Child care in Russia

C H I L D C A R E IN

RUSSIA

HARRY BAKWIN, M.D. NEW YORK, N. Y. U R I N G July, 1956, Dr. R u t h Bak-

D win and I spent three weeks tour-

ing the principal cities of E u r o p e a n R u s s i a - - L e n i n g r a d , Moscow, Stalingrad, Rostov, Odessa, and Kiev. I n all these cities we talked to p r o m i n e n t pediatricians a n d visited children's hospitals and other child care institutions. I t is not easy to obtain information in Russia. Visits to hospitals, outpatient departments, nurseries, and universities must be a r r a n g e d beforehand through official sources and definite a p p o i n t m e n t s m u s t be made. No great difficulties were encountered until we reached Moscow. There Intourist, the official Russian tourist agency, asserted t h a t it was not its function to a r r a n g e hospital visits, t h a t it h a d to do only w i t h sightseeing; and Voks, the society for cult u r a l relations w i t h foreign countries, t o o k the position t h a t it was concerned only w i t h "culture," a n d hospitals were not culture. Taunts such as, " A r e you, perhaps, a s h a m e d to let us see y o u r h o s p i t a l s ? " a n d " S h a l l we go b a c k to A m e r i c a and tell our colleagues t h a t we were not p e r m i t t e d to see y o u r h o s p i t a l s ? " seemed to have no effect. When, a f t e r f o u r d a y s of concent r a t e d effort which was getting us nowhere, the Ministry of H e a l t h fiF r o m t h e : D e p a r t m e n t of P e d i a t r i c s , N e w York University College of Medicine. and Children's Medical Service, Bellevue Hospital.

nally learned of our presence through a fellow American, the gates were opened, and we were given a cordial reception. A g r e a t b a r r i e r to getting information in Russia is the evasiveness and, sometimes, d o w n r i g h t p r e v a r i c a t i o n of the Russians. T h e y seem to be a f r a i d to say a n y t h i n g which m a y be i n t e r p r e t e d as critical of their system of c h i l d care. All questions are a n s w e r e d b y the director who, like directors elsewhere, m a y not be intim a t e l y acquainted with the minutiae of hospital w a r d practice. Conseq u e n t l y one gets glib answers like, " T h e d e a t h rate f r o m severe d i a r r h e a in babies is one-half per c e n t . " Simil a r l y wild a n d obviously ridiculous s t a t e m e n t s are m a d e r e g a r d i n g the small n u m b e r of p r e m a t u r e babies lost. As an example of the evasiveness of the Russians, in all our visits to Russian hospitals we did not see a single acutely ill child. There are, of course, acutely ill children in Russia as elsewhere. I t is obviously not possible for a visitor to see every child in a hospital with several hund r e d child p a t i e n t s - - o r to look into e v e r y nook and corner. I believe t h a t these children were not shown to us because, in t h e i r own distorted way, the Russians r e g a r d a sick child as a defeat for their "prophylactic" prog r a m which I will describe later.

313

314

T H E J O U R N A L OF PEDIATRICS

For these reasons we have attempo ted in this account to describe, so far as possible, only what we saw. When we had to rely on what we were "told," that is explicitly stated. Surprising. was the large number of physicians in the various clinics and

