Articles on International Health and Comparisons of Health Care
AMERICAN AND SOVIET MEDICAL MANPOWER: GROWTH AND EVOLUTION, 1910-1970 Mark G. Field Between 1910 and 1970 the number of physicians in the United States increased 2.5 times, in Soviet Russia almost 25 times. The number of physicians per constant unit of population remained fairly stable in the United States, rising slightly in the last few years. In the U.S.S.R. that number increased 16 t o 18 times, and now stands about SO per cent higher than in the United States. About 1 0 per cent of American physicians are women; in the U.S.S.R. it is about 70 per cent. Neither society has resolved the problem of deploying physicians to the rural areas. American physicians are more specialized than their Soviet colleagues. The article concludes with general remarks about the two health systems, pointing out resemblances and divergences. The hypothesis of a possible “convergence” is entertained.
As early as 1835, de Tocqueville described certain resemblances between the United States and Russia and predicted their emergence in the 20th century as powers that would exercise an important influence in the world. In many respects these predictions have come true. In population size the U.S.S.R. and the United States now rank third and fourth, respectively, after China and India, but second and first in industrial production, in gross national product, and in international influence. Furthermore, the United States and the Soviet Union share many features as large industrial urban societies. Thus, several aspects of the social structure of the United States and the Soviet Union are affected by the fact that the two societies utilize technologically similar means of production which produce roughly similar consequences. By such consequences we mean, for example, the separation of the home from the place of work, a situation not found in a peasant population where the family is simultaneously a solidary kinship group and an economically productive group. These similarities, however, are less marked in the health systems of the two nations; indeed, structurally and organizationally these systems are radically different from each other while still remaining within the framework of modem scientific medicine. The organization of the health system is affected by the basic ideological, political, and cultural elements of the society which give rise to the differences noted above. At the This is a translation of a paper originally delivered before the Socittk de Dkmographie et Sociologie Medicales in Paris in December 1970, and subsequently published in the Cahiers de Sociologie et Dkmographie Medicales (11: 104-119, April-June 1971). An English summary was presented before the Medical Care Section at the 99th Annual Meeting of the American Public Health Association in October 1971. The translation is by the author and the article incorporates some minor revisions, corrections, and updating. Permission to publish was kindly granted by the editor of Cahiers. This work was supported by Research Grant HS-00272, “Comparative Health Systems: Differentiation and Convergence,” National Center for Health Services Research, Health Resources Administration, Department of Health, Education, and Welfare. International Journal of Health Services, Volume 5, Number 3,1975 0 1975,Baywood Publishing C o .
doi: 10.2190/WRDE-WFNA-T1D7-33RT http://baywood.com
Same time, the health services provided to the population contribute to national development in the same manner as education, the sanitation level, housing, diet, and means of communication. Health is thus an important national resource, and the health system that protects that resource must be seen as an important national investment. There is, for example, every reason to believe that a society cannot develop effectively when its population is afflicted with high birth and death rates and consequently a low life expectancy (1, 2). If in addition that population has a fairly high morbidity, if it is debilitated and rendered lethargic by illness, development proceeds only with difficulty or not at all. Each society thus resolves its health problems, as a social investment, according to its traditions, history, ideology, and political system. It is not the purpose of this article to examine in detail the American and Soviet health systems. Rather, we shall address ourselves to a comparison of one of the fundamental resources of that system, i.e. its personnel, and here specifically, its physicians. It is true, of course, that modern medicine increasingly requires personnel of varying qualifications, most of whom are not physicians. As a result doctors increasingly become a minority among all “health workers,” albeit a minority that constitutes the keystone of the health enterprise. Hence our concentration, in this paper, on physicians. MAJOR LINES OF DEVELOPMENT The development of American medicine must be seen through the prism of private practice. The influence of the polity, particularly the federal government, has been slight up to now, whether one considers recruitment, education, or distribution of physicians or the funding of outpatient care or hospitals, medical schools, and other medical institutions. Among the major exceptions are the Hill-Burton Act to increase hospital beds, the system of medical institutions established for the treatment of veterans, and more recently such programs as Medicare and Medicaid aimed primarily at the financing of the medical and hospital costs of the elderly while leaving the health system practically untouched. An important influence in American medicine was the Flexner Report (3), published in 1910, which was quite critical of the education of physicians. The Flexner Report advocated a system based on science and research, similar to that of German universities and of Johns Hopkins and Harvard in the United States. The Flexner Report resulted in the closing of numerous underqualified private proprietary medical schools and in the integration of most other such schools into universities as medical faculties. The result of this reform, which took place entirely outside of government intervention, was that the number of physicians trained each year decreased. In 1906 there were 162 medical schools training 5364 physicians; in 1920 there were only 85 schools training 3047 physicians (4). Coincidentally with this decrease, the American Medical Association (AMA) adopted the position that the growth of the medical corps would increase competition and would thus be harmful to the interests of physicians and patients. This is why until fairly recently the M A , pointing to the fact that the supply of physicians to constant units of population had remained fairly constant since the early thirties, concluded that there was no shortage of physicians in the United States (5). The development of Soviet medicine began after the October Revolution .of 1917 about 10 years after the beginning of the modem phase of American medicine. In contrast to medicine in the United States, Soviet medicine developed entirely under the aegis of the state: the state, not the physicians or their associations, controls medicine
