FORMATION AND DEVELOPMENT OF HEALTH CARE OF THE URBAN POPULATION OF THE UkSSR DURING THE 20-ies OF THE XXth CENTURY

The purpose of the article is to try to reveal the most important components of of health care formation and development of the urban population of the UkSSR during the 20-ies and their impact on the level and quality of an urban society life. The research methodology is based on the

Ключові слова: охорона здоров 'я, міське населення, епідемії, голодомор, соціальні хвороби, туберкульоз, венеричні хвороби, науково-дослідні інститути. The Problem Statement. The study of the social situation of the urban population of the UkSSR during the 20-ies of the ХХth century, in the issue of meeting population's health care needs, is conditioned by a modern approach to assessing the social phenomena of the past through their humanistic, human dimension, when the most important factor in historical processes is not the class, not the party, but a human being and his life and health as the greatest value. The leading link in the social life of society is health care, which ensures both the physical health of the nation and its intelligence. Underestimation of these factors leads to the degradation of the nation and deprives it to enter the civilized world as an equal partner in the future.
During the 20-ies of the ХХth century the health care system achieved some results in overcoming mass epidemics, in the fight against social diseases, opened dozens of research institutes and higher medical schools. The Ukrainian scientists and doctors accumulated experience that was recognized at that time in the world. At the same time, the class policy of the ruling regime was reflected in the health care system. Contrary to the humanistic values of medicine, the authorities introduced the priority access to treatment for the working class, restricting this right to the non-proletarian strata of the society. Free of charge services for workers and the Soviet employees and the paid services -for the rest of the social groups -all these factors increased a social tension, caused dissatisfaction with the Soviet authorities in the cities.
The experience of the past shows that during the transitional periods in the history the heaviest burden of unresolved problems fell on the shoulders of the poorest social groups. Therefore, under conditions of transformation of the modern national health care system, the emergence of the pandemic of the XXIst century it is necessary to return to the systematic work in health care and revive medical institutions, which are responsible for preventive, anti-epidemiological work among the population. Organizational principles of preventive work in the context of an internal and external migration of the 1920-ies will be useful at the present stage of mobilization of financial and medical resources to overcome the challenges of the XXIst century in the field of human health.
The Analysis of Recent Research and Publications. In the Ukrainian historiography very publications deal with the health care issue of the urban population of Ukraine during the 20-ies of the ХХth century. The analysis of the available publications illustrates the study of certain aspects of a health care development in the Soviet Ukraine. F. Ya. Stupak's scientific researches reveal the organizational principles of the Soviet health care system formation under conditions of new socio-economic transformations of the 1920-ies; as well as issues of the sanitary consequences of the civil war -epidemics and famine, the search of new organizational forms of a medical care, the creation of the State Sanitary Inspectorate and sanitary-epidemiological stations (Stupak, 1998;Stupak, 2009). The social aspects of health care in Ukraine during the 1920-ies and 1930-ies are revealed in O. Movchan's publications (Movchan, 2006, рр. 19-65) and О. Melnychuk's publications (Melnychuk, 2009). The scientific researches of Yu. Barabash and I. Dovzhuk on the problem of health care in Donbass during the first decade of the Soviet power illustrate the process of a medical care formation and development for workers in this industrial region (Dovzhuk, Barabash, 2009).
Among modern studies on the global burden of disease, overcoming infectious diseases, the effectiveness of preventive technologies in public health in the USSR the publication of the authors: O. M. Dzyuba, L. M. Pazynych, O. R. Sytenko and E. M. Kryvenko should be singled out (Dziuba, Pazynych, Sytenko, Kryvenko, 2017, рр. 8-14).
V. M. Lekhan and L. V. Kryachkova substantiated the system of measures to improve health of the USSR population on the basis of the analysis of the diseases spread and the risk factors (Lekhan, Kriachkova, 2019, pp. 113-122). The researchers noted a significant contribution to achieving positive results of the impact of the health care system on the health and well-being of both individuals and the society as a whole, subsystems of a primary health care and public health. Characteristic trends can also be traced in the health care of the urban population during the 1920-ies, when the sanitary and epidemiological service achieved some progress in the fight against infectious and social diseases.
It should be noted that the publications of V. Kryshtopa, Yu. Voronenko, O. M. Holyachenko, A. M. Serdyuk, Ya. Hanitkevych illustrate a certain interest in the study of the peculiarities of the health care development in the UkSSR during the 20-ies of the ХХth century. In general, the outlined topic has a number of unexplored aspects that are relevant in the context of reforming the modern health care system of Ukraine and mass epidemiological outbreaks in the cities.
