Medical Care

Medical Care, one of the basic functions of public health (see), carried out both in the system of special institutions [hospital, outpatient clinic, polyclinic (see), etc.], and in the system of comprehensive [dispensary (see), healthcare point at an enterprise, etc.]. Historically, the organization of medical care arises at a relatively high level of development of economic forms. For primitive society, the isolation of the sick, leaving them without help, is characteristic. This also includes cases of leaving the elderly without help and even their killing, cases of killing infants, etc., i.e., the liberation of the collective from anyone who burdens the already meager budget of material resources of this society. With the development of society, the forms of isolation and the reasons for isolating individual members of the collective change [isolation of menstruating women, women in childbirth, some patients ('unclean', 'possessed')]. Further empirical experience showed that by expelling the sick beyond the limits of the collective, the latter in a number of cases was protected from the risk of diseases of other members (infectious diseases) or from patients dangerous to the collective from a social point of view (mentally ill). Social needs arising from the given economic formation, relying on empirically accumulated experience, subsequently form a series of hygienic prescriptions and instructions in one form or another of compulsion, which already arise at early stages of human history. Therapeutic medicine and medical care as known systems arise much later, as the level of productive forces and developing natural science provide material for corresponding generalization. When the social productive forces developed to such an extent that public provision of medical care for the collective as a whole or its individual parts became a necessity for this mode of production, only then does medical care begin to emerge as an organizational form of public health. A characteristic example of this is the organization of hospitals for slaves in ancient Rome. In agricultural notes (146 BCE), relating to the era when Rome had already entered a new era of capturing overseas possessions and when large estates, organized at that time, extensively exploited labor force, in which there was then no shortage, Cato wrote: 'One must remember that when nothing is done in the economy, expenses for it still go. One must use every opportunity to save: a slave, once he falls ill and is unable to work, should have his daily ration reduced... Everything unsuitable for the economy must be sold, including aged or sick slaves.' On the contrary, in Varro, writing in the early 30s BCE, the attitude toward preserving the health of slaves is already different. Large estates (latifundia) by that time had become widespread and required an ever-increasing number of workers. The need for labor force could no longer be covered by the conquest of new lands and the increase in the number of slaves. Therefore, in Varro, especially due to the low productivity of labor at that time, we observe special care for preserving purchased slaves along with ruthless, unprecedented exploitation of them. And since with the loss of slave labor force the capital spent on it was irrevocably lost, more care was taken about the health of a slave than about the fate of a hired worker. Varro directly advises putting a hired worker in place of a slave in all those cases where it is easy to fall ill and die. We therefore find in ancient Rome of this era care for the health of the population, arising from the peculiarities of the socio-economic structure of that time: care for the health of slaves on the one hand and the ruling elite on the other, while the huge masses of dispossessed and landless peasants and small artisans were left to their own fate, to death from diseases and epidemics. To this period also belongs the organization of hospitals for slaves. Even more clearly, the care for slaves is outlined in the treatise of Columella, written in the 60s of the first century CE, in an era of acute shortage in slave labor force. This enlightened owner already puts forward a number of requirements regarding the regime of slaves, insisting that they should not lack clothing and food and that their other needs should be satisfied. A hospital is already an essential part of a large latifundium. Columella also introduces elements of professional selection in the distribution of labor force. In the plantation economies of the ancient world, medical care for slaves obviously followed from the necessity of preserving and ensuring the interests of the corresponding mode of production. Subsequent historical epochs do not provide such vivid examples of the direct connection between the organization of medical care and production, and only in the era of developed capitalism and at its expense does the organization of medical care as a necessary link in public health measures again appear quite clearly, but on a new basis and in more complex connections and interactions. One of the most important driving forces for the organization