Library:Red Medicine: Socialized Health in Soviet Russia

Red Medicine: Socialized Health in Soviet Russia
Author	John Adams Kingsbury, Arthur Newsholme
First published	1933
Source	https://www.marxists.org/archive/newsholme/1933/red-medicine/index.htm

Preface

WHEN A RUSSIAN becomes ill the Government does something about it. In fact, the Government has already done something about it, for Soviet Russia has decided that the health of the individual is the concern of society as a whole. Indeed, the Soviet Union is the one nation in the world which has undertaken to set up and operate a complete organization designed to provide preventive and curative medical care for every man, woman, and child within its borders.

This vast and fascinating experiment in socialized health may not turn out as well as its originators expected, or it may turn out better. In any case it is an experiment that the rest of the world cannot afford to ignore.

In this book we present an outline of medical organization and administration in Soviet Russia, together with selected illustrative detail from the information which we assembled during our tour of that country. While we have not found any other book which covers this field in a comprehensive manner, we have been greatly helped by reading scores of books dealing with Russia in general, or with particular subjects having some connection with our own, and we have enjoyed personal conferences with a number of their authors. Of the many persons who have given us invaluable aid, a few must be named here.

Among those who have long known Russia and with whom we had stimulating conversations, Walter Duranty, Moscow correspondent of The New York Times, was especially helpful. Our receion in Russia was all the more friendly because of introductions which we carried from Senator William E. Borah and Lord Passfield (Sidney Webb). Mr. K. A. Umansky of the Foreign Office of the Soviet Union, and Dr. M. F. Vladimirsky, the Commissar of Health of the Russian Socialist Federated Republic, were prom and generous in facilitating our tour and in helping us to get the information we sought. Many other Russian leaders who are mentioned in our text rendered valuable assistance for which we are grateful. For supplementary information given us while he was in the United States on leave we are indebted to Dr. Alexandre Roubakine, of Moscow University. For assistance regarding political and economic questions we are grateful to Victor A. Yakhontoff, Major-General in the Imperial Russian Army, a member of the Kerensky Cabinet, and an historian of the Revolution; to Miss Mary Van Kleeck, Director of the Department of Industrial Studies of the Russell Sage Foundation, both of whom read the book in manuscri; and to Sidney Webb, who also read some of our chaers and made highly valuable suggestions. We are indebted to Victor O. Freeburg, of the staff of the Milbank Memorial Fund, for editorial assistance and for seeing the book through the press.

In spite of the care taken, we cannot hope that what we have written on a complicated subject involved with rapidly changing conditions will be free from error, and in this matter we crave the readers' indulgence.

We appreciate deeply the generous aid of the Milbank Memorial Fund in enabling us to pursue this study.

It may be added that we plead no cause; our only aim is to give a faithful account of what we have seen.

Introduction

THE genesis of this sketch of medical and public health administration in Soviet Russia⁽¹⁾ is soon stated.

Sir Arthur Newsholme had undertaken and carried out for the Milbank Memorial Fund an investigation into the relation between the private practice of medicine and the various activities of public authorities and social workers in medicine, including public health administration, the results of which were embodied in three volumes published under the auspices of this foundation.⁽²⁾ These volumes consisted in the main of an account of actual methods and procedure of medical practice in the chief European countries, with comment on them.

In a fourth and independent volume the problems involved in the various points of contact between private and public medicine were critically discussed in the light of the international facts previously collected, and certain definite conclusions were drawn as to desirable action for future guidance.

In this study of medicine and public health in European countries Russia had not been included; in part because the author, being solely responsible for the international investigation, was obliged to restrict his review within practicable limits; and also because at that time he scarcely thought that Russian experience was likely to give important guidance as to the direction and character of advances and reforms needed in American or English communities; for these had a history of advanced and widely diffused medical and social work not shared by Russia. Later inquiries threw some doubt on this a prioriconclusion; and a joint visit of inquiry was then initiated on behalf of the Milbank Memorial Fund. The dual personnel of this inquiry has given the advantage of both medical and lay approach to the problems concerned. Both inquirers have had extensive experience in social investigations.

The results of this joint inquiry are embodied in the following pages. It could scarcely be that two independently minded men, looking at Russian problems, each from his own viewpoint, should entirely agree as to the wisdom or expediency of all the remarkable new developments of medico-social policy which the U.S.S.R. has created, especially on their social side; and as the chief value of these pages lies in the authors' observations and not in their individual opinions, their remarks are in the main objective in character.

Although we were in Russia only during August and part of September, 1932, we had special facilities accorded to us which enabled us during this relatively short period to sample and to some extent to appraise public health and medical work in the chief towns of the U.S.S.R., from Leningrad to the Caucasus, i.e., from its most northerly great city to its southern extremity.

One of us had introductions from Lord Passfield (Sidney Webb) and other Englishmen; the other a special letter from Senator Borah, then Chairman of the Committee on Foreign Relations of the United States Senate. This led to our being received by Mr. Umansky of the Foreign Office and Dr. Vladimirsky, Commissar of Health for the R.S.F.S.R.;⁽³⁾ and on our way south by steamer on the Volga, and afterwards in Georgia and in the Crimea, we found that the introductions and instructions sent from the Foreign Office and Commissariat of Health opened every door to us. For instance, at each town at which our steamer stayed for a few hours on our four-day trip down the Volga, the local Commissar of Health, or members of his staff, met the boat and we were taken to inspect the chief medical institutions of the place. Opportunity was thus also given to obtain details of local medical administration, which are set forth in subsequent chaers.

Our description of what has been accomplished in medical administration may easily be regarded as giving a distorted and too favorable view of medico-social developments in Russia. Our statements are open to this accusation, which has been similarly urged against the particulars given in the many earlier volumes which have described personal observations made by foreign visitors to the U.S.S.R. Doubtless we were shown the best of what exists in Russia. The same would hold equally good if any foreign visitors came with influential introductions to inspect medical and public health work in England or America. We realized all the time that we were seeing the best that the U.S.S.R. had succeeded in developing. But when this best was seen repeated in many cities visited by us, and when it was everywhere frankly stated that their arrangements were not yet complete, that the dearth of doctors made more adequate provisions difficult for a few years; and when we were told openly of the great difficulties which were being experienced in extending the medical provisions of cities to the vast rural communities of Russia, and of the only partial success hitherto achieved in overcoming these difficulties, we were forced to the conclusion that we were not being victimized by a "window-dressing" display; and that, indeed, a marvelous reformed and extended medical service had been organized in Russia, the methods and procedures of which the rest of the world would do well to study.

It will be noted that we confine our remarks on administration, in the main, to medical provisions; and that in regard to other branches of social work-education, for instance-we can give only slight information; though in our earliest chaers we have thought it wise to give a somewhat detailed account of social and economic life in Russia, in order that its medicine of today may be seen in its natural setting. For the same reason, we have introduced a short historical statement of the steps leading up to the formation of the Soviet Republics.

Although we seldom stayed in a town more than two or three days, we had the great advantage of immediate access to the chief medical officials, and as a rule searching inquiries into details of administration were fully and, alas! too profusely answered; and we had little reason to suspect that information was being withheld or given with a markedly greater desire to "put the best foot forward" than would have been experienced in our own countries.

It was our object to obtain accurate information, and the question naturally arose: Were we getting it? As we necessarily depended on interpreters, we had not the clue which would have been in our hands with even the most elementary knowledge of the Russian language. We had, however, the check given by intimate knowledge and experience of the problems of our inquiry; and this knowledge every day enabled us to avoid many misapprehensions.

There were two further difficulties. Our precise and concise questions commonly led to a protracted disquisition in answer; and at the end of it the interpreter's version often appeared to be a meagre representation of these outpourings. This we tried to avoid, by urging the interpreter to obtain information and to give his translation of it in sections with intermediate pauses; but success in this direction was trifling. A final difficulty was that each interpreter was a Government official, sometimes a member of the Communist Party. Was he, when interpreting, giving an unvarnished statement, or was he giving us an admixture of intentions and accomplishments, with a slurring of statements of serious defects? We think this slurring may sometimes have occurred; but we had opportunities for correcting these errors by our own observations and by comparison of statements made in successive places visited by us.

In the first two chapters is given an account of our wanderings and visits, with short descriions of what we saw. Much of it does not deal directly with medical problems; but indirectly it does, for the medical problems and their partial solution can only be fully understood and appreciated in the light of knowledge of the Russian people; and we always need to remind our-selves that solutions of medical and other social problems which are appropriate for Soviet Russia may need much modification in the circumstances of life of the populations of Britain and the United States.

This point applies especially to methods of control and administration of medico-social work. The workers (that is, industrial workers) and peasants of Russia's vast population of one hundred and eighty-two races represent on the whole a more primitive and simpler civilization than that of western countries; and when one recollects this fact, one is filled with wonder and astonishment at what has been accomplished in so short a time. But it does not follow that in countries in which local and central government has for long been elaborately organized, similar results could be obtained in exactly the same way, even though the main principles are identical. But on this point our summary in the last Chapter should be read.

In concluding this introduction we claim that in making our investigations we had no previous bias, except some measure of scepticism as to the possibility of the western world deriving useful lessons from Eurasia. We belonged and still belong to neither of the schools satirized by MacFlecknoe in a recent number of The New Statesman and Nation:

"The sights that X selected

Bore out what he expected-

Great factories rising;

An enthusiasm surprising

For welfare and education;

A New World in formation

Much better than the Old-

Just as he had foretold."

While in similar manner

"Mr. Y saw what he expected-

Breakdowns in transportation;

A growing indignation

With the Communist oppression;

A steady retrogression

To chaos, bloody and red-

Just as he had always said."

We place ourselves rather among those

"Who believe NO `Truth about Russia'

Which harnesses every fact

To a formula exact;

And proves, in the end, to be

What the writer had wished to see."

Moscow and Leningrad

BEFORE sketching the background and setting of the present regime in Russia we propose to give an outline of our tour of nearly nine thousand miles through several republics and in many different climes, so that the reader may realize with us the characteristics of the people and the facilities for preserving or restoring their health as observed by us. Meetings with medical leaders will be referred to, as also the health institutions we visited, but the statements of these leaders as to medical procedure and our own specific observations in these institutions will be presented in subsequent chaers under their appropriate headings. Occasionally, in these narrative chaers, we shall discuss certain things not treated elsewhere.

Our journey together began on August 2, 1932, in Southamon Water on board the S.S. Bremen, en route from New York to Bremerhaven. We had already prepared ourselves by much reading about Russia and by conferences with others who had recently visited that country. Summaries of information, as well as the questions we intended to ask, had been set down on paper. On board the Bremen was an American newspaper correspondent⁽¹⁾, long experienced in Moscow, with whom one of us had frequently conferred on the way from New York. Both of us now shared the discussion of Russia as viewed by this experienced interpreter of daily events in the Soviet Union.

At Berlin we stopped at the Hotel Adlon. After dinner we talked with a wellknown American publicist who had just arrived by airplane from Moscow. His attitude on the possibilities of eventual approximation between the policies of capitalism and communism is hopeful for the future, and appears to form a not improbable forecast. He forecasted a protracted struggle between the two, in the course of which both sides will modify their positions. Capitalists, he held, will gradually part with a large share of their present profits in industrial enterprise, the workers will take an increasing share in determining the conditions of industry, and will realize that what the present employer and capitalist contributes in enterprise and initiative must be maintained and extended.

In view of reports that there was no unemployment in Russia we noted the effects of industrial depression as seen when we walked along the Berlin streets during our twoday stay. We were repeatedly asked for alms by men who appeared capable and of the type ordinarily desirous of work. Berlin is heavily taxed. At a restaurant we paid a tax on our whole bill and in addition a ten per cent tax on the coffee we had.

On the evening of our second day in Berlin we entrained for Moscow, to be ejected from the train at midnight by a Polish official, who found that the Englishman's passport had not been visaed for travel in Poland. Intourist, Ltd., the Soviet travel bureau in London, had overlooked the absence of this visa. In spite of explanation and argument on our part the official did not help us. So we perforce sat for four hours through the night in the waiting room of a small station, until there was a train back to Berlin. That the Polish official was technically justified in refusing to pass the traveler without a visa is beyond dispute, but the absurdity of the position is illustrated by the fact that in Berlin our hotel porter obtained the Polish visa without the presence of the traveler at the consulate. Later in the summer when one of us reached the Hungarian border without a visa he was able to get one on the spot and proceeded without loss of time. Our unlucky delay on the way to Moscow, we thought, illustrated the strained relations between Poland and Russia, of which we saw other evidence. It is difficult for Western Europeans to appreciate at its full significance the mental strain and the fear of war which characterize Russia, Poland, and also Czechoslovakia and Yugoslavia.

After the return to Berlin and the loss of twentyfour hours we finally got through Poland and reached Negoreloye, a Russian frontier station. Here we noticed a rather large school abutting on the railway. The children were playing a sort of football, and singing seemed to be general. Later in various parts of Russia we noted that men and women often sing together at their work. In the parks communal singing is heard everywhere.

The customs examination was interesting. No objection was made to any articles brought in, but field glasses and camera had to be declared, and we filled out forms stating the exact amount of money in our possession. Then in marched two or three porters with a chief. They gave us checks for our baggage, and after we had paid them a fee that was not too large they carried it to the train. There were no tips.

The walls of the Custom House were covered with murals illustrating the Five Year Plan and the new Russian industries, and with the following exhortation in four languages: "Workers of the world, unite!"

This is not a new slogan. Eugene V. Debs used to preach it in America. It comes from the Communist Manifesto of Karl Marx, the whole passage reading:

Let the ruling classes tremble at a communist revolution. The proletarians have nothing to lose but their chains. They have a world to gain. Working men of all countries, unite!

On the train we met Dr. and Mrs. Moissey Gourevitch. He was formerly Commissar of Health for the Ukraine, one of the leaders in establishing the Five Year Plan in Public Health. He gave us letters of introduction and valuable advice regarding our survey.

At the Moscow station we were met by the local director of The Open Road, an American organization which promotes cultural contacts between American travelers and residents in Europe, and also by the interpreter provided by Intourist.

It is convenient to state at this point something about our travel arrangements. These were made by the Intourist offices in New York, London, and Moscow. As we traveled in the "first category" we fared relatively well. An interpreter was at our disposal throughout our trip. In Moscow and Leningrad we had three interpreters at various times; afterwards one while traveling south; and from Rostovon-Don onwards, we were fortunate in having a lady interpreter who was partly English in origin. In the light of our experience we can conclude that our difficulties would have been much less had we secured one good interpreter for the whole trip. Three out of the five interpreters assigned to us were women of education; and we found them more useful than the men, although one of the latter was a teacher of English in a university! A motorcar was at our disposal everywhere, and berths were reserved for us in trains, usually without mishap.

Impressions of Moscow

In Moscow we were immediately impressed by the moving crowds, which filled the streets and tramcars. The heavy traffic was evidently due both to the hustle of going to and from work and to the rapid turnovers in labor, about which the newspaper correspondents have written. Men, women, and children with their belongings, coming in to the city or going somewhere else; laborers, clerks, intellectual workers, most of them wearing the familiar blouse, but many in nondescri clothing; some men in khaki "shorts," some young women in plain flimsy summer garments supported by shoulder straps; many little boys and girls running about almost naked; a few gay colors here and there, but mostly the drab hue of inferior clothing; the bright eager eyes of idealists, of hopeful workers; the vigorous strides of youthful strength; the tired, bewildered looks of a few old folks; the mischievous laughing faces of children; the curious, yet wellbehaved, attitude toward us foreignersthese were the aspects of the people which we first observed.

Order and good nature were in evidence. On the tramcars, for instance, a reserved section is provided for women with babies, expectant mothers, and old and feeble folk, who can enter at the front end of the car, while other passengers must enter at the rear.

There is a serious housing problem in Moscow. Its population of about three and a half millions has increased about 50 per cent since before the war. Sidney Webb remarks, however, that "measured by floor space per head, the working population of Moscow was even worse housed in 1914."(In Current History, December, 1932.) Although many new apartment houses, ten or twelve stories high, have been built, living accommodation is still so scarce that quarters are rationed to each family according to numbers. Doctors and other professional workers are assigned slightly more space than manual or clerical workers. The rental collected is in proportion to the family income and not to the accommodation provided. It is partly because of these crowded rooms, as we shall see later, that night sanatoria have been established in the cities for convalescent workers and those having "latent" tuberculosis or under suspicion of being tuberculous. Besides the new apartment houses, we saw new business buildings, clubs for workers, and factory buildings. The bustle and stir of all this construction recalled the great boom towns in western America in the latter days of the nineteenth century.

The evident shortage of food was freely discussed by those whom we met on our travels. However, we traveled nearly nine thousand miles in August and September and did not suffer seriously from unsuitable food. Watermelons were abundant, and the muskmelon was delicious. The chief lack was of good meat and milk. Quite often no milk was forthcoming with coffee. Evidently the country has not yet recovered from the wholesale destruction of cattle by the kulaks⁽²⁾ when they were forced into the collective farms. Dried milk was unknown; and if it had been known, would probably not have been available, as an essential point in Russian policy during these early years of difficulty is to restrict importations of goods from abroad, which have to be paid for in foreign currency. Coffee evidently is not favored officially, for it has to be imported; but good tea is available everywhere and is the national beverage. It is cultivated in the Caucasus, where we watched its gathering and preparation for sale on a wellorganized State farm. In Moscow, as elsewhere, we saw men and women waiting in long lines for their turn to get their rations at butchers' shops and other stations where food was distributed. At large communal kitchens we saw dinners served to all comers, irrespective of means, at a cost of 60 kopecks.⁽³⁾ Similar dinners are provided at the factories.

Not long after our arrival we surveyed Moscow from Sparrow Hill (now Lenin Hill), the historic spot from which Napoleon watched the burning city. From that height we could see the Moscow River winding through the city. Later on we saw where the old factories along the river had been torn down by the Soviet to give space for the great Park of Culture and Rest.

How this park functions in the health system will be told in a later chaer. But we may anticipate a bit by saying that, according to Soviet philosophy, rest and recreation are developed as means of exemplifying the value of socialized activity. During our visits in the park we saw groups of adults engaged in folk dancing, or community singing, or simply in friendly conversation. We saw the children in their own "village," happy at their games, or in classes receiving instruction. Whenever we stopped to take a picture, a curious circle formed around us. Along a broad walk in the park was an educational display illustrating political aims. Large figures, grotesquely formed of sheet iron or wood, satirized, for example, the disarmament conference, or predicted the "liquidation of the kulaks" by 1937! Along the Moscow River are grandstands from which spectators watch the boating and swimming.

For organized sports the city has about a hundred grounds, besides the new Dynamo Sport Club Stadium, which we visited. Over the entrance to the stadium is a huge legend reading "Be Ready for Labor and Defense," an exhortation with which we were to become very familiar, since it is seen or heard everywhere in Russia. The stadium has seats for about 50,000 spectators, and, like many stadia in Europe, has further accommodation for standing, in this case, for about 25,000 persons. Organized sport and the wide interest in physical culture are post-Revolution phenomena.

One evening we attended a motion picture show. The film was "The Road to Life," which dramatizes the need of suitable education and training for neglected and homeless children to prevent their becoming criminals.

Some years ago travelers through Russia used to come back with terrifying stories of "wild children." At that time there were large groups of "roofless children" roaming the streets and yielding to primitive instincts in getting their living. Although the problem of finding homes for these children has been largely "liquidated," juvenile delinquency has not entirely disappeared. However, the children we saw on the streets were well behaved. In fact, during our entire tour only a few persons asked us for alms. Beggars were so much more frequently seen in other European countries that there is no comparison, in this respect, between them and Russia.

Besides seeing motion pictures, we also attended performances of stage drama. We were thrilled by the great Meyerhold in his theatre in a play full of challenge to the capitalist world. In the Moscow Art Theatre in a play entitled "Fear" we saw the best acting witnessed by either of us in many years of theatregoing. The Russian Ballet in the Moscow Opera House gave an interpretation of "Swan Lake" which was surpassingly beautiful.

It was interesting to learn that workers in heavy industry are given preference in assignment of seats at the theatre and at the opera. There was an absence of dress suits and evening gowns in the audience, but there was no lack of appreciation of the music and the art of the dancers.

While it is not our purpose to describe "sightseeing" in general, we can hardly refrain from saying that in the Kremlin, that beautiful group of medieval buildings, are impressive exhibits of treasure, belying the reports that the imperial jewels were lost, stolen, or sold.

But more impressive than the historic Kremlin is the Tomb of Lenin, in Red Square, just outside the Kremlin wall. There, in a mausoleum of huge blocks of red granite, magnificent in its pure simplicity, lies the great revolutionist within an illuminated glass pyramid, with delicate hands relaxed upon his breast, looking as though he had fallen asleep, plainly visible to the thousands who come every day and bare their heads before him.

Our visits to medical institutions were, as a rule, in the company of the chiefs or other officials of these institutions, and we were given every opportunity for complete inspection. How far we ranged can be seen from the mention, in this preliminary account, of many of these interviews and visits. What we learned on such occasions with specific reference to the health services will be stated in fuller detail under the appropriate headings in other chaers.

On our first day in Moscow we had called at the headquarters of VOKS, the Russian All-Union Society for Cultural Relations with Foreign Countries. Here we had presented our letters and credentials, and an appointment with the Foreign Office had been arranged for us. At the Foreign Office we were courteously received by Mr. Umansky. To him, and likewise to Dr. Vladimirsky, Commissar of Health for the R.S.F.S.R., and to Dr. Zalujsky, Deputy Commissar, we are indebted for the special facilities and exceptional opportunities given us for the important interviews and visits upon which the contents of this book are chiefly based.

Commissar Vladimirsky, wearing a peasant blouse, had the manners of a gentleman of the old Russian school, combined with the confident briskness of a capable executive. Educated in Germany and at the Pasteur Institute in Paris, he practised medicine for many years in France. During the years of the terrible epidemics and famine in Russia, he and Dr. N. A. Semashko, his predecessor in office, used to work until late at night planning the present public health system. It was extremely helpful to us to meet Dr. Vladimirsky and to hear his survey of the present medical situation in Russia, including a reminder that because of the shortage of physicians there had necessarily been delay in progress according to plan.

Basic research in preventive medicine and study of the technique of health education are carried on at the Institute of Health in Moscow. Here we met Professor Landis, the head of the institute, who outlined the methods of public health administration and the functioning of social and sickness insurance.

Dr. Abram Genss, Assistant Director of the Institute for the Protection of Motherhood and Childhood in Moscow, enunciated the Soviet policies regarding maternity work and the care of infants and young children. Dr. Genss also summarized the Soviet experience with abortion, according to the plan which he initiated about thirteen years ago.

A few days later we witnessed a marriage and a divorce in one of Moscow's marriage bureaus, which will be described in Chapter XI. The offices were in a house that had probably been a private dwelling. On the walls of the pleasant waiting room were posters and placards giving advice on the care of babies and promoting general hygiene.

An interview with Dr. Kazaroff, head of the Moscow Institute for Skin and Venereal Diseases, gave us valuable information as to antivenereal organization. The institute, which has 400 beds, is related to five venereal disease dispensaries in the city, and to the factory and other general dispensaries which also undertake some treatment of venereal diseases.

Continuing our study of venereal disease control, we visited a "prophylactorium" for prostitutes, in which there were 500 inmates who receive medical oversight while working at and learning useful occupations. In Moscow and other parts of Russia are many "prophylactoria" of this type. One room of the "prophylactorium" we visited is devoted to historical exhibits of past and present methods of treatment and prevention of venereal disease. In the exhibits the relation of prostitution to capitalism with its associated poverty is stressed. One placard says, "To hell with charity."

The subject of free medical aid was elucidated for us by Commissar Vladimirsky in a second interview.

Then we visited one of Moscow's ten "night sanatoria" and saw how convalescent workers and those needing rest and special care were housed while continuing daily work.

A visit to an antialcoholic station, one of ten in Moscow, revealed methods of caring for those who have drunk too much vodka, and of disciplining offenders as part of the Soviet work against alcoholism.

Our study of Russian tuberculosis control gained its first impetus from a visit to the Central Tuberculosis Institute for the R.S.F.S.R., which is in Moscow. Here Dr. Neslin outlined the organization for the discovery, treatment, and prevention of tuberculosis in Moscow. This institution is related to a network of tuberculosis dispensaries and to a much larger number of polyclinics, as a centre of expert consultation.

In the Park of Culture and Rest we interviewed Professor Popoff, Director of Research in Health, and Professor L. Rosenstein, Director of Research in the Institute for Neuro-Psychiatric Prophylaxis, who explained to us the philosophy of the Russian program for the prevention of disease and the cultivation of positive health. These interviews, coming, as they did, in the midst of the Park of Culture and Rest, a characteristic Soviet institution utilized in carrying out the health program, gave an added vividness to the demonstration.

In the Children's Village, an idyllic part of the park, we saw some three hundred little tots, whose parents are engineers, doctors, and other professional workers. In each group of twentyfive the children were uniformly clad, to identify the individual with the group. On each child's costume was a symbol which corresponded exactly with the symbol on that child's drinking mug and towel. More will be said of this Village later. A special tribute to this institution was expressed by an American woman whom we met with her sixyearold daughter. She said that the girl's worst punishment was to be deprived of her daily visit to the park.

As we walked along we saw a group gathering about a man who had the text of a song unrolled on a large canvas. One of us took a snapshot of the scene. A Russian standing beside us said in perfectly good English, "Did you get a good photo?" "I hope so," was the reply. "What are they singing? Patriotic songs?" "Certainly not," came the answer. "This is a song calling upon the workers of the world to unite." Then he told us the words, and when we bantered him about patriotism he said, "Well, of course, we have songs of defense, which you might call patriotic."

Then he said, "I have been in Manchester. I have been in America, too. I was an iron worker there. I have nothing against capitalists, but only against capitalism. I met Mr. Schiff in the Henry Street Settlement in New York and liked him."

"Are you a worker now?" we inquired.

"Yes, I am a worker. This is my day of rest. I am the Commissar for the Scrap Iron Industry of the Soviet Union."

We report this incident here as typical of the cordiality shown even by those we met casually.

Having heard accounts of remarkable Russian innovations in the rehabilitation of prisoners, one of us visited a "labor commune" at Bolshevo, about thirty miles from Moscow. This is a settlement of men and women (with their families) convicted of theft, arson, and similar crimes. At the time of the visit there was a population of 2,200 in the Bolshevo colony, including about four hundred married couples. They live either in apartment houses or in separate onestory cottages built for two or three families. The workers are engaged in the manufacture of sports goods, this plant probably being the biggest of its kind in Russia. They also engage in farming and stockraising for the needs of the community. The community has a hospital and clinic, cooperative store, and school. Incidentally, the visitor found an excellent exhibition of local art on view in the school building.

The remarkable thing about this colony is that it is selfgoverning and that its members, who have been selected by a Distribution Committee from those confined in prisons, and are, strictly speaking, completing their terms, are free to go and come, and may, indeed, leave the colony forever if they choose to do so.

Mr. Boguslavasky, Director of Education, the administrator of the colony under the jurisdiction of the OGPU,⁽⁴⁾ informed the visitor that the inmates prefer to remain with the colony and predicted that the community would be permanent. Naturally it is hoped that additions by way of prisons will be reduced to a minimum.

Besides our interviews with Moscow medical leaders and other officials, we had frequent talks with Englishmen or Americans who from long experience had a good understanding of Russian affairs. Newspaper correspondents, teachers, and other foreign residents gave us valuable advice and information along with their personal opinions on Russian social phenomena. Hence when we left Moscow for the long tour up and down European Russia, our notebooks were already bulging, and Soviet public health work was beginning to emerge as a reality for us.

Visits in Leningrad

We took a night train for Leningrad, the old Tsarist capital some four hundred miles to the north. During the last few hours of our journey we gazed on vast stretches of flat land, with occasional groves of white birchthe national treeand of marshes which furnish peat used for fuel in this part of Russia.

At the station we were met by a slip of a girl who proved to be one of our most efficient guides. Leningrad, the historic seat of science and. culture, is the largest industrial centre in the Soviet Union. On the banks of the Neva River stand the palaces and cathedrals in their rich beauty of imperial times. Near by are being built new apartment houses for the families of former political prisoners, who are to be governed by their own Soviet. In the Hermitage and other museums we saw the priceless collections of pictures, precious stones, jewels, and archaeological objects, and were deeply impressed both by the collections and by the fact that, as our interpreterguide pointed out, notwithstanding the Soviet's great need of foreign money, these treasures have been scrupulously preserved.

There are eight large polyclinics in Leningrad. We visited one known as the Ambulatorium for the Volodarski District, an important manufacturing section. The building itself is a long threestory structure of concrete and steel, rigidly simple in design. Two wings and a central section bound a court formally laid out. Over the main entrance is the legend : "To the Workers of the Prophylactic Centres : You Should Be in the Front Ranks of Those Who Take Part in Socialistic Construction."

This institution was one of the largest of its kind that either of us had ever seen. It aims to provide health service for the entire population of the district, but has proved inadequate, and therefore a second polyclinic of similar size for this district is under construction.

The health work includes all branches of medicine, and also a training school for nurses. One hundred and twentyeight doctors are employed, and all workers in the district are treated free.

We next visited the Leningrad Institute for the Protection of Motherhood and Childhood, in a brick building which has been well remodeled for its purpose. Here we were shown a "creche," which might be described as a combined day nursery and school, similar to others in all the eight districts of the city. We also inspected the maternity department and learned of the care given to expectant mothers as soon as pregnancy is suspected. Here the functioning of the birth control department was also explained to us. This institute serves a district with a population of 200,000. We were told that over 90 per cent of the mothers of the district were registered in the institute.

An example of the conversion of a former palace into use as a night sanatorium was seen in a suburban house which formerly belonged to a German sugar magnate. This night sanatorium, which has 130 beds, is for early cases of tuberculosis. The palace, overlooking the Neva River, is remarkable for its lavish fittings and decorations of German taste. The doctor in charge explained the facilities and routine of the institution.

A similar palace on the Neva, expropriated from its former owner, is a House of Rest, which we visited. The gloriously large drawing room and other rooms of this palace were occupied by workers, on a fourteenday holiday, who were surrounded by abundant evidence of past luxury.

We also visited a House of Culture, a sort of clubhouse for workers. Besides providing reading rooms and lecture rooms, the house also has a room in which mothers may leave their children in care of nurses and teachers while they attend lectures or plays. There was a special Room for Foreign Guests, a combined library and exhibition room, stressing achievements of the Soviet Union. The House of Culture might be described as a glorified Y. M. C. A. and Y. W. C. A. combinedthe C., however, standing for Comrade, not for Christian!

We had long looked forward to a visit with the celebrated Dr. Pavlov, but unfortunately for us the great investigator was absent. However, we were received by his son, a lawyer, who is now chiefly engaged in preparing his father's works for publication. Mr. Pavlov, who spoke good English, gave us much valuable information. Through his kindness we were joined by Professor Orbeli, the distinguished physiologist, now professor in the Military Academy at Leningrad, who also spoke good English. Professor Pavlov and Professor Orbeli are not Communists, and it is generally known that they often disagree with the Government on the merit of measures taken, but in spite of this the Kremlin, recognizing the value of their scientific work, does not discipline them, but, on the contrary, they are given every facility to aid them in prosecuting their scientific research work.

From Moscow to Georgia and the Crimea

FROM Leningrad we returned to Moscow, where we spent a few days making further investigations before starting southward on our journey which was to take us down the Volga River, across the Caucasus Mountains, and down to the Black Sea. It has been said that he who has seen Moscow has seen in miniature what is taking place throughout the Soviet Union. We desired, however, to see, not in miniature, but in full scale, something of the health work in various republics, and under varying conditions.

We began our southern trip by spending twelve hours in a night train from Moscow to Nizhni-Novgorod. Incidentally, this city has since been renamed Gorky, but we find it convenient to use the old name. In this "Detroit of Russia" we visited the great new automobile factory. The works are on a gigantic scale. Construction was progressing on acres of large apartment houses in which the employees and their families will live. As we drove through the housing development we thought that, from English and American points of view, at least, it would have been more appropriate to build homelike cottages, each with its own garden, especially as there seemed to be vacant land available for an unlimited number of cottage homes. However, we realized that the plan adopted will probably meet the present housing emergency more rapidly and at less expense than could be done by separate buildings.

We visited the factory hospital and polyclinic in temporary quarters and saw the new buildings nearing completion. The local Commissar of Health explained the medical service in the city as well as in the factory.

The voyage down the Volga, famous in song and story, will always be remembered as a unique experience. The natural scenery, the historic towns and villages, the picturesque life along the way, the succession, as we traveled, of one race after another, the river traffic, the singing and merriment of the Russian passengers on board the steamer, our receions in cities visited, the institutions inspected, the interesting leaders with whom we talkedall contributed richly to our enjoyment and to our understanding of the Russian people and of the Soviet public health ideals and accomplishments.

From Nizhni to Kazan the Volga flows eastward in a deep channel. On the south are wooded palisades of sand and clay, or hills retreating and exposing undulating highlands, with abundant fields of grain and thatchroofed hamlets nestling in great ravines. The north bank resembles a wide sandy seashore, with deciduous woods in the background and rolling plateaus rising in the distance.

Passing from the political division called the Nizhni-Novgorod Area, through a part of the autonomous region of the Mari, a Finnish-Ugrian people, we reached Kazan, ancient stronghold of the Tartars, capital of the Tartar Republic, and cultural centre of the Volga.

Kazan has a population of 179,000, of which 50 per cent are Tartars. We learned that at the time when the Soviet Government proclaimed the Tartar Republic there was almost no hospital provision for the Tartar population. Now they have twenty large hospitals and sanatoria, while the hospitals for non-Tartars have increased in number.

We were met by the Commissar of Health, a huge finelooking Tartar. He took us to visit a large university clinic, including all the departments of medicine, in which students are taught special subjects. About 1,500 patients are treated daily at this clinic. It has 70 beds for inpatients. We got glimpses of other health institutions in the city, and we carried away an impression of an Oriental city in the course of transition, with signs of modernization already visible.

An interesting example of Soviet wholesale preventive measures is the fact that the entire population of Kazan was vaccinated or revaccinated in June, 1932, following some fifteen cases of smallpox the preceding winter. Through similar mass work typhus has disappeared from this city.

Kazan having been reached on the next day after our Volga voyage began, we were already getting acquainted with fellow passengers, and the scenes on board were becoming familiar. There were many hundreds of third- and fourthclass passengers who appeared to be chiefly peasants. Many of them were burdened with small stores of fruit and food besides other personal belongings. Their outfits commonly included bedding, two big wooden boxes, small parcels, a bottle, and a kettle. How they avoided injuring one another as they hurried aboard was a marvel. They crowded the decks, sleeping in the open at night. The secondclass passengers, having more privileges, sle in our dining room.

The colorful smocks and kerchiefed heads of the women lent a picturesque quality to the crowd. At night the men and women sang plaintive airs. And interspersed with these sad refrains on board were snatches of song recalling the Volga boatmen or faint strains floating across the still waters from groups of peasants on the sandy shores. As we sat and listened in the moonlight the effect was peculiarly romantic. But the plaintive songs on board were interrued by gay laughter. And at times some man or woman would jump up and dance with astonishing vigor.

When we docked at Bogorodsk, about sixty miles south of Kazan, a thousand people struggled for a place aboard our already overladen boat. It was distressing to see poor women, some in advanced pregnancy, others with crying babies, and all with heavy burdens, fighting to get a place on the gangplank. The caain and the mate mounted the railing and pleaded for order, explaining why it was impossible to receive them all, and at last got the mob under control.

During the night a woman who had come aboard in the crowd gave premature birth to a child; and the next morning at Ulyanovsk in the midst of a similar dock scene we saw the mother and baby carried ashore on a stretcher, both alive, thanks to the help of the ship's doctor, a woman.

Earlier in the morning a fine example of gallantry was shown by a young porter who stripped himself in an instant and jumped overboard to rescue a huge bundle of family possessions dropped by an old peasant woman.

This aquatic exploit reminds us of an amusing incident of the previous day, not far south of Kazan. The river there is shallow, and the channel frequently shifts. The ship had gone aground, and after the caain managed to get her afloat again, he decided to tie up at a dock while a boat crew searched for the channel. During this delay a number of the passengers went to a nearby beach for a swim in the Volga. One of us was among them and caused a sensation, for a reason which he could not immediately discover. But after some inquiry he learned that the natives had never before seen a man in what they called a "lady's bathing suit," because it covered the upper part of the body! As a matter of fact, nude bathing by men and women, though not in mixed parties, is very common in Russia, as we observed on the Volga, the Black Sea, and elsewhere.

In the river were all sorts of craft: steamers deluxe like ours; ferryboats, jammed with peasants and animals; extensive booms of logs carrying permanent floating cabins for the workers, and dugout canoes packed with singing peasants.

Between Kazan and Ulyanovsk the right bank of the Volga in places reaches a height of more than five hundred feet, reminding one of the Palisades of the Hudson River. Then, at Ulyanovsk, it suddenly emerges from the highlands, which retreat to a great distance, exposing vast fields of grain. But the highlands return and retreat again and again, revealing and hiding thatchroofed villages, with one or more white churches or cathedrals set off by tall poplars.

Along other stretches the landscape looks wild and lonely. Human figures are seen roaming in and out among the woods. Cattle, goats, sheep, and horses graze, often unshepherded, or come down in great herds to drink from the river, giving idyllic touches to the picture.

Ulyanovsk, scene of many battles during the civil wars, is the birthplace of Lenin, and the house in which he was born and lived as a boy is now a museum, revered as a national shrine.

The high rugged banks ended in the Samara. Bend, a horseshoe curve more than a hundred miles long, where the Volga rounds a range of the Zhiguly Mountains. At the eastern point of the bend is Samara, chief town of the Middle Volga region. This city, with a population of about 172,000, has also been the scene of recent battles. Here we were met by the Deputy Health Commissar, Professor Batrastshenca, an ophthalmologist, and Dr. Katzenellenbaum, the Director of Medical Research. They told us of activities to control trachoma, formerly prevalent in the Province of Samara, and gave us a good survey of all the other medical activities and facilities. We also had an opportunity to view one more of the famous parks of culture and rest.

West of Samara are many industrial plants working the rich deposits of chalk, gypsum, combustible shale, and phosphorites. At the village of Batraki is a railroad bridge nearly a mile long, and, as our steamer approached this, we were all ordered under cover. This seemed extraordinary, but we understood it when we learned that two spans of the bridge had been blown up by enemies and that there had been counterrevolutionary threats from time to time. The incident illustrates the "war mentality" which still continues in many parts of the country.

In the afternoon of our third day on the Volga we entered the Autonomous Republic of the Germans of the Volga. Here live half a million Germans, speaking their own language and preserving their own characteristic culture. This was evident in the general aspect of Saratov, a city of about 215,000 population.

Here the Health Commissar and practically his whole staff came aboard to meet us, a woman doctor acting as chairman and spokesman. As the boat was several hours late we were unable to make any inspection ashore, but we were fortunate in having a twohour conference with the deputation. We were informed that there is no typhus and very Iittle typhoid in Saratov, Tuberculosis is declining. Our visitors gave a very clear and concise descriion of the hospitals, sanatoria, night sanatoria, ambulatoria, consultation centres, the medical technicums (for training nurses), and antialcoholic dispensaries in Saratov. They also described the work in maternity care, birth control, and the control of prostitution.

From time to time, as the boat glided down the Volga, we had interesting discussions with fellow passengers. An Englishspeaking Russian chemical engineer talked to us about taxation, hours of labor, health facilities in factories, and the coordination of preventive and curative medicine in industry. This man had worked up from the ranks of labor, having qualified himself technically at the Workers' University. That he was important in his field was indicated by his statement that he was on his annual leave of one month with full pay.

From this discussion we turned to one with an American financier from Wall Street. He had been able to make thorough investigation of the new iron and steel works at Magnitogorsk, east of the Urals, and of other great new factories. Magnitogorsk (the Magnetic Mountain), it may be recalled, refers to a new industrial town being built around the steel plant, which is designed to be the most powerful in the world, with a projected production of 4,000,000 tons of pig iron a year. The Wall Street man was as amazed at the industrial developments he had seen as we were at the developments in the public health field. He had been impressed, among other things, by the freedom with which workmen were permitted to criticize the general management of factories as well as their coworkers. He spoke particularly of the "wall newspapers'' to which we shall refer again. The American held that the future of Sovietism was to a great extent dependent on maintaining this freedom of individual criticism. Although in the factories visited he had seen considerable inefficiency, he believed this to be of a kind which will be remedied.

