Medical Assistance

Medical Assistance. Before the October Revolution, medical assistance in Russia was provided by institutions of three types: state, public, and private. The state organization of medical assistance began with the establishment of the court (royal) pharmacy in 1581. After almost a full century (1672), the second state pharmacy was opened, but unlike the first, it was intended "for the sale of all medicines to people of all ranks." Subsequently, the direct participation of the state in the organization of pharmacy affairs was expressed only in the establishment of pharmacies at military and naval hospitals. The first garrison pharmacy was established in St. Petersburg in 1704. Along with these pharmacies, gardens for growing medicinal plants and laboratories also emerged. They also served as the first pharmaceutical schools for training doctors and pharmacists. The pharmacies of the Public Welfare Department (see Healthcare, the period before the abolition of serfdom) were of semi-state type. Private pharmacies were first established by Peter I. In Russia in the early 18th century, there were no pharmacists capable of organizing medical assistance. Pharmaceutical goods and equipment were almost entirely imported from abroad. From Holland, not only medicines but also auxiliary pharmaceutical goods were delivered, such as: vinegar, wood oil, glassware, and even thread. Goods from Arkhangelsk port to Moscow took about 6 months. At the same time, the people, accustomed to their folk healers and herbalists, did not trust foreign doctors and pharmacists. There are petitions from boyars requesting "to grant them, not to allow treatment by a foreign doctor," but to send them "an experienced expert," i.e., a folk healer. Under such circumstances, and especially with the strongly developing trade of herbalists, there were few willing to come to Russia - to a foreign, unknown and uncultured country and to spend capital on buying a house, equipment, and goods. Only the guarantee of large income could attract foreign pharmacists. That is why Peter I, when beginning to create pharmacies, first eliminated their competitors. On November 27, 1701, an edict was issued "to the green row in Kitay-gorod, as well as along the streets where there are anything in Kitay-gorod and in the White City, shops in which goods, all kinds of potions and ointments are sold as if they were medicines, and those shops are not to be, no one is to trade or sell any potions and herbs and ointments and medicines in those places except through pharmacies, and those shops along the streets and at intersections are to be cleared, and the sellers of those goods are to be expelled from the Town Hall." Then followed an order to open private pharmacies: "For all needs and requirements of medicines, eight new pharmacies are to be established in Moscow, and these pharmacies are to be built in Kitay-gorod, in the White City, and in the Earth City on large, spacious, and crowded streets; without any hindrance, to keep and sell in those pharmacies all medicines and medicinal spirits and other necessary and healing drinks belonging thereto." But the habit of herbalists was obviously too strong, and they did not think of leaving the stage, which is why soon another decree was issued against them: "and the green row and along all streets and intersections, shops in which all kinds of necessary herbs and potions were sold as if instead of medicines, by the previous decree of his great sovereign, are to be moved, and all shops in those streets and intersections are to be demolished and cleared, and in that green row to trade in other goods as is proper." In the development of Peter's charter, the interests of the private pharmacist were protected by the Pharmacy Statute of 1789, Article 4 of which states: "so that the pharmacist, using necessary expenses and labor to prepare supplies, does not suffer losses, it will be observed that nowhere anyone except pharmacies sells medicines in a scattered manner." Thus, a private pharmacy monopoly arose, which was defended by pharmacists and the government for more than two centuries. With the emergence of zemstvo institutions (see Healthcare, zemstvo medicine), the organization of public medical assistance began, but its development was hindered and limited by the system of private pharmacy monopoly. Zemstvo pharmacies were initially of the closed type, attached to hospitals. Severely limited in resources and intended for the poor, zemstvo pharmacies were built very primitively, without necessary equipment and instruments, often served by unqualified, and sometimes illiterate personnel, and in the entire organization of the business lagged significantly behind the private pharmacies of that time. Much better organized were the zemstvo "free" pharmacies, which received the right to sell medicines freely. But the development of this network of pharmacies was opposed by private