Sanitary Organization

SANITARY ORGANIZATION. The concept of a sanitary organization commonly includes not only the specific composition of the sanitary personnel engaged in sanitary supervision, but also all the issues concerning the very structure of sanitary work in a given territory, the scope and forms of activity of the respective sanitary bodies, and other organizational and practical areas of their work. Therefore, in the study of public health and its overall organization, the sanitary organization is an important component problem, often coming to the forefront among all public health problems. If it is currently considered an indisputable proposition that preventive and sanitary measures must lie at the foundation of all public health work, it is also obvious that for the implementation of these preventive measures there are necessary: a) specific sanitary bodies responsible for practical work in this field, b) a specific system of legislation defining the structure, tasks, and rights of these bodies, as well as the scope of their activities, and c) precisely developed and planned programs of health-improving measures and routine sanitary work. At the same time, it is entirely obvious that the structure and forms of activity of the sanitary organization as a whole are closely linked to the general state of the socio-economic level of a given country and correspond to the respective class interests of the ruling classes of the population (see Public Health, Hygiene, Medicine). Depending on the historical course of development, as well as on the given socio-economic level and the entire sum of living and other material factors of the surrounding environment, a sanitary organization may assume various structural types and forms of activity. The main factor in the development of the sanitary organization in the past and present is the gradual, increasingly intensifying intervention of state power in this matter. From the sphere of personal interests of individuals, sanitary work has gradually entered the sphere of activity of the collective and taken shape as specific state bodies. Currently, the sanitary organization exists everywhere as an agency of state intervention in the field of public health protection, or rather the health chiefly of certain ruling classes (in capitalist countries). With the deployment of socialist forms of the national economy, issues are advanced not only of the passive protection of the population's health from various harmful influences of the external environment and surroundings, but also of active intervention in the direction of transforming the external environment based on hygienic requirements. The role and significance of the sanitary organization in socialist construction increase many times over, for it is entrusted with the tasks of making its own contribution to socialist construction. The defense of health from the harmful influences of the environment and their elimination, and the creation of new forms of labor and daily life that strengthen health, increase labor productivity, and create new impulses for the improvement of all surrounding life—all this invests new content into the work of the sanitary organization and modifies to a certain extent its structure and relationships with other bodies of state power and various groups of public, trade union, and cooperative organizations. Consequently, the forms of the sanitary organization can change significantly depending on the tasks of the moment, while remaining at the same time an increasingly expanding function of the state. Sanitary organization in pre-revolutionary Russia. As in all countries, the first beginnings of the sanitary organization in its primitive forms were connected in Russia upon their appearance with the tasks of combating epidemics. Several decrees of Peter I, especially in the field of military medicine, as well as some other laws of the first half of the 18th century, for the first time outlined the organization of certain groups of physicians for this purpose. A decree of the Senate dated 10/V 1737 required the establishment in a number of towns of special medical practitioners with a salary of 12 rubles per month. These practitioners were to perform administrative functions as well as treat patients ("provincial gentry, magistrate merchants, and inhabitants of all ranks"). The decree specifically defines the first sanitary functions of these medical practitioners—"to treat patients above all during times of occasionally multiplying, as happens in spring or autumn, all sorts of diseases, and besides, should there appear—which God preserve—in any provinces and uyezds any dubious or epidemic and contagious diseases." This initiative remained largely on paper, and by 1756, instead of the 56 town physicians authorized by the aforementioned Senate decree, there were only 26. The central body existing at that time, the so-called Medical Chancery, outlined in those same years the creation of the first sanitary institutions as well—in the area of combating contagious diseases. It developed a project for organizing special designated houses in towns "to ward off those suffering from contagious and infectious diseases." However, by a Senate decree of May 20, 1763, it was ruled "not to build special houses and not to appoint designated doctors and medical practitioners," assigning these functions to the town physicians already available. For the purpose of combating epidemics, it was proposed "that the said town physicians travel to villages near the towns to eradicate infectious diseases." The establishment of the Boards of Public Welfare in 1775 was associated with the gradual arrangement in the towns of Russia of almshouses, hospitals, pharmacies, etc., which led a wretched existence due to a lack of funds and the general archaic structure of local administration. Concurrently, the positions of uyezd physicians were introduced, and by the law of January 19, 1797, the state organization of this matter was formalized as the establishment of medical boards in provincial towns. The law establishes that "the duty of the Medical Board, apart from the assistance that the ranks within it are obliged to render to suffering people... is based on ensuring that, through taught rules and instructions, the public health of the entire province is observed; likewise, useful advice is given regarding the preservation of livestock." It is interesting to point out that the law lists more precise functions of the medical boards in the field of combating epidemics, as well as in certain areas of sanitary work in general. The duties of the medical boards according to the instructions of the law include: 1) "a physical and topographical description of the entire province with a detailed explanation of what most of all pours into the medical part"; 2) "during epidemic diseases, to depart immediately... and upon arrival at the designated place, having entered into an examination of the manifested disease, to try as far as possible to suppress it"; 3) "since all kinds of foodstuffs and cleanliness relate to the observance of public health, the Medical Board upon every occasion when it notices anything of the kind from which harm may spread, immediately reports to the provincial administration, having described in its report... should need require, also the method by which the foreseen evil can be averted." Thus, by the beginning of the 19th century, old pre-reform Russia had already created some primitive forms of sanitary organs, or rather outlined some sanitary functions of its administrative-medical organs. In general, this coincided with similarly embryonic forms of sanitary work in European countries. In fact, the medical boards and uyezd physicians created by government decrees conducted no regular sanitary work; epidemics spread unhindered across the country, and the sanitary level of the population was extremely low. It is sufficient to recall the massive plague epidemics of 1770–1773, when one of the capitals of Russia—Moscow—was severely affected, with the plague outbreak in this city accompanied by major civil unrest. Alongside these bureaucratic attempts in the field of sanitary work, one can also note some more grounded and profound proposals aimed at protecting the health of the population. Such is the well-known letter of M. V. Lomonosov to I. I. Shuvalov, "Discourse on the Propagation and Preservation of the Russian People." In this letter, Lomonosov outlines a number of sanitary-prophylactic measures for the protection of infancy (homes for children), for combating diseases (medical education and an increase in the number of doctors in all towns), for combating alcoholism, etc. Lomonosov suggested that by implementing the measures he proposed, the government could save up to half a million people for Russia annually. However, he naturally did not provide any concrete form of sanitary organization. The first half of the 19th century brought some changes in the organization of central medical bodies, which had little overall impact on the organization of sanitary work in the country. It remained in the same embryonic state, with the same purely nominal sanitary functions of the existing uyezd physicians and medical boards. The Medical Department, organized within the Ministry of Police and subsequently the Ministry of Internal Affairs, as well as the Medical Council created in those years, were typical bureaucratic superstructures that introduced no improvement into the arrangement of sanitary work in the country. Evaluating medical affairs in Russia, even the government commission of Academician G. E. Рейн (1910) had to point out the complete unsatisfactoriness of all this work and in particular emphasize "the complete loss of independence of medical administration in the country."