A Russian jurist, whom we met on the boat, gave us much illuminating information on marriage and divorce, which is discussed in another chapter.

From Saratov to Stalingrad the Volga winds its sluggish way through vast desertlike steppes. However, the soil is productive, particularly of melons. At Bykovy-Khutor we saw peasants vending veritable mountains of delicious watermelons and muskmelons.

As we voyaged southward there were increasing evidences of subtropical life. We saw a caravan of camels drawing kola-like wagons. When the camels came down into the river, it actually seemed to subside as they drank! We did not see any sturgeonfishing, which is carried on in the lower reaches of the Volga, but we feasted daily on caviar. Indeed we were astonished that there could be so much caviar in the world!

After four days and nights on the Volga, passing through many republics and seeing many different races in their natural setting, we left our boat at Stalingrad. Although we reached this city in the evening too late to visit institutions, it was not too late to be received most cordially by Dr. Sokolova, Deputy Commissar of Health, a brilliant and attractive woman doctor, who heads the Institute for the Protection of Motherhood and Childhood for the entire Stalingrad region. We dined with her in the crowded Park of Culture and Rest, where we had an opportunity of seeing the "night life" 0f this famous tractor centre.

Stalingrad is a city of 250,000 people. It has a great number of new factories, the most celebrated being the tractor plant, with a capacity of 50,000 tractors per year. The "night life" which we saw in the Park of Culture and Rest consisted of folk dancing, bowling on the green, song fests, and great crowds strolling on the boulevard. During the evening Dr. Sokolova gave us an illuminating account of the work being done in the entire Stalingrad district in connection with motherhood and childhood. She also discussed the general work of the medical centres and the control of tuberculosis and venereal disease. She confirmed the general statement as to the similarity between the medical procedure here and elsewhere, this evidence tending to convince us that Moscow was indicating the chief outlines of the work for the rest of the country.

Through Northern Caucasus

Shortly before midnight we took a train from Stalingrad for Rostovon-Don. The next day was spent en route, traveling second category ("soft"), since there are no wagon-lits or first-class carriages on these trains. They stop at every little village and stay as long as necessary to load or unload. At every station were throngs of people, much like those we had seen at the floating piers on the Volga. Our way led across steppes, somewhat resembling the plains of the Dakotas in the United States, apparently very fertile. Here we saw sovkhozes (State farms) and kovkhozes (collective farms). On one sovkhoz we counted twenty large trucks in a long column apparently led by a commander in a Ford touring car, and obtained a good photograph of them. We were struck by the construction in progress everywhere; even in the great fields, apartment houses, granaries, and silos were rising, and evidently among them creches, nurseries, dwelling houses, schools, parks of culture and rest, and hospitals. The cities which particularly struck us were Sokhaya, Sulin, and Novocherkask.

In the evening we reached Rostovon-Don, a city of 425,000 people, which is the political, industrial, and cultural centre of the Northern Caucasus. We went to a very good hotel on Engels Avenue, which is a veritable Champs-Elysees. From the dining room on an open balcony stretching above the broad sidewalk we looked down upon the thousands of people strolling in the cool breeze of late August in this southern town near the Sea of Azov.

At Rostov we took leave of the young man who as an Intourist interpreterguide had accompanied us from Moscow. His successor, fortunately for us, was Mrs. N. Nicolich, a cultivated woman, Assistant Director of VOKS at Rostov. Through her assistance and the friendly interest of Mr. Salin, Director of VOKS, our stay in this city proved especially profitable.

Our first visit was to Selmashstroy, the great Mc-Cormicklike agricultural plant, producing harvesters for use in the great State farms such as Verblud and Gigant, which alone cover about a million acres. The head of the health service for this huge plant was a woman physician, a fact which struck us as typical of the new Russia. This leader, Dr. Marcus, explained the procedure in caring for the employees. A summary of what we learned about Selmashstroy from her and others who received us is presented in Chapter VII.

Our visit to a great medical centre in Rostov proved particularly stimulating. In its modern housing and equipment this compared quite favorably with the new medical centres in New York. Although not so large it was equally complete, so far as we could judge. The Babies' Hospital and the Hospital for Bone Tuberculosis were certainly among the finest either of us had ever seen. A characteristic of the construction is that each hospital of the aggregation is a separate and generally detached building.

A feature of the Babies' Hospital is the system of glass cubicles for isolation of children developing temperatures, and with provision in every case for nursing mothers. In the majority of cases seen by us in the Babies' Hospital the mother was with the baby. Discussing with us at some length the merits of this plan, the doctors insisted that the practice of having mothers stay with their babies hastened recovery of the infants and in many cases saved their lives.

Another splendid institution in Rostov is the polyclinic called The Unitary Dispensary, the name indicating a higher degree of unity than we usually find in polyclinics. This is admirably equipped in all departments of medicine and has a staff headed by the university professors of medicine. Dr. Rubinstein, the director of the dispensary, which handles about i,800 patients daily, explained the setup and procedure. Dr. Rubinstein also gave us statistical information on the decline of venereal disease in Rostov, which is discussed in Chapter XXI.

In Rostov we saw an educational exhibit regarding the dangers of abortion, which in its frankness, its implied outlook, and its exhibition to the public without discrimination is likely to shock many visitors.

The stay in Rostov was particularly stimulating to us and yielded a large amount of information on a variety of subjects.

Our next destination was Vladikavkaz. We had planned to fly, but could not make arrangements to do so. We left Rostov by a night train and, after a long but fascinating ride through the Northern Caucasus country the next day, we left the train about midnight and motored through the sagebrush, mysteriously beautiful in the starlight, to Vladikavkaz, the point where the Greater Caucasus Mountains begin.

Next day we took a motorcar bound for Tiflis, 135 miles away, beyond the mountains. No attem will be made to describe the scenic splendors of this towering range, extending from the Black Sea to the Caspian Sea, which is no longer a barrier to the land trails between Europe and the Near East. Our route was over the Georgian Military Highway up along mighty gorges, with their roaring torrents. Passing the famous springs from which the Narzan mineral water is obtained, we made our next important stop at the Kazbek Station, which affords a splendid view of Mt. Kazbek, an extinct volcano, higher than Mont Blanc. At Gudaur Pass, nearly 8,000 feet above sea level, we were surrounded by snowclad peaks, equaling in grandeur and somewhat resembling the Dinaric Alps. Then our route led downward among the deeply forested foothills that look down on Georgia, with its fertile farms and vineyards. Following the Kura River during a sunny afternoon, we reached Tiflis in the evening.

Subtropical Georgia

Tiflis, the capital of the Trans-Caucasian Socialist Federated Soviet Republic, as well as of the Republic of Georgia, has an interesting mixture of ancient and modern buildings, with a fascinating mixed population of Georgians, Armenians, Persians, and representatives of many other racial groups that inhabit this Eurasian borderland. In olden times Tiflis lay in the path of the trade caravans between Europe and Asia. During the past generation it became conspicuous as the scene of much revolutionary activity. Here Stalin grew up. He was born not far away in the village of Gori. Today a city of 350,000 people, Tiflis is rapidly developing as a centre of industry and culture.

Our study of health services in Tiflis began with a conference with the Commissar of Health for Georgia, Dr. G. L. Kuchaidze. We were oriented as to the character of the city, the rapid mechanization of industry, the development of the university, which now has about 16,000 students, and the preventive and curative medical services. The Commissar pointed 0ut that, except for adaation to local circumstances, the plan for health work was the same here as in the R.S.F.S.R. In Georgia, as elsewhere, there is a chain of ambulatoria, polyclinics, and hospitals, general and special, all linked together. He discussed with us at some length the education and training of doctors at the Medical Institute connected with the university, the education of midwives, instructed in Russian as well as in their native languages, maternity and child care, welfare work, and in general the procedure in preventive work and in the treatment of patients.

We visited the Tuberculosis Institute, in a beautiful new building of Renaissance style, splendidly equipped. The other tuberculosis institutions in Georgia are closely affiliated with this central institute. A day sanatorium for adult patients was under construction on a site adjoining the institute.

We next visited a creche connected with a silk factory. Although this nursery was housed in a part of the factory not built for this purpose, it seemed to function with success. Since there were two shifts of workers at the factory the creche was open from morning until 10 p. m. About 160 children were received each day.

The Hospital for Railway Employees, which we visited, was an interesting example of a hospital for a special occupational group. Its 500 beds are available for all grades of railway employees in the Republic.

This hospital is well organized and equipped, particularly the obstetric and gynecological divisions.

The special hospital for railway workers is only one instance of many in which, inside the wider community of workers, the closer community of the workers in a particular industry is encouraged. The railway workers, we found, had their own club, consisting in the main of a beautiful garden, with fountains and flowers, and playgrounds for the children. There were facilities for music and outdoor motion pictures. We saw some two hundred "Octobrist" children, aged about six to ten, who had been in this garden since 6 a. m., march away singing at 8:30 p. M. In charge of these youngsters were several "Pioneer" girls about fifteen or sixteen years old.

A method for encouraging efficiency among the railway workers was conspicuously illustrated in this garden. On a red board were listed those workers who had been exceptionally good, and on a black board those who had been notoriously bad. Such public display of names is supplementary to the posting within the factories or offices.

After completing our survey of the health services in the city of Tiflis, we took a long drive into the country to observe the health work on a typical State farm and on a collective farm. We made this trip into a sagebrush desert, now being reclaimed by a large irrigation project, in the company of the Secretary of the Communist Party of Georgia and two doctors assigned to us by the Commissar of Health. After a journey of some two hours over a rough, dusty country road, on which our automobile passed only picturesque kolas and heavily laden camels, we arrived at a State cattle farm, comprising several thousand hectares. There were a thousand head of cattle, in charge for the most part of women organized in shock brigades to compete with one another for the largest production of milk. The farming operations, including grain production, and the development of the irrigation project seemed to be largely in the hands of men. This State farm had been only recently established. Most of the buildings were new, and many of the cow barns and silos were still in the process of construction.

Notwithstanding its recent organization, however, we found the usual creche, in charge of a trained teacher, who spoke to us in French, assisted by a trained nurse. We found there a country doctor, evidently risen from the ranks of the workers. He was, however, conducting a wellordered dispensary and a small pharmacy, much of the ingenious equipment of which he had constructed himself. He assured us that all the medical needs of workers and children were being adequately met. When we inquired about dentistry and other specialties, such as nose and throat work, he informed us that he personally took care of emergencies or saw that difficult emergency cases were promly transferred to Tiflis, and that at stated intervals a group of specialists visited this and other State and collective farms. He informed us that he reserved most of the cases needing the attention of specialists for these occasions.

Although the facilities were somewhat crude, we were convinced that a genuine effort was made to provide the health needs of this community, which consisted of about a hundred families. The only serious criticism we felt was the lack of screens for the creche and the clinic and the failure generally to control the flies. But we recognized that this was not an easy matter on a cattle farm. While we did not express this criticism, it was expressed for us in no uncertain terms by the Secretary of the Communist Party, who put the responsibility squarely up to the director of the farm to "liquidate the fly nuisance" before we made our return visit, which he hoped would be in the following year.

We were interested to observe on this farm tractors and other modern agricultural machinery, and many evidences of efficient administration. The agronomist in charge was a Communist 0f German origin and Germantrained.

On our return, in the outskirts of Tiflis we visited a collective farm consisting of several hundred hectares and comprising what had formerly been 153 separate little farms. This was a general farm, but it was primarily devoted to a magnificent vineyard producing luscious grapes. This farm, all under irrigation and having every appearance of efficient administration, was under the direction of a handsome and highly intelligent young Georgian woman, a recent graduate of the Agricultural College in Tiflis. She was eager for information about irrigated farms in America and expressed her desire to visit that country and study its methods.

Although our special interest was in the health services, we undertook a long walk, in the course of which we were obliged to jump over ditches; but we were rewarded in the end by a visit to a comfortable pergola in the corner of the great vineyard, where we were protected from the hot sun's rays by the heavyladen grapevines.

Returning to the central buildings, we were taken by the doctor of the collective through the creche and the clinic and into the various clubrooms, decorated with the usual health posters and large pictures of Lenin and Stalin. Here again we were impressed 'by the order and cleanliness, by the character of the teachers, nurses, and the doctors, and by the fine, healthful appearance of the children. The children, however, seemed more interested in the leader of the Communist Party than they did in their foreign guests. It was obvious that he had a way with him which caured the children. A typical, handsome Georgian man, of charming personality, he would greet the children with, "Are you ready for labor and defense?" Rising as he entered and saluting, they would respond in chorus, "Always ready!"

From Tiflis we traveled by train to Batum, on the Black Sea. Here came into view a marvelous "Riviera" of beauty. Subtropical trees, palms, magnolias, eucalyus, and camphor laurels, gave an exotic charm to the scene. All along the coast extending northwestward to the Crimea is a continuous succession of health resorts and rest homes. Magnificent palaces which once belonged to the wealthy and the noble who came here from the north to take their ease have been confiscated and now, as sanatoria or vacation homes, are thronged by the workers.

As no special arrangements had been made for observing health work in the city of Batum, we took advantage of an opportunity to visit another State farm, a large tea sovkhoz covering many hectares, spreading over the fertile undulating, palmbordered hills rising above the Black Sea. Here we witnessed for the first time tea cultivation and harvest, and we were shown the modern process of curing tea in the large new plant situated in the midst of tropical gardens and surrounded by the usual mixture of primitive homes and modern apartments, in the midst of which we found the usual creche, health centre, clubrooms, and cultural facilities. We had no time to inspect these, but we found that they were in existence here as elsewhere. In answer to a question put to one of the doctors as to how general these health and welfare facilities were on the State and collective farms, we were told these were the first things to be established, just as in an army health facilities must be given primary consideration.

On the Black Sea

Returning to Batum, we were driven through an extensive and magnificent subtropical botanical garden. Before returning to the city itself, we visited the famous bathing beach, where one of us and our guide went swimming in the Black Sea. After dining at the hotel and walking about the city, mingling and talking with the people here and there, shortly after dusk we boarded the steamer bound via Sochi for Yalta, in the Crimea. For two days we skirted the coast, most of the time keeping in view the lovely subtropical garden scenes along the shore and the vast snowcapped Caucasus Mountains in the background.

On the boat we had interesting discussions with distinguished Russians on vacation. Mr. Minkow, one of the editors of the Radio Labor Newspaper, dwelt 0n freedom 0f publicity for everything which was not "counterrevolutionary" in effect. He stressed the liberty of criticism in factories, of which we had seen illustrations, through the medium of the "wall newspaper." As to the "black board" listing of inefficient workers, he said that there was n0 danger that men would be unfairly blacklisted because of feeble health, since the list is made up in open shop meetings.

Another fellow passenger who gave us valuable opinions on the position of scientific workers was Abraham Prigozhine, Lecturer on History in the Leningrad University. We also had a very comprehensive discussion with Dr. Olga Borisowna Lepeschinskaya, Professor of Histology in the Communist Academy, Moscow. She devotes herself entirely. t0 research, being especially interested in the study of cellular constituents. At the time we met her she was about to publish a work on the minute structure of the cell. The present proletariat Government, she remarked, does not impede the scientific work of professors. Professors' children now receive the same preferential rights as those of workers. Most professors, she said, hold two, and some hold three, positions, and thus have adequate salaries. The Government is gradually increasing salaries, thus discouraging the holding of more than two positions. The principle of "shock brigades" setting the pace for other workers, she said, is applied in scientific work. Individual scientific workers, for example, in a laboratory, may get premiums for efficiency. Nominations for such premiums are made at "production meetings" of all the workers. These nominations are discussed at professors' meetings, and finally the premiums are awarded at a grand meeting of all the workers.

Besides the comments above reported, Dr. Lepeschinskaya also gave us her considered judgment on the problems of marriage and divorce, birth control and abortions, which has helped us in interpreting the facts concerning these subjects discussed in other chapters.

After two days on the Black Sea we reached the Crimean peninsula, landing at Yalta, the workers' paradise, beautifully situated and showing palaces, gardens, and woods, with the towering Yaila Mountains rising abruly from the shores of the Black Sea. The climate is always mild, and there is said to be more sunshine than on the Mediterranean Riviera. In the Crimean region centring in Yalta there are tens of thousands of workers on vacation, living in palaces that once were the pleasure resorts of the wealthy few, from the Tsar himself down into lower ranks of nobility and wealth. Here too are sanatoria for the tuberculous and rest homes for convalescents in general.

Our first interview was with Dr. S. J. Jacobson, chief of the Social Insurance Organization for this region, who is stationed here in the summer. During the winter he is assistant surgeon in a Leningrad clinic. His exposition of the aims and methods of social insurance in emphasizing the preventive side of medicine and in developing more sanatoria and rest homes is discussed in other chapters. Incidentally, we were in. formed that workers in heavy industries and technicians had been given decided preference in dispensing aid.

Besides the private palaces formerly maintained at or near Yalta there .had also, under the imperial regime, been constructed sanatoria for aristocrats and the rich. These old sanatoria, now used by the workers, were as a rule built at sea level. But the new ones are built about 1,700 feet above sea level, in order to get the advantage of altitude as well as the other benefits of this region.

We visited Dolossy, a large sanatorium at an altitude of nearly 1,600 feet in the mountains above Yalta. This sanatorium, which was constructed with funds from social insurance, is excellently organized and equipped. Its patients number about three hundred in winter and nearly five hundred in summer. Although the ordinary "wall newspaper" of factories is not permitted here, for fear of bad psychological effect on patients, criticisms of the management can be made to the doctor.

Dr. Karpenko, the Director for State Sanatoria in the Crimea, explained the management and operation of the Crimean rest cures while accompanying us on a visit to Livadia, the former Crimean residence of the Tsars. This is certainly a most magnificent palace.

Situated in the midst of a lovely garden high on a precipice overlooking the Black Sea, Livadia is now the paradise of workers. They come here from various parts of Russia for a rest of a fortnight or longer. There were fifteen hundred of them at the time of our visit, men and women roaming about the gardens, playing games and singing, always singing to the accompaniment of the mandolin or guitar, or the balalaika, or reading, watching a motion picture, some of them resting on couches in the Tsarina's bedchamber, with its great arched plateglass windows, framing the most beautiful picture imaginable of mountain, sea, and cedars of Lebanon.

We learned that the workers admitted in the summer are chiefly from factory "shock brigades," while in the winter men and women from the collective farms preponderate, Livadia then becoming a "peasants' palace."

Besides being a rest home, Livadia is also a home for convalescents, with added facilities for patients needing special care. Patients are sent both by Social Insurance authorities and by the Health Commissariat of the R.S.F.S.R.

Incidentally, Dr. Karpenko, our companion on the visit to Livadia, is an interesting example of a class of doctors developed under the new regime. He was formerly a sailor and became a medical student at the age of twentyfour. We found him an important medical official.

In connection with our visit to Livadia we had illuminating discussions with members of its staff, especially with the medical superintendent. His preference for state medicine as contrasted with private practice and the reasons he gave harmonized with all the other testimony we heard from doctors.

Leaving Yalta, we motored to Sevastopol through the Crimean Mountains, which are a little higher than the Catskills and as rugged as the Rockies. As we drove along the side of great precipices we saw, nestling in every nook, cypresses and pines, figs and olives, vineyards and tobacco fields, and beyond these the gleaming Black Sea stretched far out to the horizon.

At the end of our drive we entered the historic "Valley of Death," the celebrated battlefield where many thousands of British, French, and Russian soldiers were killed in the Crimean War, and which, for British and American readers, has been immortalized in Tennyson's "Charge of the Light Brigade." Passing Balaklava at a distance, we arrived at Sevastopol and thence took a night train for Kharkov, the new capital of the Ukraine.

The Capital of the Ukraine

The Ukrainian Socialist Soviet Republic, one of the seven constituent republics, is important not only as the "fuel, metallurgical, and grain base of the Soviet Union" but also for its advanced position in the cultural realm. The old capital was Kiev. Kharkov, where the Soviet Government has established the new capital, is a city of about 440,000 people, threefourths of whom are Ukrainians. The rest are mainly Great Russians and Jews, with smaller proportions of Poles, Germans, and other nationalities. Ukrainian, which resembles Russian, is the official language.

In this city we first visited a day preventorium for children, accompanied by Dr. Lifschitz, a professor in the Medical Institute, and by a public health inspector in the Commissariat of Health of the Ukraine. The preventorium, housed in a large and beautiful garden in the outskirts of Kharkov, has accommodation for 700 children, who are from six to fourteen years old and come from the public elementary schools. The children have been selected because they have symoms of weakness, of incipient tuberculosis, or have been exposed to the disease at home. The selection of children considered for admission is made by school doctors with whom sits a committee including a representative of the parents; and the final selection for admission is made by the polyclinic doctor. They are met by an officer at certain streetcar centres in the morning and are similarly escorted back to these centres in the evening.

We were informed that these day sanatoria, of which there are many in the Ukraine, were instituted about 1923. Children in these institutions are periodically examined by medical experts. Dental and other treatment is given. There is instruction in physical sports and also, we were told, a certain amount of "political education."

Dr. Lifschitz, a consulting physician, was somewhat exceptional, he told us, in that his earnings from private and public practice are about equal. Most doctors, he said, have very little, if any, private practice.

We were informed later at the Commissariat of Health of the Ukraine that private practice comprised only about 10 per cent of the total medical work in the Republic. Dr. Lifschitz and his medical associate gave us a concise survey of medical organization in Kharkov, which at the time of our visit had 3,000 physicians, and in the whole of the Ukraine. Compulsory vaccination against smallpox has been enforced throughout this Republic since 1920. Since 1930 immunization against diphtheria has been obligatory, and no child is admitted into a school or sanatorium without such immunization. Dental treatment is obligatory at all schools, though perhaps not always completely carried out.

We next visited the Roentgen Institute, under the guidance of its vicedirector, Dr. B. Warshawsky. This institute, with its 500 rooms and 150 beds for patients, we found admirably equipped both for research and clinical work. There were special departments for X-ray diagnosis and treatment, for biological research, and for physical and medical treatment. The institute had 580 milligrams of radium for treatment of cancer. The staff of this institute numbered 100. In the ambulatorium there were some 80,000 attendances during a year. In other parts of the Ukraine, we learned, there are similar Roentgen institutes, though less elaborately arranged than the one we saw in Kharkov.

Further evidence of the efficient scientific work under way in Kharkov was given us at the Institute of Hygiene and of the Pathology of Labor, which was built in 1925-1926 and serves both for research and teaching. It has an admirable educational museum, which displays the chief occupational risks and the methods of avoiding them. There were also exhibits concerning the reduction of noise. This museum has a number of small traveling exhibits.

We next visited the so-called Third Labor Polyclinic in Kharkov, in a magnificent new building four stories high, which is described in Chapter XIX.

Near this new polyclinic were the immense new Tractor Works employing some 16,000 men and women. This plant had a separate polyclinic and a hospital with 400 beds.

After our personal inspection of the important public health and medical facilities in Kharkov we went, with a background of information, to the Commissariat of Health for the Ukraine, to inquire further concerning the administrative setup. There we had a conference lasting nearly three hours. The Commissar, Dr. Kantorovitch, was accompanied by the heads of all departments under him, and we were thus enabled to get direct and specific answers to our questions. We were given a clear and complete analysis of the organization of health work in the Ukraine, its divisions of responsibility, the relation between the local budgets and that of the Republic, the sources of funds and their distribution, the personal relation between doctor and patient, the education of medical personnel, and other allied subjects. What was said on all these subjects is summarized elsewhere in this book in the general discussion of the organization of medical and health work in Russia.

Leaving Kharkov on a night train, we reached Moscow about noon of the next day. We immediately plunged into a round of calls and conferences to gather up loose ends and to supplement the studies made on our long but fascinating tour up and down European Russia. It was during this third visit to Moscow, incidentally, that we saw the Moscow Art Theatre play "Fear" and the ballet "Swan Lake," mentioned earlier in our account. On the last evening in Moscow we had a late conference with foreign newspaper correspondents and other foreign observers of life in Soviet Russia.

At dawn of September 7 we boarded a plane at the Moscow airport bound for Berlin. Our notebooks contained a multitude of records, and in our memories were thousands of impressions of the means by which Russians in towns are helped to keep well and happy through a combination of abundant recreation and sports with a unique system of public health and medicine which in planning and to a large extent in accomplishment is more comprehensive and better unified than any we have found in making our surveys of other countries.

Our readers, having been taken over the ground covered by us, will appreciate the variety of problems presented and also the variety and character of sources of information. In the following chapters we propose to present, subject by subject, our findings and our interpretations.

The Background of Russian Life

AFTER the preceding sketch of our Russian travels we may observe that in our visit to the U.S.S.R. we found it of inestimable value that we had familiarized ourselves with some of its national literature, with its stormy progress towards greater liberty, with the history of its successive revolutions, and with the racial and geographical features of this vast country; and our study of medicine and social conditions in Soviet Russia can be better understood if one constantly remembers this background of Russian life. In this and the next two chapters it is proposed to outline briefly for our readers some main elements in this background, although the sketch must necessarily be incomplete. It will, however, we think, make more understandable the revolution in medical aid and in medicohygienic administration which is an outstanding feature in Soviet Russia today.

Russia is 150 times as large as England and Wales. It embraces an area more extensive than the United States and Canada combined, it comprises a sixth part of the land surface of the earth, and it contains over 165 million people.

Russia is a landlocked empire during winter; and in summer European Russia has no direct access to the wider seas except on its northern border above the Arctic Circle. Its outlet from the Black Sea can be blocked at any time in the Dardanelles. The outlet from the Baltic may be similarly blocked. This means that for world commerce Russia is almost in the position of a beleaguered city. It can have little foreign trade except at the will of its neighbors. This landlocked position needs to be remembered as exerting a psychological influence on Russians; and now to this is added the notion, carefully and continuously instilled into the minds of the entire people, that because Russia has abandoned capitalism, the capitalistic powers, one or all, are only awaiting a convenient opportunity to attack and destroy her communist organization.

A country which has natural boundaries on the shores of the Arctic, the Pacific, the Caspian Sea, and the Black Sea necessarily presents great variations of natural cultivation as well as of intellectual culture. While the "black earth" of its southern lands fits Russia to be one of the greatest granaries of the world, its vast forest regions in the north have a relatively low fertility and hence produce little of value except timber. In the subtropical climate of the Crimea, of the Caucasus, and of Turkestan, tobacco, grapes, tea, and cotton are grown; and in many parts are vast, chiefly undeveloped, mineral deposits, including oil fields. It has also great potential wealth in hydraulic power,, the "white coal."

The vast extent of Russia was more fully realized as we steamed for four days down the Volga, then went by train to Rostovon-Don, thence to Vladikavkaz (recently renamed Ordzhonikidze), and then motored through the Caucasus Mountains to Tiflis, and afterwards steamed along the coast for two days on the Black Sea to the Crimea. Yet our itinerary shown on the map carves out but a small segment of this farflung empire. Nevertheless these travels revealed the vast range of nationalities and languages embraced in Soviet Russia and served to impress upon our minds the magnitude of the land.

Although more than half the population of the Soviet Union consists of "Great Russians" (52.9 per cent) and "White Russians" (3.2 per cent) and one fifth (21.2 per cent) of Ukrainians, who are ethnologically closely related to the Russians (though they have a distinct language), there are in addition to these about one hundred and eighty nationalities, ranging from the Tartars, Armenians, and Turcomans, people with a long history, to but little known mountainous and desert tribes.

In the valley of the Volga, Tartars and other nationalities are commingled with Russians. Of the 147 million people of the Soviet Union in 1926, 78 per cent were Slavic (including Poles, a few Czechs, Serbians, etc.), while more than a million people of German origin live principally in compact groups near the Volga. According to the Guide-Book to the Soviet Union, issued officially,⁽¹⁾ the population in 19262 included 2.7 million Jews, 1.6 million Georgians, 1.3 million Armenians, and 1.5 million mountaineers of the Caucasus. Next to Slavs the largest ethnical group in the population of the Soviet Union are the Turko-Tartars (about 11 per cent).

In passing from north to south we found the different national characteristics very marked. Since the Soviet Government was established, language differences are respected and even encouraged, in contrast with the policy of Tsarist Russia. In Georgia, the Ukraine, and elsewhere, we found the language of the region being used officially. But with varying languages and races, governmental organization in essentials appears to be on identical lines in all 'parts of Soviet Russia.

The theory of the Soviet Government is that the Union is international, that its constituent parts are joined solely by their common aims and objects. In theory, also, "any nation may join the Union." Similarly any one of the seven allied republics which at present constitute the Union theoretically can secede from it.

The seven constituent republics of the Union of Soviet Socialist Republics, and their populations according to the census taken in December, 1926, are as follows :

1. The Russian Socialist Federated Soviet Republic (R.S.F.S.R.)	100,593,800
2. The Ukrainian Socialist Soviet Republic	28,887,000
3. The White Russian Socialist Soviet Republic	4,924,600
4. The Trans-Caucasian Socialist Federated Soviet Republic	5,810,300
5. The Uzbek Socialist Soviet Republic	5,058,200
6. The Turcoman Socialist Soviet Republic	1,030,500
7. The Tadjikistan Socialist Soviet Republic	663,000

To the exceptional geographical and the complex racial constitution of Russia should be added its low standard of elementary education, the vast majority of its population prior to the Revolution being illiterate. Religious influences also were largely representative of superstition and magic, and of the technique of ceremonial more than of the spiritual teachings of Christ, though doubtless there were many exceptions to this statement.

It is in the light of sympathetic interpretation of the above general facts that the recent events in. Russia need to be studied. A picture is distorted when its background is not developed and understood.

In judging what one may at first be inclined to condemn, the knowledge of Russia's antecedents is especially important; and it is thus that one can appreciate the undoubted high value of some of the Russian developments of medical practice and their bearing on future progress in other countries.

One finds occasionally an isolated community which until recently had no means of artificial illumination except candles or oil lamps, and which has skipped the period of illumination by coal gas, and now furnishes itself with electric lighting. Similarly, Russia has lagged behind other European countries in medicosocial reforms; it has remained semi-Asiatic or Eurasian; now with lightning speed it has instituted in its best organized cities provisions for medical care for approximately the entire population which are more complete and freer from inhibitions to readily accessible help than hold good in any country known to us.

Even Denmark is only a partial exception to this statement. It is no refutation of this sweeping statement to suggest that in actual practice this completeness is only very partially realized. The answer is that the organization to this end exists; and that in the cities visited by us it is in large measure functioning; and that there is reasonable prospect that, given continued progress on present lines, in a few years a complete medical service for all will be provided in both rural and urban Russia.

Russia's Travel Towards Communism

IN A survey of medicohygienic conditions we must necessarily have in mind the general social life of the country concerned, especially in relation to marriage and family life, to housing conditions, and to the industrial and agricultural work of the country. Nor can the education and the religious outlook of its people be left entirely out of the survey, for illiteracy is a chief enemy of health, while ethical standards influence health in manifold ways. In subsequent chapters these phases of national life will be mentioned or described.

In this and the next chapter we are concerned with the evolutionary and revolutionary processes which have brought about the present economic and sociological position. In Russia of today this position is one in which private capitalism and individual trading have been almost entirely abolished.

The prerequisites of a communist society have been stated as follows : The abolition of exploitation of men by men, the obliteration of the division of society into classes, the destruction of the conditions from which they arise, i.e., the abolition of private property in the means of production, and the establishment of a classless socialist society. In accordance with this, private ownership of the means of production and distribution has been abandoned, with all the practical consequences that this implies in the planning of national life.

How has this been brought about?

Russians are reputed to be dreamers and talkers; and although the same characteristics are frequently seen in western countries, Russians perhaps to an exceptional extent have the habit of "taking the will for the deed" and of regarding the enunciation of the principle of a reform as equivalent to its accomplishment. It is astounding, then, that a minority of these dreamers have been able to impose a radical reconstruction of national organization on communist lines, and that in doing so they have also succeeded in building up great industry and big machinery; for Russia is making amazing progress towards its goal of overtaking the United States of America in extreme mechanization, in mass production, and in standardization of manufactured articles. In efficiency of work, however, the progress has not been so rapid. Indeed, the difficulty of mastering technique as applied to modern industry appears to be one of the greatest handicaps in the efforts of the Russians "to overtake and surpass" the capitalistic countries.

The events leading up to this vast transformation have an enthralling interest. Many of them go back to the eighteenth century or even farther.

The "Europeanization" of Russia was begun in the reign of Peter the Great (1682-1725). Following a victorious war with Sweden, he annexed the Swedish Baltic provinces and built the new capital, St. Petersburg, which by its position brought Russia into closer contact with western countries. He promoted industry. He established the first Russian newspaper and a number of technical schools, including the Russian Academy of Sciences. He became the "creator of Russian medicine," as we shall see in Chapter XVII. But, despite his remarkable energy and his passion for efficiency, he failed to free his country from corruption.

The Russian mind is partly Asiatic, partly European, for the Russians are an imperfect amalgam of many races, representing civilization at various stages. Hordes of Tartars poured into Russia in the first half of the thirteenth century, and it was not until the fifteenth century (1480) that the Moscow princes threw off the Tartar yoke and the roles of Russians and Tartars were reversed.

Through a lengthy process of curtailing freedom, the peasants of Russia were, in the middle of the seventeenth century, completely attached to the land and the landlords. Called serfs, they were virtually slaves. The landlords' authority over them amounted practically to the power of life and death, and this almost unlimited power was abused quite often; cruelty was not uncommon. Individual serfs fled. to borderlands, while organized insurrections of peasants occurred and recurred at intervals. The great peasant revolts of Bolotnikov, Pugatchev, and Razin all were suppressed but were followed by new ones. Finally, in 1861, the peasants were released from serfdom. But the enactment did not provide them with free land. Many of them migrated into towns, where increasing industries called for their work. But the position of both workers (industrial) and peasants remained very near starvation, and an undercurrent of dissatisfaction steadily grew. Revolutionary doctrines appealed to the masses. But strikes were forbidden, and when they occurred they were suppressed as uprisings, by military force. The Tsarist police imprisoned and punished agitators mercilessly, often without trial. On the land the peasants' position was still semifeudal. They had to pay exorbitantly during long years for the small patches of land allotted to them, and there was pitiful poverty.

Immense contrasts were seen in prerevolutionary Russia. The Russian intelligentsia, a small minority of the total population, were highly educated and had a broad intellectual interest; among them appear great names in art and science. The governing class were notoriously corru.

During the nineteenth century a double current of influences conduced to the overthrow of the Tsarist regime. On the one hand, many of the educated classes, mostly outside of the official circles, were profoundly resentful of Russia's governmental corruption, and out of this intense feeling grew different revolutionary parties. On the other hand, the growth of the class of industrial workers, dissatisfied with the prevailing conditions of their life and inculcated with advanced social ideas, served to accumulate revolutionary material from the lower strata of the country. More and more peasants were sucked into the factory life of towns, and there they became tinctured with the advanced views of factory workers. Some of these visited other countries and learned how the workers in those more fortunate lands lived. The agitation for improved conditions of life increased, notwithstanding the ferocious activities of the secret police.

In the early years of the nineteenth century the so-called "Decembrists," mostly army officers who visited other European countries during the Napoleonic wars, made an attem to force reforms, but being unprepared and betrayed, they failed miserably. A number of them were executed and a still larger number exiled to Siberia by Tsar Nicholas I. Then came into existence, one after another, a number of political parties, formed almost exclusively from the educated classes. Certain of them were known abroad as "Nihilists," though none of them ever adopted that name. Among these parties were the Narodniki, i.e., populists, the party of the "Will of the People"; the party called Zemlia i Volia, or "Land to Peasants and Civic Liberties to All," and others. The aim common to all of them was the improvement of living conditions of the masses, peasants first of all.

One of the latest (1898) and best organized among radical parties was the Party of Social Revolutionaries, to which belonged a number of people who became prominent in the early stages of the Revolution of 1917. One group of the Social Revolutionaries advocated political terror as a means to combat the oppressors; they became known as the "Fighting Organization." This group, however, was not the first to advocate terror, as certain revolutionaries committed a number of political assassinations long before them. In 1881 Tsar Alexander II was assassinated; other victims followed.

The Rise of Marxism

Although the socialist ideas developed by Marx and Engels in the middle of the nineteenth century became popular among the Russians very early, the first Russian Social Democratic Party was organized by Plekhanov and others as late as 1897.

At its Second Congress, held in London in 1903, the Russian Social Democratic Party was split in two; a small majority, favoring more ardent revolutionary activity, became known as the Bolsheviks (from the word bolshinstvo, meaning "majority"), and the minority group, favoring a more moderate course, became known as Mensheviks (from the word menshinstvo, meaning "minority"). The energetic revolutionary policy was vigorously advocated by Lenin and the group of communists who were living in exile abroad. It was distinguished from evolutionary socialism by its will to revolution and by its advocacy of the "dictatorship of the proletariat." The Mensheviks, on the other hand, held that Russia was too inadequately industrialized to undertake a socialist revolution.

The "Bloody Sunday," as January 22 (old calendar, January 9), 1905, became known in Russia, when the troops killed or wounded 1,500 workmen and their wives who had assembled in the main square in front of the Winter Palace to present a peaceful petition to the Tsar, did much to fan the flames of dissatisfaction and revolutionary agitation, already accentuated by the disastrous defeat of Russia by Japan. There was extreme indignation among the workers; they started to organize groups for action, the first Soviets came into being, and the movement culminated in the autumn of the same year in a general strike, the first of the kind in history. This was in reality the First Russian Revolution. The rural population joined in the movement, seizing land from the landowners, organizing uprisings, looting, and committing arson. Under this pressure the Tsar acceed the counsel of Witte and others and conceded a Duma (Parliament) and granted a constitution. But the First Duma, being considered too "radical," was dissolved. The same fate met the Second Duma in 1907, and workers were almost completely disfranchised.

Forced underground, the revolutionary elements continued their work, while the situation in the country went from bad to worse. In 1914 the revolutionary activities became again very marked, and in July a general uprising was considered probable, but it was prevented by the outbreak of the war. In 1917 the patience of the people was exhausted; the horrors of the war, which seemed to be endless, and the misery of life, created by scarcity of manufactured goods and even of food products, promed the outburst of popular indignation which resulted in the February Revolution.

The first Provisional Government, headed by Prince Lvov, and those which followed it, under the leadership of Kerensky, represented the conservative, liberal, and mildly radical elements of the population. They failed to establish themselves solidly and were finally replaced by the Bolsheviks, headed by Lenin.

The transition from nonrevolutionary to revolutionary action in the progress of the Marxian philosophy was a turning point in history; and its success in Russia, if this proves to be permanent, cannot fail to have profound influence on the future of other countries, if in no other way, by inducing governments to hasten the ending of inequitable economic conditions.

The main argument in favor of the "Bolshevik Socialism" was that peaceful evolution to socialism could never be expected to succeed, owing to the supreme advantages enjoyed by the capitalists; and in fact this revolutionary movement succeeded in establishing order where its predecessors had failed.

Lenin's famous slogan, "Loot the loot," represented in part the ethics of Bolshevik methods for securing the ends of Bolshevism. It was by looting those "who had looted" that Lenin aimed to "give history a push." Democracy was not the aim, but communism secured by the instrumentality of the dictatorship of the proletariat.

Whether this dictatorship is entirely consistent with democracy need not detain us; but the following remarks by a highly competent observer may be quoted at this point.

In Current History, February, 1933, Sidney Webb says:

It is useless to discuss whether or not the constitution of the U.S.S.R. is what we choose to consider and to designate democratic . . . On this supreme judgment people in other countries will long continue to differ according to their bias and their information. All that need be said here is that great difficulty will be felt in convincing any thoughtful Soviet citizen, whether or not he is a Communist party member, that the constitutions of the United States, Great Britain, France, or Germany come nearer than that of the U.S.S.R. to securing what is usually meant by democracy, whether emphasis is laid on social equality or on the fulfilment of the popular desires or even on the general consciousness of consent to the actions of government.

But much struggle occurred before the constitution of the U.S.S.R. was successfully established; and we must briefly indicate the stages in this struggle which continued through years of internecine war, of pestilence, and of famine. It was not until December, 1922, that the Union of Soviet Socialist Republics (U.S.S.R.) was formed.

