Abstract
One might think that ‘socialized medicine’ potentially could transfer power over medical services from the doctors to the laymen — especially the laymen in strategic government posts: But in practice abroad, national health insurance and national health services are dominated by doctors ... A fundamental reason for domination by the doctors, of course, is lay deference to professional expertise. (Glaser, 1971, p. 43)
The definition of ‘free’ health care as both an individual civil right and collective (i.e. state) responsibility is a long-standing feature of socialism in Czechoslovakia. The organisational conception of socialist health care was worked out during the Second World War by a group of progressive doctors and published on 21 May 1945, less than two weeks after the liberation of the capital, Prague, by the Soviet army. It was enshrined as the so-called Nedvèd’s Plan, Dr Nedvéd himself having perished in 1943 in the Nazi concentration camp Osvetim. The plan, proposing a system of unified, state directed and financed care, free at the point of consumption, was, however, implemented only after the Communist take-over in February 1948. The National Insurance Act of (15 April) 1948 unified and expanded existing separate sickness/maternity and old age pension insurance schemes into a comprehensive social insurance system. At the same time, the new socialist state nationalised all hospitals, sanatoria and health spas. However, full nationalisation of the pharmaceutical industry was delayed until 1955.
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NOTES
A medical district is an administrative unit with 150 000–200 000 residents, who are served by polyclinics and hospitals of II type. A region has 1–1.5 million inhabitants, who are served by polyclinics and hospitals of III type, which offer highly specialised care. Clinics and hospitals of I type are generally found only in rural areas. In 1975, hospitals of I type accounted for 29 per cent of all hospital beds, (including maternity beds), but no expansion of these facilities with a limited number of medical specialties (4–13), including obstetrics, is planned for the future (Pro-kopec, 1975, pp. 58–9). While commentators from the socialist countries tend to emphasise the integration of the system, Western critics have highlighted its organisational fragmentation. Moreover, Millard (1981, p. 60) points out that the rationality of the division between community and industrial health centres is rarely questioned in Eastern Europe. In her view, this is so ‘probably because of the ideological aura surrounding the provision of separate treatment of industrial workers and the somewhat suspect notion that prophylactic measures are more effective when undertaken by doctors familiar with particular work conditions’.
For books on the Soviet health care system, see Field (1957, 1967), Hyde (1974), Navarro (1977), Ryan (1978) and Knaus (1981). Kaser (1976, pp. 36–92), George and Manning (1980, pp. 104–28) and Deacon (1983, pp. 70–80) each have a chapter on the subject.
It is worth pointing out that this kind of structuring of health care delivery is not confined to Eastern Europe. For example, the health care system in Israel is also characterised by an organisational separation between the clinic and the hospital services. As Shuval (1983, p. 128) argues, ‘staff members of one generally have no role in the other. Although some changes have been introduced in the structure to eliminate this sharp differentiation, it continues to prevail in most of the medical care delivery system. This separation is problematic and results in duplication of expensive tests and disrupts continuity of medical care. No less important is the fact that it has resulted in a differentiation of status between professionals in the two settings and in a corresponding differentiation in quality of care: physicians practising in hospitals enjoy higher professional status and are generally thought to deliver higher quality care than their colleagues providing primary care in community clinics’.
This blueprint is compiled from Vojta (1971), Kotásek (1975) and K. Poradovsky (1977a).An evaluation of some of these goals is under-taken in Chapters 9–11.