of medical care for workers in a highly technically organized capitalist society are the contradictions arising from class struggle and the need to maintain the continuity of the production process. The hospital of the Middle Ages and the early stage of capitalist society in industrial countries grew out of the need to isolate the contagious; it was the dominant form of organization of medical care at that time. The era of primitive capitalist accumulation with mass expropriation of peasants and unrestrained exploitation of labor force with its extensive use placed the worker in relation to the production process in different conditions than in the modern large enterprise, when the worker has completely turned into an appendage of the machine. Therefore, it is also natural that general hygienic measures and the fight against epidemics attracted more attention in that period than medical care. The treatment of the sick continued to remain a private affair, and since its cost was very high, the worker was naturally forced to turn to a folk healer. In an agrarian state, which still preserved traces of feudal survivals and was based on low technology, the main motivating factor for the development of medical care is the fight against epidemics threatening the health and life of the ruling class and constituting a threat to the commercial operations of such a state. The mass construction of hospitals by municipal and charitable organizations, as well as the construction of factory hospitals, dates back to the middle of the 19th century. The interests of maintaining the continuity of the production process on the one hand, the growth of the proletariat and its class consciousness, and consequently the increase in pressure from its side on the ruling classes on the other, created at the end of the 19th and beginning of the 20th century a different organization of medical care in social forms with a relatively wide coverage of the population. However, the antagonistic processes of development of capitalist society limited it mainly to forms of hospital care, preserving for outpatient treatment the institution of private practice in various forms (private practice in its pure form, panel doctors in Germany, Austria and a number of other countries, etc.). At the same time, technical progress forcefully invaded the field of medicine, strongly affecting and pushing its further development. A conflict arose between the medieval forms of medical labor and medical care on the one hand, and the level of modern science and technology on the other. In Western Europe, the private practicing physician still now makes attempts to turn back the wheel of history and protests against the ongoing spontaneous process of socialization of medical care and its new forms of organization in the form of outpatient clinics and dispensaries. However, modern technology, the level of medical knowledge and the need to cover significant masses of the population make the organization of large medical institutions the only possible one. The more practical American physician tries to preserve his role as a private physician in the new organizational form of a large medical institution. In the USA, groups of physicians are organized on the model of joint-stock companies, which use a hospital or outpatient clinic as a place to apply their labor. But in the USA there are also a number of private practicing physicians who make attempts to compete with both outpatient institutions and hospitals, vigorously resorting in their private medical practice to all methods of capitalist competition—advertising, generous favorable credit for patients, etc. In any case, in the main capitalist countries, the organization of medical care for the population is characterized by one common feature: low quality, in hospitals with insufficiently specialized medical personnel, with worse equipment and care for patients—for the working population; luxurious hospitals—for the exploiting elite. The organization of out-of-hospital care has not yet received the necessary development in capitalist countries, mainly due to the struggle of physicians against it; meanwhile, modern knowledge and techniques for examining patients make it impossible to have any scientifically based treatment outside an equipped medical institution.

Thus, qualified treatment using advanced research methods (X-ray, cardiography, functional diagnostic methods, competent specialist consultation, etc.) and expensive treatment methods (physiotherapy, mechanotherapy, etc.) are inaccessible to the working population; their application is limited mainly to severe cases that are accommodated in a hospital setting. A small number of institutions of this type, organized in some countries by insurance funds or municipal authorities, only to a negligible extent satisfy the need for these facilities. Private medical institutions of this kind charge such high fees that they are completely inaccessible to the working masses. The social insurance system (see) in capitalist countries, under which only a portion of the worker's wage is paid to the sick worker, keeps him from entering