War Communism

The World War gave Lenin and his associates their opportunity. The influences in favor of revolution were all intensified. Thus Russia, as we know, was chiefly an agricultural country selling a large share of its foodstuffs to Europe, and receiving its manufactured goods from the rest of Europe and especially from Germany. This interchange had almost ceased during the war. In the first three years of the war Russia had suffered very severe losses both in men and materials, perhaps more than any other combatant nation, and she was already in the position of a defeated country. It was in these circumstances that the February Revolution of 1917 (March, new calendar) occurred, in which Tsardom was overthrown by relatively moderate revolutionaries. This revolution was rendered possible by the disintegration of the Russian Army, the greatest mutiny in history, and by the almost simultaneous rebellion against civilian government.

As early as in 1915 Lenin had written to his followers that the Soviets (or Councils) of the workers' and other deputies ought to become organs of the revolt and of the revolutionary authority. With the outbreak of the Revolution of 1917 the workers started at once to form their Soviets, and on March 12 (old calendar, February 27) they organized the "Provisional Executive Committee of the Soviet of Workers' Deputies" which was convened for its first session the same day and expressed its determination to acquire the exclusive authority over the State affairs. On the same day the "Provisional Executive Committee of the Duma" was also organized, and the two became rivals for the supreme power.

On March 15 (old calendar, March 2) the two bodies came to agreement regarding the general program and policy, which included complete and immediate amnesty, political (civic) liberties, elimination of all religious, social, and racial discriminations, democratic election for selfgovernment, and a promise to refrain from any steps in determining the future form of government before the convocation of the Constituent Assembly. The clause providing that every nationality inhabiting Russia should have the right of selfdetermination, which was submitted by the delegates of the Soviets, was defeated.

In other words, from the very beginning of the new regime, which was created after the abdication of the Tsar, the power became divided between the Provisional Government and the Soviet, and a struggle between them ensued. The three main issues of discord between them were : the agrarian problem, the war, and the liquidation of the economic crisis.

The Provisional Government was careful not to commit itself by. a definite attitude on any of these issues, but in April a ministerial crisis was brought about by the declaration of Miliukoff, then Minister of Foreign Affairs, that the Dardanelles and the Bosphorus ought to come into Russian possession.

Unable to liquidate the duality of the supreme power, either by persuasion or by force, the Provisional Government placed its hopes in a coalition. The Soviets, which were dominated at that juncture by the moderates, acceed the invitation to join the Cabinet, and a new government was formed, which included, besides Kerensky (as Minister of War), a few other socialists. Still hoping to prevent the social revolution, this new Provisional Government decided to bring about certain reforms, and even demonstrated its willingness to hasten the convocation of the Constituent Assembly. At this time was heard the slogan, "Peace with no indemnity, no annexations," and the plan for an interallied conference to revise the aims of the war was fostered.

The offensive started by Kerensky to satisfy the Allies was futile in results and very costly in human lives; and the growing misery of life (scarcity of food, almost complete collapse of the system of transportation, etc.) spurred the discontent and encouraged the radicals to more revolutionary action.

The rift between the Government and the Soviets became quite acute in July. On July 21 (old calendar, July 8) Kerensky became Prime Minister, after Prince Lvov had resigned in protest against the plan of immediate agrarian reform advocated by Chernov and other socialists.

Maneuvering between opponents of various shades of political opinions and class interests, the Kerensky Cabinet on September 14 (old calendar, September I) declared Russia to be a republic. Early in October the Cabinet was reorganized again on the principle of coalition; and among other measures it decided to appeal to the Provisional Council of the Republic (as the Pre-Parliament was called by some people). In the agenda was included the early convocation of the Constituent Assembly. But it was already too late. The moderate elements lost much of their support through numerous compromises to which they agreed in the earlier days ; the "Rights," always opposed to Kerensky, became violently so after the Korniloff affair, but they had no backing from the masses in their attems to restore the old order and to crush the Revolution.

The radicals, headed by Bolsheviks, came to the front, and after having subdued the very ineffective resistance of the Provisional Government, which was deserted at that time by most of the troops and not supported by any large organized groups, the Bolsheviks seized power and so ended the Kerensky regime on November 7 (old calendar, October 25).

Soon after the advent of the Bolsheviks, in March, 1918, peace with Germany was signed at Brest-Litovsk, but this "peace" was not the end of war for Russia. A series of wars, foreign and civil, began. The Bolsheviks found themselves at war with Russian opponents of their policy, aided at first by troops of the countries which had been Russia's allies against Germany, including French, American, and British forces.

Into the details of this unhappy warfare we need not enter. But in addition Russia was torn between supporters and opponents of communism as represented by the Bolsheviks, in open warfare against each other. When internal fighting ceased, and to some extent during its continuance, epidemics of typhus, smallpox, and cholera swept over Russia, affecting almost one fifth of the entire population. The events of these years have been well summarized by Dr. W. H. Gantt.⁽¹⁾ They included a threeyear famine with acute food shortage for nearly half the total population, during which it is stated that eleven million Russians were being fed by relief from America and England, and to some extent from other countries.

It was during the three war years, 1918-1921, that the application of communism in its strictest form was attempted. The Communists enforced their national policy with unexampled intensity and ferocity. Their difficulties and failures will be further mentioned when we outline industrial and agricultural changes.

Exiles, imprisonments, and executions were frequent, as might be expected when one extreme faction replaced another in a country which was semi-Asiatic and largely feudal, and in which revolutionary doctrines had been smoldering for a century. In Dr. Gantt's words:

The sumtotal effect of these long years of war, revolution, famine, and disease has been obliteration of nearly every custom, form of society, and institution that existed under the old regime. But life pushes, and out of all this a regeneration has slowly begun, astonishingly rapid in some directions and painfully slow in others.

Communism applied in this drastic and rapid fashion created difficulties on a large scale, especially in its application to agriculture. These difficulties were so great that Lenin in 1921 replaced fullblooded communism by his New Economic Policy (NEP) which was a temporary strategic retreat permitting some private trade.

But in the main, the Communist position became firmer, and in December, 1922, as already stated, the U.S.S.R. was formally established and consolidated.

Stages in the Introduction of Communism

LENIN, from the beginning, emphasized that complete communism could not be established at once, and that, to make its ultimate success possible, Bolsheviki must resign to their leaders their intellectual liberty and abandon their right of private judgment, once a decision by these leaders is taken. Prior to this decision there was and still is abundant freedom of discussion. To a minor degree similar disciplinary control has been attempted in the parliamentary discipline of one party in Britain; and in certain orthodox Christian churches, as well as in Islam, a similar demand has been made in religious dogma; but nowhere has this been carried out with such completeness as in Soviet Russia.

This completeness was not attained at once. During Lenin's rule criticism of administration was invited and errors were acknowledged. Since his death criticism of the central government is a to be regarded as high treason; but in local administration and especially in factory organization criticism appears to be welcomed, so long as it is not anticommunist in principle.

Discipline has been steadily tightened; and even from the first Lenin's oft-repeated formula was that "the State is the tyranny of a minority over the majority," thus endorsing Marx's aphorism that force is the midwife of history. It was held that this tyranny with compulsion over the majority was necessary not only in inaugurating the Soviet regime, but also through its early years; and on this assumption the dictatorship of the proletariat was so organized that a small oligarchy controlled the main elements of government. According to communist theory this control will ultimately diminish and cease, leaving a Soviet "democracy"; but in the present stage of communist development this highly centralized organization of government is still regarded as essential. It has been laid down that "the directive principle of the organizational structure of the Party is democratic centralization."

The extent to which the Communist Party itself and the general proletariat have representative voting power will be discussed in the next chapter. There is extreme bureaucratic centralized control, while the workers and peasants participate in a large range of democratic discussion and organization. In factories and in hospitals and other institutions, workers take a real share in determining detailed management. The voting power of the peasants is on a much lower scale than that of the industrial workers.

Article 69 of the Constitution of the R.S.F.S.R. enumerates the following persons as those who may not vote or be elected :

(a) Any person who employs labor for the purpose of deriving a profit therefrom; (b) any person who lives on unearned income; (c) private traders and middlemen engaged in trade or commerce ; (d) ministers of any religious denomination or sect who practice this calling as a profession, and monks; (e) employees and agents of the former police force, of the Special Corps of Gendarmes and of the Tsarist Secret Service, members of the former reigning dynasty of Russia, and persons who directed the activities of the police, or the gendarmes or of the penal authorities; (f) any person who has been duly declared of unsound mind or mentally defective; and (g) any person who has been sentenced for a crime, if the sentence of the court specified that he was to be deprived of his political rights for a period of time.

Although many different classes are included in this list, it is obvious that the total number of disfranchised persons cannot be very large.

The actual development of the Soviet State proceeded, as we have seen, in stages. During the first months following the February Revolution, "key" positions were socialized, and the Soviets secured control of the social production and distribution of goods. Many of the great estates were parceled out to peasants; and agriculture in consequence reverted to more primitive conditions. Utterly incompetent Soviets took over the factories, managers and technicians being driven out by the classconscious proletariat. Everything was in a terrible muddle.

Then followed the period of "War Communism" in which the chief problem was military defense of the Soviets against foreign and Russian enemies. The terrible police force known as the Chekha was organized, the secret and hateful operations of which rivaled those of the Tsarist police Okhranka. Its earlier activities in shooting men and women without trial surpassed the horrors of the first French Revolution. Later the Chekha was replaced by the All-Union State Political Department (OGPU) commonly known as the "Gay-Pay-Oo."

During this period (1918-22) private property was expropriated on a wholesale scale; in towns the municipalities annexed house property and rationed it to workers; while in rural Russia agricultural products were forcibly requisitioned. Virtual martial law prevailed, and a multitude of persons suspected of hostility to communism were shot. The State took over all profits, after paying expenses, including wages, and it undertook to supply each industry with raw materials and fuel, and every citizen with all the necessities of life. Money was abolished for a time, and everything was supposed to be free (if available at all).

The natural result was chaos throughout Russia. The old propertied class had been dislodged, and four fifths of the total industry had become socialistic and was being mismanaged, and its production fell to almost nil. Agriculture also was on the verge of collapse, for the individualistically inclined peasants led by the richer kulaks among them refused to cultivate the land, once their grain was requisitioned by the authorities.

To remedy these difficulties the New Economic Policy (NEP) was introduced in 1921. It was the practical acknowledgment by Lenin that Russia could not reach fully developed socialism in a single bound. The general principle of NEP was to substitute taxation for the previous requisitioning of the peasants' superfluous grain. Peasants were permitted to sell this grain, and thus once more private trading was allowed, and a truce was established between the Marxian Government and the individualistic peasants. But simultaneously State trusts and syndicates were formed to manage the State industries. This was a temporary retreat, known as Lenin's "great strategic retreat."

An instalment plan was substituted for a fullblooded policy. Attention was concentrated on the development of an advanced industrial system, and for this purpose a supply of electric energy all over the country was made a chief point in policy. It was about this time that Lenin gave his slogan-Electrification plus the Soviet power equals Socialism in which lay the seed of the Five Year Plan. But great extensions of railway facilities and better and more roads were equally important, though they could not at once be undertaken; and many of Russia's subsequent difficulties are traceable to these deficiencies. The general policy was one of industrialization on a gigantic scale, in the shortest possible time, and, associated with this, an almost complete prohibition of importation of manufactured goods except immediately necessary machinery. The immediate consequence was a wide and serious lack of many necessities and conveniences of life.

Then followed the formulation of the Five Year Plan, under which was conceived, and has very largely been carried through, a vast extension of largescale industry, some of the developments of which outshine in magnitude - though not in efficiency - those of the vastest combines of the United States.

The plan for agricultural control was even more ambitious than that for industry, but it proved much less successful in its application. The laboremploying farmers have been the main obstacle to the complete socialization of Russia, and the end of the battle between bureaucratic socialism and the individualist instincts and longings of the worker on the land is still to seek.

Agricultural Socialization

Under the New Economic Policy private trading in agricultural products was resumed; but antiquated methods of agriculture continued, and the Government was unable to obtain enough food for the towns and for export. One reason for this was the unwillingness of the farmers to sell at the low price fixed by the Government. Then the Five Year Plan was initiated, under which it was decided that 15 per cent of the land must be collectivized by October, 1933, and 3 per cent turned into State farms, and that the small holdings and farms still individually ownedrecognized by both Lenin and Stalin as the strongholds of individualismshould ultimately become either State farms or should be collectivized. Actually, up to June, 1933, about 80 per cent of the peasants had already joined the collective farms. These comprise more than 60 per cent of the total cultivated area. A steady, persistent, and often cruel "liquidation" of the kulaks (laboremploying farmers) was carried on, and they were compelled to join with other peasants as recruits on collective farms; or even this opportunity was refused to them and many were shot; others were sent to industrial camps or to Siberia, and their property was confiscated. With these kulaks went also much of the experience needed for successful collective farms. The peasant who enlisted in the collective farms often came emyhanded. Two or three years ago their widespread slaughtering reduced the livestock 30 to 40 per cent.(According to Walter Duranty in the New York Times, February 28, 1933) Incidentally this slaughtering is one of the main causes of the present shortage of milk and meat foods. The propaganda and resultant compulsion had been too rapid and too drastic, and disaster impended. Stalin in a letter dated March, 1930, entitled "Giddiness from Success," called a partial halt, and insisted on the village emissaries of the Government replacing compulsion by persuasion.

The peasants in the early revolution had been allowed to seize their landlords' estateswithout this they would not have come in on the Soviet side. Although the land was theirs only to hold and cultivate in behalf of the State-Russia's entire land being nationalizedthey realized only their actual possession of the land. In France, after the French Revolution, the peasants came into permanent ownership of the land, with the result that France is perhaps the most individualistic country in Europe, for socialism and peasant proprietorship are incompatible. After their entry into possession of the land the Russian peasants had first been obliged to hand over its produce to the State; under the NEP they gained the right to sell their surplus supplies; but the Government realized that the continuance of this, as Lenin said, would mean "a union of the peasantry with the bourgeoisie." Then followed the persecution of kulaks, and the forced abolition of small holdings in favor of collective methods of production and living. There was utter mercilessness in the methods pursued.

More recent developments of Communist policy, both in industry and in agriculture, can be more conveniently stated in the chapter on industrial life in Russia.

Government in the U.S.S.R.

MUCH of the effectiveness of the medicohygiene provisions in any community depends on the quality of its general administrative control; and we must, therefore, at this point give a brief and elementary sketch of governmental administration. The arrangements in the U.S.S.R. differ in so many respects from western democracy as to raise the doubt whether its government is democratic in character; though if we have regard to the exceptionally high proportion of Russia's population, men and women, who take an active part in the discussion and in details in the decision of administrative matters, the claim to be democratic must be recognized.

It is necessary to bear in mind that in Russia the distinction between public and private business has ceased, as has also much of the distinction between employer and employed. As the Soviet State controls almost the entire economic life in Russia, its national budget is scarcely comparable with that of capitalistic countries.

One thing is fairly certain: what has been done in the governmental control of agriculture and industry could scarcely have been accomplished under representative democratic government of the ordinary type, and certainly not in Russia with its enormous backward and illiterate population. It has been done by a government which is not directly representative in the usual western sense of the word. It is true that each governmental proposal has been the subject of active public discussion; and that such discussion, in respect of matters of local government, is especially active; but once governmental decisions are made, further agitation which appears to be directed against general communal policy is impolitic and even dangerous. The police successfully stamp out attems of this kind, and imprisonment or banishment or death has not seldom been the penalty for such "counterrevolutionary" efforts.

The Machinery of Government

The U.S.S.R. comprises seven federated republics, which in their turn include fifteen autonomous Soviet Socialist Republics, one Socialist Soviet Republic founded by special treaty, seventeen autonomous regions, and thirteen national districts.

Each of these republics has its own separate government, and in theory at least is free to sever its connection from the Union. Nevertheless, in these republics there is remarkable uniformity in general policy. The difference between Russia Proper, White Russia, the Transcaucasian Republic, and the Ukraine was seen in our visits to be chiefly geographical, notwithstanding different languages, for the social and medical arrangements were similar.

The definition of Russia's position contained in the Guide-Book to the Soviet Union may be taken as our starting point:

The U.S.S.R. is so far the only state that is based not on bourgeois principles of private property, but on the principles of the socialist commonwealth; it is distinguished in its very nature from all other states in the world.

Supreme authority under the Soviet Constitution is vested in the All-Union Soviet Congress. As stated in Section II, Paragraph 9 of the Soviet Constitution)

The Congress of Soviets of the U.S.S.R. shall be composed of representatives of City Soviets and Soviets of Urban settlements on the basis of 1 deputy for each 25,000 electors, and of representatives of Provincial and District Soviet Congresses on the basis of 1 deputy for each 125,000 inhabitants. (The Constitution of the Union of Soviet Socialist Republics. Washington, D. C., Soviet Union Information Bureau, 1929.)

Regular meetings of the Congress are held once in two years ; the delegates having their traveling and other expenses paid by the Government. These delegates elect the Tsik, or All-Union Central Executive Committee, which is still a large body. It meets three times a year; and its members elect (1) the Presidium of the Tsik; (2) the Council of People's Commissars, or Soviet Cabinet; and (3) the Council of Labor and Defense, or Sto.

All these three separate bodies are concerned ingovernment, promulgating laws, making decrees, and making ordinances, which sometimes overlap and possibly conflict. Any confusion arising from the triple organization is unified by the coordinating action of the Communist Party, while laws, decrees, and ordinances are formally ratified at long intervals by the All-Union Soviet Congress. In its daily work the central Government is guided largely by the Council of People's Commissars. These are State Ministers who sit in the Sovnarkom, or Cabinet. Each Commissar has his own staff, which assists him in the administration of his Department, or Commissariat.

The method of popular representation may be given in Sidney Webb's words (Current History, February, 1933):

Instead of one representative system exercising all power, the U.S.S.R. has several parallel hierarchies having substantially a common form. Instead of the millions of citizens casting anonymous mass votes, in huge geographical constituencies, for the supreme legislature and executive, the citizens of the U.S.S.R. vote only in small groups of fellowworkers or village neighbors for one of themselves whom they know personally, and they delegate the rest of their power through indirect election... .

If in Western Europe and America democracy is often hastily summed up as universal suffrage with a free press, in the U.S.S.R. it might equally be summed up as universal participation in public business in the midst of incessant oral discussion.

For local government most voters vote where they work along with their coworkers; while in villages they vote along with other villagers who, like them, are mostly agriculturists. All persons over eighteen take part in the election, irrespective of sex, religion, race, or nationality. The electors number over 70 millions for the whole country, and it is significant that they have power to recall any elected person summarily and replace him by another.

In the United States important officers, including the President and the chief State officials, are elected by direct plebiscite of the people. This is not done in Britain. In Soviet Russia the local governing body, whether local or national, appoints administrative officials through its executive committee. This method may be less liable to abuse or corruption than direct election by popular vote.

But the government of the U.S.S.R is not carried on solely by the hierarchy just considered. An important part in practical government is also taken by: (a) manufacturing artels and collective farms, on the side of production, (b) the trade unions, which guard the conditions of work, and (c) the Consumers' Cooperative Organization, which regulates conditions of sale and purchase of consumers' supplies.

By the first named of these, systematization of production is facilitated, while the consumers' cooperatives organize distribution.

Consumers' cooperatives are very strong in Russia. In 1931 they had 72 million members enrolled in 45,764 separate cooperative societies (Webb), and often it is only through them that the needs of workers can be provided.

Trade Unions

In capitalist countries trade unions art an instrument of defense and, when needed, of revolt against the unbalanced control of employers of labor. They typify the antagonism between capital and labor which hereafter must inevitably be reduced or abolished if capitalism is to continue indefinitely.

In capitalist countries the organization of trade unions is chiefly according to craft. In Soviet Russia each trade union represents everyone employed in a particular class of establishment, whether he or she be artisan, clerk, cook, waiter, cleaner, manager, or doctor. Thus there are doctors in each of the 46 trade unions of the U.S.S.R. Membership may begin at the age of sixteen.

Trade unions have an important place in local and industrial administration. They have some 12 million members (more than double the total in any other country), while the Communist Party, which exercises so much control in organized Russian life, has fewer than 3 million members. Trade unions have internal autonomy in their activities, but are very strongly influenced in their decisions by members of the Communist Party. Strikes are almost eliminated. Wage conflicts sometimes occur in a factory, and the Shop or Factory Committee deals with these. This Committee consists of twentyfive or more employees; its main duty is to promote increased production, but it deals also with problems of insurance and rents of workers' rooms.

According to Chamberlin Lenin's contention was that the trade unions "should function as schools of communists," and this they do. They run the 4,000 or more workers' clubs now found in Russia. Each of these clubs is the cultural centre of the factory, doing important work in education and recreation.

It should be added that each considerable factory has its "Red Corner," where notices are posted and where there may be discussions during intervals of work. Before the World War, trade unions were persecuted; but immediately after the war many of the factories came under their control. In this task the unions naturally failed, and a system of skilled management was introduced. But in later developments they remain the centre of labor organization, and with the extension of State management, they have become in substance a division of official activity, though organized by the workers themselves. The possession of a trade union card is prized. It entitles the holder to special privileges, including free insurance and the first claim for a vacant post. Through it manual workers are given a certain preference for admission to universities and in promotion in the State services, and they receive special lowpriced tickets for entertainments.

The Soviet organization of local and central government, the producers' and consumers' organizations, and the trade unions do not exhaust the list of bodies actively concerned in the government of the U.S.S.R. There is behind and beyond all these the Communist Party.

The Communist Party

This has been described by Sidney Webb as an "extraordinary companionship," the "Keeper of the Nation's Conscience," reminding one of some religious orders, and as constituting "almost exactly what Auguste Comte designated a century ago as the spiritual power in the State.(In Current History, February, 1933.)

Webb regards it as misleading to describe the Communist Party as a political party in the western conceion of this word. Of this "Party" Stalin is the General Secretary. He acts through the central Committees which function around him.

The supreme position of the Party is indicated in the jocular remark, often heard in Moscow, that the main difference between the Party system in Western Europe and in Russia is that in the U.S.S.R. only one thing is possible: one party is in power and all the rest are in prison.

The Communist Party has become the instrument of a central dictatorship. Membership of the Party has always been limited to a minority of the population. According to Chamberlin it comprised 2,300,000 members and candidates in April, 1931. This, we are informed, corresponds to about two per cent of the adult population of the U.S.S.R. Priests, merchants, traders, and some others are definitely excluded, and every year some two per cent of its members are eliminated from the membership of the Party by local voting centrally controlled.

A third general "purge" of the Party was announced by the Central Committee on December 11, 1932; the first purge was in 1921, when the New Economic Policy was introduced (see page 81), and at that time one third of the members were expelled. Pravda, the Government's official newspaper, declared that the new purge must be thorough and merciless, and that only loyal Communists who placed the Party's interests above everything would be allowed to retain their membership.

The Communist Party is closely linked up with the Union of Communist Youths (Comsomols) and to a still larger number of younger Octobrists and Pioneers (see page 171). From the Comsomols recruits to the Party are commonly elected.

It will be seen that the Communist Party is a "highly selected, strictly disciplined, and very exclusive companionship" (Webb). Its members exercise, as such, no legal power; but in view of the methods of their selection, it is not surprising that they "hold nearly all the key positions in administration and industry," and that nearly everywhere they control the industrial and general government of the country.

The OGPU and Government

The Soviet Government is served by a highly efficient and much feared police force, the All-Union State Political Department, commonly called the OGPU, or the "Gay-Pay-Oo" (see page 25). This force is described as "at least as watchful and active as the Tsarist secret police." It must never be criticized.

It deals with a wide range of "counterrevolutionary offenses"; it has sweeping powers of arrest and punishment, and according to Chamberlin, the number of people in prison or exile for political offenses must be very large.⁽¹⁾

In one department of its work it often acts alike as police, judge, and executioner, after a quasitrial which is private.

In Stalin's words,

the punitive organ of the Soviet power . . . represents something like a military-political tribunal, constituted to protect the revolution against the assaults of the counter-revolutionary bourgeoisie and its agents.

This despotic power of the police force has become fully developed during the last ten years. The Soviet State's intolerance of any organization of political opposition necessitates the "vesting in the police of the powers of summary judgment in all cases which can be construed as political." It would appear that in Russia, the more it changes, the more it retains some at least of the characteristics of Tsarist administration.

Sidney Webb in his enlightening and authoritative studies of Russian Communism published in Current History, while highly appreciative of its methods in other respects, makes the following comment on Freedom under Soviet Rule (Current History, January, 1933):

None of the foregoing cases, however, represents the kind of repression by the Soviet Government that is most seriously complained of. That government is a dominant and intolerant autocrat in intellectual matters. In whatever it considers to be its own sphere, it suffers no rival influence to exist. . . . And this repression is exercised ruthlessly on great personages and humble folk alike, with widespread spying and delation; often, it is said, even today, without open trial . . . leading to severe sentences of imprisonment or punitive relegation to places where existence is but prolonged agony or even to secret execution. . . . How much truth there is in this matter, so far as the present practice of the Soviet Government is concerned, no man can say .. . such things have happened in past years.

The Army and Government

In the background of Russia's governmental system stands a great army, with modern equipment, well trained, and with a high morale. Wherever we went, even in children's kindergartens, the question "Are you ready?" elicited the immediate response, "We are ready for labor and defense," which may be regarded as the national slogan.

After their experience of the World War, of foreign invasions after that war, and of the years of civil warfare which followed, it is not surprising that "war mentality" should persist in an exaggerated form. It is fostered and increased by Russia's continuing belief that all capitalistic countries must necessarily desire, at the earliest possible moment, to destroy the Russian Communist regime. An example of how this stimulation is effected has been cited in Chapter II in the account of our voyage down the Volga, when we were sent under cover while passing beneath a long bridge. In fact, this happened two or three times. We learned that the people feared bomb outrages. Thus the war mentality continues and the Soviets live, as we are made to realize, in fear of attack by some other country. This has a double effect; it keeps the people's enthusiasm at fever heat, and it helps them to bear the privations involved in the hectic haste with which vast schemes of industrialization and mechanization are being carried through.

In the effort to make themselves "safe," a large, powerful, and wellequipped army has been formed. During the operation of the Five Year Plan the Government has increased the stress on military preparation.

The fear is genuine and persistent. We were struck with the militaristic characteristics displayed in the regular activities of the Youth Movement.

The army itself is a class organization, the "deprived classes" being excluded from it. More than half the officers and about an eighth of the rank and file are members of the Communist Party (Sidney Webb). Each soldier during his military training receives a general education, in which the Communist philosophy takes a prominent place. This fact is not stated as a criticism; for education in governmental principles might well figure more prominently in all countries.

Cessation of Soviet Propaganda in Foreign Countries

In this connection there arises the muchdiscussed question of Soviet propaganda in foreign countries. When the Bolsheviks seized power in November, 1917, the leaders looked upon the Russian Revolution as a part of a world revolution. Neither Lenin nor any of the other leaders considered it possible that an isolatedsocialist state could exist in the midst of a capitalist world. It was, therefore, part of the policy of the Soviets not only to meet the invading armies, but also to undermine their Governments and thus initiate international communism. The Comintern was organized to undertake foreign propaganda, and subsidies were sometimes given to strikers in foreign countries and to Communist Parties of other nations to support agitation. This attitude of the Soviet Government has changed materially, as shown in the official text of the Nonaggression Pact of 1931. This stated among other things that

1. The contracting parties once more solemnly affirm the principle of the peaceful coexistence of countries irrespective of their social, political and economic systems, proclaimed by the International Economic Conference of 1927.

2. In accordance with paragraph 1, the contracting parties undertake not to apply any discrimination whatsoever in their relations with each other, and regard the adoion in any of their countries of a special regime directed against one or several countries subscribing to this protocol as incompatible with its principles.

The apparent change in policy is expressed in the following remarks by Louis Fischer. He says ⁽²⁾

The Bolsheviks are today supremely introspective and concentrated more than ever before on the gigantic task of building up a modern industrialized Russia with a higher standard of living for all... .

Since 1927 Stalin has developed a foreign policy based on the principle of coexistence of different economic systems. If we ... fear Communism, then we must set our own house in order and relieve distress.

Summing up our discussion of government in the U.S.S.R., we may say that there are admirable points in the organization of Soviet administration. Its dictatorship was regarded as a necessary emergency measure in what is claimed to be an essential transition to Communism. Meanwhile the strongly centralized system of government is ingeniously combined with voluminous oral discussion, in minute detail, of every item of industrial or social local work. Probably the workers generally take a more detailed part in discussing points of local policy than the workers of any other country. This is compatible with rigid limitation of any criticism which can be regarded as "counter-revolutionary"; and to secure this limitation every activity of the State is closely supervised by a Party constituting a small minority of the nation, thus securing the "dictatorship of the proletariat," the Marxian and Leninist device for preventing relapse to capitalism and to the recurrent wars which it is part of their doctrine to regard as inevitable in capitalist imperialism. Lenin taught that during the period of this dictatorshipand the present position in Russia embodies his teaching in an extreme formrigid discipline is necessary; and for this purpose is needed a highly centralized government, which in his words (quoted in Chamberlin's Soviet Russia) is "quasimilitary in its severity ... guided by a group of comrades at the centre, enjoying the confidence of the rankandfile members, endowed with authority and possessing wide executive powers."

Industrial Conditions and Health

INDUSTRY, which supplies the necessaries and many of the amenities of life, is a chief condition of national welfare. It is of primary importance, for sustenance of the individual and of the family depends on working. A descriion of working conditions in the U.S.S.R. is an account of an essential part of the country's government, for the Soviet organization of industry can be described as a vast national congeries of about one hundred national combines or trusts. This organization is of unprecedented magnitude; it is organized vertically to embrace all stages of industry, and horizontally to embrace the operation of industry throughout the entire U.S.S.R.

Each industry constitutes a division of this main organization, which includes not only production, but also transportation, sale, and consumion, with the accompanying financial problems at each stage.

This is the theory; but there are obvious difficulties in ensuring its satisfactory working. The rub is to ensure due interadjustment among these various complex activities. Failure at one stage compels readjustment elsewhere, and is likely to put out of action a vast number of related works and workers; and the experience of the Five Year Plan affords numerous illustrations of this and of continuous readjustment among industries.

But communist Russia escapes one great source of industrial anarchy, that of reckless competition of rival producers or vendors. It is evident, furthermore, that collective national planning of industry is easier in a communist than in a capitalist country; for in the latter it has often been found impossible hitherto to secure combined unanimous action.

Were we to judge solely from what we saw ourselves and from our investigation of the medical supervision and care of factory life, our account would be roseate in color. An example of what can be secured in the best type of new factory life in Russia is to be seen in Selmashstroy, the great plant at Rostovon-Don for manufacturing agricultural machinery. Reference to this has already been made in Chapter II.

This great factory covers an immense area, which in 1928 was an open field, and is now an immense hive of organized industry, in which men and women carry out work, much of it involving high technical skill. There are eighteen "shops" in the factory, each having a complete organization, closely linked up with that of the entire factory. In each of these shops about one thousand men and women are employed.

Dr. Marcus, the chief doctor of the factory, is what one would call in the United States a "gogetter," and she had the medical organization in admirable control. Little medical treatment is undertaken at the factory, but the doctors (one in each shop) act as a clearing house to secure treatment for all needing it. Thus patients are relegated as may be necessary:

to the general ambulatorium of the district in which they live,

to a polyclinic,

to tuberculosis or venereal disease clinics,

to special physical or other treatment centres; or to general or special hospitals,

to university hospitals,

to tuberculosis sanatoria,

to venereal disease hospitals, or

to a night sanatorium.

One night sanatorium is for tuberculosis separately; but we saw also a night sanatorium for other cases needing special rest, connected with the factory, for example, cases of nervous exhaustion or of digestive troubles.

The night sanatorium for tuberculosis is used for patients who can do some work. Here they sleep and are fed under hygienic conditions. The institution has fifty to sixty beds. Lighter work is arranged for these patients during their six- or seven hour working day, but reduction of hours of work in accordance with physical ability has not yet been definitely arranged.

Persons beginning their work at the factory are passed through its sanitary bureau. Here they have a bath. They then receive protective vaccination against smallpox and typhoid. No further medical examination is undertaken at this stage; but when the worker is sent to his future "shop," he joins one of several brigades, and the members of each brigade are examined systematically for medical needs. The examination is undertaken jointly by a commission of doctors and is stated to be very complete. After three or four months he must return for a further examination.

Meanwhile treatment is given at the appropriate institution in the town. Some dental treatment, including provision of dentures, is given at the factory.

We were told that no applicant for work at the factory is rejected; he is put to work suitable for him. There was no unemployment in Rostov.

The doctor at each shop is usually a woman. She gives first aid in emergencies, exercises general supervision, and receives daily records from the dispensary doctor who is treating factory patients. The doctor of the shop writes out a list of absentees, and this is given to the director of labor. She pays special attention to those who are frequently ill. The shop doctor does not as a rule visit factory patients at home, but a fellowworker from the Shop Committee does this. There is stated to be no malingering. The doctors of the dispensaries obviously have no temation to be lax in certification. Workers sometimes complain that the doctors are too severe. Then they can complain to a Medical Control Committee, which consists of a worker as chairman and two or three doctors appointed by the Commissariat of Health. A similar committee decides as to sending patients to sanatoria in the Crimea, or elsewhere.

Malingering is not favored by the workers themselves, who are kept profoundly interested in the output of the works. Diagrams are exhibited in each shop of relative weekly output and of daily incidence of illness.

There are other means of reducing malingering and of increasing general efficiency. In each shop is a "wall newspaper," on which anyone can write complaints of abuses or comments on the methods of working. This form of publicity is freely adopted; and it appears clear that no evil results to the complainant follow the most candid or even overcandid criticism of shop working. This seemed to us a wholesome institution, worthy of wide imitation, perhaps with modifications. But how, outside Soviet Russia, could such criticism fail to be followed by evil consequences for the informer?

In one shop we saw a paragraph in the "wall newspaper" asking, "Why does comrade Aranova so often go on sick leave and will not work like the rest of us?" This was illustrated by a caricature of the woman, signed by the worker presenting the indictment.

It should be added that each person thus gibbeted has the right of response. There appears to be no law of libel. If the indictment is against methods of administration, the manager or committee of the shop may answer the statement, pointing out its error, or acceing its suggestions ; and important criticisms or suggestions are formally considered by the Shop Committee.

Among other notices seen on the "wall newspaper" was the announcement of a competition between two "shock brigades" in the shop in respect of quality and output of work. These contests are watched with much interest.

The whole factory has a newspaper, supplementing the "wall newspapers." During a rest time we saw one worker reading it to a group of other workers. This is said to be a general custom in all factories as well as other establishments.

We saw the workers' kitchen, at which cheap meals are provided for workers. Annexed to it is a special diet kitchen, where meals as prescribed by the doctor are given to employees under medical care. In this diet kitchen, 70 kopecks are charged for a meal. The average cost is 1 r. 70 k., the difference being paid by the insurance organization. Tuberculosis patients are not admitted to this diet kitchen.

The wages vary with the work, but there is no system of payment in proportion to size of family. At the time of our visit a chief engineer was getting 800 rubles a month. An average engineer and an average doctor received 175 to 250 rubles a month, but the doctor could do supplementary work at a second institution.

The children's nursery, or creche, of the factory is in a separate building and is well organized. At present its accommodation suffices for only 40 per cent of the children of workers in the factory. Children are admitted from three months old to three or four years old. Mothers can come every three hours to nurse their infants. Children are provided with meals, and workers on night shifts leave their children over night.

A "comrade court" is constituted in each factory to settle difficulties arising in disputes and to take action in regard to loafers, shirkers, and drunkards. In each small factory and in each shop of a large factory there is a "Red Corner" for committees. Larger factories have a special committee room for discussions, and the great factories have trade union clubhouses. Thus there may be said to be a general Parliament in every industry; and this wide distribution of discussion and responsibility doubtless is an important factor in the prevention of "ca' canny" and in speeding up and improving the standard of work and, not the least important, in safeguarding the health of the worker and providing for recreation and culture. The day's work lasts only seven hours, and these frequent meetings of workers give added interest to industrial life from which everyone profitsa partial solution of the "leisure time problem."

There is no uniformity of payment in each factory or in each shop. In a particular occupation there may be as many as eight grades of wages. All work' at Selmashstroy is now piecework, and this has been found greatly to increase efficiency.

The above account shows that at its best the factory organization in Russia is admirable. It is conducted on a large scale, and all the advantages of mass production are secured. There is specialization in the distribution of work. Each shop has its medical and general organization coordinated to that of the whole factory; and in this shop every worker knows what is the output as compared with other shops. There is evidence of intense competition to secure a maximum output, and slackers appear not to be tolerated.

Shop newspapers, in which all workers can advance suggestions and lodge complaints against individuals or details in factory work, appear to be really valuable, though the complaints against individuals run strangely counter to what the western world worker, like the public schoolboy, would regard as "playing the game." But if to "play the game" means defeating justice and in the shop means a reduced output and, for the nation as a whole, a relatively low standard of living, is it not in large measure a wrong ideal? If the right to complain and the intention to publish faults are known beforehand, taletelling against one's fellow workers or foreman or manager (let us hope after the failure of personal expostulation) is robbed of its unsavoriness, in part at least.

The conditions doubtless vary greatly in different factories; but although insanitary and otherwise unsatisfactory conditions could almost certainly be found in smaller factories and those of older date, it is nevertheless true that in factories erected under the Soviet regime the arrangements made for the welfare and health of workers are excellent. Perhaps precautions against accidents should be exceed partially from this statement, though the whole staff of factory inspection is appointed by the trade unions themselves.

In 1927 the gradual introduction of a sevenhour labor day was ordered, but in many factories it is still eight hours. Before the Revolution it was much longer.

Equal payment of wages for a given number of hours of work is not part of the policy of Russian communism. Wages are graduated differently in different factories, and often somewhat complexly. Skilled and specially needed work receives high wages, and men are encouraged to pass from one class of work to another when adequately skilled. The general standard of work is probably lower than in many other countries, a not surprising fact, as but recently most factory workers were peasants. In the Five Year Plan the wastage through misuse of machinery and through defects of manufacture has been great; and this has been especially the case in the use of tractors in farm work.

Payment on a piecework basis is very general, and we naturally questioned as to the risk of overstrain for the less vigorous section of workers. This was emphatically denied, wherever the point was raised in our inquiries. Prolonged overstrain in work, we know, may be an important factor in bringing latent tuberculosis into activity. In a few places there has been a small beginning of psychological tests of working capacity. But it is urged that everyone is eager to work to the full extent of his capacity, and that no risk of overstrain emerges even in the "shock brigades" in which competition as to quality and quantity of output is challenged between shop and shop in a factory. A check is exercised by the fact that the pace to be attained is determined by a Factory Committee. Moreover, attention was called to the short day and week, and to the provision for vacations as mitigating the strain.

Piecework system means, of course, inequality of wages. This change was one of the six chief points made in a wellknown pronouncement by Stalin. Wages vary greatly, but no figures can be given which would be fairly comparable with those of other countries. The cost of articles needed or desired by the workers has to be taken into account, and this again varies greatly.

Probably the average worker is better off than he was in 1914. He is better off in that he is almost continuously employed; but his level of living is probably still "considerably below that of the American or the British worker of equal grade who is fortunate enough to be in regular employment."(Sidney Webb, in Current History, December, 1932. )

Strikes are almost unknown in Russian factories; but there is sometimes discontent, usually due to two conditions. First, the food position may be unsatisfactory owing to the lack of coordination between rural and urban work, the difficulties with rural workers, and the imperfect transport of produce. Second, workers have no adequate outlet for their wages. Luxuries are unobtainable. Even boots are not yet manufactured in adequate numbers.⁽¹⁾

The cooperative shops are not very satisfactory, and priceswhich are proportional to scarcityare exorbitant. We met workers dining at the chief public restaurants and paying high prices for their meals; though immensely more were seen dining in public kitchens at a low cost, and in many factories special meals were provided for those under dietetic treatment. It remains true, however, that much money is spent on food, drink, and traveling, which might advantageously be diverted in part to the many items conducive to family comfort which hitherto were, as they say, "in short supply."

The shortage of manufactured consumers' goods is one of the chief grievances of Russian life. It has been primarily due to the concentration under the Five Year Plan on the manufacture of machinery for factories and similar capital goods considered necessary in order to industrialize the nation. The difficulty is increased by the unwillingness of the Government to import consumion goods for which foreign money must be paid until the urgently needed machinery has all been obtained. Meanwhile the vast increase in Russia's city population increases the famine for consumers' goods. In villages the same difficulty is felt even more markedly. Such articles as nails, boots, textiles, are very scarce. It is true that the peasants now have no rent to pay; on the State farms they are paid wages, but there is little they can buy. As Chamberlin puts it, there is "a tremendous unsatisfied internal need for manufactured goods." It is not that there is less than before the Revolution, but there is not nearly enough to satisfy the greatly increased demands of a rising standard of life.

