NOTE: This column was originally published on Friday, December 19, 2008.
The utopian ideal of equality of circumstances has captured people’s imagination since ancient times. If only everybody could have the same of everything the world would be different. There would be no envy, no crime, no poverty, no greed, and no unhappiness. From Plato to Karl Marx, many thinkers looked to the state for the creation of that heaven on earth. In our own times, this dream has remained alive in the form of the welfare state, and today it shows itself most distinctly in the appeal of government-managed health care.
Isn’t it obvious, many ask, that government can supply medical care more fairly and less expensively than the selfish profit-oriented free market? Let us remind ourselves that in the Soviet Union the road to medical-care hell was paved with the same good intentions. In October 1917, the Marxist dreams of coming to political power came true in Russia. Now that everyone was to be equal in all aspects of their lives, people would no longer die in the streets from illness. Free medical care would be available for all, rather than reserved only for the “greedy rich.”
But what did the Bolsheviks destroy and what did they create?
In Old Russia, medical care was a consumer-oriented business. Doctors’ incomes and their standard of living were totally dependent upon professionalism and reputation in the wider community. Patients decided which doctor to use, which hospital to go to, and which pharmaceutical products to trust. Doctors worked hard to establish their reputation, an important part of which came from providing charity care for the poor. As in the West, all Russian doctors upon graduation from medical school took the Hippocratic Oath, in which they swore never to reject anyone who needed medical assistance—and as a rule they were loyal to their oath.
In Russian urban areas, there were charity hospitals and out-patient care for the poor and their families. In rural areas, peasants would often pay doctors with a chicken, potatoes, bread, or in the form of domestic services—or received their medical treatment for free. Under the private medical system in Old Russia, doctors were able to earn a comfortable living and therefore could afford to be generous in supplying charity services to those who were in need.
Expectations of high income, along with the status of being a member of a respected profession, generated strong competition for acceptance into medical schools. The best were accepted as students, and the most qualified were hired as professors. At the beginning of the 20th century, the quality of Russian medical care and medical research was internationally recognized. Was it a perfect system? Of course not. But contrary to the socialist myth-makers, medical care in Imperial Russia was widely available and provided in a fairly cost-efficient manner. Both the profit motive of the competitive marketplace and the spirit of charity assured the provision of quality medical services throughout Russian society.
This, then, was the system the Bolsheviks wanted to destroy. Unfortunately, many Russian intellectuals, including medical doctors themselves, were infected with the socialist disease. Seeing so much poverty in a still underdeveloped Russia, many doctors turned their back on the free market and came to believe that government management could create a better society through planned equality of living conditions, education, and certainly medical care. Thus, guided by wrong ideas, the members of the medical profession helped to destroy with their own hands a health-care system that, while certainly not perfect, provided people with skilled treatment, regardless of their income or social background.
Equality for All
In 1917, like everything else, medical services were nationalized by the new socialist government. Gradually, small medical practices disappeared and a network of big, factory-like hospitals and out-patient clinics were established all around the country. Everyone was registered in both out-patient clinics and hospitals according to their government-assigned residence. Patient choice was completely taken away by the Soviet State, which took full responsibility for centrally planning each individual’s medical expenses and health care.
With the elimination of private expenditures for health services, the form and amount of medical care were now dependent upon the budgetary priorities of the State. All members of the medical industry were put on low fixed monthly salaries and were mandated to examine and treat an overwhelming daily quota of patients. Medical research became dependent upon inadequate annual budgetary allocations from the government. Doctors’ and nurses’ incomes no longer depended on their professional skills or the number of patients they treated. Total unionization of the medical profession made it practically impossible for anyone to be fired. Without markets and prices determining the value and availability of health care, the government imposed a rationing system for medical services and pharmaceutical products.
Specialized services (mammograms, ultrasounds, and so forth) were available only in a few select hospitals where the doctors were supposed to treat patients as well as participate in research. For example, in the case of brain or cardiovascular surgery and treatment, there were only a few specialized hospitals available in the entire country. People sometimes died waiting in line to be admitted for these treatments.
