The Free Market 8, no. 8 (August 1990)
The Soviet Union was the first country to introduce a fully nationalized healthcare system. To the cheers of Western “progressives,” Lenin signed a decree in 1919 stating that every Soviet citizen had a right to free medical care. Looking at the history of Soviet health decrees, it appears as if the system has been improved every year. And the present Soviet constitution, adopted in 1977, contains the right to “health” (not just health care).
To provide this right, the Soviet Union has more doctors than any country in the world, on a per capita basis and in absolute numbers. There are twice the number of hospital beds as in the U.S.
For years, the official Soviet health statistics looked better than any in the West. The only problem is that these institutional statistics do not correlate with vital statistics, which are more reliable and show a desperate state of public health.
The average Soviet lives about 10 years less than the average American (62 for Soviet males and 69 for females, compared to 71 and 78 in the U.S.). In certain regions of the Soviet Union (Yakutia, Karaplukia, Kalmukia, etc.), life expectancy for males is 20 years less than in the U. S. (49 for males and 58 for females). In some rural areas of the Russian Federation, the life expectancy for males is as low as 45 years.
The Soviet infant mortality rate—24.5 per 1,000—is 2.6 times as large as the U.S.’s and more than five times as large as Japan’s. The Soviet rate is even higher than Washington, D.C.’s, notoriously high rate of 23 per 1,000. In the rural regions mentioned above, and in the.republics of Central Asia, the infant mortality rate is above 100 per 1,000 births, putting these regions in the same development category as Burkina Faso, Chad, and Bangladesh.
Even these statistics mask what B. Iskakov of the Moscow Institute of National Economy calls the “worse than critical” situation in health care. He classifies the population into groups based on health. Among the people whose health indicators are within the norms, he places less than half of the Soviet Union’s 287 million people. Between 53% and 63% of the population belong in the remaining groups: people with hidden deficiencies, people who are chronically ill but can wholly or partially function, and people who cannot function because of grave physical deficiencies. Seventy to 80 million people are chronically ill and have serious physical and mental deficiencies. In Moscow alone, up to· 68% of the population is health-deficient.
The crisis will grow worse because the new generation is much less healthy than the old. Three quarters of the U.S.S.R.’s 170 million children have been officially classified as unhealthy; a quarter of them are chronically ill or handicapped. Of Moscow’s children born in the 1980s, between 70% and 90% are considered health-deficient—double the amount from the previous decade. Between 20% and 25% of these are mentally retarded. Among young people (14 to 17 years of age), one third have chronic mental and physical disorders, many inherited from their parents.
How can all this be explained? On one level, it is a complex of factors: poor diets, pollution, low quality of health care, stress (waiting in lines, red tape, humiliating bureaucracy), illegal drugs, legal drugs, and sexually transmitted diseases.
The Soviet authorities like to point to alcoholism, which is indeed rampant: per capita consumption of alcohol increased by 800% from the 1940s to the 1980s. But there is a saying in the Soviet Union that shows the deeper truth: when a nation withdraws itself from world history, everybody gets drunk.
Thus alcoholism too often serves as a scapegoat. The real culprit is socialized medicine. We are watching the effects of 70 years of Leninist health care.
Top Communist Party and government officials have their own Ministry of Health hospitals. They have full access to specialized medical care more or less on the level of Western countries, free of charge.
The masses aren’t so lucky. Their medical care is generated by an enormous bureaucratic system. At the top is the giant Ministry of Health of the U.S.S.R. Under it are the Ministries of Health of the various republics and under them. are the regional Departments of Health. Each of these have District Departments of Health, which actually run the network of hospitals, ambulances, and health clinics. All told, the Soviet health industry employs four million people.
All medical “norms” are generated by the Ministry of Health. The hospitals themselves are responsible for generating statistics, so they try to make themselves look as good as possible. For example, it’s impossible to tell how many diseases a patient catches just from the unsanitary conditions in the hospital itself. But on paper, everyone looks happy.
The industry is run according to a socialist “plan.” For example, the planned hospital stay is 21 days. And no one can stay longer. But if the bribe is high enough, you can be re-admitted for another 21 days with a different doctor in a different division. If you stay for fewer than 21 days, you would be fortunate to see a doctor, much less be treated.
It is impossible for ordinary people to get decent pharmaceuticals, and drug stores have only the most primitive medicines. Moreover, the doctors do not give prescriptions based on medical need, but on the availability of drugs. Each doctor is sent a list of everything locally available and he can only prescribe drugs on the list. If a person has a disease for which he needs a special drug, he can forget it.
The country is flooded with penicillin, however. In 1946, Stalin was impressed with how effective it was at fighting disease and ordered that the Soviet Union have the same amount the West does. The “plan” has never been altered, but 89% of citizens have built-up a resistance to penicillin’s effects. But it is still prescribed because there is nothing else.
