Dynamics and Factors of Medical Service in European Russia at the Beginning of the 20th Century

1. IntroductionFor a long time there has been a discussion in the scientific community on the topic of explaining and evaluating the historical development of the Russian Empire, in particular in the aspect of the dynamics of living standards.

The relatively long historiographical period of a negative trend in the assessment of Russia's development ^{[1; 2]} was replaced by a revisionist trend in the pre-revolutionary era. Studies of recent decades show that in the Russian Empire at the end of the XIX – beginning of the XX century there was a fairly steady economic growth ^{[3; 4]}, as well as an increase in the standard of living in its individual aspects ^{[5; 6]}. Healthcare as one of the key parameters of the standard of living, however, is still on the periphery of the research of interest, which is a significant omission, since healthcare is one of the most important foundations of economic prosperity and social well–being ^{[7, pp. 166-167]}.

This paper presents a study of healthcare in the aspect of the population's access to medical care. Access to medical care is an important indicator of the interaction between public medicine and the population; access is one of the key indicators of the effectiveness of medical institutions. The paper presents an analysis of statistical data, on the basis of which the characteristics of the processes associated with the population's access to medical care and the factors influencing them are given.

This article studies exclusively the processes of seeking medical care, outside the context of measuring their impact on the demographic situation in society. The study of the impact of reversibility on the mortality of the population is accompanied by obstacles in the form of undeveloped mortality statistics in the Russian Empire, especially in the part affecting mortality as a result of morbidity. In addition, the axiomatic nature of the relationship between medicine and the quality of life also seems rather doubtful – due to the fact that the patient's request for medical help is not a guarantee of his recovery. This is influenced by many factors besides the fact of treatment, which require a separate study: from the level of scientific medicine and the qualifications of the doctor to how the patient himself is involved in the process of his treatment.

2. Problem statementIf we reason in the logic of the distribution of services and benefits (while medical services are affiliated with a conditional good), then the dynamics of circulation should characterize the dynamics of social security and, in general, the standard of living.

However, this view of medicine is being questioned by sociologists. In the 60-70s of the XX century, the term “medicalization” appeared in sociology, which characterized the process of spreading medicine and medical knowledge into areas of human life that had not previously been affected by them. Medicalization was studied as one of the forms of social control that defines the boundaries of socially acceptable and deviant through medical concepts – thus medicine was perceived as a channel for the exercise and dissemination of power ^[8]. Moreover, in the American tradition, medicalization is severely criticized due to the neoliberal nature attached to it: medicine has the competence to pathologize the state of the human body and actually impose its services on a person, thereby, on the one hand, accumulating demand for its activities, and on the other hand, increasing the role of medical institutions in public life ^{[9; 10]}. Such a critical approach had a significant impact on the subsequent academic discussion, but did not acquire an axiomatic character ^{[11; 12; 13]}. It is impossible to discard the fact that in many ways medicine really facilitates and improves a person's life. The competence of medicine is not only direct therapy – it includes many organizational, educational, preventive practices, many of which really have a significant impact on the quality of human life (smallpox vaccination, obstetrics, personal hygiene, and others). In this regard, the study of various aspects of medicine and healthcare is a promising area of social and economic sciences. Seeking medical help is also one of these aspects, since treatment includes not only direct therapy of a disease or ailment, but also some involvement of the patient himself in the process of identifying and treating his illness, that is, it assumes the presence of several participants in this process.

In the sector of historical research of public medicine and public health, one of the main research focuses are epidemics ^{[14; 15; 16]} and infant mortality. Research in the field of infant mortality is relevant not only because this indicator is one of the most important demographic parameters of any society, but also because infant mortality, according to research, largely depends on socio-economic and, no less importantly, cultural prerequisites ^{[17; 18]}. That is, the discussion about the standard of living should include both socio-economic, socio-cultural and anthropological analysis.