a hospital until the last possible moment. The lack of qualified outpatient clinics that would provide accessible assistance to workers without removing them from production leads to a systematic increase in chronic diseases and a heightened need for hospital beds. Dispensaries (see Dispensary and Dispensarization) as a technically higher form of medical organization have extremely limited spread in capitalist countries and their activity has a specific social content. They are mainly of a philanthropic nature. Many such institutions in Europe were built by the Rockefeller organization as part of the cultural expansion of American capital. Thus, even here one cannot speak of a system of medical institutions; the chance occurrence of their establishment, territorial distribution, and methods of their work to a large extent nullify the effectiveness that a network of institutions could provide if it were rationally and systematically organized. The entire system of medical organization outside a unified state plan with the economic accounting of individual hospitals excessively increases the cost of hospital care, distributes it unevenly across the country, and does not make possible the intensive use of existing bed funds. There is as yet no unified international methodology for calculating the need for bed assistance in Western European countries, just as there are no strictly fixed coefficients for the bed network. In countries with a developed bed network, the number of inhabitants varies within the limits of about 200 per 1 somatic bed, namely: in Germany 1 bed per 200 inhabitants, in Austria 1 bed per 230 inhabitants, in Denmark 1 bed per 230 inhabitants, in the USA 1 bed per 270 inhabitants, in New Zealand 1 bed per 200 inhabitants. Although the total bed funds are significantly higher, it is necessary to calculate here on somatic beds, since it is precisely these that serve the mass morbidity of the population. In Denmark the total bed fund in 1927 was 8.5 per 1,000 inhabitants, or 1 bed per 119 inhabitants; but of this fund, beds for the mentally ill account for 1.95 beds per 1,000 inhabitants, or almost 20% of the bed fund. In New Zealand in 1927 the total bed fund was 9.2 beds per 1,000 inhabitants, and beds for the mentally ill occupied almost 50% of the entire bed fund and amounted to 4.8 per 1,000 population. In Germany the fund of beds for the mentally ill is about 30%; in America hospitals for the mentally ill and institutions for the care of the disabled also occupy a large place, thereby reducing the availability of mass service for acute cases. The distribution of the network is extremely varied, and as a result various regions of the country are usually very unevenly provided with bed service. Unprovided for in terms of medical care and in particular bed assistance remain most rural areas, and the high cost of treatment also makes qualified medical care inaccessible to the petty bourgeoisie. In Germany the norms of bed care per 1,000 population in various provinces and cities can be seen from the table provided: Number of beds per 1,000 population. Hamburg.......11.6 Berlin.......6.1 Bremen.......9.2 Mecklenburg.....3.2 Westphalia ...... 7.5 East Prussia .... 3.1 Rhine Province ... 7.1 Brandenburg .... 1.9 Baden........6.2 In the USA in 1927 there were 198 inhabitants per bed in the North Atlantic states, 209 in the Western states, 267 in the North-Central states, 430 in the South Atlantic states, and 580 inhabitants in the South-Central states. In the counties of the state of Alabama 47% of counties lack hospitals, in Arkansas only 42.6% of districts have hospitals, in Mississippi 45.2%, and in Georgia only 30.4% of districts are provided with hospitals. In the report of the federal Department of Health of the USA for 1928 it is stated that if necessary appropriations are allocated, it will take at least 10 years to create a basis for organizing medical care in rural areas. But even the existing bed network of America does not serve to provide the broad masses of the working population. The report of the Herbert Hoover committee, which conducted an investigation on the latest changes in the economy of the USA, confirms the actual non-utilization of a larger part of the bed fund by the population. The report states: 'Not all hospitals are equally accessible to persons who have become ill or have been injured. Some hospitals are under the exclusive control of the government (quarantine prisons and prison hospitals) or limited groups of donors, such as hospitals of the Veterans Bureau, military hospitals, naval hospitals, merchant marine hospitals, institutions of individual states for the nervous or mentally ill. The growth of hospitals belonging to public self-government and institutions open to the entire population more accurately indicates the actual provision with hospitals. In 1927 the number of such hospitals was equal to 442,913 beds'. Thus, of the total bed fund of 853,318 beds shown in the reports of the federal department, almost 50% serve very limited circles of the population. No less interesting is the fact that in America with its extremely