American and Soviet Medical Manpower
and determines the education of physicians and the number of physicians to be trained, their type of training, their specialization, and their distribution. In the Soviet Union the Ministry of Health Protection U.S.S.R. is the supreme general headquarters for health and must adjust its plans, its budgetary requests, and its priorities to those of the state and the Communist Party. The physician studies and works as a state functionary, salaried by the state under conditions and at a pace determined by the state through the Ministry, the counterpart republican health ministries, and their departments and subdepartments (6-8). NUMBER OF PHYSICIANS AND MEDICAL DENSITY Statistics indicate that although the U.S.S.R. started with one-seventh the number of physicians as the United States, and with a medical density (physicians per constant units of population) equivalent to one-tenth that of the United States, the U.S.S.R. has in the course of half a century caught up with the United States and overtaken it. At the present time, the U.S.S.R. enjoys a medical density that is one of the highest in the world, although certain qualifications are necessary to make a valid comparison. The U.S.S.R. has between 20 and 25 per cent of all the physicians in the world, whereas it has less than 7 per cent cf the world population. The United States has about 12 per cent of the physicians and 5.7 per cent of the population of the world. Among the factors that must be considered in any comparison with the U.S.S.R. is the fact that Soviet statistics very often list as physicians all those called “physicians in all specialties or all categories.” Thus figures for physicians actually include (a) physicians, (b) stomatologists or physicians with a higher dental education, and (c) dental assistants, called zubnie vrachi (dental physicians), who do not have a higher professional education but who are dentists of a second category, trained in secondary schools. In the data we present, we have made an effort to separate the first category from the other two, although this is not always possible. In general, the data labeled “physicians in all categories” must be reduced by 10 to 13 per cent t o determine the number of actual physicians. On the other hand, statistics of physicians invariably exclude the military whereas population statistics presumably include the entire population, both civilian and military. If this assumption is correct, the given medical densities should be inferior to the real densities on a national scale. Between 1913 and 1970, the absolute number of nonmilitary physicians in Soviet Russia (excluding dentists) went from 23,200 to 577,300, or an increase of about 25 times. In the United States, this number went from about 145,000 in 1916 to more than 340,000 in 1970, or an increase of about 2.5 times, one-tenth of the Soviet increase (Table 1). Of course, these data bear only on the absolute expansion of the medical contingent. One must examine medical densities to have a more precise idea of their significance. In 1910 in the United States, the medical density was 157 per 100,000 of the population. After 1910 it fell, for reasons mentioned earlier, and was 142 in 1916 and 126 in 1931. Since 1931 this figure has fluctuated between 129 and 163, which is the figure estimated for 1969 (the latter figure includes osteopaths). In Russia in 1913 the corresponding figure was about 14 to 15 per 100,000 or about one-tenth of the American figure at that time. By 1969-1970 it was about 50 per cent higher than the corresponding American figure for that year. The Soviet medical density increased from 16 to 18 times (depending on whether stomatologists and “dental doctors” are or are not included), whereas the American density remained more or less
Field Table 1 Number of physicians in United States' and U.S.S.R., 1910-1970b United States U.S.S.R.
1910 1913 1916 1921 1928 1931 1940 1942 1950 1960 1965 1969 1970
145,24 1 145,404
Growth Factor 1.oo 2.72
180,496 21 9,997 260 ,484d 305,115 338,379 340,000+
1.34 1.63 1.93 2.26 2.5 1 2.52+
236,900 385,400 485,000
10.21 16.61 20.91
aSources, Statistical Abstract of the United States, ,1958, p. 75, Table 84, US. Government Printing Office, Washington, D.C., 1958; Statistical Abstract of the United States, 1967, p. 66, Table 80, U.S. Government Printing Office, Washington, D.C., 1967; Statistical Abstract of the United States, 1971, p. 67, Table 94, US. Government Printing Office, Washington, D.C., 1971. bNonrnilitary physicians excluding stomatologists and dental physicians (zubnie vrachi). Sources, Zdravookhranenie v SSSR: Statisticheskii sbornik, p. 50, Moscow, 1960; Narodnoe khoziaistvo SSSR Y 1970 g, p. 689, Moscow, 1971. 'With stomatologists. dExcluding osteopaths or physicians in federal service.
constant for 7 0 years and actually fell during certain periods. As paradoxical as it may seem, the supply of physicians per constant units of American population was about the same in 1960 as it was in the first decade of the 20th century. In the light of the growing shortage of physicians in the United States (in 1970 the estimated shortage was about 50,000) to provide for the needs of the population, various programs and plans have been proposed to increase the number of students admitted t o the medical schools. In 1970 it was estimated that about 50 per cent of those applying for admission were rejected because there were not enough places, and that at least half of those had the qualifications required to become physicians. According to the 1970 projections of the Camegie Commission on Higher Medical Education, by 1982 the United States could have a density of between 168.8 and 171.3, depending on the rate of increase. The Soviets have announced a goal of between 340 and 360 by the end of the decade from 1970 to 1980 (9). Reducing these figures by 13 per cent to exclude stomatologists and dental physicians, we arrive at a Soviet density of between 296 and 313 in 1980, still 50 per cent higher than in 1970 and more than 50 per cent higher than that projected for the United States in 1982.
THE EDUCATION OF PHYSICIANS We have mentioned the Flexner Report and the resultant closing of a number of medical schools in the United States. The immediate effect of these closings was a reduction in the number of medical students and those completing their medical studies.
