1. History of Public Health in Russia
From 1800’s to 1917
This lecture has been designed to provide an overview of public health in Russia from early 1800’s up to the revolution of 1917.

2. The first medical faculty was established in 1775 at the University of Moscow.
The medical profession was a small, urban-based group, whose services were available to a limited, wealthy class. As Kate Schecter noted (1): “As late as 1850, the status of physicians was one of state servitors, and they were not to develop professional autonomy until the 1880’s.”
Main buildings of the university in the Mokhovaya Street, 1798.

3. Modern transportation: cholera epidemic
Unfortunately the great strides in modern transportation accelerated the spread of cholera from India in 1816 to the ports of the Philippines, China, Japan, Persian Gulf then north toward the Ottoman and Russian empires killing thousands by 1826.
In the 19th century cholera became the world's first truly global disease in a series of epidemics that proved to be a watershed for the history of plumbing. Festering along the Ganges River in India for centuries, the disease broke out in Calcutta in 1817 with grand - scale results. The disease is stunning in its rapidity. The onset of extreme diarrhea, sharp muscular cramps, vomiting and fever, and then death - all can transpire within hours.
"There was once a cholera epidemic in Russia. The government, in an effort to stem the disease, sent doctors to the worst-affected areas. The peasants of the province of S_____ discussed the situation and observed a very high correlation between the number of doctors in a given area and the incidence of cholera in that area (i.e. more doctors were observed in cholera areas than elsewhere). Relying on this hard fact, they rose and murdered their doctors." Franklin M. Fisher, The Identification Problem in Econometrics, (New York: McGraw-Hill, 1966) pp. 2-3. 

4. Early 19th Century Russia: Alexander I, Nicholas I, and the birth of revolutionary movement
Historians have generally agreed that a revolutionary movement was born during the reign of Alexander I. Young officers who had pursued Napoleon into Western Europe came back to Russia with revolutionary ideas, including human rights, representative government, and mass democracy. The intellectual Westernization that had been fostered in the eighteenth century by a paternalistic, autocratic Russian state now included opposition to autocracy, demands for representative government, calls for the abolition of serfdom, and, in some instances, advocacy of a revolutionary overthrow of the government. Officers were particularly incensed that Alexander had granted Poland a constitution while Russia remained without one. Several clandestine organizations were preparing for an uprising when Alexander died unexpectedly in Following his death, there was confusion about who would succeed him because the next in line, his brother Constantine, had relinquished his right to the throne. A group of officers commanding about 3,000 men refused to swear allegiance to the new tsar, Alexander's brother Nicholas, proclaiming instead their loyalty to the idea of a Russian constitution. Because these events occurred in December 1825, the rebels were called Decembrists. Nicholas easily overcame the revolt, and the Decembrists who remained alive were arrested. Many were exiled to Siberia.

5. Russia in the 1860’s Great reforms: Railway Growth of industry
Commercial ties with the Orient
During the early nineteenth century, Russia's population, resources, international diplomacy, and military forces made it one of the most powerful states in the world. Its power enabled it to play an increasingly assertive role in Europe's affairs. This role drew the empire into a series of wars against Napoleon, which had far-reaching consequences for Russia and the rest of Europe. After a period of enlightenment, Russia became an active opponent of liberalizing trends in Central and Western Europe.

6. Freeing of serfs (1864) Alexander II of Russia: The great reformer
In 1861 Alexander issued his Emancipation Manifesto that proposed 17 legislative acts that would free the serfs in Russia. Alexander announced that personal serfdom would be abolished and all peasants would be able to buy land from their landlords. The State would advance the money to the landlords and would recover it from the peasants in 49 annual sums known as redemption payments.
Alexander also introduced other reforms and in 1864 he allowed each district to set up a Zemstvo. These were local councils with powers to provide roads, schools and medical services. However, the right to elect members was restricted to the wealthy.

7. Nikolay Ivanovich Pirogov
Nikolay Ivanovich Pirogov ( ) was a prominent Russian scientist, doctor, pedagogue, public figure, and corresponding member of the Russian Academy of Sciences (1847). He is considered to be the founder of field surgery, and was one of the first surgeons in Europe to use ether for anesthesia. He was the first surgeon to use anaesthesia in a field operation (1847), invented various kinds of surgical operations, and developed his own technique of using plaster casts to treat fractured bones. His name is one of the most widely recognized in Russian medical history. Pirogov Society was named after him. Pirogov embodied the idea of a doctor as a scientist and a humanitarian.

8. 1870’s-1880’s
Zemstvo or community physicians –idealistic young people who had studied at Russian Universities during the period of relative liberalism which marked the early years of the reign of Alexander II

9. Zemstvo Medicine
A system of primary rural medical and sanitary services which was funded out of government subsidies and zemstvo taxation (available on no fee basis)
It was not easy task for zemstvo physician, and those who undertook the work found that they needed all the support they could get. The local aristocracy, who dominated the zemstvo assemblies, suspected-not without reason-that their professional employees were political radicals who believed that the zemstvo themselves ought to be democratized to teach the people about political participation in a future free and democratic Russia.