Difficulties of transport still further embarrass the situation. During the winter, fuel becomes scarce in cities. In short, Russia is still a country of rations and of queues, though efforts are now being made to increase the output of articles needed in daily life.

Queues, especially at food shops, impress the foreign visitor as sadly frequent. Sometimes they mean scarcity of essential food or other articles, but they are alsoas we foundcaused by shortage of salesmen and cashiers. At such times, the people simply fall in line as a routine of good order, just as we do at ticket windows.

The possibility that work in "shock brigades" is likely to result in overstrain appears to be recognized in the fact that "shock brigade" workers may receive longer holidays and have certain privileges as to sanatoria and rest homes. ,

On this question an interview we had on board a Black Sea steamer with a lady who is a professor in Moscow is interesting. She stated that the principle of "shock brigades" is extended into scientific work. Her assistant works in several institutions, but retains her brightness and does not appear to suffer from overwork. She obtains premiums for her work, which may be monetary or otherwise advantageous. These premiums, as for other workers, are given by the vote of the workers themselves.

Questioned as to the risks of overwork, this professor mentioned the following counteracting influences:

1. The extra work is entirely voluntary;

2. Every fifth or sixth day is a rest day and the worker may go to a night sanatorium if this is found desirable;

3. There are arrangements for recreation and gymnastics ; and

4. The worker can obtain admission to a rest home for a month.

She recognized that there has been some overwork, but social competition has been a great stimulant. Everyone wants to be on the "red board" (see page 44.) , and those on the "black board" take care not to remain there long.

Returning to the subject of professorial work, she pointed out further that each professor makes his or her own plans of work for each day and longer periods; and thus overwork is in the main voluntary.

As regards premiums in professional work, all the workers in the laboratory hold "production meetings," at which candidates for premiums are proposed. This is further discussed at a meeting of the professors, and there may be successive meetings. Finally the premium is given at a grand meeting of all the workers. Thus workers themselves take a large part in the giving of premiums to individual workers for superior work.

There is seldom abuse in the giving of premiums or in the sending of workers to homes of rest, she continued; such abuse leads to indignant letters published in the factory paper or in the local newspaper, and if proved leads to exclusion of the offender from his trade union or from the Party. This has become so true that Party men may even fear to recommend other Party men for a post. Of course there is occasional corruption ; but this is exceptional.

It is convenient to give here the opinion of this enthusiastic and highly intelligent professor on the general question of the "keenness" of workers. When we asked her about the general "keenness" and enthusiasm displayed by workers and others seen by us at various places, especially as to whether this was limited to a portion of the workers, she was emphatic that it was general. Workers generally realize that they are now not mere cogs in a machine, she said, but that each worker is a conscious part of a great organism; and that he may in his particular work have a creative function in improving it and making it perfect. Every slogan to this end is eagerly caught up by the workers, and there is generally the enthusiasm which characterizes a racing horse.

In every department and stage of industrial work there is "democratic centralization," she continued. All discussions and the opinions expressed by each single nucleus of workers are received by the managing body and are adopted or modified in practice.

We appreciate that these statements, which agree with the results of our own observations, refer to the best side of Russia's industry. There is another and less favorable side, which recent reports from Russia ( January-March, 1933) have brought into prominence. Official Soviet statements make it clear that there has been much "slacking," a large amount of incompetent work, and even willful "hooliganism" in some industries and in collective farms here and there.

But making full allowances for the many failures in the gigantic effort towards rapid industrialization, we must pay tribute to the marvelous extent to which the

U.S.S.R. has managed to secure a complete reorganization of industry. We cannot better express our views as to the facts than in the, following remarks by an American philosopher:

I cannot obtain intellectual, moral, or aesthetic satisfaction from the professed philosophy which animates Bolshevik Russia. But I am sure that the future historian of our times will combine admiration of those who had the imagination first to see that the resources of technology might be directed by organized planning to serve chosen ends with astonishment at the intellectual and moral hebetude of other peoples who were technically so much further advanced.(John Dewey in Individualism Old and New. New York, Minton, Balch & Company, 1930.)

Before closing this chapter we must add a comment on the philosophy of work in Russia. Three features are outstanding. The basic one is that in the Communist philosophy the personal incentive of gain, although it persists to some extent in wages, has been largely eliminated. This point is well stated in a report by a group of American observers as follows :

The Russian experiment is based on the theory that there is more to be gained by coordinating industry to a functional plan and so eliminating the waste of the business cycle, duplication of plant facilities, etc., than can be lost through failure to stimulate individual initiative, animated by the private profit motive. (Soviet Russia in the Second Decade. A Joint Survey of the Technical Staff of the First American Trade Union Delegation. Edited by Stuart Chase, Robert Dunn, and Rexford Guy Tugwell. New York, The John Day Company, 1928.)

It is too early to judge whether the Russian colossal experiment in the elimination of private profit and of competition between industries employed in the same sphere can succeed. But in every other part of the civilized world, by combines, trade agreements, and allied devices, increasing efforts are being made to reduce the evils associated with unrestricted competition; and for countries which cannot support themselves as selfsustained entities, the absolute necessity, as well as the almost insuperable difficulty, of international cooperation and interchange, is being realized more and more. Can a modus vivendi be found between the extremes of communism and the suicidal competitions of capitalistic countries? The future of the world hangs largely on finding a satisfactory answer to this question.

Another striking feature is that the factory in Russian towns and the State farm or the collective farm have been made the units of social life. The electoral system both for the Government and for the trade unions is based on this unit. The factory is the social unit in other respects. It is the centre for nurseries and schools, libraries, anti study circles, newspapers, trade unions, clubs, and sports.

Finally, the factory has been made the focal point of the Communist philosophy of life. This was emphasized by university professors interviewed in Moscow, and their statements are summarized in the following sentences. Life in Soviet Russia largely turns on factory organization. Each factory is in process of becoming a health centre. There are already many thousands of these, which concern themselves with sanitation and with the organization of hygiene and medical treatment. There is continuous health propaganda for work, rest, and cultural development, the medical staff of the factory cooperating with the executive staff in this work. Dispensary service is not only for personal treatment, but is also vocational and concerned with the general hygiene of life. Science and work are made to cooperate. The ideal is increased psychophysical strength and not merely protection from disease and treatment when ill. This, of course, is the ideal everywhere, but these professors claim that it is exceptionally developed in modern Russian factories; that in Russia the ideal is embodied in a definite program; that in England in the main it is chiefly implicit; and that in the United States it has scarcely reached this level. They further urge that Russia has many mystics, and that Russians reason by deduction from first principles. Thus the philosophy set forth above has been reached.

Research work is going on, they stated, as to the rationalization of rest. Rest, like work, it is urged, should be organized, not anarchistic. Labor thus may be regarded as the central point of life, as being not a personal thing, but the embodiment of a high humanism. Labor in fact changes the worker's personality. It is philosophized ; it becomes the ideal of service for the community, not for self, and a central point of life: This conceion is regarded as the philosophical justification for making the factory and the workshop the focus of the community's social as well as economic activities; work is to be idealized, and to this end all the resources of science and of education are to be invoked; while rest and recreation, preventive care and medical treatment, are in their right setting when they are regarded as adjuvants of work.

Agricultural Conditions

THE gigantic attem to socialize agriculture, as industry had already been socialized, has been referred to, but further details are needed to enable one to compare the position of the peasant worker with that of the industrial worker.

Russia has still predominantly a rural population; nearly four fifths of its people live outside of towns. At least 6o per cent of all the farming in Russia is now undertaken on collective lines, an extraordinary change from the system of small individual farms which existed everywhere in the nation a few years ago. The socialized farms are of two kinds: the State farm, or sovkhoz, run by officials of one of the State trusts, in which the workers earn wages just like factory workers; and the collective farm, or kolkhoz, which is cooperative in character, with the individual usually retaining ownership of certain tools, domestic animals, gardens, etc., and sharing profits in proportion to the service given by him.

The State farms, now numbering more than 5,000 have been formed, to a great extent, out of land formerly uncultivated or from confiscated great estates. As highly mechanized as the most advanced American farms, they function incidentally as demonstration farms, while producing livestock and most of the grain exported by Russia.

There are various types of collective farms; but broadly they all represent partial departures from complete Marxian socialism, under which all private property in the means of production would be eliminated. While neither the peasants nor the collectives actually own the land being cultivated, it has, so to speak, been granted them for purposes of production.

This collectivization and socialization of farms has revolutionized the lives of some sixteen million peasant families. Unhappily it has led to the elimination by persecution of many of the richer peasants (kulaks, who were accused of oppressing by usury), and their skill and knowledge have been lost. Furthermore, the rapid change has meant that many villages at which the collective and State farms are situated have now too many laborers. These surplus workers are swelling the already great migration from the country to the towns, where we were repeatedly informed there was no unemployment, for the rapid increase of industries meant a demand for both skilled and unskilled operatives. The incursion was therefore regarded with complacency. Since our visit this view has been revised in official circles, and recently (February and March, 1933) drastic efforts have been made to stop the influx of rural population into such cities as Moscow,

Leningrad, and Kharkov, and to refuse urban passports (allowing continued stay in cities) to all who had no work.

Thus there has been a temporary approach of the Russian towards the western position in respect of employment. It is urged, however, that this is merely a passing problem of adjustment. Furthermore, it is unemployment associated with inadequate necessaries and comforts of life, instead of their glut, which is the marked feature of unemployment in western countries.

The success of the rural revolution would have been greater had it not been for the immense difficulties in transport, either by road or railway. This, in towns, has meant undernourishment of workers, and for the peasants it brings impoverishment in all other respects.

Stalin's dictum was that towards the end of the Five Year Plan, which was scheduled for October 1, 1928, to October 1, 1933, "collectivization of land must in essence be established." Maurice Hindus in Red Bread(New York, J. Cape and H. Smith, 1931) says that this, if accomplished, will constitute "the most colossal revolution the world has ever seen," in the securing of which "terror and agony, power and grandeur" have been commingled. Hindus summarized the further changes in the Russian village as including not only collapse of the village and disappearance of the individual ownership of land, but also the rise of rural. townships, the growing sophistication of peasant women, and the collapse of religion.

Many discrepant statements have been made as to the success of the Five Year Plan in industry. In fact, its measure of success as a whole was so great as to lead to the decision to reduce the period to 4% years, ending at the end of 1932. On the factory side it has undoubtedly accomplished a large share, perhaps most, of the work planned, there having been increased production in nearly every branch of work. This has been accomplished notwithstanding precipitate action, a magnitude of scheming for which technical advice and materials were often lacking, and much incompetent work by unskilled artisans. Slower progress would probably have been safer and less wasteful of effort and materials.

On the subject of unemployment there are divergent statements. In every city visited by us we were assured that there was no unemployment, for it had been completely "liquidated." There was an inadequate supply of factory workers, and no reduction of the high Russian birth rate was desiredexcept temporarily, because of housing difficultiesin view of the almost unlimited possibilities of expansion of industry. Due to the inadequate supply of satisfactory factory labor, work is provided in so far as practicable, even for the relatively incompetent.

On this point Sidney Webb writes (Current History, January, 1933)

Practically all the 8,000 or 10,000 managers of State works of different kinds are striving desperately to enroll additional men. Even for unskilled laborers, raw peasant youths from the villages, the demand cannot be fully satisfied. Of skilled mechanics there is such a constant dearth that managers have been seeking to "steal" them from other works by offering all sorts of inducements, until the practice had to be forbidden.

There was and is much unemployment among the disfranchised classes (priests, merchants, traders, kulaks, and others accused of exploiting labor). The total number of the disfranchised adults has been estimated as high as four millions, but probably it is nearer one million.

During the winter, 1932-1933, the disequilibrium between industrial and agricultural accomplishments became more evident. However, the Kremlin has found great encouragement in the spring sowing (1933) in the Ukraine and the North Caucasus, which showed very remarkable gains as compared with last year. The peasant forms "the keystone of the Russian arch," and his passive resistance to change has been almost invincible. Gigantic food factories run by officials of the State were to replace small farms and holdings; but the attems to do this, and to transfer the millions of displaced peasants to these food factories and to send others to the timber forests of the north had at first only partial success. Consequently, in 1931, Communist policy had to be largely modified, and some individual buying and selling permitted.

As to the situation during the winter, October, 1932, to March, 1933, statements differ both in regard to the industrial and agricultural situation, which are necessarily entangled one with the other. In January, 1933, the usually very great mobility of workers from one workplace to another had greatly increased, workers seeking better conditions of work and food, while deliveries of food were inadequate; and some action was already being taken to withdraw rations from those who abandoned their work.

This excessive mobility has always been a feature in Russia. Workers, both rural and urban, change their jobs to an extent which is inimical to efficiency. In traveling down the Volga in August, 1932, we were amazed and distressed by the crowds, far beyond the accommodation of the steamer, who attempted to get on board, often loaded by bundles which appeared to contain all their possessions. At every great railway station we saw great crowds waiting hour after hour for trains and camping out in and around the station; and on the Volga steamer it was difficult to walk because of the crowds camped out on its decks. This "excessive turnover" of labor must connote some loss of working time, as well as dissatisfied flitting from job to job. On the other hand, this is cited by some observers as an evidence of the personal freedom of the worker.

The London Times (December 2, 1932) quotes a warning stated to have been issued by the Soviet State Planning Commission that one of the most important problems of 1933 will be "the struggle to distribute surplus labor."

However, the statement that many factories cannot work at full capacity, owing to lack of materials and fuel, appears to point to the conclusion that, given improved transport arrangements and given more skilled management and better discipline in industries, and given time to convert unskilled laborers into artisans, the present evils are likely to be overcome. Meanwhile, factory employment is reduced and workers are being displaced. This increases the difficulty of supporting the superfluous people in cities; and a system of "domestic passports" has been introduced, under which every individual is "required to demonstrate his right to live in his present community.(Professor Edgar S. Furniss in Current History, March, 1933) All not engaged in work which the Government approves can be expelled from the city or village.

In many parts of Russia, particularly in the Ukraine, in the North Caucasus, and in the Lower Volga, it is officially stated that there has been serious failure to carry out the rural program of collectivization. Stalin has stated that this may be ascribed to undue satisfaction with the fact that a majority of the peasants had entered into the collective farms, and subsequent neglect to supervise their work. In the words of Walter Duranty, the very competent Moscow correspondent of the New York Times (February 28, 1933), "one thing is certain, that during the last two years, farming efficiency and results have progressively degenerated throughout the three regions mentioned." Much land has been allowed to become foul and overrun with weeds, sowings have . been scanty, and many peasants are "literally lying down on the job." "Merciless steps are being taken," and it may be assumed with considerable probability that this final "struggle to win the Russian peasants to Bolshevism" . will be successful. Military discipline is being established at each State farm, and it appears likely that the severe punishment accorded to slackers and discontented ones will overcome all open opposition to the new policy. Duranty's report in April, 1933, tells of the unusually heavy spring sowing which we have already mentioned.

Financial difficulties cloud the present position in two directions. Russia must sell oil, ore, grain, and lumber to enable her to buy the needed machinery and equipment for her factories, much of which she cannot as yet produce herself. The fall in prices for Russian exports means, for instance, that the cost of the tractors bought abroad by Russia on three years' credit had increased in 1929 to such an extent that to repay the loan meant three times the amount in bushels of grain it meant when the contract was made.(William C. White, North American Review, September, 1930.) The lapse of many countries from the gold standard and the progressive increase of trade barriers in the shape of tariffs throughout the world have intensified Russia's difficulties, while at the same time other countries suffer severely from the same policy.

The preceding somewhat gloomy review of Soviet Russia's position on its agricultural side does not necessarily or even probably mean that the Communist policy on which its leaders have embarked will be shipwrecked. Far from this, much of it must remain, and the lessons for capitalist countries are fairly obvious. It is necessary, however, in considering medicohygienic activities in Russia that this background of economic revolution should be remembered, if we are to realize their full importance.

It is sometimes asserted that Russia's policy can only succeed if other countries cease to be capitalistic, and a short comment on this contention may be added here.

Is World Socialism Necessary for Russia's Success?

Lenin considered that socialism in the sense of communism must be international in order to succeed; and as already stated (see page 97) this was consistent with the formerly persistent Communist propaganda in foreign countries. But irrespective of world socialism, Russia if she emerges entirely or partially successful from her present difficulties is in a different position from capitalist countries. We do not refer to the alleged wiping out of all her foreign and national obligations and to the confiscation of private property in the means of production, to this extent abolishing heavy overhead expenses which in other countries must be met. The point now indicated is that Russia is yet to a great extent a backward country with an immense population, still living, in respect of comforts and amenities and even of so-called necessities, in circumstances greatly inferior to the circumstances of western peoples.

Other European countries are weighed down by debts, the payments on which swallow up a very large share of total earnings and make them unable to buy from each other, while their powers of production have greatly increased. We see, alike in Europe and in America, in this year 1933, excessive production, diminished consumion, lowered prices, lowered' wages, and unemployment on a vast scale.

In Soviet Russia, on the other hand, supply does not keep up with demand, notwithstanding Russia's phenomenal increase in industrialization. In other countries there is starvation in the midst of overabundance; in Russia, owing to her inadequate training in industry, her lightning changes in policy, and especially owing to her selfsustained policy, there is, notwithstanding continuous increase in output, underproduction relative to demand, and inefficient distribution of what is produced. And yet the Russians claim, and it seems to be generally believed, that there are greater potentialities of steady elevation of the standard of living, owing to unlimited natural resources, than in any western country, not even exceing America. In the statement of this claim, the present low standard of living in Russia must be borne in mind. Other countries need not lay undue stress on future competition of Russia, given equitable conditions of trading, for it will probably be many years before Russia overcomes her handicap and approaches the level of western Europe or of America.

Religious and Civil Liberty and Law

OUTSIDE of working hours the health and welfare of workers, men and women, as well as of their families, are affected by their home circumstances, by their possibilities of recreation and mental refreshment, by the educational facilities for them and their children, and by their general ethical outlook on life.

It is convenient to consider first this last named aspect of life and its effect on religious and civil liberty and on law enforcement.

From its initiation the policy of Soviet Russia has been actively antireligious. Under its constitution, the Soviet Government, while insisting on a complete separation between Church and State, added the principle of freedom for any kind of religious belief. It is not surprising, however, that this principle is largely controverted in practice, for Lenin whose sayings are often quoted as final judgments in the same way as Scriptural texts are sometimes bandied about by theologians has expressed himself as follows:

'Religion is one of the forms of spiritual oppression... . To him who works and is poor all his life religion teaches passivity and patience in earthly life, consoling him with the hope of a heavenly reward. . . . Religion is opium for the people.' [Quoted by Chamberlin in Soviet Russia.]

No person can become a member of the Communist Party or of the Union of Communist Youth unless he renounces religious faith.

Stalin said in an interview with an American labor delegation, September 15, 1927:

The Party cannot be neutral in regard to religion. Communists who hinder the broadest development of antireligious propaganda have no place in the ranks of the Party.

One has to bear in mind the type of religious belief and expression against which this revolt has occurred. On this point Maurice Hindus affirms that the Orthodox Church in Russia sterilized the spiritual life of the peasant, for it emphasized form rather than substance, and the technique more than the spirit of worship. It made its appeal to magic, and Bible reading could supply no corrective, as most of the people were illiterate. Whatever may be said about the State Church, there were doubtless numberless individuals in whom a Christlike life evidenced itself both in true worship and in fruitful Christian love. The evil side of the official church, however, gives force to Trotsky's indictment in his History of the Russian Revolution, where he writes :

The Church in Russia was satisfied with the role of spiritual servant of the autocracy, and counted this a recompense for its humility.

We need not wonder, then, that in most homes the picture of Lenin may be seen where the Ikon used to be. Religion is not merely tabooed, but opportunity is seized by the Communist Party, the "keeper of the nation's conscience," to suppress churches and to make religious belief appear ridiculous.

Believers may still attend church, and they do so in large numbers; but the priests are prohibited from organizing any social work, and no school for minors is allowed in which religious teaching is given. Churches are closed if the congregation fails to maintain the building or to pay the taxes, which may be very high. In rural districts a church may be closed by resolution of the local Soviet, but definite instructions have now been given forbidding this to be done, unless the closure is desired, not by a mere majority, but by a really preponderating mass vote. The latest information indicates that a large majority of the village churches are still functioning as such.

Although many churches remain and function, others, especially in the cities, have been taken over for secular purposes, such as clubs or motion picture houses. In a few cases churches have been converted into antireligious museums. We saw two of these museums, one in St. Isaac's Cathedral in Leningrad. In this museum were models and caricatures of religious personages, pictures showing their close connection with the Tsar, sneering cartoons, charts and diagrams indicating how much money the State Church had obtained from the people, illustrations of religious persecutions which have stained the course of all religions, exposures of sham miracles, and illustrations of every other feature of mistaken orthodoxy. But the genuine faith of millions in true spiritual Christianity is simply ignored.

Antireligious pamphlets and exhibitions and cinema films of an intensely antireligious character abound. Bolshevism is materialistic communism of an intolerant type, and the abolition of every religion, except that of the materialistic philosophy, which is nationally raised to the rank of a quasireligion, is a definite part of its policy. Yet it is but fair to add, on the good authority of Sidney Webb, that religious literature, hymns, etc., are actually being published by the Government Printing Houses.

The practical abolition of religious liberty in Russia for anyone wishing to take his share in active communal life or in the Youth Movement must be related to a corresponding restriction of civil liberty when open criticism of the Communist Party is attemed. As already stated (page 78), there is free criticism of collective methods or policy in any and every branch of administration, always limited by the condition that the criticism must not take the form of arguing against the fundamental principles of Marxism or Leninism or aim at anything which is counter-revolutionary. Criticism on these points makes the critic a marked man with possible severe punishment, such criticism being regarded as sedition in the present continuing "state of war."

The administration of law and justice in Soviet Russia throws some further light on the problems of religious and civil liberty. In minor cases justice is administered by People's Courts, the judges in which are appointed by the local Soviet.

There is also a Supreme Court, presided over by a permanent judge and two assessors. Justice, like government, is boasted to be "class justice," being based on the fundamental dictatorship of the proletariat, "the conceion of the State as the instrument of class domination"; and justice is employed as an instrument in the class struggle. This is clearly indicated in a statement by the officer equivalent to the Attorney General of the Soviet Union, quoted by Chamberlin (in Soviet Russia) :

[There must be] consideration of the social position of the person who has committed a crime. . . . Naturally, in the case of two quite identical crimes, the Soviet court will act differently toward the bourgeois, who has committed a crime as a result of his class ideology and habits, and toward the worker, who has committed a crime from poverty or from slightly developed social consciousness.

The social danger of the offender to the State and to the proletarian dictatorship is made to determine the magnitude of punishment. Thus the London Times (October 25, 1932) records that in view of recent increase of thieving all thieves who steal at the expense of the State shall be subject to the death penalty. The Commissar of Justice of the R.S.F.S.R., it says, has issued an apologia for this new enactment, defending this "sharp and cruel law" for the offense of stealing grain or a cart wheel or an agricultural tool. Such offenses are favoring actual famine, and, as he puts it, "people who have not learnt to respect property in the course of fifteen years are incorrigible and must be shot ... the time for mercy to these malefactors has gone, and they must now be destroyed."

The law is specially directed against definite class enemies who organize arson, etc.; against unscrupulous private traders, batches of whom have already been shot in various centres; also against peasants stealing produce for illicit sale, and against town thieves and brigands.

The Commissar concludes his apologia in these words :

The class war is a cruel thing. But the working class is not to blame for the fact that its enemies force it to resort to these methods.

Subject to the above limitations, there is much on the judicial side of Soviet life which is interesting and highminded. The penal system is intended to be "modern and redemive." Prisons (many of them) have become reformatories, in which leaves of absence, and even family life while in prison, are permitted. The most advanced prisons are really settlements in which wages are paid, while escape from them is not severely punished. (See page 25.)

The position in these particulars is partially reminiscent of Samuel Butler's Erewhon, in which criminals were put in hospitals; but it does not complete that topsyturvy Utopia in placing the sick in prison. The oldfashioned prison is reserved for political offenders, and over this is drawn a veil.

Mention should be made of the Comrade Courts, in which a man's neighbors or fellowworkers sit in judgment on domestic offenses. If in a large house a wife beater is brought before a meeting of the tenants, he is first admonished. For a second offense his bad conduct is published on the house door. If he again offends, his office or factory is informed; and he then has to draw his weekly wages at a flimsy wooden structure covered with caricatures and known as the "black pay office." For further incorrigibility he may be banished to a distant city. Similar methods are adopted in schools, factories, and even in prisons! (See Progress, December, 1932, 1, No. 3.)

In our wanderings we were surprised at the infrequency of drunken persons. During six or seven days spent on steamships on the Volga and the Black Sea we saw very little drinking and no drunkenness.

There is active official propaganda against drinking. In workshops, factories, schools, and parks, exhibits warning against the evils of vodka are common, as are also cartoons and dummy figures throwing contumely on the drunkard. These all show that addiction to alcoholic drink continues to be regarded as a great national evil, and as responsible for much carelessness in the use of materials and machinery, and thus a definite impediment to the success of the national industrial plans.

On a visit to one of the ten antialcoholic stations in Moscow, we learned that "drunks" are brought in droshkies to the station, bathed and put to bed, and may be kept one or more days. The drunkard's home address is obtained ; also the name of the trade union to which the man belongs, and the man's condition is reported to the union. The man may be sent to a special dispensary for treatment.

In each factory there is a wall display of the name and photograph of the drunkard and a descriion of his fault. For this purpose a card is sent from the antialcoholic station to the factory, and disciplinary action follows on the initiative of the committee of the shop in which the drunkard works.

A useful enactment is that liquor shops near factories can be closed if the workmen vote for it; another is that the sale of vodka on pay days and holidays is forbidden. It should be added that every obvious inducement to drink has been abolished in premises where vodka is sold, and we saw no advertisements of alcoholic drinks. Reform is complicated by the revenue derived from vodka. Prior to the Great War one fourth of the nation's budget came from this source. There was war prohibition of the sale of vodka on the authority of the Tsar; but in October, 1925, largely because prohibition resulted in immense illicit production of spirits, vodka of its full 40 per cent strength was restored. At the present time, although the Government derives much income from vodka, it is conducting a systematized education campaign against alcoholic indulgence.

Home Life, Recreation, Clubs, Education

AN OUTSTANDING feature of Soviet administration is the partial displacement of the home as the normal centre of family life and especially of life for the young. The factory in towns and, to a less extent, the State or collective farm in the country now form the axle of the wheel of life in Russia. The creches, common dining rooms, clubs and social circles, schools, and grounds for recreation and games are all of them closely interrelated with factory life. Even during his annual holiday of a fortnight with full pay, the factory worker is sent, in company with a multitude of other workers, to a rest home, a convalescent home, or to a sanatorium, if his needs call for this.

His wife, as a worker, has the same privileges as men, and she receives equal insurance benefits when sick. Creches are provided for the youngest children during working hours and also during holidays. They undertake a large share of the care of her children, and their work is followed up by that of kindergartens and schools.

The worker's home, whether in a large apartment house or in one or two rooms (seldom two rooms) of a smaller house, is usually crowded, and there is little privacy.

To quote Sidney Webb :

This overcrowding is quite natural when one considers the rapidity of industrialization and the enormous concentration of population in industrial cities. In spite of this great increase in population, however, there is slightly less overcrowding as compared with prewar days, based on the number of square feet of housing space per person.

It is not surprising, in view of housing conditions, that for the adult worker the shop and the club rather than the home become the centre of life. There must be many, however, who share the regret expressed to us by a distinguished Russian professor, that "aloneness" has become almost impossible in Russian life and that one must nearly always live in a crowd. He added that for real rest a greater "aloneness" was an important ideal.

The quality of home life must become modified and its scope diminished in this extension of "club" life to most ages and to all classes; and we do not feel competent to forecast whether the balance will be on the side of social betterment or not. But the magnitude of the change implied by the almost universal industrial life of men and women, married and unmarried, in cities can scarcely be exaggerated. Through clubs, rest houses, convalescent homes, summer camps for children, and a vast provision of creches and kindergartens, Russia now has provided for its proletariat what in western countries is on a limited scale, and in some respects limited to welltodo classes.

The effect of easy divorce on the average integrity of family life and on the welfare of children cannot as yet be accurately gauged.

Our opportunities for visiting dwellings in Russia were scanty, but certain facts are beyond dispute. In the Tsarist period the housing conditions of peasants and workers alike were extremely bad, and notwithstanding the efforts made in the last few years the ever increasing congestion of urban life caused by the rapid flocking of workers to the towns has not been relieved.

The vast majority of the city people cannot live in the new apartment houses, which were conspicuous in every city visited by us. These houses doubtless have done much to relieve crowding, but it is sad to see them so often near large factories where ample land is available for separate dwellings; although their erection has helped to diminish overcrowding more rapidly and at less expense than the building of small separate houses would have done.

Dwellings are rationed according to the size of the family; and the rent to be paid is graduated according to earnings as well as according to the industrial category of the occupant. (See page 14.) Rentals are one tenth of the income of workers in the first category,(e.g., manual workers) ; higher for all others. In the waiting list for housing accommodation, personal influence, we were informed in one city, was helpful in securing an early tenancy.

Professors and doctors have some additional room allowance for a laboratory and possibly also for a library.

Even the new apartment houses are terribly overcrowded. More than one room to a family appears to be exceptional, and the single room may be shared by subletting. In these conditions it is difficult to prevent rapid spread of infection and its intensification among children. Nevertheless infant mortality has greatly declined. (See page 203.)

"House pride" is said to be often regarded as a bourgeois characteristic; and the tendency in Russia appears to be to view the dwelling as little more than a place for sleeping and for storing personal belongings. Home life in the western sense of the phrase is under a process of profound change. Strenuous efforts are being made to increase the output of work and to industrialize both town and country, and thus realize with almost indecent haste an anticipated millennium. Whether intentionally or not family life must suffer in this gigantic and longcontinued effort; but the enthusiastic Bolshevik will deny the appropriateness of the word "suffer" and will substitute the words "be changed."

But it must be emphasized that the State is making strenuous efforts to compensate the children for the lack, or at least the intermittency, of parental care; and the satirical statement often heard that "a robot is replacing the mother" does injustice to the admirable work of the creches and of other aids to the welfare of childhood and youth, which is outlined in Chapter 12.

Physical Culture

The problem of the right use of leisure, which is now causing so much concern in capitalist countries, has to a notable extent been solved in Soviet Russia. On the physical side is the vast development of games and athletics, which cannot fail to impress the visitor. In Moscow alone there are 100 sports grounds. One of our earliest visits in that city was to the new Dynamo Sport Club Stadium. Here all sports are provided for, but in football only a modified soccer is played. The openair stadium has seating accommodation for 50,000 people, and 25,000 more can stand. All taking part in competitive sports are said to be medically examined. Special diplomas are awarded, and if a sportsman passes the tests in twentytwo varieties of sports, he is entitled to wear a badge of distinction.

Outside the entrance of the stadium is the inscriion in large red letters :

"Be ready for Labor and for Defense"

and within the entrance is the sentence:

Long live the leader of the great Communist Party, the friend of the sportsman, Comrade Stalin.

The stadium appears to be run on a self-supporting basis. It is intensely popular; and this nationwide popularity of sports and physical culture appears to be entirely a post-Revolution phenomenon.

Besides the sports organized to develop athletic prowess, there is physical culture in less strenuous form. In the Park of Culture and Rest, for example, we watched with great interest the communal dancing. This goes on during summer right from the cessation of the seven hours of daily work till midnight. In one group a girl of about seventeen, completely unselfconscious, was teaching special steps to a large group gathered in a circle. An accordion, here as elsewhere, was the chosen instrument for accompaniment. After each demonstration volunteers from the crowd joined in, and then the dancing became general. In a few minutes another girl came forward as leader, and similar action occurred. The movements were carried out with military precision as to time.

Similarly in group singing, one leader succeeded an other, and evidently all the time training of a large number of enthusiastic and competent leaders, mass education and recreation of an admirable character were in progress.

In every chief industry club life is largely developed, and in many of these clubs, as well as in the factories themselves, technical and other forms of education are actively pursued. The development of the guild spirit in industry may be illustrated by describing something of what we saw in a garden club for railway workers in Tiflis. The club consists in the main of a beautiful garden, with fountains and flowers, and arrangements for music, for an outdoor cinema, etc. It is used also as a playground for children, and just as we were leaving, at 8:30 p.m., we saw some two hundred Octobrist children, aged probably from six to ten, marching and singing as they left the park for their homes. They had been in the park since 6 a.m., their meals being supplied there. Several Pioneer girls about fifteen or sixteen years old were in charge of them. There could be no doubt about the enthusiasm of the children for their leaders. This "parking" of children is arranged each year for the school vacations.

This railway workers' park showed another side of the workers' organization. Close to the fountains and in the most prominent place was affixed a double list of names, so largely written that all could read. The names in one column were those of twenty specially good railway workers, and in the other column of sixteen specially bad railway workers. The quality of exceptional goodness or badness was not stated; but here was displayed a continuous eulogy and a continuous exposure to contumely of a number of workers. The list cannot be modified without the consent of the Committee of Railway Workers, by whose authority it is exhibited. Meanwhile the names of the best of the good workers and the worst of the bad are displayed on an average to 5,000 workers and their families who come daily to this garden!

Similar action is taken, we were informed, in other club gardens not visited by us; and it will be remembered that this action is supplementary to the posting of names in the factory itself.

Propaganda

There can be little doubt that the younger generation in Russia has been caured by Communism, and is intensely "keen" in assisting its development. Some details of the Russian Youth Movement, which is an essential organ for this purpose, are given in Chapter 12. In every relation of life, propaganda calculated to promote enthusiasm in Communism is being actively pursued; and this is being done continuously. It is indeed regarded as a point of honor with Communists to take part in this; illustrating what we have elsewhere suggested, that belief in Communism has some of the characteristics of religious zeal.

Cinema pictures seen by us exemplified Bolshevik doctrine, and this was true of theatrical plays. Even in the opera, by song or otherwise, the Communist philosophy was fostered. Every stadium, recreation ground, and park is beset by propagandist posters, cartoons, and models illustrating the "evils" of capitalism and throwing contem on religious belief; in the parks dancing parties alternate with communal singing of Communist hymns, a movable scroll giving the words to each member of the crowd, and an active member of the Party appearing to be always available to lead both dancing and singing. The juvenile associations are schools of Communism, political instruction forming a large part of their daily program. In the factory and its "Red Corner," in every social club, a similar policy is being pursued with a completeness and assiduity which call for wonder and some admiration. The embellishment of the flower gardens in the parks is also utilized, as we utilize national or municipal symbols; for beds of red flowers are planted in the shape of the Soviet device of the Hammer and the Sickle, to symbolize the union of the interests of the peasant and the workman.

Education

Russian schools were on vacation at the time of our visit, but we give a few notes of information received from various sources. An official statement (Soviet Culture Review, Nos. 7-9, 1932) claims that for the first time in the history of humanity, in the place of the privileged social stratum which monopolized culture, millions of souls have come forward as the creators of new values intellectual as well as material.

From the time of the October Revolution public education has become the business of the masses, ranging from kindergartens to universities; and it is claimed in the same review that "at the present time every second person in the country is studying."

Preschool education, chiefly in the form of kindergartens, was rare in Tsarist Russia; at the beginning of the first Five Year Plan kindergartens had in them some 400,000 children. In 1932 ten million children were included in their activities.

In 1923 a beginning was made with general compulsory education. Great difficulties are still encountered in making this effective everywhere, owing to the shortage of teachers. Comsomols and trade union organizations, as well as cooperative societies, have helped in supplementing the teaching staff. The ideal, not yet achieved, is that each child shall remain a scholar from the age of seven until he is seventeen. At first the school course was only four years; now it is extended to seven years. The following official figures show the rapidity of growth of number of scholars

	PRIMARY SCHOOLS			HIGH SCHOOLS
Year	Total	Town	Village	Total	Town	Village
1914	7,200,000			564,000
1927-28	10,503,000	2,139,000	8,364,000	1,399,000	1,048,000	351,000
1932	19,001,000	3,250,000	15,751,000	4,675,000	1,630,000	3,045,000

Before the Revolution scarcely a fourth of the proletarian children of school age attended school; it was anticipated that in 1933 the attendance would be 100 per cent.

In August, 1931, a decree was issued requiring the general compulsory education of illiterate adults; and in our visits last autumn we saw such educational work going on in factories, in rest homes, in sanatoria, and also in institutions for the reform of prostitutes. Russia in another decade appears likely to cease to be less literate than western countries. Already, it is officially reported, "more than 90 per cent of the entire population from eight to fifty years of age have received a primary education."

We were informed in Rostov that children do not begin daily work until they are sixteen years old. Then they become apprentices and work six hours a day, without any night shifts, and they must not be employed underground or in dangerous factories. At the age of eighteen they become full workers.

If a youth is recommended as a student, his student life may be prolonged, and he is given a monthly allowance by the Government for maintenance.

The statement that work does not begin till the age of sixteen needs to be modified for scholars who enter a factory school at the age of fourteen. Here the scholar continues his studies in all branches, and he works for four hours daily in a shop or factory. During the next year at the factory school the scholar works for six hours daily in the factory during two months; and after three years in the factory school he enters as a skilled worker in a special department of the factory. The studies in the factory school are largely technical.

A medical student is paid during his or her training, and in addition is paid for any work done which otherwise would have to be paid for.

Other technical students are treated similarly. These students often go at a relatively high age for their technical studies, and are therefore paid somewhat highly, as they may have families. Subsequent increases of remuneration during training are given on the basis of reports submitted to the Workers' Committee dealing with this problem.

The Press and Literature

The report from which official figures as to education are quoted gives also figures showing the vast amount of published matter now being issued in the U.S.S.R. In 1931 the "number of titles" in the U.S.S.R. was 56,500 as compared with 14,688 for England with a population about one fourth that of Russia. Pamphlets and books are being utilized as "a powerful means of diffusing the Marxist-Leninist theory and technical education among the masses," and of mobilizing workers "for the task of economic and cultural construction."

The number of copies of newspapers issued daily in the U.S.S.R. according to the same source was 32 millions as compared with nearly 39 millions in the U. S. A. Details of this aspect of Soviet advance are given in an article by Sidney Webb in Current History., March, 1933.

In these newspapers there appears much criticism of details of administration in various parts of Soviet life, subject to the limitation that this criticism must not be of a "counter-revolutionary" character.

Women in Soviet Russia; Marriage and Divorce

EVERYWHERE in our travels we saw illustrations of the general fact that sex differences do not count in the outer life of Soviet Russia. There were women conductors of tramcars, and often women did the switching at intricate junctions. Women worked at roadmending, and in factories they were doing heavy work alongside men. Many women engage in occupations usually regarded as suitable only for men, as, for instance, following the sea, and in underground mining. We met more women doctors than men doctors.⁽¹⁾ We all know that Russian women soldiers distinguished themselves in the Great War.

At one of our meetings with local authorities a woman acted as head and chief spokesman of a deputation of public health officials. Women, like men, become citizens at the age of eighteen. The industrial rule is to give equal pay for equal work, and no distinction is made between men and women in sickness insurance benefits; although women receive in addition maternity benefits. Women have actively promoted such institutions as public laundries, public dining centres, and public nurseries, which help to release them from household cares and free them for industrial and political activities. This political activity of women is not new; women played an important part in the "Nihilist" and other revolutionary activities. Moreover, women in Russia have always engaged in heavy labor, working side by side with men, but the control over their life and labor was entirely in the hands of men before the Revolution. Women in Russia have been completely emancipated. They enjoy complete political and economic equality.

Sex differences were swept away by an early act of the Soviet Government, except a few regulations to protect women in industry; and the equality is carried into the marriage relation. Either partner is free to dissolve it at his or her own free will or caprice.

This new order of things carries with it the implication that the husband is no more the family's provider of means than is the wife; and every capable wife is expected to earn her own living, barring special circumstances.

Clearly the relative position of woman has greatly changed under the new regime. Prior to the Revolution she was illiterate; now she has an equal opportunity with men for education and for work, and, as we have said in the preceding chapter, 90 per cent of Russians aged from eight to fifty have received at least a primary education. When she marries she is not deprived of her job. She has special privileges as regards care during pregnancy and after it (see page 192) ; but she is eligible for all occupations undertaken by men.