This is a slightly lower proportion than that in medicine as a whole, where women comprise 40 per cent of the total (compared to 70 per cent in the USSR). As argued elsewhere (Heitlinger, 1979, pp. 149, 161), women doctors face a lot of problems not encountered by their male colleagues. Although the theoretical standards achieved by female medical students are often higher than those of their male counterparts, when it comes to clinical practice, it is the male doctor who is considered to be the more talented and skilful one. Patients tend to prefer and trust male doctors more than female ones. The latter are not so much appreciated for their expertise as for their ‘human’ (presumably ‘maternal’) approach to patients. Women doctors are further handicapped by their family duties, which prevent them from acquiring further qualifications and the more prestigeous and better paid hospital jobs. Slovak women doctors spend only two hours daily on further study, while their male colleagues can afford between three and ten hours a day. Thirty-one per cent of Slovak male doctors but only 10 per cent of female doctors acquire a specialist postgraduate qualification (the so-called first and second degree atestace) at the expected age of 34. The first degree arestace in obstetrics/gynaecology is obtained after a minimum of three years prac-tice in the discipline, part-time attendance of a postgraduate course and passing of a relevant written examination. The second degree specialty is obtained after three subsequent years of clinical practice, study and another exam. For more information on the Czechoslovak system of postgraduate medical education, see ROdling (1980).
A large-scale preventive campaign against VD, especially syphillis, was launched in the early 1950s. Every person over the age of 14 was required by law to undertake a blood test to make sure that he/she was not affected by the disease. A failure to produce the relevant medical certificate resulted in one’s inability to obtain ration tickets. This proved to be a strong enough incentive for most people to undergo the test, which led to the treatment of many people who did not know that they had the disease. The incidence of VD subsequently declined, though in the 1960s, VD made a comeback. The incidence of VD tripled between 1960 and 1968 from 37.7 to 109.6 per 100 000 population, mainly on account of gonorrhoea, which increased from 28.8 in 1966 to 104.1 in 1968 per 100 000 population. However, by 1974, the incidence of VD levelled off to 101.9 per 100 000 population. The increase in the incidence of VD is officially blamed on sexual promiscuity and the lessening of fear of the disease, which in turn is a result of its successful treatment bv antibiotics (Chalupsky, 1984; Kaser, 1976, p. 121).
Medical sociology is much more developed in Poland, thanks largely to the efforts of the prominent Polish woman sociologist, Magdalena Sokolowska. The Polish Academy of Sciences has a Department of Medical Sociology and affiliated departments in several research institutes and universities. In 1977, the British Medical Research Council (MRC) and the Polish Academy of Sciences signed a five-year agreement to promote and facilitate scientific cooperation in medical sociology. The agreement was mainly concerned with exchange of staff, but it also provided for alternate joint meetings in Warsaw and Aberdeen. For an account of the first of these symposia, held at the Jablona Palace near Warsaw, 13–20 May 1978, see Taylor (1979). The symposium was attended by nine sociologists from the MRC Medical Sociology Unit in Aberdeen and a similar number of Polish medical sociologists.
According to Parmeggiani (1982, p. 279), industrial medicine in Western Europe is characterised by frequent external hampering or interference from the management or the state. However, Shuval (1983, pp. 60, 58) argues that ‘conflicted loyalty between the welfare of the state and the individual’s health is hardly sensed by the Israeli physician whose professional orientation is entirely focused on the latter’. In her view, primary care physicians in Israel are guided by their own professional judgments and their dominant concern is the individual patient’s health and wel-fare. With the possible exception of army physicians, there is little institutionalised societal pressure to counter these criteria of decision-making. The predominant concern of physicians in Israel is not to be ‘exploited’ or thought gullible by patients seeking such certification. Their responsibility is therefore to their own professional standards and to the patient’s welfare.
As is evident from Table 12.10 in Chapter 12, sickness benefits and various other forms of social security constitute an important component of households’ income in Czechoslovakia, currently comprising 22 per cent of total per capita income.
In the Soviet Union, estimates of days lost due to illness range from 6 to 15 days per year; in Israel, the range is similar — from 10 to 15 days per year (Shuval, 1983, p. 58).
Following the Soviet model, the health care services of the army and the railways are outside the jurisdiction of the ministry of health, as are medical and pharmaceutical faculties, enterprises producing medical supplies and technology, and the review activity in social security (e.g. absenteeism from work). These activities and facilities are under the jurisdiction of corresponding ministries of defence, transport, industry and social security. Prior to 1969, when Czechoslovakia became a federal republic, there was only one national ministry of health.