Separate government decrees from the same years provide only partial instructions on individual issues of epidemic control (decrees on reporting cases of contagious diseases in 1839 and 1842, on the establishment of quarantines in 1837, etc.). The Law of 1865 once again reviewed the scope and tasks of medical boards and again limited their functions in the field of public health protection solely to measures for combating epidemics. The so-called Medical Charter, which was in effect in Russia until the revolution, likewise did not contain any developed sanitary requirements and norms, repeating in some articles almost verbatim the texts of the aforementioned Regulation of 1797. The same governmental commission of Academician G. E. Rein (1912–1916) also points out here that "after 1865, the legislative activity of the government concerning the organization and arrangement of provincial and district governmental organs for the protection of public health was completely devoid of a general character and reduced exclusively to the issuance of minor clarifications, additions, and partial amendments to individual chapters of previously enacted legislative acts." The general system of state administration of the country and the socio-economic structure of the national economy did not create the necessary soil for the deployment of state sanitary organs and state sanitary legislation. However, the growing contradictions between this lack of state care for the sanitary setup of the country and the growing needs of the latter in this regard, especially after the abolition of serfdom and the development of new capitalist forms of economy (industry, trade, growth of cities, growth of the proletariat), nevertheless had to bring sanitary issues before the government in one form or another. And here the occasions for raising these issues were epidemics. Huge cholera epidemics from the beginning of the 19th century, as well as the Sevastopol campaign with its colossal outbreaks of typhus and other diseases, put forward the issues of combating epidemics as an urgent task for that time as well. As is known, the cholera epidemic of 1848 affected 50 provinces and, according to official data, yielded 1,742,439 cases of illness with a 40% mortality rate; the same cholera in 1853 yielded 249,788 illnesses and in 1855—331,025 cases. In the medical press of that time, issues of the reform of medical and sanitary affairs were discussed. Starting in 1865, the first journal in Russia dedicated to a certain extent to issues of hygiene and sanitation began to be published. This was the Archive of Forensic Medicine and Public Hygiene, where in the first years a number of articles by the first pioneers of sanitary work in Russia (Erisman, Molesson, and others) were published. This journal also reflected those forms and methods of sanitary work that began to be applied at that time by individual groups of doctors in the localities. The awakening of interest in sanitary issues was also facilitated by the general cultural upsurge of that era (the so-called 1860s and the reformist activity of the government), as well as the flourishing of hygienic knowledge of that time (Pettenkofer). In the same journal, in a supplement to it, an epidemiological sheet was printed with relevant data from European literature, etc. This revival of sanitary thought subsequently proceeded not along the line of reorganizing government medical organs and creating a state sanitary organization, but along the line of the emergence of the first sanitary cells in the localities under the jurisdiction of the local self-government bodies created at that time (zemstvos, cities—see below). To this same category of facts of awakening interest in sanitary issues should also be attributed the appearance of a number of sanitary-topographical descriptions of individual localities and cities, printed in various medical journals of that time. Among the government attempts aimed at the reorganization of sanitary affairs and some practical state intervention in this matter, over the entire period of the second half of the 19th century and right up to the revolution of 1917, one should dwell on: 1) the works of the so-called Botkin Commission (1886–87), 2) the organization of the central anti-plague commission (1897) and local sanitary-executive commissions, and 3) the creation of the ephemeral Main Administration of Public Health (Academician G. E. Rein, 1916). The occasion for the work of the Botkin Commission was the resolutions of the International Sanitary Conference in Rome in 1883, which emphasized the danger of the introduction of cholera and plague into Europe from within the borders of Russia. In connection with this, a report by Dr. N. Eck (Russia's delegate at the conference in Rome) on the topic "On Excessive Mortality in Russia and the Need for Sanitation" was heard in the Society of Russian Physicians in St. Petersburg in 1835 [sic: 1885]. This interesting report with a number of figures and comparisons, printed in the journal International Clinic for 1886, was submitted for discussion to the Society of Russian Physicians, for the consideration of which the author proposed the following three points: "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 and the usefulness of which has been proved by the experience of numerous cities and entire countries; 2) excessive mortality among the Russian population reduces its working capacity and brings the national economy to unprofitability; 3) raising the working capacity of the population, and with it the well-being and enlightenment in our homeland, is impossible without reducing mortality, and therefore the reduction of mortality and the means closest to it—sanitation, constitute our primary state necessity." The corresponding resolution of the Society was brought to the attention of the government, and the latter formed a special commission under the Medical Council "On the Issue of Improving Sanitary Conditions and Reducing Mortality in Russia." Botkin was appointed chairman of the commission. In the aforementioned report by Dr. Eck, high mortality figures in Russia were emphasized. In 1878, general mortality in Russia per 1,000 population was 37.2; in 1882 it was even higher—39. In that same year of 1882, the number of all deceased was 3,464,404, with the cause of death being determined by doctors for only 11% of this number, while 89% died without being seen by a doctor. The average life expectancy of a person living in Russia was estimated by the author for that time at 29 years; for Germany it was calculated at 37 years and for England at 53 years. In comparison with mortality in some European countries (England), Russia lost annually approx. 1,500,000 needless victims thanks to its high mortality. The Botkin Commission appealed to the localities in order to collect opinions on the issue placed before it. A summary of these data was published (see Public Health). A explanatory memo by the well-known hygienist Prof. A. P. Dobroslavin was submitted to the commission, who, having outlined a number of general measures, emphasized the necessity "to reorganize existing institutions in such a way that they could actually and constantly satisfy the primary state needs (sanitation of populated localities) or to create entirely new sanitary institutions and organs." Accepting this explanatory memo as the basis for discussion, the Botkin Commission came to the conclusion that "1) the business of preventing and stopping epidemic contagious diseases is an all-state matter and that the execution of sanitary engineering works and the management and observance of sanitary measures must be under constant government control, mandatory for everyone; 2) a central government institution is necessary which would manage all sanitary affairs of the empire both in eliminating influences harmful to health and in finding and carrying into execution conditions contributing to the improvement of public and private health, which would guide all initiatives of local institutions in introducing sanitary transformations." In accordance with the foregoing, the commission came to a unanimous resolution that it is necessary to establish a Main Administration for Health Affairs, where all sanitary affairs of the empire and permanent government supervision over the execution of sanitary engineering works and the application of sanitary measures should be concentrated. The work of S. P. Botkin's commission was not completed; the gathered questionnaire material remained merely material, and no practical steps were taken by the government. The very liberal public opinion of medical circles reacted skeptically to these projects. Corresponding reports at Pirogov Congresses in those years also did not meet with sympathy (the report of Dr. P. G. Rozanov—"On the Necessity of a Separate Ministry of Public Health in Russia" and Dr. A. L. Eberman—"On the Establishment of a Ministry of Public Health"—6th Congress). Continuing epidemics (cholera in 1892—620,051 cases; 1893—106,600), and then the dangers of plague outbreaks (large plague epidemics in India in 1896) led to a second attempt, already somewhat more real, in the field of state intervention in sanitary matters. By a decree of January 11, 1897, a special "Commission on Measures for the Prevention of and Combat against the Plague Contagion" was established. This commission was given broad powers, and it essentially had to replace the absent central government organ in this field. Certain funds were placed at its disposal. In 1900, the fight against cholera and yellow fever was also introduced into the functions of this commission, and in 1908—against typhus. Prince Oldenburgsky was appointed chairman of the commission, and from 1900—the Minister of the Interior.