We do not propose to discuss the marriage laws presented in the following pages, as to their influence on the integrity of the family and the sum of happiness of married life. Evidently they must affect family life and communal welfare as we view it to an extent and in ways which cannot yet be measured.

On our visit to a marriage bureau in Moscow we observed that the walls of the waiting room were covered with diagrams and notes of advice. Thus :

A child should not be born in the midst of bad conditions.

Don't handle a child too much. [Pictures shown of right methods of handling.]

Every family. should have a medical emergency outfit.

If the family is crowded a child cannot be well reared.

The mother as soon as she leaves the Maternity Hospital should go to the special Consultation Clinic of her district. [At this she is allotted to one doctor continuously]

Here is the complete translation of the marriage particulars which are entered by the cleck:

[image]

Incidentally, we may note that each person has an identification book which he obtains at the age of eighteen from his local Police Office. This is always obtained. It can be checked from the Apartment House Register, and each person needs the identification book for all social purposes. Many carry it about with them. A second identification book is the trade union book, and a man can be married with this as identification.

We watched a double event, in which a divorce was secured and the person obtaining the divorce was remarried in the course of from ten to fifteen minutes. The man was about thirty years old and had married in 1922. He is a musician. There sat beside him facing the clerk, a young woman, who is a telephone operator. She watched the details of the divorce with interest and then proceeded to marry the man.

From the official Register of Divorce we obtained the following blank form:

[image]

At this point we may recall an interview with a Russian jurist during our voyage down the Volga. He said that bigamy is practicable only if a man or woman produces false identification cards, and this may mean five years' imprisonment. Apart from this there is little more limitation to marriage than to irregular sex relations apart from marriage. If, however, a man marries at frequent intervals with obvious disregard of future life, he may be prosecuted for seduction. Some restriction on frequent remarriages by a licentious man arises from the possibility of his prosecution if unworthy motives can be proved.

The children, if any, complicate divorce. The marriage registrar's duty is to record any agreement of the husband and wife as to the maintenance of the children; and in the absence of such agreement the amount of alimony for the children is settled by an ordinary lawsuit.

The same obligation can be enforced for unmarried couples with children who separate. Thus cohabitation and marriage are made synonymous in their legal consequences.

When the new divorce laws were introduced, divorces were very numerous. No general statistics are available, but the figures were undoubtedly high. The number of divorces has now decreased, but one cannot view the freedom to marry and divorce at the caprice of one person without questioning its influence on the continuity and integrity of the family in Russia, as in other countries in which similar conditions prevail.

Further, while Russian laws favor early "marriages," the married condition appears likely sometimes to be a subject of anxiety for women over thirty years of age. The danger is not of sexual promiscuity; but the shadow of possible separation may cloud the life of many women whose physical charms are passing. Thus it is possible that often "the odds are stacked" not only against the family, but even more so against the wife as she ages and loses her confidence that she can "keep her man."

Among the many conversations we had on the subject of marriage and divorce we may cite two or three.

The lawyer son of a distinguished biology professor in a capital city said to us that when the new law facilitating divorces was passed, divorces became much more numerous. This was the first impulse, in accord with psychology. As the experience of greater freedom became general, this excessive impulse exhausted itself, and now "divorces were only used when needed." The "formal fictions" of former illregulated and miserable life had been reduced, and there was now relatively little misapplication of the new freedom. The hypothetical case of a married woman who had ceased to be attractive was put to him. He regarded this as an abstract case, not fitting in with experience. Women were citizens like men, and there were strong inhibitory forces in custom and public opinion against inequitable action on the part of husbands.

An interview with an English tutor who has lived some years in one of the two chief cities of Russia elicited the opinion that it was a gain that as regards marriage everything is perfectly open and free. There is no furtiveness. The Russians are much less sexconscious than most peoples. He regarded the freedom from furtiveness as a great gain. Russian marriage laws, he said, are chaotic: but this gives the advantage of a start ab initio. It is the great virtue of Communism, he held, that it faces the facts.

An interview with a lady coming from an Englishspeaking country who has done social work in Russia for some years was even more interesting. She stated that in the old days divorce was almost impossible, even for those who were not Roman Catholics. Although this is not now so, millions of "misfits" continue to be linked together. It has to be remembered that people who were over thirtyfive at the time of the Revolution are practically unaffected by the change in national policy. In western countries problems are regarded from the personal standpoint, she pointed out, and chastity is a supremely important thing. The Russian does not take the same view. Chastity is admirable; but a girl who "slips," and still more a boy, is regarded as merely foolish. The feeling of shame is said to have nearly disappeared. The same was suggested in regard to the United States, but whether this is so to the same extent as in the U.S.S.R. is extremely doubtful. On the contrary, she declared, you will not see in Russia the fondling common elsewhere; and especially there is nothing analogous to the "parking out" of amorous couples in other countries.

We were ourselves struck by the complete absence of such manifestations in the many public parks and other centres of resort visited by us. A further illustration is that in railway trains a man and a woman who are strangers often sleep in the same compartment. No objection is taken to this; and we were informed by a Russian doctor that of course no advance is ever attempted "unless the woman shows that she desires it." There is, in fact, a large amount of camaraderie between Russian men and women which is innocent of sex impulses, but which in Anglo-Saxon countries would be otherwise viewed.

On the subject of divorce the lady interviewed was equally explicit. She regarded the dissolution of an unsatisfactory union as always desirable.

We may add a few instances which show how the divorce laws may work.

One is the story of a wife who ceased to love her husband and transferred her affections to a younger man. The husband was informed and the wife obtained a divorce and married the younger man. As it was extremely difficult for the former husband to secure a place to live, his exwife informed him that he might share the single room of the newly married couple; and the offer was acceed!

A recent play at a Moscow theatre had a didactic plot which is shortly summarized as follows: Two young men lodging in the same single room were embarrassed one evening, and eventually each of them informed the other that he had married and that his wife would join him that night. Amicable arrangements were made for screening the two halves of the room. It soon appeared that each of the men had married the wife who was more suitable by temperament, etc., for the other. They kept silent and a somewhat unhappy menage was maintained, until an old friend of both couples visited them. He diagnosed the situation, advised them accordingly, and soon there occurred a double divorce and a double marriage; and presumably they lived happily ever after!

A story occurring in real life touches another aspect of married life. A middleaged man married a young wife; no children came, much to the disappointment of both and especially of the husband. Then the wife announced that she was pregnant, and in due course a son was born, to whom the ostensible father was devoted. But the wife's conscience accused her, and eventually she confessed that the previous summer while on a holiday, which her husband had insisted on her taking, she had received the advances of a young man, with the sole purpose of supplying her husband with the child he so ardently desired. A reconciliation occurred and the family was not broken up.

As our aim in this and other chapters is to record rather than to judge, we refrain from general comments.

Care of Children and Youths

CARE of maternity is considered in the next chapter, but it requires a note here, because this care is the most important element in ensuring the infant's welfare. In Russian towns nearly all confinements occur in hospitals, and this enormously enhances the infant's prospect of future health. During the week or fortnight in which the mother is cared for institutionally, the infant secures a good start, whichespecially in the home circumstances of Russiawould otherwise be lacking.

The arrangements for infant consultations in Moscow, Leningrad, Rostov, and Kharkov, are described in Chapter 19.

As already indicated, the care of children has been transferred in large measure from parents to public nurseries, to open air and other schools, and to summer camps. For children and still more for youths of both sexes, club life has become fairly general. This is a novel and profoundly interesting feature in proletarian life. It may be compared with the more limited provision of boarding schools for the middle and upper class children in England, but it is vaster in its scope both as to age and numbers.

As early as the first Congress of the International, Marx insisted on state protection of mothers and children. And factory nurseries or creches were a very early development of the Soviet Government.

In capitalistic countries the death rate among illegitimate infants usually is about double that of infants born in matrimony. Under the Soviet regime marriage has become a civil partnership which becomes void as soon as either partner wishes this and registers his or her intention; while living together without civil marriage has become equivalent to marriage, and to this extent the Soviet Revolution can be said to have "liquidated" the problems of illegitimacy.

The centres for infant consultation which are found in every city are closely linked up with other medical arrangements, and home visits are made to infants not able to be brought to the centre. Often the Infant Consultation and General Medical Centre are on the same premises as the creche. Attendance at these centres may be one of the conditions attaching to the mother's maternity benefits, and this in most instances ensures attendance. Mrs. Alice W. Field states that in 1931 there were thirty-five child welfare centres in Moscow, each of which had its own milk kitchen. Each centre dealt with 7,000 children in the year, and its health visitors made some 40,000 home visits.

Work similar to that done in these centres and in the creches described in the following paragraphs is being done in other countries; but a feature which cannot fail to impress the visitor is the intensive and continuous publicity given to this work in Russia. At every club and factory, in the trade union meetings, frequently in cinemas and theatres, and by means of posters, mothers are invited to bring their children to these centres and creches, and their work thus is universally known and emphasized as of profound national importance.

Public Nurseries or Creches

Public nurseries or creches are indispensable in view of the almost universal industrial life of women. They are not yet adequate to the requirements of all the industrially employed women, but are intended to become so, and their number is increasing with amazing rapidity on collective and State farms, as well as in the cities and towns. Creches are of two kinds, permanent and seasonal. The following figures' show the rapid progress made:

NUMBER OF BEDS IN CRECHES IN THE R.S.F.S.R.
(in thousands)
	1927-28	1931(1)	1932(2)
In town creches	34	129	263
In village creches:
(a) Permanent	2.5	103	329
(b) Seasonal	101	1,426	3,501

Children are brought to the creches at the age of one or two months and until they are three, sometimes five, years old. Each creche accommodates from fifty to one hundred children. They are arranged in three groups according to age, the management being differentiated for each group.

In the creches seen by us, and we believe generally, intelligent precautions are taken against infection. Each child is stripped when brought, and clad in special clothes. If it is verminous, the child is sent back home with its mother and is not readmitted until a health visitor has visited and inspected the home. If the infant is a suckling, the factory working mother comes twice to nurse her infant during her working hours and once during her dinner hour.

It is stated that fortnightly visits are made to the homes of the children of the creche. Creches are not merely nurseries; they are seriously regarded also as training centres for the future Soviet workers.

The training the children receive is a most valuable function of the centres. Each child is kept scrupulously clean. The infants are encouraged in appropriate exercises. Regular habits in regard to natural functions are inculcated, and instruction in the proper use of modern sanitary facilities is given as soon as the child is old enough to use them. The older children are treated on the principle that nothing must be done for them which they can do themselves. They wash themselves, help to lay tables, and put their toys away after playing. Each child has his own towel, glass, and toothbrush.

We found arrangements fulfilling in the main the above conditions in each creche visited by us.

The kindergarten takes the place of the creche for children more than three, or sometimes five, years old, until they attend school at the age of seven, at which age school attendance becomes compulsory.

The creches, kindergartens, open air and other schools and summer camps have to a very great extent taken over from parents the care of their children. Such transfer of responsibility applies even more to older children and youths of both sexes, for whom forms of club life have become fairly general. This is a new feature in proletarian life. In other countries there are boarding schools for children of the middle and upper classes, and in some countries there are meagre arrangements for very poor children to be boarded out during a part of the holidays in the country or at the seaside. The Russian arrangements of a similar kind are on a very large scale. These arrangements are highly beneficial; the quality of the provision made for the hygienic and medical care of infants bears comparison with any similar arrangements in western countries, and in quantity it is vastly greater.

The total provision for children is good evidence of the real economic equality of women with men; as are also the equal benefits of women under social insurance and the maternity benefits received by mothers. (See page 192.)

This equality carries with it a correlative obligation in Soviet policy; for work is a universal obligation without distinction of sex, and ablebodied persons living without working are deprived of electoral rights. It is not intended that women shall ordinarily be only housekeepers, although when there are dependents or when a woman cares domestically for others who are regularly employed this is permissible!

Some natural perturbation is felt by one accustomed to western life at the supersession, at least in part, of the home by the public nursery. Is it not inimical to family life? Is not much that is precious lost, which even devoted nurses in a creche cannot supply? The answer to this puzzle is that one must balance good and evil or less good on either side. In a good home in which a mother gives intelligent as well as loving care she gives more than can be obtained in full measure otherwise. The Russians claim, however, that there is no lack of affection between mother and child under their plan. On the contrary, they say, because the mother is free from all the little irritations of trying to care for a number of children, while at the same time endeavoring to carry on her household and social du- . ties, she is better able and more eager to devote herself to her children at the end of a short day's work. Similarly, they say, the children are more anxious to see their parents and are better prepared to enjoy them.

One may well ask in what proportion of families either in Britain or in the United States of America is maternal care complete and of the highest quality? Is not, for instance, the attem to control the passions and prejudices of the child commonly illinformed, careless ethically, and in the end sometimes even ruinous to his character? This is too often true, even in welltodo households, for the child is left largely to the care of an untrained nursemaid who may practice bribery and instill fear to secure a quiet nursery. In the household of the wage earnercomprising, it must not be forgotten, a very large part of the populationfurther disadvantages are added. There is inadequate space for play, and the children need frequent attention when the mother is busily engaged in cooking or cleaning; and there may be serious accidents while she is temporarily absent.

The common ignorance of child hygiene and dietetics in rich and poor households alike must also be remembered. Some of these evils are being lessened in most countries with advancing education and especially following on the domiciliary visits of health visitors (public health nurses) and the work of child welfare centres. But even so, in western countries public nurseries continue to be needed for many children; and in the present circumstances of Russia, including not only the industrial occupation of mothers, but the defective housing conditions, creches undoubtedly are doing highly beneficent work. Creches and kindergartens are training schools in health and dietetics, and through them the mothers of the children at these institutions are being trained to a better life more rapidly than would be possible without them.

On this question a highly intelligent British resident in Russia told us that he did not think maternal love is enhanced by having one's children around while working. In these circumstances half the mother's relationship may be made one of endurance. Quoting the instance of even welltodo people having an unskilled nurse, he thinks that under the Soviet regime mothers now see more of their children and in a better way.

One of the finest illustrations of inclusive child welfare work was in the Children's Village in the Park of Culture and Rest at Moscow, which we visited under the guidance of Professor Popoff, Director of Research in Health, and Professor L. Rosenstein, Director of Research in the Institute for Neuro-Psychiatric Prophylaxis. This park has been open for three years. In its children's section three hundred children at a time are cared for, and a doctor is always present.

A record is kept of each child. Exact social particulars are taken as to each child when received.

Each child after being examined by the doctor of the Children's Village receives a numbered card which is pinned to his dress by a safety pin, and a second copy of this is given to the parent. Lockers for clothes are provided, separate clothes being worn by the child while in the Village. No disciplinary measures appear to be needed.

The children in each group of twentyfive are identically clad to show the group to which they belong. Children of workers are taken to a factory creche on four days, and on the fifth day are brought here. Engineers, doctors, and other professional workers place their children here. If the mother goes to a rest home, the child goes with her and is specially provided for. Our attention was drawn to the contrast between conditions in the Children's Village and in homes of the welltodo where only an untrained nurse is available. The nurse here is a collegiate graduate and afterwards has had a special course of training for her work. Older help in entertaining younger children.

In this park there are 3,500 workers in all its departments, and for them eight doctors are employed.

At Rostov we were informed that while children under three are cared for at the special child centres, those aged from four to seven attend kindergartens, which are being provided in increasing numbers. There are no domestic servants, and these kindergartens are a partial substitute for them. In important respects the kindergarten is superior to the domestic service obtained in many western homes; for the children are under skilled care and are trained in good personal habits.

At the age of seven, compulsory school attendance begins. School life is divided into a number of grades, of which there were formerly seven, now commonly nine. If the scholar successfully passes nine grades, he can enter the university without further examination.

Dr. Genss, Assistant Director of the Institute for the Protection of Motherhood and Childhood, Moscow, elucidated from another angle some of the points already made. He laid down three chief principles and aims:

1. That the protection given is entirely by State organization;

2. That no charity whatever is involved; and

3. That a chief aim is to make it possible by means of creches, etc., for the working woman to continue her work in the factory.

Dr. Genss told us that a French visitor in reference to this second point remarked : "Thus the working woman comes, not asking, but demanding, help."

It is an essential part of the organization that workers themselves take a considerable part in its work.

None of this work existed in the pre-Revolution period, Dr. Genss informed us. There were only 14 creches before 1914. Now there are 2,000 with 1,750,000 children in them. Creches are either temporary and seasonal or permanent. None of the latter existed in villages, but with the development of collectivism, 50,000 children are now cared for in creches in villages.

In 1913: 600,000 children were in seasonal creches.

In 1931: 1,100,000 children were in seasonal creches.

In 1932: 3,000,000 children, according to estimate, were in them.

At the admirably organized Institute for the Protection of Motherhood and Childhood in Leningrad, we found a complete organization comprising every phase of maternity and child hygiene work. We were shown first the creche in which children are kept while their mothers are at work. This creche, owing to the mothers working double shifts, is open long hours, small children in one shift being kept until 1 a.m. Every arrangement is made for cleanliness and for the prevention of infection. No sick babies are taken, and there are special isolation cubicles for doubtful cases. Children are taken from the age of two months, when the obligatory period of absence from industrial work ceases. The doctors of the rest of the institute are in regular attendance. There are similar creches in all the eight districts of Leningrad.

All working mothers bring their children to the creche. Although there is no compulsion, insurance payments to mothers appear to be related to attendance at the institute. The children of mothers who are not workers also nearly all come to the creche.

There is close cooperation between home medical attendance and the work of the creche and of other departments of the institute. The district served by the institute is subdivided and each subdistrict has a special member of the medical staff to make home visits and to see patients at the institute from that district.

During the medical consultations at the institute the doctor sees only twelve patients in two hours. Children attend here at least up to the age of four. School attendance begins at the age of seven. A continuous record is kept of the history of each child and is available for reference.

Milk is supplied to those children needing it, and modified milks are prepared. The milk is derived from a collective farm and is pasteurized.

In Tiflis we visited a nursery attached to a silk factory. A part of the factory not intended for this purpose had been set aside for children, and good work is being done. At this factory there are two shifts, so the nursery is open each. day until io p.m. About eighty children are received at each shift. All the children's clothes are deposited in a special compartment in the receion room. There are separate rooms for infants, for very young children, for crawlers, and for older children. Each child is weighed fortnightly, and a doctor attends in the morning and again in the evening. The directress also has had a medical training. Each child is trained in selfhelp and selfcontrol, as regards washing and natural functions. Crossinfections do not often occur, and there has been no trouble with eye infections. All the mothers in the factory use this nursery, except a few who have some relative at home who can care for the child.

The Youth Movement

Several references have already been made to the arrangements for educating the youth of Russia and for training them in civic philosophy (see pages 94 and 97) which, Russia being a Communist State, is naturally Communism.

The entire Youth Movement is under State guidance, and altogetherapart from education in schools six or seven million youths are under its influence. The movement is for both boys and girls, no sex difference being made. It embraces all ages from seven to twentyfive. The Octobrist groups include children aged from five to eight, the Pioneers include youths aged eight to eighteen, and the Comsomols, youths and young adults from eighteen to twentyfive.

The two younger branches of the Youth Movement undertake work resembling that of British or American Boy Scouts and Girl Guides or Girl Scouts. Boy Scouts owe loyalty to the individual leader of their group and are not expected to take part in production. The Pioneers owe loyalty to the collectivist principles of Sovietism and embrace production within their activities.

In all divisions initiative is encouraged, and games and athletics, form an important branch of their activities. They also undertake parades and demonstrations. Some parades seen by us were very impressivebanners with party mottoes flying, bands playing, and much evidence of the semimilitary background of the movement. Some parades are devoted to antialcoholic propaganda. The movement against vodka is actively pushed, because vodka means ill health and inefficiency in work.

According to one of the rules of his organization the Pioneer watches over his health and cleanliness, and neither smokes nor drinks nor swears. This injunction is prefaced by an undertaking to be true to the "workers' cause and the commandments of Lenin."

The two higher divisions of the Youth Movement control the divisions below them. Over the Pioneers is the Union of Communist Youth, whose members are called Comsomols. Membership in it is conditional on renunciation of religious belief. It is really a junior division preparatory to candidature for membership in the Communist Party.

Most of the work done in all three divisions is admirable, as is also the exaltation of motives of nonacquisitiveness. But we strongly deprecate the great stress laid in each of the three sections on persistent instruction favoring continuance of the active sentiment of hatred of class enemies, and the antireligious bias. Each youth is taught that world revolution and communism are inevitable. In every unit there is military training, and military phraseology is used. There are campaigns, drives, and parades. The Youth Movement undoubtedly gives its members an important realization of their citizenship in the State and of their individual importance in relation to it.

Since the Revolution a new generation is growing up under Communist teaching and conditions of life. More than two thirds of the whole population has been born since 1905 and about one half since 1915, a circumstance having important bearing on the prospect of maintenance of the chief features of Communist organization.

At the age of eighteen, over a fourth of the Comsomols voluntarily become candidates for membership in the Communist Party, into which they are, for the most part, co-opted, after the satisfactory completion of a strictly supervised period of probation.

Care of Maternity

THE benefits given to women workers before and after confinement in the shape of full wages during absence from work and the money allowances to mothers while nursing their infants are enumerated on page 192. These special benefits come from insurance funds. The free attendance at infant consultations and the care given to children in creches constitute important additional benefits ; and the most important benefit of all is the care of the mother in pregnancy and during her confinement in the hospital. These lastnamed benefits are not limited to the insured.

Russia has always had a high birth rate (see page 202), probably higher than that of any other European country. Of these births some 80 per cent at least occur in its scattered rural districts, a fact which makes it additionally impressive that under the Soviet regime a very high proportion of these births occur in institutions. In London probably not more than one tenth of all births occur in institutions;⁽¹⁾ in rural Soviet Russia wherever we went this proportion is attained or exceeded. We were officially informed that the proportion of institutional births in villages is about 20 per cent as against 7 per cent before the Revolution, while in cities it is approximating loo per cent.

At Kazan, the capital of the Tartar Republic, the 100 per cent rate is reached in the case of workers. At Samara and Saratov we found similar conditions. In Stalingrad nearly all city confinements are in hospitals. In Rostov in the North Caucasus, in Tiflis, and in other Georgian towns we were informed that the vast majority of confinements are in hospitals, the proportion of hospital confinements in rural districts being unknown.

The vast increase in the institutional care of the parturient mother is in the main a development of Soviet administration. It forms an essential part of general policy. As already stated, the care of motherhood and childhood is regarded as a first charge on Soviet funds. But under the new regime the rapid industrialization of Russia is also regarded as of primary importance, even of urgency; and maternity must not, therefore, be allowed to diminish, more than is inevitable, the working capacity of women. According to the Economic Review of the Soviet Union (June 15, 1932) the number of women industrial workers in the U.S.S.R. in 1932 was expected to be six and one half millions, an increase of 25 per cent during the year.

The needs of industry as a motive for maternity hospital provision are reinforced by the deficiencies of housing accommodation. It was always inadequate, but the inadequacy has been increased by the flocking of people into the towns. However, as we previously said, the housing conditions even in the crowded cities are not as bad as they were before the Revolution.

To reduce the industrial loss of working power, and as part of general policy, the three lines of action taken are

1. The insurance provisions for mothers and their infants already indicated;

2. Hospital provision on a liberal scale, and free for all workers, during the prenatal period and at confinement, and;

3. The care of children in factory and other public nurseries.

The proportion of children thus cared for in factory and other public nurseries is variously stated (see, for instance, pages 161 and 165) ; but it is rapidly extending and is being introduced into collective farms.

The maternity hospitals seen by us were of a high type, the arrangements for preventing crossinfection being excellent. (See, for instance, page 240.)

The Leningrad centre illustrates well the unification of all the related provisions for mothers and their infants (see page 27). In a single institution there are prenatal clinics, clinics at which contraceive advice is given, and clinics for the various periods of infancy and childhood, all these being coordinated with arrangements for domiciliary medical care as needed. Here also advice as to abortion can be obtained, a subject on which more is written in the next chapter. A remarkable fact is that nearly every pregnant woman comes under medical supervision at an early stage, often with a view to possible abortion, from which she is dissuaded if medical opinion is against it in the particular case. Wassermann tests are always made, and if the patient does not attend regularly she is visited by a nurse at home. The same applies to children; and the nurses appear to be acquainted with every mother and child in their respective subdistricts.

On attending a prenatal centre the expectant mother receives a card which entitles her to: (a) the right of precedence in tramcars and a sheltered place in them (see also page 14) ; (b) service in shops without waiting in a queue; (c) a supplementary food ration; (d) lighter work in the office or shop in which she is employed; and (e), as already stated, two months' rest without loss of wages.

Mrs. Field (in her book already cited) states that, of every hundred pregnant women who come to the Moscow clinics, from 17 to 20 ask for abortion. Leaving aside the provisions for abortion, our observations on Soviet arrangements for the medical and hygienic care of mothers and their children have filled us with admiration and with wonder that such good work, scientific and advanced work, should be undertaken and successfully accomplished in a period when the finances of the country are at a low ebb. The maternity and child welfare institutions and arrangements seen by us gave us the impression that they were nowhere being stinted or restricted because of financial stress.

Prenatal Care

Dr. Genss (see page 21) informed us that prophylactic care has been developed, especially prenatal. In every city there are stated to be special consultation centres for pregnant women, and we found this to be so in all the cities visited by us.

The duty has been imposed on the doctor at the consultation centre of fixing the date when the mother should cease industrial work (two months before confinement), a difficult task. Much investigation has been carried out in Dr. Genss's department to secure an accurate test for diagnosing (through the urine) very early pregnancy.

During last year each prenatal centre in Moscow has been linked up with a gynecological clinic to avoid overlap of work.

When the woman is first interviewed she receives a complete medical card, thus avoiding unnecessary subsequent examinations. Dr. Genss informed us that in villages about 20 per cent of pregnant women are cared for in institutions, and that in cities the number has approached Ioo per cent. However, recently the strain of work with an inadequate staff has reduced the lastnamed percentage. Now approximately 90 per cent of confinements take place in hospitals.

Obstetric care at home is given when needed, and midwives are employed. These are required to undertake a threeyear course of training, and unqualified practice is forbidden. Notwithstanding this, women in villages are still commonly attended by their neighbors. Recently, in view of the urgent need of midwives, the experiment has been begun of training them for a year only.

After a patient is confined in the hospital a postal card is sent from the hospital to the centre for infant consultation, and another to the mother's clinic, giving the necessary medical information.

At Kazan, the capital of the Tartar Republic, we found that in each ambulatorium there are two beds for confinements, and that all confinements of workers in the city are in hospitals, in which also 6o per cent of other confinements take place. On State and collective farms in this republic hospital provision is rapidly increasing. In the rural parts fewer confinements are in hospitals; it may be as low as 30 per cent. Midwives and partially educated medical workers ("feldschers") attend half the home cases. Trained nurses are increasing; and as a rule, in this republic, every doctor undertakes a postgraduate course usually of three months every third year. The child welfare centres are supplemented by kindergartens; and nearly every factory has its special nursery.

Questioning Russian authorities regarding infant diet, they admitted that in some places the children suffer somewhat from deficiency of fatty foods.

The Problem of Abortion

A SPECIAL chapter on abortion appears to be called for, in view of the unique official attitude adopted by the Soviet Government. We confine ourselves strictly to a statement of facts, so far as we could ascertain them. This chapter might have been placed in the later medical section; but it is placed here in view of the intimate relation of abortion to married life and economic conditions.

In most countries the purposeful production of abortion except for medical reasons is regarded as murder. The Soviet Government in 1920 repealed the existing laws against abortion and legalized it under certain specific conditions. This law contained the provisions summarized below, which are more fully stated in Mrs. Field's Protection of Women and Children in Soviet Russia.

1. Abortion must be undertaken only by a licensed surgeon. Midwives are prohibited from performing abortions.⁽¹⁾

2. It must, as a rule, be the result of a surgical operation, and not of drugs.

3. The patient must afterwards remain in bed in the hospital or place of operation for three full days.

4. She must not be allowed to go to work for two weeks after the operation.

5. For a first pregnancy an abortion must not be performed unless childbirth would seriously endanger the mother's life.'

6. Abortion is forbidden if the pregnancy has lasted for more than two and a half months.

7. A doctor cannot refuse an application for abortion, except as stated under 5 and 6. He may, however, discourage it in any way he thinks fit.

8. It is recommended that all abortions be performed in those State hospitals which have a division for this purpose. An insured woman or the wife of an insured man can claim abortion free of charge in a State hospital. For others a small charge may be made.

9. A private doctor or anyone else producing an abortion which results in death can be tried for manslaughter. Women cannot be punished for performing on themselves.

10. The doctor is recommended to discourage a woman from abortion if there are no social, economic, or medical reasons for it, and particularly if she has fewer than three children, or has adequate means for supporting another child.

It is stated that few abortions are asked for by women desiring to conceal illicit relations. Under the circumstances set out in Chapter 11 the significance of such relations has largely disappeared; and the prohibition of abortion for first pregnancies also bears on this point.

In Mrs. Field's valuable volume it is stated that since 1920 less than one per cent (0.74) of abortions performed in State hospitals resulted in death.

Dr. Alexandre Roubakine, of Moscow University, informed us that of 11,000 abortions induced in the Moscow hospitals in 1925 not a single case proved fatal. In the same year, he said, there was not a single fatal case out of 2,366 abortions in Saratov.

The experience of other countries would suggest that these figures are either too favorable even when the operation is performed in a good hospital and by a surgeon having special skill, or they do not tell the whole story. The experience of gynecologists in other countries would almost certainly show a higher fatality rate than this, even when the utmost skill is utilized.

The figures given doubtless refer to hospitals in which the surgeons have specialized in operations for abortion. The majority of abortions would occur outside the cities if they were distributed according to population. Although this is not the case, a high proportion of abortions must be induced under relatively unskilled management, and serious complications cannot be very infrequent.

In one city we were informed that mothers preferred the few minutes' pain of abortion to the frequent efforts at contraceion! Charges, if made, are according to wages; never more than 40 rubles. Social insurance covers the charges for women who are insured or whose husbands are insured, which, as will be seen in Chapter XV, accounts for all the women of the proletariat.

Dr. Genss informed us that in twelve years legalized abortion had saved the lives, of 300,000 women and he considered that hygienists should from this viewpoint strongly support it. He added that special skill has been developed in the operation, which now occupies only three to five minutes, instead of half an hour as formerly, all the patients being treated by specialists in hospitals. Each patient stays three days in the hospital and can resume work in ten days.

No difficulty has arisen because of the unwillingness of women to come to hospitals for this purpose. No distinction is drawn between married and unmarried women. In an earlier year all the available hospital accommodation was exhausted, and experience showed that patients refused at the hospital went to inexperienced midwives. So a system of payment for treatment was introduced, and the payments were used for providing additional accommodation. The position as to payment now varies, some clinics retaining it.

In Moscow the usual procedure appears to be that the woman desiring abortion applies to the special consultation centre of her own district. There are now fifty of these in Moscow. Her application, we were informed, is examined by a special committee for this purpose at each centre, the committee comprising three women, namely, a doctor, a representative of the Commissariat of Health, and a secretary. However, Doctors Hamant and Cuenot,⁽²⁾ who especially investigated the subject in Moscow, regard this. inquiry as "illusory," since consent is given, for instance, when a woman is about to travel, or is going in for an examination, or is about to be divorced, or because the last confinement was painful. But as already indicated, the will of the patient, except in the first pregnancy, is the governing factor.

Consent being given, the woman is referred to one of the thirteen special abortariums in Moscow. The process adopted is curetting, usually without an anesthetic. According to the above reporters, of 52,412 abortions, 50,283 were followed by no untoward incident.

These writers quote Lippermann as stating that in Germany 50,000 deaths (or 5 per cent) have occurred in a million abortions. Sternberg gives 3.3 per cent of deaths in 2,617 abortions.

According to the official statistics of Moscow, which may be taken as being the city in which abortion is probably practised to the greatest extent, the total births (confinements at term plus abortions) increased between 1922 and 1929 threefold, from 43,289 to 133,076, while confinements at term only increased from 35,520 to 51,059, or about 43 per cent. Total abortions became from ten to eleven times as frequent in 1929 as in 1922. The official figures distinguish between induced and spontaneous abortions. The proportion between the two varieties of abortion is shown below, the number of spontaneous abortions each year being stated as too:

	1922	1923	1924	1925	1926	1927	1928	1929
Base for spontaneous abortions	100	100	100	100	100	100	100	100
Induced abortions	114	73	131	402	417	695	894	1,240

The proportion of abortions intentionally produced has increased enormously; according to Doctors Hamant and Cuenot, total abortions in Moscow are now much more numerous than confinements at the end of a normal pregnancy. In 1929 they were 61 per cent in excess of normal births.

It must be remembered, of course, that the statistics given refer to recorded abortions and not to those secretly performed. There can be no doubt that secret abortions have greatly decreased in number during the same period that the recorded number has increased.

The experience of Moscow is almost certainly exceptional as regards the amount of abortion; and it is evident that the practice of contraceion, notwithstanding the facilities provided by advice concerning it at most of the maternity centres seen by us, remains exceptional. This is confirmed by the national birth rate (see page 202) which although lower than in the past is still higher than in non-Catholic countries.

The decision of the Soviet Government to legalize abortion appears to have been determined by several considerations. In Soviet Russia as in other continental countries there was a vast amount of unskilled abortion, with terribly serious results in the destruction or damage of maternal health and life.⁽³⁾ This partially explains the public abortion exhibitions, of which we saw an example at Rostovon-Don. The primary object of this exhibition was to warn all members of the public of the danger to health and life of unskillfully induced abortion, and it doubtless did this. Some of the exhibits in this exhibition were unsuitable for unrestricted display; but if there is still a large amount of unlicensed abortion the need for warning of its dangers is evident. It may be that although provision is made for obtaining officially sanctioned abortion, this provision is still defective in scattered districts, and that much suffering results from unskilled intervention.

The Soviet policy was possibly also determined by the consideration that as abortion could not be prevented by deterrent punishment, it should be regarded, like irregular sexual intercourse, as not being a crime. We need not animadvert on the differences between these two.

Occupational requirements have also had much influence in determining the Soviet policy on abortion.

Seventy per cent of the women in Russia between the ages of eighteen and fortyfive are workers, although in some districts this proportion may be only 30 per cent. If a woman who is a worker already has living children, pregnancy is a to make her wish to have an abortion.

Dr. Genss (see page 21) impressed upon us the official view that abortion is a necessary evil, and that it is hoped eventually to "liquidate" abortion by preventing conceion, when this is desired. At present, he stated, there is no completely dependable method of contraceion, though he thinks such a method, without mechanical appliances, may soon be within reach.

It will be understood that in this volume the authors are abstaining from expressions of opinion in respect of either abortion or contraceion; they are recorders of momentous social facts, concerning which each reader will form his own judgment, in the light of his hygienic and social outlook and his ethical attitude.

Social Insurance

IT HAS already been noted that in Russia social insurance differs from that of any capitalist country in that the workers do not contribute to the funds. No contributions are paid by them week by week as in other countries, but necessarily it is the funds chiefly created by their work which provide for their insurance. In each factory or other institution there is a Social Insurance Bank, in which the contributions from the industry or institution to the insurance fund are deposited. These contributions are calculated on a per capita basis according to wages. The bank is controlled by a committee of the workers, without any representative of the administration. This committee is elected at trade union meetings. The Central Office of Social Insurance is at Moscow, in the All-Union Commissariat of Labor. The director of this central office is elected by the Council of the People's Commissariat, on the recommendation of the Central Committee of Trade Unions.

It must be noted also that although "all workers are included without exception," this does not apply to the adults and their dependents who are deprived of their civil rights. The number of these is estimated by Calvin B. Hoover⁽¹⁾ at eight millions, including their dependents, but, as we have said, it is much less than this (see page 122) . The "deprived" persons include former landlords, bourgeoisie, nobles, Tsarist officials, merchants, kulaks, and Tsarist army officers. Social insurance does not as yet include the peasants, who form the vast majority of the population. These are, however, partially relieved from taxation; and since 1930 the position of the disfranchised classes enumerated above has been somewhat ameliorated. In the main it still remains true that deprivation of civil rights means also that those deprived are not entitled to a ration card or a cooperative card, or to be registered on the regular unemployed list, or to attend school above the school of the "second step."

The details of social insurance are set out in Dr. Hoover's work, and a useful summary is contained in the official Guide-Book to the Soviet Union. The provisions for insurance come under six headings — sickness, permanent incapacity, maternity, unemployment, old age, and burial.

Full wages are paid during leave of absence because of illness; during absence from work while quarantined because of infectious disease in the family of the insured; or during absence while nursing a sick member of the insured person's family. The full wages during incapacitating illness continue until complete recovery or until the disability becomes permanent. Sick leave after ten days is only continued after consultation between the doctor treating the case and the medical referee. If difference of opinion arises, the case is referred to the medical supervisory Committee.⁽²⁾ There are thus ample safeguards against malingering, which is said not to exist.

During illness, whether incapacitating or not, medical services are given. These are not administered by the insurance department, but by the Commissariats of Health or the Local Boards of Health. These services include hospital treatment and specialists when needed.

The dependents of the insured, all unemployed persons, and all trade unionists are similarly entitled to free medical treatment, including the supply of drugs.

In addition there is very large provision of rest homes, sanatoria, and beds at health resorts. Three fourths of the beds in these are reserved for industrial and transport workers. Certain rest homes are maintained by the trade unions. The funds for free medical service are obtained to the extent of to per cent from local funds. A further demand of 3 per cent may be made by the trade unions. Social insurance funds provide the largest share of medical expenses. Sanatoria are supported, some of them by social insurance and some by public health funds.

If permanent incapacity occurs, a pension is given, the amount of which varies with the degree of incapacity. It is more liberal when the incapacity is due to industrial accident or to disease incidental to the insured person's occupation. It varies from two thirds to one third of the person's regular wage. A similar system applies to pensions for dependent widows. If permanent invalidity occurs after the age of fifty, the worker must qualify for pension by proving that he has been employed during at least eight years preceding the beginning of this invalidity.

Women employed in manual work are entitled to eight weeks, and women employed in non-manual work are entitled to six weeks, of rest at full wages before confinement, and the same benefit after confinement. They are entitled to a single bonus, for infants' clothing, of one half of the mother's wage when the birth is registered, and afterwards, during nine months, to a monthly nursing benefit of one fourth of the average monthly wage. These benefits accrue also to unemployed women and to the wives of unemployed men. The benefits given in nursing homes for infants and children are stated in Chapter XII.

There was social insurance prior to 1913, and the fund then accumulated, we were informed by Professor Landis, the head of the Institute of Public Health in Moscow, still exists. It is now being utilized for the provision of creches and similar institutions. For skilled workers who have been at the place of registry for nine months about 30 per cent, and for unskilled workers 20 per cent, of the average working wage is paid during a period of six months when unemployed.

The statistics of unemployment do not include expropriated kulaks and many others, and, as previously noted (pages 119 and 122), statements as to the present absence of unemployment have an application which is restricted to this extent. No person can claim unemployment pay because he cannot get the work for which he was trained. It is conceivable, therefore, that a lawyer, for instance, may be required to work as a laborer. We were repeatedly informed there was no unemployment in towns, a statement which is probably true for efficient workers coming within the scope of the insurance scheme.⁽³⁾

Funeral expenses are paid in the case of insured persons, or of those in recei of pensions or unemployment pay, and of the dependents of these.

Pensions for old age and for dependent widows are also provided. According to G. R. Mitchison (in one of the Twelve Studies in Soviet Russia) all who have been employed for twenty-five years get old-age pensions at the age of sixty to the amount of half their wages for their last year of employment. Workers in mines and in textile and chemical trades can get their pensions at the age of fifty and besides can continue to work at full wages if they like.

These extensive benefits call for vast funds. The total contributions made by industry naturally vary according to the wages paid, and, on the average, represent a tax of nearly 18 per cent of total wages. The rate of contribution varies from 5 per cent for home workers to 22 per cent for workers in unhealthful or dangerous occupations, we are informed by Dr. Roubakine. According to Chamberlin (in Soviet Russia) the total expenditures for insurance and miscellaneous welfare are calculated at 32 per cent of the wage bill, but this includes also activities not coming within the range of insurance benefits. Mitchison, in the work quoted above, says that the contributions average about 14 per cent of the wages paid. But although the exact percentage is doubtful, the insurance contributions of industry are much larger than those made in other countries.