The purpose of the article is to try to reveal the most important components of health care formation and development of the urban population of the UkSSR during the 20-ies and their impact on the level and quality of an urban society life.
The Statement of the Basic Material. Analyzing the sources and literature on the research problem, we singled out two periods of health care formation and development in the UkSSR. The first period: during 1920 -1923 -one of the most difficult periods in the history of health care in the UkSSR, when the main focus of the city service was on overcoming the severe effects of famine, the elimination of outbreaks of mass epidemics. During this period, the state health care system in Ukraine was created, the People's Commissariat of health care and the sanitary and epidemiological service were organized. The second period: during 1924 -1929 -the period of the health care system strengthening, preventive work strengthening among the urban population, combating social diseases and creating new research and medical institutes for the introduction of scientific developments and training of a medical personnel.
At the beginning of the 20-ies of the ХХth century the entire health care budget was divided into state and local. The rural health network and part of the county network were included into the local budget. At that time there were not enough hospital beds, and in Kyiv the amount of beds was even decreased from 2,600 to 1,600 (Kahan, 1928, р. 57). During 1922, the provincial health departments shortened their staff for almost 50%. The catastrophic deterioration of health care in cities and provinces made the heads of provincial health departments meet on December 2-5, 1922 in Kharkov for an All-Ukrainian meeting, where it was decided to delimit the activities of health care in the UkSSR regarding their funding for 4 categories: a) health care facilities maintained at the expense of the state budget; b) at the expense of the local budget; c) at the expense of the state budget and insurance fund; d) at the expense of economic calculation. At the meeting it was decided to finance from the state budget the entire sanitary organization with auxiliary institutions, maintenance of a certain number of beds for infectious patients for the next 4 months, to finance exemplary institutions and the health care apparatus and a free provision with medicines (Kahan, 1928, р. 58).
The famine of 1921 -1922 became a serious obstacle to the health care formation and development for the urban population and the establishment of its organizational structures. The famine made the government, the health care system, which was in the process of formation, focus all its efforts on eliminating this phenomenon, which slowed down the revival of the national economy of the UkSSR, and most importantly led to mass deaths in urban and rural areas. According to the People's Commissariat of Health, in August 1922 the number of starving people in the five provinces of Ukraine was 4 272 584, of whom only 2 318 400 (54,2%) received food aid. Since the beginning of the year, 279 352 people fell ill because of famine and 47 525 people died (Ulyanov, 1922, р. 142).
Simultaniously with the famine, infectious diseases began to spread. Thus, in five provinces of Ukraine 350 787 cases were registered of only different types of typhus (rash, abdominal, unexplained) for 7 months of 1922. According to registries, in January -March, 1922 199 persons were born, and 7 323 died in the towns of Mykolayiv province, in Odessa accordingly -1495 and 10 679 (Ulyanov, 1922, р. 143).
The scale of the famine was so great that all central, provincial and county newspapers introduced special sections "Help to Starving People", "Week of Helping the Starving" and the others. According to our estimates, under these headings, for example, the newspaper "The Communist" published 814 materials, the newspaper "Visti VUTSVK" -359, the newspaper "Volyn Proletarian" -206. On the pages of the periodicals it was reported on the organization of provincial and county committees to help the starving, organizing weeks and months of help to victims and etc.
For some time the scale of the famine in the UkSSR was concealed, but in December 1921 it was impossible to do so. Therefore, the representatives of the mass media of the republic received the right to inform the citizens about the famine, as evidenced by the above examples from the newspapers.
In the UkSSR during 1921 -1923 the mass famine undermined the republic's productive forces, led to the mass extinction of the rural and urban population and caused the outbreaks of epidemics. Many researchers, including B. Dramaretsky, believe that the famine was the result of "a conscious and purposeful line of the Bilshovyk regime aimed at subduing the multimillion masses of the Ukrainian peasantry, the entire Ukrainian people" (Dramaretskyi, 1997, р. 24). In our opinion, the famine of 1921 -1923 was also caused by Bilshovyk experimentation, the devaluation of human values, when political and ideological projections prevailed over a common sense.
Thus, the famine of 1921 -1923 increased the mortality of the urban population both as a result of a chronic malnutrition and due to the spread of infectious diseases. The spread of infectious diseases among the urban population was facilitated by its mass movements in search of food during the famine of 1921 -1923. The mass movements led to the spread of cholera and typhus throughout the UkSSR. Thus, during 11 months of 1922, 322 850 cases of rash typhus and 426 642 typhus were registered in Ukraine (Marzeev, 1922, р. 90). The sanitary epidemiological service, which itself was in a state of formation, could not prevent mass diseases. However, even a small number of doctors waged a resolute fight against infectious diseases, organizing "weeks of cleanliness", "months of water supply", "bath weeks", etc. (Solovev, 1928, р. 25). As a result, in 1923 there was a significant reduction in diseases with various types of typhus. For instance, in Volyn province from 5 568 in 1922 to 1 207 in 1923, in Poltava province from 61 538 to 7 696 (Marzeev, 1922, р. 90). According to our calculations, the tendency to diseases decline was 4,6 -7,9 times.