American and Soviet Medical Manpower
In 1900, 5,214 received their medical diplomas; by 1910 the number had fallen to 4,400, and by 1920 to 3,047. Since 1930, the number has increased, but rather slowly: it went from 4,565 that year to 5,097 in 1940, 5,553 in 1950, and 7,574 in 1966. It can be estimated that the number in 1970 was over 8,000. In the fall of 1970, 11,300 students were admitted to medical schools (10). Even with t h i s increase in the number of medical students finishing their studies, the present density of over 160 could not have been reached without another factor which began to appear after 1950: a steady influx of foreign-trained physicians. In recent years, approximately 20 per cent of the newly granted licenses have been to physicians trained outside the United States and Canada and 30 per cent of all physicians working full-time in hospitals belong to the same category. A distinction must be made between American nationals studying abroad because they could not gain access to American medical schools and foreign nationals. For example, about 11 per cent of all Americans who study medicine are doing so in countries other than the United States and Canada. But the percentage of these American foreign medical graduates (FMGs) to all foreign medical graduates is not very significant. The bulk of FMGs now practicing in the United States are foreign nationals trained abroad. In all, Americans and foreigners who studied abroad (foreign medical graduates) represented 46,000 physicians in 1967, or about 15 per cent of all physicians in the United States. Of these, approximately 19,000 were in private practice, 14,000 were residents, and 9,000 worked full-time in hospitals. The remainder (about 4,000) worked primarily as members of medical faculties, as administrators, or in research (11). In 1969, more complete figures indicated that there were 58,000 foreign medical graduates representing 22 per cent of physicians in the United States (12). For the U.S.S.R. we have obtained figures for the years 1928 to 1959. These numbers are probably for physicians and stomatologists (the latter constitute on the average less than 10 per cent of the total). The number of students admitted into the medical schools went from 6,200 in 1928 to 17,400 in 1940 (more than 2.5 times), to 20,000 in 1950, and 29,500 in 1959 (13). Compensating for the stomatologists and a few physicians for physical culture and sports who sometimes are included in such data, it can be estimated that in rough terms, the U.S.S.R. in 1970 was training from 2.5 to 3 times as many physicians as the United States for a population that is about 20 per cent larger. As indicated earlier, the growth of the American medical contingent depends not only on those who complete their studies in the United States and Canada but also on those who finish their studies in foreign schools. Thus the difference in the growth of the American and the Soviet medical contingents is, to some important degree, muted by the large-scale importation of foreign medical graduates into the United States. A comparison of the domestic production of physicians in the two countries would thus be considerably more in favor of the Soviet Union. Whereas practically all physicians in the U.S.S.R. were born and educated in their country, the United States depends on the products of foreign medical education which it imports at the expense of the producing countries. These countries have invested large funds to educate these physicians and often lack medical personnel for their own needs. From this standpoint, the United States is parasitic. It should be noted that physicians in underdeveloped countries are frequently adjudged to be of mediocre quality when compared with their colleagues educated in the United States or in Western Europe. Furthermore, their often rudimentary knowledge of English creates difficulties in their relationships with patients. The only acceptable solution would thus be the increased training of American nationals, as advocated by the Carnegie Commission. The projections of the Carnegie Commission indicate that between 1968 and 1977 13,000 foreign
physicians will enter the United States to take up permanent residence, but the Commission recommends that none be admitted permanently after this time (11). It must be recognized that many foreign physicians come to the United States ostensibly to continue their studies, but are employed as residents to give services in the hospitals and often decide to settle in the United States rather than return home. This practice continues the cycle of dependency on other countries to supply physicians to the United States. AGE DISTRIBUTION OF PHYSICIANS We did not succeed in finding data that would permit us to examine the evolution of the age distribution of the professions in the U.S. and U.S.S.R. We must thus content ourselves with presenting, in Table 2, a comparison between the United States in 1967 and the U.S.S.R. in 1963. The difference is striking. The Soviet medical profession (including stomatologists) is considerably younger than the American profession (without dentists). Indeed, according to these statistics, twice as many Soviet physicians as American physicians are under 30. And more than twice as many American physicians are over 50 compared to Soviet physicians. Using United States data this time for 1960 and Soviet for 1963, it could be estimated that three-fourths of all active Soviet physicians were under 45, as against a little over half of the American physicians. Table 2 Age distribution of physicians in United States (1967) and U.S.S.R. (1963) as percentage of total number of physicians in each age groupa Country
70 and Over
‘Sources, Statistical Abstract of the United States, 1971, p. 66, Table 91, U.S. Government Printing Office, Washington, D.C., 1971; Jacques Chassin du Guerny, Note statistique SW la ddmographie mddicale de 1’U.R.S.S. Cahiers de Sociologie et Dkmographie Mkdicales lO(1): 31-34, Table 3, 1970. bActive physicians. CIncludingstomatologists. dApplies to ages 50 and over.
There are several possible reasons for this marked difference: (a) the higher rate of production of young medical graduates in the U.S.S.R. against a more stable production and slower increase in the United States; (b) the fact that in the U.S.S.R. medical students complete their studies earlier (around 24) than in the United States, where college delays entry into medical schools by 4 years and an internship of one year’s duration is followed by residency which may last several years, so that the physician begins practice when he approaches 30; (c) the fact that officially Soviet physicians can retire at a relatively young age-55 for women, who constitute three-quarters of the profession, and 60 for men. According to data brought back by Chassin de Guerny (14), it is primarily the men (only one-fourth of all physicians) who continue to be active beyond retirement age.
American and Soviet Medical Manpower
FEMINIZATION OF THE MEDICAL PROFESSION The accelerated expansion of the Soviet medical profession could not have taken place without a massive influx of women into medicine. Although there was a traditionof medical studies for women under Czarism and medical schools for them had been established, before the Revolution women comprised less than 10 per cent of the profession. Soviet medical authorities presumably judged that medicine could easily become a feminine profession, reserving for men the technical and military occupations necessary for a nation that wanted to industrialize rapidly and acquire means of defense. By 1928, women comprised 45 per cent of those persons in medicine and stomatology. On the eve of World War I1 they comprised 62 per cent and by 1950,77 per cent. Between 1960 and 1970, however, their percentage decreased from 76 at the beginning of that decade to 72 at the end (Table 3). There is reason to believe that the regime is not entirely satisfied with such an extreme feminization (perhaps for “medical productivity” and military reasons). According to Bowers (15), who unfortunately does not give the source of his information, the percentage of women admitted to study medicine was officially reduced by government decree from 85 to 65 per cent in 1966 or 1967. If this tendency continues it is therefore possible that in a generation the proportion of women in medicine in the U.S.S.P.. could fall back to 65 per cent or even less, particularly if the government simultaneously encourages men to enter medicine. The situation in the United States, on the other hand, shows that on the average in the last 50 years women have comprised less than 10 per cent-in fact closer to 5 per cent-of the medical profession (Table 3). We have not been able to find data strictly comparable to those of the Soviet Union which would indicate the percentage of women in medicine in the United States from year to year or decade to decade. In 1967, for example, 7 per cent of the physicians practicing in the United States were women, but 30 per cent of these women had done their medical studies abroad as against only 13.8 per cent of the men (16). Proportionately then the United States imports more women physicians than men. Since 1929-1930, the percentage of women admitted as students to medical schools has increased, indeed more than doubled. For the school year of 1929-1930,4.5 per cent of admitted students were women; for 1940-1941, 4.8 per cent; for 1950-1951, 5.3 per cent; for 1960-1961, 7 per cent; and for 1970, 11 per cent (10, 17). The percentage of women among those who complete their medical studies, however, shows more modest gains, as can be seen from Table 4, as a higher percentage of men than women complete their studies in medicine. For example, of all the students who began their studies between 1948 and 1959, 91 per cent of men as against 84 per cent of women completed them (17). It is also important to take into consideration this difference in feminization between the professions in the United States and the U.S.S.R. in comparing the medical work “produced” by each sex. For example, in an inquiry made in the United States the median number of hours of work of active physicians was 60 per week (1 1). In the U.S.S.R. doctors must work officially about 40 hours per week. Apparently, women physicians who have domestic responsibilities do not work more than these 40 hours, although they have a right to work an additional 20 hours and earn a salary and a half. Most of the men do work the additional 20 hours, since salaries are low, even for the Soviet Union.