pharmacists, citing a violation by the zemstvos of their (pharmacists') right to private property, i.e., privilege. Seeking to reduce the cost of medical assistance, the most advanced Tver zemstvo as early as 1887 conceived of organizing its own pharmaceutical warehouse and ordering medicines from abroad, bypassing private intermediaries. But it turned out that Russian druggists had protected themselves from such attempts by public institutions by concluding a "convention" with foreign firms, whereby the latter had the right to sell medicines to Russian buyers exclusively through the mediation of Russian druggists. It took quite some time before the Tver Provincial Zemstvo Administration managed to find a commission office that agreed, for a certain remuneration, to order medicines in its own name and then deliver them to the provincial hospital. The struggle between the zemstvo and the private pharmacy owner developed especially sharply in the countryside, where by law there could be no more than one free pharmacy. Rural pharmacists also protested against the reduction in drug prices practiced in some zemstvo hospitals, where along with free medicine, prescriptions were dispensed for an average of 5-10 kopecks. However, most zemstvo self-governments showed no particular zeal for the proper organization of medical assistance, and this matter developed very slowly and only in individual zemstvos. Thus, in the 1890s, pharmaceutical warehouses appeared in Elisavetgrad and at the Moscow City Administration, and in the 1900s - in Kostroma, Yekaterinoslav, and Yekaterinburg. The most significant warehouse was in Tver; it supplied about 100 county zemstvos and put forward the idea of all-zemstvo ordering of medicines, implemented only during the imperialist war. Laboratories were also built at zemstvo warehouses. But the development of laboratory-plant affairs again encountered opposition from the pharmacy monopoly law. The organization of laboratories with free sale of products was permitted only at free pharmacies, and zemstvos were severely limited in opening such. Even the Tver pharmaceutical plant, which had developed to a large size, was forced to exist semi-legally, being registered as part of a closed-type pharmacy. The petition of the St. Petersburg City Duma in 1907 for the opening of 14 city free pharmacies was rejected, and in the same year private individuals were permitted to open 24 new pharmacies in St. Petersburg and 16 in Moscow. Thus, the pharmacy monopoly system, which initially played a positive role as a factor in the development of rational pharmacy, subsequently turned into its opposite and became a brake on the further development of medical assistance. The long struggle of some local self-governments against the pharmacy monopoly, supported by pharmacist employee organizations that revealed all the negative aspects of private pharmacies, did not remain without result, and in 1912 a law was enacted whereby zemstvos and cities were granted the preferential right to open free pharmacies. However, the reactionary self-governments of that time, in the vast majority, did not hurry to take advantage of this right, and until the revolution itself, the number of free municipal pharmacies did not even reach 300 (according to 1914 data, there were 4,791 private pharmacies in Russia; of these, 2,029 in cities, 2,762 in villages; 32,412,972 prescriptions were prepared in these pharmacies per year). The organization of affairs in zemstvo free pharmacies was significantly better than in hospital and district pharmacies. Thus, here too medical assistance was organized on a purely class principle: qualified and exemplary for the well-off strata of the population for money, and second-rate for the poor. The rural private pharmacy played a special role. This type of pharmacy arose on the basis of special rules of 1881. The rural pharmacy, unlike the "normal" one, was not obliged to have a laboratory, conduct forensic-chemical analyses, or train students; the list of medicines and instruments was limited, and pharmacy assistants were admitted to the management of a rural pharmacy. Since the main financial base for a private pharmacy was private medical practice, and there was almost none in the countryside, rural pharmacists were interested in the development of the so-called "manual sales." Taking advantage of the ignorance of the population, the extreme insufficiency of properly organized medical assistance, as well as the age-old habit of peasants to be treated by folk healers, the rural pharmacist widely developed self-medication and accustomed the population to seek help directly in the pharmacy, bypassing the doctor. Medical advice and treatment were of course practiced in all private pharmacies, but the rural pharmacy created in this regard a more complete and consolidated system. Such activity could not but cause sharp condemnation from progressive-minded doctors.

