgeons, and apothecaries. One of the first steps of the Medical Chancery was the concern for finding mineral springs in Russia, which was entrusted to Dr. Schober. In 1718-19, a plague that broke out in the south of Russia in the Kiev and Azov provinces required extraordinary anti-epidemic measures. Specially authorized persons with dictatorial powers were sent. At the same time, measures were taken to plant a network of medical institutions, primarily pharmacies. By a decree of 1721, it was permitted to establish free pharmacies in St. Petersburg and other provincial cities, and the pharmacy business itself was regulated in such a way that all hospitals and public and private pharmacies were subject to the Medical Chancery. In order to reduce the need for ordering and purchasing medicines abroad, the Medical Chancery took the initiative in studying domestic medicinal plants, and governors and other viceroys received a supreme decree to provide assistance to this initiative of the Medical Chancery. The Regulation of 1721 obliged the magistrates to build "at the expense of the zemstvo hospitals for the care of the orphaned, sick, and maimed and for the very elderly people of both sexes." However, the lack of funds in the country, exhausted by the Northern War, and, most importantly, the lack of medical personnel left these prescriptions only on paper. Due to the increasing demand for medical assistance, quackery developed in the country, and many wandering healers who had not received any education appeared, "Caesarians" or "Hungarians," as they were then called. In 1721, the Medical Chancery developed a decree according to which no doctor or healer was allowed to practice freely without undergoing an examination in medical sciences by the Medical Chancery and receiving a certificate from it. In connection with the growth of the population of the capitals and the need to care for the quality of food for them, the first beginning of sanitary measures was laid: for example, in the 1722 instruction of the Moscow Police Chancery, it was indicated that meat should be kept clean and covered with clean canvas. To 1712 also belongs an extremely important act, the progenitor of sanitary statistics. In the supplement to the church regulation, it was ordered that the clergy submit a report every 4 months on the number of births and deaths. Peter I sought, as indicated above, to build the matter of charity under the guidance of the Medical Chancery. Starting from 1697, the sums received by the church for charitable purposes were directed to other state needs. However, at the end of his reign, after the Treaty of Nystad, with the financial crisis that had emerged and the decline in public attention to the cause of charity, Peter I again tried to entrust this matter to the clergy, and the Spiritual Regulation of 1721 ordered monasteries to "...build hospices and infirmaries and gather in them the elderly and those completely deprived of health." By a decree of 1722, it was ordered "to send the old to the Synod for assignment to a hospital." Even earlier, Peter I involved the church in the duty of organizing shelters and foundling homes for abandoned children. By a decree of 1715, it was prescribed: "in Moscow and other cities at churches, where it is decent, build hospitals at the fences... and choose skilled women for the preservation of shameful infants, whom wives and maids give birth to unlawfully; explain by decree that such infants should not be thrown into indecent places, but brought to the above-mentioned hospitals and placed secretly in a window through such a covering, so that the brought persons would not be seen." The extent to which this measure stemmed from the rigid need of the new imperial conquering power to increase the population is evident from the severe measures that fell on the heads of those who violated this decree: "to punish with death those who dared to reject this help, resorting to infanticide." By bringing to the forefront of state activity the new service nobility, which often rose from the lower classes, and fighting against the degenerating generation of boyar families of landowners, Peter I instructed the Medical Chancery to compile a eugenic decree (1722-23) curious for its time, which forbade the mentally retarded to marry and manage an estate. It goes without saying that there could be no talk of providing medical assistance to the rural population—the serf peasantry. It was directed only at soldiers and sailors. However, under Peter, medical assistance at factory and plant enterprises was also born. Continuous campaigns and wars required gold, metal for guns and shells, and cloth for the army.

The state-owned and possessional manufactories that developed in response to these requirements were established in the remote and distant corners of the Urals and Siberia. To serve the foreign engineers, craftsmen, and even skilled workers brought there, it was necessary to have medical personnel and pharmacies. However, the further formalization of this type of medical aid was given by the successors of Peter. Under the immediate successors of Peter I, wars did not cease, industry developed, and cities grew, especially the capital cities. Other cities that emerged at this time were primarily administrative centers, which attracted a large number of service people and, in part, craftsmen. The stumbling block on the path to establishing proper medical care in them was the shortage of doctors. It is interesting to note, from the realm of attempts to increase the number of such personnel, a clause in the Hospital Regulations of 1733, by which the chief doctor of a hospital was tasked with the duty of instructing young people in medico-surgical schools. It was also decreed, among other things, that elderly doctors who had served their term in the military department should be assigned to city service. To organize medical service in the capitals, the positions of state-physicians, subordinate to the Medical Chancellery, were established. They had the right to approach the government with representations on all subjects generally 'concerning the health of the inhabitants.' They subjected all newly arrived doctors wishing to enter state service to examinations, supervised pharmacies, and monitored the prevention of persons who had not received a medical education from practicing. They were required to examine the disabled and take care of timely assistance to the sick. Finally, the physicians were entrusted with the task of resolving judicial complaints of medical officials among themselves and taking care of the promotion of doctors, making representations about them to the government. Thus, in the person of the state-physicians, who were doctors, one can note the progenitors of local health care bodies. In 1738, a special doctor for the poor was appointed by a decree of Anna Ioannovna, who was obliged to be present daily at the main pharmacy (St. Petersburg) to 'prescribe medicines to the poor and helpless and distribute them free of charge.' Later figures of the Medico-Philanthropic Committee in the Alexandrian era were ready to see in this act an anticipation of the ideas laid down by the creation of dispensaries in London in the mid-18th century. By a decree of 1737, magistrates of a number of cities, and primarily those close to the capital (such as Pskov, Novgorod, Tver, Yaroslavl, etc.), were ordered to establish city doctors with a salary from the town hall of 12 rubles per month and a free apartment. However, in 1756, instead of the 56 doctors legalized by the Senate decree, there were only 26. A new decree of 1756 confirmed the requirement for the introduction of this institution of doctors in cities with the obligation of providing apartments and paying salaries in thirds of the year without the slightest delay, under penalty of double recovery from the magistrates for slow payment. City doctors were intended for the treatment of residents. A more precise characterization of the circle of persons served by these doctors is given by the same 1756 decree, which orders the separate appointment of three doctors, two doctors of medicine and one surgeon, for Moscow and the Moscow Governorate 'due to the greatness of the city and its populousness.' One doctor of medicine and one surgeon were to be attached to the Moscow Governorate Chancellery, and the other doctor of medicine to the magistracy. They were to examine the sick or beaten, as well as those who died suddenly, and treat the sick: the governorate doctor for the nobility, the magisterial one for the merchant class. However, the main functions of the governorate surgeon and doctor of medicine were reduced to fighting epidemics: 'contagious and infectious diseases, especially during times when they sometimes multiply, as happens in spring or autumn.' In these cases, they already treated residents of every rank and were obliged to make trips into the governorate. To fight against quacks, measures were taken to deprive them of the possibility of using medications from pharmacies, and restrictions were introduced on 'over-the-counter sales.' However, the archiaters of the Elizabethan era not only fought with severe punishments against persons 'who had not studied medicine and did not have a certificate for it from the Medical Chancellery,' but also took care of increasing the cadre of medical workers, with Archiater Kondoidi paying particular attention to the training of a sufficient number of midwives. In 1748, to increase the number of students in the medico-surgical schools at hospitals, a decree was issued for the Moscow Theological Academy to send a sufficient number of its students, who had preparation in the knowledge of languages, to replenish the surgical schools. Curious is such a heroic measure to create 'dynasties of doctors' as the order of 1758, which stated that widows of doctors of medicine, surgeons, and pharmacists should be issued a widow's pension only if they committed in writing to raise their children for service in the medical field. Without such a subscription, they were deprived of the right to a pension and any other widow's allowance. However, the most important measure for creating cadres of domestic doctors was the opening of Moscow University in 1756, with the opening of the first medical faculty in 1764, which already belongs to the time of Catherine II. The latter transformed the Medical Chancellery into the Medical Collegium, headed by a president, and these were no longer doctors, but prominent dignitaries. The Medical Collegium was divided into two departments, of which the first managed scientific affairs, and the second, under the name of the Chancellery, managed administrative and financial-economic affairs. The presence of the collegium consisted of six members of medical rank under the chairmanship of the president. The commission had a branch in Moscow—the Office, consisting of two officials under the chairmanship of a state-physician. The activity of this Medical Collegium proceeded under the sign of the fight against incessant contagious diseases, to which the spread of syphilis was added. The Medical Chancellery developed a project and estimate for the construction and maintenance of special hospitals—'special houses'—in the Moscow, St. Petersburg, and Novgorod governorates and the invitation of additional personnel so that, in case of a successful experiment, the arrangement of hospitals could be extended to other cities. According to the authors of the report, these 'special houses' 'can be used by the destitute, among whom, as well as in their families, contagious and infectious diseases and prolonged illnesses are more widespread than among the wealthy, who can find for their healing all the means belonging to them from everywhere, while the destitute suffer from those diseases without any care and help.' The project envisaged free treatment and provision of food at the expense of the treasury even after recovery. However, the Senate decree of 1763 rejected the construction of new houses and the invitation of special personnel, but only ordered the existing city doctors and surgeons to treat those patients who appeared to them for assistance or invited the doctors to their homes. It was permitted to use state-provided medications and food only for the poorest people. Only in cases of extreme necessity, obviously during the time of an epidemic outbreak, was it permitted 'for the swifter suppression of such diseases' to invite temporary additional personnel and to set up a hospital, finding houses for this in convenient places, not in the city itself, 'but outside of it, and away from the main roads.' It is not uninteresting that this same decree, in order to overcome the false modesty that turns patients with contagious diseases away from medical help, orders doctors by no means to ask patients 'who is of what rank and surname.' On the contrary, in military hospitals, it was ordered to question soldiers who had fallen ill with 'French venereal disease' about whom they had been infected by, so that by subsequent searches for the source of infection, the spread of this disease among military ranks could be stopped. 20 years after the issuance of the above decree, a secret hospital for 30 men and 30 women afflicted with venereal disease was set up in St. Petersburg. Regarding these patients, it was ordered to observe strict silence, which explains the very name of the hospital, where entry for outside visitors was forbidden. As one of the measures for the purpose of fighting contagious diseases, one should cite the prohibition in 1782 of burying the dead inside cities in churchyards, and it was ordered to set aside places for cemeteries at a distance from cities. Among other measures to improve medical aid, it is necessary to note the improvement of teaching in medical schools: the teaching of midwifery was introduced (midwifery institutes were created), the number of professors was increased and adjuncts were added to them, and the first clinics—clinical wards—were established. Physical and mineralogical cabinets were set up at medical schools, and anatomical, surgical, and physical cabinets were expanded. For the printing of medical books, a special printing house was established at the Medical Collegium. In 1793, the first 'Medical Gazette' in Russia began to appear, in which articles with instructions for preserving health were placed. The Gazette was published for only a year. The hygienic educational activity, begun back in the time of Peter and aimed at serving the landed nobility and the upper strata of the city, received special development in the second half of the 18th century.

A huge number of both original and translated books appeared on issues of dietetics, dental hygiene, personal hygiene, "venereal diseases," and first aid in accidents, and issues of child care and the ideas of breastfeeding were propagated with particular zeal. A number of pamphlets covered issues of combating infectious diseases, especially rabies, fevers, the plague, and were also devoted to the promotion of smallpox vaccination. Along with such literature, which proclaimed the principle: "it is more important to prevent than to cure a disease," all sorts of home medical guides, which were snapped up instantly, enjoyed much greater demand and interest. The literature of those years also touched upon issues of population growth and the fight against infant mortality. The most complete program of government activity in this area is outlined in the speeches of the Moscow professor Zybelin ("A Word on the Method of How to Prevent the Not Inconsiderable Among Others Cause of the Slow Multiplication of the People," Moscow, 1789). The decree of 1785, which stated that girls suspected of pregnancy should be examined and not forced to perform heavy labor until the time of delivery, should be considered a response to these trends. Catherine II also completed the issue, raised back at the end of the 17th century, of the care of foundlings by creating foundling homes in Moscow and St. Petersburg. Their initiator, Betskoy, was also guided by the idea of creating a "third estate," free and trained in crafts and trades. The developing urban bourgeoisie was looking for free hands for the factories and plants that were opening. The need for the care of the disabled and assistance to the disadvantaged grew as the Turkish war dragged on and the treasury was depleted. In search of public funds and to attract the interest of all strata of the population to the cause of charity, when the law "Institutions for the Administration of Provinces" (1775) was issued, Boards of Public Charity were introduced. They were charged with the duty of organizing orphanages, hospitals, pharmacies, almshouses, homes for the incurably ill, and homes for the insane. The Boards were established in all provinces, and to carry out all the outlined goals, each Board was granted "as capital" 15,000 rubles and authorized a whole range of commercial operations, up to and including lending, to find and increase further funds. The Boards consisted of the civil governor as chairman, two assessors of the upper land court elected from the nobility, two assessors of the provincial magistrate as representatives of the merchant and petty bourgeois class, and finally two assessors from the upper rural court, i.e., representatives from the peasantry. In addition, the Boards were granted the right to invite the marshal of the nobility and the mayor to their meetings if necessary. With such a composition, it was obviously intended to create in the Boards a representation of the "needs and benefits" of all estates, undoubtedly interested in the organization of charity work. True, this representation was not elective and not accountable to the electors. No business could be decided without the participation of estate representatives, since according to the law, "all matters relating to the establishment of the Board" had to be discussed by the "general presence of the same." However, a few years after the issuance of the institution on provinces, it was established that the Board must send the journals of its meetings for the review of the provincial prosecutor before execution. In the hospitals of the Boards, it was necessary to treat "the poor and destitute of every rank free of charge, and to accept other patients and masters' servants only when there are vacant places, and to place them separately, and to set a moderate fee for the treatment of these." In addition, it was permitted to accept free of charge into the St. Petersburg hospitals: board clerks and lower clerical officials sent by government offices that do not have their own special doctors, "retired people of the state department," wives and children of soldiers, sailors, and other teams that do not have special hospitals, merchants and petty bourgeois of the St. Petersburg province who contribute a certain sum to the Board of Public Charity for the maintenance of hospitals, peasants of the state department, and people of both sexes released into freedom forever. Officials, merchants, and petty bourgeois of other provinces, landlord peasants, and servants had to pay a fee for their stay in the hospital (7 rubles 50 kopecks per month). Thus, "Board medicine" was intended to serve the needs of the official and merchant strata of the 18th-century city. By this time, the nobility had already begun to use the help of private practitioners primarily. Regarding the service of the rural population, there are some hints in the decree of 1765, when, in order to fight epidemics, city doctors were ordered to "travel to villages near cities" to eradicate various diseases. The rural population used the hospitals of the Boards of Public Charity only in cases of severe injury, poisoning, etc., especially since the aforementioned monthly fee, which was charged in full even in the case of staying in the hospital for a few days, was high for them. Simultaneously with the Boards, the positions of district doctors were established, and under Paul I in 1797, medical boards were established in all provincial cities (except for both capitals), which were also charged with the duty of taking care of organizing medical aid to the population. Thus, the beginning of the fragmentation of the organization of Health Care was laid again. Nevertheless, the 18th century made significant shifts in the matter of providing the country with medical assistance. If at the beginning of the 18th century there were only up to 150 foreign doctors and healers, then by 1802 there were 1,519 doctors in total. Of these: 422 in the army, 218 in the navy, and 879 in medical boards, quarantines, and hospitals. How many private practitioners there were in addition, and whether there were any, is not indicated in the ministry's report. At the end of the 17th century, there was not a single hospital, while at the end of the 18th century, there were 13 land and 7 naval military hospitals alone. The number of civilian medical institutions was already significant. There were 2 pharmacies at the end of the 17th century, and 14 at the end of the 18th century. Some understanding of the state significance of Health Care and the need to give it an appropriate place in the general system of administration is outlined at the beginning of the reign of Alexander I, who in 1803 approved the report of the Minister of Internal Affairs "On the New Formation of Medical Administration." Pointing to "two essential connections of medical science with general state administration, namely: 1) in relation to public health and 2) in difficult cases regarding civil and criminal matters," the Minister of Internal Affairs concluded that "in every well-ordered state there must be a medical administration and that therefore, instead of the Medical College, which is subject to abolition, a state medical board should be formed, which would consist of a medical council and an expedition managing current and economic affairs in the medical part. Persons who have acquired their fame through their merits in science should be appointed to the medical council, as only such persons can be true judges in medical matters of state importance." The influence of the famous "father of medical police," Johann Peter Frank, was also evident in the development of this project. The Napoleonic wars, which economically shook the country, and the government's reaction also affected the cause of Health Care. Instead of an independent main administration, we find a medical department within the Ministry of Police, with the director of the department not being a doctor. In 1819, the Ministry of Police was joined in its entirety to the Ministry of Internal Affairs. In 1829, all matters concerning the medical part, which had previously been under the jurisdiction of spiritual affairs and public education, were transferred to this ministry. According to the statute of 1836, the medical department consisted of three sections and a secretariat, and its functions were reduced to government medical and sanitary supervision, which over time turned into bureaucratic guardianship. The police-serf system of the Nicholas era swept away all the broad goals of organizing medical affairs and reduced them to the simplified function of providing medical assistance to certain strata of the population through the efforts of the relevant department. That is why in the 1840s, the organization of Health Care appears even more fragmented. Medical affairs, in part, besides the Ministry of War, are also found in the Ministry of Finance, the Ministry of Public Education, the Main Administration of Railways and Public Buildings, and the Ministry of State Domains. The latter concentrated the organization of medical assistance to state and appanage peasants, as well as the Bashkirs of the former Ufa and Orenburg provinces. By the time of the fall of serfdom, this organization consisted of about 900 paramedic stations with about a hundred (approximately) reception rooms, which had a total of about 300 beds. There was one to three or more volosts per paramedic station. There was also a small number of midwives and quite a few smallpox vaccinators from among the peasants. The paramedics were under the purely formal control of district doctors, one for every 3-5 uyezds. In the provincial city, there was a senior doctor who supervised the medical part in the province.