otolaryngologists, dentists, and others. The clinics are equipped with quartz lamps, high-frequency machines, diathermy machines--apparatus which is of little use in the general treatment of children--and these are proudly demonstrated to the visitor. Children hospitals. It is not clear how they are brought here for check-ups and occupy their time. For example, at also when they are sick. If a house an obstetrical hospital where 300 call is necessary the parents telephone babies are delivered each month there the clinic or call in person and are told are thirteen obstetricians and three the approximate time when the physipediatricians. Normal deliveries are cian will make the visit. Despite the managed by midwives. Even if the large number of doctors, appointments doctors were to deliver the babies at the clinics are not kept rigidly and themselves there would be less than it is customary to wait about an hour. one delivery per day per doctor. Pre- The patient usually sees the same docnatal and postnatal visits would be tor each time unless he is off duty. hardly enough to occupy the doctors' The only person with whom I had an time. I t is also hard to figure out opportunity to discuss this told of what three pediatricians do with their having four different doctors for his 4-year-old child. Sometimes when the time in such a hospital. Dr. C. Fraser Brockington, pro- mother comes to see the doctor she fessor of social and preventive medi- may find him surrounded by a group cine in the University of Manchester, 1 of a dozen or more students. No charge is made for medical care was similarly impressed by the superabundance of doctors. In a 450-bed but the parents must pay for medicamaternity hospital which he visited tions. Doctors work six to six and a hal:[ in Tashkent there were seventy-five doctors. Here again there would be hours a day, two hours less on Saturless than one delivery per doctor per days, and they are free on Sundays, A certain number are on call evenings day. In the pediatric hospitals and clinics and weekends. Consequently, in case the doctors seemed to "stand a r o u n d " of illness after hours or on weekends, a great deal. Much time is spent in the patients are seen b y different filling out elaborate hospital records. doctors. When the Russian doctors were told The hospital charts are voluminous and contain diagrams illustrating the that American physicians work about child's hospital course. sixty hours or more a week they exChild care is distributed through pressed sincere sympathy for their opthe district clinics which may or may pressed and overworked American not be connected with a district hospi- colleagues. The Russian pediatricians work, for tal. There are no doctors' offices in our sense. The clinics are manned by the most part, like junior hospital pediatricians and, in addition, by a interns. Except when making house group of specialists--ophthalmologists, calls, they work under supervision.

BAKWII~."

WELL-BABY

CHILD

CARE

The Russians take great pride in their preventive program. This program is, in a general way, similar to that practiced here and in much of the western world. According to our informants, children are seen monthly during the first year of life but more often during the first three months. Mothers are said to remain in the obstetrical hospital for seven to ten days. The infant death rate in the large cities, judging from the appearance of the children, is probably low, but in the absence of accurate data it is easy to be misled. According to Dr. Brockington, who visited Russia in the fall of 1955, "the diet for both adults and children is almost certainly low in prorein and there seem to be no measures of priority feeding." Presumably by "priority feedings" he refers to special food allowances for pregnant women, children, and so on. I t is not possible to make any estimate of rural death rates since ~oreigners are not permitted to visit villages. With few exceptions babies in Russia are breast-fed. This applies to the professional groups as well as to the laboring classes. Babies are still fed every three hours, and women are given time off from their work to go to the factory nursery to nurse their babies. Babies are still swaddled. The Russians use three layers of swaddling cloth under which the baby wears a shirt and diaper. Although the babies are swaddled tightly, they seem quite comfortable and contented. Prophylactic inoculations are given against smallpox, diphtheria, and

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tuberculosis. Inoculations against tetanus are not given in Russia because, we were told, " t h e r e is no lockjaw in the U.S.S.R.," an obvious absurdity. Poliomyelitis is uncommon in Russia. A small epidemic occurred in Stalingrad in 1954, and as hygiene improves it will probably become an important problem there as elsewhere. Russian doctors showed no curiosity regarding American pediatrics and never volunteered questions. When we offered to answer any queries which they might have, they asked only about the Salk vaccine. Vitamins are given to all infants and great reliance is placed on them. Thus we were told in Leningrad that children with pneumonia are treated with penicillin and "vitamins." The vitamins used are vitamin C, niacin, and "vitamin B." These are given "to increase resistance to infection." Check-ups are continued throughout childhood, but it was not possible to find out at what intervals. When we asked what is done about mothers who fail to come back regularly for check-ups we were told that they always return. Although categorically denied by some physicians of whom we made inquiry, there is a certain amount of private practice in Russia. One father told of a consultation regarding the advisability of tonsillectomy for his child for which a fee of 100 rubles ~ was paid. Some persons, impatient with the time required in going to the clinic to make an appointment, the inconvenience of the hour of the appoint* T h e official r a t e o f e x c h a n g e is 25 c e n t s f o r a r u b l e . A t t h i s r a t e a p a i r of s h o e s c o s t s approximately $100, a n embroidered shirt $100, t h e c h e a p e s t m a n ' s s h i r t $20, a m a n ' s s u i t o v e r $200, a n d a c h i l d ' s c o t t o n d r e s s $25 t o $40.