Organizations of pharmaceutical employees, which fought against the exploitation of labor and for the proper organization of affairs in pharmacies, began to point to the better organization of affairs in free zemstvo pharmacies. Starting from 1905, the demand for the municipalization of pharmacies was increasingly put forward. In 1910, the Society of Pharmaceutical Employees presented a report on the advantages of municipalizing pharmacies to the XI Pirogov Congress, and the physician A. Voskresensky at the same congress demanded the removal of rural pharmacies from private hands and their transfer to the zemstvo, of course, by means of "redemption". The Society of Pharmaceutical Employees demanded the immediate abolition of the monopoly as a necessary stage in the transition of pharmacies to self-government. In the aforementioned report, the society of pharmacists states: "Being principled supporters of free treatment for all the poor, we assume that the most direct path to achieving this goal is the widest possible dissemination of urban and zemstvo sanitary institutions. The second and very serious reason for transferring pharmaceutical affairs to the jurisdiction of municipalities is the consideration that medicinal products are least accessible to the control of the consumer themselves, and the greatest guarantee of their quality would be the elimination of motives encouraging poor quality," i.e., profiteering at the expense of the sick. Pharmaceutical stores also played no small role in the dispensing of medicinal products. The prices of the monopoly pharmacy were obviously beyond the means of the population, and it constantly seeks ways to satisfy the need for medicines outside the pharmacy. Under the pressure of this need, the State Council was forced, in violation of the aforementioned monopoly, as early as 1814, to decree the "permission to sell simple harmless pharmaceutical remedies in any quantity in herbal stores in the paint and green rows". Since then, non-pharmaceutical trade in medicines began to develop. Pharmaceutical stores grew rapidly, were often run by pharmacists, and not only sold harmless remedies but also secretly prepared medicines, gave medical advice, competing with pharmacies. In 1913, the number of pharmaceutical stores reached 7,256 (in European Russia and the Caucasus), i.e., almost double the number of pharmacies. In the first decade of the 20th century, the private pharmacy, attacked by municipalities, stores, and mainly by the factory production of medicines, which had developed widely abroad, lost its secure income, began to decline, and lost the remnants of its scientific-production and health-sanitary tasks. Medical assistance progressively deteriorated and required a radical solution, for which examples were sought in other countries. Foreign legislation had long placed the pharmaceutical industry under special conditions of greater or lesser regulation and guarantee of quality. In individual states, there existed and still exist various systems of concessions, privileges, or other restrictions, under which the establishment of pharmacies is strictly regulated, management and the right to work are conditioned by special qualifications, etc. The concession system currently exists in Austria, Germany, Greece, Denmark, Italy, Latvia, Lithuania, Luxembourg, Norway, Poland, Romania, Finland, Sweden, Yugoslavia, Estonia. In other countries (England, Belgium, Holland, Spain, Portugal, Turkey, France, Switzerland), there is a notification system, i.e., the opening of pharmacies without prior permission, but their functioning is subject to special rules, supervision, and control. However, all these measures fail to achieve their goals, and countries with the concession system differ little from countries with the notification system in terms of rational service of health needs. In both places, the pharmacy is a vehicle of sanitary ignorance, drug fetishism, self-medication, and sometimes simple exploitation. The idea of socializing pharmaceutical affairs as the only correct form of its organization also arose abroad. As early as the 19th century, bills on the municipalization of pharmacies were introduced in some parliaments by socialist factions. It was pointed out that all kinds of concessions, supervisions, and revisions cannot change the basic nature of the institution - to serve as a source of profit for individuals. Under the private ownership system of organizing medical assistance, the state is powerless to combat the flood of useless patented and secret remedies, numbering tens of thousands, to stop the practice of healing in pharmacies, to condone self-medication, etc. Therefore, the idea of municipalizing pharmacies was already very popular among the advanced strata of the medical and pharmaceutical communities in prerevolutionary Russia. During the imperialist war, the degeneration of the private pharmacy reached its limit, as the pharmacy became additionally a hotbed of drunkenness, using the prohibition of vodka products to spread alcohol-containing solutions, tinctures, and pure alcohol on fictitious prescriptions. The medicine shortage caused unbridled speculation in medicines, in which few pharmacies did not participate. The February Revolution sparked a wave of strikes by pharmacy employees. The strikes took on a protracted character due to the dispersion of pharmacies, small staffs, and the organized opposition of pharmacists. The demands for the removal of pharmacies from private hands became increasingly insistent, but only the October Revolution could solve this question, cutting through the tangled knot of the institution of private property. At the initiative of the organization of pharmaceutical employees, pharmacies were taken from private hands and transferred to the jurisdiction of local councils starting from early 1918. All this was done spontaneously, without instructions, and sometimes contrary to the instructions of the center. Pharmaceutical affairs did not belong to the economic commanding heights of the proletariat, the nationalization of which was necessary in the first place. In addition, the blockade, sabotage, and speculation led to the exhaustion of the last reserves of medicines. Management, control, and supply organs had not yet been established. All this made one fear the results of the immediate nationalization of such small and scattered enterprises throughout the country, which is why the decree on the nationalization of pharmacies was only issued on December 28, 1918; this decree completed the nationalization on an all-state scale. According to the decree, "all pharmacies, whoever they may belong to and in whose jurisdiction they may be, with all the inventory in them, with all accessories and supplies, with laboratories and warehouses existing with them, as well as with working capital, become the property