high technology and high cost of hospital construction, a significant portion of hospitals are not equipped with qualified diagnostic facilities; in 1927 only '64% of hospitals were equipped with clinical laboratories and X-ray equipment. Data that can serve to characterize the accessibility of medical care in the USA are also provided by Louis and Dublin, who calculated that the total amount of expenses for maintaining patients in somatic hospitals amounts to about 500 million dollars a year, of which about ²/3 of this expense is covered by the income received by hospitals from their patients, and only about 116 million dollars constitute the value of services rendered by hospitals free of charge. But even this amount, if subjected to further breakdown, is significantly reduced. Of the total expenses for free treatment only 42 million dollars were spent on general hospitals, and over 120 million dollars on hospitals for the mentally ill. The authors of the report on the state of health in America in the 'Annual of the League of Nations' indicate that only the rich, who can afford medical care and bed treatment, and the poor, who resort to charity, can use the existing network. For the majority of the population, i.e. about 75% of it, as indicated in the report, obtaining medical care is often almost unattainable. If one turns to the materials on Germany, then here too one can observe some similar facts, although for workers who are covered by social insurance (in the USA there is no social insurance), bed care is paid for by the fund. The most suffering group of the population in Germany is the rural peasantry; the average payment for maintenance in a hospital per day ranges from 4 to 5^th/100 marks in the III class, with additional charges being made for special medicines and treatment up to a special payment beyond the cost of the bed-day for the administration of salvarsan.--The unplanned organization of bed care, the uneven territorial distribution of the network, the economic accounting of hospitals, the high cost of treatment and mutual competition are accompanied by another phenomenon, which to an even greater extent reduces the effectiveness of the large bed fund. Bed vacancy reaches enormous proportions. In Germany the bed network should be considered 30% lower than actually existing. In somatic hospitals one bed functions 235.5 days a year, in maternity institutions only 220.3 days and even in hospitals for the mentally ill only 300 days. The effectiveness of the use of the network can be traced by the following comparative data. In 1924 the bed network of Germany with 471,716 beds produced 119.7 million bed-days; in the RSFSR in the same year the bed network, which was 117,077 beds, i.e. four times smaller, produced only half as much-53.1 million bed-days. Through the bed network of Germany in the same year passed 2,887,000, and through the bed network of the RSFSR-3,695,000 patients. .. In pre-revolutionary Russia the beginning of the more or less widespread development of medical care should be attributed to the era of zemstvos. The specific conditions of an agrarian semi-feudal country with very high epidemicity gave the organization of medical care in Russia at the end of the 19th century a somewhat different character than in industrial countries.

Zemstvo medicine was predominantly rural medicine (see Healthcare) in contrast to the West and America, where public medicine developed mainly as an organization of urban medicine. Another of its organizational features was that it was built to a large extent as an outpatient organization, and its inpatient network was comparatively insignificant. Most zemstvo hospitals were very small in size, were not equipped with qualified facilities, and did not provide to a proper extent qualified and specialized medical care. This should also be attributed to the network of outpatient clinics, which in the best case were served by one doctor who had a huge workload and a large area radius, and in a significant number of cases were served by a feldsher. The territorial placement and development of the zemstvo medicine network also usually had a random, unplanned character, and medical areas were actually inaccessible to the majority of the peasant population, which due to the lack of horses and poor roads in tsarist Russia could not make sufficient use of them. Urban medical care was also underdeveloped; especially underdeveloped was the medical care for the factory and plant proletariat (see Healthcare). The October Revolution inherited from the old order an unplanned built, incorrectly territorially placed, low-qualified apparatus of medical care, which completely did not satisfy the class demands of the proletarian state. A radical restructuring of the entire healthcare system had to take place, it was necessary to organize the service for the urban industrial proletariat and develop a network of qualified medical institutions with specialized medical care.-The dynamics of the development of medical care for the working population after the October Revolution in the USSR is characterized by the following figures: 1913 G.