At the same time, with the general decrease in infectious diseases in 1923, the number of malaria patients increased. In July -August 1923, there were 254 346 infected people (Ulyanov, 1923, р. 97), and in provinces: in Donetsk -115 949, Katerynoslav -57 308, Odessa -33 162, Kharkiv -13 031 and Poltava -8 301 (Ulyanov, 1923, р. 98). To get rid of malaria in 1923 in Kharkiv there was established Protozoinyi Institute for the scientific study of malaria and training specialists. Ukraine was covered with a network of malaria stations and detachments, of which there were 47 at the beginning of 1926 (Nikolaev, 1927, р. 5). The costs of the state and local budgets for the production of quinine, which was used in the fight against malaria, increased. Reclamation works, preventive chemicalization and other preventive measures, etc., were carried out in a number of the largest foci of malaria.
In April 1922, the sanitary and epidemiological service was established at the First All-Ukrainian sanitary meeting. Its founder was the head of the sanitary and anti-epidemic department of the People's Commissariat of Health, Academician O. M. Marzeev. It was he, who came up with the idea of creating sanitary stations, which was expressed at the III All-Ukrainian Congress of bacteriologists and epidemiologists (Yefimov, 1927, р. 104).
Beginning in 1923, the allocations for the development of the sanitary epidemiological service grew. In particular, in 1923In particular, in -1924 588 rubles were allocated from the state budget for the sanitary epidemiological service development, and 636 681 rubles from the local budget, which contributed to its organizational and financial strengthening (Marzeev, 1922, р. 88).
An important role in the fight against epidemics, the implementation of preventive measures among urban residents was given to the sanitary technical councils, the formation of which was proposed at the 11th All-Ukrainian Sanitary Council on May 14 -19, 1923. Subsequently, the People's Commissariat of Health drafted the Bill on "Sanitary and Technical Councils", which was adopted by the People's Commissar of the UkSSR on September 13, 1923. This document became one of the most important acts in the sanitary legislation of Ukraine. Sanitary and technical councils performed sanitary and technical measures for the protection of water, air, soil; food products; sanitary improvement of settlements, labour protection, etc. Sanitary and technical councils had great powers -all practical measures of a sanitary nature, by whomever they were carried out, were preliminarily agreed and approved by the sanitary councils (Marzeev, 1924, р. 132).
Thus, in 1921 -1923 the process of the health care structure formation, the network formation of sanitary epidemiological institutions continued and the primary efforts of doctors were aimed at eliminating epidemics and the severe consequences of famine.
The next period of formation and development of the health care of the urban population covers 1924 -1929, when the famine vanished and a number of epidemics were eliminated. Health care centers focused on strengthening the entire health care system, strengthening prevention work among the urban population, creating new research and medical institutes for research and development, and overcoming social diseases. During this period, allocations to the health care system increase significantly. In particular, investments in medical institutions increased in the cities of Kyiv region by 360%, and in health care centers for workers -by 908% (Kagan, 1928, р. 86).
The cities of Ukraine needed to improve a sanitary and epidemiological control (Yefimov, 1927, р. 103), which led to an increase of various specialists: epidemiologists, sanitary industrial doctors, communal sanitary inspectors, sanitary food doctors in 1928 (Marzeev, 1925, р. 56). Specialists of these profiles appeared not only in cities, but also in some industrial areas. During this period, the sanitary system of Ukraine included 4 bacteriological institutes: in Kharkiv, Kyiv, Odesa, Katerynoslav, and later joined the fifth one -in Chernihiv. A certain achievement of medicine in the field of sanitation was the growth of the number of sanitary bacteriological laboratories: 1925-77, 1926-96, 1927-113 (Marzeev, 1922.
Despite some shifts in the development of the sanitary service during the second half of the 1920-ies, the situation concerning disinfection work remained difficult, as it required a sufficient number of disinfection cameras, disinfection stations, disinfection devices. Domestic production of these disinfection devices began only to be established at the enterprises of the UkSSR, which had a negative impact on the fight against infectious diseases.