The insignificance of the network and the primitive training of feldschers determined the extremely low quality of medical aid provided to state peasants. Medical aid was no better organized in the departments of military settlements, foreign colonists, and Jewish farmers of the Kherson Governorate. As for serf peasants, only in exceptional cases did a few landowners maintain feldschers and, even more rarely, doctors with hospitals for them. The village was entirely left to folk healers and midwives. In factories and plants, medical aid was encountered extremely rarely. It was provided for by law only in the Mining Regulations of 1806 and was concentrated in the mining department of the Ministry of Finance, which organized relatively satisfactory hospitals only in the Perm Governorate. The beginning of medical service for workers was laid, as indicated above, with the development of state industry under Peter I, when a decree of 1724 ordered the establishment of a physician with medicines at the Sestroretsk plant. Under his successors, the matter received further development and a certain regulation. Under Catherine I, on the initiative of the head of the Ural plants, Henning, a hospital was established in Yekaterinburg for the treatment of craftsmen and workers, which is apparently the oldest of the factory hospitals. In 1734, at the request of the ordnance office, the Medical Chancellery appointed physicians to the Tula plants. The Factory Statute of 1735, compiled by Tatishchev, already definitely prescribes "to treat the sick, for which doctors of medicine, physicians, an apothecary, and necessary servants are to be maintained from our factory treasury." At the same time, during the time of using the hospital, half of the salary and provisions were withheld from craftsmen and piece-workers, not counting a constant deduction for medicines in the amount of 1%. However, the organization of the hospitals was extremely primitive, and the network was negligible in its size. During the time of the "constitutional" projects of Alexander I, a new trend is noticeable in the field of providing medical aid to workers. In the explanatory note of the Ministry of Finance to the draft of the Mining Regulations (1806), it is noted that "hospitals were previously established only at the main plants, and the transfer of sick people to them from remote plants usually caused death." In view of such an unsatisfactory state of medical aid, the Mining Regulations prescribed the establishment of hospitals and physicians at them at every plant, both state and private, with the expectation that the entrepreneurs themselves, "in the interests of philanthropy and their own," would meet the concerns of the state power halfway. "All plant owners are obliged to have a hospital at each plant on the same basis as such are established at state plants." Regarding the latter, the Mining Regulations of 1806 required that at each hospital there be at least one physician and several medical apprentices depending on the number of workers, that each hospital be supplied with surgical instruments, and be kept clean and tidy; the physician attached to the hospital was obligated to examine the sick twice a day, etc. According to the Mining Regulations, almshouses were to be established in each plant or one for two or more plants lying at short distances from one another (see Social Security). If at state plants these requirements were fulfilled half-heartedly, so that by the 1860s there were 18 doctors at 13 hospitals, then private plants completely neglected the government's appeals to their philanthropy. The Nicholas government, which was dependent in its financial undertakings to strengthen the monetary system on the owners of plants and factories that began to develop widely in the first half of the 19th century, looked indifferently at the incredible exploitation that these industrialists were developing. The situation was especially deplorable at enterprises of the manufacturing industry. Only in a few of the largest establishments were there hospitals, to the maintenance of which the workers themselves were drawn by means of withholding 1-2% from their salary or monthly contributions of 10 kopecks in silver. The Nicholas government was forced to deal with this issue only under the pressure of worker unrest and direct riots in the 1830s, especially the Ural uprising of 1841. A Buxhoeveden commission was hastily created to examine the life of working people and to find means to improve their situation. The "gracious" monarch Nicholas I, at the end of 1840, while visiting city hospitals in St. Petersburg, noticed that the sick from the working class had an emaciated appearance. The commission, assuming that this was happening due to their poor housing and delays in providing medical aid, deemed it desirable to form a special guardianship committee. But the measures of influence of this committee did not go further than the Mining Regulations of 1806 and boiled down to "persuading factory owners, plant owners, masters, and contractors to treat workers and craftsmen humanely and conscientiously in all respects and especially in case of disease." However, by imperial decree, the obligation was placed on contractors to have apartments for workers that were "not damp and harmful to health," and police officials were ordered to strictly monitor that workers were accommodated as spaciously as possible and in dry apartments, and that the sick did not remain for long without proper help for the simple reason that they did not have the ability to pay the fee established in the hospitals of the Charity Boards. It was ordered to allocate special wards for workers, and the funds for this were determined from the workers themselves. By the regulation of April 16, 1842, a special levy was introduced on manual laborers of 60 kopecks in silver per year, for which contribution the worker acquired the right to use the hospital without any payment. At first, only one ward for 240 beds was created in St. Petersburg, but by the end of the 1840s, the number of the latter was brought up to 4,500. Subsequently, on similar grounds, a hospital for manual laborers was opened in Moscow (the former Yauzskaya), and in 1860 in Ivanovo-Voznesensk. The idea of the obligations of owners in relation to their workers in case of illness or loss of ability to work was expressed in the draft regulation on possessional factories (1845), but even in such a general form, it was not approved. The government was occupied with the implementation of other demands of both the owners of possessional factories and large landowners-manufacturers, and even the owners of huge estates with corvée cultivation. This was the demand for a free, voluntary worker, since serf and corvée "forced labor, by virtue of its low productivity, became a stumbling block on the paths of the country's industrial development." The Journal of Manufactures and Trade, starting from 1830, tirelessly convinced its readers that "any work in which coercion is the only spring will never be performed successfully." The labor of free-hired workers turned out to be much more productive and brought more benefit. However, high wages, which had to be paid to these free-hired workers, were unprofitable for plant owners, because these were not free peasants, but quitrent peasants, and the manufacturer was indirectly obliged to pay the landowner, under the guise of wages to the workers, a part of his land rent. Serfdom stood across the path of the development of the manufacturing industry. The secret committees of Nicholas I, under the pressure of the demands of industrialists, began to prepare a reform. Its implementation was accelerated by the catastrophe of the Crimean War, which exposed the entire rottenness of the serf system. However, the Alexander reform took place, on the one hand, under the sign of a compromise between the demands of the industrial bourgeoisie and liberal southern landowners, owners of corvée estates, and on the other, the demands of the large landowners of quitrent estates who enjoyed the greatest influence. The period before the October Revolution. Industry did not immediately receive a free, landless proletarian-farmhand; the peasants were left with a cut-down allotment with the appearances of an independent farmer, but in fact doomed to rent the lands of the nobility. The latter also won in the respect that, having freed itself from any obligations in relation to the free peasants, it received into its hands the administration on the ground, the disposal of finances and local duties, having received, by its property qualification, a guiding influence in the Zemstvos. They turned out to be the arbiters of the fates of the local population, and the function of caring for public health (see below - Zemstvo medicine) was also transferred to them, dictated by the needs of life and to a certain extent by the aspirations to provide medical aid to their estates at the expense of the peasants, and subsequently to improve the health of their districts. All the real activity of Zemstvo medicine is colored in the color of the interests of this landed aristocracy, benefiting the peasants only insofar as this is combined with the interests of the landowners. Just as in the village, so too in the city, the bureaucratic monarchy distributed its functions for caring for the population between commercial capital and industrialists. Into the hands of the merchantry and homeowners was transferred the care for the improvement of cities (see below - city medicine), and into the hands of industrialists from 1866, before the threat of a cholera invasion, at the petition of the Moscow governor, was transferred the care for the organization of medical aid to workers.

The numerous sanitary descriptions by Zemstvo doctors, which began in the era of reforms, painted an unsightly picture of the country as a continuous volcano of epidemics. The government's financial and tax system, which fell with all its weight on the peasantry, the impoverishment of the middle nobility, especially in the central provinces, the dispossession of the peasantry and its proletarianization undermined the last resources for the possibility of improving the country's health. Meanwhile, railway construction, strengthened ties with Western Europe due to the growth of grain exports, and over time, the penetration of foreign capital, could not but affect the government's attention to issues of the country's sanitary condition. Russia, with its incredible epidemic rate, was a dangerous neighbor. Another, no less important reason was that the development of industrial capital made serious progress in the 1880s, despite the crisis of 1884-85. An inevitable consequence of this was the development of workers' strikes, which in the 1880s ceased to be accidental and became a constant phenomenon of Russian life. The famous Morozov strike of 1885 began a new phase in the development of the labor movement. Under the influence of the mass strikes that had begun, the government, starting in 1882, issued a whole series of laws concerning the protection of the labor of minors, women, etc. A certain shift was also outlined in the matter of reforming the organization of Health Care, and a curious project was born to create an independent Main Administration of Health Care. The fact is that the sanitary legislation of Western European countries in the 1880s had reached, as indicated above, significant development, and the accidental meeting of Russian doctors with foreign colleagues received some response in government circles as well. In 1885, an international sanitary conference was held in Rome. Its central point was the report of the English delegate Thorne Thorne on the successes of improving the country's health through the development of a unified plan of broad sanitary measures. Three questions were discussed at it: 1) sanitary notification, 2) prevention of cholera, and 3) measures against yellow fever. The representatives of Russia were the ambassador in Rome, Ikskul-Gildenband, and Dr. Nikolai Eck. The report of the latter in the Medical Council, and especially the notes of the Italian and Netherlands missions regarding the obligations undertaken to implement the conference's resolutions, made an impression on the ruling circles, and a commission was created (1886) under the chairmanship of Botkin (see) to find measures for the universal improvement of health in Russia. The formation of this commission was preceded by a report by the same Eck on 5/XII 1885 on the topic: "On the extraordinary mortality in Russia and the necessity of improving health" at the Society of Russian Doctors in St. Petersburg. The Society unanimously accepted the speaker's provisions: "1) Death from the majority of diseases is a violent, not a natural death, and depends on the failure to take appropriate preventive measures indicated by science, the benefit of which has been proven by the experience of numerous cities and countries; 2) excessive mortality among the Russian population reduces its working capacity and brings the national economy to unprofitability; 3) increasing the working capacity of the population, and with it the well-being and enlightenment in our fatherland, is impossible without reducing mortality, and therefore reducing mortality and the nearest means to that—improving health—constitutes our primary state need; 4) bring this resolution to the attention of the Minister of Internal Affairs." In its report to the Botkin commission, the Medical Department stated that "since its founding, the science of public hygiene has gone far ahead, and in other countries, there are already entire legislations for the protection of public health and various kinds of extensive public institutions are being built. Since that time, the borders of the Russian state have expanded significantly, and the population has increased more than threefold; life has brought forward a multitude of new questions and needs regarding medical-hospital and sanitary matters. Meanwhile, the Medical Department, which should have been in charge of the expanded, changed new matters of protecting public health, has not undergone any significant changes and, just like the medical charter, is already proving to be behind the demands of science and the needs of the population." It is necessary to establish a Main Administration for Health Affairs, under whose jurisdiction all sanitary matters would be concentrated, which would be authorized to spend the credits intended for this kind of business, to carry out actual supervision over local sanitary institutions, to take by its own authority all general administrative measures necessary for the operation of existing and future laws on the protection of public health. If the government does not have such an organ, then it can neither know sanitary needs nor manage sanitary affairs. Society in its initiatives to improve sanitary conditions has so far been acting in a disjointed manner, and it will continue to go in the same direction until there is a unifying competent center. Only then will society cease to be indifferent to epidemic morbidity and excessive mortality, cease to act in a disjointed manner and waste its funds in vain on a fruitless struggle with numerous diseases. All local sanitary bodies subordinate to the Main Administration for Health Affairs or those that are to be placed in defined relations to it must not be limited only to reports about sanitary shortcomings and the powerlessness of supervision, as is observed now, but they must be authorized to take sanitary measures and constantly, from year to year, certify not negative, but positive facts of the improvement of sanitary conditions. Only then will the population be convinced of the possibility of lowering morbidity and reducing mortality. Provincial and regional government sanitary inspectors and their assistants must be subordinate directly to the Main Administration and must be completely independent of the numerous local administrations of various departments: police, factory, educational, religious, railway, steamship, municipal, and others." If the representative of the Ministry of Internal Affairs reduced all measures for improving the health of Russia to the creation of an influential central bureaucratic organ—the Main Administration for Health Affairs—then within the bowels of the commission itself, one of its most competent members, Dobroslavin, expanded these measures further. He also believed that "without the reorganization of medical-sanitary institutions in Russia, it is impossible to do anything to improve the sanitary situation of the population, it is impossible even to reason about it due to the complete absence of data on which such reasoning could be based." Dobroslavin, drawing as his ideal the creation of an organ analogous to the German Reichsgesundheitsamt, puts forward the following causes of the country's difficult sanitary state that are subject to change: 1) a shortage of doctors in general; 2) the absence of a proper organization for collecting information about the health of the population; 3) the abnormal organization of the sanitary structure of the administration; 4) the absence of funds for the implementation of measures possible even under existing conditions; 5) the shakiness of convictions regarding the path along which, even when possessing funds, sanitary measures should be directed. The Botkin commission decided to obtain the conclusions of a whole series of figures in public medicine (Zemstvo, municipal, factory, district), having sent its resolution to them. From the number of responses received from the localities, two are especially curious: one from the famous figure in labor hygiene, Pogozhev, and the other, signed by Erisman and Osipov, but reflecting the opinion of a whole group of Zemstvo doctors of the Moscow provincial Zemstvo. Pogozhev generally agreed with the opinion of the commission. In defining the competence of the central organ, he went even further than its opinion, declaring that the Main Administration for Health Affairs, by virtue of the extraordinary importance of its administrative-state tasks, should be assigned the rights and name of an independent Ministry of Public Health as the highest sanitary organ guiding the general course of all sanitary-medical affairs in the empire. It should not be constrained by any narrow frameworks in its activity, but, on the contrary, should with all its might facilitate the successful and non-burdensome implementation of various kinds of health-improving works for the population, the correct organization and maintenance of medical-statistical records, strict universal sanitary supervision, provide state credit for sanitary measures to the most needy localities, convene and authorize local and regional congresses of doctors, organize advisory-technical commissions on special sanitary issues, appoint prizes and competitions for the compilation of the cheapest and most expedient projects and drawings for sanitary and public institutions, etc. Pogozhev also raised the question of the general improvement of the entire medical organization, such as, for example, increasing the number of medical personnel, standardizing the areas of activity of Zemstvo, government, and other doctors, in terms of space and the number of inhabitants, weakening the independent uncontrolled practice of paramedics, ensuring the livelihood of doctors and other medical employees, reducing the cost of medicines, and abolishing the pharmacy monopoly.