10. Who was a zemstvo physician?
In modern terms, the best equivalent would be primary care provider.
By the end of the 1890’s, the community physician, now the dominant group in the prestigious Pirogov Society of Russian Physicians, were moving from social reform to political activism.

11. Formation of Pirogov Society of Russian Physicians
law in 1838 set some basic standards for all physicians. Important changes, however, occurred in the second half of the 19th century with the
Zemstvo reforms of the 1860’s and the founding of the Pirogov Society in The Zemstvo movement was an attempt by Alexander II to improve the lot of rural Russia. The Zemstvo reform decentralized controls and brought physicians to the rural areas. A paradoxical effect of this movement, it is said, was to make physicians more independent and professionally more autonomous.
The Pirogov Society, founded in honor of Nicho-
las I. Pirogov, sought to enhance the professional
prestige of physicians and create a “semi-autonomous
corporate identity” (2).

12. 1880’s
S.P. Botkin recommended that Russia set up a powerful central administrative agency to direct public health affairs.

13. Bacteriological revolution (1880’s)
History of I.I. Mechnikov
Diphtheria serum-1893/94
Bacteriology was now championed by community physicians who saw it a s tool to be used for the benefit of the people
llya Ilyich Mechnikov ( ) was a Russian microbiologist best remembered for his pioneering research into the immune system. Mechnikov received the Nobel Prize in Medicine in 1908, for his work on phagocytosis.

14. Alexander III Famine of 1891-92 Cholera epidemic 1892-93
The government of Tsar Alexander III had shown itself to be no friend of local autonomy or the aspirations o Russia’s small but growing body of zemstvo professionals-among whom were physicians and various ancillary medical personnel. The terrible famine of 1891/92 and the ensuing cholera epidemic of 1892/93 provided chillingly conclusive evidence the Russian government was considerably better at exacerbating than relieving the country’s health problems.

15. From the memo of Professor N. A. Veliaminov, 1901
What is the sanitary state of Russia?-In comparison with the states of Western Europe, and even with our own Finland, it has to be admitted that it is dismal in the extreme: the percentage mortality of the population is high, the average life expectancy is short, and there is a great amount of contagious, epidemic and endemic disease
At the beginning of the twentieth century, the Russian Empire was an extremely unhealthy place in which to live.
…From John F Hutchinson

16. 1905 “Making Russia Healthy”—the slogan of community physicians
Cholera congress
During the 1905 revolution, community physicians challenged both the political legitimacy of the tsarist regime and the professional dominance of the St. Petersburg medical establishment. No longer were they willing to play the subordinate role to which they had been condemned by the laws, political customs, and political structure of tsarist Russia

17. The opportunity for developing preventive education work in connection with such a system is practically unlimited… We may therefore look in the future, as zemstvo and municipal medicine develop and acquire the educational and preventive quality which is in accord with modern progress, for unprecedented successes in the control of preventable diseases in the great sister Republic..
Charles-Edward Amory Winslow (1877–1957) was a seminal figure in public health, not only in his own country, the United States, but in the wider Western world. His vision and intellectual leadership enabled him, more than anyone else, to influence the development of public health services in the United States as well as in many European nations. His inspired leadership did much to ensure that the rapidly developing industrial cities and the rural regions of the United States were adequately provided with the essential public health services of sanitation, regulation of food-and waterborne hazards to health, development of health-education programs, and education of public health specialists. In a period dominated by discoveries in bacteriology, he recognized the importance of a broader perspective on causation than that embraced by the germ theory of disease.
From the report of
Charles Edward Amory Winslow, APHA, 1917

18. Community Medicine in Dissaray 1907-1914
Stolypin and his reforms
In 1910’s, there were extreme difficulties in attracting and retaining physicians in zemstvos. Zemstvo physicians wanted to get paid to come to the meetings.

19. Establishment of Narkomzdrav, Centralized public health/medical system
1918
Establishment of Narkomzdrav, Centralized public health/medical system
Narkomzdrav was the first ministry of health in the postrevolutionary Russia. Just like Zemstvo medicine, Narkomzdrav activities concentrated on preventive medicine. Of particular concern in the Russia after the revolution of 1917 was fighting STDs and the epidemic of alcohol abuse.

20. What was happening after 1917?
In 1925, the Pirogov Society was forced to disband and the Hippocratic Oath was abandoned

21. Summary
Historically, Russian medical system was intertwined with the political situation in the county
At the end of the 19th century, Russia’s system of zemstvo medicine provided a very good foundation for preventive care
Zemstvo physicians became a powerful force in the early 20th century
With the revolution of 1917, Russian medical system started to change rapidly with different theories existing about the fate of zemstvo medicine