of the Republic (RSFSR). Nationalized pharmaceutical enterprises are transferred to the jurisdiction of the People's Commissariat of Health and are managed according to the rules and instructions issued by the Commissariat." General guidance, control, and direction of the activities of nationalized pharmacies and pharmaceutical enterprises was entrusted to the Pharmaceutical Department, while direct management was entrusted to local pharmaceutical subdepartments. For supply, gubernatorial pharmaceutical warehouses with laboratories attached to them were established. Funds were issued from the state treasury funds according to budgets approved by the People's Commissariat of Health. To coordinate activities and develop a general line, the All-Russian Congress of Pharmaceutical Subdepartments was convened in early 1919. The main tasks formulated by the congress for organizing medical assistance are as follows: Medical assistance must be prompt, accessible, and rational. The production of medicines that can be made in stock should be transferred to factories and plants. All pharmacies of various departments and institutions should be built according to a single type. Pharmacies should be consolidated and should also serve the population with all items of sanitation and hygiene. Medical advice in pharmacies, as well as the dispensing of secret and questionable remedies, should be discontinued. These general principles formed the basis of all subsequent development of pharmaceutical affairs. In addition to the general direction, the congress developed detailed instructions on methods of managing state pharmacies, their financing, supply, the organization of gubernatorial warehouses and district distributors, laboratories, etc. The II Congress of Pharmaceutical Subdepartments, held in July 1920, developed and deepened the work on organizing medical assistance. The congress sanctioned the liquidation of rural pharmacies and the consolidation of hospital pharmacies with non-hospital pharmacies, significantly reducing the number of the latter and establishing numerical norms for the pharmacy network. The congress established the order of managing pharmacies in medical institutions and normal staffs, indicated measures to increase labor productivity, to organize statistics, reporting, office work, and accounting. Issues of financing, supply, education, etc. were developed (see Pharmacy and Pharmacy Network). I. Levinstein. The period of war communism in medical assistance is characterized by the centralization of management, administration, and supply. All medicinal resources are accounted for by the People's Commissariat of Health; local organizations are supplied according to a certain strict distribution of the latter. The blockade, the weak development of the pharmaceutical industry, the impossibility of replenishing medicine reserves, the need to satisfy the general needs of the country and numerous fronts required the establishment of strict consumption norms and the most economical expenditure of medicines and medical property.

From the nationalized (formerly private) pharmacies, the dispensing of medicines became free of charge, just as from pharmacies at medical-sanitary institutions. Gradually, by the end of the period of war communism, the condition of medical assistance greatly deteriorated, and medical supplies were almost exhausted. With the introduction of the New Economic Policy, by a resolution of the Council of People's Commissars of January 9, 1922, the opening of private pharmacies was permitted under the control of the People's Commissariat of Health and local health authorities. By a circular of the People's Commissariat of Health of the RSFSR of July 1, 1922, health departments were instructed to convert non-hospital pharmacies to business accounting. Along with this, instructions were given for the leasing of non-hospital pharmacies, and leasing could and should only take place if it proved to be more advantageous and appropriate than transition to business accounting. Both the permission to open private pharmacies and the leasing were necessitated by the needs of the time. The People's Commissariat of Health instructed local authorities to lease the least well-equipped, poorly supplied pharmacies, and leasing could be permitted for a limited period. As the general state economy was restored and as industry grew, pharmacies were gradually taken back from private owners-lessees and passed into the hands of the state, so that by the end of 1928 there were no pharmacies (with the exception of homeopathic ones) in leasehold use or private ownership. At present, the entire network of pharmacies, through which medical assistance is provided, is in the hands of the state and consists of business-accounting pharmacies and pharmacies at medical-sanitary institutions. The number of business-accounting pharmacies in 1928/29 in the RSFSR was: in cities-1,124, in rural areas-1,033. At medical-sanitary institutions as of October 1, 1929, there were pharmacies: in the RSFSR-5,733; in the Ukrainian SSR-957; in the Byelorussian SSR-52; in the Transcaucasian SFSR-92 (incomplete information). In addition, pharmacies serving transport, located at medical-sanitary institutions of transport, as of January 1, 1929, numbered 924. For the same period, the number of business-accounting pharmacies was: in the RSFSR-2,124; in the Ukrainian SSR-1,126; in the Byelorussian SSR-169; in the Transcaucasian SFSR-326; in other republics-83; for the entire Union-3,828. The number of prescriptions dispensed for the main types of assistance from all pharmacies of the RSFSR, excluding transport ones, for 1928/29 amounted to 221 million; of these, 50 million were dispensed by business-accounting pharmacies; of the total number of prescriptions, 68 million were dispensed to insured persons, including 45 million from business-accounting pharmacies; for the rural population-127 million, including 5 million from business-accounting pharmacies; 26 million prescriptions were dispensed for payment, which constitutes 11.76% of the total number of prescriptions dispensed in 1928/29. All prescription medical assistance, with the exception of business-accounting pharmacies, is carried out by health departments at their own expense. In 1927/28, the total health budget without capital investments amounted to 357.8 million rubles; of this, 35.8 million rubles were spent on medicines and dressings, i.e., 9.8% of the health budget. Expenses for dressings amount to approximately 50% of this entire amount, so expenses for medicines constitute only about 5% of the health budget. For 1927/28, the expenditure on medicines, carried out by pharmacy administrations at the expense of health authorities and in the business-accounting sector, amounted to 40 million rubles, of which 21 million were at the expense of health authorities and 19 