David R. Henderson  

Communist Medical Care

The Evidence of Altruism... I don't believe you (you're a ...

A former student, an officer in the U.S. Navy, gave me permission to post an edited version of his story of growing up in the Soviet Union and his and his family's experiences with the Communist system of medical care. He is LCDR Ilia K. Ermoshkin and this is his story:

I grew up in the USSR and became familiar with the healthcare system both from the beneficiary point of view and from that of a provider, as my grandmother was a dentist. The government owned and ran all health care, and it was free to the people. However, the quality and the "care" in the health care system were dismal: long waits for specialists and advanced procedures, etc. But, as anywhere, people have developed ways to get around and get what they want. Here are some examples of wonderful free health care in the USSR.

Birth was to take place only at birth clinics, of which there were about half a dozen in a city of five million people. Husbands or any other family are not permitted to even enter, under the premise of keeping the place free of germs, etc. My delivery was very difficult for my mother, she was in labor for three days, and it was deemed unnecessary to give her any pain medication or do a Cesarean. So she roamed the hallways of this clinic/hospital howling with pain. Nobody was permitted to use the phone (there were only a few in the administrative offices), so she could see my father and her parents only through a window once a day. When I was finally born, I was taken away from my mother immediately to be placed in a post-birth unit (this was done to all newborns), and my mother did not see me until about 24 hours later. We were released from the hospital after 7 days, and that was the first time my father saw me. This is a story that was a fairly normal routine for the Soviet women, and no other options were available as it would be then nearly impossible to get a birth certificate for the newborn. When my mother told this to my wife, who is American, she was horrified and had nightmares about it. [DRH note: for similar stories about the birth process, see Red Plenty. I reviewed it here.]

When I was two, I got severe pneumonia. I was at home with fever of 42C [DRH note: this is over 107 degrees Fahrenheit] and the doctor decided that this was a lost case and would not even prescribe penicillin to try to fight the disease. It took my parents and grandparents pulling all their connections and bribing to get penicillin that fairly promptly took effect and saved me.

The health care was provided on the basis of one's residency. Everyone was attached to a clinic close to where they lived and had a general family practitioner that was the "primary provider" and who was able to refer patients to specialists, procedures, etc. So in some way it was very similar to the HMO system in the US. On average doctors received about half of what a skilled industrial worker received and had to put in longer hours, years of study, etc. Still there were about the same number of doctors per 100,000 of population as there were in the US, but there were fewer specialists than here. One of the reasons that there was no lack of people wanting to become doctors was the prestige and respect of the profession and possibly a self-selection of individuals that were caring and wanted to help others. However, as shown by previous examples, such attitudes quickly disappeared once these doctors became part of the system. There was very little incentive within the official system for the doctors to provide better care for their patients as it did not affect their pay in any way. All health care was free, but it was customary to bring something for the doctor: chocolates, gifts, etc. To get better, prompter care, and get referred to a better specialist required more valuable "gifts". "Out-of-town" people could get emergency care, but were turned down for any chronic disease treatment and had to go back to their primary care provider at their place of residency and get referred locally. But the higher class specialists were in Leningrad and Moscow and they were in high demand. So there was a widespread and highly illegal private practice by specialist doctors and dentists. They would see patients at home and receive cash for their services. My grandmother was a dentist and was practicing after work from her apartment. For decades she was looking over her shoulder, afraid that she would get arrested. She had to pay her neighbors monthly not to tell on her. But the money she made was such that it was worth the risk, as it provided for a much better life for my grandparents, and allowed them to help my mother and her brother and their families. And the story was the same for thousands of other doctors and dentists, so in the end a market, albeit "black market", was the vessel that enabled people to get what they wanted and needed, and quite possibly saving countless lives in the process.

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COMMENTS (25 to date)
Hazel Meade writes:

One thing many supporters of "single-payer" don't grasp is that single-payer literally means just that: it means that ONLY the government can purchase health care, private payment for services is banned.

Your mother worked outside of the system for cash, but of course, the time she spent doing that likely meant less time spent in the public clinic. There is a reason why they made it illegal. The black market sucked resources out of the public system and meant that wealthier patients could get better, faster treatment, which is precisely what single-payer supporters feel is immoral.