Medical care became a producer-oriented industry, instead of the consumer-oriented market that it had been in Old Russia. But even the State cannot kill the market, just as the State cannot repeal the laws of God and nature. The market was simply driven “underground,” and thus became the black market. The black-market response to State-rationing occurred immediately. Doctors’ services and pharmaceutical products (both domestic and foreign-made), as well as access to medical-testing equipment, became available for bribes. Unfortunately, only the wealthy elite could afford expensive black-market medical services, while the poor majority could no longer count upon charity.
In the world of “free” medical care in the Soviet Union, people often had to have connections to obtain many of the medicines prescribed by physicians to save their family members and friends. Indifferent and often hostile nurses and orderlies had to be bribed to change a patient’s bedpan or to provide ordinary attention that any American would take for granted during a stay in a hospital.
Hospital wards were crowded and far from antiseptically clean. Anesthetics and basic painkillers were frequently unavailable. The crying of patients in pain could sometimes be heard from outside a hospital by passersby.
Some Are More Equal than Others
Not surprisingly, those in the political elite did not want to be treated in the medical system provided for “the people.” One of the greatest myths about the Soviet Union was its supposed equality for all. No society was so divided into privileged groups and classes as was Soviet society. Where an individual stood in the political hierarchy of the Communist Party and the bureaucratic structure of the socialist economy determined his access to all the essentials as well as the luxuries of life.
Special hospitals were created all around the Soviet Union. These were reserved for the members of the Central Committee of the Communist Party, the Council of Ministers, the local and regional Party elites, and so forth. The “servants of the people,” as a result, received a qualitatively different level of medical care than “the masses.” The privileged few had access not only to Soviet-made drugs and medications but also to Western European and American medicines and equipment, which could never be within the reach of the ordinary “proletarian” patient.
Affirmative Action, Soviet Style
The nature and quality of medical education were affected, as well. Bribes and connections determined both the hiring and admission processes in medical schools. Skills and professionalism mattered very little, and service to the community did not matter at all.
This poor medical care was reinforced by the fact that entrance into higher education in the Soviet Union was dictated by a system of affirmative action that had been introduced shortly after the triumph of the Socialist Revolution in 1917. At first belonging to a social class —worker, peasant, or intellectual—determined the entry quotas into colleges, universities, and technical schools. But the Soviet affirmative action system was soon expanded to include gender and ethnic classifications as well. A young person’s professional and career opportunities were greatly influenced not by his individual merit but by whether he was, for example, a Russian, an Uzbek, a Georgian, a Lithuanian, a Jew, or somebody else. Every class, gender, and ethnic group had its own quota for admission and hiring into institutions of higher learning.
Connections, bribes, class, gender, and ethnicity heavily determined who were admitted into and graduated from medical schools throughout the Soviet Union. Thus the supplies of hospitals, physicians, medical equipment, and pharmaceuticals all became victims of socialist central planning and political priorities just like everything else in the “workers’ paradise.” At the end of the 20th century, Russia was infamous for having one of the worst health-care systems in the world.
In bitter situations, Russians often respond with jokes and anecdotes. In one of them, an American and a Soviet doctor are talking. The American says, “Dear colleague, our profession is imperfect. You treat the patient from one disease and he dies from another.” The Soviet doctor replies, “No, dear colleague, this is not the case with me. Mine die from whatever I treat them.”
It is easy to say that the present system is imperfect and a radical change will make it perfect in a relatively short period of time. But there are always lessons from history from which to learn. Sometimes, your neighbor’s history warns you which path never to follow.
Anna Ebeling was born, raised, and educated in the former Soviet Union. Living much of her life in the heart of what Ronald Reagan called “the evil empire,” she experienced first hand the reality of “the workers’ paradise.” Her stories of the absurdities of life in the collectivist utopia are many. Anna met Richard Ebeling in Moscow in May 1991 and married him later that year. Together they joined the defenders of liberty and faced Soviet tanks at the Russian Parliament in Moscow during the attempted hard-line communist coup d’état.
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