The doctors who have medicines unavailable in drug stores open underground medical services and charge extremely high prices for even minor treatments. In many cases, only one antibiotic shot is necessary, but the doctors will continue to charge for placebos. Because there is little competition in the underground doctors, these practices are neither exposed nor challenged.
All hospitals are extremely congested. In Moscow, the hospitals keep four to six patients per room, but in the outskirts, the hospitals house 12 to 16 patients per room. Private rooms are only available for people who are dying.
Officially, all medical care is supposed to be free. But there are enormous lines for such things as preventive check-ups and surgery. People with chronic appendicitis must wait a year and a half for service. And cancer detection is very poor. There is no screening for the masses, so by the time it is detected, it is too late.
Rural areas have virtually no real medical care. Thirty-six percent of rural hospitals have no running water or modem sewage systems.
There are no disposable syringes in rural hospitals, so they are re-used an average of 1,000 times. They are sterilized by boiling, which is fine provided they are boiled for 40 minutes. But they are often not, because the workers have no real incentive to do so. That’s why there is an epidemic of hepatitis in the Soviet Union (716,000 cases were reported in 1988, over 30 times the number of cases reported in the U.S.).
More than 85% of Soviet AIDS patients were given the disease through dirty government needles or the AIDS-infected public blood supply. The medical authorities dump the blood into a common pool, separated only by blood type. If 599 donors are healthy, and one has AIDS, the blood is potentially deadly for everyone who receives it. More recently, they have adopted a supposed system for screening the blood, but because of negligence, it doesn’t work.
Because there is no private property, the hospital staff dumps test tubes filled with infectious disease any place they can. In rural areas, you can find glass mountains filled with test tubes and beakers carrying, for example, the tuberculosis bacillus which lasts for 90 years.
The “plan” says that medical treatment for anyone patient must not cost more than the official rate of 11 cents per day. If the hospital spends more, they must give other patients less.
The hospitals must even abide by a planned death rate, which is set to make the system look better than it is. The lower the rate reported by the hospital, the better. If the patient dies on the front steps, it doesn’t go into the statistics. The hospitals throw people out when they are dying. Doctors will tell the family how much better it would be if the patient spent his dying days at home. Or the doctors will simply give the patient a clean bill of health and· evict him from the bed. In this way, the hospital stays within the planned mortality rate.
Physicians are required to study medicine for seven years. Yet their wages are extremely low—about one-third of bus drivers, for example. The state sees this as a way for the physician to “pay back society” for all the resources he took going through “free” schooling. The concept of intellectual capital is as absent as private property.
Why then would anyone go into medicine? Partly because they work less (36 hours per week) and hold jobs with high prestige. But the main reason is that the profession offers tremendous access to resalable goods and bribes.
The average physician has 3,000-5,000 people assigned to him. The patients have no choice. They must take whoever they are assigned in any given territory. If the local physician is a butcher, that’s too bad. The patient cannot change. If the doctor kills you, relatives have no recourse.
Doctors expect bribes, but they go about it subtly. “We can operate for free, but we will have to do so without anesthesia,” one will say. “If you want some anesthesia, I have a friend who can get it, but I’ll have to pay for it out of my own pocket. Will you reimburse me?” As bad as this system of bribes is, of course, health care would be worse without it.
Bribing for anesthesia is most common for abortions. And the Soviet Union has the highest rate of abortion in the world, 106 per 1,000 fertile females (the U. S. is second with 29). And the primitive quality of care results in an enormously high rate of pelvic disease.
The “plan” stipulates that food served in hospitals be limited to 14 cents per day. And it tastes like 14 cents a day. Everything in the kitchen which is decent is stolen by the employees and sold on the black market.
Under perestroika, the authorities briefly allowed doctors (retired and active) to open cooperatives and openly charge for medical care. (”Cooperatives” is a euphemism for private ownership.) The cooperatives were highly regulated, taxed at 60%, harassed, and attacked through red tape. And there were constant streams of bureaucrats wanting payoffs. But the cooperatives were much more efficient and humane than the state clinics. Patients were able to get the service they wanted and were able to avoid the risk of getting AIDS.
But on December 21, 1988, the Ministry of Health banned medical cooperatives. Since the health-care system is supposed to be one of the great achievements of socialism, the government could no longer stand the embarrassment. The cooperatives became a threat to bureaucratic empires.
There is a tendency in Russia to exempt medical care from serious reforms. The people have been promised health, and they don’t know why they are not getting it. The public thinks that if everything is private, they will get the same system, but have to pay for it. They don’t understand that the costs of socialized medicine are expressed in lives and health lost. Under a private system, these costs would fall, and service would improve—dramatically. Because of these misunderstandings, however, health care may be one of the last areas to be privatized.
Government control takes freedom of choice away from the public and puts it in the hands of bureaucrats responsive only to their own interests and those of the state, instead of the buying public. Private enterprise in medical care means patient sovereignty. The Soviets ignored this principle, and the public is now paying for it with their health and lives.
Americans who are thinking about the virtues of a socialized medical system ought to think again—about the Soviet experience.
