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Soviet time health and health care in Latvia

Being part of it

In 1979 after graduating from high-school, I had to make a choice, how should I go on? In school, biology teaching was interesting, we were injecting oranges, studying big back flies, experimenting them to death etc. And as my mother was an x-ray technician in a hospital, the smell of hospitals was familiar to me, and medicine became an obvious option. At twelve, a fifth grade school boy, I had been playing the part of a wounded person at a civil force rehearsal and had stolen some disposable syringes. That was also a starter. Besides that, if entering medical school, successful students could avoid compulsory Army service – a strong motivation in the year when Soviets invaded Afghanistan and the world situation was tense.

The competition for admission to medical school was hard, among four applicants for every one admitted, but I was lucky. The first years of the medical curriculum were a peculiar encounter between ideals and reality: Piles of books in chemistry, anatomy, histology etc, should be digested and regurgitated. Every year we had one subject covering ideology, starting with the history of the Soviet Communist Party, followed by Marxist philosophy, political economy with emphasis on benefits of socialistic planning economy, scientific atheism, ending with scientific communism. On political holidays, such as May 1, the International Workers’ Day, and on November 7, the celebration of the Great Revolution, we had to participate in demonstrations and were checked that we did so. Was this a part of medicine? OK, we could joke about the situation, but we did not object so much, we were simply in it. On the other hand, objecting could lead to unpleasant experiences, and loyalty could be rewarded in many ways. So we read the speeches of Lenin and the history of the League of Young Communists (Komsomol) and so forth.

We were working in groups of ten to twelve, a good principle for learning. 160 Latvian students were divided into such groups and taught in Latvian, 100 Russian students in the same way were taught in Russian. In each group there were so called informants, which we could not exactly identify. They reported upwards on our political behaviour – we knew that, it was part of life. Once I was offered by a KGB representative to become an informant, but I declined for a series of reasons. Such offers often were accompanied by temptations, for example to get a stipend, to go abroad and so forth, and it might even have been dangerous to decline.

However, when looking back on these student days, I think that we perceived the situation as normal, we led a happy, yet simple life, reading and partying, sometimes appearing at the anatomy demonstration in such a shape that when somebody fainted, the teachers thought it was due to the sight of the preparations. We did not reflect so much on things that might have been different.

There was an ever present feeling of insecurity which was perceived as normal. «Kitchen parliament» was an expression frequently used. People unplugged their telephones and went into another room when stuff should be discussed or when jokes should be told. You could never know who was listening. A sort of general paranoia was not perceived as such, it was just what the world was like.

The first glimpses of real medicine appeared in the third year. Only after half of the study years did we experience what medicine really is in hospitals and at other encounters with patients. When we were confronted with real life, this real life admittedly lost some of its thrill. Years went on, and we probably became more and more qualified as medical students and physicians.

However, there were also other parts of medical life to go through. We had military training as part of the curriculum. In the military classes some of the students were very interested, posed questions and kept the teachers occupied. The rest kept the time going with activities under the desk, playing peasant chess, a clandestine game of cards or simply reading a book. In the beginning of the eighties Rubik’s cubes were popular, and you could see hands eagerly turning the cubes under the desks. One day the colonel announced with a sombre face that a serious thing had happened to the country: the message had come that Secretary General of the Communist Party of the Soviet Union Mr. Leonid Brezhnev had passed away. He caught the attention of the audience only briefly. The faces of the students did not react that much. Rubiks continued to be turned. I remember that I was reading Bulgakov’s «Master and Margarita» under my desk when the announcement was given. I was just arrived at the point where she rubs herself with ointment in order to be able to fly. I proceeded to read, as it was exciting.

Political unrest, a case for whom?

These early eighties were quite special years. We were taught that socialism was near its peak and soon real communism would be here, the real happy stage. At the same time the halt and stagnation in the Soviet Union was quite obvious to everyone. There was almost nothing in the shops. You had to line up for a long time to obtain necessities of food and clothes etc. And shop sellers and other people distributing goods became key persons in the world around you. Money piled up, although in humble amounts, but there was only very little to get from them. Was this the road to the ultimate happiness?