As indicated above, in furtherance of this general resolution, the rules of August 11, 1903 established locally the so-called Sanitary-Executive Commissions to combat plague, cholera (and later typhus). These commissions were to be established in provinces and along railways immediately after the central commission declared a given area of the country unsafe regarding these infections. The local sanitary-executive commissions were to be guided in their activities by the instructions of the central commission. The composition of the local sanitary-executive commissions consisted mainly of administrative persons down to representatives of the clergy; the chairmanship was in the hands of the governor and, as stated in § 9 of the Rules, "furthermore, the commission includes 1 physician each from the provincial and municipal boards." Approximately the same composition was found in the uyezd sanitary-executive commissions. Thus, the main workers of sanitary affairs—physicians—were mere units in these commissions. The rules themselves largely repeated the general requirements contained in International Sanitary Conventions (Paris Convention of 1903). The commissions were granted broad powers to adopt specific measures—quarantines, cordons, compulsory isolation, deployment of hospitals, mobilization of medical personnel, closure of certain enterprises or institutions, measures along railways and waterways, etc. At the same time, in the practice of applying these rules, their main shortcoming immediately became apparent: a purely bureaucratic approach to organizing control measures, the incompetence of the commission's membership, the absence of permanent local sanitary bodies capable of carrying out operational work, and the persisting disunity of the entire medical organization among separate departments. Therefore, the activity of these commissions was purely superficial, and it had a certain significance only in organizing measures to combat plague in its endemic foci, where the first plague stations were organized using funds from this central commission. With respect to cholera and typhus, the role of these commissions was negligible. It must be pointed out that the creation of these commissions simultaneously provoked widespread protest from public medical bodies and local self-governments, which rightly emphasized the bureaucratic character of these Rules and the curtailment of the already insignificant rights of public organizations. The Pirogov Congresses, which headed public medical opinion at that time, also reacted negatively to these rules, and locally a boycott of these commissions was actually carried out by a number of zemstvo and municipal sanitary organizations. The government responded first with repressions and then with certain concessions. In 1905 (law of March 17), local sanitary physicians and physicians of city hospitals were introduced as permanent members into the provincial and uyezd sanitary-executive commissions. Subsequently, the Central Anti-Plague Commission limited its activity merely to allocating to localities the small monetary credits that were at its disposal (2-3 million rubles per year). Thus, this attempt by the government to create locally at least some temporary sanitary bodies with limited functions for combating certain infections produced essentially no results. From 1905 to 1916, there were new attempts by the government to reform the sanitary affairs of the country. In 1905-06, a commission under the chairmanship of Prof. Anrep worked under the Medical Council to draft a project for the organization of the medical and sanitary part in the Empire. A new cholera epidemic in 1907-10 (230,232 cases in 1910) served as an impetus for a new formulation of this question. The material for this served as a explanatory memorandum by Academician G. E. Rein, who was then Chairman of the Medical Council. A new commission under the chairmanship of S. E. Kryzhanovsky in 1910-11 again discussed issues regarding "the shortcomings of the medical and sanitary organization operating in the Empire and the establishment of general principles for the reorganization of this organization." At the same time, in that same year of 1910, there followed a legislative statement by 83 members of the State Duma pursuant to Art. 55 of the Establishment of the State Duma concerning the draft of a new law on improving the state-wide sanitary condition in Russia (Octobrist faction). Finally, even the State Council at its meeting on May 10, 1911 expressed the wish that "the government should proceed first of all to reorganize and unify the medical and sanitary part in the Empire." The memorandum of the 83 members of the State Duma, written in a very elevated and pathetic style, does not mince words in characterizing the bleak sanitary condition of the country and provides materials both on the organizational confusion in the management of this matter and on the high figures of morbidity and mortality of the population. As a conclusion, the memorandum proposes the creation of a central independent medical body that would engage in the detailed elaboration of the non-existent sanitary legislation in Russia, unite the fragmented sanitary activities of cities, zemstvo and local administrative organs, and also develop a provision and a plan for the general amelioration of the country and immediate measures to reduce pandemics and epidemics. The organizational form of such a central institution should have been, according to the memorandum, the creation of a Ministry of Public Health. The memorandum pathetically emphasizes that "we, the representatives of the people, can no longer remain silent; we have no right to do so and will be endlessly guilty before those who authorized us if we do not now say: further in the matter of state public hygiene of the people, it is no longer possible to continue like this, we have no right to tolerate any extra day and hour of state-wide unhealthiness and our unsanitary state one minute longer, every minute of delay is a state crime." It is completely obvious that all these resolutions, proposals, and decisions coming from the very top of the then government organs had their justifications in those economic losses that the developing industry and landlord economy were suffering from continuous epidemics and the low labor productivity of workers due to the same high morbidity. The pre-reform state of sanitary affairs in the country came into increasingly sharp contradiction with the demands of economic development. However, the methods of solving the issue naturally remained within the framework of the existing political system and did not attempt to touch upon the root questions in this area. The consequence of all the above-mentioned proposals was the formation of the last interdepartmental commission under the old regime in Russia to revise medical and sanitary legislation (Highest Decree of 1912), and here too there was a note by Nicholas II: "conduct the matter at an accelerated pace." Academician G. E. Rein was appointed chairman of the commission. The said interdepartmental commission commenced work on June 16, 1912 and during 1912-15 developed extensive material on the outlined issues. Within this commission, a special sanitary subcommittee was formed, whose tasks included the development of sanitary legislation in its material expression, as well as an organizational subcommittee, whose tasks included questions on the creation of central and local sanitary supervision bodies. As is known, the result of the work of G. E. Rein's commission was: 1) the drafting of a number of separate laws both on the general organization of medical affairs and on individual sections of sanitary affairs and 2) the organization of the Main Administration of Public Health, formed on the model of existing ministries (see Public Health). In extensive explanatory memoranda, the commission once again characterizes the sanitary condition of the country as very grave, again cites corresponding figures, and makes corresponding economic calculations of losses. The commission indicates that according to data for 1910, in European Russia 30.5 per 1,000 inhabitants died, whereas in Germany for the same year only 16.2 died. If one translates the difference in this mortality into absolute figures, it turns out that in 1910 alone in Russia 2,288,000 fewer people would have died if our mortality had equaled that in Germany. The infant mortality rate for 1907 was 23.2 per 100 born; out of 5,221,369 born, 1,217,436 children died under the age of 1 year. From acute infectious diseases during the five-year period 1905-09, 527.7 people died per 100,000 inhabitants per year in Russia (Norway—50.6). Finally, an exemplary experiment in calculating losses from high mortality and morbidity in Russia with a mortality of 28.9 per 1,000 in 1909 yielded the following figures: with a decrease in mortality to at least 18.0 per 1,000, there would be a saving of lives per year in the amount of 1,383,808, and a saving in funds of 615,241,420 rubles (treatment of patients, missed work days, premature deaths, etc.). Within the Main Administration of Public Health, the creation of a special sanitary department was outlined. This department was entrusted with the management of sanitary organization in the country, the prevention and termination of epidemics, and the fight against contagious and occupational diseases and alcoholism. In addition, within the Main Administration of Public Health there were also special sanitary-technical and construction parts with corresponding technical personnel.