However, regarding the scope of duties and sphere of influence of local government bodies, Pogozhev assigned them a narrow role as merely an intermediary link between the highest sanitary authority in the empire and local self-government bodies in all matters concerning the preservation of public health. The entire organization of medical-sanitary affairs should be given over to local self-government, and Zemstvo and municipal sanitary institutions, which have a more or less established organization in various regions of Russia (the Moscow provincial Zemstvo and many others), should be granted fully independent status within the given province, unencumbered by any external formalities. It is not surprising, therefore, that representatives of the Moscow Zemstvo sanitary organization itself took a sharp stance in opposition to the Botkin Commission's project. Their objections are interesting as the credo of the ideologues of Zemstvo medicine. Erisman and Osipov, in their long letter, first of all rightly pointed out that the improvement of the sanitary condition of Russia can in no case be reduced to bare sanitary-technical measures, and even less so to merely refacing the facade of a non-viable bureaucratic organ—the Medical Department. The general conditions of the country, its economic backwardness, and the ignorance of the population are to blame for the poor sanitary condition of Russia. Zemstvo doctors, through their numerous studies, established the dependence of the population's health on its economic situation. Consequently, reforms for the improvement of Russia's health must be of a deeper and more organic nature. Outside of and without them, the situation will not change, whether the officials of the autocratic government act on behalf of the department or the Main Administration. In the latter case, it would even be worse if the number of supervising and controlling government doctor-officials increases, when, on the contrary, a large number of public-spirited doctors are needed—direct executors and creators, free from the shackles of formalities and state tutelage. The Moscow Zemstvo members therefore requested to limit the competence of the already existing lower-level government agents, who often hinder the fight against epidemics and the implementation of health-improvement measures. They pointed out that, for example, district doctors should be left only with forensic medical expertise. Osipov and Erisman do not view with particular enthusiasm the idea that, with the organization of a Main Administration for Health Affairs, the entire business of protecting public health will be in the only competent hands, i.e., those of doctors. They point out, relying on the experience of Zemstvo work, that even Zemstvo doctors are far from always at the level of understanding the tasks of public health and the prevention of diseases, but on the contrary, Zemstvo representatives help to implement health-improvement measures. Therefore, the solution is not a new bureaucratic medical department, but the expansion of the rights of the Zemstvo and Zemstvo doctors. Erisman and Osipov only emphasize that even at the present time, without reform, the Medical Department could, if it wished, cope with the tasks of providing assistance to the cause of the Zemstvo sanitary organization. They consider it a priority for the department to concern itself with the reform of medical education, introducing future doctors to the nature and essence of health-improvement measures while still at the university. A correct and scientific organization of sanitary-statistical work is also necessary, which, incidentally, Dobroslavin and Pogozhev also insisted upon in their opinions. The projects of the Botkin Commission remained on paper: reviews were collected, printed, and the matter died out. Foreign pressure weakened, and the reaction of Alexander III reached its apogee. Here, the extreme contradictoriness and peculiarity of the 1880s manifested itself. The large landowning nobility became the arbiter of destinies, with a bureaucratic apparatus obedient to it. The inspirer of the latter was the obscurantist Pobedonostsev with his theory of the usefulness of popular ignorance. In defense of the foundations of "autocracy, orthodoxy, and nationality," the monarchy and the church were reunited. The People's Will movement, the intelligentsia movement of the raznochintsy and repentant nobles, was crushed: having no economic roots, it was inevitably bound to end this way. The labor movement was still young and unformed, just as the working class of Russia was young and dispersed. The Pobedonostsev clique pushed through the reactionary Zemstvo Statute of 1890, which granted even more influence to high-property-qualification elements in self-government. Thereby, the conditions for the deployment of systematic Zemstvo sanitary activity, and primarily for the implementation of health-improvement measures, were worsened. However, from the beginning of the 1890s, that industrial upswing of Russia took place, which developed incessantly until the first third of the first decade of the 20th century, and in connection with which the 1890s have many of the most striking examples of organized action by the working class. Thanks to this, although bit by bit, further factory Health Care was won, and medical-sanitary work in cities developed. On the other hand, the aggravated crisis of agriculture caused the ruin of the peasantry and its continuous unrest. Partly under the influence of this, and mainly because the government's patronage of the industrial bourgeoisie, which was growing in its demands, encroached upon the interests of the landowners, the 1890s were years of a peculiar landlord liberalism. By virtue of this, the 1890s passed under the sign of the expansion of Zemstvo medical activity: the Pirogov Commission for the dissemination of hygienic knowledge was created, the number of Zemstvo sanitary bureaus, sanitary doctors, and chronicles grew, many sanitary-statistical studies were conducted, and Pirogov congresses worked actively. Populist-minded Zemstvo doctors strove in their rural medical activity to fulfill the ideals of the enlighteners of the people, to fulfill the proud mission—"to modify the worldview of the people." This activity was inevitably combined with an understanding of the necessity of overthrowing the autocracy. The culmination point was the famous cholera Pirogov Congress of 1905 with its political resolutions, demands for a Constituent Assembly, political freedoms, and universal, equal, and secret suffrage. Constituting a general part of the radical intelligentsia movement, Zemstvo doctors, just like the entire Zemstvo movement, experienced their apogee with the revolution of 1905. Political class myopia deprived Zemstvo doctors of the ability to understand the significance of the labor movement, the role of the working class in the cause of social development, and in particular in the cause of Health Care. In their continuous, often fruitless, and energy-draining struggle for one medical initiative or another, the Zemstvo doctor involuntarily became imbued with the psychology of the sole "intercessor" and "advocate" for the people, having appropriated for himself a mandate, issued by no one, as a representative of this "poor, suffering people." In the very understanding of the tasks of organizing Health Care, they also failed to divine its true paths. The historical conditions of Zemstvo activity forced sanitary bureaus to take on the functions not only of sanitary affairs but also of organizers of medical affairs in general, a kind of unofficial member of the board. Hence, along with the theory of mutual opposition and dualism of sanitary and treatment organizations, there also appeared the theory of the hegemony of the former. However, in the last years before the imperialist war, divergences in views on the role of the sanitary organization also began—the well-known disputes about the sanitary-social and sanitary-technical directions. The reaction after 1905, having, firstly, caused devastation in the ranks of Zemstvo activists (exiles, loss of positions), and secondly, having transferred the Zemstvo economy into the hands of already undisguised "bison," who replaced the liberalizing nobles of the late 1890s, also broke Zemstvo medicine. Its forward movement, although it did not cease (expenditures over the decade even doubled from 24.6 to 48.3 million), the pace significantly decreased compared to the previous decade, both in terms of the growth of Zemstvo districts, hospitals, and the influx of Zemstvo doctors. Capitalist development led to the emergence of other factors. Along with the growth of industry, the working class became more numerous, European technology led to a greater concentration of workers in one enterprise; the growth of the working class led to the development of the labor movement, which, in connection with the influence of Russian social democracy and especially the Bolshevik wing on it, early on freed itself from narrow economic demands and took on a deeply political character. Strikes and unrest of the early 1900s, besides economic demands to the owners, also bore a clearly anti-government character. The unsuccessful Russo-Japanese War, peasant unrest, and workers' strikes, which ended with the events of January 9, 1905, forced the government to announce impending reforms in the form of a consultative Duma. At the same time, among other initiatives, a revision of the laws on the status of workers was planned. As a result, a successive series of senatorial commissions arose, starting with the Shidlovsky Commission and continuing until the end of the days of the Third State Duma.

One of the main issues for these commissions was the question of providing medical assistance to workers, which was at an extremely low level, and the payment of benefits to sick workers. If the first commissions, under the impression of the revolution, tried to place as much responsibility as possible on entrepreneurs in terms of financing, the size, and the duration of temporary disability benefits, the situation changed sharply with the era of the Stolypin reaction. The industrialists, who had raised their heads and by this time created large associations such as "Produgol" and "Prodamet" and strengthened their influence on the government through a number of banks, resolutely refused the obligation to maintain medical institutions, agreeing only to a very insignificant participation in insurance contributions, while retaining, however, great influence in the management of sick funds (see). The Lena events forced the government to accelerate the passage through the Third Duma of the 1912 law on social insurance (see). This law did not satisfy the factory owners, and for the workers, it was even a step backward compared to the outdated law of August 26, 1866. Only the protection of the pre- and post-natal period for female workers was a certain achievement of the new law. On the other hand, industrialists were freed from the obligation to provide workers with the possibility of inpatient treatment. The obligation for the industrialist to provide workers with initial and outpatient assistance could be reduced to a fiction due to the fact that the issued rules regulated the nature and size of this assistance in the most vague terms. The Zemstvos, meanwhile, could not organize medical assistance for workers because they did not receive any funds for this; the existing network was insufficient even for helping the rural population, and in terms of its location, size, and qualifications, it did not correspond at all to the needs of the workers. The sick funds created by the new law were financially weakened by the transfer to them of a significant share of the industrialist's monetary obligations. On the other hand, their attachment to individual enterprises, which increased their dependence on the entrepreneur, the composition of general meetings, and especially the boards of the funds, in which too many seats were given to representatives of the entrepreneurs, and administrative tutelage did not give the sick funds the opportunity to organize medical assistance, reducing their activity in this direction to pitiful penny-pinching. Thus, the maximum demands of revolutionary social democracy in the field of health protection, which at that time amounted only to ensuring free and qualified assistance for workers and maternity insurance, remained an unattainable ideal even after the 1912 law. It only created, in the form of sick funds, an initial school of class consciousness, a school of organization for the working class. This is how the Bolsheviks viewed it, striving to find in the insurance funds legal strongholds for their work on the further consolidation of the labor movement and the preparation of the proletariat for its revolutionary tasks. At the same time, the government was busy resurrecting the project of the Botkin Commission on the organization of the Main Administration for Health Affairs, which had been taken out from under the bushel. The incessant epidemics, of which cholera had become endemic to St. Petersburg, famines, and enormous infant mortality were indicators of the country's low sanitary level. The St. Petersburg bureaucracy found a recipe for improving the sanitary state of Russia in the creation of a new ministry. The project for the latter was entrusted to the commission of Professor Rein, whose merit is only a rather in-depth development, or rather, a collection of almost exhaustive materials on all issues of organizing medical assistance. In a whole series of subcommissions, norms for hospital and outpatient care, the areas of activity for doctors, and the organization of maternity and infant protection and even sanitary education were outlined. The Rein Commission's project singled out the management of health care into a separate department and provided for the allocation of special credits for the fight against infectious diseases and for general sanitary measures, but it did not bring the unification of the management of all medical affairs to a conclusion. For purely tactical reasons, the project preserved the existing medical organizations of other ministries, limiting itself only to giving the Main Administration of State Health Care general directive functions regarding health care. To establish contact with relevant government and public organizations, a Main Sanitary Council was established. These measures were a reflection of the policy of the Tsarist government, which, under the influence of the interests of the large financial and industrial bourgeoisie, entered the fairway of the influence of the future Entente, began to draw closer to England, and diligently prepared for war with Germany (the Guchkov Defense Commission in the Third Duma). In such an environment, the necessity was dictated to smooth over the dark reputation of being the epidemic center of Europe and to turn attention to raising the physical strength of the future cannon fodder. On the other hand, the reaction hoped that by creating authoritative government supervision and regulating the forms and methods of providing medical assistance from the center, it could finally constrain and reduce to a minimum those leftist tendencies of Zemstvo and municipal medicine that were still smoldering. It is not surprising, therefore, that the draft of the medical-sanitary reform of the Rein Commission met with even greater resistance from Zemstvo doctors than the Botkin project had in its time. The XII Pirogov Congress (1913) spoke out against the establishment of a Ministry of Public Health and any other similar bureaucratic central body, believing that "such an institution is inexpedient, harmful, and not called for by the interests of public health." In its resolution, the Congress stated the following: "The reform of the medical-sanitary structure, designed by the Rein Commission, which assumes the interference of local government medical-sanitary supervision bodies in the activities of local self-governments in the field of public health, the regulation from the center of the forms and methods of providing medical assistance, and which imposes on local self-government a whole series of mandatory expenses without indicating the sources for meeting them, while at the same time leaving the structure of local self-governments unchanged, not only does not ensure the success of health care but will be a serious brake on the paths of its development. For the correct and unimpeded development of medical-sanitary affairs, the Congress considers it necessary to carry out strictly democratic reforms in the organization of legislative institutions and self-government bodies." The Rein project on the creation of a Ministry of Health was approved during the war (September 3, 1916) by order of Article 87 of the Fundamental Law, i.e., by its approval by the supreme authority with subsequent submission to the State Duma. However, the State Duma rejected the law. The tension caused by the war brought a significant deterioration in the organization of medical assistance and, in particular, undermined Zemstvo medicine. Everything went to serving the war, to numerous hospitals and infirmaries, sanitary trains, and medical-nutritional points for serving refugees, which were organized by the Zemstvo and City Unions in the person of their medical-sanitary departments. The latter worked a lot in the fight against epidemics by organizing a number of disinfection bases, infectious disease hospitals, etc. The war also paralyzed and brought to a pitiful level, for the same reasons, the activities of municipal medical-sanitary institutions. Public organizations that had arisen with the rise of the labor movement on the initiative of left-wing figures of the Pirogov Society with the funds of the liberal industrial bourgeoisie, such as the League for the Fight against Tuberculosis (see Tuberculosis) and the League for the Fight against Infant Mortality (see Protection of Motherhood and Infancy), also died out before they could flourish. The political-economic crisis that developed with the prolongation of the war also heavily affected the sanitary state of the country; the birth rate fell, and the mortality rate grew. The undermining of the nutritional conditions of the broad masses of the population, the deterioration of the housing situation, and the accumulation of refugee masses prepared favorable ground for the development of epidemics. The February Revolution, which placed at the head of the government classes closely connected with the bourgeoisie of the Entente and interested in continuing the war, did nothing to lead the country out of the crisis, but on the contrary, brought it to its highest limits. In the clearly adventurous policy of "continuing the war to a victorious end" and delaying the resolution of the land question, the Provisional Government, apart from a series of declarations, did not carry out any organic measures to improve the situation of the broad masses of the population. In the field of health care organization—with the general preservation of the existing administration without change—a Central Medical-Sanitary Council was convened in April 1917, in which representatives of the Zemstvos and Zemstvo medicine played a leading role. The Extraordinary Pirogov Congress of 1917, in its resolution on the issue of "the foundations of the sanitary-medical structure in liberated Russia," carried out its old views on the organization of health care—on reducing to a minimum the interference of government bodies in medical-sanitary affairs and transferring it entirely into the hands of numerous local organizations."

"The practical management of medical-sanitary affairs among the civilian population at the local level must be entirely concentrated in the hands of democratized zemstvos, cities, and self-governing hospital funds, as appropriate, and for the purpose of coordinating their actions, a Central Council of representatives of public organizations must be formed under the Provisional Government. The administration of the Chief Medical Inspector, along with the medical-sanitary bodies of other departments, should be only an auxiliary body of the Council already formed under the Provisional Government. The liquidation of the local medical-administrative bodies of the old regime must be carried out by transferring their duties and functions to the jurisdiction of the medical-sanitary organizations of the zemstvos and cities." Inspired by the Provisional Government's appeal for the opinion of the Pirogov Congress on the issue of medical-sanitary organization in Russia, the congress demanded that the plan for permanent public health care organizations, which was to be developed later by the central medical-sanitary council, be submitted for its consideration. Without giving any clear instructions or guidelines in the field of organizational issues of health care, the Pirogov Congress at the same time bypassed a number of fundamental problems, necessary prerequisites for a radical reform of medical-sanitary affairs, namely the issues of land, labor protection, and raising the nutrition of the working class. On the issue of the war, the congress joined the appeal of the Petrograd Soviet of Workers' and Soldiers' Deputies to the peoples of the whole world with a call to act in solidarity for the struggle for peace and the brotherhood of peoples and called on the citizens of Russia, "as long as the war lasts, to mobilize all forces and to exert them to the maximum for the defense of the country and the gains of the revolution." And since the Provisional Government, the mouthpiece of these petty-bourgeois strata, was unable to resolve the fundamental questions of the revolution, it could do nothing in the field of reorganizing the cause of health care.

I. Strashun. Zemstvo medicine was a medical-sanitary organization maintained by Zemstvo self-government—the Zemstvo—and serving mainly the peasant population. Having grown on the basis of the socio-economic conditions of the Zemstvo era, Zemstvo medicine reflected all the contradictions of the economic development of Russia in the 19th and early 20th centuries: a combination of progressive, growing capitalist forms of economy with still quite viable and significant remnants of the feudal-serf system; the dominance of groups of the nobility in the entire state apparatus alongside the ever-growing claims of the developing bourgeoisie to participate in state administration; and the ever-developing movement of the working class and the destitute masses of the peasantry. The peculiarity of the organization and development of Zemstvo medicine was conditioned by a number of socio-economic factors: the noble Zemstvo was directly interested in preserving the tax-paying capacity of the peasant economy; landowners, striving to increase grain exports, and factory owners, seeking cheap labor, naturally had to take care of at least some minimum of medical-sanitary service for the peasantry, which ensured a constant influx of healthy labor. The peasantry, destitute and uncultured, representing fertile ground for the spread of epidemics that hindered trade with the West, especially grain exports, needed a certain organization of medical aid of a public nature, especially since the living conditions of the peasantry could least of all attract private practitioners to the village, who were generally very few. And the nobility itself received certain benefits from the opening, at the expense of the Zemstvo, of medical-sanitary institutions near their noble estates, which guaranteed them to some extent against the danger of the spread of epidemics. But the steps taken by the Zemstvo in the field of organizing medical aid were very indecisive, and only those measures were carried out that were prompted by extreme necessity and did not contradict its class interests. The construction of Zemstvo medicine was influenced by the economic situation and public sentiment, especially the revolutionary movement. The beginning of the emergence of Zemstvo medicine dates back to the time of the introduction of the 'Regulations on Zemstvo Institutions,' issued in 1864. According to this regulation (Art. 2), the Zemstvo was entrusted with 'care, within the limits defined by law and primarily in economic terms, for public health.' But this care for public health was classified as one of the non-mandatory duties of the Zemstvo. The law obliged the Zemstvos only to maintain the institutions of the former Boards of Public Charity transferred to them and to take measures to organize smallpox vaccination. According to the 'Regulations on Zemstvo Institutions' issued in 1890 (Art. 2), the Zemstvo in the field of public health was entrusted with: 'management of Zemstvo medical and charitable institutions, care for the relief of the poor, incurable patients and the insane, as well as the orphaned and crippled, participation in measures to protect public health, development of means of medical aid to the population and finding ways to ensure the sanitary condition of the area, as well as participation in veterinary-police measures.' The Medical Charter, issued in 1905 (Art. 641), also refers to the subject of the jurisdiction of Zemstvo institutions 'participation in measures to protect public health and the prevention and cessation of contagious and epidemic diseases in animals, the development of means of medical aid to the population and finding ways to ensure the sanitary condition of the area' within the limits indicated by the regulations on Zemstvo institutions, the medical charter, and other statutes. There was no precise regulation of the duties of the Zemstvos to provide medical aid to the rural population. It is worth noting the fact that a Senate clarification in 1910 established that it was not mandatory for Zemstvos to admit contagious patients if there was no contagious ward in the Zemstvo hospital. When assessing the work done by the Zemstvo in the field of health care, it is necessary to take into account the social structure of the Zemstvo and its class composition. The organization of the Zemstvo was based on the estate-census principle, i.e., belonging to a certain estate and owning more or less large land property or other property, and the process of electing Zemstvo deputies ensured a preponderance in Zemstvo institutions of nobles, landowners, and officials (see table). The predominance of the influence of the class interests of the nobility is even more clearly visible from the composition of the district and provincial Zemstvo boards, which actually managed the entire Zemstvo economy, including medical-sanitary affairs. The peasants who were part of the Zemstvo self-government bodies, according to their census, belonged to the upper layers of the peasantry or the group protecting the peasantry, connected with the entire administrative-police apparatus—volost elders, assessors, judges, village headmen, etc. As can be seen, the overwhelming majority in these bodies consisted of the nobility, merchants, officials, and kulak groups of peasants. It should be borne in mind that the composition of the Zemstvo boards was approved by the governor. For all that, fearing the manifestation of progressive tendencies in the work of Zemstvo self-government, the government, which had severely limited its rights in the 1864 regulation, curtailed its rights even more in the 'Regulations on Zemstvo Institutions' of 1890. Administrative tutelage over the Zemstvo extended to the point that even decisions on issuing loan subsidies for the fight against contagious and epidemic diseases were subject to approval by the Minister of Internal Affairs. In the words of Lenin, 'the Zemstvo was from the very beginning condemned to be the fifth wheel in the cart of Russian state administration, a wheel permitted by the bureaucracy only insofar as its omnipotence was not violated, and the role of deputies from the population was limited to bare practice, simple technical execution of the range of tasks outlined by the same bureaucracy. The Zemstvos did not have their own executive bodies, they had to act through the police, the Zemstvos were not connected with each other, the Zemstvos were immediately placed under the control of the administration, and, having made such a harmless concession to itself, the government, on the very next day after the introduction of the Zemstvo, began to systematically constrain and limit it.' Prohibitory circulars in various areas of Zemstvo work followed one after another—in this regard, the laws on the fixation of Zemstvo budgets, restrictive rules on Zemstvo book publishing, the normal charter of 1901 for provincial Zemstvo medical-sanitary congresses, which placed the latter in complete dependence on the governor, the prohibition of inter-Zemstvo agreements on joint petitions, the suspension by imperial command of statistical surveys in 12 provinces (after agrarian unrest in the Poltava and Kharkov provinces), and the restrictive rules of 1903 on sanitary-executive commissions for the fight against cholera and plague, according to which the Zemstvo was deprived of the leadership of this matter, are of particular interest. These prohibitions were a response to the so-called Zemstvo movement, in which progressive layers of Zemstvo figures took part. The development of the Zemstvo medical-sanitary organization was conditioned not only by the degree of power of the Zemstvo economy but also depended to a significant extent on the composition of the Zemstvo and reflected the fluctuations in the moods of the Zemstvo members, which in turn were the result of changes in the economic and political conditions of the country. When the revolution of 1905 was defeated, the reactionary elements of the Zemstvo, especially under the influence of the agrarian unrest of that time, moved even further to the right. Allocating significant sums for the organization of the police guard and waging an active struggle against the peasant movement (e.g., the Voronezh, Kherson, Kursk, and Yekaterinoslav Zemstvos), a number of Zemstvos at the same time closed bookstores, liquidated agronomic and sanitary organizations, and mercilessly dismissed from service all those suspected of political unreliability. In 1906, Zemstvo sanitary bureaus were destroyed by the following Zemstvos: Pskov, Tver, Simbirsk, Samara, Vyatka, and Yaroslavl. The following Zemstvos completely liquidated their sanitary organizations: Voronezh, Kursk, Tula, Saratov (restored the sanitary organization in 1909), Yekaterinoslav (restored in 1908), and Ufa (restored in 1909); the Saratov, Voronezh, and Yekaterinoslav Zemstvos dismissed all sanitary doctors. The Kharkov Zemstvo reduced the number of sanitary doctors from 11 to 3; 13 Zemstvos decided to abolish or stop appropriations for sanitary and epidemic organizations.