million in the business-accounting sector. The average cost per prescription in the RSFSR for insured persons is 22 kopecks. The average cost per paid prescription in the RSFSR is 63 kopecks (pre-war average-56 kopecks). The average cost of a prescription dispensed from pharmacies at medical-sanitary institutions in rural areas is significantly lower than the cost of a prescription for insured persons due to insufficient appropriations for medical assistance for the rural population. Insured persons, along with free medical care, also receive free medical assistance. By a circular of the People's Commissariat of Health of the RSFSR of February 6, 1925, No. 57, health departments were instructed to dispense medicines to insured persons not only from pharmacies of medical-sanitary institutions where they receive medical care, but also from all business-accounting pharmacies. This measure brought medical assistance closer to insured persons and significantly improved it. Medical assistance to insured persons is paid for by health authorities at cost, without adding a profit. By a circular of the People's Commissariat of Health of the RSFSR of March 31, 1926, No. 39, this order of service with medical assistance was extended to factory districts located outside cities. By a resolution of the Council of People's Commissars of the RSFSR 'On the Order of Providing Medical Care to the Rural Population' of January 31, 1930, it is provided that those groups of the rural population that actively participate in the reorganization of agriculture on socialist principles are served free of charge in the first place. This includes: workers and employees of industrial enterprises, state farms and collective farms, as well as farm laborers, shepherds, lumberjacks and other groups of insured population. Members of collective farms (communes and artels) and their members of families are equated in terms of medical care in rural areas to the members of families of the above-mentioned groups and are served preferentially over the rest of the rural population. This resolution on medical care applies entirely to medical assistance as well. To increase funds for medical assistance to the rural population, the People's Commissariat of Health enacted a law (resolution of the Council of People's Commissars of December 28, 1927) that the profits of pharmacy administrations should be directed to improving medical assistance in rural areas. In development of this law, the People's Commissariat of Health issued a number of instructions on the procedure for using profits, as a result of which 29% of the net profit of pharmacy administrations should be spent at the direction of health departments to improve medical assistance provided from pharmacies at medical-sanitary institutions in rural areas; the remaining profit should be directed to expanding the pharmacy network in rural areas, first of all in areas of mass collectivization. These additional resources in some places amount to up to 30% of the appropriations of the local budget for medical assistance in rural areas. In 1927/28, the profit of pharmacy administrations amounted to 4,760,000 rubles, in 1928/29-6,063,000 rubles, i.e., 3.93% and 4.3% respectively of the turnover. In the five-year plan, the People's Commissariat of Health provides for further increasing appropriations for medical assistance to the rural population; expansion and construction of the pharmacy network is planned mainly in rural areas and first of all for serving the socialist sector of agriculture. However, the existing division into business-accounting pharmacies and pharmacies at medical-sanitary institutions was considered inappropriate, and therefore the People's Commissariat of Health proposed that the construction of the pharmacy network, especially in rural areas and factory districts, be carried out on the principle of a unified pharmacy, i.e., a pharmacy serving both outpatient and inpatient patients and dispensing equally to all for payment both medicines and items of sanitation and hygiene (circular of the People's Commissariat of Health No. 158/64 of May 4, 1930). Medical assistance on transport stands somewhat apart, as does the entire matter of medical-sanitary service of transport. The network of transport pharmacies is located exclusively at medical-sanitary institutions of transport and serves only transport workers. The question of merging this network of pharmacies with the territorial one can only be resolved when the general question of the gradual planned merger of the transport medical-sanitary network with the territorial one is resolved. In addition to pharmacies, medicines are also dispensed from stores of sanitation and hygiene, the number of which in the RSFSR reached 374 as of October 1, 1929, in the Ukrainian SSR-250, in the Byelorussian SSR-20, in the entire USSR-651. Only the simplest medicines, usually used in the home without prescriptions, are permitted to be dispensed from stores of sanitation and hygiene. With the introduction of the NEP, wholesale trade in medicines to private individuals was permitted, but as early as 1925, the People's Commissariat of Health took measures to completely eliminate private individuals from the trade in medicines, and such trade is now exclusively in the hands of the state. To non-pharmacy trade in medicines, one must also include the dispensing of certain medicines from cooperative shops in rural areas according to a specific list (circular of the People's Commissariat of Health of June 11, 1925, No. 123, Bulletin of the People's Commissariat of Health, No. 11, 1925). This measure was necessitated by the extremely inadequate pharmacy network in rural areas and the need to at least to some extent satisfy the need of the peasantry for the most essential medicinal preparations. However, this leads to a number of negative phenomena. A cooperative shop cannot create conditions guaranteeing the preservation of the quality of dispensed medicines; moreover, one cannot entrust the dispensing of a medicine to a seller of a cooperative shop in which he is completely unversed; therefore, the People's Commissariat of Health has given subsequent instructions that the dispensing of medicines according to a specific list from cooperative shops should be permitted only in rural areas where there are no pharmacies or stores of sanitation and hygiene, and that the construction of pharmacies should be carried out first of all and mainly in rural areas by organizing unified pharmacies. Along with the transfer of pharmacies to business accounting, the People's Commissariat of Health gave instructions on the organization of pharmacy administrations (see). Management of the pharmacy network is concentrated in pharmacy administrations (business-accounting pharmacy network) and in health departments (pharmacies at medical-sanitary institutions).