Millard (1981, p. 64) claims that in Poland there are no officially-designated specialists in general medicine, ‘yet this is the specialty, along with pediatrics and industrial medicine, of the primary care system’.
Gross Domestic Product (GDP) differs from Gross National Product (GNP) by the exclusion of net income from abroad. Total health care expenditures as a percentage of the two indicators in 1975 was the same in Australia, West Germay, Italy, Netherlands, Sweden and the UK; for the other four Western countries, total health care expenditures as a proportion of GNP was 0.1–0.3 higher than as a percentage of GDP.
However, what may be true of the United States may not apply elsewhere. As Strong (1979, p. 206) notes, ‘capitalism comes in many guises and, although there is an important sense in which one can talk of a general style of Welfare State capitalism, the extent of working-class power and thus the extent to which control is exercised over medicine, does vary significantly. In the United States the vague attempts to produce Welfare State medicine have merely served the financial interests of private medicine.’ Strong (1979, p.208) also notes that while ‘the American introduction of federal programs for the poor and the elderly has undoubtedly led to an exploitation of such resources by some doctors, the very fact of government intervention, however inept, has itself politicised medicine and led to demands for more systematic financial control’. Since the capitalist ‘purse is not bottomless’, Strong (1979, pp. 208–9) argues,’ there is a growing emphasis on cost-effectiveness ... This principle is already clearly at work in some of the areas which are supposed, by some, to be under threat of medicalisation and is in fact one of the principal barriers to any major expansion there ... Review of British government policy statements concerning the elderly indicates that financial economy and the burden to the taxpayer which care for the elderly represents have been the piedominant, if not the only, themes ... There is little that can be done to prevent aging. Money spent in these areas has a relatively small return. Health administrators are only too well aware of the fact that there are millions of potential “patients” out there and this of course acts as a major deterrent to their medicalisation’. Moreover, as we noted in Chapter 2, the existence of a demographic need does not in itself guarantee that it will be socially met since public expenditures on particular social services are also related to political pressures.
Wolchik (1983, pp. 122–3) has argued that disciplinary training and occupational affiliation are often not as important as informal, ad hoc coalitions of various experts and members of the political elite in the formulation of particular socialist policy perspectives. In her study of demographic debates in Czechoslovakia from the 1950s on, Wolchik found that experts with the same specialty often held opposing views on particular issues. For example, demographers were sharply divided on the issue of how to best deal with the care of small children. Moreover, certain demographers opposed the employment of women with small children, thus coming close to a position shared by the majority of economists. However, Wolchik also points out that most demographers were in agreement on the use of positive incentives to encourage child-bearing and opposed restricting the grounds for abortion. In contrast, medical opinion on access to abortion was extremely divided, as we shall see in more detail in Chapter 8.
ASPO stands for the American Society for Psycho-prophylaxis in Obstetrics. As Rothman (1983, pp. 91–2) argues, ‘from its inception, ASPO has been geared to the American hospital and the American way of birth. The only challenge ASPO offered to the American birth concerned the use of anesthesia. ASPO substituted psychological for pharmacological control of pain ... This certainly poses no threat to the control of birth by obstetricians ... Even more basically, ASPO accepted the medical model’s separation of childbirth from the rest of the maternity experience, stating in this first manual that rooming-in (mother and baby not being separated) and breast feeding are “entirely separate questions from the Lamaze method.” ASPO thus managed to meet on the one hand the demand of women for a “natural” childbirth and, on the other, the demand of obstetricians for “good medical management”.’
The widespread medical practice to withhold from patients and their families the full knowledge of their medical condition(s), especially in cases which doctors regard as incurable, is based on the paternalistic ideology of not ‘unnecessarily’ disturbing or upsetting the patient, who is deemed to be emotionally incapable of dealing with the knowledge of the full extent of his/her disease.