Statistics were abolished in the Bessarabian, Vyatka, Kursk, Novgorod, Saratov, Samara, and Olonets Zemstvos; even the Moscow Zemstvo significantly reduced appropriations for statistical work. The Zemstvo received from the 'Boards of Public Charity' their so-called 'capitals,' about 8 3/4 million rubles, although the sizes of these sums varied greatly in different provinces (ranging from 55 thousand in Ufa Province to 503 thousand rubles in Oryol Province). Initially, a significant number of Zemstvos maintained the wretched medical network inherited from the Boards of Public Charity using interest from the very capitals received from them, adding nothing from their own budgets, but later, as the work of the Zemstvo developed and the demands and requests of the population regarding the provision of medical aid grew, the Zemstvos began to allocate certain sums for the needs of health care. In the 1870s, these sums were for the most part very small (for example, in 1868 only 1.2 million rubles were appropriated; 58 Zemstvos did not allocate a single kopeck in their budgets for health care), and for a long time the Zemstvos limited their concerns for public health to paying some additional remuneration to district government doctors (who, even as late as 1890, still made up about 15% of all Zemstvo doctors, working concurrently in Zemstvo service) for performing additional functions assigned to them by the Zemstvo, such as managing the city hospital and supervising the activities of paramedics and smallpox vaccinators, the so-called 'volost smallpox vaccinators,' most of whom received remuneration for their work from the peasants themselves. A number of Zemstvos did not have their own doctors until the end of the 1870s and even the beginning of the 1880s. A number of Zemstvos petitioned for the establishment of a special hospital tax on migrant workers. The Zemstvos, avoiding large expenditures on health care in every possible way, tried to shift the expenses for medical aid onto the peasantry: they charged fees for consultations and medicine, introduced special medical taxes, etc. It is noteworthy that the principle of charging for medical aid was applied by the Zemstvo until the very last years of its existence; the abolition of fees charged to peasants for hospital treatment began only from the second half of the 1880s, with the 'indigent' being exempted from payment first, and then all patients of their district. The daily fee ranged from 5 to 40 kopecks. In 1904–05, fees were charged mainly in district city hospitals and, moreover, from residents of other districts. In provincial Zemstvo hospitals, a fee of 6–12 rubles per month per patient was charged, with the corresponding district Zemstvos paying the fee, which they were then supposed to collect from the patients. Paid inpatient treatment was widespread in the Yaroslavl, Oryol, Vladimir, Poltava, Samara, Chernigov, Ufa, and Pskov provinces. Regarding the abolition of fees for outpatient care, the Zemstvos showed less flexibility. Already from the end of the 1870s and especially in the 1880s, the Zemstvos began to widely practice charging fees for 'consultations,' 'medicines,' 'prescriptions,' 'containers,' etc. In 1890, fees for outpatient treatment existed in various forms in 99 Zemstvos; in 1898, they still remained in 69 Zemstvos, and were collected in the amount of 5–10 kopecks per consultation and medicine. Some Zemstvos introduced special taxes for medical aid. Until 1876, exemption from payment was conditional upon the presentation of police certificates of poverty, and later, upon special permission from the board in each individual case. When, in later years, doctors were finally granted the right to exempt patients from payment at their own discretion, this right was still limited by various conditions, for example, that the number of free prescriptions should not exceed 10% of the total number of prescriptions issued. 62.J For many years, in the interests of economy, the Zemstvos invited paramedics into their service, who were granted the right to independently treat patients. The paramedics were stationed at various points in the district; occasionally, these paramedic stations were visited for the purpose of supervising their activities by traveling Zemstvo doctors, of whom there were very few. In the first decades of the Zemstvo's existence, Zemstvo figures held the view that the 'common people' usually had 'simple' diseases, that the paramedic was supposedly closer to the population, i.e., that 'the doctor is a gentleman's healer, and the paramedic is a peasant's healer.' Even the more progressive Moscow Provincial Zemstvo held the opinion at the beginning of its activities that 'in general, peasants like to be treated at home and that one only needs to provide the doctor with a clean hut for receiving patients, arranged in the simplest way, since peasants always prefer to live in a simple hut and remain in their own clothes, avoid well-appointed rooms equipped with conveniences..., and the establishment of a real hospital will only entail unnecessary expenses, while almost no one will willingly go to it.' The extent to which paramedical practice was developed in the Zemstvo can be seen from the fact that in 34 Zemstvo provinces, as late as 1910, there were 2,620 independent paramedic stations. The development of paramedical practice was closely connected with the so-called 'traveling system' of medical aid. Its essence lay in the fact that the Zemstvo doctor, who lived in the city or in the district at an outpatient clinic, was obligated to travel around all the villages of the corresponding area at specified times to provide medical aid to the population or to visit paramedic stations for the same purpose. Since doctors also had to visit villages affected by some epidemic disease, travel at the invitation of sick residents, and upon the demand of judicial-investigative authorities, most of their time was spent uselessly on travel, especially in view of the large radii of the territories served. Due to the constant traveling of the doctors, it was difficult for patients to find them at home or even to know where to find them. Zemstvo figures for a long time did not reckon with the opinion of doctors and medical congresses regarding the inexpediency of the traveling system, believing that doctors supposedly wished to get rid of burdensome travel and were striving for a 'more convenient and quiet life' (resolution of the Kharkov Zemstvo Congress of 1881); the traveling system seemed to the Zemstvo members most rational due to its cheapness, most supposedly corresponding to the sanitary tasks—familiarization with the living conditions of the population (mere familiarization, of course, did not require large expenditures from the Zemstvo)—facing Zemstvo medicine, and it answered, in their opinion, the idea of so-called Zemstvo egalitarianism, i.e., the uniform service of those paying Zemstvo taxes. Medical congresses in the 1870s and 1880s demanded the abolition of the traveling system; the medical commission of the Poltava Zemstvo, as early as 1867–70, in its project for the organization of district medicine, which became historic, spoke out in favor of the stationary system. It should be borne in mind that only from the 1880s did progressive Zemstvos begin the construction of rural hospitals and reception wards, and the work of the Zemstvo in this area unfolded only in the 1890s. After a long and persistent multi-year struggle, the traveling system began from the 1880s to be gradually displaced by the so-called 'stationary system' of medical aid, under which the district was divided into a certain number of medical sections served by doctors living in a specific place, for the most part at the district hospital. An outpatient clinic for visiting patients, a maternity ward, and sometimes special infectious disease barracks were usually set up at the hospital. The district doctor, who provided outpatient and hospital care on-site, was obligated to travel to villages only in cases of necessity to provide emergency aid upon the appearance of epidemic diseases. In a whole series of Zemstvo provinces, a so-called 'mixed system' of providing medical aid existed, i.e., districts were divided into medical sections with hospitals and outpatient clinics in the center and with paramedic stations on the periphery, which the doctor was obligated to visit at specified times to receive patients and supervise the activities of these stations, or else the stationary system was applied in some parts of the district, and only the traveling system in others. By 1890, the exclusively traveling system remained in only 50 Zemstvo districts, in 46 there was only the stationary system, and in 258 Zemstvo districts there was the mixed system, while in 1900 the exclusively traveling system was preserved in only two districts, the stationary system in 138, and the mixed system in 219 districts. According to the law, the Zemstvos had the right to decide for themselves the question of attributing certain expenses to the account of the provincial or district Zemstvo. Provincial Zemstvos maintained provincial hospitals, psychiatric hospitals, paramedic schools, and schools for midwives, and partially bore the expenses for combating epidemics and appropriated certain sums for organizing congresses of Zemstvo doctors. District Zemstvos covered the expenses for maintaining the network of medical institutions in rural areas and in district cities, and also, to a significant extent, bore the expenses for combating epidemics. As for smallpox vaccination, in some provinces it was under the jurisdiction of the provincial Zemstvos, and in others, under the jurisdiction of the district Zemstvos. Provincial or district Zemstvos worked independently of one another until almost the end of the 1880s, and only in some provinces was close cooperation in work established between them. An interesting example in this regard was provided by the Kherson Provincial Zemstvo, which, as early as 1874, began to provide subsidies to district Zemstvos in the amount of 1/3 of their expenses for medical aid.

In the majority of provinces, a closer connection between provincial and district zemstvos in the matter of medical-sanitary service for the population began to be established from the beginning of the 90s. In 1868, zemstvos spent 8.3% of their budget on medical aid, and 5.1% on public education; in 1871, the corresponding figures were 13.2% and 7.7%; in 1880—17.9% and 14.3%; in 1890—21.2% and 15.3%. In 1901, the majority of provincial and district zemstvos spent about 1/4 to 1/3 of their budget on medical needs. Five zemstvos spent over 1/3 of their budget: Penza (40%), Poltava (33.4%), Tambov (37%), Tver (35%), and Smolensk (34%). The provincial zemstvos that spent the least were Vyatka (10%), Saratov (14%), and Kharkov (13%). In 1910, about 28.1% of the entire budget (48.3 million rubles) was spent on zemstvo medicine, and 24.9% on public education. In 1912, expenditure on zemstvo medicine according to the estimates of 34 zemstvo provinces constituted 26.2% of the entire zemstvo budget (57.7 million rubles), and on public education—30.2% of all zemstvo appropriations (about 66.5 million rubles), i.e., for the first time in the entire existence of zemstvo medicine, expenses for it were less than expenses for public education. All zemstvo expenses in 1912 in 34 zemstvo provinces amounted to 2 rubles 52 kopecks per capita, and in 6 new western zemstvo provinces—1 ruble 60 kopecks, with the amount per capita in the first provinces for health care being only 66 kopecks, and in the latter—38 kopecks; the corresponding figures for public charity were 4 kopecks and 3.5 kopecks; for public education—76 kopecks and 38 kopecks, and for veterinary services—7 kopecks and 3.6 kopecks. The growth of zemstvo estimates (in thousands of rubles) over the last two decades of the zemstvo's existence can be seen from the following table. Growth of zemstvo estimates (in thousands of rubles) over the last two decades of the zemstvo's existence: Expenditure items: District zemstvos, Provincial zemstvos. For the maintenance of doctors: 17.2, 17.4. For other personnel: 20.6, 14.5. Medicines: 0.7, 13.0. District hospitals: 1.9, 0.9. Provincial hospitals: 13.8, 8.2. Rural medical hospitals: 3.1, 7.9. Outpatient points: 0.1, 28.3. Epidemic needs: 31.2, 2.8. Total: 0.1, 4.6, 13.7. The zemstvo accepted from the Boards of Public Charity 351 medical institutions: 32 provincial hospitals (with 5,150 beds) and 319 district ones (6,431 beds), in which there were 11,581 authorized beds, including 10,414 somatic and 1,167 beds for the mentally ill. All these medical institutions were in a very deplorable state regarding their layout, equipment, and maintenance, not meeting the most elementary requirements of sanitation and hygiene. In addition, in the rural territory of 34 zemstvo provinces, there were 791 feldsher points and 84 receiving wards with 269 beds, a small number of midwives, and a fairly significant number of smallpox vaccinators from among the peasants. In 1870, there were only 530 medical districts in all zemstvo provinces, with 70 rural medical hospitals, serving only 7% of the entire area of the zemstvo provinces—within a radius of ten versts from the hospitals. In 1910, in all zemstvo hospitals of the 34 zemstvo provinces, there were 42,500 somatic beds, and in the six western zemstvo provinces—5,860 somatic beds (in 313 hospitals). Up until 1910, the number of independent feldsher points sharply predominated over the number of medical districts, and with the general growth of the network, a significant percentage of outpatient districts, a large average radius of medical districts, an extremely insufficient number of beds in hospital districts, and an insignificant number of doctors were observed the entire time. The growth in the number of doctors was strongly linked in many provinces to the appearance of epidemics, which prompted the zemstvos to increase medical personnel, who were then usually retained as permanent staff. How the growth of the network of medical districts and zemstvo district hospitals proceeded from 1870 to 1910 can be seen from the following table (data developed for the Dresden hygiene exhibition). Medical network: Years 1870, 1880, 1890, 1900, 1910. Number of medical districts: 530, 850, 1,200, 1,800, 2,800. Of them: Outpatient (25%), (27%), (30%), (29%), (24%). Hospital-based in rural areas (13%), (40%), (47%), (54%), (64%). Hospital-based in district towns: 326. Average radius in versts: 89. Population per medical district in thousands: 14.4, 14.8, 14.4, 13.2, 13.7. Number of villages per average medical district: 2.5, 3.4, 4.0, 4.8. Average number of beds per 1 medical district: 2.5, 2.6, 1.75. Number of beds per 10,000 inhabitants: 1.5, 1.8, 2.2, 2.8, 3.6. Number of independent feldsher points: 9,327, 16,544, 35,856, 25,314, 37.7. Ratio of the number of feldsher points to medical districts: 48,103.2, 42,882.4, 4,652.1. Number of doctors in the service of district zemstvos: 1,091, 2,011, 6,280, 2,980, 3,479.7. Of them in rural areas: 1.7, 2.2, 5.1, 2.4, 1.9. As for the size of zemstvo hospitals, a rural hospital had on average 13 beds, a district hospital—45 beds, and a provincial hospital—190 beds. There were large fluctuations in the nature of service in different zemstvo provinces; for example, Moscow province had a network of medical districts with a radius of 8.9 versts, with 14 thousand inhabitants per district, while in Vologda province the corresponding figures were 43.2 and 25.4, in Perm—28.4 and 30.8, in Ufa—26.3 and 52.4, in Vyatka—25.3 and 52.3, etc. The role played by zemstvo hospitals in 34 zemstvo provinces can be seen from the following table, the data of which refer to 1907. Hospitals: Quantity, absolute, %; Number of beds, absolute, %. Zemstvo: 2,034, 45.9, 58,160, 49.7. City: 148, 8.3, 20,743, 17.7. Factories and plants: 1,054, 23.9, 12,262, 10.5. Private and charitable: 442, 10.0, 8,776, 7.4. Railway: 176, 3.9, 1,554, 1.3. Educational institutions: 236, 5.3, 3,922, 3.4. Prisons: 237, 5.4, 3,704, 3.1. Total: 102, 2.3, 7,985, 6.8. When considering this table, it should be taken into account that 1/5 of all beds of city self-governments were located in Moscow and St. Petersburg; consequently, if one excludes this and almost the same number in some large cities, it becomes clear why the urban population in zemstvo provinces was predominantly served by zemstvo hospitals. For comparison, it is interesting to note that in 1910, in the six new western zemstvo provinces, there were 395 medical districts, of which 313 were hospital-based; in total, in all zemstvo hospitals of these provinces, there were 5,860 beds, and there were 558 independent feldsher points. In the entire former Russian Empire, there were 3,800 medical districts and 4,600 independent feldsher points in 1910. The share of all zemstvo provinces accounted for about 90% of all medical districts and over 80% of hospital beds available in European Russia and the Caucasus. The following table makes it possible to compare the degree of provision of zemstvo provinces with non-zemstvo ones in 1910. Regions: 34 zemstvo provinces, 6 semi-zemstvo provinces, Don Host Oblast, Caucasus, Astrakhan, Orenburg, and Arkhangelsk. Number of medical districts: 28,000, 42,000, 62,000, 73,000. Population per 1 medical district: 725, 2,970, 2,800. Area of average medical district in square versts: * (excluding uninhabited space). In 1910, no more than 30% of the area of the zemstvo provinces was actually served by the district network, and 48% of the entire area of the zemstvo provinces fell on inhabited but medically and sanitarily unserved spaces (zemstvo self-government was introduced on a territory equal to 55% of the entire territory of European Russia with a population constituting 3/4 of the entire population of European Russia and the Caucasus). Organizing medical aid, the zemstvos for many years had no plan.