The formation of the sanitary epidemiological service of the USSR was facilitated by the legislative framework, which was actively created during 1922 -1928. The laws were passed on the sanitary bodies of the Republic, sanitary technical councils, sanitary protection of water, foodstuffs, on obligatory vaccination against smallpox, typhoid fever, on the fight against malaria, on sanitary stations for newly arrived workers, etc.
Despite the huge difficulties associated with funding, logistics, lack of qualified personnel, there should be noted the positive changes in the organizational strengthening of the sanitary epidemiological service, its achievement of concrete results. For instance, if the incidence of typhoid fever per 10 000 population was 13,2% in 1912, then in 1928 -2,7%; the incidence of typhoid fever in 1913 was 4,3%, and in 1926 it was 0,5%; typhoid fever affected 38,6% of people in 1913, and 8,3% in 1926, dysentery affected 41,5% in 1913, and 9,1% in 1926. However, the best results were found in the elimination of smallpox. In 1913, smallpox affected 4,8% people, and in 1926 -0,09% (Yefimov, 1927, р. 104). The authors' analysis of epidemics outbreaks illustrated a steady and significant reduction of smallpox, typhoid, intestinal infections and malaria. At the same time, child infectious diseases (scarlet fever and the measles) were still quite common.
Thus, mass vaccinations, sanitary and anti-epidemic measures, sanitary education, growth of sanitary culture, activities of a number of sanitary and anti-epidemiological institutionsall these measures led to a significant reduction in infectious diseases of the urban population, which generally had a positive effect on the revival of industry.
Industry reconstruction required only skilled but also physically healthy workers. The introduction of a social insurance and the law on providing workers with qualified medical care in the UkSSR accelerated the development of health care, the construction of a medical network, and brought to the forefront the solution of new urgent tasks. Among them -the deployment of medical institutions network to serve the urban population. This issue was especially acute in industrial areas, where the network of medical institutions was extremely neglected during the Civil War. Moreover, the old network of medical institutions was created based on the needs of employees at individual enterprises, without taking into account the needs of residents of the entire industrial area. There was a lack of qualified specialistsdoctors. At the reception there were 20 or more patients per doctor instead of the established 6 patients per hour (Somov, 1926, р. 135). That is why, it was necessary to create a new network of medical institutions in the cities of the USSR.
Important for the development of health care in the UkSSR, the improvement of medical care for the urban population, were research institutes, which were established during the 1920-ies. By 1927, there were already 25 in the UkSSR (Kagan, 1927, р. 180). In addition to scientific work, in the institutes the skills of district doctors were improved.
At the same time, on the basis of the first polyclinic in Kharkiv, the Institute of Working Class Medicine was established in 1923. Its main tasks, in addition to research work on occupational pathology and hygiene, were to improve the skills of working class medicine and pathology.
In 1923, Kharkiv Institute of Mother and Child Protection and Kyiv State Children's Orthopedic Institute were established. In 1925, Kharkiv Institute for the Improvement of Physicians began its work, where during three years there were retrained 250 district physicians (Nikolaev, 1927, р. 173).
Thus, in the first half of the 20-ies of the ХХth century new research institutes of a medical profile were founded, which significantly improved the quality of treatment of the urban population, which had a positive effect on the industrial sector.
The elimination of mass epidemics during the beginning of the 1920-ies, the strengthening of the material and technical base of medical institutions, the establishment of medical research institutes allowed the entire health care system to move to new urgent tasks, namely, the systematic treatment of social diseases.
One of the work direction to overcome social diseases in cities was the treatment of tuberculosis. Tuberculosis dispensaries and dispensaries stations were opened in the cities of the UkSSR. If in 1923, according to the People's Commissariat of Health of the UkSSR, there were only 53 dispensaries and 14 sanatoriums of various types with 866 beds, during the mid-1920-ies there were already 113 tuberculosis dispensaries and 46 dispensaries stations. In fact, at this time there was no single district without TB dispensaries. In a number of cities, dispensaries almost completed their main work -the initial check up of the districts population. If the best dispensaries in Western Europe were 80% informed about tuberculosis, and in the UkSSR in 1923 this percentage was only 35, then in 1926 it was equated to the percentage in Western Europe.
Taking into account the difficult social situation in the country, local authorities, together with tuberculosis dispensaries, involved the city community into conducting "tuberculosis three days" to raise funds. In four years, 4 million rubles were collected (Trakhtman, 1927, р. 101). At the same time, sanitary and educational work was carried out among the population, which included the publication of various posters, brochures, leaflets on tuberculosis prevention. Thousands of lectures were conducted, sanitary and other antituberculosis education activities were held.