During the mid eighties some parabola antennas came up in Latvia and gave the TV-watchers glimpses of the Western world, creating headaches for the KGB of how to handle this information attack from the West. It was even worse when video equipment appeared. It was very expensive, which indeed limited its popularity, but with the video came an additional cultural attack: Latvians could watch Western movies, entertainment programmes, political documentaries and even pornography. More importantly, they could also see foreign reports from the big non-communicated issue of the time – the war in Afghanistan.

I think that the students’ attitudes to political events like the death of Brezhnev were quite typical. Politics was there, but it was simply going on outside our world. On the other hand, without knowing we were quite right when we did not react that much to the important death of the Secretary General. Under his successor Konstantin Tchernenko nothing special happened, and under the next, Andropov, stagnation proceeded even more, and people were checked in the streets by the police if they had left their working places during normal working hours.

When Mikhail Gorbachev doubled the price of alcohol, it was obviously a good idea in light of the health and working hours lost through binge drinking, but not for us trying to get hold of alcohol for festive occasions.

Days of a doctor

Thirty days of compulsory military service concluded the studies. For me, it took place in the Kaliningrad Oblast, in the city of Sovetsk. After that I obtained my final papers which I presented to the head of the hospital of Jelgava, where I had my mandatory hospital service. A one year internship in Jelgava City Hospital was followed by three compulsory years in a district hospital in Kalnciems, some twenty-five kilometres from the city but still in the Jelgava district. At that time this hospital was mostly used for long term care, for patients with back pain, pneumonia, peptic ulcers, and so forth. At my disposal, in terms of advanced equipment, were an electrocardiograph, an x-ray machine and some laboratory tests – blood count and urinary analyses. Biochemistry services were only available twice a week. We were two and a half physicians responsible for around seventy beds. There were ambulance services as well, so we had to perform first aid and minor surgery too, based on a minimum of equipment and assistance and with limited professional experience.

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Jelgava, January 2001. Fishing for fun or for food?

I often had to rely on my books. I had to go to my office and read what to do. Back to Bulgakov: I felt like the doctor in Bulgakov’s short stories; he was educated as a doctor himself. Anyhow, books were indispensable for daily work. Many of these, basically, Russian books were not even too up to date. I still remember my pride and happiness when I had succeeded in buying a copy of the prestigious Harrison’s Principles of Internal Medicine as a student in 1984. It cost me a personal fortune, but I praised every word in it.

One day a week for years I did night shifts in the Jelgava City Hospital. When on duty there, the doctors were alone and carried responsibility for three hundred patients, many of them critically ill. Apprehension and anxiety was a frequent feeling, not on behalf of myself, but for the patients. Still, I often recall the smell and the mood of the hospital nights, especially at five o’clock in the morning, before relief came in the form of the experienced nurses who came on duty at seven. It was a strenuous time, but that sort of service is an underestimated part of the hard-way-training to become a physician. My four years in the Jelgava region were a very good training period. Even if many conditions were rather primitive, colleagues were supportive and interested. At that time, the knowledge, skills and paedagogic abilities of the senior physicians were of paramount importance to the trainees. As a young doctor, you had to work hard, and your boss might give you opportunities to participate in activities which really gave you insight in health and biology. So, in the Jelgava hospital I was expected to be present at every autopsy performed on patients from our department – a highly appreciated training element.

Perhaps the basic setup of Soviet style medicine even enhanced the training effect. In Soviet times medicine was paternalistic. The doctor, in a way, took over the patient’s problems and responsibility. This posed a special stress on the requirements to be accurate and confident. A young intern there might encounter special problems, such as in the collaboration with seasoned old nurses. For example: The century-old practice of blood cupping on the back was used in the treatment of pneumonia. The nurses snubbed to me in public over my objection that I had to wait with giving them advice until I no longer had milk under my young nose. Such experiences are probably shared by all new doctors, irrespective of health care system

At that time, when the ideology was that the health care system took over the patient’s disease, the system really took it over for quite a long time. Patients stayed normally in hospital for a relatively long period: A peptic ulcer patient three weeks, a cardiac infarction four weeks, back pain up to two weeks. Recovery from surgery required a minimum of two weeks. The system was hospital and specialist oriented. This of course required a large amount of hospital beds. In light of what has happened elsewhere and in other countries of the world, was this a waste of resources? Not necessarily. The cramped conditions in most apartments made the caring of a patient at home difficult. Almost no primary health care existed in the modern sense. District paediatricians took care of the children and there were district internists for the grown-ups, with limitations to what conditions could be treated in out-patient settings.