But of course the reality is that even under communism, a black market system survived. Enforcing anything like single payer thus means subjecting doctors to the same experience that your mother had to endure - paying off her neighbors to keep quite about her private, cash under the table, dental practice. And if the Soviet Union couldn't keep doctors from running illegal side-businesses, then America certainly won't. Canada's system survives because wealthier people, and better doctors, opt out by going to the US (where the weather is nicer anyway). If they didn't have that option, I don't doubt Canada would have a thriving medical black market too. (Dental care isn't part of the single payer system either.)

E. Harding writes:

There was one great virtue in the Soviet medical system- much greater organization & centralization than in the U.S. There were no compatibility issues with medical records. For an example of how this could save lives, look at

vikingvista writes:

My mother-in-law was a nurse in a Baltic Soviet state. When working in an oncology hospital, she had to cover 60 patients at a time. Physicians often arrived to work drunk. Some patients were hauled around on stretchers, others by their ankles and wrists. Of course everything, including needles, were reused.

She also worked in a psychiatric hospital. Some of the patients there were afflicted with the mental illness of being critical of socialism.

Apparently, black markets were not just available, but were ubiquitous (in health care and everything else), and were necessary to one's survival.

Oddly, or not (considering her Soviet education), my mother-in-law says that was a better system because people were not "stuck up".

Pajser writes:
    "And the story was the same for thousands of other doctors and dentists, so in the end a market, albeit "black market", was the vessel that enabled people to get what they wanted and needed, and quite possibly saving countless lives in the process."

In 1970., USSR GDP (PPP)/capita was 5500 $. Only capitalist countries with GDP/capita between 5000 and 6000 were: Portugal, Chile, Uruguay and surprisingly, Gabon. According to Google public data:

Child mortality:
Uruguay 54
Portugal 68
Chile 79
Gabon no data, huge

Life expectancy:

Uruguay 69
Portugal 67
Chile 62
Gabon 47

For better picture, USA at the time had some 2.5 x higher GDP/capita, life expectancy 71, child mortality 22. So, it appears that Soviets did at least as good as capitalist countries of similar wealth. These days, Russia doesn't compare so well with mentioned countries as it did in 1970.

One may ask whether USSR GDP/capita was very low, because of pseudo-communist system. In that case, system would be responsible again. But it wasn't - in 1913, Russian GDP/capita was about equal to world average, while in 1970 it was 30% above world average. Anecdotal experiences are interesting, but confirmation bias is pervasive.

ThomasH writes:

ACA sounds like a much better system.

mico writes:

Pajser - Your definition of "non-communism" seems to be "not politically aligned with or dependent on the USSR and PRC". Neither the Estado Novo nor Tsarist Russia were liberal, just an other-than-communist brand of authoritarian collectivist. There were no countries institutionally similar to the Western liberal democracies with a GDP per capita of $5,500 at that time because those institutions caused convergence to a much higher level of economic development.

Hazel Meade writes:

Yes, the idea that Portugal, Uruguay, and Chile were "capitalist" countries in 1970 is a little silly.

Aaron McNay writes:


I also find a couple of your selections of countries to compare to be a bit amusing. It was around 1970 that Chile was undergoing a strong shift toward socialist policies, culminating with Salvador Allende's election in 1970. Uruguay was also placed in a state of emergency in 1968, due to militancy and labor unrest. Gabon also underwent a similar coup in 1968. So, three of your examples only show that the Soviet Union was doing relatively better than another relatively socialist country (Chile), and only doing slightly better than a country undergoing significant civil unrest (Uruguay).

vikingvista writes:

Using unqualified average life expectancy as a measure of the general quality of available health care services is a bit like using the average SAT score as a measure of the quality of 3rd grade public school education.

You expect average life expectancy to be dramatically affected by sweeping improvements in nutrition, environmental conditions, and perhaps occupational safety and vaccinations. You only expect *specific health care outcomes* to be dramatically affected by health care quality and access improvements.

I don't know why people assume that health care is the major determinant of a population's life expectancy.

David R. Henderson writes:

Interesting story about your mother-in-law. Thanks.

Chris Wegener writes:

You're kidding right? The USSR was a lot of things, but "communist" was not one. Just because a country claims to be Communist does not mean that it is.