Field Table 3 Percentage of women physicians in United States and U.S.S.R., 1913-1970” Year U.S. U.S.S.R.b % n.a.c n.a. n.a. n.a. 6.0 7.0 7.0 7 .O
1913 1920 1928 1940 1950 1960 1967 1970
% 10.0 n.a. 45 .O 62.0 77.0 76.0 71 .O 72.0
‘Sources, Annuaire de Statistiques Sanitaires Mondiales, 1966, Vol. 111: Personnel de Santk et Etablissements Hospitaliers, p. 36, Organisation Mondiale de la Santd, Gene& 1970; Statistical Abstract of the United States, 1971, p. 66, Table 91, U.S. Government Printing Office, Washington, D.C., 1971; Zdravookhranenie v SSSR: Statisticheskii sbornik, p. 787, Moscow, 1960; Narodnoe khoziaistvo SSSR v 1970 g, p. 691, Moscow, 1971. bIncluding stomatologistsand dental assistants. ‘n.a. signifies data not available. Table 4 Enrollment of women in medical schools in United States, 1930-1971‘
Year 1930 1935 1940 1945 1950 1955 1960 1965 1967 1968 1969 1970 1971
No. of Women Students
Women as Percentage of All Students
955 1,077 1,145 1,352 1,806 1,537 1,710 2,503
4.4 4.7 5.4 5.6 7.2 5.4 5.7 7.7
Women Admitted t o Medical School
Percentage of All Students Admitted in U.S.
No. of Women Who Finished Studies 204 207 253 262 595 345 405 503
934 887 948 1,256 1,693
Women as Percentage of All Who Finished 4.5 4.1 5 .O 5.1 10.7 4.9 5.5 7.3
9.9 9.0 9.1 11.1 13.7
‘Sources, Association of American Medical Colleges, Datagrams 7(8): Table 2, 1968; Journal of Medical Education 48(5): 408, 1973. It is interesting t o note that the situation of the woman physician in the U.S.S.R. resembles in many respects that of the American school teacher of elementary and secondary grades: she has important functions but relatively low salary and little prestige. In general, one can say that the two occupations are not so much a “career” as a way of earning a living while awaiting marriage. Once married, she can continue to work t o augment the family budget.
American and Soviet Medical Manpower
According to the data of a Soviet professor, in the U.S.S.R. male physicians work an average of 270 days per year and women 155, or 42 per cent less (18). This situation is not very different from that of the American woman doctor. A study comparing men and women who finished their medical studies at the University of Pennsylvania between 1943 and 1956 shows that “. . . on the average a woman works in medicine 36.4 hours per week and a man 58.27” (19), i.e. 38 per cent less time. In the U.S.S.R., medicine is apparently also not as much a career for women (particularly those who are married and have children) as it is for men. Indeed, the proportion of women is relatively weak in higher positions in teaching, research, and administration. To date only one woman has served as Health Minister for the U.S.S.R. Fewer than 5 per cent of the full members of the Academy of Medical Sciences are women; among corresponding members, the figure is about 13 per cent. Thus, although the Soviet medical density is about 50 per cent superior to the American one, it should be remembered that three-fourths of all physicians in the U.S.S.R. are women, as against less than 10 per cent in the U.S.A.; if it is correct, furthermore, that women doctors, in both countries, work on the average 40 per cent fewer hours than their male colleagues, then the difference in medical acts or services between the two nations may not be as great as what a simple comparison of the number of physicians per population would show. GEOGRAPHIC DISTRIBUTION The geographic distribution to meet the needs of the population does not seem to be better resolved in the U.S.S.R. than it is in the United States. In the United States that distribution between the four major regions (Northeast, North Central, South, and West) indicates that the spread in medical densities increased between 1921 and 1969 (Table 5). The South, in particular, which is the least urbanized of the four regions, had in 1969 an average number of physicians per population equivalent to 70 per cent of the national figure, and 60 per cent of the figure for the Northeast (the highest). Table 5 Medical d e n s i t y in United States by region, 1921-1969’
1921 1931 1942 1957 1967 1969
134.0 126.0 134.0 132.0 158.0 163.0
138.0 141.O 172.0 163.0 171.9 192.3
138.0 128.0 132.0 112.0 112.3 125.4
121.0 104.0 105.0 98.0 112.9 113.7
152.0 147.0 138.0 141.0 134.5 135.4
‘Medical density (physicians per 100,000 population) is given for the total population including the armed forces, except for 1957, which is for the civilian population only. bSources, Statistical Abstract of the United States, 1923, p. 63, US.Government Printing Office, Washington, D.C., 1923; Statistical Abstract of the United States, 1934, p. 8 2 , U.S. Government hinting Office, Washington, D.C., 1934; Statistical Abstract of the United States, 1944, p. 1 5 , US. Government Printing Office, Washington, D.C., 1944; Statistical Abstract of the United States, 1960, P. 73, U.S. Government Printing Office, Washington, D.C., 1960; Statistical Abstract of the United states, 1969, p. 66, Table 87,Washington, D.C., 1969; Statistical Abstract of the United States, 1970, P. 67, Table 80, U.S. Government Printing Office, Washington, D.C., 1970.
