Socialized medicine, 1917-2017

This year millions felt the Bern for single-payer healthcare in the US, and have continued to mobilize against Trumps’ attacks on healthcare and social security. With increasing interest in both socialized medicine and socialism, it’s useful to review their rise and fall 100 years ago in revolutionary Russia.

Most discussion of the Soviet Union falls into two camps who both see continuity between Lenin and Stalin: right-wing anti-Bolshevism condemns the 1917 revolution and sees it leading inevitably to the gulag, while Stalinist apologists defend the repressive state that emerged from counter-revolution. In 1977, during the Cold War, public health researcher Vicente Navarro wrote Social Security and medicine in the USSR: a Marxist critique, which challenged the right-wing dismissal of the gains of 1917 while exposing the Stalinist reversal of these policies.

Revolution in health

Under tsarism medicine served the nobility in both provision of services and ideological content—reducing illnesses to narrow biological and individual causes that deflected from the poverty and exploitation that produced recurring epidemics. As one Russian physician described, “Medicine is a science dealing with the treatment of the rich only. It relation to everybody else, it is merely a theoretical science dealing with how they could be cured if they were rich.”

In the wake of strike waves that culminated in the 1905 revolution, the Tsar was forced to offer a limited social insurance program that provided few benefits to a minority of workers—along with the creation of a limited legislative assembly, the Duma. The Bolsheviks exposed the limits of the program and the assembly by campaigning inside and outside the Duma. They demanded a widespread social insurance plan that would provide benefits equal to earnings, covering all wage earners and their families, with all costs covered by the employer and the state, and provided in all cases of accidents and illnesses, old age, death of the breadwinner and maternity leave.

The February revolution of 1917 created a situation of dual power, balanced precariously between the Provisional government and the democratic councils of workers, peasants and soldiers (soviets). To defend their professional privilege, a majority of doctors campaigned against the Bolsheviks—as many continued to do against attempts at universal healthcare the US, Medicare in the US or broad reforms in Chile under Allende (who Navarro advised). But the Bolsheviks built support among a minority of physicians and a majority of health workers.

In October 1917 the Bolsheviks, democratically elected to a majority in the soviets, organized an insurrection that took power. As Navarro explained, “It is symptomatic of its priorities that the first decrees signed by the new government…were the peace offer to Germany (not accepted until 1918), the legalization of the peasantry’s and workers’ takeovers, and the establishment of a comprehensive social security system.” The Bolshevik slogan “all power to the Soviets” meant power over the healthcare system as well, including a deprofessionalization and democratization of the health sector that would see all health workers within the same union at the same pay and at the service of local soviets. Similar developments emerged in revolutionary Egypt in 2011, when hospital unions began organizing all health workers together, undermining the traditional hierarchy in health care.

The massive expansion of social security was accompanied by a quantitative and qualitative expansion of physicians, tripling the number of doctors and reversing historic inequalities. As Navarro explained, “Prior to the Soviet Revolution, women composed less than 10 percent of all medical students…Similarly, Jews were allotted a special quota of no more than 3 percent of total enrollment. In contrast to that situation, the Soviet Revolution made a commitment to open the university to both sexes and all classes and races previously discriminated against, and in medical and all other schools preference was given to applicants from the working class and peasantry, as well as to women.”

Deadly counter-revolution

While there was the start of a revolution in the production and distribution of healthcare, it didn’t have time to revolutionize its content—which remained dominated by biomedical ideology. Without successful revolutions elsewhere, revolutionary Russia was isolated by economic blockade, invaded by a dozen armies and forced into focusing on production at all cost to survive—which the rising Stalinist bureaucracy turned from a necessity into a virtue. As Navarro explains, Stalin killed most of the old Bolsheviks and reversed every gain of the revolution: using social insurance as a weapon to force workers to produce, reducing maternity benefits, recriminalizing abortion, reintroducing a hierarchy of labor and income differentials, and turning healthcare into a tool to increase the efficiency of labour and the accumulation of capital.

While the majority on the right and the left saw the Cold War as the competition between two totally different societies, Navarro’s analysis drew out what they shared in common: “There are elements of similarity, both within and outside medicine, between the United States and the USSR. And those elements translate a similar commitment in both societies to capital accumulation as the first objective, with concomitant and consequent mass industrialization and specialization and hierarchicalization of labor. Both those processes of industrialization respond to the needs of different constituencies, ie the capitalist class in the United States and the dominant class in the USSR, the top echelons of the Party.”

Nationalization vs socialization

By exposing the Stalinist conception of top-down management, Navarro draws a distinction between nationalization and socialization (though he doesn’t apply this same distinction to the Cuban regime): “the nationalization of a sector of economic or social activity (like the health sector) can only be referred to as the socialization of that activity when it improves the direct control over the activity by the population. In other words, nationalization is socialization only when it is part of a process toward the democratization and self-government of the people. And the degree of socialization in that activity can be measured by the degree of popular participation in the running of that activity.”

This applies to current national health systems, from the NHS in Britain to Medicare in Canada, which have been vaguely define as socialized. These were the result of popular demands and broadened access to healthcare, but did not revolutionize the control of health resources—which has made it easier for the gains to be gradually stripped away: “the nationalization of the health sector in Great Britain in 1948 by the Labour government was a very positive step that undoubtedly benefited the majority of the British population,” but “the NHS and its institutions have not received any direct form of input from the British population. And the reforms that are currently taking place in the NHS are primarily aimed at even further strengthening the managerial forces as opposed to strengthening the workers’ and communities’ input.”

A hundred years after the Russian revolution and 40 years after Navarro’s book, the lessons he outlines still apply. Whether it’s the defense of Medicare or the NHS or demands of single-payer healthcare in the US, reforms over the distribution of healthcare can be part of movements to revolutionize the production and control of healthcare and society in general.

As Navarro concludes, “a socialist process in medicine is not the change of the control over medicine from one party to another or from one minority to another, but most importantly, the process whereby the concept and meaning of medicine change as well, ie, from the bourgeois, individualist understanding of medicine to the collective, political, and mass understanding of medicine, resultant from massive popular participation in the decision-making and implementation of whatever form of medicine may evolve in a socialist society…Second, another conclusion to be drawn from that initial experience of the October Revolution period is that a socialist process in medicine is not possible unless it is part and parcel of the larger process of democratization of the entire society.”