Social Medicine in Eastern Europe: The Organization of Health Services and the Education of Medical Personnel in Czechoslovakia, Hungary, and Poland [Reprint 2014 ed.] 9780674593503, 9780674593497

Citation preview

SOCIAL MEDICINE IN EASTERN EUROPE The Organization of Health Services and the Education of Medical Personnel in Czechoslovakia, Hungary, and Poland

A COMMONWEALTH FUND BOOK

SOCIAL MEDICINE IN EASTERN EUROPE The Organization of Health Services and the Education of Medical Personnel in Czechoslovakia, Hungary, and Poland

E. RICHARD WEINERMAN, M.D. With the Assistance of Shirley B.

Weinerman

HARVARD UNIVERSITY PRESS Cambridge, Massachusetts

/ 1969

© 1969 by the President and Fellows of Harvard College All rights reserved Distributed in Great Britain by Oxford University Press, London Library of Congress Catalog Card Number 72-78525 SBN 674-81380-4 Printed in the United States of America

PREFACE

The rapid process of urbanization and industrialization now affecting so many areas of the world has created wholly new health problems at the same time that vast new resources for health protection are becoming available. In this context, especially, there is a compelling need to re-examine the methods by which health services are organized and health personnel prepared. Conditioned and characterized by the different economic and political systems currently competing for popular attention and support, a variety of health schemes and training programs have developed which invite investigation. If the new problems are to receive effective new solutions, the lessons gained from this type of comparative study must be identified and shared. Particular emphasis has been given to health matters by the socialist countries of Eastern Europe. But while there is an increasingly vigorous exchange of information between the Soviet Union and the United States, comparatively little is yet known in this country of the health services in the smaller nations of the socialist group. This study was undertaken, therefore, in an effort to narrow this informational gap. Because I had the opportunity to conduct a field study of medical care and some aspects of medical education in Western Europe in 1950 under World Health Organization auspices (1), I had hoped to be able to make some comparative assessments between the two groups of European countries. The time lapse between the two sets of observations, however, makes such direct comparisons difficult to validate. My interest in this study was further stimulated by a more recent assignment to review current American and European research into the organization of medical practice (2) and by past studies of medical care among specialized groups in the

vi / Preface United States such as the American Indian and Eskimo populations, industrial labor groups, and Appalachian coal miners. The study in Eastern Europe was financed by a Senior Faculty Award from The Commonwealth Fund, supplemented by support from Yale University and the Yale-New Haven Hospital. The field observations were conducted during the spring of 1967, the month of April being spent in Hungary, May in Czechoslovakia, and June in Poland. I also devoted a short period to interviews and library research at the Geneva offices of the World Health Organization prior to the field work, and worked briefly at the European Regional Office of W H O in Copenhagen following the observational activities. I had originally intended to spend enough time in selected countries of Western Europe to update the information on the organization of social medicine in these areas, but had to abandon this plan for personal reasons. I did, however, review the recent literature on the subject and spend approximately one week in Norway studying various aspects of health service organization in that country. All field observations in Eastern Europe were conducted personally with the assistance, in most situations, of my wife, Shirley B. Weinerman, whose experience in community health work enabled her to concentrate especially on aspects of maternal and child care and social welfare services. In addition to the general aim of gathering information on the programs of health care and kinds of professional training available in the three selected countries, two other specific objectives were defined. One was to assess the relative importance of the system of health service organization, on the one hand, and of the pattern of medical education, on the other, in influencing the nature of medical practice. The second was to examine in some detail teaching and research activities in the field of "social medicine"—defined for this purpose as the scientific discipline concerned with the social factors affecting health and social methods of health protection.