Under the Main Administration, a Main Sanitary Council was established, which was entrusted with discussing legislative proposals, reviewing local petitions, and addressing matters of subsidies to localities. The Sanitary Council was scheduled to meet in sessions twice a year; its composition included representatives of the zemstvos and cities. Locally, district and gubernia medical-sanitary administrations and corresponding medical-sanitary councils were established, while in the uyezds there were uyezd medical-sanitary inspectors and their assistants (as well as uyezd medical-sanitary councils). In enumerating the functions of these local bodies, the main role was assigned to general administrative guidance and control over the activities of the sanitary bodies of the zemstvos and cities. During epidemics, the rights of all these bodies were expanded. The Regulation on the Institutions of the Main Administration of State Public Health was approved pursuant to Article 87 of the Fundamental State Laws on September 3, 1916, and thus a centralized medical-sanitary governmental organization was created in the country on the basis of a unified law. In practice, it was not implemented, because the State Duma rejected this law in the same year. All these projects of G. E. Rein's commission caused a sharply negative attitude on the part of public medical-sanitary circles and local self-government, which saw in them the same previous attempts to diminish their rights. This negative attitude was also transferred to those sanitary bills that had been developed by the commission (laws on the protection of water, air and soil, housing, foodstuffs, etc.), although they contained various necessary sanitary norms that had not existed previously. They were also noted for a predominantly formal resolution of issues, without sufficient elaboration of the organizational aspects and the participation of the population itself. By the period of the February Revolution of 1917, the country remained as before without a central body directing sanitary affairs, without a unified state sanitary legislation, and without an empowered sanitary organization universally implemented on the periphery. At the same time, negligible sums were spent on sanitary affairs in the country. According to the report of A. I. Shingarev at the 2nd Pirogov Congress in 1910, preventive medicine accounted for only 5.3% of the total expenditures on public health. Per capita expenditure on medicine and public charity in Russia in those years amounted to 62 kopecks. At the same time, the state with its central funds did not participate essentially in these expenses; allocations came almost entirely from local funds. The period from the February Revolution of 1917 to the October days, that is, the period of the Provisional Government's rule, did not introduce any practical changes to the general state of sanitary affairs. The sanitary condition of the country deteriorated even further as a result of the war and the food disruption, refugee crisis, and epidemics associated with it. By a decree of the Provisional Government of June 16, 1917, the commission for the fight against plague (see above 1897) was abolished, as well as the Administration of the Supreme Chief of the Sanitary-Evacuation Section, created during military operations in 1914. The same decree approved the Regulation on the Creation of a Temporary Central Medical-Sanitary Council, which was entrusted with a number of functions of a guiding and unifying nature, including on sanitary issues. The Central Medical-Sanitary Council was a collegial body that included representatives of various departments, material organizations, and also representatives of the Soviet of Workers' Deputies. The first session of this council took place in Petrograd on August 22-26 of the same year; it heard some reports of an organizational nature, bearing predominantly current significance. The Central Medical-Sanitary Council did not raise any major issues changing the entire structure of sanitary affairs and sanitary inspection in the country. The principal stance of the council, in accordance with the directives and moods of the Pirogov Congresses, followed the line of completely transferring all sanitary functions to the localities, that is, to the reorganized zemstvos and cities. The organization of the central sanitary body remained extremely unclear; questions of central sanitary legislation were equally indefinite. These tendencies manifested themselves in the sole document that partly attempted to reorganize sanitary affairs locally. A circular of the Ministry of the Interior addressed to the gubernia commissars of the Provisional Government on June 17, 1917, proposed to withdraw general sanitary inspection from the jurisdiction of local medical administrations (governmental) "if the respective zemstvos and cities express their consent to entirely assume this inspection. Likewise, Medical Administrations may be exempted from the obligation to participate in measures to combat contagious diseases on the condition that zemstvos and cities assume these obligations." The complete unsatisfactoriness of the state of sanitary affairs and the sanitary organization in the country remained unchanged. This lack of a state sanitary organization in connection with the growing demands of life led in prerevolutionary Russia to the creation of its peculiar forms of so-called public sanitation within the framework of the activities of zemstvo and municipal medical organizations. According to the statute on zemstvo and municipal self-governments, the latter were charged with caring for public health; however, expenditures for this cause were classified as non-obligatory. Thus, the law not only failed to fix the creation of any permanent local sanitary bodies here, but also transferred even current-nature measures in this area to the discretion of each individual municipal and zemstvo unit (city dumas and zemstvo assemblies). This led to the fact that no unified organization of sanitary affairs could be created in the hands of zemstvos and cities either. The very statute on zemstvo and municipal self-government covered only a part of the country's territory (34 old zemstvo gubernias and 9 so-called zemstvos of the Western Krai). A large number of cities also had only the so-called simplified municipal statute. Thus, a significant part of the country's territory could not be served by sanitary assistance even within the limits of their local rights. Zemstvo and municipal self-governments, which were nevertheless closer to the immediate demands of life than governmental bodies, could not remain aloof from issues of sanitary order. Epidemics, especially in rural Russia, and various other sanitary shortcomings could not fail to be the subject of attention of local bodies; however, the class character of zemstvos and cities manifested itself in this respect as well. In zemstvos with a predominance of landlord interests and large kulak farming, and in cities with a predominance of merchants and petty bourgeois, sanitary issues were formulated primarily in measures protecting chiefly the interests of these classes. Along with the development of medical aid by zemstvos and cities (see Public Health), sanitary bodies with a peculiar content of their work began to emerge. These bodies received the greatest development in the zemstvos of industrial gubernias (Moscow, Yekaterinoslav gubernias) and gubernias with large movements of agricultural workers (Saratov, Kherson, and other gubernias). In cities, these bodies began to emerge primarily in connection with the growth of industry and the general complication of urban life (large cities). The main type of local sanitary bodies was zemstvo sanitary organizations; municipal sanitary organizations were built on this type with some deviations. Chronologically, one of the first attempts to create local zemstvo sanitary organizations dates back to 1868, when the Medical Society in Kazan (chairman Prof. A. V. Petrov) developed a project for creating an institute of hygiene physicians in the gubernia. This project was submitted to the Kazan zemstvo, but was not accepted. An equally unsuccessful attempt was made in the Poltava zemstvo (1869), where the matter was also limited to corresponding projects. Further, in 1872 in Perm, the work of the first sanitary physician (I. I. Molesson) began. More systematically, this work began in Moscow Gubernia, where the first sanitary physician (E. A. Osipov) was also invited in 1876. A few years later, in 1885, a gubernia sanitary bureau was created in Moscow Gubernia and uyezd sanitary physicians were introduced, 1 per uyezd. Similar initiatives, expressed in the invitation of individual sanitary physicians, were also underway in some other gubernias (Samara, Kherson, Kursk, etc.), but according to data by Dr. Zhbankov, by the beginning of the 20th century these attempts in general were noted in only 11 zemstvos. By the period before the revolution (1910), according to data by the same Zhbankov, these attempts had already touched in one form or another 31 gubernias. As this author puts it, in these 31 gubernias sanitary bureaus either existed or currently exist (1910). In this year, sanitary organizations across Russia were noted in only 20 gubernias (Vladimir, Vologda, Voronezh, Yekaterinoslav, Kaluga, Kostroma, Moscow, Nizhny Novgorod, Novgorod, Penza, Perm, Ryazan, St. Petersburg, Saratov, Smolensk, Taurida, Tambov, Ufa, Kharkov, Kherson). In a number of gubernias, sanitary organizations were alternately opened and closed; a particularly large number of them were closed in 1905–1906 in connection with the revolutionary events of that time. The reasons for this closure were political considerations of Black-Hundred zemstvos.