In greater detail, and in regrouping the states into nine regions, one could see in 1969 the following differences: Region
Middle Atlantic New England Pacific East North Central South Atlantic Mountain West North Central West South Central East South Central
171.8 174.0 145.6 131.4 125.4 129.O 121.1 110.8 96.0
Average for U.S.A.
Examining medical densities by state (Table 6), one can see that in 1969 the State of Mississippi had a density equal to half the national level and that certain states like Alabama, Arkansas, South Carolina, and South Dakota, i.e. states that are not highly urbanized, had a density just under 50 per cent of the national figure. On the other hand, an industrial state like Massachusetts had a density one-third higher than the national average, and the District of Columbia had a density more than double the national average. This means that the countryside, sparsely populated states, rural counties, and small towns have no physicians or not enough of them. Specialization in medicine which is practiced in urban centers is partially responsible for this problem. Thus the high medical densities in urban and metropolitan centers in no way guarantee an equitable distribution of medical care. The poor, Blacks, and ghetto inhabitants, like the population in the countryside, receive less medical attention than the middle classes and those who live in the suburbs. In general, one can make the same case for the U.S.S.R., where the average national density does not indicate the variations that exist among the 15 republics which constitute the Soviet Union (Table 7). For example, in 1940, with an average national density of 72 per 100,000, Georgia had a figure of 128 (the highest) and Kirghizia 34 (the lowest). In 1950, Georgia had almost twice the national medical density, whereas Tadzhikistan had slightly more than half. In 1970, the differences were less marked, though they had not been obliterated. Georgia had about 30 per cent more physicians than the national average (the highest figure) and Tadzhikistan had about 40 per cent less than the national average (the lowest figure). It seems that Georgia is a special case since it is neither heavily urban nor industrial. It might be fair to say that, as a rule, the Central Asian republics did more poorly when compared with the more industrial' and urban western areas of the Soviet Union in general, with the only major exception being Moldavia, a predominantly agricultural republic. The great centers like Leningrad and Moscow had 3 and 3.5 times as many physicians per capita as the national average, and the greater the distance from the large towns, the smaller the supply of physicians (20). In the villages and isolated areas, there are almost no physicians, and the greatest part of ordinary medical services is provided by auxiliary personnel like feldshers (21). Thus, even a highly centralized country with a state-run health service apparently cannot freely deploy its health personnel.
American and Soviet Medical Manpower
Table 6 Medical density (physicians per 100,000 population)a in United States by state, 1969b No. of Physicians Density
State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana
3,008 195 2,680 1,745 37,032 3,968 5,673 737 2,905 10,576 4,811 1,130 677 15,314 5,328 3,282 2,736 3,290 4,256 1,262 6,811 11,634 13,076 5,725 1,807 7,019 72 1
86 78 161
88 194 194 190 138 371 169 106 153 95 139 104 118 120 103 115 131 184 214 149 155 78 152 105
No. of Physicians
State Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico PossessionsC Total physicians Average density
1,705 529 1,025
10,765 1,170 42,824 5,417 587 14,922 2,989 3,087 19,190 1,482 2,232 568 4,605 13,391 1,423 862 5,120 5,023 1,925 5,325 3 24 2,3 13 142 338,379
Density 119 118 144 152 120 234 107 97 139 118 152 163 168 85 87 117 122 137 197 121 151 106 126 102 84 43 163
'Excluding nonfederal physicians with temporary foreign addresses (3,784), and including 29,650 physicians in federal service not assigned by state, and 2,081 physicians with unknown addresses. These figures are for medical doctors (324,942) and osteopaths (13,437). %ource, StatisticalAbstract of the United States, 1970, p. 67, Table 89, U.S.Government Printing Office, Washington, D.C., 1970. CAmericanSamoa, Canal Zone, Guam, Virgin Islands, and island territories of the Pacific. Table 7 Medical density (physicians per 100,000 PO ulation)' in U.S.S.R. by republic, 1913-1 970
R.S.F.S.R. Ukraine Belorussia Uzbekistan Kazakhstan Georgia Azerbaidzhan
15 19 13 3 3 13 12
74 80 47 42 39 128 92
145 131 80 95 90 263 20 1
209 199 164 138 139 330 237
273 26 1 239 181 201 359 243
290 276 258 200 21 9 362 250
/ Field Table 7 (C0nt.d)
Republic Lithuania Moldavia Latvia Kirghizia Tadzhikistan Armenia Turkmenistan Estonia
12 12 21 2 1 6 5 45
67 40 109 34 38 68 67 83
106 98 146 95 77 172 124 127
1960 173 143 265 154 127 242 187 239
252 192 339 195 154 30 1 21 1 320
274 205 356 207 159 288 214 33 1
aExcluding the military, including stomatologists and “dental physicians.” bSources, Zdravookhranenie v SSSR: Statisticheskii sbornik, pp. 81-82, Moscow, 1960; Narodnoe khoziaistvo SSSR v 1959g. p. 788, Moscow, 1960; Narodnoe khoziaistvo SSSR v 1961 g, p. 143, Moscow, 1962; Narodnoe khoziaistvo SSSR v 1968 g, p. 130,Moscow, 1969;Narodnoe khoziaistvo SSSR v 1970g,p. 690,Moscow, 1971.