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ment, the waiting, and the lack of privacy, p r e f e r to p a y a doctor to be seen in private. TRAINING

Ol~ T H E

PEDIATRICIAN

The medical course in Russia lasts six years. The average age at e n t r y to medical school is 17 years. The classes are v e r y large--700 at the F i r s t Moscow Medical Institute. I t is hard to see how such large numbers of students can receive the individual instruction which we consider necessary for the p r o p e r training of a doctor. Moreover, immense numbers of sick patients would be necessary if the students were to have sufficient clinical material. Training for the specialty of pediatries begins in the t h i r d year at medical school and continues until graduation at 23 years, when the physicians are considered to be qualified pediatricians. The number of physicians graduated each year in Russia is enormous. In the R.S.F.S.R. which includes about 110,000,000 out of a total population of 200,000,000 in U.S.S.R., 2,000 to 2,500 "pediatricians" are graduated each year. Leningrad alone, one of the fourteen schools in the R.S.F.S.R. which h a s a pediatric "institute," graduates about 330 a year. I n all of the United States there are about 6,000 properly qualified pediatricians. During their training, students receive an allowance from the government which is meager but seemingly adequate. On graduation, the physician is assigned to practice in a designated area. A certain amount of choice is g i v e n - he may select one of five or six locations. The salary on graduation is 800 rubles per month. (Our chauffeur's

OF

PEDIATRICS

salary was 1,300 rubles plus bonuses for using little gasoline, for keeping down car repairs, and so on.) The salary is increased every two or three years so that a physician ten years after graduation receives about 2,000 rubles monthly. A few of the top professors receive 6,000 rubles. A certain number of physicians ret u r n later on for advanced trai~ing. Pediatrics is the most popular of all the specialties. It is chosen by 30 per cent or m o r e of all the medical students. P s y c h i a t r y is the least popular of the major specialties. There is much less interest in child psychiatry than here in the States. F u l l y 90 per cent of the pediatricians in Russia are women. However, most of the leading pediatricians are men. A notable exception is Professor Olga Soko]ovna of Moscow who bears the title of Academician---the highest scientific title in Russia. Many of the hospital directors and public health officials are women. The principal pediatricians are, for the most part, of an age indicating that they were trained before the Revolution or in the twenties. HOSPITALS

The children's hospitals in Russia are housed in v e r y poor buildings. In none of the cities that we visited did we see a hospital that looked as though it had been built after the Revolution. Some are probably converted homes. The large hospitals consist of a number of separate buildings for different diseases--rheumatic fever, contagious diseases, infants' diseases, tuberculosis, and so on. The larger hospitals are generally surrounded b y extensive parks with beautiful, well-kept flower

BAKWIN :

CHILD

gardens and p l a y areas for the children who are well enough to go outdoors. Permission to visit a hospital m u s t be a r r a n g e d beforehand. The visit is made u n d e r the guidance of the hospital director or lais assistant and questions are answered b y him. The visitor is clothed in cap and gown; sometimes the wearing of masks is also required. Little effort is made to give the hospital an informal air. Although murals and toys are occasionally used, one

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g a r d to the qualities of the persons who r u n it. I n most of the hospitals which we visited, free visiting by parents was permitted. The wards are clean and free from flies and smells. The beds are closer together than in most American hospitals. The nurses lack the trim, efficient a p p e a r a n c e of the American nurses but they impress one as w a r m and motherly and kind. M a n y of the beds are occupied b y children with minor ill-

:Fig'. 1 . - - T h e C h i l d r e n ' s t t o s p i t a l i n L e n i n g r a d .

