Spain

SPAIN. Area—505,207 km². Population in 1925—22,127,699 people with a density according to the 1920 census of 43.8 people per 1 km². Spain is a country with a high birth rate and a comparatively high death rate; the birth rate has decreased slightly over the last quarter-century. The death rate has decreased significantly more. Table 1. Natural movement of the population in Spain (per 1,000 inhabitants): [The table lists years, birth rates, death rates, and natural increase]. Fluctuations in mortality and natural increase in Spain are connected with various epidemics (in particular, the 1918 influenza epidemic) and morbidity among infants. Changes in population movement over the indicated period are very weak, which indicates little progress in improving living conditions. Births were distributed as follows: [Table 2 shows legitimate and illegitimate children, live and stillbirths]. The increasing number of illegitimate children and the high percentage of stillbirths are noteworthy, due on one hand to the indissolubility of marriage according to the Catholic rite, and on the other, to the complete absence of measures for the protection of motherhood and childhood. In 1928, the birth rate was 29.67 per 1,000, and the death rate was 18.4. Infant mortality in Spain is still high, although a certain decline has been observed in recent years. In 1906, this mortality rate was 17.4%, in 1920—16.5%, and in 1924—14%. Emigration plays an important role in the life of Spain. Due to low wages in Spain and the lack of work, the population leaves for temporary earnings in other countries. The main wave of emigration is directed to France: these are agricultural workers, masons, etc., who go for temporary seasonal work but often remain in France forever. In 1926, for example, there were 450,000 Spanish workers in France. Emigration to other countries amounted to 43,867 people in 1927. Health organization. The organization of public health is in an embryonic state; almost all treatment is in the hands of private doctors, of whom there are about 26,000 in Spain. Sanitary administration and sanitary control were established by the laws of December 28, 1855, and January 12, 1904. There is no separate Ministry of Health; sanitary administration is part of the Ministry of the Interior. At its head is a director appointed by the government. The central administration was divided into 4 departments until 1927. 1. Department of public sanitary institutions, managing sanitary institutions (Alfonso XIII Institute of Hygiene, epidemiological section, and special institutions for the fight against tuberculosis, cancer, leprosy, malaria). 2. Department of sanitary personnel within the country, headed by a special sanitary inspector, monitoring the activities of provincial sanitary inspectors and the activities of medical, pharmaceutical, and veterinary institutions. Each of the 49 provinces has its own sanitary inspector. 3. Sanitary department of external supervision for the sanitary protection of borders, ports, etc. 4. Administrative department (issues regulations concerning health protection and takes general measures). By decree of March 31, 1927, the first three departments were combined into one. Attached to the Central Sanitary Administration is the 'Royal Sanitary Council'—the highest consultative body on health issues. The Royal Medical Academy is a similar body. In each province, under the local administration, there is a health section, which is maintained by 2% deductions from the local provincial or municipal budget. This section is a local consultative body on health issues under the 'Juntas Provinciales': it studies the sanitary situation locally and proposes measures, develops local sanitary regulations, etc. The juntas include: in the provinces—the governor, the local sanitary inspector, a representative of the provincial administration, the municipality and the military-sanitary department, architects, professors of the medical faculty, etc.; in the municipalities, this section includes: a representative of the municipality (alcalde), doctors and architects, the local priest, a teacher, a private practitioner, representatives of owners (landlords) and workers appointed by the alcalde. Practically, the work of these institutions is very weak, and their class character is clearly expressed. According to the decree of March 8, 1924, which established new rules for the organization of municipal institutions (severely curtailed in their rights), they are entrusted with the duty of taking sanitary measures in the following areas: supervision of sewage, water supply, housing, public roads and streets, slaughterhouses, markets, baths, cemeteries, toilets, school supervision, the fight against epidemic diseases, and mandatory vaccination. All cities with a population of over 30,000 inhabitants are required to have a municipal laboratory for the analysis of food products, drinks, and medicinal substances (a Central Institute was opened in 1928 in Madrid), a disinfection chamber (for the poor), and free baths. The decree of March 23, 1926, prescribes that all provinces organize institutes of hygiene. In fact, most of these measures have not yet been implemented. Morbidity. One can judge it only by the statistics of causes of death and by the statistics of infectious diseases subject to mandatory registration: according to the 1919 law, such registration includes plague, cholera, yellow fever, typhus and typhoid fever, smallpox, chickenpox, diphtheria, scarlet fever, measles, cerebrospinal meningitis, septicemia, in particular postpartum, whooping