Try examples like western Europe to try and refute universal health care and see how far you get.


David R. Henderson writes:

@Chris Wegener,
You're kidding right?

Floccina writes:

Paragraph 3 above explains why the birth rate fell so low in the USSR. :-)

It is a good thing that health care beyond vaccinations does effect health much else they'd have been in really trouble.

Floccina writes:

I wonder, does the Peltzman effect have an impact on life expectancy i.e. do people take more risk with their health in countries with good healthcare? Did people in the USSR do their best to stay out of hospitals?

Greg Jaxon writes:

Melchior Palyi's 1949 book on this topic notes the important role compulsory health insurance played in converting Wiemar Germany into the Third Reich, among other historical incidents. He says:

As a committee report on health insurance of the Canadian House of Commons put it (March 16, 1943): "During the early years of Hitler's regime, the government's medical program was looked upon by many observers as one of the greatest props of the totalitarian state."

Pajser writes:

Wegner & Henderson: USSR missed essential element of the communism - collective rule. They said they were socialist country, but then Mr. Pot said that Kampuchea was democratic. USSR wasn't capitalist, and they tried to be egalitarian in distribution of goods, so some experiences matter. The graph that depicts dramatic increase of life expectancy in USSR is here. You cannot honestly ignore it. Russians are not known for healthy lifestyle, it must be they did something well. If someone has better data - lets hear. Modern example of similar health system is Cuba. I wrote about it few times here.

McNay & Hazel: There is, of course, whole specter between imaginable pure capitalism and pure socialism. As little as I know, in Uruguay, Portugal and Chile had private means of production, and I do not know data about taxes or nationalizations or anything suggesting that these three countries were in 1960's significantly "less capitalist" than say Western Europe.

Methinks writes:

I'm shocked they refused Ilya penicillin. It was the only thing available in abundance in Soviet hospitals. We had nothing else, but we had rivers of penicillin. They used it for everything. They kept giving me the stuff long after it was determined that I went into anaphylactic shock from the stuff. And that's one of the reasons I got the pleasure of experiencing clinical death on more than one occasion in the great Soviet system.

Ilya's mother was "lucky" she was able to walk around while in labour. The nurses got tired of my cousin's screams, so they shot her full of paralyzing agent. She felt every contraction but couldn't move or make a sound. If anything went wrong she would have had no way to tell anyone.

I spent four years in and out of Soviet hospitals. As a child I was seriously ill. I remember ambulance drivers withholding life-saving adrenaline (I had asthma even kids in America die of to this day) until my parents produced an acceptable bribe in the middle of the night.

I woke up in the middle of an adenoidectomy I had no idea I was having to find myself tied down and blind-folded. The nurse asked if she should give me more anesthesia (it was likely local as general anesthesia was scarce) but the doctor told her he had to ration it. The surgery was completed as feeling returned.

As with Birthing clinics, family was not allowed in the hospital. Family members would drop off care packages for their children. I only found out about that years later because the nurses stole them. I never saw any care packages. Some of the women in my family got crafty and bleached the floors in exchange for some time with me. They would bring treats like impossible to find strawberries (I had a grandmother who operated in the black market like a gangster), which I would eat with my back turned to the nurses and my aunt "covering" me so they wouldn't confiscate them.

There wasn't any modern equipment to monitor patients, so nobody knew if a patient passed out. Soviet hospitals mandated one toilet per 76 patients. They were always down a very very long hallway (long especially for a weak, sick child). Under stress sick children often wet their beds or wet themselves on the long hike to the loo. The nurses would scream, beat the "offenders" and push our faces into the urine-soaked sheets. What were we going to do about it?

Every patient of Soviet hospitals left with a polka-dotted bum. from daily injections of God only knows what. Every afternoon they'd take around a cart with pills and shots. Every patient got the same pills and shots in their behind. With the same needle. One time the nurse let my ten-year-old friend deliver the shot. The consequences were...not good for me.

Patients with different contagious diseases were kept in the same rooms in close quarters. So, when my roommate had the mumps, I came down with the mumps and was returned to hospital. I'm sure I passed that joy on to whoever was rooming with me and picked up whatever she had. The Soviets unbelievably believed that the germs were OUTSIDE the hospital.