Despite the fact that in the Russian research tradition, the study of medicine and healthcare in the Russian Empire is represented by a considerable number of works ^{[19; 20; 21]}, there are practically no studies devoted to the aspect of the population's access to medical care, which, from the author's point of view, is a big omission. This indicator, being an indicator of the relationship between medical institutions and the population (as well as bureaucratic departments, scientific institutions), contains the potential to make a certain contribution to the characterization of institutional relations within Russian society in the pre-revolutionary period.

3. Data sources and methods

The study uses data on the population's access to medical care. In the Russian Empire, the sphere of healthcare and public medicine was a disparate structure with a weakly expressed single center of influence. A separate ministry of public medicine, despite repeated attempts to create such a ministry ^{[22, pp. 8-10]}, did not exist in the Russian Empire. By the beginning of the XX century, there were several departments whose responsibilities included the provision of medical services (prison, military, naval, zemstvo, city medicine, etc.). Due to such fragmentation, the collection of statistical data was complicated. The Department of the Chief Medical Inspector at the Ministry of Internal Affairs was engaged in collecting medical statistics. The management was subordinated to the provincial medical departments, whose list of duties included accounting for medical statistics. All civilian and freelance doctors were ordered to report to local medical departments about their activities and general information about the patients they examined. Based on these data, the provincial medical departments compiled annual reports, which were then collected by the Office of the Chief Medical Inspector and issued in the form of "Reports on the state of public health and medical care to the population in Russia" ^{[23, pp. 249-254; 24-35]}. In the future, the Central Committee of the Ministry of Internal Affairs duplicated the basic information, which was presented in a much more limited format, in the Statistical Yearbooks of the Russian Empire.

The “Reports” consist of two main parts: the first, the “Text”, is devoted to a general overview of the state of healthcare in the empire for the reporting year; the second, the “Tables” consists of statistical information on separate categories of data for each province. This study uses data related to the population's access to medical care, medical personnel, the state of medical infrastructure (hospitals, hospital sites, etc.), and healthcare financing. Statistics on the number of requests for medical care is the main one in this study. It is given both at the level of the province and at the level of cities /counties, but compiled in a generalized (within the province) format, without division into specific cities and counties. 

The study also uses demographic data: population size, literacy rate, confessional composition. The source of these data is the Statistical Yearbooks of the Russian Empire ^[36].

The appeal of the population for medical care is a combination of the action and interaction of factors of the infrastructural state of health care and social and economic features, including those related to the degree of medicalization, characteristic of the studied societies. The logic of the study is formed in such a way that the appeal for medical care is studied in the light of the influence of medical, organizational, social and economic factors on it. For this purpose, the methods of descriptive statistics, correlation and regression analysis (the least squares method) are used in the work. When conducting regression analysis, the rule of multicollinearity is observed: independent features, between which there is a strong significant correlation, are not included in one regression equation.

For more convenient handling of the data, during the study, it was decided to divide the totality of the provinces of European Russia into 4 groups: zemstvo (34 zemstvo provinces defined by the “Regulations on Zemstvo Institutions” of 1890), non-zemstvo (the group includes, among others, provinces to which the “Regulations” were extended in 1911), Privislinsky (Polish) and ostzeysky (Baltic). The provinces of the Grand Duchy of Finland were not included in the study. 

4. Access to medical care: general characteristicsThe general picture of the processes of seeking medical help at the beginning of the XX century is as follows: in 1902, on average, there were 368 requests for medical help per 1000 people in European Russia, and by 1913 it had grown by almost half and reached 550 requests.

This means that in 1913, medical care was provided to no more than every second citizen in the Russian Empire – at least half of the population of European Russia did not interact with health institutions, even despite a significant increase in the rate of appeal for a relatively short period of time.

Such dynamics can be considered in more detail in two formats. With the differentiation of provinces into zemstvo, non–Zemstvo, as well as Ostsee (Baltic) and Privislinsky (Polish), the dynamics picture becomes more complicated: the highest rates of circulation are in zemstvo provinces, the lowest are in Privislinsky (with the overall positive nature of the dynamics). Also, the frequency of circulation of the population differed significantly in cities and counties – in urbanized areas it was much higher than in the provinces.