Before the regionalization of pharmacy management, there were guberniya (provincial) and uezd (district) level organizations, and as of October 1, 1929, there were 89 of them. After regionalization, pharmacy management was correspondingly enlarged into oblast (regional) and krai (territorial) organizations, which are attached to the respective health departments, and their number equals the number of enlarged administrative divisions—37 oblasts and kraev. The supply of all pharmacy management organizations is carried out by central production and trading organizations under a general contract, which establishes both the amount and the specification of goods. Their own institutions and the institutions of health departments supply themselves through their network of warehouses. To a large extent, supply is carried out by pharmacy management organizations on a transit basis, without bringing goods to local central warehouses, and through distributor pharmacies. Sources of supply are our domestic production and imports. The pharmaceutical industry before the October Revolution was extremely underdeveloped and mainly limited to the production of galenic preparations and various ready-made remedies. Chemical medicines (salicylic acid group and others) began to be prepared in our country during the imperialist war, but only in small quantities. The ratio of imports and domestic production is illustrated by the following table (in thousands of rubles). Years Quinine and cinchona 1912 . . 1923/24 .1924/25 1925/26 1926/27 1927/28 domestic prod. import 5.100' - : 2.400 - ! 2.650 - 3.000 Chemical medicines domestic prod. import 41% 1 59% ; 5.300 72% | 28% 1 8.100 72% ! *8% 84% 16% 85% 15% 88% ! 12% * On the territory of the entire former Russian Empire This table testifies to the steady growth of our domestic production. Galenic preparations are prepared within the country, and this type of production is decentralized, i.e., each oblast pharmacy management prepares independently in its laboratories and factories galenic preparations to meet the needs of the population of its district. The production of chemical medicines is concentrated in one organization—Gosmedtorgprom—with the exception of individual preparations, the production of which in isolated cases is in other organizations (pharmacy management organizations and republican medtorgs); all production is regulated by a single program of the USSR Supreme Economic Council, coordinated with the People's Commissariat of Health of the RSFSR. The production program of the pharmaceutical industry is regulated by the People's Commissariat of Health of the RSFSR with the participation of the People's Commissariats of Health of the union republics, both in terms of nomenclature and quantity of each preparation; the priority of production of each item is established from the point of view of the most correct satisfaction of the needs of public health. Distribution is carried out according to norms established by the people's commissariats of health in accordance with indicators characterizing the state of public health in a given oblast or krai. The regulation by the People's Commissariat of Health also extends to goods produced by other branches of industry: chemical, textile, etc. The distribution of imported medicines and equipment is also carried out according to coefficients established by the people's commissariats of health. Gosmedtorgprom implements all import applications on a commission basis, without bringing the orders of pharmacy management organizations to its warehouse. The regulatory role of the People's Commissariats of Health consists not only in establishing limits for the amounts of the import contingent, but also in establishing the nomenclature of medicines and medical equipment permitted for import. The most important items are allowed to be imported, without which public health cannot do without.