misses the colorful window hangings and the g a y furnishings which have become essential features of the modern American children's hospital. Oldfashioned glass cubicles are still widely used for the babies. W h e n we asked in each city to see the "best" children's hospital we were told that all were of the same high caliber, the inference being t h a t a prog r a m of child care has been p u t into operation which functions without re-

nesses--colds, stomach and intestinal upsets, acute hepatitis--cases which are not ordinarily admitted to American hospitals. There are several reasons for having these children in the hospb tal: most of the mothers work and consequently there is no one to look a f t e r a child--well or sick---at home. The homes are t i n y and crowded. The poorly trained physicians can hardly be expected to distinguish a really sick f r o m a well child and, eonsequently,

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where the least doubt exists, send the child into the hospital. When a physician makes a visit to a strange hospital, it is customary to show him unusual or rare diseases, difficult diagnostic problems, a n d newly discovered syndromes. During our visits to hospitals in the various cities we saw none of these. Instead the visits consisted of a walk through the wards, in the course of which we asked questions about the nature of the illnesses and their treatment. Conse-

:Fig. 2 . - - T h e

Children's Hospital

OF P E D I A T R I C S

When we asked about cardiac surgery in Leningrad we were told the children were sent for operation to Moscow. In Moscow we were told the patients were sent to Leningrad. Visitors to the permanent Agricultural Exhibit in Moscow are usually conducted through a pavilion in which is shown Russia's modern medical equipment for x-ray, electroencephalography, electrocardiography, anesthesia, and the like. The equipment is bright and shiny and impressive-

in M o s c o w in w h i c h t h e b e d s w e r e c r o w d e d .

quently it was not possible to gauge the knowledge of the Russians. By and large, treatment follows the lines used here and elsewhere in the western world. Most of the antibiotics available here--penicillin, streptomycin, Aureomycin, Chloromycetin--were found there--bearing Russian labels. We saw a great many children with rheumatic fever. Rheumatic fever prophylaxis is not used.

looking, but the practicing physician can hardly be expected to judge the quality of manufacture or the newness of design. The apparatus seen at the hospitals was, for the most part, shoddy and antiquated. When we asked when the new equipment was to be put into production the guide's answer was a silent shrug. Dr. Emery Rovenstine, professor of anesthesiology at New York University,

BAKWIN:

CHILD CARE IN RUSSIA

who visited Moscow in August, 1956, f o u n d the anesthesia a p p a r a t u s which was being demonstrated at the Exhibit, p r e s u m a b l y Russian m a n u f a c t u r e d , identical with the one he uses in his own d e p a r t m e n t here. Moreover, the Russian a p p a r a t u s had an a t t a c h m e n t for cyclopropane which is not used in Russia. W h e n he asked about the cyclopropane a t t a c h m e n t he was told t h a t it was there in case the use of cyclopropane is adopted later on. Anesthesiology is not regarded as a specialty in Russia.

Fig. 3 , - - u

319

journal was a copy of the April, 1956, issue of T H E JOURNAL OF PEDIATRICS. VITAL S'rATISTICS F o r some obscure reason vital statistics arc a state secret in Russia. No d a t a are available on births or deaths. I t was our impression t h a t the birth r a t e in the large cities was low--especially among the professional groups. W e saw few p r e g n a n t women on the streets and few children. Professional

people with whom we spoke usually h a d one childl occasionally two, often none a f t e r several years of marriage.

m o t h e r s at the Childrea's Hospital in Moscow.