Only at the end of the 1880s did isolated, sporadic attempts begin to develop a plan for a district network, and by the end of the 1890s, some zemstvos already had a plan for deploying medical districts, which was gradually being implemented. Provincial zemstvos, at the beginning of their activity, strove to improve and expand provincial hospitals received from the Boards of Public Charity, spending significant sums on their maintenance, thinking that in this way they would make medical aid more accessible to the peasantry. However, soon the greater part of the provincial zemstvos, under the pressure of the social upsurge of the 1890s and medical congresses, which proved that provincial hospitals served primarily the urban population of the provincial city and that the main task in the matter of bringing medical aid closer to the peasantry was the planting of a network of district infirmaries, began as early as the 1890s to reduce appropriations for the maintenance of provincial hospitals. As late as 1901, provincial hospitals absorbed more than 27% of all zemstvo expenditures on hospital affairs (excluding psychiatric hospitals). Rural hospitals accounted for only approx. 37% of all the indicated expenses, and 36% for the maintenance of hospitals in district towns. In 1910, about 3,600 thousand rubles were spent on provincial zemstvo hospitals. In the 1900s, the majority of zemstvos embarked on the path of decentralizing medical aid, reducing the number of authorized beds in provincial hospitals. On average in 1913, there were 202 authorized beds per 1 provincial zemstvo hospital, and 224 actually occupied. Provincial zemstvos, which had also received from the Boards of Public Charity homes for the mentally ill with 1,167 beds, mostly in the form of wards attached to hospitals, began from the 1890s, simultaneously with the reduction of provincial somatic hospitals, to expand and improve psychiatric care. Provincial zemstvos carried out a great deal of work on the organization of psychiatric care: they began to invite specialist psychiatrists (in 1897 there were 90 zemstvo psychiatrist doctors, in 1913 already 216), and to improve the management of affairs in psychiatric wards, which from the 1880s became independent psychiatric institutions in many cities. The staffs of psychiatric hospitals were highly insufficient; as late as 1913, there were 120 mentally ill patients per one doctor, and almost everywhere there was enormous overcrowding, while the zemstvos in 1896, according to the calculations of V. I. Yakovenko, were providing care and treatment to only about 7% of the mentally ill. In 1913, the zemstvos were providing care to less than 15% of the mentally ill, whereas no less than 45% of the mentally ill were in need of care. The number of psychiatric zemstvo beds grew from 1,167 in 1866 to 19,164 in 1904 and 23,500 in 45 zemstvo psychiatric hospitals in 1910. Zemstvos built many new psychiatric hospitals and colonies, in a number of cases with the help of government subsidies, of which about 17.5 million rubles had been given to the zemstvos by the mid-1890s. The size of this subsidy, according to the 1879 regulation of the Committee of Ministers, could amount to a sum not exceeding 50% of local zemstvo expenditures. It should be noted that as late as the mid-1890s, in the greater part of the zemstvos, a fee was charged for the maintenance of patients in psychiatric hospitals, on average about 6 rubles 50 kopecks per month; only in 12 provinces was no fee charged. In 1910, provincial zemstvos spent 10-20% of their budget on psychiatric care. The estimate of zemstvo expenditures for the maintenance of psychiatric hospitals in 1912 exceeded 7.5 million rubles. According to the law of December 5, 1912, 7/8 of the zemstvos' expenses for the care of the mentally ill were covered by the treasury. As for family care of the mentally ill, patronage, as early as 1872 the Ryazan provincial zemstvo proposed that relatives take non-dangerous patients for maintenance for a special fee from the zemstvo, but patronage did not develop there. In the 1890s, patronage was introduced in the Kursk, Moscow, Smolensk, and Yekaterinoslav provinces, where for the maintenance of a patient the zemstvos paid the peasants from 2 to 5 rubles per month. A number of provincial zemstvos issued grants to district ones for the construction of infectious disease barracks, disinfection chambers, and for the additional equipment of medical districts in the form of covering part of the expenses and issuing interest-free long-term loans. Loans were issued in some places (e.g., in the Moscow zemstvo) both for the construction of new zemstvo infirmaries and for the expansion and reconstruction of existing ones. Many provincial zemstvos (Kursk, St. Petersburg, Voronezh, Kharkov, Samara, Kostroma, Kaluga, Nizhny Novgorod, Tula, and others) were engaged in the organization of so-called inter-district medical units to serve those border areas which include parts of different districts that cannot use accessible medical aid from the existing or projected network of district medical infirmary institutions due to their remoteness. In 1913, there were 64 such inter-district units in 15 provinces (2.2% of the total number of zemstvo units) with 50 hospitals, with 840 beds (4% of the total number of beds in rural infirmaries of 34 zemstvo provinces), 78 doctors, and 180 paramedics (including 14 inter-district units of Moscow province with 460 beds). Only in 4 provinces were these units under the jurisdiction of the corresponding district zemstvos. As the district medical-sanitary network grew and its radius decreased, some former inter-district units already fell into the district network and, naturally, passed to the corresponding district. Expenses for the maintenance of inter-district units in some provinces were covered by provincial zemstvos, in others they were charged to the districts that used these units. Initially, zemstvos were forbidden to sell medications even at reduced prices; in 1872, zemstvos were permitted to dispense medicines free of charge only to the poor upon presentation of a police certificate of poverty, and in 1876, upon certification of poverty by a zemstvo doctor. Zemstvos were granted the right to open pharmacies only on general grounds, and only where there were no private pharmacies did they have the right to serve the population with pharmaceutical aid. In total, in 1905, the zemstvos had 159 district pharmacies with the right of free sale and 1 provincial one; 18 pharmacies of the indicated number were located in villages and posads. The distribution of pharmacies did not correspond at all to the actual need. A significant part of these pharmacies were opened in the 1880s-1890s. A whole series of medical congresses took a negative attitude toward the opening of pharmacies with the free sale of medicines, because these pharmacies pursued the goal of extracting profit and led to the development of self-medication through the dispensing of medicines in the order of over-the-counter sales. Some zemstvos practiced the wholesale purchase of medications. Provincial zemstvos concentrated in their own hands the entire business of the free supply of districts with therapeutic and prophylactic sera, while some zemstvos established their own bacteriological institutes (Saratov, Samara, Yekaterinoslav, Smolensk, Tula, Chernigov, Kherson, Ufa, Perm). A whole series of provincial zemstvos maintained special smallpox vaccination institutes or smallpox calf-lymph stations; the latter existed in 1913 already in 14 provincial zemstvos. For a long time, the zemstvo did not take upon itself the expenses for smallpox vaccination; it only supplied the detritus, while the vaccinators, initially poorly literate "smallpox-men," had to receive maintenance from peasant societies. With the passage of time, from the second half of the 1880s and especially from the 1890s, the zemstvos began to conduct smallpox vaccination at their own expense, attracting paramedics, teachers, midwives, and medical students to this work. In the 1900s, smallpox vaccination was already primarily in the hands of medical personnel, with district doctors exercising control over it. Provincial zemstvos concentrated in their own hands the supply of districts with detritus. - Midwifery aid was developed extremely weakly by the zemstvos. At rural district hospitals, maternity wards or rooms were encountered very rarely right up to the 1900s. The zemstvo usually set up midwifery stations in villages (in 1898 - 402). From the mid-1890s, zemstvos began to invite female paramedic-midwives into service. In general, there was no system in the development of midwifery aid among the zemstvos, with few exceptions (Vologda, Novgorod, Kharkov). Midwifery stations arose and closed randomly, no training of personnel was conducted (only 5 zemstvos had midwifery schools for a total of 240 students), and stationary midwifery aid was not expanded according to any known plan. -For the first time, on the initiative of the Perm Congress of Doctors in 1896, several summer nurseries were opened by the Perm provincial zemstvo, which were then transferred to the district zemstvos. The Poltava zemstvo from 1897 to 1902 increased the number of nurseries from 8 to 200. In 1904, 14 provincial zemstvos had 375 nurseries; most of them were in the Poltava, Voronezh, and Kursk provinces, while in the remaining 11 provinces there were very few. Nurseries in most cases were maintained not at the expense of general zemstvo funds, but from the sums of compulsory insurance capital, i.e., at the expense of peasant funds. Provincial zemstvos usually covered 5/8 of the expenses of district zemstvos for nurseries or appropriated the same sums as the district zemstvos; these appropriations for the most part were of a random nature. In many provinces, the number of nurseries after 1905 decreased significantly. In 1910, nurseries were set up in 16 provinces, and in 1913 only 9 provincial zemstvos allocated funds for the maintenance of nurseries. Sanitary description of schools and examination of the health and physical development of students were conducted in a number of provinces.

Provincial zemstvos also bore the expenses for the maintenance of feldsher schools, which had been transferred to a number of zemstvos as early as 1867 by the chambers of state property and the hospitals of the boards of public charity. At first, a whole series of new feldsher schools were opened, but in the 1880s, many zemstvos began to close their schools, striving to reduce their expenses. In 1905, the zemstvos maintained 22 feldsher schools with 2,600 students and 5 schools for midwives with 240 students; in 1910, 23 provincial zemstvos maintained feldsher and feldsher-midwifery schools with 3,261 students. A major role in the organization of zemstvo medicine was played by provincial zemstvo medical congresses. The first such congress was convened in Tver Province in 1871; on average, 9-10 provincial congresses of physicians took place annually. Special congresses were also convened on individual issues of combating cholera, diphtheria, etc., as well as regional congresses [e.g., Samara (1908) on combating cholera, Kharkiv (1911) and Kyiv (1913) on combating epidemics, and Yekaterinoslav (1911) on combating cholera]. The so-called Pirogov congresses of physicians played an especially large role in the organization of zemstvo medicine, at which fundamental questions of public health protection were often raised and the foundations of the sanitary direction in medicine were laid. The first such congress was in 1885. The zemstvo devoted very little attention to sanitary organization; it even made little use of the right granted to it to issue mandatory sanitary regulations. According to Article 108 of the 1890 Statute on Zemstvo Institutions, the provincial zemstvo assembly had the right to draw up mandatory regulations for the population "on the procedure for maintaining the cleanliness of squares, streets, roads, sewers, ponds, wells, ditches, natural watercourses, and bridges; on the cleanliness of courtyards; on the arrangement and procedure for maintaining slaughterhouses, factories, plants, and other industrial establishments in sanitary terms; on measures to observe cleanliness in premises for the sale of food supplies and to ensure their harmlessness; on precautionary measures against water contamination; on measures for the prevention and cessation of contagious, epidemic, and local diseases; and on measures regarding veterinary matters based on the rules set forth in the medical charter." The majority of zemstvos, representing mainly the interests of the wealthy and privileged strata of the population, treated the issue of issuing mandatory sanitary regulations with sharp negativity, and such regulations numbered only a few. In addition, these regulations had to be approved by the governor. The matter of sanitary supervision over factory and plant enterprises and agricultural work was in a particularly difficult position; defending their narrow class interests, the zemstvo members resisted in every way the implementation of industrial-sanitary supervision and the organization of medical-food supply points for workers. In the matter of combating epidemics, there was also no definite system or plan for the participation of provincial and district zemstvos in carrying out anti-epidemic measures; the role of provincial zemstvos in this regard was reduced only to granting subsidies to district zemstvos during the severe development of epidemics. According to Zhbankov's data, until 1898, 11 provincial zemstvos took part only in the fight against cholera, and 8 provincial zemstvos participated in the fight against epidemics only in emergency cases when there was a shortage of local forces and resources by dispatching temporary epidemic detachments. Only the Moscow, Novgorod, Samara, and, in part, Pskov zemstvos developed a large and permanent organization for combating epidemics. By 1910, such an organization was completely absent in 13 provinces, 14 provincial zemstvos had an approved regulation on their participation in the fight against epidemics, and for 18 provinces, there was information about special appropriations for the fight against epidemics. In the majority of zemstvo provinces, general sanitary organizations led the fight against epidemics. In 1901, provincial zemstvos allocated 4.6% of their health care budget to the fight against epidemics, while district zemstvos allocated only 0.9%. As for the leading sanitary bodies, they developed very slowly, facing enormous obstacles not only from the administration but also from the zemstvo itself. In the history of the development of zemstvo sanitation, three periods can be noted. The first period—up to the end of the 1890s—is characterized only by scattered sanitary measures of an accidental nature: here and there one sanitary worker was invited or a "sanitary desk" was established without definite functions; there were no programs of sanitary activity whatsoever. The sanitary physicians invited to service were often soon dismissed, and sanitary bodies in a number of places were liquidated shortly after their emergence. The second period of the development of zemstvo sanitation was already distinguished by greater planning in the deployment of the zemstvo sanitary organization—sanitary and medico-statistical bureaus were established, mostly on the initiative of zemstvo medical congresses and often with the stubborn resistance of the zemstvos, which subsequently repeatedly terminated the activities of these bureaus. The first sanitary bureau was organized by the Moscow zemstvo in 1875, the second by the St. Petersburg zemstvo in 1878. Zemstvo sanitary bureaus were engaged in studying the medical-sanitary state of the provinces, developing a plan for a normal network of medical districts, carrying out anti-epidemic and sanitary measures of the provincial zemstvos, and publishing corresponding "sanitary reviews" or "medical chronicles." As zemstvo activity developed, some zemstvos, already in 1900-04, began to create an entire sanitary organization: they established the positions of district and provincial sanitary physicians, created provincial and district sanitary councils, and in some places (in Tula, Kursk, Kostroma, and other provinces) even district sanitary trusteeships. The years of deploying a more planned sanitary organization mark the beginning of the third period of the development of zemstvo sanitation. A complete sanitary organization was envisioned by zemstvo medical circles in the following form: at the provincial center—provincial sanitary councils or collegiate advisory medical-sanitary bodies replacing them under the provincial zemstvo board as permanently operating institutions, guiding and uniting the work of the medical-sanitary councils of the district zemstvos; a sanitary bureau under the provincial zemstvo board as a working body of the provincial zemstvo, engaged in the organization of medical-sanitary affairs and exercising constant guidance over the entire sanitary organization; a whole staff of special sanitary physicians of the provincial zemstvo in the districts; and finally, periodic provincial congresses of zemstvo physicians and representatives of the zemstvos to resolve the fundamental questions of the organization of health care. Sanitary bodies were the organizers of zemstvo curative medicine, since all sanitary work in the countryside could be deployed only on the basis of the district network, and the immediate heads of medical districts mostly did not engage in sanitary and preventive work. Only in very few zemstvo provinces did the zemstvo districts pay attention to the sanitary state of their district and sanitary-preventive measures, lead the fight against social diseases, engage in the organization of the protection of motherhood, infancy, and childhood, and conduct sanitary-educational work (for details, see Medical District).