cough, influenza, tuberculosis, poliomyelitis, leprosy, trachoma, parasitic childhood diseases, and lethargic encephalitis. Under the Ministry of the Interior, there is a Bureau of Sanitary Statistics, which collects information of a sanitary nature and demographic data and publishes its monthly bulletin. This bureau has now been transferred to the National Institute of Hygiene in Madrid. It receives information from sanitary officials in the provinces, from hospitals, and other institutions depending on municipal or provincial 'juntas'. This same bureau publishes, together with the Central Statistical Bureau of the Statistical and Geographical Institute, the Yearbook of the Main Sanitary Administration. Infectious diseases. The largest number of deaths in recent years has been caused by tuberculosis, typhoid fever, influenza, and meningitis. The accuracy of the statistical data is subject to strong doubt. The main causes of death for 1926 (in absolute figures) from infectious diseases are given in the following table: [Table 3 lists deaths from diphtheria, postpartum infection, whooping cough, scarlet fever, typhus, pulmonary tuberculosis, meningitis, pneumonia, influenza, typhoid fever, measles, and tuberculosis of other organs]. These data relate to only 1/6 of the total number of deaths in Spain for 1926. Typhoid fever is especially widespread; the mortality rate from it, the highest in Europe, was 19.1 per 100,000 inhabitants in 1925, 21.5 in 1926, and 20.5 in 1927. The mortality rate from typhoid is especially high in the provinces of Seville and Valencia. In 1926, it was 45.1 per 100,000 inhabitants in Seville, and 37.9 in Valencia. In cities, the mortality rate from typhoid is also very high. Tuberculosis. The law of September 3, 1926, prescribes that provinces organize an active fight against tuberculosis and obliges doctors treating patients with open forms of tuberculosis to inform local sanitary authorities about them, which must, under threat of penalty, bring this to the attention of the local dispensary. In 1927, there were 24 anti-tuberculosis dispensaries and 20 sanatoriums in Spain, having about 1,000 beds, mainly on the seashore; some of them are for the treatment of surgical tuberculosis. In 1924, there were 2,040 beds in summer sanatoriums. Dispensaries sometimes belong to municipalities, but more often to local public organizations. Malaria. One of the most common diseases in Spain. Data on mortality from malaria indicate its decline in recent years. [Table 4 lists years and number of deaths from malaria]. Since 1924, after a preliminary study of the issue carried out by a special commission, the government has taken the fight against malaria into its own hands and opened special credits. Malaria commissions were established in the provinces. They have the right to declare certain areas infected with malaria and to supervise rice plantations. In 1928, there were already 35 anti-malaria dispensaries in Spain. These same commissions are entrusted with the supervision of water bodies and the free distribution of quinine to the needy. Many dispensaries are open only in the summer. Dispensaries, malaria commissions, and other institutions conduct propaganda among the population against malaria, in which they are greatly helped by the funds of the Rockefeller Foundation.

Among other infectious diseases, one must note dengue (see), which in 1927 assumed an epidemic character in Andalusia. Trachoma is very widespread in Spain, especially in the southern provinces and along the Mediterranean Sea. In April 1927, a special commission for the control of trachoma was established under the Ministry of the Interior, and funds were allocated. The number of patients in 1925 was estimated at 49,413 people. Leprosy. Starting from 1928, all leprosy patients must be concentrated in two centers: Fontilles (Alicante province) and Orense (in the northwest of Spain). These two provinces and the Canary Islands are the main foci of leprosy. The construction of leprosaria in the provinces of Galicia and Andalusia is planned. Venereal diseases. The fight against them is entrusted to a special commission under the Sanitary Administration and local juntas. In 1924, there were 30 dispensaries in cities and several special hospitals for syphilitics. There are no statistical data on venereal morbidity in Spain. The treatment of sailors in ports, by virtue of the international convention of 1924 signed by Spain, is provided free of charge, and there are dispensaries in all major ports. Fight against cancer. In recent years, attention has also been turned to this. A special commission for the study of cancer has been founded, surveys are being conducted, and about 11,000 cases of death from cancer have been registered and studied. Sanitary education is very poorly developed. It is conducted partly by the state (fight against malaria, tuberculosis), partly by the Red Cross and public organizations, as well as by municipalities. The methods of propaganda are the usual ones—brochures, leaflets, lectures, etc. School hygiene. In 1913, an institute of school medical inspection in the kingdom was established by decree. In fact, this decree was implemented only in Madrid and Barcelona. By a decree of March 7, 1922, the Higher Institute of School Hygiene was founded in Madrid. This institute is to train school medical inspectors and organize courses on hygiene for school teachers and for the parents of students. Protection of motherhood and infancy. By a decree of March 22, 1929, compulsory maternity insurance was established in Spain, which applies to three categories of