The most accepted forms of the Zemstvo sanitary organizations were: a) the provincial sanitary bureau consisting of one or several sanitary physicians; b) peripheral sanitary physicians, usually 1 per uezd; and c) sanitary councils as collegial bodies in the province and uezd. An attempt to create grassroots sanitary organs was the so-called sanitary trusteeships. Peripheral sanitary physicians—the most essential part of the sanitary organization—increased in number extremely slowly. The reason for this was, as indicated above, the absence of directive instructions by law and the hostility of the local sentiments of the property-owning classes. By 1910, peripheral sanitary physicians existed in only 12 Zemstvos. The total number of sanitary physicians in the 20 Zemstvo provinces where there were various sanitary organizations amounted by 1910 to 142 physicians, of whom 20 were heads of sanitary bureaus, 8 were their assistants, 90 were sanitary and sanitary-epidemic physicians, and 24 were permanent epidemic physicians. At the same time, in some of the provinces these physicians formed a so-called full staff—1 per uezd, while in others there were 1–3 physicians. According to data by Z. G. Frenkel (All-Russian Hygienic Exhibition of 1913), there were 221 sanitary physicians in the 34 old Zemstvo provinces and 36 in the 6 western ones; a total of 257 physicians. According to data by Chertov and Zhbankov, the number of sanitary physicians in cities was significantly smaller, not counting Moscow and Petersburg, where, understandably, there were already at that time more significant contingents of sanitary physicians. In Moscow, the first sanitary commission under the city administration was established in 1878 in connection with the smallpox epidemic. This commission received a more solid formalization in 1884, which can be considered the beginning of the Moscow municipal sanitary organization. Until the very war (1914), the number of sanitary physicians in the city of Moscow did not change and consisted of 20 general sanitary physicians and 10 so-called market physicians; by the end of this period, there were 2 physicians in the municipal sanitary bureau. In most other cities, the number of sanitary physicians was counted in units (Nizhny Novgorod—3, Penza—1, Kyiv—4). Many cities had no sanitary physicians at all. The activity of the Zemstvo and municipal sanitary organizations was closely connected with the activity of medical care organizations. In their historical development, sanitary organizations (especially in the Zemstvos) went through a certain path of branching off from medical care organs, in the bowels of which they essentially originated and only gradually filled the content of their work with sanitary questions. This was the peculiar feature of the pre-war sanitary organization in Russia in contrast to the completely different type of sanitary organization in Europe. The latter arose everywhere as state organs on the basis of definite laws, with sharply outlined sanitary functions. Zemstvo-municipal sanitary organizations arose in the absence of state regulation of them and in the presence in their work primarily of administrative and organizational functions in the field of the general organization of medical aid. The medical district network that arose in a number of Zemstvos, the organization of hospitals, and epidemic needs necessitated the development of a number of issues of an organizational nature. These include the compilation of general reporting data on the activity of medical institutions, medical-statistical reviews of data on attendance for medical aid and on morbidity, preparation of issues on the further deployment of the medical network (service norms), issues of hospital construction, issues of hospital economy equipment (pharmaceutical business, nutrition of patients, etc.). Since Zemstvo and municipal medicine was under the jurisdiction of self-governments and maintained at their expense, all these materials had to be reported and included in annual reports. To carry out all this work, one of the physicians of the province or uezd was usually singled out, who added this activity to his usual official functions. This latter historically entered as the first content into the work of future sanitary physicians. On the other hand, the issues of combating epidemics—collecting and processing data on epidemic morbidity, organization of smallpox vaccinations and arrangement of calf-sheds, organization of epidemic detachments and infectious barracks, and some embryos of sanitary-educational work—constituted the second group of those questions that entered the sphere of activity of the first levies of sanitary physicians. Thus, for the first decades of the work of Zemstvo sanitary organizations (1870–1900), the applied significance of their work in relation to medical aid was characteristic. The sanitary organization of that time did not set itself independent sanitary tasks, or rather set them extremely insufficiently, paying main attention to the organizational issues of the medical business as a whole and to the sanitary maintenance of medical institutions. For this same reason, sanitary-statistical works became widespread, providing extensive and interesting sanitary-statistical material in a number of provinces. For these works, uniform programs and schemes were drawn up by a special commission of the Pirogov Society, which made it possible to make comparisons and conclusions across a number of provinces (work of P. I. Kurkin). These limited sanitary functions of Zemstvo and municipal sanitary organizations are reflected in all those instructions that regulate their work. In the same work by Zhbankov, a summary is made compiling all these programs and instructions. For sanitary bureaus, these functions were expressed as follows: 1) the sanitary bureau under the provincial administration is an executive body for all medical and sanitary affairs falling within the jurisdiction of the Zemstvo; 2) the sanitary bureau compiles all reviews and reports on the medical and sanitary part of the province; 3) the sanitary bureau organizes congresses of physicians; 4) the sanitary bureau processes data on the activity of medical institutions, on the morbidity of the population, and on its natural movement; 5) the bureau directs the fight against epidemics; 6) the bureau takes part in sanitary measures; 7) the bureau bears consultative and intermediary functions (supply of vaccines, ordering of medicines, invitation of physicians, management of inter-district plots, etc.). "Such are the complex functions of the sanitary bureau," notes D. N. Zhbankov. However, the greater part of these complex functions has only an indirect relation to sanitary work, and this reflected the peculiarity of the content of the activity of sanitary organs of that time in Russia. They could not acquire the actual significance of real sanitary organs. If one decodes that point of these instructions which speaks of sanitary measures, then here too the limitation of this activity is sharply noted. According to Zemstvo instructions, these measures, in which the sanitary bureau takes part, include: a) sanitary surveys and descriptions, b) compilation of mandatory decrees, c) sanitary supervision of factories, agricultural workers, schools, d) studies of water supply, e) arrangement of medical and food stations in places of movement of the labor force, f) arrangement of nurseries, g) sanitary enlightenment. Only in some programs are works of a laboratory nature outlined. As can be seen from the foregoing, a whole range of areas of sanitary supervision did not even formally enter into the activity of Zemstvo sanitary organizations; such are housing and sanitary supervision, food supervision, general improvement, etc. Along with this, in the practice of the sanitary organization of that time, sanitary institutions as such were also absent, i.e., the organization of sanitary laboratories, sanitary stations, disinfection bureaus, vaccination points, etc., was extremely weakly developed. All this was extremely accidental and fragmented. Any plans for the deployment of a network of sanitary institutions and installations across the province were usually not drawn up. Only some provinces organized their own bacteriological institutes in the pre-war time (7–8 provinces); local calf-sheds were created in some provinces. All other institutions were sporadic in nature and in a certain part reflected the class interests of the same ruling classes. Such are, for example, the so-called medical and food stations, which were formed in places of hiring of agricultural workers. These stations provided cheap food and carried out medical services for workers arriving for summer work in large landowner economies, and thereby served the economic interests of the landowner groups. According to data by Z. G. Frenkel for 1913, all sanitary institutions together ultimately numbered negligible figures. Thus, medical and food stations were organized in 5 provinces (31 stations), summer nurseries in 6 provinces (122), the so-called hydrotechnical bureaus to assist rural water supply in 16 provinces. It goes without saying that the specialization of the sanitary business in this period also did not exist. Only in some cities were there food sanitary physicians, and even then with limited functions (Moscow—market physicians). The rest of the mass of sanitary physicians was not differentiated. At the same time, the cadres of sanitary physicians were staffed mainly from the ranks of district physicians, often with long medical experience. Physicians did not undergo special sanitary training, and special methods of sanitary-hygienic and sanitary-bacteriological studies were usually inaccessible to them. This to a certain extent subordinate attitude of the sanitary organization to the general medical organization and the absence of independent broad tasks caused a certain reaction in the time just before the war. Under the influence of the same demands of life, the growth of industry and cities, more complex sanitary and sanitary-technical demands began to be made on the sanitary organization, requiring greater competence. Simultaneously with this, new areas of the sanitary business began to be outlined. These moments were reflected in relevant reports and speeches at congresses and in the press, and a new trend took shape in socio-sanitary thought, the so-called sanitary-technical trend.