Insurance is organized on a unified and territorial basis, including insurance against accidents as well as sickness and unemployment. Transport and railway workers are under direct All-Union jurisdiction, and Public hence are an exception to this territorial arrangement.

The preceding summary makes it clear that social insurance plays an important part in the economy of Russian life in towns. Its distinguishing feature is that the cost falls on the employer whether this be the state, or a cooperative body, or any other employer. This statement applies completely to monetary benefits. Part of the cost of the medical part of insurance is derived from general taxation.

It has already been noted that deprived classes are excluded from insurance benefits, and that its benefits have not yet been extended to peasants.

With these important exceptions it appears that, in Russia, greater security is being given against economic and health hazards than in any capitalist countries. The U.S.S.R. compares very favorably with the United States in this respect, but it will be remembered that there is a vast difference between the wages in the two countries.

The aim of insurance in Soviet Russia, as elsewhere, is to replace charitable relief by aid to which the worker is entitled, and, subject to the exceptions named above, this aim is being fulfilled. There is no charitable relief in Russia.

Health and Medical Administration

IT IS desirable to give a preliminary statement on public health administration and especially on the evidence which vital statistics give as to health conditions, before describing the general conditions of clinical work in Russia. In actual fact public health administration is in so large a measure combined with clinical work that the two cannot be logically separated.

Throughout our inquiry we have regarded the entire framework of Russian society as involved in any inquiry into medical work in Russia; for national health is a function of society, and the normality of other aspects of communal life has an influence on health not less than that of medical care. It is for this reason we have brought into our review, as factors of health, the conditions of industry and agriculture, housing, home life, marriage and divorce, and social insurance.

Several chapters have already been devoted to the physiological side of special health work, including the activities of infant consultations, of child centres, of creches and kindergartens, and of prenatal consultations and maternity homes and hospitals. In one chapter we have already stepped over the dividing line between physiology and pathology in discussing intentional abortion, which has momentous social as well as medical importance.

The framework of public health administration is identical with that of general medical administration. The entire practice of medicine, institutional and domiciliary, having been socialized, is supervised and controlled by the public health organization in each of the seven constituent republics. In this respect, as also in the main in actual working, there is no separation between clinical and preventive medicine. Each doctor is expected to consider the health of his patient, not merely as a patient, but as a member of the community, whose efficiency, if possible, must be increased.

The organization of the public health and medical service is centralized in each of the seven constituent republics, but there is no central All-Union department of health. exceptions, however, are that the health service in the Army and Navy and for the railroad workers is administered by All-Union authorities. While the seven People's Commissariats of Public Health and their subordinate organizations are politically independent of one another, the system established in the R.S.F.S.R., with the seat in Moscow, in most respects serves as a model for the other six. The scope of each of the seven commissariats includes administration of preventive medicine, medical care, pharmacy, medical training; and of certain health resorts not under control of the social insurance system.

Subordinate to the Commissariat of a constituent republic are District and Regional Branch Commissariats. There are also Special Commissariats in the cities.

Each of the seven People's Commissars is appointed by the Presidium, a committee representing the Tsik, another committee; which in turn represents the Congress of Soviets. Heads of the District or Regional Commissariats are appointed by District Committees. The Commissar of Health of the republic is entitled to nominate a candidate, and although the local Committee chooses him, the centrally nominated candidate is seldom rejected. The Commissar may also veto a local nomination. The only difference of opinion likely to arise is as to qualifications. An official can be dismissed either by a local or the central committee.

We may cite one or two examples of how the State and local authorities cooperate. In Kharkov special committees of institutions and of local authorities nominate candidates, and these are appointed if approved by the Commissar of Health of the Ukraine. Even in large factories, such as the Tractor Works, the final medical appointments rest with the Commissar, who can also remove unsuitable persons from their posts.

In Tiflis we were informed that local authorities recommend candidates for special local posts. These, if endorsed by the Commissar of Health for Georgia, become valid; if not, a more appropriate appointment must be made. The local body can appeal against this decision to the governing body of Georgia.

If a doctor does his work well, he is reappointed. Political considerations are stated not to weigh in the appointments, and in fact 70 per cent of the medical officers in the employment of the Republic of Georgia are non-Party men. The desire for efficiency on every side is said to be such that Party considerations and favoritism have no chance.

The preceding statements apply to appointments both for clinical and special public health posts.

The people generally are stated to take unusual interest in public health administration, and our observations confirmed this claim.

The general principle of medical organization is that of a chain of controlling bodies each closely related to the other. There are "flying squads" of officials through whom it is possible to concentrate on places in which serious needs arise, especially in areas in which great construction works are in progress.

In each constituent republic of the Soviet Union and in its chief divisions a few doctors are always available for special public health work; but in each district the local doctor is expected to supervise health conditions as well as to treat the sick. This is true also in the medical administration of large factories, the physicians of which are more engaged in hygienic work and in the regulation of the medical care of workers than in actually undertaking this care.

The detailed organization of general medical and health work in the Ukraine may be outlined as an example. This outline is based on an interview with Dr. Kantorovitch, Commissar of Health of the Ukraine:

The heads of each special department form the Collegium at which points of policy are discussed. The chief departments are concerned with :

1. Therapeutics.

2. Medical work in institutions (dispensaries, hospitals, etc.) . This section has many inspectors and subinspectors.

3. Care of mothers and children.

The last section cares for kindergartens, nurseries, and mothers' consultations, and prepares the staff for their work and nurses for work in the nurseries of collective farms, etc. Last year 57,000 women were prepared for this work.

4. Industrial hygiene, factory doctors, etc.

5. The betterment of children's health, school hygiene, etc.

6. Sanitary conditions of life:

    (a) Feeding and nutrition.

    (b) Housing.

    (c) Water, sewage, etc.

    (d) Epidemiology and prevention of infections.

7. Scientific research.

Arrangements are made for technical instructions of workers, for correspondence classes, and for encouraging scientific research at polyclinics. Fiftytwo scientific institutions come within this division's supervision.

8. Popular sanitary education.

Much work of this kind is done by university professors, and special courses of one or two years have been organized. Persons having gone through these courses are often invited to become social workers in the centres of medical work.

9. Rationalization.

Problems are given to the several institutes for study and the suggestion of remedial measures.

10. Planning department, including finance and statistics.

11. Supply department for food, etc., and for maintenance of institutions.

12. Division for plans of buildings.

Local budgets are framed by the local Executive Committee, and then submitted to the Ukraine Central Government, which may send them back for revision. They finally require to be approved by the People's Commissars of the Republic.

The financial needs of social and medical work are met from three sources, namely:

1. Local taxes used for supporting local institutions.

2. Central funds contributed especially for maintenance of medical and other staff.

3. Insurance funds from which most of the money needed is derived.

This expenditure is solely for insured persons and their families, which form a great majority of the total population.

Vital Statistics

In the following pages are given some of the chief vital statistics of the U.S.S.R. They have been abstracted chiefly from the International Health Year-Book, published by the Health Section of the League of Nations.

In 1929 the population of the U.S.S.R. is estimated to have been 157,611,ooo as compared with 39,607,000 for England and Wales and 120,000,000 for the United States.⁽¹⁾

Russia's industrial population in 1929-30 is given as 10,887,000 as compared with 8,886,ooo two years earlier, an increase in this short interval of 22.8 per cent as compared with an increase of 2.2 per cent of the total population in the same interval.

The International Health Year-Book for 193o gives the birth rate in 1929 in the R.S.F.S.R. (European territories) as 38.6 per 1,000 of population, while the death rate was 20.6. In the rural population the birth rate was 41.4, in the urban population, 28.4. The following figures for some Russian cities are given:

BIRTH RATES			DEATH RATES
	1913	1929	1929
Moscow	32.2	22.0	13.2
Leningrad	26.4	22.1	15.4
Kharkov	46.5	19.1	11.8
Rostov		22.3	13.8
Saratov		24.6	18.8

Infant mortality rates form a sensitive index of domestic sanitation and of personal hygiene and care, and, assuming that registration of birth and deaths is fairly accurate, the following figures are important.

In European Russia the infant mortality rate per 1,000 births in 1913 was 275; in 1927 it was 186, annd in 1930 it was 141.

In 1929 the infant mortality rate was in Moscow 131; Kharkov 106; Leningrad 151; Rostov 146; and Saratov 178.

Evidently, although infant mortality remains excessive, there has been a marked reduction in it, which indicates a great improvement in personal hygiene since the Revolution.

The following additional figures from the same source are useful indices of public health in Russia. Those of England and Wales are given in a parallel column for rough comparison, and the two can be compared by remembering that the population of the U.S.S.R. is about four times that of England and Wales. The figures for England and Wales are approximately complete; it is likely that those for Russia are not equally so.

CASES OF ACUTE INFECTIOUS DISEASES IN 1929
	U.S.S.R.	England and Wales
Smallpox	6,099	10,967
Scarlet Fever	458,704	120,232
Diphtheria	98,565	62,774
Dysentery*	177,252	573
Typhoid Fever*	171,263	2,835
Typhus*	33,127	1
Relapsing Fever	2,939	0
Malaria	2,993,072	0

As bearing on domestic cleanliness and communal sanitation, the figures for the items marked* have special significance.

The figures for relapsing and typhus fevers are important indices of intense overcrowding and personal hygiene and of social backwardness. So also are the figures for trachoma, of which there were 1,146,599 cases in the Union, chiefly in the more remote and primitive parts. The fact that there is fifteen times as much typhoid fever in Russia as in England for equal units of population shows the need for great reforms in municipal and communal sanitation, as regards water supplies and other sources of infection.

Russian Medical History and the Training of Doctors

PRIOR to the Revolution, Russia was extremely backward in its medical provision for the mass of the people. Since that time a vast advance has been made. The sanitation and public health of Russia, which were also imperfect, remain so, though to a much smaller degree, to the present day.

Our review of present conditions in preventive and clinical medicine in Russia is based on inquiries and inspections during a relatively short visit; and although it has been associated with much study of authoritative writings, we do not pose as competent to judge the merits of Russian medicine as a whole, but only of this medicine as we have been able to observe it. We are confident, however, that even when all its present incompleteness and imperfections are emphasized, the wide sweep of the newly organized medicine of Russia presents features from which other countries may derive important lessons.

In judging the present position of medical practice in Russia, her past in medicine must be borne in mind.

An excellent account of Russian medicine in the past is given in Colonel F. H. Garrison's "Russian Medicine Under the Old Regime" in the Bulletin of the New York Academy of Medicine, September, 1931. The following statements are derived largely from this source.

In the reign of Ivan IV, "the Terrible" (1533-84), a contemporary of Queen Elizabeth of England, four physicians, two surgeons, eight surgical dressers, eight barbersurgeons, and four apothecaries were brought from Germany, but how many of these escaped the enemies by whom their ship was attacked is not clear. In 1557 two English physicians were brought to Moscow by the Russian ambassador. At the end of the sixteenth century, Garrison states, the first Russian medical publication was printed.

With the reign of Peter the Great (1682-1725) a new. order of things began. He may be regarded as the creator of Russian medicine, as he was the first person in power who attempted seriously to Europeanize Russia. It is to him that the first hospital (1706) and medical school (1707) in Russia owe their foundation; and in some other respects, he acted in accord with his motto : "I am of those who seek knowledge and are willing to learn." He gave his army an organized medical service. During his European travels he "picked up all the training he could get on medicine and surgery" and is said to have tapped dropsies and even couched cataracts on his own subjects, "sometimes with untoward results." (Garrison)

The reign of Catherine II (1762-96) was a period of cultural awakening, rather than, in Garrison's words, a time of "true progression towards economic and social betterment." Queen Catherine was inoculated against smallpox by an Englishman. In this reign a medical college and hospitals for the insane and for venereal diseases were opened, as well as foundling asylums. By 1804, according to Garrison, there were medical faculties in five Russian institutions, namely, the Universities of Moscow, Dorpat, Kharkov, and Kazan, and the Medico-Chirurgical Academy in St. Petersburg. But, except at the academy, which became the Military. Medical Academy in 1835, the teaching was "poor and feeble in quality." The Napoleonic wars had left Russia exhausted and unready for any scientific advance.

Pirogov (1810-81) became professor of surgery at the Military Medical Academy in 1840, and he lifted it to a very high level of efficiency. He introduced dissections and pathological anatomy into the teaching of medical students; and he deserves to be regarded as the greatest figure in the history of Russian medical practice.

A succession of distinguished medical scientists have followed him; among whom the names of Metchnikov (1845-1916), whose work was done chiefly in Paris, and of Pavlov, born in 1849 and still living, are of worldwide repute.

But although there were distinguished Russian scientists, physicians, and surgeons, the number of practitioners was entirely inadequate and the vast majority of the people of prerevolutionary Russia outside the large cities were almost destitute of medical aid.

The emancipation of the serfs in 1861 was both an effect and a cause of greater attention to the wellbeing of the individual. Shortly afterwards territorial selfgovernment in the form of district (zemstvo) assemblies was established, and along with this came local administrative control of medical aid. But for most of Russia medical care remained in the hands of unskilled persons and sometimes of the country clergy; and in view of its vast extent of territory and the widely scattered distribution of its villages the problems of supplying medical aid for these inevitably remained unsolved. The Russian peasant could not, and, if he were called upon to do so, could not now, afford to pay a doctor.

Gradually, however, medical provision became less exiguous, and here and there some hygienic propaganda and actual preventive work began.

Medical provision and hygienic work increased each decade, and in the years immediately preceding the Revolution there were some hospitals in most large centres of population, and a limited amount of medical aid was accessible to the poor. For the welltodo, medical aid of a high standard was generally available, and many sanatoria and hospitals were provided. This provision for the poor remained miserably inadequate.

The medical departments of universities were well equipped, and medical students were well trained, better than now; but their number was very inadequate for Russia's needs.

Then came the two revolutions of 1917; and during the four years which followed, external war and civil war, revolution, famine, and disease decimated the population and left the survivors impoverished and enfeebled.

The protracted struggle against famine and disease had serious effects on medical education and practice. Medical schools and hospitals received scarcely any funds. No repairs were possible, and food and means of heating for these institutions and their staff failed.⁽¹⁾ Students and professors suffered alike. Only bare subsistence was possible, and professors stood in line for their daily rations. Gantt says, "distinguished professors spent part of their time in squads shoveling snow."

On the inceion of the New Economic Policy in 1921, with its partial supersession of "war communism," the position of hospitals somewhat improved. Medical schools also improved slowly, and during later years there has been a marvelous advance in the volume of medical education and in the amount and quality of medical aid provided for the masses of the people. The new medical education, hitherto, in view of the very great increase in the numbers educated, is, as might be expected, inferior to the old in quantity and quality; but for the first time this education is bringing medical aid of a fair quality to the masses of the people.

Post-Revolution General Education

General, cannot be separated entirely from medical, education, and a few words are needed as to this, additional to what is stated in Chapter X. Prior to the Revolution the few were well educated, while the people generally were almost entirely illiterate. The new regime meant the abolition of the existing schools for the children of the upper classes and the substitution of a system in which millions receive at least elementary instruction. Civic instructionnaturally communism as taught by Marx and developed by Leninoccupies a prominent place throughout school life. In 'every school elementary education, to quote official language, is "combined with a course of political and cultural education," including "the basic principles of the social order under the Soviets."

The amount of illiteracy has been enormously reduced, and, as we have said in Chapter X, 90 per cent of adults, aged, from eight to fifty, have received a primary education. This, however, still leaves a considerable part of the adult Russian population unable to read or write. It is the steady policy of the Soviet administration to reduce this illiteracy of adults, and we saw elementary school teaching undertaken as a side activity in factories, in sanatoria, and also in institutions for the treatment and reform of former prostitutes. The voluntary work undertaken by the Pioneers often takes the form of teaching the illiterate. The creches and kindergartens, to which most children in the first eight years of life are taken, are also centres of elementary instruction; and all those seen by us were well equipped and models of cleanliness. In them the children are instructed in selfcontrol and cleanly personal habits. They are taught at a very tender age to wash and dress themselves and in all respects to conform to hygienic habits. In the elementary schools, in the vast numbers of open air schools and day camps, and in the juvenile clubs which belong to the Youth Movement, education, including Communist civic instruction, is proceeding continuously.

Post-Revolution Medical Education

That is the background for the recent extension of medical education. As members of the proletariat receive preferential nomination, many students now starting their medical training have had inadequate education. Many candidates are adults and sometimes married. They are selected by committees of their. fellowworkers, as are also nonmedical university students. The choice depends greatly on the social occupation of the student, manual workers having a preference. There is probably some favoritism in choosing candidates for training, as well as in medical appointments. But "graft" is treason in Russia, and it is doubtful if it exists in this connection. This does not mean that there is an absence of "political pull" in the sense of influence of the Communist Party on behalf of any candidate. We met doctors who had been selected for medical training by these committees, and in the instances thus encountered the selection was justified. Evidently, however, deficiency of preliminary general and scientific education must lower the standard of subsequent medical service. This is recognized by hygienic and medical leaders in the official world of Russia, and doubtless the quality of students selected, as well as the details of present medical instruction, will improve as they need to do. Even now it is indubitable that, although the average individual standard of training of the multitude of medical students of today is lower than that of the fewer students in pre-Revolution days, the aggregate quantity as well as the quality of medical aid available for the mass of the people is being enormously increased and improved.

We were informed by Dr. Vladimirsky, Commissar of Health of the R.S.F.S.R., that in 1932 there were 36,000 medical students, and it was hoped that by 1937 the present deficiency of doctors would be overtaken. He estimated that Russia was still short of 20,000 physicians, as compared with the quota of the Five Year Plan, and that this meant retardation of public health and of medicine. It was officially considered that eventually as an ideal there should be one doctor to 1,000 population.

He stated that they were quite aware that Russian methods of medical education needed overhauling, as, he believed, was the case in other countries.

The extension of medical education is indicated in figures supplied by the Commissar of Health of Moscow. In 1912 there were six institutions for medical training in the Soviet Union; in 1930 there were thirtyfour. In 1912 there were no medical research institutions; now there are one hundred and six such institutions, thirtyfive of which are supervised by the Governments of constituent republics, while seventyone are regional and autonomous, i.e., under separate cities and autonomous republics.

Medical Education in Rostov

At Rostov we obtained interesting information as to the training of medical students in its university. Until last year there was a fouryear course of medical training; now it has been increased to five years, as before the war. It was stated that most of the large cities now had a medical faculty for training students. "Each student is carefully chosen as a medical student, and he has a monetary allowance to cover expenses. For definite work in the hospital done 'by him, he is paid according to current rates. The choice of candidates for medical students is decided by a commission, applications for vacancies being sent from schools and works. On these applications a Workmen's Committee first sits, and their recommendations come before a commission consisting of a representative of: (1) the administrative medical faculty, (2) the professorial staff, (3) the trade " unions, and (4) the student workers.

The final decision as to candidates rests with this commission. Any exhibition of favoritism means a "row" and much discussion in workers' journals.

From the beginning of his course each student must engage in practical work bearing on his future career.

In his first year he must assist in minor medical and surgical work, including cleaning up after the work is finished.

In his second year the medical student has to help in actual nursing; and in his next three years the student likewise engages in practical medical work at various hospitals, polyclinics, and ambulatoria, while continuing his scientific training.

When qualified, the doctor is offered a post at once. He may have specialized from the end of his third year, though this is a debatable policy. He is required to be fairly competent in all branches of medicine, as he may have to practise alone in a country district.

The risks of inadequate training of new doctors are appreciated, and still more the need for additional trained nurses. Lay workers in hospitals are being utilized, and it is intended to give selected candidates from these full medical training. A recent regulation has made the conditions for becoming medical students more stringent.

Postgraduate courses are given to doctors every three years, so far as is practicable.

Some home visits are made by nurses, in relation to child welfare, tuberculosis, and venereal disease, but these are not fully organized.

Medical Education in Tiflis

In Tiflis the population has been augmented, apart from growth of trade, by the growth of the city as a university centre for Georgia and the neighboring republics. A separate section of the town has become a university centre in which some 15,000 students live. There are special institutes in various branches of science and medicine at the university; and students have special residential quarters. The largest of these institutes is devoted to agriculture, as this is the chief industry of Georgia. Before the Revolution the university had only some 2,000 students.

In Tiflis there are 945 doctors, and in all Georgia 2,080. Dr. Kuchaidze, Commissar of Health for Georgia, declined to draw a distinction between physicians and public medical officers; for "all doctors are health officers," and only the chiefs of public medical departments do not engage in some form of clinical work.

Dr. Kuchaidze stressed the fact as had been done in every centre visited by usthat the general plan of medical and of public health work is identical throughout Russia, local circumstances necessarily implying some variations in detail.

There is a medical institute attached to the University of Georgia, in Tiflis, where since 1919 medical students are trained. Practical medical work is begun in the second year of training. All students are paid by the Government and are also trained gratuitously. The full medical course is five years.

There is a special "technicum" for training of midwives and a subsidiary variety of doctors. Instruction to midwives is given not only in the Russian and Georgian languages, but also in several other languages of the Trans-Caucasian confederation of republics. Midwives are required by law to call in a doctor on the occurrence of an obstetric complication. Their course of training covers three years; and the practice of unqualified women is prohibited, though not strictly so. In towns at least 95 per cent of the midwives are trained. In most villages are voluntary social workers who assist in maintaining the standard of maternity and child welfare work.

There was evidence of the provision of postgraduate courses of instruction in each chief city visited by us. These are said to be a new development, not seen in pre-Revolution Russia. The extent to which this postgraduate instruction is utilized varies much in different parts of Russia. In one city we were told that while normally it is obligatory for every doctor each second or third year to have four months of postgraduate medical teaching, this has not so far been generally practicable, owing to dearth of doctors. In one or two cities we were informed that it was generally enforced; in others, that the scarcity of doctors had prevented this. Rural doctors are specially encouraged to take these courses; their expenses are paid during the course, as are those of other doctors.

There is no complete provision, as yet, for the special training of sanitary officers, or for insisting on their possessing a satisfactory diploma before they undertake public health supervision and control. Some special training is given to medical men for public health work at the Institute of Health, Moscow, which we discussed with Professor Landis, its head. This institute is concerned both with the teaching of hygiene and research in that field. Hitherto graduation at the institute is not made a condition of official appointments; but such graduates have preference for important posts. Doctors appointed to administrative posts are sent to the institute for instruction and training.

The Medical Care of the Sick

AN ESSENTIAL difference between the practice of medicine in the U.S.S.R. and in capitalist countries is that every doctor is a State official, and in most instances is exclusively so. A few doctors, especially older doctors, still retain some private individual practice; but their number is diminishing, and practically all the younger doctors are exclusively officials of the State.

Each State doctor is expected to work six or six and one half hours each working day for the State. Every fifth day he has complete cessation from work. If he is a specialist, e.g., in Roentgen ray [X-ray] or radium [radiation] work, he may have only a four-hour day. Like every worker, he has at least two weeks' holiday annually; and he may receive longer leave if he is a specialist or for special reasons. The triennial longer leave of the rural doctor has already been mentioned.

Medical salaries are paid by the Government, being graduated according to work and duration of service. In some instances an increase of to per cent in salary is given annually; or of 20 per cent after service in special institutions. Some indication of relative salaries is given on page 250. Earnings may be increased by working for two or even more institutions daily. Only in the event of a calamity can a doctor be transferred to another district without his consent. Many doctors are still overworked; and although at the public clinics special precautions are enforced to prevent hasty consultations, this overwork must tend to lower the quality .of medical care.

In Russia, before the Revolution, there were approximately 26,000 physicians. In 1931, according to Dr. Roubakine, the total number of physicians was about 76,000.

For ordinary illness the treatment is undertaken: (a), in the homes of the sick (in small part), and much more (b) at factories or other institutions where they work, and (c) in dispensaries and polyclinics. For more serious disease, treatment is given to a preponderant extent in hospitals and other residential institutions; while for convalescent patients, and for others with a view to warding off illness, a vast amount of provision is made in rest homes of various kinds. In this chapter domiciliary treatment and other forms of medical treatment which cannot be discussed clearly in separation from home treatment are considered.

It is noteworthy that Russian doctors seldom attend mothers in childbirth in the cases which are still confined in their homes. Midwives and, much oftener in rural districts, unskilled women are employed, unless or until some serious complication arises.

As already stated, very few doctors now have private practice, independent of State arrangements. Those who have are chiefly physicians who have acquired special reputations.

In the following pages we give the reader the substance of a series of interviews, with practically no change in the notes taken at the respective interviews. Although this method involves repeated discussion of the same topics, we hope that this will be compensated for by the documentary directness gained for the reader.

Interview with Commissar Vladimirsky

Dr. Vladimirsky,. Commissar of Health of the R.S.F.S.R., informed us that legally any physician can engage in private practice, the tendency of three years ago to forbid this having ceased. For many doctors, as those employed in hospitals and public health physicians, private practice is impracticable; and hospital physicians are prohibited from treating at home privately their patients treated in hospitals.

In villages private practitioners are almost nonexistent. Social help is free; and the district doctor is so fully occupied that there is no time for private work.

In cities also the average physician, being fully occupied with official duties, does not engage in private practice, but consultants and a few others do. In fact 90 per cent of Russian physicians work in State institutions, said Commissar Vladimirsky, and do not practise medicine privately.

Even before the Revolution it was usual for district physicians to treat most of the people without fees. In this respect the Commissar contrasted his experience during three years in which he worked medically in a French village, with corresponding work in a Russian village. In the former, patients would be amazed if they were not charged; in the latter, they would be amazed if they were charged!

Second Interview with Commissar Fladimirsky

In this interview the Commissar emphasized the fact that medical aid was given without payment to all workers and peasants, who form the bulk of the population. For the rest the desire is to serve all gratuitously, but hitherto they were not included in the general service, the first call being for the workers. Thus in a dispensary an intellectual will have to wait until all the workers have been treated.

For venereal disease, this being a social menace, no such distinction is made, and no charges are ever made; and the same applies to various forms of emergency treatment. Similarly attendance in childbirth is free to all, irrespective of social position.

An Interview with a Writer

A writer of English books on Russia, who has lived many years in that country, stressed the fact that the element of profit has been almost entirely eliminated from national and private affairs. A few private doctors continue, but young graduates do not go into private practice. The same remark applies to dentists. New dentures are supplied free for workers. In villages there is no private medical practice, and in some cities it has entirely disappeared.

The chief difficulty is the shortage of physicians. The number of doctors is increasing, but quality is not increasing so fast as the quantity.

Domiciliary medical practice in Russia is not carried on independently of institutional practice in residential institutions and at polyclinics. The only exception is formed by the rare instances in which patients afford a private physician.

In most instances, domiciliary medical visits are almost entirely limited to emergencies and restricted to patients who cannot attend at a dispensary.

An Interview with the Commissar of Health in Kazan

The people of Kazan are medically attended under a general dispensary system, the city being divided into four dispensary districts each serving some forty to fifty thousand people.

Although private medical treatment is allowed, it is rapidly disappearing and probably does not now apply to 1o per cent of the population. Most doctors, of whom there are about thirty in Kazan, are Government officials. In the Tartar republic outside Kazan, doctors number about seven hundred, and there is no private medical practice.

Every sick person in Kazan can send for a doctor from the polyclinic of his district to see him at home, but there appear to be strict rules to minimize unnecessary home calls. These can be made by telephone. The doctors of the polyclinic make home visits.

In four polyclinics in the town free treatment is given, and in five a small payment is required. In the latter, two to four rubles may be paid per consultation. These are under the control of the People's Commissariat or the Red Cross organization.

Summary of Interviews in Rostov

At Rostovon-Don we were informed by a member of VOKS and by others that a few private doctors remain, chiefly those who have acquired special reputations.

Most patients in the town are attended from ambulatoria (dispensaries) and polyclinics. The distinction between these two is not very definite; but broadly the lastnamed are more fully equipped in the special departments of medicine, while ordinary cases go to the ambulatorium.

A patient can choose his own doctor at the medical centre for his district; and he can subsequently change his doctor if reasonable cause is shown. There is the right to complain to the head of the institution or to the Commissariat of Health. Similarly a patient can refuse to be operated on by a particular surgeon if another is available.

Patients who are very ill can be seen at home by the dispensary doctor for that district, or they are taken in an ambulance to the ambulatorium or direct to a hospital. Each doctor attends at fixed hours at the dispensary, but severe cases are seen at home at once. A fine is inflicted if an ambulance is demanded unnecessarily. The application for a doctor at home cannot be for a special doctor, but only for the doctor allotted to that district.

All the doctors are overworked ; but to avoid hasty work, the number of patients a doctor may see in a given time at the dispensary is limited to six in an hour; and in the registration department the number allotted to him is limited to this extent. Often the doctors work overtime.

From the ambulatorium cases may be referred to the polyclinic for special consultations, or may be admitted into a hospital.

Each patient admitted into a hospital takes his written report with him and brings back from the hospital a continued statement of his case. Hospital doctors do not give the certificates needed for social insurance; this is done by the doctor of the ambulatorium when attendance under him is resumed.

A doctor may undertake several tasks and thus increase his income. He nearly always undertakes popular hygienic lecturing, and he may engage in private practice if any is forthcoming. Not infrequently he helps in a hospital in the morning and in an ambulatorium in the evening.

An Interview with the Commissar of Health of Georgia

Dr. Kuchaidze, Commissar of Health of Georgia, informed us that medical care in that republic is arranged similarly to that in other parts of Russia.

Every doctor is attached to some medical institution, all of which are State institutions. Special doctors are attached to ambulatoria and polyclinics, to hospitals, and to each factory or collective farm.

Every official doctor can also take private paying patients, outside his official work. But private is almost entirely superseded by the public practice of medicine.

The workers always take precedence in any provision that is made. All medical treatment at publicly provided centres is free; but patients desiring it can resort to private doctors and pay them out of their personal funds. This is seldom done, though older and distinguished physicians still have some private practice; and no objection is raised to any official physician receiving private patients outside official hours.

Dr. Kuchaidze himself was formerly a chief physician at the Georgian mineral-water cure places, and his opinion regarding the comparison between the past and present in Russian medicine, similar to what we heard from many others, may be placed on record at this point.

Formerly there were almost no private doctors for the very poor, and patients had to pay almost impossible fees. Hospitals for the poor were few and most inadequate. Even in hospitals the treatment they received in the main was "general practitioner treatment"; they had no chance of being treated in the valuable cure places of Georgia. Now the number of doctors has been multiplied, and a still larger number are being trained. The former hospitals for the rich are now devoted primarily to the workers, and their accommodation has been greatly increased. New hospitals for general and special diseases have been built; and the poorest in the land have the advantage, in every department of medicine, of skilled aid in need. The cure places, furthermore, are used by the entire population, and patients from every part of Russia are sent to them. Thus efficiency and universality of medical aid have succeeded a system under which medical care could be secured only by the wealthy, or by the fortunate few among the workers who could gain admission to a good hospital.

The doubt was raised as to whether under the new regime enterprise and energy of work would not be lowered, now that the incentive of high professional earnings had disappeared. This, we were told, was actively debated among doctors "after the October Revolution," and most of the better physicians feared such a result. Now, after fifteen years of planning and execution of better medical work, it could be definitely said that the fears then entertained were groundless, and that the younger doctors in all respects display greater efficiency and zeal than was shown in the past. They now work in teams, in close cooperation with other doctors, and their work is scientific in character.

The doctors working in villages, in whom all-round competence is required, have their salaries increased after three years of work, and their children are entitled to all the privileges of workers' children. The rule of giving a three-months postgraduate course of instruction to all doctors after three years of clinical work is carried out for only half the doctors. The high tempo of medical changes has made it impossible to go further than this at present.

Returning now to our general discussion, we take up the subject of costs to patients. Most workers and their families receive free medical treatment as insured persons, but the funds for this treatment do not come from insurance funds, but from general taxation; and, as previously stated, medical care is administered, like other branches of public health work, by the Commissariats of Health for each constituent republic and its subordinate divisions and by the local Boards of Health.

All trade unionists, all insured persons, all unemployed persons and their dependents, are entitled to free medical treatment, as are also students and the incapacitated. Persons in the "deprived class" are not included in the scheme of free medical service, though as already stated they are not cut off from treatment.

Published statements could be quoted as to workers who were dissatisfied with the medical service of the State. The dissatisfied patients objected to the many formalities before they were allowed to see a doctor at the public clinic, and to the fact that the intervals before they saw him again were excessive. Other complaints have been of lack of hospital beds when needed, and that medical attendance at home is unsatisfactory.

In our own observations we discovered no evidence of the earlier conditions which led to complaints. Such complaints are heard in other countries, including England, in which the insurance medical service is, as a whole, fairly satisfactory.

The crowding and insanitary housing which prevail render domiciliary treatment very difficult; and actual medical care at home is limited in extent. The private medical practitioner having almost disappeared, the work of the district medical officer for each district consists in large measure in arranging the details of institutional (resident or nonresident) treatment for the patient. As already stated, nearly all confinements in towns occur in hospitals, and expectant mothers, their infants and children receive treatment at various clinics, as do also workers who are not too ill to attend them.

Any worker requiring a home visit by a doctor makes application personally or by telephone at the nearest station and receives home treatment free of charge. A physician attends from this station and certifies the illness if it is incapacitating, thus enabling the patient to obtain his full wages for a maximum period of ten days dating from the beginning of the illness. Further financial benefit can be given only after a medical consultation.

It is officially stated that "in all cases of life and death an emergency service is rendered to all citizens free of charge." The word "citizen" does not appear to be defined.

In some places the arrangements for domiciliary medical attendance continue to be imperfect. Thus one observer informed us that long waiting for a doctor sometimes occurred. At Kazan there are strict rules tominimize unnecessary home visits, which, when needed, are made by the doctors of the polyclinic.

At Kharkov we met a physicianrara aviswhose earnings from private and public practice were about equal; but he informed us that most medical practice is official and gratuitous. In the Ukraine many appeals from the first medical opinion occur.

Broadly it may be stated that the trend is to minimize the domiciliary treatment of illness; and in view of housing conditions this is wise, as is also the universal institutional care of parturition in cities. Something is lost in not securing the individual care and continuous treatment of each family by one doctor, but much is gained in the greater completeness of treatment and, when necessary, the specialized treatment which is obtained in clinics and hospitals.

Factory Medicine

Much work is being done in factory hygiene. Formerly the working day was eight hours, but the sevenhour day is being gradually introduced in all Soviet plants and factories; and a sixhour day is in force for all underground workers and for minors. A day's rest is given regularly on the fifth or sixth day, according to the working week of the plant. Every employee is entitled to twelve working days' annual vacation. This is increased to twentyfour days for trades injurious to health; and minors under eighteen years receive a month's leave.

All wage and salary earners are insured, trade unions controlling the organization for insurance. Seasonal workers come only partially under the insurance scheme; and according to a recent regulation the amount of nonmedical benefits under insurance is being made conditional on the length of time the worker has worked for wages. It is also intended (we were informed), in view of the excessive mobility or "turnover" of labor, to make the amount of insurance benefits depend in part on the length of stay in a single plant.

Some beginning has been made of systematic supervision of workers engaged in injurious trades; and with a view to prophylactic measures a periodical examination has been introduced for those handling foodstuffs, and for workers in lead, mercury, rubber, tobacco, and in some other industries.

Factory schools may be regarded as a part of Soviet factory hygiene. Here, from the age of fourteen, school life is continued for three years, combined with four hours' daily work in a shop or factory. This course is intended especially for the training of skilled workers.

Medical factory organization at its best was seen by us in Selmashstroy, the agricultural machine factory at Rostovon-Don, in which, in eighteen shops, some 18,000 workers are employed. There is a special doctor for each shop, who gives first aid in emergencies, supervises the hygiene of workers, and keeps daily records of the number of workers who are absentees and who are under dispensary treatment. This is shown on a graph in each shop. Those ill are visited by a fellowworker of the same shop. The means of exposing malingering and slacking have been discussed on page 104. Of malingering under the Soviet medical system, there is said to be little or none. If any complaint is made as to medical care, a hearing is given before a Medical Control Committee, on which sit two or three doctors appointed by the Commissar of Health, a worker sitting as chairman. This committee decides as to patients needing treatment at a rest home or a sanatorium.

A really important part of factory hygiene is the publicity given to the toper. Over his working bench or loom is a statement of his offence, possibly with a derisive picture or figure attached.

Factory workers when ill may be seen by a doctor at home if too ill to go elsewhere. Ordinarily they are sent by the factory doctor to the dispensary of the district in which they live; or they may be sent directly to a specialist in a polyclinic, to a tuberculosis or venereal disease clinic, or to special physical or other treatment centres. They may be treated in a night sanatorium while continuing their daily work; or they may be admitted from a nonresidential clinic into a general or special hospital, or, at the discretion of the factory doctor, sent direct to one of these.

In addition, the factory has, besides ordinary dining rooms for the workers, a special dining room where meals prescribed by the doctor can be given to employees who are under medical care.

It should be added that each worker when he begins his work at a factory is inoculated against smallpox and typhoid. When sent to his particular shop he becomes a member of a brigade which is medically examined at intervals. There is a commission of doctors for this purpose.

The work of the factory creche has already been described. It has great importance as bearing on the mother's maintenance of health and fitness.

At Kharkov we expressed doubt as to whether the ready access of workers to the specialists at its splendid polyclinics did not lead to their excessive use. The medical administrators of the Health Commissariat stated that only occasional difficulty arose from this. Each doctor in the dispensary and polyclinic is related to a special district of the city, and thus a local organization is created which takes the place of the American or British private practitioner, but with free and full use of expert medical aid. It was further contended that while the private doctor can do little to better the conditions of a worker's life, it is the duty of the Russian doctor to secure not only the personal but also the collective and environmental treatment of each patient. In fact the Soviet claim is that the dispensary and polyclinic in association with the factory and the hospital are securing the complete unification of medical work, so far as workers are concerned.

Treatment in Residential and Nonresidential Institutions

NEXT in significance to the fact that every doctor in Soviet Russia is a State official, is a further exceptionally developed feature of Soviet Medicine, namely, the concentration of medical practice in dispensaries, poly-clinics, and hospitals, in which the individual doctor is never an isolated unit, but is in systematic touch with every branch of medicine.

Dispensaries and Polyclinics

In this unified medical organization the next link after the home doctor and the factory doctor is constituted by dispensaries and polyclinics. There is no sharp line of demarcation between these, but usually each dispensary serves the population of a particular district. It is claimed that, by the partial and almost complete "dispensarization" of medical practice, supervision is being exercised over the healthy as well as the sick persons in a district, including not only workers and their families, but the entire population; and that thus the integration of preventive and curative medicine for the community is being reached.

Kazan, with a population of 175,000, has four free dispensaries and five at which some payment is made. These are linked up with a large university clinic.

In Samara, with a population of 172,000, there is a polyclinic in each of its seven districts with additional dispensaries. In Saratov the organization was similar.

In Rostovon-Don we found, as elsewhere, that a doctor at the dispensary is allowed to see only six patients in an hour, even though this often necessitates his working overtime.

In Rostov we inspected The Unitary Dispensary, one of the finest in Russia. It is further described in this chapter, but we may here note one rule of this dispensary, to the effect that every patient treated at the institution must be exhaustively overhauled, passing through all its departments. Furthermore, a nurse visits each patient's home to ascertain domestic and working conditions of life and to arrange for any steps needed for their improvement. Thus there is working in this instanceto some extent in other polyclinicsthat complete integration between medicine on its medical and medicine on its social side which gives the best promise of satisfactory treatment and undelayed return to health and work.

Kharkov has a magnificent polyclinic. Every special branch of medicine is provided for under the same general control, and thus each patient can receive any special skill his case may require. (See also page 238.)

In Leningrad there are eight large polyclinics. We inspected one of them (see page 235), and the remaining seven were stated to be similar to it. This was a most elaborate establishment like those seen in Kharkov and Rostov.

Nonresident institutional treatment for tuberculosis and for venereal diseases and for mothers and their young children may be given at special institutions or may form part of the various polyclinics. The latter arrangement is the most satisfactory from the point of view of securing complete cooperation between the physicians attached to various special branches of medicine. It has already been stated that most confinements in cities occur in maternity hospitals or in maternity wings of general hospitals.

The special arrangements for treating tuberculosis and venereal diseases are described in succeeding chapters.

Domiciliary and factory treatment are linked up with dispensaries and polyclinics, and the chain of medical service is completed in the official hospitals, night, day, and completely residential sanatoria, rest homes, and various forms of physical therapy.