The polyclinics that handed out analgesic powder (cut with chalk) and provided bandages were free. If you wanted real medical care you had to bribe people AND have connections.

My aunt and uncle were surgeons. My aunt describes performing abdominal surgery in a regional hospital surrounded by buckets catching rain water in the operating theatre in a hospital with no running hot water (and no, it was not out temporarily).

Autoclaves are not always working or available.

No offense to Ilya's grandmother, but the materials dentists had to work with was so rudimentary that the mouths of soviet people were often half empty of teeth and those that remained were covered in hideous metal crowns. When one American dentist looked at our mouths he was so horrified that he told my mother if he did to her what they did to her mouth in the Soviet Union, he'd lose his license.

methinks writes:

Chris Wegener,

Of course the USSR was not communist. We were still in the process of building communism when you capitalist underminers and, according to Gorbachev, the stupid, lazy and drunk Soviet people made the whole thing fall apart.

Lenin tried actual Marxian communism for about two weeks soon after wresting control. The entire economy came to a huge screeching halt. Seems you need at the very least prices to send signals and a medium of exchange. Oops. Overriding the purists in his party, Lenin urged them to forget about communism and hold on to power any way that they can. The speeches are available in the Collected Works of V.I. Lenin. You should check 'em out. They're impressive in all the wrong ways.

There is only one outcome of attempting to cram everyone into communism and when you look at the Soviet Union, you're looking at that one outcome. And you see it repeated wherever it is tried.

Dan JJ writes:

As for data concerning reported medical information such as Infant Mortality Rate, Child Mortality Rate, etc. The govts of nations, compliant hospitals and clinics report such information. It isn't scientific. On top of that, such data is compiled using different measurements and definitions of what is to be categorized and enters into the data.
The USSR, known quite well for misleading the rest of the world on its economic, social, and military status is going to provide accurate data on its medical system?
Hhmmmmm..... Would you like buy an invisible watch?

James writes:


In the USSR, the Eastern Bloc countries, China, Vietnam, North Korea and Cuba and most every other country that was ruled by a communist party, two things happened:

Governments found it necessary to use deadly force to prevent people from leaving and yet countless people still risked their lives to try to leave.

The people found it necessary to turn to black markets rather than rely entirely on planned economies.

Why do you think that is?

Of course sick people in other nations could always have defected into the USSR to obtain the benefits of communist health care, but this didn't happen.

Why do you think that is?

In the US, nothing prevents people from pooling their resources, appointing a planning committee and living the communist dream. Very few people actually choose this way of life and those that do choose it generally practice collectivized agriculture but depend on the existing mixed economy health care system, rather than forming a collectivised hospital.

Why do you think that is?

My explanation is that communism doesn't work for health care any better than it works for potatoes, rice, shoes, cars, hammers, nails or any other good or service. This explanation is consistent with the stories I've heard from every immigrant I've ever known from any communist country.

Do you have a better explanation?

Pajser writes:

Here is relevant data for GDP per capita, 1990 International Geary-Khamis dollars from Maddisson, Historical statistics of the world economy.

1913: Total ex USSR 1488,   97% of world average (1524), 43% of Western Europe   (3457)
1970: Total ex USSR 5575, 149% of world average (3729), 55% of Western Europe (10169)
1990: Total ex USSR 6894, 138% of world average (5130), 43% of Western Europe (15908)
2008: Total ex USSR 7614, 104% of world average (7614), 36% of Western Europe (21672)

Methinks writes:

Soviet statics were as reliable as a politician's word. That fact should be really old news by now.

Not only is GDP a poor indicator of welfare but in the USSR the GDP consisted of:

1.) Military

2.) Military

3.) Military

(Yet when my uncle the military surgeon was sent to Cuba on a warship he was expected to make - yes make - his own autoclave for sterilization.)

4.) ball bearings the size of a human head (production quota was measured by weight)

5.) shirts that started out an adult size but shrank to fit a doll because production quotas were by piece and the factory stretched the cotton cloth to make more pieces.

6.) When shoe production quotas were by piece the shoes were paper thin and fell apart immediately. Changing the quota to weight produced shoes too heavy to move your feet.