According to Zhbankov, a sanitary organization with sanitary physicians existed in 1908–09 only in 12 provincial Zemstvos, and among the district Zemstvos, only 3 districts had sanitary physicians at the expense of the district Zemstvo—the Kovrov and Shuya districts of Vladimir Province and the Kursk district. Sanitary bureaus existed in only 20 provinces (in 11 provinces they had been closed earlier). In 1913, a more or less fully developed sanitary organization in the form indicated above existed in only 18 of the 34 old Zemstvo provinces and in 3 of the 6 new western Zemstvo provinces. A provincial sanitary council or a medical meeting replacing it under the provincial board existed in 28 Zemstvo provinces. Sanitary bureaus existed under 31 provincial boards. Only 21 provincial Zemstvos had sanitary physicians in the districts (a total of 210 physicians). Only 20 provinces had permanent epidemic physicians; 24 provincial sanitary bureaus published periodic medical-sanitary chronicles or reviews; only in 4 provinces did hydraulic engineering bureaus exist as part of the sanitary department of the provincial board. A whole series of bureaus processed data on the natural movement of the population for individual periods and on general morbidity. In those Zemstvos where a card registration system was established, entire districts and sanitary councils refused to maintain it or maintained it with very great delays. Data on infectious morbidity were processed almost everywhere. In general, sanitary statistics encountered a mostly negative, or at best skeptical, attitude from the Zemstvo. The work of the bureaus encountered a sharply hostile attitude from the Zemstvo in 20 provinces (Zhbankov), where the entire activity of the so-called "third element" was viewed with suspicion as politically unreliable. The Zemstvos allocated meager appropriations for sanitary measures. According to Zhbankov's calculations, 30 provincial Zemstvos allocated in 1910 for the sanitary section (including the fight against epidemics, the convening of congresses, the organization of nurseries and medical-food supply points, sanitary-educational work, and the maintenance of the sanitary organization) only 2.9% of the entire medical budget. It is not surprising after all this that practical sanitary-preventive work was insignificant. For example, in 1910, only 7 Zemstvo sanitary bureaus dealt with issues of water supply in the village (Moscow, Smolensk, St. Petersburg, Ufa, Simbirsk, Kostroma, and Vologda); the Zemstvos paid almost no attention to the tasks of rural improvement, to issues of improving rural housing, etc. The situation with the dissemination of sanitary-hygienic knowledge among the population was very weak, despite the great efforts of the Pirogov Commission for the dissemination of hygienic knowledge. In the first 30 years of the Zemstvo's existence, sanitary-educational work was reduced to episodic sanitary talks by physicians in outpatient clinics and hospitals. The administration created great obstacles in the matter of sanitary education—not a single lecture or talk could be organized without the permission of the police, to whom a synopsis of the lecture had to be submitted. In the work of the Zemstvo, the initiative of the population could also not manifest itself. Only in 3 provinces (Vologda, Kostroma, and Tula) did there exist (Zhbankov) in 1910 permanent sanitary guardianships, which, in addition to physicians, included representatives of the local population, so-called sanitary guardians. The guardianships arose during epidemics and, upon their conclusion, were closed by the Zemstvos themselves or by the administration. The provincial Zemstvo assembly in Tula Province closed the provincial sanitary bureau for the latter's assistance in organizing guardianships; even in Moscow Province, guardianships for the liquidation of epidemics ceased their activity. However, Zemstvo medicine represented a special, huge step forward compared to the medical-sanitary organization of the Boards of Public Charity (see Medical District). Zemstvo medicine, with all its shortcomings, left a deep mark on the history of the development of Health Care, laying the foundation for new forms of organizing the protection of the health of the rural population and the development of its basic principles: the free and universal accessibility of medical aid. The war of 1914 reflected in the most deplorable way on the activity and organization of Zemstvo medicine. A special survey by the Pirogov Society of Physicians in 187 districts of 40 Zemstvo provinces revealed a significant destructive process in district Zemstvo medicine. About 28% of all medical districts were "vacant," i.e., had lost their physicians (443 districts out of 1,605 districts); in 72 districts, the number of "vacant" districts constituted from 1/5 to 1/2 and even 2/3 of all districts and higher. In the vast majority of Zemstvo districts, in almost 90% of all districts for which survey data were received, there were medical districts that remained without physicians for a more or less long time, and only in 26 districts were there no vacant districts. Among these districts were the most powerful provinces and districts with a very small number of districts. The number of beds to satisfy the needs of the local population decreased by 16% compared to the previous year; many hospital districts turned into outpatient ones and even closed completely. In many places, one physician had to manage many districts. 40.5% of all physicians left their districts in connection with the circumstances of wartime, and only half of those who left were subsequently replaced. A huge part of the districts passed into the charge of feldschers. It goes without saying that new hospital construction and the deployment of new districts ceased completely. Kurkin, having analyzed the relevant survey materials, comes to the conclusion that already after the first year of the war, "the district Zemstvo medical organization can be recognized with full right as being in a state of deep and severe disorder." Slavsky, based on the materials of the survey of the All-Russian Zemstvo Union for 1915, processed for 228 districts of 42 provinces, confirms in general the conclusions of Kurkin. 55% of physicians left service in the districts, and by September 1915, 26.6% of the staff number of physicians were missing. Some Zemstvos lost all their old personnel, more than 50% of Zemstvos lost more than half of their medical staff, 33% of Zemstvos lost more than 60% of their medical staff, and 22% of Zemstvos more than 70% of their staff. In the following years of the war, the destruction of the district medical-sanitary organization continued, which in rural areas was in the most severe state. As a legacy from the Zemstvo, Soviet medicine received an extremely weak sanitary organization and a very insufficient network of medical and sanitary institutions, which was almost in a state of complete decay. Urban medicine means the system of pre-revolutionary medical-sanitary service of cities, organized by former city self-governments in the person of city dumas, in contrast to the system of so-called Zemstvo medicine, organized by Zemstvo self-governments. Urban medicine in its present understanding began to develop from the 80s, and to a large extent the experience of Zemstvo medicine was used. According to the "City Statute" (ed. 1892) and additions to it from 1906, the subjects of jurisdiction of city public self-government in the field of Health Care included: the establishment of medical institutions and their management on the same basis as Zemstvo institutions, participation in measures for the protection of public health and the prevention and cessation of infectious and epidemic diseases in animals, the development of means of medical aid to the urban population, and the search for ways to improve local conditions in a sanitary regard (Art. 642 of the Medical Statute, ed. 1905). The City Duma was granted the right to issue mandatory sanitary regulations "on measures against the spoilage of water and on the cessation and prevention of infectious and epidemic diseases, on sanitary conditions subject to observance in premises for the sale of food supplies and beverages to ensure their harmlessness, and on the arrangement and order of maintenance in a sanitary regard of factory and craft establishments, within the limits of the rights granted on this subject in general to city self-governments, lodging houses, baths and slaughterhouses, the cleaning of courtyards, the arrangement and cleaning of cesspools and latrines" (Arts. 2 and 108). The law did not establish a definite responsibility for the non-fulfillment of these regulations, and in addition, the right to issue sanitary regulations was very limited by the general legal position of city self-governments, which were very constrained in their activity by constant administrative interference by police authorities. The governor often simply did not approve those sanitary regulations which seemed to him to exceed the limits of the rights granted to city self-government or not to correspond to the letter of the law or the intentions of the government authority. The law itself did not contain a precise formulation of the rights and duties of city self-governments in the field of Health Care. Moreover, it should be taken into account that, according to the law, the composition of the City Duma included in the overwhelming majority representatives of the propertied strata of the population—merchants, homeowners, factory owners, who naturally took little into account the interests of protecting the health of the city's working people.

City Dumas, representing a part of the general state-bureaucratic apparatus, usually acted by the methods of the latter, although sometimes the clash of interests between noble elements and various groups of the strengthening bourgeoisie, which entered into the composition of the Dumas, prompted the latter to attract to their side a part of the intelligentsia and to create various medical-collegial auxiliary bodies, which did not essentially change the character of the entire system of medical service. Even in 1903, a more or less ramified medical-sanitary organization in cities was encountered as a rare exception. The structure of the urban medical-sanitary organization, which began to develop only in the last decade before the war, was quite diverse. Usually, it was headed by the city board or one of the members of the board; in many cities, a medical-sanitary council or sanitary commission functioned under the board as an advisory body, consisting of deputies and physicians, whereby physicians often enjoyed only an advisory vote; in the majority of cities, no instructions defining the composition and functions, rights and duties of these collegial bodies existed. In large cities, there also functioned medical meetings or commissions, consisting of city physicians and having as their task the preliminary development of questions for the sanitary council. In 39 cities, there existed sanitary or sanitary-statistical bureaus, the tasks of which included the preparation of reports for the council, secretarial work in the latter, management of meetings, implementation of the decisions of the sanitary council, etc. In the remaining cities, these functions were carried out by one of the sanitary physicians. In the capitals, the structure of the sanitary organization was different. In Moscow, at the head of the sanitary organization stood the Commission of Public Health, consisting of 15 deputies, which prepared the corresponding reports for the Duma. Under the city board, there was an advisory body—a medical council consisting of physicians and representatives of medical corporations, under the chairmanship of a member of the board—and 9 more commissions: sanitary, hospital, school, psychiatric, etc. In St. Petersburg, there existed two executive commissions—hospital and sanitary; the latter was headed by a member of the Duma and consisted of 11 district sanitary trustees, while physicians participated in it with an advisory vote. Representatives of the corporations of physicians—sanitary, Duma, etc.—were part of the medical councils that existed under each of the indicated commissions. During epidemics, in a number of cities, so-called sanitary trusteeships were elected, which had oversight of the sanitary condition of the city and the fulfillment of mandatory sanitary regulations. Such trusteeships existed as a permanent body in 40 cities, and as a temporary body in 76 cities, but in reality, they displayed very weak activity. From information on 258 cities, it is evident that about ³/₄ of these cities by 1903 had no medical institutions under the administration of city public boards, while in the majority of the remaining cities, the latter had only reception rooms and outpatient clinics with general reception; sanitary organization in cities was encountered as a rare exception, and even then only in the form of one or two sanitary physicians. Indigent patients in cities where there were no medical institutions under city public self-governments were served by Zemstvo hospitals or hospitals of the Boards of Public Charity for a certain fee, which was sometimes covered by the city; the fee was 7 rubles 20 kopecks per month in the hospitals of the Boards of Public Charity, and in the others usually 9 rubles; non-residents paid significantly more. Along with the fragmentation, the extreme insufficiency of the urban medical-sanitary network in the pre-war years was striking. Medical aid. According to available information on the state of urban medicine in 224 cities for 1912-14, compiled by Zhbankov, in 35% of the indicated cities (among them Orel, Kaluga, Mogilev, Kremenchug, Zhitomir, etc.), city self-governments had not begun to organize medical aid; in 77 cities, there were not even city physicians for medical treatment, and in 107 cities, there were no independent outpatient clinics, and in 53 small cities, only outpatient aid was provided. Only 117 cities had independent outpatient clinics, and even then, the reception time was limited in the majority of cities to 1/2-3 hours, and in a significant number of medium (50-100 thousand population) and small cities, outpatient reception was performed by Zemstvo, city, or government physicians who were concurrently in the service of the city self-government, or even by sanitary physicians; the population of 143 cities used the beds of medical institutions of the Zemstvo and other departments. In 73 cities, there were only the beginnings of city medical aid, including in many large cities (e.g., in Minsk, Vitebsk, Perm, Simferopol, Penza, Vladimir, Ryazan, Chernigov, Ivanovo-Voznesensk, Kherson, Tambov, Arkhangelsk, etc.). With the exception of some large cities that were relatively well provided with beds—St. Petersburg, Moscow, Yekaterinodar, Odessa, Rostov-on-Don, Yekaterinburg (1 bed per 140-200 people)—the general provision of beds was very small and fluctuated from 300-400 (Kharkov, Nizhny Novgorod, Nikolayev) to 4,000-5,600 people per 1 bed (Penza, Stavropol, Simferopol). In 124 cities, there were no infectious disease barracks or hospitals at all, or special wards for infectious patients. In 160 cities, there were no maternity institutions or delivery wards at all, and in the remaining 64 cities, there were from 4 to 40 maternity beds, with the exception of Moscow (565 beds), St. Petersburg (465), Kiev (80), and Odessa (50). Even in St. Petersburg in 1912, only 39% of all births were accepted in hospitals. Obstetric aid at home was almost not provided at all. The situation was even worse with the organization of home care: among the indicated 224 cities, it was listed as organized in only 34; it is characteristic that it was absent even in such large cities as Moscow, Rostov-on-Don, and Saratov. Home care was provided by Duma physicians (e.g., in St. Petersburg), mostly by so-called physicians for the poor (e.g., Odessa), and in a number of cities by city and even sanitary physicians (e.g., Vladikavkaz) in extremely limited dimensions, and even then only to the poorest population and in cases of severe illnesses. In cities on the territory corresponding to the RSFSR, there were 16 home care points in 1913. Here it is necessary to note that the organization of home care arose not as an organic part of the medical-sanitary organization in the process of the latter's growth, but mostly during epidemic outbreaks, under the pressure of circumstances, in the form of an institute of temporary home care physicians. Thus, in Leningrad, the diphtheria epidemic in 1881 and the scarlet fever epidemic in 1882 forced the organization of medical aid at home. Emergency aid was organized in only 13 cities, and in cities on the territory of the RSFSR—only in 4; night duties of physicians—in 20 cities. For the provision of inpatient and outpatient care, a fee was charged in many cities, from 40 kopecks to 1 ruble per bed per day (e.g., in Saratov, Chelyabinsk, Yekaterinburg, etc., in Kutaisi even 3 rubles) and 5-30 kopecks per outpatient visit (Rostov-on-Don, Tiflis, Novorossiysk). To cover part of the expenses of city self-governments for hospital care, a so-called hospital tax was established in cities (according to the law of 1890), which was collected mostly from the indigent strata of the population. In Moscow, for example, this tax was collected in the amount of 1 ruble 25 kopecks per year from all persons, regardless of sex and rank, who were engaged within the city limits in any craft, work for hire as servants, peddling, cab driving, etc. Persons who did not pay the hospital tax did not enjoy free treatment in hospitals, with the exception of infectious and venereal patients. What role the hospital tax played in the general revenue budget of cities and the general expenditure for the maintenance of hospitals in Moscow can be seen from the following table (in rubles): City budget 1909, 1910. Amount of hospital tax. Expenditure on maintenance of hospitals. Percentage ratio: 10.2, 9.0. Total revenue of the city budget. Percentage ratio of hospital tax to city budget: 2.2, 2.0. The collection of fees was especially widespread in cities of non-Zemstvo provinces. Regarding the organization of pharmacy affairs, the city self-government did very little. Only 33 cities had in 1913 their own pharmacies with rights of free sale, whereby in a number of cities where there was no medical-sanitary organization at all, pharmacies were established with the exclusive goal of obtaining profit (Izyum, Kasimov). Even large cities like Irkutsk, Kazan, and Tiflis, pursuing the same goal, leased out their pharmacies. Only in individual cities (Khvalynsk, Novozybkov) did city pharmacies dispense medicines to the poorest population at a discount. Sanitary organization in cities. Of the indicated cities, 138 had no sanitary organization at all, in 41 cities there were only primary beginnings of an organization, and only in 45 cities did a more or less ramified sanitary organization exist; in 121 cities, there were no sanitary physicians at all. City Dumas paid little attention to sanitary affairs and often invited physicians to sanitary service on a concurrent basis, for a small additional remuneration.

The fight against epidemics was conducted quite insufficiently, which was explained to a significant degree by the general weakness of the medical-sanitary organization, and was directed mainly at stopping epidemics that had already arisen, rather than at carrying out preventive and health-improving measures. Uniform card registration of general morbidity in city outpatient clinics and hospitals was conducted in only 33 cities; in the others, it was done differently, and only in 15 cities was there proper processing of morbidity data by sanitary authorities or statistical bureaus. Registration of infectious patients was conducted in only 122 cities, and data on infectious diseases were processed in only 47 cities. Data on population movement were collected and processed for only 30 cities. Laboratories existed in only 49 cities, and a whole series of laboratories had no specialized personnel. Disinfection chambers existed in only 54 cities. The matter of smallpox vaccination was set up unsatisfactorily in the majority of cities. Sanitary supervision of factory and plant enterprises was almost entirely not carried out by sanitary organizations, and only in rare cases were sanitary descriptions of factories and plants produced; other systematic sanitary research and descriptions of the sanitary condition of cities were also absent; only sanitary descriptions of individual objects, produced from time to time, were encountered. School-sanitary supervision and school doctors were noted in only 49 cities, and even then, in a number of cities, school doctors, working mostly part-time, had a significant number of schools under their jurisdiction and provided only medical assistance to schoolchildren. Systematic sanitary-food supervision, connected with the entire medical-sanitary organization of municipal self-government, existed almost nowhere. It is characteristic that even in Moscow, food sanitation was under the jurisdiction of 10 so-called market doctors, who were subordinate to the department of the city administration that oversaw the "trade police." These market doctors carried out the functions of monitoring the quality of food products in places of their manufacture and sale and the sanitary condition of the corresponding premises. They were not connected with the city sanitary station. In St. Petersburg, there existed for this same purpose an institute of trade-sanitary doctors, also detached from the city sanitary-hygienic laboratory. The situation with housing-sanitary supervision was just as bad, which was carried out by general sanitary doctors and, moreover, in very meager dimensions. In St. Petersburg and Moscow, there were special sanitary doctors for the supervision of lodging houses. Almost no work on the protection of motherhood and infancy was conducted in cities, if one does not count the foundling homes (see) that existed here and there, which were a kind of "angel factory," and isolated nurseries and milk kitchens-"drop of milk." The vast majority of cities, with the exception of the capital and some of the largest cities, spent very insignificant sums on health care, and the urban population used primarily provincial and district zemstvo hospitals and outpatient clinics. In the years preceding the imperialist war, various kinds of epidemics, which strongly gripped the cities, on the one hand, and the growth and industrialization of urban centers, on the other, led to increased attention to issues related to improving the extremely unfavorable sanitary condition of cities and to the organization of medical-sanitary service for the urban population. However, in view of the absence of a definite legislative act on the duty of cities to provide the population with medical assistance and the low interest of the "city fathers" in carrying out broad sanitary measures, the development of the medical-sanitary organization in cities proceeded very slowly, and a significant burden regarding the service of the urban population lay as before on the zemstvo budget. The majority of municipal self-governments believed that townspeople, as zemstvo taxpayers, had the right to be treated in zemstvo medical institutions, to which subsidies were given by municipal self-government only in individual cities; there were no permanent agreements between zemstvos and cities in the field of organizing medical-sanitary assistance and participation in expenses as a system. Only private agreements were concluded on individual issues, most often on the organization of a joint fight against epidemics. Conflicts often arose between zemstvos and cities on the grounds of different interpretations of their duties regarding the provision of medical assistance to urban residents; mutual representation of city sanitary organizations in zemstvo medical councils and congresses and vice versa contributed little to the establishment of correct relationships. All expenses of municipal self-government in 1913 per 1 inhabitant were very small: 75% of all cities spent less than 10 rubles, 61.2% of large cities had expenses from 6 to 15 rubles, 78% of medium cities (from 50,000 to 100,000 population) and 81% of smaller cities spent 1-10 rubles per inhabitant. Of these expenses, a mostly very small sum fell to health care, which stemmed from the inattentive attitude of city dumas to the tasks of protecting public health. 38 cities spent 1/2-5% of all city expenses on health care, in 44 cities 6-10%, in 40 cities 11-15%, in 37 cities 16-20%, in the rest 32% and higher. Expenses for sanitary measures in cities constituted negligible sums: 72 cities spent 1/2-10 kopecks per 1 inhabitant, 93 cities from 20 kopecks to 1 ruble, 32 cities from 1 ruble to 2 rubles, and only 5 cities from 2 rubles to 4 rubles 53 kopecks; in general, 157 cities spent from 1 to 10 kopecks per inhabitant on the sanitary department, and 35 cities from 20 to 40 kopecks (Moscow and St. Petersburg 35 kopecks each). On medical assistance, over 1/3 of the indicated cities (74) spent 1-10 kopecks per one inhabitant, 1/3 of cities from 20 to 50 kopecks, 31 cities from 60 kopecks to 1 ruble, and only 23 cities 1-5 rubles (Moscow-4 rubles 65 kopecks, St. Petersburg-3 rubles 88 kopecks). In general, cities allocated 11% of their entire general budget of 214,256,000 rubles to medical affairs, with 12.8% of the city budget in large cities (over 100,000 population), 6% in medium (50,000-100,000 population), and 4.2% in small ones. Very little attention was paid to sanitary affairs. Allocations for the sanitary department were 10 times less than for medical affairs-1.2% of the city budget, with this expense constituting 1.1% of the entire city budget in large cities, 1.1% in small ones as well, and 1.4% in medium ones. The expenses of cities for general sanitary measures constituted 8.5% of the city budget, with 9% in large cities, 7.5% in medium, and 6.4% in small. It is necessary to emphasize here that the concerns of municipal self-governments about improving the sanitary condition of cities when carrying out sanitary measures extended mainly to the center of the city, to quarters inhabited by wealthy strata of the population, while the outskirts were completely destitute in sanitary terms-they remained unpaved, without watering, lighting, were not connected to water supply and sewage networks, and only during epidemics did they become, for understandable reasons, a subject of concern for the duma deputies. Materials and exhibits displayed in the "city medicine" section at the All-Russian Hygienic Exhibition in 1913 also showed the extreme insufficiency of the medical-sanitary organization in cities. Interesting is the illustration presented there of comparative expenses for health care and public education in 1912. Specific weight of expenses in the city budget. Cities and their budgets: Medical and sanitary measures: Public education: 5 cities with a budget over 1 million rubles: 4.3% 8.7%; 9 cities 1-2 million rubles: 5.1% 10.5%; 20 cities 1/2-1 million rubles: 13.6% 3.4% 12.7%; 28 cities 300,000-500,000 rubles: 7.6% 3.7% 12.5%; 25 cities 200,000-300,000 rubles: 7.2% 2.6% 12.4%; 51 cities 100,000-200,000 rubles: 4.5% 3.8% 12.8%; 94 cities 50,000-100,000 rubles: 6.3% 3.3% 18.1%; 4.8% 3.2% 19.9%. The very meager network of factory medical-sanitary institutions or institutions of hospital funds that arose shortly before the war introduced little change into the general picture of the insufficiency of the medical-sanitary network that was under the jurisdiction of municipal self-government. The imperialist war introduced strong disorder into the city medical-sanitary organization: many city doctors were mobilized for military service; a huge part of city medical institutions was occupied for military hospitals and infirmaries. The medical-sanitary needs of the civilian population were almost entirely sacrificed to the interests of serving the wounded-victims of the imperialist war. The All-Russian Union of Cities set as one of its main tasks the adaptation of the city medical-sanitary network to serving military-sanitary needs. By the beginning of the revolution, as a result of the imperialist war, the urban population was even worse provided with medical assistance than before the war. (For the further development of medical-sanitary service of cities under Soviet power-see USSR.)