Essentially these were simply correctly set tasks of sanitary supervision as a specific branch of medical activity. This trend emphasized the need to free the sanitary organization from administrative and organizational functions of a general nature and to elevate specialized sanitary work. The fore-front was given here to measures of a sanitary-technical nature for the improvement of populated localities and for raising the general sanitary culture. The necessity for greater qualification of sanitary physicians, their training, and their mastery of experimental methods was also emphasized. Thus, in pre-revolutionary Russia by the time of the organization of the Soviet power, the following situation existed regarding the setup of sanitary affairs in the country. On the one hand, state sanitary legislation and central bodies directing sanitary affairs in the correct and broad understanding of this word were absent. On the other hand, locally there existed a local sanitary organization, scattered unevenly and in extremely insufficient numbers across the territory, not formalized by a single legislative act and subject to all kinds of contingencies in the sense of its very existence. The scope and character of the activity of these sanitary organizations was only to a certain extent regulated in a public order by resolutions of public congresses, but in its content it was extremely limited and incomplete. It should only be mentioned for the completeness of information about individual sanitary organizations which existed in individual departments. Such are the bodies of the ways of communication, prisons, the resettlement department, and others. Everywhere, however, isolated sanitary organizations did not exist; only certain sanitary functions were entrusted to general medical bodies and thus it was considered that to a certain extent sanitary supervision was also carried out. Development of the sanitary organization in the USSR. A decisive turning point in the construction and practical activity of the sanitary organization began after the October Revolution. The principled basis of this business is the corresponding points in the program of the party of the All-Union Communist Party (Bolsheviks), as well as a number of subsequent directive resolutions of the party, among which one must particularly note the resolution of the Central Committee of the party (December 1929) On the Medical Service of the Toilers. In the party program as the main tasks in the field of raising the sanitary culture and improving the health of the toiling masses of the population, the following sections were put forward: the resolute implementation of sanitary measures in the interests of the toilers, such as: a) the improvement of populated localities, b) the organization of public catering on scientific-hygienic principles, c) the organization of measures preventing the development and spread of contagious diseases, and d) the creation of sanitary legislation. After some individual steps in the direction of creating certain collegial central bodies in the field of medical-sanitary affairs by the resolution of the party and government were created, as is known, the people's commissariats of health of the union republics, the tasks of which also included sanitary functions. Like all bodies of Soviet power, the People's Commissariat of Health and the entire business of sanitary improvement of the country are linked with the general restructuring of economic and social-economic relations and are built on the concrete direct participation of the toilers themselves in this business. The first practical body in the system of the People's Commissariat of Health (RSFSR) was the so-called Sanitary-Epidemiological Section of the People's Commissariat of Health, the constituent parts of which were initially the departments: sanitary, sanitary-technical, epidemiological, and sanitary enlightenment; subsequently, the departments of food sanitation and the fight against occupational diseases also entered here. Locally, sanitary functions, as well as general cares for public health, were, according to the Constitution of the USSR, the tasks of local Soviets of Workers' and Peasants' Deputies. For the first time, thus, the basic law of the state established the obligation for all local authorities to conduct sanitary work and thereby be responsible for the sanitary condition of their regions and territories. At the same time, insofar as local authorities (Soviets of Workers' and Peasants' Deputies) were organized everywhere, to that extent corresponding local sanitary bodies also began to arise everywhere. In the very first months of the emergence of Soviet power, therefore, wide, although not entirely formalized and organized at first, construction of sanitary affairs in the country began. The wide initiative of localities and the working masses themselves was an extremely significant factor in the unfolding of this business; the needs of life everywhere imperatively posed the questions of the practical implementation of a number of sanitary measures. On October 28-31, 1918, the first conference under Soviet power of sanitary physicians and representatives of medical-sanitary departments of the Soviet of Workers' and Peasants' Deputies was created under the People's Commissariat of Health of the RSFSR in Moscow. The tasks of this conference were set as organizational questions on the structure of sanitary bodies in the center and locally and on the immediate tasks of their activity. The main principled guidelines on these issues as well were given at the conference in the introductory speech of the People's Commissar N. A. Semashko. The conference adopted the outlined scheme of organization within the limits of the People's Commissariat of Health of the central sanitary body (Sanitary-Epidemiological Section) with the invitation to it of a number of specialists—physicians and technicians—and established the necessity of carrying out along with this a number of preparatory steps for the implementation of general improvement plans in connection with the restructuring of the entire economic and political system of the country. These were to include: a) the organization of state sanitary statistics; b) the development of all-state sanitary, sanitary-technical, and anti-epidemic legislation; c) the creation of central scientific institutes and laboratories; d) the establishment of a system of financing localities for improvement measures; e) the organization and elaboration of a definite type of local sanitary bodies (report by A. N. Sysin). Further at the conference, questions on the organizational forms of local sanitary work were worked out. The initial outline of the composition of local sanitary bodies in provinces and cities had in mind the invitation for this purpose of the following persons: 1) head of the sanitary sub-department (general sanitation), 2) epidemiologist physician, 3) school-sanitary physician, 4) sanitary engineer, and 5) physician for factory-sanitary supervision. The composition of the county sanitary organization was outlined as follows: sanitary physician, epidemiologist physician, school-sanitary physician, and sanitary technician. As working bodies, sanitary-hygienic and bacteriological laboratories, disinfection bureaus, consultative sanitary-technical bureaus, and periodic printed sanitary organs (province) were to be created everywhere. All these plans to a significant degree preserved the old terminology and some old skills of Zemsky work, but in their content, scope, and scale of activity and methods of work they created the basis for the construction of a new Soviet sanitary organization. As the report on this conference indicates, all heard reports from localities definitely established the fact of the overcoming of the period of organizational ruin locally, the presence of wide and to a significant degree already systematic sanitary work, the increase of sanitary personnel, etc. Besides that, it was noted that everywhere a rapid growth of sanitary organizations is observed, the birth of such where they were previously absent, the expansion of sanitary activity and the aspiration for its specialization. At the same time, the conference stated that the main reason for this upsurge of sanitary activity lies in the general social-legal conditions of the life of the country created now by the Soviet power. The conference also stated a definite fact of the growth of sanitary demands on the part of the broad masses of the population and the active participation of the latter in the very setup of sanitary work. Finally, the conference emphasized the need for a definite allocation of sanitary functions within the composition of local medical-sanitary departments of the Soviets. The first years of the revolution (1917-1922) are the period of the above-mentioned wide unfolding of sanitary bodies locally, and their structure, rights, and duties differed by significant diversity and underwent a number of changes in connection with local conditions. The main content of the work of the sanitary organization in the center and locally in these years consisted in the fight against major epidemics of those years; against food ruin and its sanitary consequences and in initial measures in the field of communal improvement. The number of sanitary physicians in the coming years significantly increased; by 1922 their total number exceeded 1,000. At the same time, the network of various sanitary institutions also began to unfold. The annual congresses taking place at first of bacteriologists and epidemiologists, and then of sanitary physicians as well, summarized the constantly growing expansion of sanitary work and sanitary cadres. At the same time, work also began in the field of sanitary legislation (see). Thus in this first period of the revolution the sanitary affairs of the country were restructured on completely new bases corresponding to the Soviet system, namely: 1) the formalization of the state character of the sanitary organization; 2) the ubiquitous unfolding of sanitary bodies as a mandatory part of health departments locally; 3) the expansion of the functions of sanitary bodies and their extension to new areas of sanitary affairs—housing, food supervision, etc.; 4) the participation of the toilers and the development of public initiative in sanitary affairs; 5) the close connection of sanitary affairs with adjacent areas of communal work, labor protection, etc.; 6) sanitary-enlightenment work.