Preface

/ vii

The program of study consisted essentially of four parts: one, review of available published information; two, structured interviews with health personnel on all levels of policy-making, administration, service, education, and research; three, direct observation, both organizational and clinical, of service and training activities; and four, analysis of published and collected information. Within each of the countries visited, an initial period of about one week was spent in learning as much as possible about the theoretical structure of the health services and about the nature of professional training in the health fields. The remainder of each monthly study period was devoted to direct observation and to discussions at all administrative levels with personnel from the widest possible variety of health service and academic activities. The lists of places and individuals visited are presented in the Appendix. In each country this included at least the following: the national ministry of health, national research institutes, schools of medicine and of allied health professions, postgraduate medical training institutions, regional and district health departments, hospitals, polyclinics, local health care offices, maternal and child health centers, industrial medical units, emergency medical stations, sanitation and epidemiological units ("sanepid stations"), cooperative and private medical offices, nursery schools and kindergartens, rehabilitation centers, and facilities for such special problems as mental illness, tuberculosis, children's disabilities, and so forth. In each service or academic unit, I discussed the overall program with responsible directing personnel, inspected the physical facilities, examined records, and—since I am experienced in the clinical practice of internal medicine as well as in public health—it was possible to observe directly the care of patients at each organizational level. I was able to make rounds on hospitalized medical patients, to witness general and specialist office practice, and to observe patient care in emergency situations,

viii /

Preface

factory units, nursery schools, and university clinics. Such observations were made in urban, small-town, and rural settings. W e were able to surmount the language barrier almost completely because of the constant availability of expert interpreters and the direct use of English or mutual secondary languages (French and German). In addition, a considerable amount of descriptive and statistical material was made available in English. In each of the three countries visited, the Ministry of Health acted as official host and sponsor, facilitated all study arrangements, and provided a car and driver as well as an interpreterguide for all trips where transportation or communication was difficult. It should be stated clearly that no aspects of the health service were closed to our observation, that no restrictions were placed on either our professional or tourist travels, and that every possible assistance in the conduct of the study was afforded by official personnel as well as by our informal associates. It should also be stated that not every aspect of health service and education could be examined with equal thoroughness. The specific focus of the study made it necessary to assign priority to the work of the physician in ambulatory settings, to personal rather than to environmental health services, and to the training of doctors rather than allied health personnel. Certain quite important specialized activities, such as the pharmaceutical program, communicable disease control, treatment of mental illness, public health education, and clinical research, had to be reviewed only in the more general context. For this reason, the descriptions and commentaries of this report are addressed primarily to those aspects of medical care and medical training which were given primary attention. It is also important to note that I am chiefly concerned in my own work with the organizational, rather than the technical, aspects of medical practice and with teaching and research in social, rather than in clinical, medicine. These aspects of the overall study were, therefore, also given special attention.

Preface / ix

The report consists of three main sections: (I) general observations relating to all three of the countries visited; (II) presentation of data from each of the countries separately; and (III) personal commentary. In addition, there is separate discussion of the general characteristics of each country insofar as they affect health and health service, an analysis of the health services themselves, and descriptions of educational and research activities. While I tried to avoid the duplication of data already available, some simple tabulations and graphic illustrations are included to amplify the understanding of health problems, resources, and achievements. I am indebted for valuable counsel to the following American colleagues: Lester Breslow, Charles D. Cook, Martin Popper, George Silver, and Kerr White; and to European advisers Frederick Bauhofer, Karl Evang, Anthony Payne, and Michael Sachs. I deeply appreciate the cooperative and friendly spirit shown by all those persons interviewed during the study as well as by their many associates whose names may not appear on the appended roster. Special thanks go to our official hosts in each country and—through them—to their colleagues who made such useful and agreeable schedule arrangements: Dr. D. Felkai in Hungary, Professor Ö. Smahel in Czechoslovakia, and Dr. K. Kostecki in Poland. I would also like to express gratitude for the wisdom and patience of our major interpreter-guides: Mrs. Ericka Szücz in Hungary, Dr. Oldrich Uhlir in Czechoslovakia, and Mr. Stanislaw Trzcinski in Poland. I am deeply indebted to the officers and staff of The Commonwealth Fund and of the Yale-New Haven Medical Center for their generous financial support of the study and to my colleagues in the Office of Ambulatory Services of the Yale-New Haven Hospital and in the Departments of Medicine and of Epidemiology and Public Health of the School of Medicine for