M. Khaimovich.

In addition to establishing management, financing, supply, and other organizational aspects of M. A., the reforms also affected the internal side of the matter. M. A. becomes the most important component of public health not only as part of therapy, but also as one of the essential measures for the prevention of diseases. The fight against infectious diseases (disinfection, hygiene items, sanitary chemicals), against carriers of infections (insects, pests, rodents), and other measures for the improvement of the population cannot do without the use of medicinal substances in the broad sense. The task is only to bring M. A. in line with modern needs and to rationalize it, and most importantly, to establish the correct attitude toward medicine and its role. For this purpose, the drug catalog was first revised. In no field of production is there such a huge quantity of products and such a rich nomenclature as in the pharmaceutical. Throughout the centuries, man has tried everything and anything to overcome his ailments. A thousand-year empiricism has left us a mass of all kinds of medicinal materials and means. Many of them were at one time rejected and then again came into use. Means, long ignored as 'folk' or shamanistic, suddenly receive justification and widespread application (adonis, ephedra, harmal, etc.). In the tariff of 1911 there were over 4,000 means, in any foreign price list one can count many thousands of preparations; one patented means circulating on the foreign market number several tens of thousands. Medicines of the same composition are masked by various names and through all kinds of advertising are brought into general use. One and the same preparation is issued in different kinds and forms, for example: powder, aqueous infusion, alcoholic tincture, liquid, semi-liquid and dry extract, etc. With the predominant significance of private medical practice and private organization of M. A., there is no incentive for a radical revision of this entire arsenal of means and for a thorough cleaning of it. But already at the first steps of the nationalized pharmacy, the question of revising the catalog was raised in our country, and in 1920 a solid list of medicines was published, containing only 324 names. In addition to this first-priority list, lists of the second and third priority were developed. In the current rules on the procedure for organizing a pharmacy, the list has been extended to 300 items (circ. NKZ No. 286, 1927). With patented means, if they are not expedient, a relentless struggle is conducted (see Ready-made means). In addition to strict registration rules in the USSR, advertising of medical means is limited. Means of secret composition are completely not allowed. Instead of the previous system—to allow into circulation everything that is not harmful, the rule is introduced—to allow only what is unquestionably beneficial. The value of new means is preliminarily tested in pharmaceutical laboratories and clinics. Measures have been taken to rationalize M. A. by standardizing active principles, clarifying the rationality of one or another medicinal form, rationalizing prescriptions, replacing imported raw materials with domestic, etc. For the purpose of combating symptomatic self-medication and pharmacy shamanism, orders have been issued (circ. No. 134, 1919 and No. 73, 1926) to discontinue the dispensing from pharmacies of means with the name of the disease for which they are used, as for example 'tooth drops', 'cough drops', 'powders for headache', 'stomach drops', etc. By these same circulars, the dispensing of any means without indication of composition is prohibited, and treatment in pharmacies is forbidden. For the purpose of rationalizing M. A., a whole series of instructions on the preparation and dispensing of medicines, on the procedure for writing prescriptions, etc., have been issued (see Prescription). One of the forms of rationalization of M. A. is the mechanization of medicinal forms and standardization of prescription formulas (see Dosed preparations). Of the 395 million prescriptions per year projected in the five-year plan for the RSFSR for the main types of medical assistance (for the USSR over 500 million), 70-75% will be prepared in factories and laboratories according to standard formulas. This enormous work raises a number of scientific and technical problems, for the solution of which appropriate specialists and research institutions are required. The new organization of M. A. raised the question of the proper equipment and arrangement of pharmacy institutions. On the other hand, the nationalization of the pharmacy led to the concentration of pharmacy affairs. In 1914, 6,700 prescriptions (on average) fell on one private pharmacy, while in 1928—about 32,000. In cities, a pharmacy filling 200 prescriptions a day was previously considered very large, but now it is not uncommon for pharmacies to issue 1,000 or more prescriptions a day. These circumstances made it necessary to rebuild pharmacies and rationalize labor processes. Large sums have been spent on reconstruction and new equipment. For example, the Moscow Pharmacy Administration spent over 1½ million rubles on this purpose in 6 years, and about 1 million rubles on the establishment of new pharmacies. The aim of all reconstructions was to ensure the best sanitary-hygienic conditions for the storage of materials, for workers, and for visitors, and to create conditions for the most productive and least tiring pharmacy labor. Significant division of labor and specialization have been introduced, convenient assistant desks adapted to new tasks, consultation rooms, duty rooms, etc., have been arranged. In terms of external arrangement, we have achieved significant success and have given an example of a new modern pharmacy seen nowhere else so far. For the further improvement and enhancement of M. assistance, an experimental station of the NKZdr. for the rationalization of the work of pharmacy institutions has