LIBRARIES

The hospital medical libraries which we visited were v e r y poor. The books are, for the most p a r t , old and poorly printed, and the p a p e r is of inferior quality. The books are not w e l l arranged, space f o r readers is inadequate, and no effort seems to have been made for the comfort of the reader. We saw few English-language journals. The only English-language pediatric

The reason given for the small n u m b e r of children was inadequate housing. RESEAt~CH

The clinical research which we observed was not impressive~ I n Moscow a s t u d y was in progress on the application of the "conditioned reflex" in the t r e a t m e n t of chorea. On admission the patients were sedated with bromides. G r a d u a l l y a placebo was substituted

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for the bromides until finally the child received only the placebo. The sedative effect continued. W i t h this new t~eatment, we were told, the length of hospital stay was reduced from ten to s i x weeks. The statistical criteria would h a r d l y satisfy the critical investigator. Another study had to do with the effect of aerosols containing various antimicrobials on respiratory infections. In Leningrad the development of bacterial resistance to various drugs was u n d e r study. In Moscow the reflex responses of infants was being investigated. The babies were completely enclosed in a light- and sound-proof shell, various stimuli were applied, and the responses measured on revolving smoked drums. PERSONALITY

A

striking

OF

THE

feature

RUSSIAN

CHILD

of the Russian

child is his docility. We were impressed, in visiting a dental clinic, to see three small children seated in dentaI chMrs accepting the dentists' ministrations without any protest whatsoever. This impression was :~urther borne out by the relatively quiet play of Russian children. When we remarked on the quietness of the children in the hospitals we were told that they had been instructed beforehand to be good. NURSERIES

Working mothers keep their children in nurseries, m a n y of which are connected with the factories where they work. The children are deposited there in the morning and are generally taken home in the evening. The nurseries which we visited, like the hospitals, were neat and clean and the ehil-

OF P E D I A T R I C S

dren seemed contented. We were told by Russians that the nurseries varied widely--some good ones, some bad ones.

We had an impression that putting a child in a day nursery was looked down upon. No person whom we asked--all w e r e of. "professional" status--admitted that he himself had been reared in a nursery or that his child was being cared for in a nursery. The replies were that the mother did not work, or that a relative, usually a grandparent, looked after the child while the mother worked. It is easy to understand how regimentation in a nursery might lead to the docile personality which struck us

so lorcibly~ On the whole, the doctors impressed us as job-holders r a t h e r than professionals. W h e n their short day's work at" hospital or clinic is over, they go out and do their shopping--a major task in Russia since there are shortages and consequently much queuing-up, and since the tiny, overcrowded apartments have little space for storing. They then prepare the evening meal. They do not seem to understand the continued interest which physicians elsewhere have in their chosen profession. W h e n toId of the long hours spent by American physicians at their work they said it was " n o t allowed" in Russia. The principal interest--indeed, perhaps the sole interest of the Russian pediatricians--seems to be in the prophylactic program and in the care of the mildly ill. We saw no evidence of the great amount of time, effort, and money which are spent elsewhere on the care of children who are desperately ill. or who have unusual illnesses. At no hospital that we visited did we

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CHILD CARE IN RUSSIA

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happen on a elinicM conference. At a bottle of perfume; and in Leningrad, the large children's hospital in Moscow a busman, his night's work over and on a conference was held in our honor, his way to the garage with his bus, but there was no presentation or dis- seeing us standing in front of the cussion of patients. Instead, t h e opera waiting for transportation, inDirector made a flowery welcoming vited us into his bus and drove ns to speech and described the prophylactic the door of our hotel. program. Medicine, like everything' Our over-all impression of Russia else in Russia, seems to be geared to was one of poverty, drabness, mothe "greatest good to the greatest notony, lack of gaiety. One misses the number." well-dressed people, fine shops, shiny We were touched by the warmth ears, p r e t t y homes--even garish adand friendliness of the Russian people. vertisements. The tree-lined streets Again and again we were accosted on the street b y ICussians who, in frag- and the lovely flower gardens which m e n t a r y English, sought to express one sees in abundance in most of Rustheir friendliness. A t several of the sia's large cities and the occasional hospitals the young doctors picked imposing public building are n o t flowers and presented them to my wife. enough to lift the depressing' impresAt the university a young student un- sion. REFE;RENCE dertook to guide us; the " d i r e c t o r " of the children's railway in Kiev, a 17- 1. B r o c k i n g t o n , C. F.: P u b l i c H e a l t h in R u s s i a , L a n c e t 2: 138, 1956. year-old girl, presented my wife with