1927 G. Rural medical areas ... 3 935

1,068 Dental care for the population has developed significantly, which before the revolution was limited only to the offices of private practitioners. In 1927, there were 2,383 dental chairs in the RSFSR, and in the outpatient clinics of the Ukrainian SSR - 1,053. Special physical therapy clinics were newly built, and a network of physical therapy installations was developed in outpatient clinics (see Physiotherapy). Special diagnostic and sanatorium beds for tuberculosis patients were organized. Along with this, special state institutes were newly established, which not only provide qualified treatment but also develop scientific problems in all branches of therapeutic medicine (see Institutes). It is particularly necessary to note the development of medical care in the national republics and on the outskirts. Resort care, which is only accessible to workers in the USSR (see Resorts), the widespread development of local sanatoriums, and the system of rest homes (see) are necessary elements in the organization of medical care in the Soviet Union. It is also necessary to note a special system of institutions in the form of night and day sanatoriums (see) and dietary canteens (see), which have as their purpose, without removing the worker from production, to provide him with qualified treatment, the most favorable aspects of living conditions and regimen, which would allow him to compensate for the beginning or developing disease in a short time. A very important link in the system of medical institutions during the reconstruction period is the health post at the enterprise (first aid post). In relation to medical care, it is entrusted with the task of organizing highly qualified first aid, which is the starting point for preventing the consequences of professional trauma, disability, and the fastest restoration of working capacity. The organization of medical care in the USSR strives to create a systematic organizational structure that should primarily reflect the need to preserve and quickly restore the working capacity of the production collective. It strives not only to provide rational and qualified assistance to the already sick, but also to influence the early stages of the disease in an organic connection with all branches of socialist health care. Thus, medical care in the system of socialist health care, in its specific application, is permeated with elements of prevention, and the treatment itself, in accordance with the current level of science, relying on prevention in its practice and methodology or supplementing it, becomes itself the starting point for preventive measures. Such an organization of medical care requires a high specialization of medical personnel, based on the physician's mastery, along with deep knowledge in their specific specialty, of the general methodology of medicine and socialist health care. Therefore, at the present time, it would be incorrect to build medical education and the organization of medical care with an eye toward a universal physician, a non-specialized 'therapist' with the assignment of a number of other functions (zemstvo district physician). This type of physician corresponds to an underdeveloped system of medical organization even under conditions of its greatest accessibility and proximity (universal home physician). The historical development of medical care, as well as medical-sanitary affairs in general, went in the direction of increasing specialization and differentiation of functions. However, under the conditions of bourgeois medicine, such specialization leads to professional limitations. This professional limitation cannot be overcome by bourgeois medicine even under conditions of the growth of technically more perfect forms of organization of medical care-institutions of public health (large hospitals, dispensaries, etc.). Under the conditions of socialist construction, the specialization of medical-sanitary care, representing a necessary form of division of labor, at the same time ensures the unity of medical care and a unified approach to the patient despite this differentiation, thanks to the principle of planning inherent in the system of socialist health care. The class orientation of medical care in the USSR consists not only in the preferential service of the working population, but also in the fact that the organization of medical care is inextricably linked with the tasks of socialist construction and ensures primarily its leading sectors. The organization of medical care sets as its goal the improvement of the broad masses of workers, the struggle to reduce morbidity in the overall system of measures of Soviet socialist medicine. Planning of medical care should therefore ensure the implementation of these tasks. When planning the bed network, it is necessary to proceed from its geographical location in accordance with the requirements of socialist reconstruction (main industrial areas, the socialist sector of agriculture), as well as from the accounting of the need for inpatient treatment of certain groups of the working population. Materials for calculations that most fully reflect the need for hospitalization of patients can serve as statistics of morbidity with loss of working capacity. The basis for calculating beds for the five-year health plan in the RSFSR was the selection for a bed at the rate of 18% of the total number of cases of disability. This number almost coincides with the number of days of illness requiring hospitalization, developed according to the nosological table of diseases, and is the upper limit of saturation of the need for beds. To calculate the need for infectious disease beds, it is necessary to proceed from the actual morbidity of infectious diseases and multiply the coefficient of cases of this infection by the average duration of the disease - in this infection or group of infections; the product will give the coefficient of the number of bed-days, and the quotient from dividing by the number of days of functioning of the bed - the coefficient of infectious disease beds. The methodology for planning outpatient care is significantly more complex. The need for outpatient care (see) is formed under the influence of a number of factors: the size and composition of the population, demographic processes, morbidity, the nature of production, its role in socialist construction, etc. The most difficult is determining the saturation threshold in these types of care. Materials of appeal and attendance are very unreliable, as they are extremely variable; they could serve as a reference point only in the case if they exhaustively covered the actual morbidity. A more reliable material in this case should be considered the statistics of morbidity with loss of working capacity with correction based on materials of some types of morbidity without loss of working capacity. The system of outpatient care institutions plays an extremely important role in the struggle to reduce morbidity, as it must ensure the provision of medical care without removing the worker from the process of labor; it must be sufficiently flexible in its forms and methods of work and correspond to the main requirements made by the branch of the national economy to which the organization of medical care is adapted. The Soviet state, completing the construction of the foundation of socialist society, is transforming the entire system of human habitation, thereby eliminating the causes of morbidity. Therefore, in the perspective of socialist construction, medical care as such will have to follow a declining curve.

M. Landis