Hospitals

We made many visits to hospitals, some of which are described below. In the cities visited by us, the general standard of hospital treatment appeared to us to be good. We found new hospitals, with the newest and best appliances, and without any evidence of the relative poverty which one would expect in Russia under present circumstances.

Sanatoria and Rest Homes

The same remark applies to convalescent institutions visited by us, though in these there was sometimes a closer approximation of beds than is desirable. But the astonishing fact is the vast provision of convalescent home and sanatorium accommodation, probably larger in proportion to population than in any other civilized country. This has been facilitated by the previous confiscation of the palaces and palatial homes of pre-Revolution Russia. But the wealth of convalescent accommodation now available is a very hopeful feature in the health prospects of the Russians.

A Polyclinic in Leningrad

The large polyclinic known as the Ambulatorium for Volodarski District in Leningrad includes all branches of medicine and also a training school for nurses.

All workers in the district are treated free. They apply direct to the polyclinic and are not sent by a district doctor. From the clinic the patient is transferred to hospital if this is necessary. There is close cooperation with other districts, and the same doctor sees the patient at the clinic throughout.

One hundred and twentyeight doctors are employed at this polyclinic. These doctors go to the homes of the people when this is necessary. There are no district doctors in the ordinary sense, the patient being expected to go to the doctor at the polyclinic unless he is unable to walk, or there is some other physical reason preventing his attendance. In this case a doctor from the clinic visits him at home.

For industrial purposes the main difficulty, namely, that of overcertification, has disappeared, because of the independent position of the doctor.

The Unitary Dispensary at Rostov

The best example of polyclinic organization and equipment was seen in Rostovon-Don, at the dispensary. The institution so called is the chief polyclinic in the city, admirably equipped in all special departments of medicine, and with a staff in each department which includes the university professors of medicine. Medical students are trained here and are required also to attend at ambulatoria.

There are four dispensaries or ambulatoria attached to the polyclinic, in which ordinary cases are treated. There are also night sanatoria for patients with stomachic diseases, where the patients sleep, are given appropriate food, and from which they go to their daily work. There is a similar institution for nervous cases.

There is a special venereal disease centre for treatment, with a branch at the polyclinic.

Recently a department has been opened for the treatment of alcoholics, with arrangements for antialcoholic addresses, in the giving of which the People's Committee help.

Dr. Rubinstein, the director of The Unitary Dispensary, explained the working of each section and subsequently presented us with a set of the interesting educational diagrams and cartoons which were found in the waiting rooms and in some consulting rooms.

At this polyclinic about 1,800 patients are treated daily. All diseases are treated, including formerly tuberculosis; but for this disease it has been found more convenient to use the tuberculosis sections of the clinic chiefly for consultation in difficult cases sent from other institutions.

All the documents relating to the patient are collected and kept. Thus a tuberculous patient is treated with complete medical knowledge of his condition. During the last three years, we were told, a Tuberculosis Care Committee had been meeting every ten days. In this committee are included the patient's doctor at the polyclinic, and the doctor from the ambulatorium who knows the conditions of his daily work. The future conditions of the patient's working are determined, the deficiency in his wage created by his partial inability being paid by the insurance bureau. He remains under the supervision of the ambulatorium doctor and of the doctor at the factory where he works. Workers take great interest in this branch of health work and in the committees of workmen concerned in it.

Every child patient is examined with a fluoroscope, and in selected cases an X-ray photograph is preserved. Contacts are examined.

The polyclinic serves a section of the city having a population of some 25,000. Its area is divided into twelve subdistricts, each of which has a doctor allotted to it. He has charge of about 2,100 people. He may live where he likes, not necessarily in the district allotted to him. He is an employee of the dispensary of his district and spends part of each day working there. He may also be the school doctor for the school in his subdistrict. He has sanitary supervision of those living in his area, and gives addresses on health problems to the people.

But this district doctor, although he may be described as the family doctor for those living in his area, is not in sole possession of the field. The children attend a Children's Centre for advice and treatment, and the children's doctor from the centre visits them when visits are called for.

The Third Labor Polyclinic, in Kharkov

In Kharkov we visited The Third Labor Polyclinic, a magnificent new building. In the following brief descriion of it we have utilized a handsome volume giving full details, issued jointly by the People's Commissar of Health of the Ukrainian Socialist Soviet Republic and the chairman of the City Soviet. The prefatory statement of this volume is significant. It claims that "Soviet medicine is social and prophylactic in character"; and that "like the whole State, Soviet medicine is built up and directed by the workers themselves."

This particular polyclinic is situated in a workers' district and is intended primarily to give gratuitous medical aid in the factories of Kharkov.

The polyclinic is a great multiform dispensary, serving some 40,000 workers and their families. It is controlled by the Department of Health of the Kharkov City Soviet and is supported out of insurance funds. . The new building consists of four floors. On the ground floor are placed the Roentgen diagnostic and therapeutic offices, the registry, committee room for employees, their dining hall, and various other offices.

The first floor comprises surgical, urological, and orthopedic departments, a chemical and bacteriological laboratory, a dispensary for children under four years old, offices for the physicians, for inquiry, and for receion.

The second floor has a therapeutic department and a special department for the treatment of workers in dangerous industries, a department for consultations on physical culture, a psychoneurological dispensary, a dispensary for antinarcotic treatment, a dispensary for prenatal and gynecological care and for consultation on questions of sex and marriage, a department for electric and lightradiating treatments, and a hall for corrective gymnastics.

On the third floor is the ophthalmic department and the department for ear, nose, and throat diseases, an inhalatorium, a sanitary consultation, a dental department, and a dispensary for young children.

There are in addition four old pavilions, a tuberculosis dispensary, a venereological department, a dietetic dispensary, a milkfood kitchen, a dietetic dining hall, a pharmacy, and diagnostic wards with ninety beds and physiotherapeutic wards with sixty beds.

The above enumeration gives only an imperfect idea of the elaboration and completeness of the arrangements for every branch of medical or hygienic need; nor does it express the completeness of the arrangements for cooperation between these various special departments for the benefit of patients.

The Third Labor Polyclinic is admirably equipped for research as well as for clinical work; and in order to make use of the valuable material for research passing through the polyclinic, an institute for special researches is maintained there.

Near this new polyclinic are the immense new Tractor Works employing some 16,000 workers. This plant has a separate but similar polyclinic and a hospital of its own with four hundred beds.

The Therapeutic Hospital at Rostov

The Therapeutic Hospital at Rostov is a general hospital of 1,200 beds, having many separate departments, including provisions for hydropathic, X-ray treatment for cancer, thermotherapy, etc. The hospital has its own power station supplying hot water and steam to every room. The ambulance for the district in which this splendid hospital is situated is lodged in the hospital grounds.

At the time of our visit fiftysix of the eightyeight children in the hospital were accompanied by their mothers.

If a child develops a cough, a glass screen is at once placed on each side of its bed.

Our attention was drawn to the experience that the children, in the cubicles are not fretful. For convalescent children there is a charming playroom and a balcony leading from this.

Preschool children and school children are sent to this hospital for special examination in its tuberculosis department. The fluoroscope is employed in each case, but as a rule X-ray photographs are not taken.

Open cases of tuberculosis are sent to a special hospital.

The doors of the part of the hospital in which seic cases are treated are kept locked to ensure complete separation from the rest of the hospital.

The Hospital for Railway Employees in Tiflis

At Tiflis we visited the Hospital for Railway Employees. This is a splendidly equipped institution with five hundred beds, intended for all grades of railway employees in the State. Its existence shows that within the State system of medical attendance special arrangements can be made for those engaged in a particular occupation. Evidently if this separate provision of hospitals according to occupation were to become general there might be danger of redundant effort and of rivalry in standard of provision.

This particular hospital was splendidly organized. We were especially interested in its obstetric and gynecological divisions. The staff for these two divisions is kept strictly separate. In the obstetric division there are special rooms for confinement. Then the patients are put in a general ward, and the infants in another ward in strict isolation. Each infant is brought to its mother for breastfeeding and then taken back to the infants' ward. Any febrile patient is at once isolated.

The patients confined in this institution have previously attended at a prenatal consultation centre, and the record of their condition comes with them to the hospital. Women are brought by ambulance at the beginning of labor. When complications indicate the need, they are sent to hospital before labor begins.

The hospital midwife delivers each mother, but a doctor supervises.

Integration of Institutional and Noninstitutional Treatment

The integration of the practice of medicine within and without institutions may be illustrated by the experience related to us by an American citizen, formerly secretary of a public welfare society in a New York county, who for seven weeks had been an instructor in English under the Soviet Government in Moscow. He fell ill with tonsillitis, followed by acute rheumatism and pleurisy. As a Soviet worker he was attended at home by the Soviet doctor of his district. This district doctor was expected to be familiar with the sanitary conditions as well as the personal welfare of his patients. The American's progress not being satisfactory, he was sent to a hospital, and there he was treated in the general ward as a worker, although he had been a worker for only seven weeks.

He found the treatment in the hospital satisfactory, and, apart from the quality of the food, general arrangements were good. Nursing was fairly good. He was in the hospital for six weeks, and the feature of his treatment was that his case, like others, was regarded as a consilium, i.e., a subject for expert consultations, every collateral medical help being invoked. The hospital treatment was gratuitous.

After leaving the hospital he was under the care of the district doctor again for a month; but specialist aid was still available when circumstances called for it.

He was then sent for protracted treatment at a sanatorium on the Russian Riviera, where the charge was 222 rubles for a month's residential treatment. It appears that all workmen must pay for this special sanatorium treatment, the trade union being expected to defray the cost when necessary.

The American's relation to the system of state insurance is interesting. When the district doctor first diagnosed his illness, he filled in a certificate which authorized him to obtain monetary aid to a limit of fifty rubles for emergency expenses. He was ill altogether for ten weeks, and during this time was paid half his salary as a teacher. Had he been a member of a trade union he would, he stated, have received his full salary.

He considers that he was treated exactly as a Russian worker would have been, and that his nationality did not give him special attention. The case is an example of almost complete integration of medicine, with an almost ideal absence of redundance or deficiency of service, and with exact linking up of domiciliary and institutional, including expert, services.

We were informed that complete strangers, including foreigners, would be admitted to hospitals without distinction, except that when in any community skilled services are not adequate, the peasant and worker must be served first, all others being served to the extent possible. This is defended on the ground that workers are producers and must always take first place.

Further Data on Institutions

In Russia the care of the lyingin woman is almost universally arranged in special hospitals in its cities, and largely also in rural districts.

The rapidly increasing number of beds in hospitals is shown below. In institutional treatment must be included the outpatient treatment given in factories, dispensaries, and the various general and special clinics and polyclinics. Patients are expected to go to these for treatment, and are only treated at home when they are unable to travel or when traveling would be detrimental.

The following statistics indicating the increasing amount of institutional treatment and of other expert facilities for diagnosis and treatment are derived from the Soviet Culture Review, Nos. 7-9, 1932.

NUMBER OF HOSPITAL BEDS IN THE R.S.F.S.R.
	1927-8	1931*	1932*
In towns	111,095	139,594	162,366
In villages	43,590	67,908	82,009

*Figures for 1931 are preliminary and those for 1932 estimated.

In the same period the number of rural medical districts in the R.S.F.S.R. has increased from 4,667 to 7,962.

NUMBER OF BEDS IN SANATORIA IN THE R.S.F.S.R., NOT INCLUDING THOSE OF SOCIAL INSURANCE AND OTHER DEPARTMENTS
	1927-8	1931	1932
All-Union	11,277	18,250	21,431
Local	8,887	14,763	17,580

These figures are rightly quoted as triumphs of the Five Year Plan, as are also the following figures, which deal with special public health organization:

SANITARY PROVISIONS
	1927-8	1931	1932
Hospital beds for infectious diseases	19,500	32,650	40,554
Laboratories	189	357	575
Disinfection points	56	243	592
Disinfection stations	13	49	68
Sanitary doctors	1,289	1,989	3,846

We regret that in the above tables figures giving statistical comparison with the pre-Revolution period are absent. In the following table is given a comparison between 1913 and 1926 or 1927 for the R.S.F.S.R.:

	1913	1926	1927
Bacteriological institutes	12		37
Bacteriological laboratories	29		189
Malaria stations			102
Pasteur stations	19		50
Tuberculosis dispensaries	A few		248
Venereal disease dispensaries			159
"   "   stations		144
Consultations for children in towns	6	461
"   "   " villages	7	268
No. of beds in lyingin homes	5,280	12,910
No. of beds in hospitals (not including military)	146,381	206,414*

*There appears to be a discrepancy between this total for 1926 and the total of beds in towns and villages for 1927-28 in the table on page 244.

	1913	1926	1927
Stations for emergency help	4	99
Firstaid stations	A few		1,064
Stations for home attendance	16	457
Physiotherapeutic institutions	4	94
Village medical stations	2,732	4,397

In another part of the same medical report the following table is given which further shows the rapid progress of medical provisions when 1927-8 is compared with 1932. In each instance the provision in the earlier year is given as 100 and that in 1932 in proportion to this.

RELATIVE INCREASE IN PROVISION IN 1932 (Provision in 1927-28 under each heading being taken as = 100)
	In the Districts and Regions of the R.S.F.S.R.	In National Republics
Hospital beds in towns	144	174
Doctors' receptions in towns	212	270
Medical stations in towns	338	650
Nursery beds in towns	673	782
Hospital beds in villages	7	196
Ambulatories in villages	167	188
Beds in permanent creches in villages	12,935	15,950

Care of Tuberculosis-Sanatoria and Allied Institutions

NOTHING strikes the medical visitor to the U.S.S.R. more than the almost lavish provision of rest homes, convalescent homes, and sanatoria. These are largely concerned with the care of tuberculous patients, though they have been widely extended and are more generally utilized.

Dealing first with tuberculosis, the following official figures are important, as indicating the progress already made in the two chief cities of Russia:

LUNG TUBERCULOSIS-DEATH RATE PER 100,000
	Moscow	Leningrad
1914	280	300
1931	120	130

The control of tuberculosis is regulated by a decree concerning Tuberculosis Centres ( June 15, 1929). It is laid down that these centres are social prophylactic institutes for carrying out all antituberculosis measures in the rural districts; and that these centres are organized in the district hospitals. Each has its own definite area of action; and it is laid down that precedence in their organization shall be given where there is a high incidence of tuberculosis, or there are many occupations away from home, or there are State and collective farms. It is also enjoined that working and living conditions favoring tuberculosis shall be specially investigated, that there shall be close cooperation with the area medical officers of health and with maternity and child welfare institutions in the area. The centres are to concern themselves with the giving of prophylactic and social aid to every tuberculous patient, and to select patients to be sent to the various health institutes; and they are required to organize tuberculosis exhibitions or tuberculosis sections in general health exhibitions. For their laboratory work the tuberculosis centres use the hospital of the medical district.

We had many opportunities of seeing to what extent the excellent program set out above is being carried out, and some of our observations are included in the accounts of interviews and visits given below.

In several cities we found that advanced work was being done in the diagnosis of tuberculosis, including the use of the fluoroscope and X-ray. The social arrangements for tuberculous patients were also good, including continued medical supervision after return to work. Furthermore, arrangements are made by the insurance bureau to pay the worker any deficiency in the remuneration for his work caused by his partial incapacity.

Many institutions had divisions for graduated heliotherapy. Children were treated in separate parts of the tuberculosis dispensaries. In Tiflis, for example, all children sent to summer rest places and sanatoria have to pass through the Tuberculosis Institute.

How Tuberculosis Control Is Organized in the R.S.F.S.R.

The Commissar of Health of the R.S.F.S.R. gave us figures which illustrate the magnitude of official provision for tuberculosis. There are now 24 tuberculosis dispensaries in Moscow with 226 fulltime physicians. In 1931, 776,000 patients were treated, 90,000 of whom came for the first time. Only 30,000 out of the lastnamed number proved to be tuberculous. All the chief tuberculosis physicians work in these dispensaries.

At the Central Tuberculosis Institute for the R.S.F.S.R. we were received by Dr. Neslin. He described the network of dispensaries in Moscow, each of which has a certain number of beds, with access to further beds in a sanatorium or hospital.

In tuberculosis dispensaries various forms of special treatment are given, including the production of pneumothorax. The first choice in securing institutional treatment is always given to workers. Contacts are watched, especially children, and examinations made every three to six months; for children tuberculin tests and X-rays are employed.

For "open" tuberculosis in towns there is institutional treatment for approximately too per cent of the cases. Before the Revolution there were 350 beds for tuberculosis in the whole of Russia, now 35,000, and in addition some 12,000 beds in day sanatoria and night sanatoria.

These day and night sanatoria are usually attached to a dispensary, and they give provision for many patients who may be working in one of the three or even four shifts of the Soviet factory work. No charge is made for treatment, and the same applies for sanatorium treatment. Most patients have been in a sanatorium.

In the factory dining rooms special diets are arranged for consumives. Very rarely is objection taken by a patient with "open" tuberculosis to removal to a hospital.

All the institutional tuberculosis physicians are wholetime officers. Only a few patients are treated by private physicians, because the tuberculosis dispensary is much better equipped than a private doctor.

There is a trade union comprising doctors and nurses and other members of the tuberculosis staff. As we have noted, the trade unions in Russia differ from those of the American or British type which are based on the

specific craft of the members; in Russia the rule is "one undertaking, one union."

Occasional collisions may arise between the expert and the administrative side of an institution; but generally trade unions facilitate the work of the Soviet organization.

The physician, whether a general or tuberculosis physician, receives a salary which is about two and a half times that of the nurse; but it is less than that of a professional engineer, and not much above that of the teacher. Special salaries are given to exceptional men; but Dr. Neslin explained that this does not raise the problem of capitalism; for in Russia the person who saves money cannot get control over the means of production.

Nursing of tuberculous patients until recently was specialized; now it is combined with that of other patients.

Although already the number of sanatorium beds is adequate for "open" cases, this is not regarded as sufficient. Although tuberculosis is being "liquidated," Dr. Neslin expressed the view that for more rapid reduction of this disease the number of beds now available needs to be increased.

The Institutes in Samara and Tiflis

At Samara, as elsewhere, we found that tuberculosis is considered specially in relation to industrial conditions. There are six sanatoria for Samara. In some of them treatment by koumiss is practiced. During the last three years the number of tuberculous patients has been halved. There is a night sanatorium at which patients are kept for two months while going to their work daily.

At Tiflis we inspected the splendid new Tuberculosis Institute. Here we visited a class of secondyear students at the medical school connected with the institute. The instruction is given in the Georgian, not the Russian, language. We observed that the students varied considerably in age, as they do in other educational institutions in Russia.

Sometimes tuberculous patients come to the Tiflis Institute independently; but mostly they are referred from the ambulatoria and factories. Children are treated in a part of the institute having a separate entrance and waiting room. All children sent to summer rest places and sanatoria have to be examined at this institution. The other tuberculosis institutions in Georgia are closely related to this central institute.

Attached to the institute is a division for graduated heliotherapy; and a separate block is being built which will be used as a day sanatorium for adult patients.

All school children are screened, and an X-ray photograph is taken in suspicious cases.

A Night Sanatorium in Moscow

We visited one of ten night sanatoria in Moscow. This institution is not intended for any special disease, but for workers needing rest, e.g., cases of neurasthenia, anmmia, etc. Patients are sent commonly by factory doctors.

The institution has accommodation for 39 men or for 36 women. Patients come each day at 4:00 to 5:30 p.m., have a bath, and a change of clothes, are examined by a doctor, and leave the institution next morning. Single rooms are provided.

A Preventorium for Children in Kharkov

At Kharkov we visited a sanatorium or preventorium for specially selected children. The selection is made in February and March; the work of the sanatorium begins in May.

During the summer two groups of children are received, each group remaining for forty days. During their stay at the sanatorium the children are periodically examined by medical experts, and some dental and other treatment is given. There are teachers for physical sports, and civic education is given to the children for twenty minutes each day. No payments are received from parents.

There are similar sanatoria throughout the Ukraine, so we were informed. They were initiated nine years ago and form a distinctive feature of the public health administrative machinery in the Ukrainian S.S.R.

Factories are a chief centre of antituberculosis effort. In them instruction is given on precautionary measures against its spread; and in every factory the Workers' Committee discusses keenly the question of who shall be sent to available institutions. We can agree with the opinion expressed to us by a distinguished university professor in Leningrad that perhaps the greatest boon arising from the Revolution is the wide utilization of sanatoria and cure places for the workers. These scarcely existed before the Revolution. Now each worker has a chance to go annually for a fortnight's rest cure at the public cost.

Rest Homes and Sanatoria

The number of the various rest homes and sanatoria throughout Russia fills one with surprise. Everywhere this provision is available. Even when the worker is not actually ill, he or she appears to be able each year to claim a fortnight's residence in a rest home.

We have already referred in Chapters I and II to the various rest homes and sanatoria which we visited, but further details will be given here. A beautiful palace on the banks of the Neva, in Leningrad, is now used as a home of rest for the fourteenday holiday given to workers, while they are on full pay. No payment is exacted at the home, but to the limit of accommodation all workers can take their holiday in it or in others similarly constituted. We found the magnificent rooms of the palace occupied by workers living amid scenes of vanished private luxury.

In Leningrad also we visited a night sanatorium housed in a palatial suburban house, formerly a private residence. Here also the lavish fittings and decorations remain. This institution has 13o beds. It is intended for early cases of tuberculosis, and 35 women and 35 men are admitted at one time. These go to their work daily, working seven hours each day, return to this institution, bathe, rest for an hour, then have supper, and afterwards consult with the doctor, whom we met.

Exsanatorium patients do not appear to be received in this night sanatorium with a view to continuing under hygienic conditions, nor is there, as yet, any arrangement for giving patients work determined by their medical condition; but an attem is being made to select lighter employment for these workers.

Some of the patients appeared to us to be more in need of protracted continuous treatment in a sanatorium; but presumably this accommodation is not always available.

But the Crimea is the region in which the chief health resorts of Soviet Russia are situated. This arises not solely or directly because of its climatic superiority, but because in it were found the imperial and aristocratic palaces, private mansions, and sanatoria, previously the almost complete monopoly of the welltodo.

In Yalta

We landed from the Black Sea steamer at Yalta, the centre of the health resorts on the Crimean coast. It is a town with some 20,000 inhabitants, sheltered by high mountains, and going back in history to ancient Greek occupation. The morning after our arrival we were met by Dr. S. J. Jacobson, Chief of the Social Insurance Organization for the Crimea region.

In a conversation on social insurance in Russia he stated as its chief objects: (1) the emphasizing of prophylaxis in medical treatment, and (2) the organization and development of increasing numbers of sanatoria and rest houses. Already the number of these institutions is several times greater than before the Revolution.

The chief aim is to help workers, and in accordance with present needs 90 per cent of those helped must be workers in the heavy industries. Technicians are included in this preferential treatment.

In medical work in the Crimea the chief aim is to obtain full advantage of its. special climatic healing powers; and from this point of view, said Dr. Jacobson, it is being found desirable to develop sanatoria about 1,700 feet above sea level. Those formerly built were on the sea level.

In addition to the insurance sanatoria and homes, there are similar (perhaps not equally good) institutions administered by the Commissariats of Health. There is agreement between the two, patients being sent from a central bureau. Actual fusion of the two sets of institutions is contemplated. Patients are sent to the Crimea from all parts of the U.S.S.R. Advanced cases are seldom sent to these distant sanatoria. When an insured patient is under treatment he receives full wages, is treated free, and special help is given before he leaves home.

On the Crimean coast there are more beds for the noninsured than for the insured.

At least half the cost of maintenance of workers in sanatoria and homes of rest appears to come from public health funds, said Dr. Jacobson, the insurance funds not sufficing for all applicants.

A select committee decides on patients to be sent from the heavy industries. The local tuberculosis dispensary organization is utilized in deciding on cases.

Night, and day, sanatoria for workers are relatively little developed in the Crimea. Pulmonary cavitation cases are specially trained in photographic and other light industries. Some work has been done in occupational therapy. There is no difficulty in selling goods produced.

Each patient on returning home is handed a copy of the history of his illness, and this and his record card he takes with him to his local dispensary.

There are few special children's sanatoria in the Crimea. It has been found necessary to concentrate first on the workers themselves. These are a main source of infection to others.

Cases of tuberculosis, even in children, are always treated separately from other illnesses.

Visit to Dolossy Sanatorium

We visited Dolossy, a large sanatorium in the mountains above Yalta, at an altitude of about 1,600 feet. This is magnificently situated and organized. In winter it has about 300 patients, in summer 480. In admitting patients special precautions are taken against the introduction of extraneous infection; all crockery and spoons, etc., are sterilized after each meal; sputa are cremated.

The funds for building and equipping the sanatorium were derived from social insurance. Each patient costs 6 rubles a day for maintenance.

Touch is kept with patients who have left the institution, the records of factories and other work places and of tuberculosis dispensaries being available for this purpose.

Visit to Livadia

We next visited Livadia, the former Crimean residence of Tsar Alexander III, a magnificent building, with many subsidiary houses. The palace and other buildings now house from 1,300 to 1,500 workers from various parts of Russia, sent here for a fortnight's or, longer rest cure. It is in fact a vast convalescent home, with added facilities for patients needing special care. It is intended for workers sent by both insurance and public health authorities.

We were accompanied by Dr. Karpenko, the Director for State Sanatoria in the Crimea, who explained the working of the rest cures. They are under centralized direction from Moscow. The patients who are sent here are workers on collective farms who are not insured, also insured persons who are not ill enough or for whom beds are not available under the insurance scheme. These must buy their own traveling tickets and are required also to be members of a trade union.

The workers admitted to Livadia in the summer are chiefly "shock brigade" workers from factories; in the winter patients from collective farms preponderate. Thus Livadia has become a "peasants' palace."

Usually patients stay six weeks in Livadia. They come in groups from various areas, and these groups enjoy a certain amount of autonomous management. Discipline is found to be easy among the hard workers sent here.

On our visit to Livadia we had interesting discussions with its staff, including especially the medical superintendent. He was most emphatic in his preference for the new regime, and had no doubt that, although his remuneration was lower than formerly, he had much greater influence for good now that all financial considerations between him and his patients had ceased. Furthermore, he had no doubt that his interest in each patient as an individual had increased ; and regarded it as certain that this feeling would continue, because the young were being sedulously educated in the principles of socialism, which meant that personal welfare was to be sought through communal welfare.

Finally, we may quote from a distinguished woman professor of histology in Moscow. She is over sixty years old, came from a wealthy family, and had been engaged in revolutionary activities during the Tsarist period. As evidence of progress made, she instanced the gigantic growth of rest homes and sanatoria to which, she said, a great majority of the proletariat go for a fortnight each year. Before the Revolution the proletariat did not count; now they count for everything. They had suffered most from the old bourgeoisie, and in her view it was right that they should receive the first and chief benefit of the new regime. It is they who form the vanguard of socialism and are building it up, and theirs must be the first benefit.

The Treatment and Prevention of Venereal Diseases

THE consideration of the treatment and prevention of venereal diseases is closely wrapped up with the problems of marriage and divorce discussed briefly in Chapter XI. One general comment may be made. However seriously the objections to the great facilities for divorce in Russia may be regarded, it appears highly probable that temporary unions such as occur in Russia, whether with or without registration of marriage, are likely to be associated with much less spread of venereal infection than the casual sexual promiscuity which had been widespread.

Statistics of incidence of venereal diseases are notably untrustworthy, but the following figures taken from the International Health Year-Book may be quoted:

CASES OF VENEREAL DISEASES, 1929
Syphilis	Soft Chancre	Gonorrhoea
354,295	13,841	411,015

Prior to the Revolution many parts of Russia are stated to have been devastated by syphilis, a very large part of which was "innocent," i.e., spread otherwise than by sexual congress. This, we were informed, was so in the Samara districts. Now the amount is greatly decreasing.

At Rostovon-Don there was also formerly much "innocent" syphilis, acquired for instance through kissing or breastfeeding, but its amount, Dr. Rubinstein informed us, has declined from 45 per 10,000 in 1924 to 0.5 in 1930.

On a visit to the Moscow Institute for Skin and Venereal Diseases, Dr. Kazaroff, the head of this institution, gave us valuable information as to antivenereal organization. Both syphilis and gonorrhoea, and especially the former, are declining. The registered number of cases of syphilis in Moscow and district in-

1927 was 57.75 per 10,000 population.

1928 was 46.42 per 10,000 population.

1929 was 44.30 per 10,000 population.

1930 was 38.5 per 10,000 population.

1931 was 31.0 per 10,000 population.

Treatment is seldom neglected. It is always gratuitous and unrestricted, whatever the social position of the patient. Much educational work is done to ensure continued treatment, including home visits when needed. It has never been necessary to enforce continued treatment.

At the Moscow institution there are 400 beds. There are also five venereal disease dispensaries in the city, and in the factory and other dispensaries some treatment of venereal disease is carried out. Freedom from syphilis is determined by examination of blood and cerebrospinal fluid.

The decrease in venereal diseases is ascribed by Dr. Kazaroff not only to treatment, but also to the facts (a) that the workers themselves have control of the antivenereal provisions, and thus realize the need for selfcontrol; and (b) that there has been a general "liquidation" of prostitution, as unemployment has disappeared. Now very few prostitutes are to be found in Moscow.

Talks on venereal diseases are given at factories by the staff of the institute, and it is noticed that this is followed by an increase of patients. Moving pictures as well as printed matter are utilized for educational work.

Laboratory diagnosis is also gratuitous, and special studies on the gonococcus are being made at the institute.

Dr. Kazaroff hopes to "liquidate" syphilis as a mass phenomenon before the end of the second fiveyear period.

A certificate of health is required at marriage from each partner, but this requirement is not generally enforced. If the certificate is not given, then, if either partner becomes venereally infected, the responsible partner is subject to imprisonment. Similarly, if a man and woman live together without marriage, this penalty for infection can be enforced.

As the cultural level of the people rises, marriage consultations are becoming more common. These are held at venereological dispensaries.

Prophylactoria for Prostitutes

In Moscow we visited a "prophylactorium" for the reclamation of prostitutes. There are 500 resident women to whom medical treatment is given. Girls come voluntarily. They are first examined by the doctor and may be transferred to a hospital if their condition calls for special treatment. Other cases are treated here while pursuing their daily work. Much knitting and sewing work is done at the institution, for which the workers are paid, the average amount paid being 70 rubles a month; 35 rubles are deducted for maintenance. All the inmates must attend school if illiterate. About to per cent are said to be defective.

Fifteen doctors work here, including dentists, each attending from three to seven hours.

Many of the inmates go to work in a factory for seven hours a day, and on discharge they generally continue factory work. About 5 per cent run away, but they generally return. Inmates may go out for the day once in four days. Patients are kept track of and are visited at home. Also conferences are held at the institution for expatients.

The majority of the patients subsequently marry and have children. Some women have children with them in the prophylactorium, and pregnant women are admitted.

There are several institutions of this type in Moscow.

At Rostovon-Don there is a special venereal disease centre which has four, dispensaries or ambulatoria in different districts for treatment of these diseases. One of these is at The Unitary Dispensary (see page 235), thus securing direct collaboration with the doctors in other departments of this dispensary.

The statistics and clinical records from all the dispensaries in Rostov are collected in one office for reference and for statistical inquiry.

We noted that venereal disease is regarded as a misfortune, not as a cause for shame.

The following figures were supplied by Dr. Rubinstein as to the incidence of syphilis and its decline in the city of Rostov:

CASES PER 10,000 OF POPULATION
	Syphilis	Gonorrhoea
1927	80.3	126.1
1930	51.0	100.0

In Tiflis there is a venereological institute with branches throughout the Republic of Georgia. In addition there are special departments for treating venereal diseases at the various polyclinics. Some prostitution still occurs, and prostitutes may be placed, in reformatories.

The Characteristics of Medical Practice

IN THE light of what has already been written we can discuss more fully the leading characteristics of Russian medicine.

Before doing so we should, once more, make it clear that our account brings into relief what is best and what has been most highly developed in Russian cities. In the background there is, as we were repeatedly informed, an inadequate supply of doctors for the needs of the teeming city dwellers and still more for the immense and widely scattered rural population; but the deficiency is being rapidly overcome, and one cannot withhold admiration for what has already been accomplished.

In preceding chapters we have already set out two outstanding characteristics of Russian medicine: First, every doctor, with negligible exceptions, is an official of the State, and second, there is a remarkable concentration of medical practice in coordinated institutions, which ensures that every doctor has ready and daily access to expert and institutional help as it may be needed.

We have already made it clear that monetary motives have almost entirely ceased to operate in medical practice in Soviet Russia. The doctor has been removed from the field of monetary competition. The small and decreasing percentage of private practice with fees may almost be left out of the reckoning, not only because of the general poverty of the population, but more so because public medical provisions in cities are immensely superior to what is possible in private practice, not only in hospital accommodation when needed, but also in the possession of elaborate consultative facilities.

The question at once suggests itself: Can as good medical work be expected in the new circumstances as was secured when a doctor's livelihood depended on his obtaining and retaining the favor of his feepaying patients? The question for the vast majority of patients is academic; for in Russia the masses of the people previously received little or no medical aid, except very inadequately from the medical staffs of hospitals and from the district public assistance medical officers. For this vast majority of the total population the medical care now given is almost incredibly better than it was, both in quality and specialist differentiation and in availability.

The Russian doctors with whom we discussed the question propounded above have no hesitation in giving an affirmative answer. (See, for instance, page 224.) It was even claimed that the removal of the cash nexus from the relationship between the doctor and his patient had greatly increased the doctor's power for good curative and preventive work. This is consistent with the conclusion reached in Medicine and the State. Thus, referring to the doctor's work under English sickness insurance, it is stated (see page 145):

For the conscientious insurance doctor it is a great boon to be able to give satisfactory treatment to the persons on his panel, without regard to a future doctor's bill;

though it was added that under these circumstances

the too complaisant doctor may incur serious moral damage by hasty consultations with his patients and by giving equally hasty and unjudicial medical certificates of inability to work.

The following additional extract from page 250 of the same volume is relevant to this subject:

It is frequently argued that wholetime salaried appointments are destructive of personal initiative and inhibitory to continued effort. This incidentally is a grave and undeserved reflection on present wholetime officers in the medical and in the scholastic professions. The reflection is deserved in individual instances. and these instances in the aggregate may bulk somewhat largely, but in my judgment they form but a small proportion of the total. In these instances security of tenure of office reduces effort and short of this may and sometimes does stereotype and render static present methods of work.

But it cannot be said that intellectual stagnation and moral lethargy, when they occur in officials, are their special possession. With these occasional accompaniments of a too sure livelihood may be compared the medical work of an occasional private medical practitioner in a poor district, his hurried interviews with patients, his too frequent treatment of many patients without diagnosis, the pile of weekly medical journals which one can see unopened on his table, and the inability to attend the meetings of medical societies, still less to cultivate postgraduate work.

The comparison with British insurance experience is apposite so far as concerns avoidance of neglect or of excessive medical visits, one or other of which may arise when a doctor is paid per visit. The comparison is irrelevant to Russian experience in the fact that in Britain the number of patients on an insurance "panel" and, therefore, the doctor's income depend on his personal popularity with his patients. In Russian practice the patient, as a rule, consults the doctor allotted to him, though this rule is not rigid. But in this respect, the position is what it has always been in rural Russia. In Britain also the same position holds good in country villages and for most patients who receive medical aid in hospitals or dispensaries.

Financial motives for efficiency have weight; but in many walks of life they do not determine human conduct, and, as we have seen, good medical service is given in departments of practice in some countries where these motives have disappeared. Professional pride, desire to excel, desire to stand well with one's fellows, count for much in a doctor's mind as in all human minds; and the satisfaction which comes from doing beneficent work, the sheer love of serving and desire to serve the suffering, possess medical hearts at least as much as the hearts of the laity.

Another feature of Soviet medicine, a feature which is perhaps its guiding principle, is that the new service is made available in a special degree to all industrial workers and the poorest of the peasants, and to their families. These form the vast majority of the population. They are given priority of treatment at the various dispensaries and polyclinics and have the first call on hospital beds and on treatment in sanatoria and convalescent homes.

The nationalization of medicine under the Soviet administration, including the organization of a public health service, was entrusted, after the Revolution, to Dr. N. A. Semashko, the first Commissar of Public Health in Soviet Russia. His descriion of the medical organization of Tsarist Russia includes a statement that it

possessed all the characteristics of the capitalistic state; a better service for those who were rich, an inferior one for the poor; practically no preventive medicine; no special care for the poor; sanatoria, etc., the monopoly of the rich.

It is noteworthy that already by 1931 there were in Russia 724,000 beds in convalescent homes and sanatoria for the poorer population.

But although priority and preference are given to workers, treatment is not withheld from those who do not come within the category of workers. It was difficult for us to get into touch with nonworkers (for definition of these see page 80) and to ascertain personal experiences; but this general statement is at least approximately correct. As stated by the Commissar of Health of the R.S.F.S.R. in the interview we had with him (see page 221), the desire is to serve all gratuitously, but the first call necessarily is for the manual workers. Thus at a dispensary an intellectual will wait until the workers have been treated.

In other matters the lot of the nonworker appears to be less happy; he is not likely to have a ration ticket; he cannot buy advantageously at the official stores; he cannot obtain the cheap tickets for the theatre, opera, and motion pictures which are accorded to trade unionists.⁽¹⁾ His position in sickness insurance is indicated later.

The nonworker's position as regards medical aid is anomalous. He may be poorer than the worker; but, unlike him, he cannot demand the best medical treatment. However, so far as we could ascertain, he usually receives it.

Some nonworkers still employ official doctors privately in their free time. But, as we have said, private practice probably does not amount to 10 per cent of total medical work in Russia.

An important feature of Soviet medicine is that there is practically only one channel through which it flows. In each republic there is a unit national system for the entire population. The fact that, in theory at least, kulaks and other "nonworkers" receive only such treatment as is available after workers' needs have been satisfied does not alter this main fact.

In the main also the treatment of disease is entirely gratuitous to those receiving it. Its cost is defrayed by governmental funds, which are derived chiefly from the pursuit of its monopolistic industries.

There are minor exceptions to the rule of gratuitous treatment, as for instance in the induction of abortion (see page 181), and in obtaining accommodation at sanatoria (see page 242). At some clinics and sometimes in hospitals partial payment is required.

In Soviet Russia the treatment of disease has been institutionalized more completely than in any other country, clinics and other nonresidential institutions being included in this statement. The tendency to institutionalization of medical treatment is seen in all countries, the extent to which it has advanced depending in large measure though not entirely on the financial resources of each country. Given adequate funds, the urge in this direction appears to be overwhelming. The reasons for this need not be discussed here; they are fully considered in Medicine and the State.

American and Soviet Medical Care Compared

While this section of the present volume was being written we received the final report of the Committee on the Costs of Medical Care, which had completed a fiveyear study in America. This report enumerates the present maladjustments in the provisions for medical care in America, such as:

(1.) Uneven distribution in the costs of medical care among families.

(2.) Acute shortage of physicians and hospitals in certain rural areas.

(3.) General shortage of convalescent facilities.

(4.) General shortage of dentists to meet the real needs of the people.

(5.) Inadequacy of personnel and financial support among official health agencies.

(6.) Inability of many patients to obtain nursing services because of cost; actual shortage of nurses trained in obstetrics and public health; a surplus of privateduty nurses, considering present inability of people to employ them.

(7.) Extensive use of inferior types of treatment and widespread selfmedication.

(8.) Low net incomes of many physicians, dentists, and nurses.

(9.) Insufficient utilization of preventive procedures.

(10.) Inability of many people to differentiate accurately between good and poor medical service.

It is convenient to compare these findings with what we found in the great towns of Soviet Russia. For convenience the headings have been numbered.

(1.) In Russia for four fifths of the population in cities and a majority in rural districts the uneven distribution of the costs of medical care has disappeared. It has not disappeared for the dwindling remnant of the "deprived classes," nor entirely for independent brain workers outside any organization, together with their families; but these depend in the main on the same official system of medical care as that given to the manual workers and peasants and to the members of any of the various social organizations.

(2.) There still exists a great shortage of physicians and of. hospitals in rural districts both in the United States and the U.S.S.R., but in the latter country the disadvantages are immensely greater, owing to the deficiency of roads and other facilities for travel.

(3.) In the United States there is a general shortage of convalescent facilities. Russia is exceptionally well provided in this respect; though owing to its vast area its rest homes and sanatoria are unequally distributed.