Some ward chiefs have pursued the ‘struggle against bribery’ rather vigorously, while others have reacted only formally, by posting notices that doctors in socialist society serve the people, are paid by the state and do not accept tips. However, I was told of one labour and delivery ward where physicians are not allowed to attend any individual woman in labour for more than four hours, on the grounds that a patient is less likely to tip if there is more than one doctor involved in managing her labour and delivery. Some doctors have apparently found a way around this administrative restriction by inducing labours, which are then much faster (though much more painful) than labours which are allowed to proceed spontaneously for up to 12 hours or even longer. In either case, the outcome is detrimental to patient care. Women and doctors who neither expect nor receive any tips suffer from lack of continuity of care, while women whose labour was induced often experience greater pain and more health hazards (discussed in more detail in Chapter 10).
Strong (1979, p. 211) argues along similar, though greatly expanded lines: ‘Whereas the British system minimizes choice of doctor for those who decide to seek treatment, the American system allows patients a very wide selection (though in practice this applies only to the rich) ... However, not only may such choice be delusory ... but the provision of choice, whatever its other advantages, is a clear incentive to medical imperialism ... Although patients may have some general distrust of doctors, they normally lack the knowledge to pass correct technical judgements on the wisdom of any one doctor. Nevertheless, they still make such judgements for what else can they do? ... The private practice style is one in which the doctor subtly indicates his own individual merit, flatters patients by treating them as particularly promising medical students and congratulates them on having chosen so well ... In such a pleasant ambience, it is only too easy for patients to be persuaded that they cannot be healthy unless they have regular checkups, nor sane unless they see a psychiatrist once a week. One can even come to believe that only payment demonstrates a proper commitment to analysis ... Competitive private practice thus enforces product differentiation and creates disease where none existed before.’
A similar kind of ‘convergence’ between the professions and occupations related to ‘servicing’ of socially valued consumer durables (traditionally unrelated to the ‘professions’ as such) is also noted by Johnson (1972, pp. 89–90) in his pioneering sociological analysis of various forms of occupational control. Johnson argues that the key sociological questions in this area are the power resources available to occupational groups as well as other social groupings who may attempt to supervise the application of knowledge and skills to further their own or others’ interests. Furthermore, Johnson speculates that the importance of consumer durables in a mass-consumption economy may encourage stronger consumer movements and the emergence of ‘communalism’ as a form of ‘client’ control over ‘servicing’ occupational practices. Since state-socialist economies are ‘consumer-weak’ and since independent consumer movements (i.e. separate from party-state control) are not allowed, ‘client control’ typically takes the form of individual ‘tipping’ of all practitioners providing services or goods which are socially desired and/or in short supply.
The analysis of state socialist societies as ‘totalitarian’ has been developed by Western political scientists who have studied the Soviet Union in association with a significantly different political system, namely Nazi Germany. In the context of the Cold War, the concept of totalitarianism acquired a strong, for some an ineradicable, bias against the Communist system, thus making it a useless analytical tool in scholarly discussions. As Brown (1984, pp. 55–6) points out, in the 1960s the concept was sometimes discarded for the wrong reasons. Brown claims that ‘the term “totalitarianism” is increasingly used by Soviet and East European scholars in official publications (though not with reference to the Soviet Union and Eastern Europe). It was also used by Trotsky in exile about Stalin’s Russia, and it has been used to describe the contemporary Soviet Union and Eastern Europe by many former prominent East European Communists now living in the West. The concept is not, in other words, the exclusive property of any one section of the political spectrum.’
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© 1987 Alena Heitlinger
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Heitlinger, A. (1987). Socialist Medicine and Reproduction. In: Reproduction, Medicine and the Socialist State. Palgrave Macmillan, London. https://doi.org/10.1007/978-1-349-07162-3_5
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