All these facts of the rapid growth of the sanitary organization in connection with the problems of combating epidemics, which were widespread at that time, posed the general task of issuing a unified general law on the sanitary organs of the republic. On the basis of the report of the People's Commissariat of Health of the RSFSR on the cholera epidemic of 1921–1922, the Presidium of the All-Russian Central Executive Committee proposed to draft a corresponding legislative enactment, and in 1922, by a decree of the Council of People's Commissars dated September 15, the general organization of sanitary affairs in the republic was established (the decree "On the Sanitary Organs of the Republic"). This decree, repeated in general terms in other union republics as well, officially finalized the general structure of the sanitary organization in the country and precisely determined the rights and duties of the sanitary organs. This decree was subsequently expanded and supplemented, and was again reviewed and approved in an amended form by the Council of People's Commissars of the RSFSR in 1927 (the "Regulations on the Sanitary Organs of the Republic" dated October 8, 1927). Article 2 of this law establishes that sanitary supervision in the republic is carried out by sanitary organs under the jurisdiction of the People's Commissariat of Health of the RSFSR, the People's Commissariat of Health of autonomous republics, and regional, oblast, and other departments of health. In accordance with the Labor Code, industrial sanitary supervision over working conditions in enterprises is carried out by the sanitary inspection of the People's Commissariat of Labor (now the All-Union Central Council of Trade Unions). Article 3 of the law defines the scope of competence of the sanitary organs: a) sanitary protection of water, air, and soil; b) sanitary protection of populated areas; c) sanitary protection of dwellings and places of public use and special purpose; d) sanitary protection of food products and beverages and public catering; e) prevention of and fight against contagious diseases and the organization of anti-epidemic measures; f) control of contagious diseases; g) control of occupational diseases and mortality; h) protection of the health of children and adolescents; i) sanitary protection and promotion of the development of physical culture; j) implementation of measures for sanitary enlightenment; k) maintenance of sanitary statistics; l) participation in the sanitary protection of labor; m) participation in the preventive work of medical-sanitary institutions and in the organization of the public health service. In later years, a number of changes occurred in the distribution of the work of local sanitary organs, but the general wide scope of sanitary activity established by the 1927 decree remains very large as before. Article 5 of the law lists the positions that make up the sanitary organs. These are: a) general sanitary physicians—district, city, and precinct; b) transport sanitary physicians; c) sanitary physicians in charge of individual branches of sanitary work—housing and sanitation, communal, food, epidemiologists, industrial sanitary physicians, and so on; d) sanitary physicians of the central bodies of the People's Commissariat of Health of the republics. Articles 6, 7, 9, 10, 11, 12, 13, 15, and 16 detail the rights of sanitary physicians in their work—the right of entry, the right of seizure, the right to issue demands, the right to conduct judicial inquiries, the right to isolate contagious patients, and so forth (see Sanitary Legislation). Separate articles of the 1927 law established the obligation for all administrative and economic bodies to provide sanitary physicians with all necessary information. The 1922 law also indicated (Articles 3 and 4) the basic norms for local sanitary personnel. In 1927, by a separate resolution of the Council of People's Commissars dated February 19, new norms for sanitary organs to serve the population of the RSFSR were established. These norms were expanded compared to the norms of 1922. Life's demands subsequently brought about the necessity of a new review of these norms, and presently new norms are in effect on the territory of the RSFSR, revised in the direction of their expansion, qualification, and preferential service to the industrial proletariat and the socialized sector of agriculture. According to the resolution of the Council of People's Commissars dated June 6, 1931 ("On the Norms of the Sanitary Organs of the RSFSR"), the following norms were established. In cities and workers' settlements: a) for general sanitary supervision—1 position of sanitary physician and 1 position of assistant sanitary physician for every 25,000 residents. In cities and workers' settlements with a number of industrial workers in the mining, chemical, metallurgical, and textile industries exceeding 5,000, the indicated positions are introduced even when the total number of residents does not reach 25,000; b) For special sanitary supervision: 1) 1 position of housing and communal physician with 1 assistant for every 25,000 residents (in the presence of the industrial proletariat of the aforementioned industrial branches, the norms are increased in the same manner as in clause a); 2) 1 position for food supervision with 1 assistant for every 50,000 residents (the presence of the same industrial proletariat exceeding 10,000 gives the right to these positions even in cities with a population of less than 50,000). In addition, separate positions of sanitary food physicians are established at factory-kitchens, slaughterhouses, cannery and fish processing plants, and margarine and oil mills; 3) 1 position of industrial sanitary physician for every 10,000 workers in the mining, chemical, metallurgical, and textile industries and for every 15,000 workers engaged in other branches of industry; 4) 1 position of sanitary epidemiologist with an assistant for every 50,000 residents. In rural areas: a) 1 position of sanitary physician and assistant for general sanitary supervision per each district; b) positions of sanitary physician specialists in housing-communal or food sanitary supervision in the areas where large state farms and machine-tractor stations are located, as well as in areas of industrial processing of food products. The same law of June 6, 1931, also established norms for sanitary institutions. In cities and workers' settlements: a) sanitary-bacteriological institutes or laboratories with a Pasteur station, an institute for occupational diseases, and a house of sanitary enlightenment in each main city of an autonomous republic and in each oblast and krai center; b) one sanitary-bacteriological laboratory and one disinfection station in all cities and workers' settlements with a population of over 50,000; calculation of disinfection personnel—1 disinfector for every 25,000 residents; c) one sanitary-bacteriological laboratory and 1 disinfection point in all cities and workers' settlements with a population of over 25,000, as well as in all other settlements with a number of industrial workers of at least 5,000; d) vaccination detachments in all cities, workers', dacha, and resort settlements at the rate of 1 vaccinator for every 25,000 residents. In rural areas, the norms for these institutions are as follows: one sanitary-bacteriological laboratory per district, one disinfection point at each hospital precinct, vaccination detachments at the rate of one vaccinator for every 20,000 residents. These institutions are organized primarily in areas of large state farm construction and total collectivization. For water and rail transport, the 1931 law establishes its own detailed norms (see the text of the law, the journal *Hygiene and Epidemiology*, 1931, no. 6–7). All these laws on the sanitary organs of the republics provide a precise legislative basis for the activity of the sanitary organization and regulate both the expansion of the number of sanitary organs and the improvement of the quality of their work. The total number of sanitary physicians, both general and in individual specialties, as well as the network of sanitary institutions over these years, has increased sharply, contributing to the elevation of the sanitary level of the country and the general improvement of labor and living conditions. In 1929, upon the report of the People's Commissariat of Health of the RSFSR to the Council of People's Commissars, the latter issued the following resolution (dated July 7, 1929; see *Voprosy Zdravookhraneniya*, official section, 1929, no. 32): "1) to state that in the field of sanitary improvement of the RSFSR there are a number of achievements characterized by a decrease in recent years in both general and infant mortality, a significant drop in a number of epidemic diseases, especially parasitic typhus and smallpox, as well as a decrease in the incidence of tuberculosis and syphilis in cities and industrial regions; 2) to recognize that despite the presence of these achievements, the sanitary condition of the country still remains unsatisfactory." Having emphasized certain shortcomings in this matter, the Council of People's Commissars resolved (Article 5) "to propose to the People's Commissariat of Health of the RSFSR, the Councils of People's Commissars of the autonomous republics, and the krai and oblast executive committees to pay special attention in the future to the tasks of sanitary improvement of the main industrial regions, as well as regions where the construction of large Soviet and collective farms is unfolding." This statement of known defects in sanitary services, along with the rapid paces of economic and cultural construction, was also emphasized in the well-known resolution of the Party Central Committee dated December 23, 1929, "On the Medical Service of Workers and Peasants." This resolution gave directive instructions on the reorganization of the practical work of public health organs, and consequently of sanitary organs, reflecting the class line more clearly therein and singling out as primary the main industrial regions, state farms, and collective farms. In connection with this, as well as in connection with the fulfillment of the five-year plans of socialist construction, the structure of the sanitary organs and the scope of their work have significantly changed. By a resolution of the Council of People's Commissars of the USSR dated September 9, 1931, "On Measures to Improve the Sanitary Condition of Workers' Districts and Settlements and Public Catering Institutions," a new organization of sanitary supervision within the public health organs was introduced across the Union—the State Sanitary Inspection for sanitary supervision.