been organized, whose tasks, among other things, include the rationalization of M. A. based on improving quality, speeding up dispensing and reducing cost, the study of labor and technological processes of work, the rationalization of the preparation and storage of medicines, the arrangement and equipment of pharmacies, warehouses and laboratories, the development of standards of medicinal forms, apparatus, etc. The new pharmacy created a need for workers of a new formation, and the training of personnel was fundamentally changed. Instead of the former apprenticeship training in pharmacies with subsequent examination, special secondary and higher pharmaceutical educational institutions were opened (see Pharmaceutical education). Supervision over the quality of medicines as products not subject to control by the consumer himself plays a special role. Before the revolution, each pharmacy was obliged to analyze all incoming medicines, but this requirement was observed nowhere with the rarest exceptions. Revisions of pharmacies were carried out rarely and mostly under the guidance of medical inspectors incompetent in pharmacy matters. Control often amounted to the fulfillment of formal procedures. The fragmentation of enterprises hindered the establishment of a proper system of supervision. In the Soviet pharmacy, a systematic system of measures has been developed for this purpose. A system for controlling the production of pharmaceutical preparations in factories has been established (circ. NKZdrava No. 114, 1928), periodic revisions of warehouses and pharmacies (circ. NKZdr. No. 114, 1922 and No. 134, 1923). Each warehouse must have an analytical laboratory for checking all incoming medicinal materials (circ. NKZdr. No. 141, 1924 and No. 125, 1929). In many places, the periodic withdrawal from pharmacies of medicines prepared there according to doctors' prescriptions for checking in the laboratory is practiced. For general supervision of the activities of all pharmacy institutions and systematic revisions, pharmaceutical subdepartments were established at health departments, and at present the position of pharmaceutical inspector exists. At the NKZdr. of the RSFSR there is a pharmaceutical control-testing laboratory, whose duties include: a) development of new methods for the research of medicinal raw materials, pharmaceutical preparations and ready-made medicines; checking and modifying existing research methods; b) study and development of questions of pharmaceutical practice concerning the preparation of medicines, storage of raw materials, pharmaceutical preparations and ready-made means; c) study and development of questions concerning the rationalization of the drug catalog; d) study and development of questions in phytotoxicology. In addition, the laboratory performs control analyses and expert examinations on issues of research of medicinal materials. In the jurisdiction of the NKZdr. of Ukraine there is an experimental pharmaceutical institute, whose tasks include the experimental development of scientific questions of pharmacy, the search for new medicinal means, the study of medicinal plants of the Ukrainian SSR, control over the quality of medicines, care for the improvement of the qualifications of pharmaceutical workers, etc. Scientific research in the field of pharmacology in the RSFSR is carried out by the chemical-pharmaceutical institute of the VSNH, which mainly serves the needs of the pharmaceutical industry. Sanitary-educational ideas, implemented in the concrete practical work of the pharmacist and pharmacy, are supplemented by educational propaganda carried out through the printing of sanitary-hygienic information on packages, labels, wrapping paper, the organization of exhibitions, the sale of popular brochures, etc.

Through one wrapping paper and packaging material, prepared by Gos-medizdat, about 60 million leaflet-slogans were distributed in 1928 and 1929 through pharmacies. The entire enormous work of reorganizing medical assistance was carried out with the active participation of the mass of pharmacy workers and their union organizations. With their help, management and control bodies were created and all guiding provisions and circulars were developed. All congresses and conferences of pharmacy workers were devoted to general and specific issues of pharmaceutical construction. In addition to trade union congresses, mention should be made of the All-Russian pharmaceutical conference in 1926. In terms of the number of participants (587), in terms of the volume and nature of the issues and methods of their development, this congress was the largest stage in the construction of medical assistance in the recovery period of the national economy. Provisions on central and local management and supply bodies were developed depending on new conditions, special forms of organizing medical assistance for peasants and insured persons were established for the first time, and attention was fixed on the special importance of the quality of medical assistance, on the state and prospects of the pharmaceutical industry. For the first time, the role of the pharmacy in the Soviet healthcare system was defined with sufficient clarity. The congress paid exceptional attention to issues of personnel training, developing the fundamental principles and details of higher and secondary pharmaceutical education. For the first time at an organizational congress, scientific issues of pharmacy were raised in a special section with reports on experimental work, with criticism of the pharmacopoeia, with the development of analysis methods, etc. Thus, the entire Soviet system of medical assistance, which fights against medicinal fetishism, against panaceas, against patent medicine, against symptomatic self-treatment for the economical and rational use of drugs, performs its role in the healthcare system in establishing the principles of prevention, sanitary education, planning, and improving quality.

I. Levinstein. V.M.E. vol. XV.