wage earners: female agricultural workers, domestic workers, and employees of public or private enterprises. It is intended to extend the operation of the law to other categories of workers. The law provides the insured with obstetric care during normal childbirth, medical care during pathological childbirth, medical examination during pregnancy, free provision of necessary medicines, an allowance for nursing mothers for 10 weeks (the minimum amount of the allowance is 52.50 pesetas), and unemployment benefits during pregnancy or after childbirth. In addition, deductions are made to a special fund for the organization of institutions for the protection of motherhood and childhood. The sums necessary for insurance are made up of contributions from workers, enterprise owners, and state, municipal, and provincial subsidies. After three years of experience, the law is to be revised in accordance with the results obtained from its application. Medical practice. Medical care is in principle always paid, although for the destitute, free care has been created in all provinces and cities by local institutions, with the local municipality allocating funds for it. In cities, there are municipal hospitals almost everywhere, maintained partly by city funds, partly by donations, or by the funds of Catholic organizations. Psychiatric care. By a royal decree of July 28, 1925, a commission was established, which developed a draft for psychiatric care and the teaching of psychiatry. The Ministry of the Interior intends to "implement this project when it has sufficient funds at its disposal." At the present time, care for psychiatric patients is either in private hands, or in the hands of charitable societies, or in the hands of local municipalities, and is insufficient. Pharmacy. The rights of pharmacists were established by a decree of April 18, 1860. Hospitals are granted the right to have their own pharmacies. The pharmacopoeia and tariffs were established by a decree of June 21, 1905; at the present time, they are being revised. Special attention is paid to the trade in narcotic substances, in particular opium and its derivatives. In 1928, a special commission was established for stricter control of the sale of opium. For the manufacture of sera, vaccines, viruses, and toxins, special permission from the General Sanitary Directorate is required, and their manufacture can be entrusted only to a physician, pharmacist, or veterinarian (decree of October 10, 1919). Labor protection. Social legislation in the field of labor protection is practically almost non-existent. While in some industrial areas workers have managed to achieve the establishment of an eight-hour working day, in other areas the limitation of working hours has not been implemented. In 1919, a law on compulsory disability insurance for all wage earners was passed. In 1921, compulsory insurance for the same categories against old age was established, and in 1922, against accidents at work. The law does not apply to domestic workers. When granting an allowance, the average earnings for the last two years of work are taken into account. Regarding disability, the amount of the allowance is the same for everyone. Contributions to the insurance fund are made by entrepreneurs and partly by the state in the form of subsidies. Enterprise owners can insure their workers in state funds or in private insurance companies. By a decree of March 31, 1925, a special Commissariat of Public Health was established to control enterprises in which there is an organization of medical care for workers. The commissariat includes representatives of the state, doctors of hospital funds where they exist at private enterprises, and representatives of the members of these funds. This commissariat is to determine the amounts of the insurance contribution, doctors' fees, and the number of insured per doctor, as well as the nature of medical care. Its goal is not so much the protection of the interests of the workers as the protection of the standards of fees for doctors treating workers.

Medical education. In Spain, there are 10 medical faculties. In 1925, the National School of Hygiene was founded in Madrid, which is to train hygiene physicians to fill sanitary positions, as well as paramedical personnel—nurses, etc. Doctors are admitted to it by competition and during their stay receive a salary of 3,000 pesetas per year. In 1925, the Institute for the Protection of Motherhood was founded for the education of women and the protection of infancy. The health budget in 1924/25 amounted to 7,721,600 pesetas according to the state budget. To this must be added the income from special state lotteries (in total about 3 million pesetas), which goes partly to the benefit of the Red Cross, partly to the fight against tuberculosis, malaria, and leprosy. The total budget of the state in the same year amounted to 2,941,724,000 pesetas. The state spends an average of 0.35 pesetas per capita per year on public health. But to this must be added the budget of local institutions, which significantly exceeds the state one. Thus, the Madrid municipality alone spends about 10 million pesetas every year on public health and charity (public health is considered in Spain to be one of the forms of charity). In addition to the ordinary state budget for public health, there is an extraordinary budget. In 1927, an extraordinary appropriation for 6 years was made in the amount of 11,600,000 pesetas, intended exclusively for the construction of new dispensaries, sanatoria, the construction of a School of Hygiene, a psychiatric hospital, etc. A. Rubakin.