SPECIALIZATION A very marked characteristic of the structural evolution of the medical profession in the United States is the dramatic increase in medical specialization (Table 8). In 1931, 73.5 per cent of practicing physicians were in general practice. In 1963,33 per cent were in this type of practice, and in 1.968, 26 per cent. In 1971, 16.3 per cent of all active physicians were in general practice, although there is reason to believe that this low figure is the result of a reclassification. On the average, since 1931, the percentage of American physicians in general practice has decreased by almost one and a half points each year. It is therefore not surprising, as Magraw (22) wrote in 1966, that: “There is little justification to predict that this trend [toward specialization] will stop before specialization of the entire medical profession within 15 to 20 years if not earlier.” Indeed, very few of those who finished their medical studies in the United States in the sixties chose to go into general practice. There has been of late, it is true, a growing interest in family practice but it is too early to determine the significance of that trend. The fact of the matter is that retiring general practitioners usually are not replaced, that the average age of general practitioners increases yearly, and that the population, particularly in rural and isolated areas, but also in poor neighborhoods, often has little chance of finding a physician. The paucity of primary care or family physicians is thus a very serious problem, and is part of the “crisis” of the American medical system. At the same time that the proportion of specialists increases, the number of specialties and subspecialties also continues to grow. For example, in 1931 there were approximately 15 recognized medical specialties; in 1966 there were 33. If the subspecialties are included, 52 specialties are recognized by the American Medical Association. These specialties are certified by 19 boards. The majority of these boards (1 1 out of 19) were established in 1935 or after. One must also add that although a physician in the United States can call himself a specialist without being board-certified, the tendency of most physicians is t o take board examinations and to receive an official certification by a board. Along with specialization, another tendency is clearly evident. Physicians are increasingly occupied in medical activities other than treating patients: laboratory research, industry, public health, teaching, or administration. It can be estimated that between 2 0
125,599 24,826 150,425
No.of Physicians 33.0 67.0
No. of Physicians
Growth of medical specialization in United States, 1931-1971a
No. of Physicians
‘Sources, Magraw, R.M., Ferment in Medicine, p. 150, Table 8, W.B. Saunders Company, Philadelphia and London, 1966; Statistical Abstract of the United States, 1970, p. 6 5 , Table 8, U.S. Government Printing Office, Washington, D.C., 1970; Statistical Abstract of the United States, 1973, p. 71, Table 102, U.S. Government Printing Office, Washington, D.C., 1973; Health Manpower, US. 1955-1967. Ser. 14, No. 1, p. 19, Table 4, National Center for Health Statistics, U.S. Department of Health, Education, and Welfare, 1963.
Type of Medicine
and 30 per cent of all physicians in the United States are not in direct contact with patients. When we turn to the U.S.S.R., a different picture emerges: one of remarkable stability from 1940 to 1970 (the period for which we have relatively precise figures) in the percentage of specialists to all physicians (Table 9). Altogether that percentage has increased by 4 points in the last 30 years. There is, however, a question of definition. The therapist (terapevt) although listed in Soviet tables as a “specialist” and not unlike the American internist, seems to us to be the equivalent, in the Soviet context, of the American general practitioner or generalist. As such, the percentage of therapists to the total has decreased between 1940 and 1970 by one-third. On the other hand, if we were to add the therapists to other specialists, then the 1970 Soviet figure for specialists as a percentage of all physicians would be similar to the American picture. Those whom we have listed as “others” under the rubric of general medicine are not identified as such in Soviet tables. They consist of the difference between the total number of physicians and those listed as specialists. Presumably they are physicians in training rather than physicians without a specialty. As noted earlier, although specialization proceeds at a great pace in the United States (for example, more than 10 percentage points between 1958 and 1963), the situation in the U.S.S.R. remains fairly stable for the moment. It would seem that the Soviet system is able to control the rate of specialization in the medical profession and to maintain a certain proportion of physicians in general practice (or in “internal” medicine). At the present time, the Soviets recognize 14 major specialties (including stomatology). In addition, certain of the specialties include subspecialties. Thus the “therapists” include physiotherapists, endocrinologists, and infectionists. Among the surgeons are included traumatologists, orthopedists, onco!ogists, anesthesiologists, and urologists. Among physicians in public health and epidemiology the following are included: virologists, epidemiologists, malarialogists, bacteriologists, helminthologists, desinfectionists, and other parasitologists. The list is considerably shorter than that of the United States. In the United States, on the other hand, the absence of control and planning at the national level permits an expansion of medical specialization that is almost random, determined by, among other things, considerations of personal prestige and income. We have not been able to uncover parallel data that would indicate how many Soviet physicians are occupied in tasks other than the treatment of patients. We think that, in view of the bureaucratic nature of the medical system and the tendency to assign only physicians to responsible positions in that system (the Minister of Health is always a physician) this proportion cannot be too different from that of the United States. For example, of the 900 staff members of the Ministry of Health U.S.S.R., 600 are physicians (23). We would like to note, very briefly, two other trends in the structural evolution of these two health systems. 1. As society and its health system evolve, the proportion of those in the labor force who are occupied in the health sector increases more rapidly than the total labor force itself. This means that the “weight” of the health system (in terms of its needs for manpower) increases faster than almost any other sector of society. In the United States, for example, according to Magraw (22), between 1950 and 1960 the total civilian labor force in selected industries increased 15 per cent. The labor force in agriculture decreased
No. of Physicians
% of Total
% of Total
bSources, Narodnoe khoziaistvo SSSR v I959 g, p. 187, Moscow, 1960; Narodnoe khoziaismo SSSR v 1961 g, p. 744, Moscow, 1962; Narodnoe khoziaistvo SSSR v 1968 g, p. 731,Moscow, 1968;Narodnoe khoziaistvo SSSR v 1970g, p. 691, Moscow, 1971.