Corresponding decrees of the Councils of People's Commissars of the Union Republics carried out this measure throughout the territory of the entire Union. According to the statute on state inspectors for sanitary inspection (appendix to the resolution of the Council of People's Commissars of the RSFSR of August 10, 1931), these inspectors are assigned primarily to combat the unsanitary state of large municipal and food industry enterprises, as well as major new construction projects. The sanitary inspection inspector (Article 4 of the Statute) is entrusted with: a) day-to-day observation of the sanitary condition of the above-mentioned institutions and enterprises, and b) organization and instruction in conducting sanitary measures, as well as direct leadership and participation in enforcing measures for the fulfillment of sanitary and hygienic requirements. Article 5 of the Statute establishes the appointment from among the sanitary activists of the local public of special so-called public inspectors for sanitary inspection. The duty of these inspectors is to supervise the implementation of sanitary measures at the same enterprises, and these inspectors are each assigned to one specific enterprise. State sanitary inspection inspectors (Article 8) have the right: a) to bring persons guilty of violating sanitary requirements to disciplinary and judicial responsibility, and b) to impose fines of up to 100 rubles on persons guilty of non-fulfillment of sanitary requirements. The remaining articles of the Statute reaffirm other rights of the sanitary inspection, similar to those specified in the general law on the sanitary organs of the republic of 1927. At the head of the local sanitary inspection are krai (oblast) and republican sanitary inspection inspectors. These inspectors simultaneously serve as deputy heads of krai and oblast health departments and deputy people's commissars of autonomous republics. The law on sanitary inspection strengthened the control functions of the sanitary organs and increased the rights of the latter. At the same time, by specifying current sanitary work to a significant extent, it singled out the main objects of sanitary supervision most important at the present time (workers' housing, barracks, canteens, bathhouses, etc.). The law on the creation of a public sanitary inspection in turn strengthened the personnel of the sanitary supervision organs. Very soon in a number of industrial centers, these numerous new personnel emerged, and here too the implemented principle of assigning public sanitary inspectors to specific enterprises and facilities ("combating depersonalization") should yield concrete results. The need for a more thorough and close sanitary service of the environment and daily life of the working people further raised the issue of involving other departments and organizations in the simplest forms of sanitary supervision, as well as expanding and creating new methods of the work itself. This goal was met by corresponding Government orders on involving police organs and mass public organizations (Red Cross, etc.) in sanitary supervision work and the decree of the Council of People's Commissars on the sanitary minimum (see). On October 25, 1931, a joint resolution was issued by the People's Commissariat of Health of the RSFSR, the Central Committee of the Russian Society of the Red Cross, Osoaviahim, and Centrosoyuz on the involvement of the proletarian public in the sanitary service of the population; in the same year (October 19), a similar joint resolution of the People's Commissariat of Health and the Main Police Administration and the People's Commissariat of Communal Economy (RSFSR) was published ("Instruction on the delineation of duties of sanitary physicians, the Workers' and Peasants' Police, and the People's Commissariat of Communal Economy"). Thus, it can now be considered that the sanitary organs on the territory of the USSR include not only qualified sanitary physicians (partly sanitary inspectors), but also a number of other forces—assistants to sanitary physicians, public sanitary inspectors, workers of certain mass public organizations (Russian Society of the Red Cross, etc.), workers and agents of the police. All these additional forces are entrusted, to one degree or another, with the functions of current sanitary supervision where in-depth specialized knowledge is often not required (cleaning of courtyards, dwellings, etc.). At the same time, qualified sanitary personnel are largely freed from minor daily work ("toilet sanitation") and can move directly to planned core work. The same role of bringing sanitary supervision closer to the population was played by the decree on the sanitary minimum, drawing broad working masses into sanitary self-service and the spread of hygienic skills through this new method of work. Within the health organs themselves, the sanitary functions of current supervision have also been transferred to physicians of health stations and partly to some other categories of medical workers. Finally, of equal importance was the establishment of an organizational connection between sanitary organs and polyclinics and united dispensaries. For the unification of preventive work locally, the inclusion of sanitary organs into the composition of united dispensaries was carried out in many cases. Having a certain positive side, such inclusion in some respects dispersed the sanitary organization and reduced its overall specific weight. Today, a straightening of this line is planned, aimed at creating a greater cohesion of the sanitary organization in operational terms, while maintaining a certain connection with the polyclinic and dispensary where general accounting and study of the population's morbidity take place, by strengthening its subordination to the central leadership of the sanitary organs. It must be remembered at the same time that along with leadership and instruction in the field of current sanitary supervision, the sanitary organization bears responsible functions for preventive supervision (see Sanitary Supervision) and for the development of planned measures. At the head of the sanitary organs of the republics of the USSR today are state sanitary inspectors under the People's Commissariats of Health of the union republics. In the Ukrainian SSR and the RSFSR, there are in addition "Sanitary Councils" under the People's Commissariats of Health, convened either on specific issues or sessionally (Ukraine). General normative guidelines on the composition and structure of sanitary organs in the RSFSR are now given in a consolidated form and in the corresponding sections of the draft sanitary code. In addition to the sanitary organization under the jurisdiction and composition of health organs, there are now sanitary organizations within certain other departments. These are the sanitary inspection of the People's Commissariat of Railways in railway transport, the sanitary physicians of the People's Commissariat of Supply and certain associations of the People's Commissariat of Heavy Industry, etc. Some of them (People's Commissariat of Railways) are granted the rights of a sanitary inspection; others carry out sanitary supervision without possessing all these rights (sanitary physicians of various economic enterprises). A special place is occupied by sanitary labor inspectors, now part of the All-Union Central Council of Trade Unions. The latest legislative act that introduced a new organizational structure of the sanitary organization of the Union is the resolution of the Central Executive Committee and the Council of People's Commissars of the USSR dated December 23, 1933, "On the Organization of State Sanitary Inspection": "1. To form state sanitary inspections within the people's commissariats of health of the union republics, headed by a deputy people's commissar of health as the chief sanitary inspector. Sanitary inspections are formed under the people's commissars of autonomous republics and health organs of executive committees of autonomous oblasts, krais, oblasts, and city soviets, and positions of sanitary inspectors are established under raiispolkoms, the rights and duties of which are determined by the legislation of the union republics.—2. The state sanitary inspections of the union republics are entrusted with supervision over the implementation of established sanitary and hygienic norms and rules, both of a general sanitary nature and of all special types of sanitary supervision, by all all-union, republican, and local organs, institutions, enterprises, and house administrations located on the territory of the corresponding union republic.—3. The People's Commissariats of Health of the union republics develop sanitary and hygienic norms and rules, mandatory for execution by all departments, institutions, organizations, and citizens on the territory of the corresponding union republic, approved by the councils of people's commissars of the union republics.—4. Sanitary and hygienic norms and rules regarding the food industry and trade in food products are established by the Council of People's Commissars of the USSR as uniform for the entire Union of SSR and mandatory for execution throughout the entire territory of the USSR.—5. To grant the right to the chief sanitary inspectors of the union republics, for violation of established sanitary norms and rules, to initiate criminal prosecution, impose fines, and take administrative measures up to and including the closure of enterprises of all-union, republican, and local significance.—6. To grant the right to state sanitary inspections under the people's commissariats of health of autonomous republics and under health organs of executive committees of autonomous oblasts, krais, and oblasts and city soviets, for violation of sanitary and hygienic norms and rules, to bring to judicial responsibility and impose fines on enterprises, institutions, and individuals in accordance with existing legislation.—7. Under the People's Commissariat of Railways, the People's Commissariat of Supply of the USSR and the People's Commissariats of Supply of the union republics and Centrosoyuz, administrations of special sanitary services are formed to supervise the implementation of sanitary measures at enterprises and in places of public use of the respective departments.—8. To instruct the governments of the union republics within a month to issue statutes on the state sanitary inspections of the union republics and sanitary inspections of local authorities."

This law establishes henceforth that the functions of the state sanitary inspection are assigned exclusively to the respective organs of the People's Commissariats of Health of the union republics (People's Commissariat of Health, territorial and regional health departments, city health departments, district health departments); while in other departments, corresponding "sanitary service directorates" are established. The main task of the sanitary inspection is the "development of mandatory sanitary-hygienic norms and rules," subsequently approved by the Councils of People's Commissars of the union republics, general control over the activities of all other bodies and institutions carrying out sanitary supervision in the country, and the organization of the corresponding sanitary supervision along the lines of the People's Commissariats of Health. In furtherance of the law of December 23, 1933, a new statute on the sanitary organs of the union republics has now been developed, which has recently received legislative approval (decree of the All-Russian Central Executive Committee and the Council of People's Commissars of the RSFSR of March 20, 1934). (For statistical data on the sanitary organization in the USSR, see USSR. For materials on the sanitary organization in European countries, see the respective articles—Great Britain, Germany, Italy, etc.).