D. Gorfin. Factory and plant medicine is a special form of organizing medical aid for factory, plant, and mining workers and, in part, members of their families. This original organization, which existed only in Russia and was mandatory for owners of private enterprises, and which was arranged and maintained entirely on private funds in the form of inpatient and outpatient institutions, was obligated to serve a fairly large group of the working population, which is subjected to increased morbidity and traumatism and differs from the surrounding population by greater activity in general and a greater need for medical aid. Factory and plant medicine emerged in Russia as an independent organization in the sixties of the 19th century, when capitalism in Russia had already reached a certain development and factory and plant industry encompassed no less than 1 million workers. When cholera cases appeared in the central, most industrial part of Russia in 1865, the government, fearing that industrial centers could become hotbeds and breeding grounds for cholera cases, issued an order in August 1866 (at the request of the Moscow governor) on the organization of hospital treatment for factory workers. According to this regulation of the Committee of Ministers, factories and plants having 1,000 workers were required to set up a hospital facility for 10 beds; over 1,000 workers—for 15 beds or more; less than 1,000 workers—for 5 beds or more, calculated at one bed per 100 workers. The regulation itself was only temporary, did not contain precise sanitary-technical standards for inpatient care, instructions regarding the quality and quantity of service personnel, about outpatient treatment of workers, about home treatment, or regarding the treatment of family members. Another legislative act on which factory and plant medicine was built was Article 107 of the Charter on Industry, according to which it was forbidden to charge workers for medical aid, understanding by the latter, according to subsequent clarifications, not only pharmaceutical treatment, but also the dietary and hygienic environment of the patient, care for them, etc. But even these few legal provisions, to please entrepreneurs, were not combined into any coherent legislation on factory and plant medicine, but, on the contrary, were limited in every way by circular, contradictory clarifications and resolutions: thus, although in 1867 the State Council found that the regulation of August 26, 1866, issued as a temporary measure, could have force for an indefinitely long time, however, subsequently, by government orders on the establishment of a hospital city tax, seven of the largest industrial cities (Moscow, Petersburg, Odessa, Ivanovo-Voznesensk, Lodz, Kharkov, and Warsaw) were removed from the operation of this law, and hospital aid to factory and plant workers in these cities had to be provided by city administrations (at the expense of the hospital tax paid by the workers themselves), and factories were required to have only small reception rooms for providing outpatient aid; furthermore, in 1886, a law permitted all factory owners to dismiss workers who fell ill with a contagious disease (without providing them with any treatment), and in 1908, the Senate, regarding a complaint by a Tver factory owner, clarified that the entire "law" of 1866 as "temporary" should be considered to have lost its force with the introduction of the Zemstvo and City Regulations, according to which the right to issue resolutions on the protection of public health was granted to zemstvos and cities. In fact, in the first years of its existence, some zemstvos, taking advantage of the right of supervision over the execution of the law of 1866, issued a number of resolutions on regulating medical aid in factories and their sanitary condition, but in 1886 this right of supervision was taken away from the zemstvos, and the issuance of mandatory resolutions on the protection of the life and health of workers in factories was granted to the main and provincial "presences for factory and mining affairs," in the composition of which, besides officials, there was a sufficient number of representatives of capital, and whose activities, according to official government data, tended mainly "to facilitate the factory owners." As a result of all these circumstances, factory and plant medicine was often actually fictitious: factories had premises with signs "hospital," in which there were beds, but patients were not admitted; several hospitals were "managed" by a district doctor who arrived occasionally, and constant work in them was carried out by feldschers. All these shortcomings of factory medicine were first revealed in plain view by a sanitary survey of factories and plants of Moscow province, which was conducted in 1884-86 by Erisman, Pogozhev, and Dementyev, and on the basis of these surveys, Erisman developed and presented to the IX Congress of Doctors of Moscow Province in 1887 the first proposals for the reorganization of factory and plant medicine in the Moscow district, which were then extended to the entire Moscow province. These proposals boiled down to shifting the in-kind obligation of factory and plant owners to a monetary one and to transferring the medical organization itself to zemstvo institutions. The proposals were accepted by the Moscow provincial zemstvo assembly, and under the pressure of the latter, and mainly in connection with the intensified labor movement and the cholera epidemic of 1892-93, instead of feldscher medicine under the cover of district doctors, properly organized factory hospitals with a doctor permanently living at them began to arise in Moscow province, and many factory owners began to enter into agreements with the zemstvo on organizing medical aid, whereby these zemstvo-factory doctors were in the service of the zemstvo and consequently were removed from direct dependence on the enterprise owners. The successful experience of Moscow province, which was reported at Pirogov congresses, and, most importantly, the growth of the labor movement in a number of industrial provinces, where demands for improving medical aid were more than once put forward in the demands of strikers, led to the spread of this experience to other places, and factory and plant medicine began to develop slowly in the 90s of the 19th century. According to the report of the Ministry of Finance in 1898, large factories and plants had more or less organized medical aid, namely: out of 3,488 industrial enterprises with 1,017,309 workers—1,028 enterprises with 579,000 workers provided full medical aid (inpatient and outpatient), and at the remaining enterprises only outpatient aid was provided. It should be noted that the larger the industrial establishment, the relatively better medical aid was organized: out of 194 factories having 1,000 or more workers, medical aid was provided at 185 (94.5%), where 400,836 workers (94.7%) worked; out of 1,812 factories with a number of workers from 101 to 500 people, medical aid was provided at 1,282 (70.8%), where 320,475 workers (77.2%) worked, and out of 8,778 factories with a number of workers up to 15 people, medical aid was provided only in 1.7% of factories with 2.8% of the total number of workers in them. The unsatisfactory state of factory and plant medicine and the desire of the zemstvos to expand the sphere of their influence prompted many zemstvo administrations to raise the question of transferring factory and plant medicine to zemstvo and city administrations. Thus, as early as 1904, the IX Pirogov Congress adopted the following resolution: "The question of providing workers with medical aid can be correctly resolved in Russia only by transferring factory and mining medicine to zemstvo and city public institutions, provided that the in-kind obligation of owners of industrial establishments is converted to a monetary one, with the inclusion of the fulfillment of this obligation to the bodies of zemstvo and city self-government. The establishment of the norm of transfer should be entrusted to zemstvo and city public institutions." But this unanimous decision of the medical congress, which became a creed for many public doctors for a whole decade, met with serious public and practical criticism during the period of the 1905 revolution from workers' organizations and a group of doctors who ideologically and practically joined the labor movement. Among the various demands put forward by workers in 1905 during strikes that spread throughout the country, there were not a few demands for the improvement and reorganization of medical aid, and, what is especially important, these demands were developed not by individual factories or plants, but by entire groups of factories or districts, for example, by representatives of all St. Petersburg factories for the processing of fibrous substances, the Ivanovo-Voznesensk factory association, and all factories of the cities of Shuya and Tsaritsyn.

In 1905, trade unions emerged in Russia by way of self-assertion, and although their main attention was naturally focused on the combat tasks of organizing the broad working masses, the central bureaus of the Moscow and St. Petersburg trade unions developed principles for organizing medical aid for their members on the basis of mutual assistance. The Metalworkers' Union in St. Petersburg managed to create, with the assistance of doctors, a voluntary insurance medical organization consisting of more than 30 doctors, which worked quite successfully until 1909 inclusive. The organization of medical aid under trade unions achieved the greatest success in the city of Yekaterinoslav, where, under the leadership of Vinokurov, the trade unions managed to force employers to contribute additional funds for the treatment of workers, to take into their own hands a large hospital with a large number of doctors, and to consolidate medical aid for 3,000 workers from 59 industrial enterprises. Under the influence of the growth of the labor movement, issues of organizing factory medicine attracted more attention, and after 1905, a number of factory doctors' societies were formed (in Moscow, Baku, Yekaterinoslav, Lodz, and Kadiyevka), which set themselves the goal of uniting the scattered forces of factory doctors, providing them with mutual support, and, through united work, influencing the improvement of the state of medical affairs in factories and plants. The Moscow Society of Factory Doctors did particularly much in this direction, managing to convene two All-Russian congresses of factory doctors and representatives of factory-plant industry in 1909 and 1911. At the first congress, representatives of workers elected in various regions of Russia took an active part, and this workers' group, united among themselves and guided by the party organizations of the RSDLP, played a major role in formulating new ways of resolving the crisis in factory medicine. For representatives of the labor movement, there was no doubt that factory medicine in Russia was 'nothing more than a surrogate for insurance, and that the introduction of true social insurance was sooner or later inevitable,' and therefore they outlined a path toward the reorganization of factory medicine in accordance with this historical perspective. The slogan of transferring factory medicine into the hands of the workers themselves in the form of self-governing sick funds was first put forward in the medical press by Vigdorchik in 1907 and provoked lively and sharp controversy from the Zemstvo doctors, who stood on the point of view of the IX Pirogov Congress. This slogan entered the program of the struggling working masses over the next few years, and, reflecting it, the workers' group at the I All-Russian Congress of Factory Doctors introduced and passed the following resolution: 'Recognizing: 1) that the treatment of workers should take place entirely at the expense of the entrepreneurs; 2) that under the currently existing legislation this duty is already imposed on them, but is not actually being fulfilled by them; 3) rejecting both the leaving of medical affairs under the management of entrepreneurs and their transfer to local self-government bodies, the congress finds the only expedient solution, corresponding to the interests of the working class, to be the transfer of all medical affairs for all branches of wage labor into the hands of self-governing workers' sick funds.' The XII Pirogov Congress in 1913, already after the publication of the law on workers' insurance against illness, was presented with two reports on the issue of the fate of factory medicine by representatives of both currents, in which information was provided on the state of factory medicine in 1907 according to official data from the Ministry of Trade and Industry. Out of 14,297 factories and plants (subject to factory inspection) with 1,818,629 workers, 5,439 factories with 1,528,600 workers had medical aid, i.e., 38.2 percent of all factories with 84 percent of workers. However, a more detailed examination shows that the actual state of affairs was much worse. According to the same data, in 1908, out of the total number of 5,439 establishments with 1,528,600 workers that had an organization for medical aid, only 964 establishments with 798,279 workers, or 17.7% of establishments with 52.2% of workers, had separate or joint outpatient clinics and hospitals; 3,529 establishments with 584,744 workers, or 60% of all establishments with 38.2% of workers, had only outpatient clinics without any hospitals at all or with receiving rooms instead of them; 675 factories with 43,766 workers, or 12.4% of establishments with 2.8% of workers, had an absolutely unsatisfactory organization of aid (occasional visits by a doctor or paramedic), and the remaining 541 factories with 101,911 workers, or 10% of all establishments with 6.6% of workers, had agreements with Zemstvos, cities, and other institutions and private individuals. And since only an organization that provides the worker with inpatient care in addition to outpatient care can be considered satisfactory, on the basis of the data provided, it could be said that only 1/6 of all factories and about half of all workers had a satisfactory organization of aid. According to data from the commission of the III State Duma, it is evident that in 1912, 19% of permanent urban workers and 28% of temporary workers did not use any medical aid from enterprises. The cited figures spoke in objective statistical language that in the 42 years of its existence, factory medicine had provided very little in the sense of ensuring medical aid for all workers. Along with this, it could not be ignored that out of large factories with more than 1,000 workers, almost 70% had hospitals, while out of small ones with 50 to 100 workers, only 6% had hospitals. Likewise, the reports noted that the most complete and expedient regulations for the protection of the health and life of workers existed in those provinces where the labor movement had reached the greatest development. From all these data, Vigdorchik drew the natural conclusion that 'the development of factory medicine in Russia was determined not by legislative norms, not by the enlightened concerns of the government, but by the growth of the needs and demands of the working masses.' After heated debates, the Pirogov Congress, having unanimously condemned the 1912 law on insurance as clearly drawn up in the interests of the factory owners, recognized that 'in the interests of the further progress of factory medicine, it is necessary to grant the sick funds broad worker self-activity. The question of the forms of factory-medical organization most suitable to the peculiarities of individual enterprises or individual localities must be decided by the sick funds themselves, insofar as they, under the present political conditions, will be the spokesmen for the organized opinion of the workers. Since the new law, by making it the duty of entrepreneurs to organize inpatient care for workers, actually forces the worker to seek this aid primarily in Zemstvo and city hospitals, medical-sanitary organizations must pay serious attention to the issues of organizing medical aid for workers and clarify, while considering the opinion of the sick funds, the conditions for organizing such aid and the methods of its implementation. Public doctors must enter into close contact with the sick funds and help the workers with their specialized knowledge and their organizational experience.' In fact, with the beginning of the organization of sick funds, a portion of factory medicine institutions gradually began to pass into the hands of fund-based, or insurance, medicine, and factory medicine finally merged with the latter after the October Revolution on the basis of the decree of the Council of People's Commissars of November 16, 1917, which transferred all factory medical institutions with all their movable and immovable property into the possession of the sick funds free of charge. With the liquidation of the sick funds themselves at the end of 1918 and with the strengthening of the newly created state bodies of health care, the latter were first transferred the treatment of the family members of the insured, and then, by a decree of the Council of People's Commissars of February 18, 1919, all medical institutions of the sick funds were transferred to the health care bodies, and fund-based medicine merged entirely with Soviet medicine.

M. Rafes. IV. Soviet Medicine. The October Revolution, having handed power into the hands of the working people, created a new form of state—the dictatorship of the proletariat.