7.) dosing patients was a nightmare because drugs produced in the USSR were cut with chalk, sawdust and god only knows what else to meet production quotas.

8.) The USSR could export only commodities because finished goods found no market outside of those of us in communist captivity. A Scandinavian economist calculated that Soviet produced goods were worth less than the sum of their parts.

THAT is the GDP we produced in my "rodina". The shelves, of course, were empty of edible meat, vegetables and consumer goods.

When the Soviet Union finally collapsed, Western economists finally got a look at what was going on in the mighty USSR. Turns out the black market was at least as large as the official economy. Some economists think it was bigger.


Lorenzo from Oz writes:

Tsarist Russia was a somewhat ramshackle authoritarian state with a large peasant population, low literacy, poor infrastructure which nevertheless managed quite high rates of economic growth (from a low base) in its last decades.

If you educate the population, provide sewerage, clean water, vaccinations, and better food storage, the life expectancy will go up, more or less regardless of how good or bad the health system happens to be. Since Leninist states operate by extracting labour surplus from workers through ownership of all productive assets, they had an interest in increasing life expectancy, so did. It was the other side of banning exit (which permitted said extraction: essentially the same dynamics as serf systems, just on a much vaster scale).

Moving resources from low-productivity agriculture to manufacturing was more or less guaranteed to produce economic growth. This, of course, ground to a halt once the gains from such simple transfer converged with the general level of economic efficiency in the system.

The declining life expectancy later in history of the system was another sign of sclerosis setting in. Especially from massive corruption, as people in the system colluded to manipulate output and targets for private gain and block contrary information from going up the command structure. (Basically, if the local Party chief, Government chief and KGB chief got together--at any level--they could milk the system.)

The transition to private (but not free) enterprise has been problematic--to a significant degree because the same collusive networks just re-invented themselves.

One has to understand the dynamics of the system in order to understand its trajectory.

JKB writes:

What was via very good propaganda labeled Communism in the 1920s and 30s, is really just Socialism with gun control. Extreme socialism but never the less.

If we go back before the substantial rebranding after the take over of Russia, we find definitions such as this, from 1886, that better describe:

The Socialist, under this definition, would be the man who, in general, distrusts the effects of individual initiative and individual enterprise ; who is easily convinced of the utility of an assumption, by the State, of functions which have hitherto been left to personal choices and personal aims ; and who, in fact, supports and advocates many and large schemes of this character.

A man of whom all this could be said might, in strict justice, be termed a Socialist. The extreme Socialist is he who would make the State all in all, individual initiative and enterprise disappearing in that engrossing democracy of labor to which he aspires. In his view, the powers and rights of the State represent the sum of all the powers and all the rights of the individuals who compose it ; and government becomes the organ of society in respect to all its interests and all its acts. So much for the Socialist.

Socialism, under our definition, would be a term properly to be applied (1) to the aggregate of many and large schemes of this nature, actually urged for present or early adoption ; or (2) to a programme contemplated, at whatever distance, for the gradual replacement of private by public activity ; or (3) to an observed movement or tendency, of a highly marked character, in the direction indicated.

Such would be the significance properly to be attributed to the terms Socialist and Socialism, consistently with the definition proposed to be given to the word socialistic viz., that which causes government functions to transcend the line of the strictly police powers.

Now, the sad reality is that, unless we abandon Christian morality, society will always be a mixture of socialism and, we hope, capitalism. As has been seen when the socialist part becomes to large and/or takes over the economic transactions, the whole mess collapses from lack of other people's money.

Daublin writes:

Anecdotally, I've heard the same thing about retail in the USSR. Expats tell me, if you ran a store, you always ran two stores.

One of the two stores is the official store, where you carry exactly the products you are supposed to and charge exactly the prices you are supposed to. For the other store, you buy products that you think will be profitable, and you sell them at the rate your customers will bear. It's the latter store that kept you profitable; the former store kept you legal.

The USSR may seem a long way away, but we see similar things in the U.S. where the official version of a business is just too expensive. For example, jobs for teenagers are mostly on the black market nowadays. You can't pay a teenager the official mimimum wage and benefits to do be a babysitter or to mow your lawn. So everyone just hands them a wad of cash and tries not to think about it too much.

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