Specialized research institutes played an important role in overcoming tuberculosis and other social diseases. There were three tuberculosis institutes in Ukraine: in Kharkiv, Odesa, and Kyiv. The departments of social pathology and tuberculosis prevention of these institutes focused on the study of the ways of tuberculosis spread among the rural population and national minorities, and conducted special expeditions to check up the population of certain districts and localities. The institutes did not restrict their activity in purely scientific work, but became scientific advisory centers, where meetings were held with general practitioners of cities, towns, urban-type settlements, short-term training courses for TB doctors were organized, and etc.
Along with the work on the elimination of mass tuberculosis diseases in cities, medical institutions paid much attention to the eradication of socially dangerous sexually transmitted diseases. As early as January 1920, a venereology section was established at the People's Commissariat of Health, and later such sections appeared at the provincial departments. The work of the venereology section of NCHC (National Committee of Health Care), as well as local sections was carried out in two directions -disease prevention and treatment. As of October 1, 1921, there were 2,600 beds for venereal patients in Ukraine. But the poor harvest of 1921, the food crisis and famine had a negative impact on the state of both medical care for the urban population, in general, and anti-venereological work, in particular, the number of hospital beds in Ukraine decreased to 1 100 beds on April 1, 1922. Only from the second half of 1922 the planned work on the struggle against venereal diseases was adjusted.
The work on the treatment of patients with sexually transmitted diseases in the cities went through several stages: from its organization and laboratory examination during 1922 -1923 to treatment, and most importantly -the implementation of preventive measures, mass checks up of the population, including family members (Fedorovskiy, 1927, р. 104).
The statistics data of the People's Commissariat of Health illustrate a high percentage of syphilis infection in the UkSSR. Per 10 thousand population in 1912 there was 41, 3% of infected people, during 1923during -1924during -44,9%, during 1924during -1925during -46,2%, during 1925during -1926during -39,3% (Fedorovskiy, 1924). There was a tendency of venereological diseases decrease during 1925 -1926 not only in comparison with the period of 1923 -1924 but also during the prewar period. Some positive changes in the treatment of sexually transmitted diseases were observed against the background of increasing training of qualified doctors and the creation of new scientific venereology centers.
Scientific contacts of doctors with foreign colleagues were of a great practical importance to the development of health care in the UkSSR. After the signing on March 1, 1921 of the Soviet-German protocol on the exchange of experience in the field of practical and scientific medicine, medical scientists from the UkSSR were trained in medical institutions of the Weimar Republic.
The development of medical science in the UkSSR required the use of foreign experience, as domestic medical science during the beginning of the 1920-ies was in the process of its formation. At that time, oncology, radiology, ophthalmology, social hygiene were just emerging as independent branches in the field of medical science and practice.
At the same time, the German doctors visited the UkSSR, in particular, in 1924, Professor Rezle became acquainted with the work of the Ukrainian medical institutions, and after returning to Germany he noted a high level of professional training of the Ukrainian doctors (Kalinicheva, 1996, р. 125). In July 1924, an international commission on malaria, headed by German Professor Nocht, visited Ukraine to find out the spread of malaria and to get acquainted with the organization of antimalarial care in the UkSSR.
Professors Jodason and Pinkus, who took part in the work of the All-Union Congress on the Control of Sexually Transmitted Diseases, which took place in May 1925 in Kharkiv, noted the success of medical science in the UkSSR. During 1922During -1923 in the Weimar Republic the Ukrainian doctors got acquainted with new methods of treatment and cooperated with German colleagues, in particular: S. I. Zlatohorov, L. A. Sobolev, N. K. Pidkomynsky, A. G. Fischer, K. H. Platonov, V. M. Shaler, V. I. Konotantynov, P. Kh. Khazhynsky and other representatives of various branches and directions of a medical science of the UkSSR. During 10 years, more than 200 physicians were on work trip abroad (mostly in Germany) (Kalinicheva, 1996, р. 128).
The Conclusions. An important indicator of the social standard of living of the urban population during the 1920-ies was their access to the health care service. After overcoming the effects of famine and outbreaks of epidemics during 1921 -1923, the city health service during 1924 -1929 focused on the fight against social diseases -tuberculosis and sexually transmitted diseases. As the epidemiological situation in the cities improved, social illnesses were overcome, and funding for the establishment of medical research institutes increased, and contacts were established with foreign specialists in this sphere.
The prospects for a further scientific research consist in the preparation of a historiographical study on the history of social medicine during the 20-ies and 30-ies of the ХХth century, which would reveal the main stages of the historical knowledge accumulation, showed the evolution of conceptual views on this issue, revealed to researchers a modern arsenal of methods and techniques for studying historical processes.