The necessity of opposing governments to local self-government bodies disappeared within it. The proletariat in power had to face, from the very first steps, the issues of improving the health of the country and overcoming the difficult situation that affected the working people most painfully. And if, under the conditions of the revolutionary struggle against Tsarism, social democracy demanded in the field of health care only "the supervision by local self-government bodies, with the participation of elected representatives from workers, over the sanitary condition of residential premises allocated to workers by entrepreneurs; the establishment of properly organized sanitary supervision in all enterprises employing hired labor, with the complete independence of the entire medical-sanitary organization from entrepreneurs; free medical assistance for workers at the expense of entrepreneurs, with the retention of wages during illness," then the Communist Party—the leader and creator of the October Revolution—in its program "bases its activities in the field of protecting public health primarily on the implementation of broad health-improving and sanitary measures aimed at preventing the development of diseases. In accordance with this, the immediate tasks of the party are: 1. Decisive implementation of sanitary measures in the interests of the working people, such as: a) improvement of populated areas, b) organization of public catering on scientific-hygienic principles, c) organization of measures preventing the development and spread of infectious diseases, d) creation of sanitary legislation. 2. Struggle against social diseases (tuberculosis, venereal diseases, alcoholism, etc.). 3. Provision of universally accessible, free, and qualified medical and pharmaceutical assistance." Along with this, broad legislation on labor protection, social insurance, practical planned activity in the field of the housing question, and food policy in the interests of the proletarian masses constitute the complex of measures that contributes to the preservation of the health of the working people and determines the raising of their standard of living. Under the conditions of the dictatorship of the proletariat, the health care system naturally sets as its task the primary service, and in the most developed form, of the working class—the main bearer of the revolution and socialist construction. The health of the proletariat is one of the most important resources of the country, a major factor in increasing labor productivity. The reproduction of the labor force is one of the most important functions of the Soviet state, while specific historical conditions require combined work both in the direction of providing medical assistance to the sick and the consistent implementation of medical-social measures ensuring the health of the working people. These new tasks brought to life new forms of health care organization. The first germ, the first cell of the new medical-sanitary organization was the medical-sanitary department of the Military Revolutionary Committee under the Petrograd Soviet of Workers' and Soldiers' Deputies, which arose at the first shots on October 25, 1917. This department was tasked with the fundamental dismantling of the entire bureaucratic medical apparatus, current operational work, and the preparation of further transformations in the field of building the Soviet system of protecting the health of the working people. In three People's Commissariats—State Charity, Internal Affairs, and Communications—medical collegiums were created, which took upon themselves the leadership of the medical part in these institutions. From the very beginning of the activity, the conviction began to grow and strengthen regarding the necessity to coordinate and unite efforts for health protection. The first united step of these collegiums was a joint appeal "On the struggle against morbidity, mortality, and unsanitary living conditions of the broad masses of the population," signed by, among others, Vinokurov, Barsukov, and Veger. In this appeal, it was primarily pointed out that "the war, economic collapse, and the malnutrition and exhaustion caused by them place before the workers' and peasants' government the question of the struggle on a state scale against morbidity, mortality, and unsanitary living conditions of the broad masses of the population." It is possible to fulfill these huge tasks only by involving the broadest strata of the population in the work. "For this purpose, the medical-sanitary organizations of public self-governments must be used. These organizations, in their present structure, although they are elected bodies of zemstvo and city self-governments, nevertheless, broad strata of the local population, workers' and peasant organizations are insufficiently represented in them. A complete democratization of these medical-sanitary organizations with broad representation from the local population is necessary. A congress of representatives of medical personnel who stand on the Soviet position is necessary for the final development of the medical questions on the agenda." This appeal appeared in an atmosphere of sabotage and even strikes by a part of the doctors in some cities. The Pirogov Society took a clearly hostile position toward the Soviet power, calling on doctors to "show resistance to the forces destroying the country..., to sharply and definitely dissociate themselves from doctors acting in the camp of the oppressors." The conference (November 1917), convened by the Central Medical-Sanitary Council (see above), although it noted that the strike of medical institutions as a method of political struggle cannot be permissible, nevertheless recognized "the possibility of the actual cessation of work when moral or technical conditions make the continuation of work impossible." The conference refused to work with the Soviet power. The revolution in the matter of health care passed by these medical groups, which stood on the other side of the barricade, and found other creative forces. The initiative for building a new system of protecting the health of the working people was raised by the grassroots soviets. Everywhere there was a dismantling of the old, the transfer of the cause of public health from narrow corporate organizations "with the participation of the working people" into the hands of the organizations of the working population itself, into the hands of the soviets of workers', soldiers', and peasants' deputies. On the periphery, the necessity of uniting the forces and means of the medical-sanitary organizations, which were scattered until then, was even more sharply visible; here, the demand for the creation of a single body was suggested even more clearly. In this regard, from the numerous documents of the turbulent year 1917, the appeal of the Executive Committee of the Soviet of Deputies of Eastern Siberia to all local soviets regarding the basic principles of organizing medical-sanitary affairs is especially characteristic: "The Soviet power is morally and legally responsible for the organization of the treatment of the citizens of the Republic, which is why it is necessary to pay special attention to this and reorganize the entire medical-sanitary business, withdrawing it from the hands hostile to the interests of the working masses, merging into a single harmonious organization—military, railway, rural, urban, etc., medicine." Along with these unifying tendencies in the localities and the creation of single medical-sanitary bodies under the soviets, in the center, it was still far from clear what the new health protection system would be, and the government recognized all steps to transform medical administration as temporary "until the formation of the entire organization of medical affairs of the Russian Republic." But already in February 1918, to unite the activities of the medical collegiums under various commissariats, the Council of Medical Collegiums was formed under the chairmanship of Vinokurov—the "highest medical body of the workers' and peasants' government." The Council consisted of representatives of the collegiums and individual administrations, as well as persons personally invited. It was an independent body that had legislative initiative and the right to defend its proposals and the interests of medical-sanitary affairs in the Council of People's Commissars, as it entered the composition of the Council of People's Commissars through its representative with a consultative vote on issues of medical-sanitary affairs. However, it still represented a purely mechanical, accidental coupling of the medical collegiums of various commissariats. Meanwhile, the questions arising before it regarding the organization of military-sanitary affairs, the fight against tuberculosis, venereal diseases, the organization of psychiatric assistance, the establishment of a competent Scientific Medical Council, and especially the fight against epidemics pushed for a further expansion of the competence of this body. In the midst of the Council of Medical Collegiums, in whose work N. A. Semashko and Z. P. Solovyov also took part after moving to Moscow, the idea of establishing a separate People's Commissariat of Health first matured with full clarity. It received its formalization in the resolution of the I Congress of Medical-Sanitary Departments of Soviets (Moscow, June 15–18, 1918) based on the reports of Solovyov and Pervukhin: "On the tasks and organization of the People's Commissariat of Health." "Proceeding from the unity of state power, which is the basis of the structure of the Soviet Republic, it is necessary to recognize the need to create a single central body—the Commissariat of Health, which manages all medical-sanitary affairs." At this same congress, in Semashko's report, the main tasks of medicine under the conditions of the Soviet system and thanks to the conditions of the Soviet system were revealed. "Only the Soviet power, which consistently implements the principles of communism, which does not stop before the destruction of private property and social-economic inequality, provides a firm foundation for the correct setting of the struggle both against social diseases and against unsanitary housing conditions."

In the resolution on this same report, those principles were formulated which served as the "foundations of Soviet medicine." It outlined that "firstly, the urgent organizational task of Soviet medicine locally is the elimination of the former interdepartmental frameworks and its unification; secondly, curative medicine must be built on the consistent implementation of the principles of a) accessibility and b) free-of-charge service; thirdly, it is necessary to immediately concern oneself with improving the quality of medical aid (specialized appointments, outpatient clinics, and hospitals); fourthly, it is necessary to immediately develop the widest possible sanitary-educational activity among the population (talks, lectures, exhibitions, etc.); fifthly, the forms of population participation in medical-sanitary activity and the forms of its self-activity must be radically changed: the widest active participation of organized workers and the rural poor in this activity is necessary." At the V All-Russian Congress of Soviets, in the constitution adopted by it at the session of July 10, 1918, the formation by the will of the workers and peasants of the People's Commissariat of Health (Section III A, Ch. VIII, p. 44-t) was proclaimed for the first time, which became the first ministry of health in the world. On July 11, 1918, a resolution of the Council of People's Commissars was issued on the organization of the People's Commissariat of Health, with Semashko appointed as People's Commissar, and Solovyov as his deputy. The members of the first board were Dauge, Golubkov, Bonch-Bruyevich, and Pervukhin. By the resolution of the Council of People's Commissars of July 18, 1918, the functions and competencies of the commissariat were defined in accordance with the resolutions of the I Congress of Medical-Sanitary Departments. According to this decree: "The People's Commissariat of Health is the central medical body directing all medical-sanitary affairs of the RSFSR. The People's Commissariat of Health is charged with: a) the development and preparation of legislative norms in the field of medical-sanitary affairs; b) supervision and control over the application of these norms and the adoption of measures for their strict implementation; c) the issuance of orders and resolutions in the field of medical-sanitary affairs that are universally binding for all institutions and citizens of the RSFSR; d) assistance to all institutions of the Republic in the implementation of medical-sanitary tasks; e) the organization and management of central medical-sanitary institutions of a scientific and practical nature; f) financial control and financial assistance in the field of medical-sanitary activity of central and local medical-sanitary institutions; g) the unification and coordination of the medical-sanitary activity of local councils of workers' and peasants' deputies." One of the first resolutions of the People's Commissariat of Health was the establishment under it, with the rights of an advisory body, of the Scientific Medical Council. The Scientific Medical Council was charged with the development and consideration of scientific-practical and educational questions in the field of medicine and sanitation, and the provision of conclusions on these questions. The initially planned structure of the People's Commissariat of Health consisting of 6 departments—1) military-sanitary, 2) civil medicine (zemstvo and urban), 3) insurance medicine, 4) school-sanitary, 5) communications [with sub-departments: a) railway, b) waterways], and 6) veterinary—still testified to the mechanical unification under one roof of medical-sanitary departments from the corresponding commissariats. However, this structure changed extremely quickly, adopting a functional character, and the veterinary department was not organized at all. During 1918-19, the incorporation into the People's Commissariat of Health of branches of medical-sanitary affairs that had remained outside of it took place. In February 1919, the institutions of the sick funds were transferred to the People's Commissariat of Health; in the autumn of 1919, the Department for the Protection of Motherhood and Infancy was transferred from the People's Commissariat of Social Security. Thus, a powerful central organism was organized, encompassing all aspects of medical-sanitary affairs. Further changes in the structure of the People's Commissariat of Health occurred both in connection with the development of new aspects of activity and as functions changed in accordance with the reorganization of management locally (regionalization, creation of krai and oblast health departments). (For the structure of the People's Commissariat of Health according to the latest regulation on it and local health bodies, see USSR.) Already in the first resolution of the Council of People's Commissars of July 11, 1918, on the organization of the People's Commissariat of Health, there are a number of points instructing the People's Commissariat of Health to take a number of emergency measures to combat cholera. The first period of the activity of the People's Commissariat of Health, covering approximately five years (1918-23), is characterized primarily by the fight against epidemics and intense activity to ensure medical-sanitary service for the Red Army. The uprising of the Czechoslovaks, the intervention of the Entente, which created the internal front of Kolchak, Denikin, and Yudenich, and the blockade determined this task of the People's Commissariat of Health. To this period belongs a number of energetic measures to ensure the supply of Red Army units with medical personnel, the creation of hospitals and sanitary trains, and the supply of medicines and linens. This activity could only be successful thanks to the unification in one body of the entire management of health care affairs and the maneuvering of resources. In the field of the fight against epidemics (1918-22), and then the famine of 1921 and its consequences, along with the colossal deployment of epidemic beds, isolation-transit points, and disinfection installations, sanitary education received extremely great development, having developed great publishing activity both in the center and locally. In this same period, the foundation was laid for sanitary and epidemiological legislation, one of the first acts of which were the housing-sanitary law (decree of the Council of People's Commissars of 1919), laws on compulsory smallpox vaccination (1918, 1924), and on the fight against typhus (1919) and malaria (1922). Under the People's Commissariat of Health, the Central Epidemic Commission worked energetically throughout this period; a special malaria commission was created, which unfolded enormous work on the study of malaria and on attracting economic bodies (like the Central Peat Administration) and trade unions, primarily miners, to the fight against malaria. Congresses of bacteriologists and epidemiologists were devoted to questions of the fight against epidemics. In 1922, the Council of People's Commissars of the RSFSR adopted the decree "On the Sanitary Organs of the Republic." For the first time in the entire time of the existence in Russia of any state concerns for the health of the population, the state character of the activity and structure of sanitary organs was established, and their rights, tasks, and duties were defined. On its basis, local sanitary organs expanded rapidly. Despite the diversion of all forces and resources to the fight against epidemics, a beginning was also made on social-preventive measures, such as the protection of motherhood and infancy, the protection of children's health, and the fight against tuberculosis. In connection with the surrounding situation, the food crisis, and the deterioration of the housing situation, among the institutions for the protection of motherhood and infancy, closed institutions (mother and child homes, infant homes) received special development; among institutions for the fight against tuberculosis, primarily sanatoriums were built, and in the field of children's health protection, special attention was paid to the organization of nutrition for the child population (decrees of 1918). Of the social-hygiene legislation, the decree of the People's Commissariat of Health and the People's Commissariat of Justice on the legalization of abortion and the decree of the Council of People's Commissars of 1922 on the periodic examination of adolescent workers acquire special significance. The decree of the Council of People's Commissars (1918) on the nationalization of pharmacies was the main turning point in the organization of pharmacy affairs, banishing from it forever the elements of hucksterism, quackery, and speculation on the health of the broad masses of the population. The most prominent aspect of the activity of the People's Commissariat of Health during this period, in terms of its influence on the modern and subsequent development of health care, is the creation of a whole complex of scientific institutes; in conditions of an extreme economic crisis and the most strained material situation, the People's Commissariat of Health developed a network of scientific institutions with particular completeness, moreover, it established institutes not only for the practical purposes of producing vaccines and sera, not only for the educational purposes of training and improving specialists in various branches of medicine, but also institutions with scientific-research purposes for the scientific development of health care problems in the broad sense. This primarily includes the State Scientific Institute of Health (GINZ), which includes: a) the Institute of Protozoal Diseases and Chemotherapy (Tropical Institute) with an entomological department, b) the Sanitary-Hygienic Institute, c) the Institute for the Control of Sera and Vaccines, d) the Institute of Physiology of Nutrition, e) the Microbiological Institute, f) the Institute of Experimental Biology, g) the Institute of Biological Chemistry, h) the Institute of Physiological Chemistry, i) the X-ray Institute. In the field of the study of social-preventive questions, the following were created in the period 1918-23: 1) the State Institute of Social Hygiene with a popular exhibition on health protection, 2) the State Venereological Institute, 3) the State Tuberculosis Institute, 4) the State Institute of Physical Culture. In addition, the following passed into the jurisdiction of the People's Commissariat of Health: the State Institute of Experimental Medicine (Leningrad), state physical-therapy institutes in Leningrad and the Sechenov Institute in Sevastopol, two institutes for the advanced training of physicians in Leningrad and Kazan, and the State Traumatological Institute. At the same time, a whole series of bacteriological institutes were created, of which the Regional State Institute of Microbiology and Epidemiology in Saratov acquired special significance in the fight against plague. At the same time, the People's Commissariat of Health organized a whole series of experimental-demonstration institutions in the field of the fight against tuberculosis, the protection of motherhood and infancy, and the protection of children's health.

The necessity of building a new enterprise from scratch, the lack of funds and manpower, and at the same time the general conditions of Soviet construction during the period of War Communism led to the highly centralized activity of the People's Commissariat of Health. It represented an apparatus not only of general guidance and control, but also of direct management, whereby from May 1919 to May 1922, the entire maintenance of therapeutic medicine was on the state budget. The second period of Soviet medicine's activity, ending approximately in 1927, coincides with the period of the country's economic restoration, the expansion of the rights and activities of local bodies. It can be characterized primarily by the powerful deployment of prophylactic institutions. In the field of maternity and infant protection, open institutions (creches) are growing, and summer rural creches are receiving special development. In the field of combating tuberculosis and venereal diseases, a downright gigantic leap is observed in the network of dispensaries. Sanitary-educational work receives a firm footing both in the form of newly emerging houses of sanitary education, permanent and mobile exhibitions, and by virtue of the development of medical publishing, the release of a large number of visual aids. In the matter of providing medical assistance to the insured, the sector of special types of assistance (physiotherapy, X-ray, dental care) is growing especially. The resort business is growing rapidly from year to year, restoring the entire received nationalized fund and having begun new construction. The rural medical network, which suffered particularly during the period of the imperialist and civil wars, is beginning to recover rapidly by virtue of a whole series of special government decrees, congresses of soviets, and the improvement of funding sources (subventions, income from pharmacy administrations). Along with the rebuilding of medico-sanitary institutions in national regions and republics, the study of the physical development of individual nationalities, and in particular the peoples of the North, is beginning. Sanitary legislation is being enriched by a number of decrees on the protection of food products (1922, 1927), the law on hydraulic engineering measures (1923), and the regulation on the sanitary protection zone for water supply systems (1925). The development of the country's industrialization attracts the special attention of the People's Commissariat of Health to the study of occupational diseases and poisonings. Rules on mandatory examinations of workers in harmful professions are issued (1925), and a Central Institute for the Study of Occupational Diseases is created. To this same period belongs the beginning of the reform of medical education (see) under the influence of the requirements of Soviet medicine and the new tasks of the physician. A number of prophylactic disciplines, such as social hygiene, labor hygiene, and hygiene of upbringing, are included in the curriculum of medical higher education institutions. The regionalization of the country and the expansion of the administrative-economic rights of the soviets (regional, district, raion) predetermine the changes in the activity of the People's Commissariat of Health that characterize the third period of its activity, which began in 1928. Liberation from the tasks of direct management pushes to the forefront the tasks of the People's Commissariat of Health as a planning body, ensuring general guidance and control over the activities of grassroots bodies. In connection with this, the scientifically competent development of issues of planning, organization, and study of the activities of individual links of the medico-sanitary network acquires special significance. In this way, the activity of scientific research institutes approaches the People's Commissariat of Health and receives a new character. On the other hand, the reconstructive period of the Soviet economy that has begun, the construction of new factories, housing, state farms, collective farms, the development of cooperation, and public catering place the relationships of the People's Commissariat of Health with other bodies in a new way. The new hospital construction that had already begun at the end of the second period, and the construction of other therapeutic-prophylactic institutions, in connection with the ways of providing medical assistance to the working people, raises the question of new types of organizations of medico-sanitary institutions and the character of their activity. (For the characterization of work principles, types of institutions, and their network, see Ambulatory, Hospital, Venereal diseases, Dispensarization, Resorts, Therapeutic assistance, Protection of children's health, Maternity and infant protection, Occupational diseases, Sanitary education, etc.—For the organization and history of Health Care in the union republics, see USSR.)

I. Strashun.