(4.) As regards shortage of dentists, undoubtedly this is much greater in the U.S.S.R. than in the United States; though we have no exact figures on this point.

(5.) In the United States as in other capitalist countries the financial support received by official medical agencies is quite unequal to their real and urgent requirements for good work; furthermore this support is very unequally distributed, some communities having a fairly complete organization, at any rate in some branches of medical work, while in other communities all medical work is being restricted.

In the U.S.S.R., in the rural sections, which include more than four fifths of the total population, medical provision both of institutional and noninstitutional treatment remains deficient. Inadequacy of a much less serious character continues in many rural parts in the United States. In the Russian cities visited by.us, excellent medical treatment is available, especially for workers, and this treatment is almost completely integrated, so that no form of treatment is lacking. Gaps have been filled up, except to some extent in dental treatment. This unification of medical practice means an absence of redundant effort.

(6.) The deficiency of nursing services found in the United States is shared by many countries. In Russia it is immensely more serious than in western countries, owing both to deficient numbers and inadequate training. The fact, however, that the treatment of disease in Russia is chiefly institutional probably reduces the suffering from inadequate nursing.

(7.) Selfmedication, except with herbs and the like, is likely to be exceptional in the U.S.S.R. Drugs are almost fabulously dear and scarce.

(8.) As to incomes of physicians it is difficult to find a basis of comparison of the two countries. In 1929, that is, virtually before the depression began, the net income for one half of all American physicians in private practice was less than $3,800. For one third it was less than $2,500; for 18 per cent it was below $1,500. Probably $3,800 could purchase a higher standard of living in America in 1929 than is possible in Russia today for the best paid doctors, but it is doubtful if the earnings of many Russian doctors have a purchasing power lower than $1,500 represents in America.

(9.) In insufficient utilization of preventive measures all civilized countries stand condemned. The U.S.S.R. is still behind other countries which began preventive work much earlier and probably from an initially higher level. But as to factory medical work and the work of the dispensaries and polyclinics, we were impressed by the extent to which each patient was regarded as a member of the community as well as an individual, and by the extent to which his treatment was directed to the group of which he was a member. Instances of this have been given in the preceding pages.

(10.) The inability of the majority of the public to distinguish between good and poor medical services is a universal characteristic. It will become less marked as biology and science generally are taught. Meanwhile a question obtrudes itself, even though one wishes it did not: Is not this inability to distinguish between good and poor medical care likely to be more hurtful to patients and to the public when the doctor is remunerated on a fee basis than when he has no concern with the cost of the treatment he is privileged to give? The answer must, we think, lean towards the system begun in the U.S.S.R., although, as yet, it is being incompletely carried out.

In some prefatory remarks we assumed that the medical arrangements seen by us in the U.S.S.R. were the best which it possesses. Even so they showed some imperfections and varying degrees of completeness. They sometimes illustrated, furthermore, the risk which all highly organized medical units experience of "running to excessive specialism." The U.S.S.R. arrangements may also be regarded by many as open to the accusation of lack of the "human touch" which is regarded as the saving grace and overwhelming merit of private medical practice in western countries. We saw no evidence of this, and we do not regard it as a necessary consequence of officially organized medical practice. Furthermore, if one has to choose between the unaided sympathetic family doctor of average skill and the Russian system of a chain of dispensaries, polyclinics, hospitals, and sanatoria when well run, the latter is preferable for a large proportion of total cases; and it does not necessarily mean the loss of the "human touch."

Our imperfect review of medicine in the U.S.S.R. shows that it has great merits, even in its present incompleteness. True, it has the faults of youth and beginnings; and it has the supreme fault, common to the U.S.S.R. and other countries, of not being fully available, without discrimination, for the entire population. But even in this respect it differs from other countries; for the excluded section of the population is a small nonproletarian minority, and these are only partially excluded. On the other hand, in most western countries, including the United States, the very poor and the wealthy can obtain the best possible treatment at home, in the consultation rooms of experts, or in the general and special hospitals, but there remains a large part of the total population for whom this provision is beyond their means and is not adequately forthcoming from charity or from public funds. The varying provisions of medical insurance in different countries modify this statement; but even when allowance is made for the provision made in insurance schemes in any of the western countries the average medical service available is less complete and, as far as we can judge, somewhat less satisfactory than the provision sampled by us which is made for industrial workers in the cities of Soviet Russia.

The Soviet service has the great merit that the direct payment of fees has ceased, and with it has ceased the burning problem of the relation between the private and the public practice of medicine, which in capitalist countries is always with us.

The further salient features of this service gratuitous provision for all the medical needs of the proletariat at the expense of the State, and the coordination, apparently without gaps or overlapping, between the various portions of the national medical servicemust commend themselves to the physician and the hygienist.

General Considerations on the Medical Care in Large Communities

IT HAS already been indicated in the Introduction that our inquiry into Russian medicohygienic arrangements was intended as an extension of the International Studies (referred to on page 1) on the arrangements and procedures in eighteen European countries. The evidence derived from those studies was subsequently summarized in Medicine and the State (1932), and a number of farreaching conclusions were reached, which, if followed by appropriate action, would go very far towards integrating medical provision and rendering it universally available. As our Russian inquiry proceeded, it became evident that, if it were to be as fully useful as was possible, it must have a wider social scope than the preceding inquiries in other countries.

In order that the position of Russian medicine as related to the ideals of medical practice may be more fully considered, it is proposed to set out in this chapter the postulates of a good medical service, and to indicate points in which in Soviet Russia a nearer fulfillment of these postulates has been reached than in other countries. For the purpose of this statement, the general propositions set out in Medicine and the State are utilized in the following paragraphs. Although no quotation marks appear, the emphasized sentences in most instances are derived verbatim from this source.

1. The health and therefore the hygienic and medical care of every person in a community is a matter of concern and responsibility not only for himself, but also for every other person in the same community. [Medicine and the State, Chapter 1]

No person liveth to himself. If through sickness he becomes dependent or is rendered less efficient, the rest of the community necessarily suffers. This is the selfinterested motive for providing medical service, the force of which is being increasingly realized. But there is also the higher motive of love of one's neighbor.

2. It follows that the organized community through its government is called on to concern itself with the practical application of all the known laws of health and of all remedial measures which will help in the restoration of health. [Ibid., Chapter 2]

The only acceable alternative to this universally called for governmental action is that every person in the community shall be alive to and shall undertake all needed hygienic and medical work, personally or through mutual help. This alternative is scarcely conceivable in large communities; for medical and hygienic needs are complex and require, in some respects at least, action on a communal scale. This alternative, furthermore, can only come completely within the sphere of "`practical politics," when the roots of selfishness have been removed from every human breast.

3. This being so, governmental bodies are called on to act with full realization of the facts that everywhere there is a lamentable amount of inadequacy and discontinuity in the medicohygienic provision for the community; also that for a high proportion of the total sick adequate medical care necessitates the organization of measures and of institutions beyond what the individual medical practitioner can provide.[Ibid., Chapter 2]

It is unnecessary to give here the evidence on which these universally acceed propositions are based. In the experience of no single country can their accuracy be denied ; but the defects in some countries are much greater than in some others.

4. It is abundantly clear that for a large section of the population in all countries the cost of sickness is overwhelmingly great; and that while domiciliary medical care does not ensure for a large proportion of the total sick satisfactory treatment and rapid convalescence, the cost of hospital treatment is beyond the means of a large proportion of the total population.[Ibid., Chapter 3]

5. The preceding statements necessitate the conclusion that, in order to supply adequate medical aid for all, either private charity, or provident insurance,⁽¹⁾ or taxation (in which the needed expenditure is distributed over the whole community according to means) must be forthcoming in a continuous, even, and adequate stream.

This conclusion follows from the axiom acceed in all civilized countries, though nearly everywhere acted on most inadequately, that no person shall be allowed to die or suffer serious harm through the lack of shelter or food or medical aid.[Ibid., Chapter 4]

6. A sick person is seldom in need solely of medical aid (the doctor and ancillary medical services). His sickness has been determined in part and is likely to be increased and repeated by adverse factors in his personality and in his environmental circumstances, whether industrial, economic, sanitary, or mental and spiritual; and therefore economy and wisdom alike demand that each illness shall be investigated and treated socially as well as medically, with a view to the ascertainment and removal of conditions inimical to health.[Ibid., Chapter 4]

7. It is essential that, whether domiciliary or institutional treatment is required for the adequate skilled care of a sick person, this treatment should be available to the fullest extent necessitated by the patient's illness, irrespective of his financial circumstances.[Ibid., Chapter 5]

To regard medical treatment otherwise than in accord with this proposition implies a misconceion and contradiction of the communal principles laid down under 1 and 2 above.

This does not necessarily imply that gratuitous treatment (that is, treatment paid for by the community as a whole, according to the means of each taxpayer) shall be offered unconditionally to all applicants; but it does mean that it is incumbent on governmental bodies to anticipate the contingency of illness, and to ado measurescompulsory when necessarywhich shall ensure that every member of the community has contributed his share, to the extent of his competence, to provide against the contingency of sickness.[Ibid., Chapter 5 & 6]

8. It is an acceed principle that prevention (of disease) is always more important than (medical) provision.[Ibid., Chapter 7]

This being so, all medical work must be assessed according to its approximation to fulfillment of this principle.

Among the forms of medical work which are specially noteworthy in their preventive value are:

Prenatal and postnatal care of expectant mothers. Medical care in childbirth.

Infant consultations and health visits for children up to school age.

School medical supervision.

The adoption of measures of personal hygiene in shops, offices, workshops, factories, etc.

Complete medical overhaul of all patients when, first they come under a doctor's care, and at intervals.

It will be noted that, in most of the items enumerated above, persons can be examined as to physiological conditions before aberration from health has occurred.

The preceding postulates of a good medical service for the community involve certain further desiderata, failing the fulfillment of which a medical service will be unsatisfactory in one or more respects. To some extent these desiderata are embraced in the postulates already stated; but they are now stated separately as they serve to indicate in partial outline the medical machinery needed for the fulfillment of the preceding postulates.

1. It is necessary that, for a fairly large proportion of the patients who come under treatment, there should be exchanges of insight between the general and the special practitioner of medicine.

2. It is further necessary that each of these, and especially the general practitioner, should have a fuller acquaintance than is now usual with the normal physiological state and social conditions of patients, through contacts with these patients prior to the occurrence of illness.

3. There should be an end of that greatest evil in medical practice, especially among wage earners, the frequent treatment of illness without accurate diagnosis to the fullest extent that this is attainable.[Medicine and the State, Chapter XII.]

4. The governments of all civilized countries have subsidized or themselves undertaken various forms of medical work, including much treatment of sickness. Medical work, with or without official financial support, is being done in more or less watertight compartments by:

public health authorities;

public assistance authorities (charities) ;

private voluntary charities (hospitals, dispensaries, etc.) ;

private medical practitioners.

In different countries the activities of these various medical bodies overlap to a varying extent. They often work in competition, direct or implied. They usually work without, or with little of, that interchange of facts concerning their patients which is needed for the patient's satisfactory treatment.

In some countries official medical work has very largely replaced the work of private medical practitioners and of voluntary charities.

5. A most notable feature of medicine in recent decades is the extent to which local and central governments acting as public health authorities have been impelled into medical work for the maintenance and restoration of personal health, as well as for the improvement of environmental conditions. This has shown itself particularly in infant consultations and clinics, in school medical inspection and treatment, in tuberculosis dispensaries and sanatoria, in the treatment of venereal diseases, of cripples, of the feebleminded, and so on. The more recent development of prenatal consultations and the vast extension of institutional provision for childbirth will also be remembered.

In most countries also the treatment of the destitute for ordinary sickness is now in the hands of public health authorities, and this is true also for the provision of mental hospitals.

The process of unification of medical services under public health authorities has already proceeded far in most countries. In some countries it is complete, except in so far as the treatment of persons under sickness insurance schemes is concerned; and in the U.S.S.R. this also is included in the unified national medical service. Furthermore, in the U.S.S.R. the unification has proceeded to the inclusion of any domiciliary medical care which is given apart from insurance.

To contemplate the provision of a statesubsidized medical service of group practice separate from the already extensive medical service provided by public health authorities, which covers a large part of the same ground, would be to submit to a continuance and extension of present unsatisfactory incoordinations, redundancies, and defects. Whether in the United States or in Great Britain any such additional provision which fails to be part of an extended public health service will necessarily prove unsatisfactory.

Nor can a continuance or extension of duality be justified scientifically. Public health administration is not concerned solely with "communicable" and "preventible" diseases. The day for this distinction has passed. Public health administration concerns itself with all failures in health and efficiency; and it is doing some of its best work when it curtails the duration of inefficiency, even when the occurrence of this inefficiency was unavoidable. The vast work now being done by public health authorities for cripples is perhaps the best instance of this.

6. To promote unification of medical work, modifications of public and private medical practice are needed for all except the rich.

This unification does not necessarily imply fusion of various medical organizations, though fusion of some of these is highly desirable; but it necessitates accurate planning for cooperation at every point, in order that completeness of provision and prevention of gaps and overlapping in provision may be attained.

The essential change in private medical practice needed to this end is the cessation of remuneration for each medical act, and the substitution of medical work on a contract basis. The idea of "contracts" in medical practice is. obnoxious to many conservative minds. It is forgotten that family practice, in which patients loyally send for their doctor when needed, is a form of contract practice without financial definition. The essence of a contract is the engagement or implied engagement of a person to supply service and of another person to receive and to continue to receive service from the firstnamed person. To the sensitive doctor the abolition of any financial motive for increasing or decreasing consultations or visits is an enormous relief and conduces to the welfare of his patients.[Medicine and the State, pages 40-42, 249-255, 259-264.]

Whether remuneration under the altered conditions comes from the patient himself, or from him (partially or entirely) under an insurance scheme, or from taxation must depend on circumstances. [Medicine and the State, Chapters VI, VII, XV.]

7. The cessation of payment of private practitioners according to the current number of consultations or visits will render it easier to ado group practice when it is needed for a patient. The consultative work rendered practicable by group practice should always be available for entire families. A team of doctors on the medical side must be the counterpart of the family on the patient's side. [Ibid., Chapter XIII.]

But as regards the need for group practice it is important to remember that the public mind is too much obsessed with the belief in a wide necessity of specialist medical aid. A majority of cases of illness can be satisfactorily treated by an intelligent experienced general practitioner. [Ibid., Chapter XV.]

8. Group medical practice, including hospital treatment as needed, is only practicable for the majority of the community if fees on a low scale are acceed; and assistance is indispensable from insurance funds (paid over a series of years by the insured family with additions perhaps from the employer of the wage earner) and from taxation imposed on the general community, if group practice is to become possible for the majority of the population.

In view of the last statement the only form of group practice worthy of consideration, for wage earners and for the lower salaried population, is one in which the municipality or county forms the unit of administration, as in other forms of government; in which the local governing body contributes material financial aid to the unified medical service; and in which the central government of the state also gives financial support to the scheme, and in return has a voice in determining minimum standards of efficiency and adequacy of the services to be rendered.

This is entirely consistent with selfgovernment by doctors in medical matters.

The idea of financial or professional competition between groups is inadmissible.

Group practice, if it is to be satisfactory, should be so arranged as to permit of the continuance of individual medical practice, in which, so far as is consistent with an economical and efficient geographical distribution of doctors, a given doctor may be chosen by and remain the trusted adviser of the family; but in which he is constantly supported by group workers, whether in hospitals or clinics, to the fullest extent which is desirable.[Ibid., Chapters XIII-XVI.]

Evidently in rural districts the possibility of choice of private doctors must always be limited, but inaccessibility to consultant and hospital aids to family practice cannot be allowed to continue without prejudice to many patients.

Tests of Medical Service

Having given some of the chief conditions which in our opinion need to be fulfilled in a satisfactory medical service, it remains to compare these with the Russian conditions outlined in this book.

In judging of the merits of a medical service there are three main tests of efficiency and success:

1. How far does the system tend to reduce the amount of sickness in the community by curtailment of duration or by preventive action?

2. Does it supply all the health needs of the community, medical, dental, nursing, and all necessary ancillary needs?

3. Is the service so arranged that it provides an efficient service both to rural and urban populations, without gaps or overlapping in this service?

These measurements overlap; but stated thus, it may at once be said that no civilized community has hitherto developed medical service or services which meets these tests in all respects satisfactorily and completely.

Applying the first test, we find that the reduction of morbidity in Soviet Russia has been general, and in the case of certain acute infectious diseases must be termed sensational. Cholera has been stamped out, no cases having been registered since 1927. Smallpox, which had a case rate of 5 per 10,000 in 1912, and 6 in 1914, shot up to a rate of 30 in 1919, was brought rapidly down to 7 in 1922, 2 in 1924, 0.6 in 1928, and the remarkably low rate of 0.37 in 1929. The epidemic of typhus in 1920-1921 resulted in a total of four million cases. During the four years 1925-1929 the annual average was only slightly more than 40,000 cases.

Typhoid fever, on the other hand, is still a problem. The cases reported in 1929 numbered 171,263, which is at a rate of 10.5 per 10,000 inhabitants as compared with a rate of to in 1927. The rates for scarlet fever and diphtheria were also higher in 1929 than in 1927.

The comparative incidence of tuberculosis in Tsarist and Soviet Russia is almost unknown. Before the Revolution as in the earliest years following it there was relatively poor organization for recording cases of tuberculosis. Hence a much larger percentage of the number of the tuberculous was then left unrecorded as compared with the results in recent years. Russian authorities say that this circumstance and not actual increased incidence explains the following figures, which we received from Dr. Roubakine:

TUBERCULOSIS MORBIDITY IN THE U.S.S.R. Case Rate per 10,000 Inhabitants
	Pulmonary	Other Forms
1913	59
1924	54.5	14.1
1925	76.3	21
1926	79.9	27.4
1927	88.1	30.5
1928	90.5	30.4
1929	86.1	30.4

The recorded cases of syphilis, primary and secondary, soft chancre, and gonorrhoea showed a marked decline in the reports for the three years 1927-1929, according to the International Health Year-Book. Dr. Roubakine has stated that "in 1913 in the Army the rate of venereal disease cases among the soldiers was 12.8 per 1,000 whilst in 1924--1927 the rate was only 8.02." In ChapterXXII we have cited marked reductions for Moscow and Rostov.

Further evidence regarding morbidity in Russia may be inferred from the general and the infant death rates, which, though fluctuating in recent years, are decidedly lower than before or just after the Revolution. The tables given below are prepared from figures published in the International Health Year-Book.

[table]

Infant Mortality per Thousand Living Births
	R.S.F.S.R. in Europe	Ukraine	Moscow	Leningrad
1916				270
1917				236
1919				284
1921				173
1922				228
1923		273	163	138
1924		128	177	168
1925		145	132	149
1926	187	141	134	147
1927			139	167
1928	167	136	127	136
1929	205.6	150.49	130.9	150.8
1930				141

Thus, tested by the changes in the rates of morbidity and mortality, the public health and medical service in Soviet Russia has already been associated with lowered death rates, including infant death rates.

Turning to the second test proposed, the question of adequacy of supply of health needsmedical, dental, nursing, and ancillaryan affirmative answer can be given in respect of many urban areas as to the medical services described and commented upon by us in preceding chapters.

Dental service, on the other hand, is admittedly inadequate, particularly in rural regions. Although we made no special inquiry concerning the supply of dentists, and have seen scarcely any printed material on this subject, it is our impression that a demand for dental care is being fostered through education and that corresponding measures are taken to train a professional personnel and to increase the number of dental clinics.⁽²⁾

The following figures for the Ukraine were given us by Dr. Roubakine, who said that there was no detailed information available for the other federated republics :

NUMBER OF PATIENTS AT DENTAL CLINICS IN THE UKRAINE
	Total	Insured
1924	6,956,561	5,113,036
1925	10,861,356	8,110,214
1926	12,519,443	9,633,422
1927	14,686,273	11,577,650

In 1926 the population of the Ukraine was 28,887,000.

In midwifery the U.S.S.R. has more complete arrangements for institutional treatment than any other country. Its system of dispensaries and polyclinics in cities is admirable, as is also the usual avoidance of special institutions devoted to a single disease.

A weak point in Soviet state medicine is the domiciliary treatment of illness. In view of present housing conditions in Russia, institutional treatment of most patients is desirable and inevitable. We had reason to doubt whether domiciliary medical calls for treatment, when made, received prom attention in all cases.

The great superiority of Russian medicine lies in its unitary arrangements, in the complete avoidance of redundancy or gaps in the city services, and in the special precautions taken to ensure that every patient receives as complete an overhaul as is required.

In Russia, as in other countries, but even more so, the health facilities in rural regions are less adequate than in the cities. But we have seen evidence that progress is being made, and undoubtedly the peasants and the workers in villages are receiving far better medical care, inadequate as it may be, than was possible before the Revolution.

Measured against the postulates set out earlier in this chapter, it would seem fair to conclude that Soviet Russia has, at least in many respects, come nearer to fulfillment of these postulates than any of the other countries studied by us or of which we have knowledge. Indeed, Soviet medicine is largely based on the general propositions which are here enunciated as standards for adequate medical care of all the people. In its program, at least, we must conclude that the Soviet system of medicine is more comprehensive and inclusive than is to be found in any other country. And while performance in many respects still stops short of the program, progress toward its fulfillment is being made with remarkable rapidity, so rapid in fact that unquestionably quality is temporarily being sacrificed to quantity. This feature appears to hold good in almost every phase of the planned economy of the U.S.S.R.

Concluding Observations

PRIMARILY our inquiries in the U.S.S.R. were concerned with its medicohygienic activities, and if we were literally restricted to these domains, any statement of conclusions as to the more general policy and activities of the Soviet Government might be avoided. Even then, however, we could scarcely evade the question: Does the Soviet organization — including all that is implied in the unification of financial responsibilities and control of the entire resources of the country — assist to an exceptional extent a complete medical and hygienic service for the entire community? To this question we can at once give a definitely affirmative answer.

The Soviet Government is the most gigantic experiment in the deliberate public organization of social and economic life in the history of the world.

That it is a system of government under control of a minority is a well-recognized fact, more so even than the so-called democratic government of certain countries in which centralized wire-pulling and local boss control have sapped the reality out of representative government. There is a universal basis of representative government in the U.S.S.R. grounded in ubiquitous electoral meetings open to all but the "deprived classes"; but in practice, authority is wielded by an exclusive, highly selected companionship or order called the Communist Party, the numbers of which are systematically kept down by the exclusion of all who fail to maintain its high standard of obedience and good conduct. This "companionship" is directed by a small committee (see page 93). True, every item of policy is exhaustively discussed before it becomes the policy of the Party; and at these earlier stages free and public debate is welcomed. Once a decision has been arrived at, the rule is one of absolute obedience, enforced by the penalty of exclusion from the Party. Continued intrigue or rebellion is drastically punished by transportation to a remote part of the Russian world, or even exile.

Loyal members of this companionship occupy most of the important positions in the government and dominate the whole social structure. As defined by Lenin, the dictatorship of the proletariat, or government by the workers, becomes the "dictatorship of its determined conscious minority."

Or in Trotsky's words "just as France stepped over the Reformation, so Russia stepped over the formal democracy"; and instead it adopted the policy of "rule of the toilers," whose "general will" the Communist Party claims (it may be with no little warrant) to interpret and embody in legislation. This authority, if we believe an opponent of the present regime, "whatever its immediate political vicissitudes, has penetrated as irrevocably into the consciousness of the masses as did in its day the system of the Reformation or of pure democracy."⁽¹⁾

Lenin is quoted by F. J. P. Veale⁽²⁾ as stating that "among a hundred so-called Bolsheviks there is one genuine Bolshevik with 39 criminals and 60 fools." This may be merely a cynical variation of Thomas Carlyle's oft-quoted cynical descriion of the British people as "mostly fools"; but it is consistent with the deliberate Soviet view that the mass of the people will accept the policy imposed by an active, belligerent minority who have in one or another way obtained and continue to hold power.

In the establishment of Marxism and of the policy needed for its enforcement, the standard of Soviet ethics is definitely utilitarian, any particular conduct being judged according as it tends to bring about an approximation to the earthly paradise expected from Marxism and Leninism; and in discussions of Soviet policy, extracts from the writings of these two masters are used and regarded as finally authoritative, just as texts of Scriure have been employed in theological discussions.

The utilitarian principle is applied in the administration of criminal justice, which, as we have stated (see page 132), shows some excellent features, but which for the same offence may inflict capital punishment when the offence is directed against the Government or the commonweal and only nominal imprisonment if it injures only a private person.

This is seen most markedly of all in the treatment of those small farmers who have been unwilling to give up their holdings in favor of collective farming. It is doubtful if the terrible hardships of these individualistic sufferers will ever be fully told. Many of these may have been guilty not only of individualism but also of actual crime. During 1932-1933 severe treatment was being meted out to members of communal farms who had not given full service in their new position. Multitudes had stolen or hidden the wheat of the collectivity for their personal benefit, or otherwise lowered the productivity of their work for the common advantage, with the result, it is reportedit is hard to say with what truththat during the winter of 1932-1933 the urban population of Russia was being grievously underfed.⁽³⁾

The severity against the kulaks is defended on the ground that small farms and peasant holdings are incompatible with any adequate productivityas they areand that in the establishment of a complete socialist system the obstacles to it must ruthlessly be swept away. This is the method of war; and the policy of the Soviet Government implies and is openly acceed as requiring for many years to come action on the lines of warfare against those who obstruct or injure the policy of collectivism.

In carrying out what is really the policy of Communism - in which punishment is apportioned according to whether the crime injures the community or only an individualthe OGPU can by its own secret tribunal accuse, convict, and punish (even with death), those judged by it to be offenders against the State.

It is the fond hope of the Party that the young people approaching adult lifemore than 100,000,000 of the present population are under twentyfivewill be enthusiastic supporters of the new regime; and if persistent and universal indoctrination can do this, the hope will be realized. There are indications suggesting that it is succeeding according to plan.

A complete national socialism implies the ownership by the nation of land and other forms of industrial property and the suppression of all private business carried on for profit. This has been largely achieved in the U.S.S.R. without the compensation due to private owners. This confiscation partially explains the enormous provision of holiday homes, convalescent homes, and sanatoria in Soviet Russia.

At the present time the progressive income tax is as severe as that of Great Britain, whilst the death duties rise steeply to the point of virtual confiscation of all above a modest patrimony. The ownership of houses, of motorcars, and similar possessions is restricted to personal use without pecuniary profit to the owner. In fact "civil liberties" as understood in other countries are abridged to a great extent.

All this carries with it the almost complete abolition of the motive of private profit, as distinguished from wages or salaries for actual work done. Wages and salaries are not uniform, and to this extent rivalry may come in; but its scope is limited, and were it otherwise, the spending motives of high salaries are lacking to a noteworthy extent. The Soviet teaching is that private profit is at the root of the evils of capitalism; and furthermore that the internal market of a country is inexhaustible under noncapitalist conditions where the object of production is not profit but consumion. The last proposition remains to be proved by experience. At present (1932-1933) the international position is that in capitalist countries extensive unemployment prevails along with a glut of food and other products for which purchasers cannot be found; while in Russia, with no involuntary unemployment among those competent to undertake industrial work, there is still inadequacy, with a steady increase in the production and distribution of food and of manufactured articles for daily use.

But the motive of private profit has been practically abandoned; and a story told by Louis Fischer may be repeated as embodying a basic principle of Soviet industrial organization.

A boy was asked : "If a man buys 6 dozen apples at 18 kopeks a dozen and sells them at 36 kopeks a dozen, what does he get?" The boy's answer was: "A jail sentence."

The motive of private profit having been abolished or minimized, can a high standard of individual effort be reached and maintained?

Evidently the intensity of the individual economic struggle among the former employers and owners of capital has been reduced. Workers do not work so hard as they did. Social competition on the monetary plane has nearly gone; though the struggle for power may replace to a large extent the struggle for wealth.

With average human nature as it is, one can scarcely expect that in those circumstances a standard of production will be maintained equal to that developed under competitive conditions in a capitalistic country. Yet our own observations did not give color to this anticipation so far as the vast numbers who have to work for wages or salaries are concerned; and anyone who has witnessed the intense enthusiasm of the younger population of the U.S.S.R. for Communism and the fanatical belief and equally fanatical "shock working" of a large part of the older manual workers will appreciate that forebodings may not be generally realized, once the difficulty of inexperience of workers has been overcome.

But already, especially in the rural population, among the peasants whose immemorial desire for independent tilling of the soil has been interfered with by the organization of collective farms, there has been evidence of serious "slacking," and for slackers a government is faced with the alternative of supporting

idleness or of coercion of the worker as a condition of relief. An omnipotent bureaucracy is inevitable in a socialist government; and everyone becomes in fact an employee of the State. This is stated neutrally and not necessarily as a desirable or undesirable result. As altruistic motives increase and predominate, the Christian ideal that "whosoever would be first among you shall be servant of all" will approach realization, and compulsion will become unnecessary. It is to be expected that, in present civilization, coercion will sometimes be needed for a section of the population in which the motive of private profit has disappeared, or from which it is excluded.

In our view the most serious objection to the Soviet State is that it is a system of class preferences. Its policy is often compared with that of the French Revolution with its triple slogan of liberty, equality, and fraternity. The French Revolution never fulfilled its ideals; and if the Soviet State were to be tested by the French ideals of 1789, it also might fail. There cannot be said, at present, to be complete equality of opportunity and privileges for the entire community; and no state has ever yet practiced universal fraternity. Meanwhile the existence of a continuing condition of warinpeacetime is alleged as justifying all the various shortcomings of Soviet Russia.

The Soviet system of class government has a further lamentable ethical aspect. To aid in the social war against the classes who were deemed to live without work or useful service (such as the landlord and the capitalist, together with such of the intelligentsia as defended them) there is persistent stimulation by word and action of hatred of these excluded classes.

We do not think this can continue. The Soviet Government for its own sake must give all who work, in all occupations permitted by law, equal privileges though not necessarily equal wages, if effort to build up a completely socialist community is to have its fullest chance of permanent success. An even higher ethical standard is necessary under a socialist than under a capitalist administration. Can this be secured so long as the Communist Party dominates the Government and continues its present attitude as to class distinctions and as to religious beliefs?

Russian administration under the Tsarist regime was characterized by the worst kinds of corruption; and the new Soviet regime inaugurated fifteen years ago, even if consistently honest, may prove inadequate to its task. If it should become also corrupt can Soviet Russia's government permanently succeed?

These are questions which cannot be answered with confidence. If everyone's character were impeccable, if personal motives were never allowed to conflict with communal interests, one could anticipate a successful future for Russia and its vast experiment in enforced idealism. But we live in the actual world, with its conglomerate assembly of conflicting, multifarious, and selfcentred interests, in which pure altruism plays a relatively insignificant part. Can Soviet Russia seriously expect to develop a higher standard of morality than Great Britain or the United States? The most favorable fulfillment of the arbitrarily enforced ideals of a minority that can be anticipated for Russia is a large measure of success, in the most colossal experiment in the economic history of the world.

Even if the Communist experiment fails, Russian government cannot be expected to revert entirely to capitalist conditions. The entire community has too great a stake in what has already been established to render this feasible. Hence the Russian experiment is a portent to the rest of the world; and it will have profound influence on the future outlook of the workers, especially the wage earners of the world, who constitute at least two thirds of the total inhabitants of all advanced countries. It is incumbent, therefore, on the leaders of thought and the governments of countries outside of Russia to consider whether, in order to obtain a reasonably high standard of living for all workers, free from the haunting fear of destitution in an indefinite but perhaps very near tomorrow, they can ensure, under modified capitalist conditions, what socialism of the communist type promises and may succeed at least partially in giving in the Soviet Union. It is not merely a question of livelihood. As Carlyle says,[In Past and Present, Book III, Chapter 13. ]

It is not to die, or even to die of hunger, that makes a man wretched; many men have died; all men must die,-the last exit of us all is in a firechariot of pain. But it is to live miserable ' we know not why; to work sore and yet gain nothing; to be heartworn, weary, yet isolated, unrelated, girt in with a cold universal Laissez-faire.

The U.S.S.R. not only permits but encourages the workers in every industry, rural and urban, to give suggestions or to criticize administration, and their comments become the subject of elaborate discussion. They are given a share in determining policy and are made to realize that the industry is theirs in part. They are as yet less efficient, on the average, than workers in capitalist countries, but they are exalted into partnership or at least into active concern with the industry of which they form an essential part; and this is a great social gain. This exaltation is not beyond reach in other countries, but it obviously necessitates cooperative action, attems at which have hitherto had little success.

Professor Harold J. Laski says [In Communism. New York, H. Holt & Company; London, Williams; Newgate, 1927.]:

The world has to find response to the promise of communism in alternative forms, or it will discover that neither the crimes nor the follies of the Russian experiment will lessen the power to compel kindred action. In other words, the only way to avoid communism is to prove by public policy that it is unnecessary. Thoughtful men and women in every walk of life are searching seriously today for such alternative forms; statesmen are seeking a public policy which will serve to rehabilitate capitalism and avoid the catastrophe which would probably be the attribute of communism.

First of all, in capitalistic countries measures are called for to establish economic security and to improve the standard of living of the poorer workers; secondly, deliberately planned cooperative action must somehow be secured between industrialists in the same country; and thirdly, corresponding industries in other countries must be so guided as to prevent the cut-throat competition and overproduction now so prevalent.

Towards the first of these ends much has already been done. The various forms of social insurance and pensions for the old and for widows and their children, improved sanitation, protection of food supplies, enforced standards of housing may be instanced. Political equality has been secured at least nominally in most countries. It cannot continue to exist alone; there is needed also a nearer approach, if not to economic equality, at least to a higher standard of living and its security.

Many minds are concentrating on methods for securing an interest of workers in their work equal to that of employers in their profits. The Russian experiment at least shows the necessity of further action in other countries. Capitalism will be judged according to its power to secure active cooperation of all concerned in every kind of industry. A communist has one great advantage over a capitalist country in the fact that there is no waste of effort in rivalry between producers. Capitalist countries must secure similar cooperation if they are to continue to prosper. We were greatly impressed by what we saw in Denmark of commercial cooperation among farmers. Cooperative buying of everything needed on every farm and cooperative selling preceded by standardization of all farm products have led to prosperity and contentment, which is now only disturbed by foreign tariffs.

And this brings us to the final test of the continuance of capitalism. Can the rivalries of production in different countries be reconciled, when these countries are not so situated that they can afford to be absolutely selfcontained?

It was an appreciation of this difficulty which made internationalism an essential part of the policy of Marx and Lenin, and this difficulty explains Russia's incitement to other countries to follow her example!

If capitalist countries cannot agree together as to international trade, and if Russia makes even a partial success of its communist socialism, the rest of the world is likely to experience periods of greater agita-, tion and turmoil besides continuing to suffer from unemployment and its attendant troubles.

Our belief is that capitalism and socialism alike will fail to maintain the position now reached, and that the extremes in the position on either side will of necessity have to be abandoned. Our views were substantially stated in a recent article by a prominent member of the American bar, who has many important connections with banking and large industrial corporations. He says: [Albert G. Milbank in "Socialized Capitalism" in the Survey Graphic, July, 1932]

The progress of socialistic thought in the past twentyfive years, whether it be of the bright red variety finding its expression in Russian Communism, or of the less vivid tones found in other countries, is a factor which intelligent men cannot ignore. It has made its influence felt upon capitalistic thought and action and will continue to affect the thought and action of the world, including those who by temperament and by environment are its most violent opponents.

It is equally true, however, that the Communism of Russia, as preached and practised in 1917 and for some years thereafter, has felt the impact of capitalistic influence. The Union of Soviet Socialist Republics has been borrowing back capitalistic practices which the revolutionary leaders of 1917 spurned and discarded. Those theoristic leaders failed to take into account certain inherent traits of human nature. The individual will refuse to remain a pawn to be moved about at will, whether that will be exercised by a State which unduly suppresses the individual, or by a capitalistic system which unduly ignores its social obligation.

It is high time that we explore the possibility of whether the virtues of the two schools may not be combined into a workable scheme that will provide a better foundation than either one of them alone upon which to build an improved economic and social order.

The Socialization of Medicine

So far our sketchy remarks relate to general policy, with special reference to economics. In some respects there is no sharp line of demarcation between capitalist and socialist communities. There is much socialism in capitalist countries, in the sense of provision, from communal funds, of necessities and amenities of life. Water supplies, sewerage, scavenging, public provision of parks, museums, picture galleries and concerts, and all branches of education are of this nature. So also are the various medical activities of the State and of municipalities in which free provision is made out of taxes. And the various forms of social insurance are in part a policy of State socialism.

We are especially concerned with the socialization of medicinein the sense of the provision of medical aid out of communal funds. In Chapter XXIII are set out the conditions of medical aid which humanity and science demand. In various chapters are stated the chief characteristics of medical aid in the U.S.S.R. The arrangements we have described should be judged on their merits and apart from any preconceions or prejudices as to state socialism. The worst slavery is that of the mind whichwhen right and wrong are not concernedprejudges a social activity according as it fits or does not fit a pet doctrine as to the constitution of society. Happily most countries have refused to be bound in this way, and we are thus the freer to sum up the merits and demerits of Russian medicine as presented in this volume.

In every civilized country medicine has become more than half socialized. There is more hospital and institutional treatment of illness (including insanity) than domiciliary treatment. Much domiciliary treatment is partially or entirely a state or municipal service, including the various sickness insurance schemes; and except in Britain and America nearly all hospital treatment is a state service. Even in these two countries it is to a very great extent a state service.

It is unnecessary to detail here the various state services for mothers and their infants, for the poor, for such special diseases as tuberculosis and venereal diseases; but it can be safely affirmed that in all countries west of the U.S.S.R., total official, bulk larger than total private, medical activities.

The position of the U.S.S.R. as already seen is very special. In some essential particulars it has surpassed all other countries in its socialization of medicine. It has removed the doctor almost entirely from the field of monetary competition, and has thus abolished a chief source of inadequate medical service. It has made a gratuitous (that is, statepaid) medical service of an astonishingly complete character promly available for the vast majority of urban populations, a service which is being rapidly extended to rural Russia; and it has given the whole of this service an admirable turn in the direction of social as well as medical preventive measures.

It has constituted a single unit system of medical service for the population, freed from the complications, overlappings, and gaps of western medicine. However, the occurrence of gaps in the service for rural Russia is admitted.

These are great achievements. The new arrangements are far from perfect; but perfection could not be expected after only a dozen years of strenuous organization. But other countries may well envy Soviet Russia's elaborately centralized government in this respect, in that it has been able to brush aside all past complexities and to initiate a nearly universal national medical service on unified lines, untrammeled by such complications as exist in western Europe and America. There are some advantages in starting, as Russia has done, almost from zero point; but the realization of unification and of universality of a satisfactory medical service, available for all who cannot now afford it, should not be beyond the reach of other countries. Almost certainly, however, progress in western countries towards the goal of a national medical service will not follow the exact procedure which Russia is adoing.

To mention only one problem, those countries which remain capitalist will be likely to continue direct weekly payment by the worker in sickness insurance, so far as monetary benefits are concerned; for such direct payments by the future beneficiary give an obvious personal stake in social insurance. It is an open question whether this will continue to hold good for medical benefits.

So far as concerns the medical part of social insurance and the wider problem of a unified medical service, the objects and ideals are those categorically set out in Chapter XXI, to which the reader's attention may once more be drawn.

What Russia has accomplished in its courageously original schemes for the health and social wellbeing of its people constitutes a challenge to other countries. The Reverend Doctor Harry Emerson Fosdick recently [As reported in the New York Herald. Tribune, January 23, 1933.] interpreted the significance of this challenge for one country, when, speaking of communism and in relation to America, he said: "... the only method by which the United States can prevent its adoion is to display equal efforts in a drive for social reform ... those communists in Russia really are on fire with sacrificial and determined zeal, at all costs, even at the cost of ruthless persecution, to build what seems to them a more decent society, and the only way we can ultimately compete with them is to be, at least, equally zealous for social reformation." And he concludes: "What if in the end these atheists in Russia should turn out to care more for building a better social order than we Christians in America do? That is the moral crux of the competition between us."

The issue here is clearly put, subject to an adequately inclusive definition of "a better social order." Can such an order in the fullest sense be created, which does not include recognition of man's spiritual relation to the divine?

Given this more complete definition, the issue is not so unequal as may appear; but the challenge remains: a challenge which western civilization must accept and meet.