Another hallmark of Soviet medicine, was that the doctors had to make do with basic instruments and diagnostic equipment. The traditional physical examination was the really valuable tool for daily work, and the skills had to be good. When you once have learnt the special sounds of, say, some peculiar lung infection or of a subtle heart failure, these sounds are yours. You will recognise them when you meet them again. The simplicity of Soviet medicine had its assets.

Politics close up

Politics entered medicine more than before at the end of the 1980s. If we previously had been rather disengaged from political issues in our health care workplaces, the situation changed. However, we did not have political arguments around our coffee tables. What happened was that some topics disappeared from our conversation.

In the 1980s the prevailing tensions between the Russians and the Latvians came more to light. Perhaps it started with the allegations that the Latvians had been on the bright side of life in the Soviet Union. That Latvians were the welloff of the nations within the Union, showing off affluence and arrogance. Latvia had been a major supplier to the East of industrial products, e.g. drugs, minibuses, railway carriages, textiles. Latvian living standards were regarded as good. On the other hand, the immigration of Russians into Latvia had been substantial, just because of that positive development, and it had also contributed to it.

After Gorbachev’s perestroika had come up, Latvian mass media were covering this new situation in a very cautious way. However, Moscow magazines and newspapers were also read here, and they brought new information with a striking approach to modern events. Issues from the «kitchen parliament» were now out in the media! We could read critical articles on recent history, for example on the Stalinistic regime and on its part in the slaughters of the Second World War. Although we had learnt that the Union lost twenty million during the war against the fascists, the great patriotic war, allegations were sustained that another twenty million lives had been lost due to the cruel regime in force between the revolution of 1917 and the entry into the war against the Germans. We also discovered that twenty million were lost in the years to come after the defeat of Hitler and until the death of Stalin in 1953.

Such issues, in a way, opened our eyes, and new sentiments emerged about the relationship between Latvia and the Soviet Union. What the luncheon time discussions, when held, were dealing with, were the prospects of a sort of financial independence from Moscow. A total, political freedom was in the mind of nobody.

1998 the Latvian Popular Front was established, and its first congress was held in October 1988. This was the first time that such an event was broadcast directly on television and radio. It was the first time you could see people walking around with radios in the city, listening to what was said. This was a national awakening, followed by the May 4th 1990 Declaration of Independence.

A major personal experience

To myself, my time in Jelgava was over, and in 1989 I took over a job in the Riga Hospital Number 4, later named the Red Cross Hospital. After one year I became Head of the Internal Medicine Department, having responsibility for up to one hundred and ten beds. Nowadays, a ward that size would have been a whole hospital, but then it was only a department, in line with the principles of health care at that time.

The Red Cross Hospital had a good reputation. The staff members were mainly Latvian and the leadership was eager to maintain the high quality position under the new political conditions which now were popping up. Together with a colleague, I was offered an opportunity to go to the United States on a study trip for three months, so that we could come back to Riga with new impressions and updated knowledge. Of course I accepted. And off we went one day in 1993, heading for Dallas, Texas.

The weeks at the Methodist Medical centre turned into a cultural shock. We were following a training programme, working from early morning to late evening, visiting medical specialist departments of all kinds. There was even a training programme in topics from the field of health administration, opening our eyes to how a medical department could be run in a very efficient way. Experiencing all this, it was fully understandable when some doctors choose to become a permanent part of it and settled abroad, working in Western medicine.

Guntis Kilkuts

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Michael, c/o professor Øivind Larsen | p.o.box 1130 Blindern | N-0318 Oslo, Norway |

Epost: oivind.larsen@medisin.uio.no