General medicine Terapia “Others” Specialized medicine
Type of Practice
Growth of medical specialization‘ in U.S.S.R., 1940-1970b
by 38 per cent and that in construction by 10 per cent, but the labor force in health increased by 54 per cent. Table 10 compares, for certain years between 1930 and 1970, the proportion of those in health to the total labor force for the United States and the U.S.S.R. In the United States that proportion has almost tripled in 40 years; in the U.S.S.R. it has almost doubled. As an American report published in 1967 states “. . . a considerable growth has also taken place in the number of persons employed in the health industry-cooks, secretaries, janitors to name only a few. One estimates that there are more than a million such workers” (24). Thus, if these 1,000,000 plus workers were added for 1966, the proportion of those who work in the American health sector would climb from 3.7 to 5.0 per cent in 1966, and such personnel might also increase the percentage figure of 5.32 for 1970 by about the same number of percentage points. We believe, however, that for purposes of comparison we had better stick to the percentage figures obtained when the number of health specialists is computed as a percentage of the civilian labor force in the two countries. This is because of the nature of the Soviet data available. Soviet statistics, for example, provide total civilian labor force data and a category that includes “health, physical culture, and social welfare” personnel. It is thus impossible to determine the magnitude of the “health” component in these figures. But it is possible to aggregate those in the health sector who are specialists with a higher education (physicians, stomatologists, and “dental doctors”) and those listed as “middle medical personnel” (feldshers, midwives, nurses, technicians, and so on) and excluding those supportive personnel whose occupations are not health specific (cooks, secretaries, drivers, maintenance personnel, and so on). Using such data, as we have in Table 10, we can see that the “weights” were pretty much the same for the two societies until 1960, but that thereafter the United States figure has increased significantly, whereas the Soviet one has remained practically the same. In 1970, according to our data (which in the nature of the case must remain tentative), the American health “weight” was two-thirds higher than the corresponding Soviet “weight .” 2. The other trend is that, as the number of those who work in health increases, the physicians, who as stated earlier constitute the keystone of the health system, become a diminishing minority among health workers. The data of Table 11 show that since 1960 physicians have constituted at the most 14 per cent of those in the United States who work in health and that for 1970 this proportion was less than 10 per cent for the United States. The Soviet figures, again, are not strictly comparable to the American ones because included in the “total employed in health” are those in physical culture and in social welfare. If these categories were removed, in all instances the percentage of the physicians to all those employed in health would increase, probably by somewhere around 50 per cent. At any rate, in the two systems the physicians are now in the numerical minority, but to a greater degree in the United States than in the Soviet Union. If there is an evolution of health systems in the direction of an increase in size and in internal complexity, one might well expect that in the course of time, the Soviet percentage of physicians to all those in health would follow the downward trends noted in the United States.
Total 900 399
Health 1.8 1.6
51,742 1,090 33,926 627
2.1 62,208 1,440 2.3 1.8 40,400 984 2.4
69,628 2,040 2.9 82,715 62,032 1,820 2.9 90,186
aSources, Estimates and fiojections of the Labor Force and Civilian Employment in the U.S.S.R.: 1950-1975, Series P-91, No. 15, p. 26, U.S. Department of Commerce, Bureau of Census, U.S. Government Printing Office, International Population Reports, Washington, D.C., 1967; Health Manpower Perspective: 1967, p. 5 , Table 1, U.S. Department of Health, Education, and Welfare, Public Health Service, Bureau of Health Manpower, U.S. Government Printing Office, Washington, D.C., 1967; Statistical Abstract of the United States, 1973, p. 71, Table 103, U.S. Government Printing Office, Washington, D.C., 1973; Narodnoe khoziaistvo SSSR v 1968 g , pp. 547-549, Moscow, 1969; Nar dnoe khoziaistvo SSSR v 1970 g , pp. 509,511, 689, Moscow, 1971. gExcluding members of collective farms.
Unitedstates 48,686 U.S.S.R.b 24,200
Increase in labor force and health workers in United States and U.S.S.R., 1930-1970 (in thousands)’
s. ?+ 0
/ Field Table 1 1 Increase in health workers, physicians, osteopaths, and dentists in United States and U.S.S.R., 1960-1970a
Type of Health Worker
Total employed in health Physicians and osteopaths Dentists Total M.D.s, osteopaths, and dentists
No. in 1960 No. in 1966 No. in 1970
2,642,300 274,834 82,630
3,672,000 305,115 86,317
4,403,000 348,328 116,280
3 5 7,464
Physicians, osteopaths, and dentists as percentage of total U.S.S.R.
Totalb Physicians and stomatologists Physicians and stomatologists as percentage of total
(14) 3,461,000 361,600 (10)
(11) 4,427,000 53 1,600 (12)
(10.6) 5,080,000 6 16,900 (12)
‘Sources, Statistical Abstract of the United States, 1970, pp. 64, 67, U S . Government Printing
Office, Washington, D.C., 1970; Narodnoe khoziaistvo SSSR v I967 g, p. 843, Moscow, 1966; Health Manpower, US.,196567, Ser. 14, No. 1, p. 53, Table 17, National Center for Health Statistics, U.S. Department of Health, Education, and Welfare, U.S. Government Printing Office, Washington, D.C., 1968; Statistical Abstract of the United States, 1973, pp. 71-72, U.S. Government Printing Office, Washington, D.C., 1973. bIncludes health, physical culture, and social welfare workers. CONCLUSION This essay has been but a brief summary. Because certain data are not available to us, certain analyses could not be done. We hope that in the future such data will become more easily accessible not only for the United States and the U.S.S.R. but also for other countries in the world. It is also clear that this work should be complemented by a deeper study of at least two additional factors: 1 . The contribution to “medical productivity” of auxiliaries, paramedical personnel, and other health workers, whose number is increasing very rapidly in the United States and at a slower rate in the U.S.S.R. 2. The contribution to “medical productivity” of capital investments, and particularly the contribution of biomedical technology. For example, between 1955 and 1965, the number of active physicians in the United States increased by 22 per cent (the population increased by 17 per cent), but their productivity (services or medical acts directed by physicians) increased by 81 per cent (25). In our opinion, the same factors operate in the U.S.S.R. (perhaps at a reduced rate) and in other health systems. Because the Soviets have more physicians than the Americans, physicians in the U.S.S.R. often perform tasks that their American colleagues delegate either to other personnel (nurses, technicians, or typists) or to advanced equipment (automatic analyzers and computers). One must note another paradoxical effect. Often the introduction of equipment and technology in medicine (contrary to industry) increases the demand for manpower rather than decreases it. Additional personnel are needed to operate the equipment, to repair it, to calibrate it, to monitor it, and so on.