χ /

Preface

shouldering my responsibilities so uncomplainingly during my absence. The successful conduct of the entire study is due, in large measure, to the support and forbearance of my wifecollaborator, Shirley Bäsch Weinerman. While the study would have been impossible without the assistance of all these individuals, the responsibility for the descriptions and formulations contained in this report is, of course, mine alone. New Haven, Connecticut September 1968

E. Richard Weinerman

CONTENTS

I: General Observations Relating to All Three Countries

II: The National Health Programs of Czechoslovakia, Hungary, and Poland

Czechoslovakia

42

Hungary

82

Poland

1

42

117

III: Commentary and Conclusions

156

Appendix: Persons and Places Visited

181

References

194

Index

197

TABLES 1. Demographic and geographic features by country, selected years

3

2. Government expenditures for health services as compared with United States, 1964

5

3. Vital statistics by country, selected years

8

4. Leading causes of death by country, 1938 and 1965

9

5. Incidence of reported communicable diseases by country, 1965

11

6. Resources for health service by country, selected years

12

FIGURES 1. Government Organization in Relation to Health Services

19

2. Health Service Organization in Relation to Government

20

3. District and Local Health Service Organization

23

SOCIAL MEDICINE IN E A S T E R N EUROPE The Organization of Health Services and the Education of Medical Personnel in Czechoslovakia, Hungary, and Poland

I I GENERAL OBSERVATIONS RELATING TO ALL THREE COUNTRIES

The formal economic and political structures of the three countries under study are essentially similar, as is the organizational pattern of their health services. This basic similarity reflects the postwar circumstances in which the socialist revolutions took place in Eastern Europe, the pervasive influence of the Soviet Union, and the common historical forces which have long interlaced the destinies of the peoples living in the heartland of the Continent. (3-8) Yet national differences, both gross and subtle, do exist and are also reflected in the various health service systems, demanding recognition by those who would understand current events in these countries. Here, explanations must be sought in the individual history, geography, and culture of each of the three nations. (9-14, 21-25, 30-32) While it is beyond the scope of this study to deal directly with such matters, it is essential that their relevance be appreciated in any effort to assess the problems and achievements of the health services in this part of the world. Patterns of social organization, planning objectives, essential priorities—all have been set more by economic and political requirements than by purely medical considerations. The crucial factor of adequacy of material resources is determined almost wholly by forces outside the health field itself. It is also clear that the present health service programs were not organized in a medical vacuum, but were themselves conditioned by, and additions to, the more or less developed systems of social insurance and public welfare which had preceded the socialist regimes.

2 / Social Medicine in Eastern Eur ope FACTORS INFLUENCING HEALTH SERVICE The impact of history, both remote and recent, is evident in almost every facet of the health problems and programs of these countries. For over 1,000 years the various tribes and clans of middle Europe attacked, subjugated, and resisted each other, or, alternately, merged with one another. In centuries past they defended themselves against eastern invaders; today they join together in blocs which sense threat from the west. The resultant pattern is one of small, often landlocked, rarely self-sufficient national entities whose population profiles are as often the result of military fortune as of ethnic self-determination. The overwhelming historical influence on the health and social services of the Eastern European countries is that of the Nazi occupation and the devastation left by World War II. In 1945, when the new governments began to emerge, large segments of the population had been wiped out, material resources were in large measure destroyed, malnutrition and disease were widespread, and medical and sanitation systems almost wholly disrupted. It is essential that the outside observer relate the current level of achievement in the health field to this historic baseline rather than to the attainments of more fortunate countries. The countries under study are, as indicated in Table 1, essentially small, demographically stable, densely populated, and increasingly urban, with relatively good networks of communication and transportation. In some contrast to the limiting economic factors, these features of size and accessibility contribute positively to the function of a unified health service system. This generalization is somewhat less applicable to Poland, with its larger land area, more rural economy, and more scattered population. While the form and structure of the national health programs are the product of ideological and political decisions, their content and level of adequacy are determined largely by economic considerations. As indicated above, all three of these countries

General Observations / 3 υ-ι

ΓΑ

CN

γα

Ό C rt

ΓΑ

00 •Φ