American and Soviet Medical Manpower
Finally, in the American system the development of medicine takes place in an unsystematic way. This creates certain problems, such as a large discrepancy between the best and the worst, an inflation of costs, a lack of equity in the distribution of care, an emphasis on research rather than on the treatment of patients, and a lack of control over the development of the medical contingent regarding the number of physicians, their specialization, and their geographic deployment. These constitute the major aspects of the American health crisis. In the Soviet system, the development of medicine takes place within an administrative framework. The state has a fairly well established control over almost all phases of this development, except for the distribution of physicians outside the cities. The differences, the discrepancies, and the contrasts are less marked than in the United States. If there is a problem in the Soviet system, it may be in the qualitative domain-in personal services as well as research. Theoretically, the Soviet system seems to be better equipped to respond to the changing needs of the population because it is directed by a centralized administration. On the other hand, the American pluralistic system has a certain flexibility. On the whole, these two systems, like those of other countries, are subject to the same universal constraints: the increasing demand for medical services (a quantitative factor) and the ever-growing application of knowledge and biomedical technology (a qualitative factor). It seems to us that in the future we shall see the health systems of industrial societies evolve structurally toward a pattern that will have more elements in common than differences. This may well begin also to reduce the differences, noted at the beginning of this paper, between the American and the Soviet health systems. Acknowledgments-I am most grateful to Ms. Judy H. Koivumaki, who most ably assisted me in preparing the original version of this paper, and to Ms. Sharon A. Lef6vre for help in preparing and editing the revision of the paper for publication in English.
REFERENCES 1. Bryant, J. H. Health & the Developing World. Cornell University Press, Ithaca, N.Y., 1969. 2. Prost, A. Services de santb en pays africains. Masson, Paris, 1970. 3. Flexner, A. Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4. D. B. Updike, The Merrymount Press, Boston, 1910. 4. Fein, R. The Doctor Shortage: An Economic Diagnosis, p. 67. Brookings Institution, Washington, D.C., 1967. 5. Williams, G. Quality versus quantity in American medical education. Science 153: 956-961, August 26,1966. 6. Field, M. G. Soviet Socialized Medicine. Free Press, New York, 1967. 7. Field, M. G. Le s y s t h e de skuritdmddicale sovi$tique.Mkdecine e t Hygidne 892: 1334-1337, 1969. 8. Field, M. G . Pratique mddicale sovidtique revisitde: Cinq cas particuliers. Mkdecine e t Hygikne 959: 625-630, 1971. (In English in Review of Soviet Medical Sciences 7(2): 1-12, 1970.) 9. Log of the Visit of the United States Delegation on Health Planning to the Soviet Union, May 16June 3, 1970, p. 10 (mimeographed). 10. Altman. L. K. More students enter medicine. New York Times. p. 27, November 12, 1970. 11. Higher Education and the Nation’s Health: Policies for Medica? and Dental Education. A Special Report and Recommendations by the Carnegie Commission on Higher Education, p. 36. McGrawHill Book Company, New York, 1970. 12. Association of American Medical Colleges. DIME Dialogue-Division O f International Medical Education 3(3): 1,1970. 13. De Witt, N. Education and Professional Employment in the U.S.S.R., p. 323. National Science Foundation, Washington, D. C., 1961.
14. Chassin de Guerny, J. Note statistique sur la ddmographie mddicale de l’U.R.S.S. Cahiers de Sociologie etDdmographieM&ficales lO(1): 31-34,1970. 15. Bowers, J. C. Special problems of women medical students. J. Med. Educ. 43: 532-537,May 1968. 16. Statistical Abstract of the United States, 1970, p. 65, Table 85. Bureau of the Census, U.S. Government Printing Office, Washington, D. C., 1970. 17. Association of American Medical Colleges. Datagrams 7(8): Table 1,1966. 18. Situation, dvolution et perspective des effective de medecins en France, et dam le pays d’Europe et aux USA, cited by G. Rdsch.Association Medicale Mondiale, MC/DC p. 9, note 7, March 24, 1969. 19. Rosenlund, M. L., and Oski, F. A. Women in medicine. Ann. Intern. Med. 66(5): 1009-1012, 1967. 20. Field, M. G. Health personnel in the Soviet Union: Achievements and Problems. A m . J. Public Health 56: 1904-1920,November 1966. 21. Sidel, V. W. Feldshers and “feldsherism.”N. End. J. Med. 278: 934-992, April 25, 1968. 22. Magraw, R. M. Ferment in Medicine, p. 146.W. B. Saunders Company, Philadelphia and London, 1966. 23. Department of Health, Education, and Welfare, Public Health Service. A n Introduction to the Soviet Health Care System, p. 2. Office of International Health, Washington, D. C., August 1974. 24. Department of Health, Education, and Welfare, Bureau of Health Manpower. Health Manpower Perspective: 1967, p. 5 , Table 5 . U.S. Government Printing Office, Washington, D. C., 1967. 25. Miller, J. I. Report of the National Advisory Commission on Health Manpower, Appendix 1, pp. 87-88.U.S. Government Printing Office, Washington, D.C., 1967.
Manuscript submitted for publication, April 4,1974 Direct reprint requests to: Dr. Mark G.Field College of Liberal Arts Boston University 96-100 Cummington Street Boston, Massachusetts 02215