These data already indicate a significant degree of heterogeneity of the provinces of European Russia in terms of access to medical care. The spread of the indicator between individual provinces was up to 1,000 appeals per 1,000 people, and the coefficient of variation reached 0.6 and higher (for the level of cities and counties) and varied between 0.4 – 0.53 at the provincial level. 

Table 1. Descriptive statistics of medical treatment in European Russia in 1902-1904 and 1911-1913.1902-1904

The explanation of such a picture of the conversion rate intuitively tends to the dominant story in historiography about the merits of zemstvo medicine and its legacy in Russian history. However, the cartograms (Fig. 2) show that the circulation of the population in the zemstvo provinces is not only far from homogeneous, but also in some cases is smaller in comparison with the non-Zemstvo provinces (primarily related to the Western Edge). The Privislinsky and Ostzey provinces stand apart, in which the conversion rates are significantly lower than in the rest of European Russia. 

Such data can be explained by the hypothesis of the prevailing importance of zemstvo medicine only in part, since it formally refers only to the sector of public medicine in the province and theoretically should not explain the trends of seeking medical care in cities. Moreover, there is practically no separate story in historiography that the zemstvo form of organization of medicine contributes to a greater number of requests for medical help from the population, other things being equal. Due to the fact that at the moment there is virtually no interpretation of such a phenomenon of reversibility, a more detailed approach is required to study the factors affecting the distribution of the index of reversibility in European Russia.

5. Factors of circulation of the populationThis section provides an assessment of the effects of the infrastructural state of healthcare, economic development and human capital on the level of access to medical care in European Russia.

The regression analysis method was used for the study. The dependent variable is the level of access to medical care per 1000 people. The share of the urban population, the literacy rate and the share of the Orthodox population for 1897, the level of financing of health care per 1,000 people, the provision of the population with medical staff (doctors and paramedics) per 10,000 people and the zemstvo status of provinces for current years were selected as independent variables. The period of 1902-1913 is divided into 4 time periods of 3 years each, for each of which all the listed parameters are reduced to average values.

The literacy of the population was chosen as an explanatory factor due to the fact that as a result of a fairly broad discussion by the scientific community, a trend about the positive impact of literacy on the level of public health is still highlighted ^{[37, pp. 1236-1237]}. What is the reason for this – the fact that the level of literacy is quite often associated with the level of well–being, or the fact that even basic literacy can contribute to the growth of medical literacy - has not been definitively clarified. However, such conclusions are formulated when studying modern data, while much less attention is paid to how the level of literacy affects the level of public health in general and health processes. 

The level of funding and provision of the population with medical staff in this study characterize the infrastructural state of healthcare in European Russia. The main emphasis is placed on the second factor, as it is given in the source in a more detailed format (there is a differentiation on the principle of city / county). The factor of zemstvo status is a nominative variable, it is used to study the role of zemstvos in the processes of the population seeking medical care.

The share of the Orthodox population was chosen as an independent variable because some studies have shown how cultural factors due to ethnicity and confessional affiliation influence behavior patterns in relation to physical health and body ^[38]. This article examines whether there is a similar pattern in the field of seeking medical help.

The calculation results are shown in the tables. Each column in the table means a separate model, which includes combinations of independent factors.

Table 2 presents the results of the first variants of the regression analysis model, which includes the parameters of literacy and confessional composition for 1897. All six models have significant explanatory power, while the factor of the share of the Orthodox population acquires maximum importance. This picture is not surprising, since in the Privislinsky and Ostzey provinces, in which the proportion of Orthodox is significantly less than in the zemsky and non-Zemsky provinces, the rate of population seeking medical care is very low (including this explains the negative value of the regression coefficient of the literacy factor). 

Table 2. Results of regression analysis of the appeal in European Russia, 1902-1904(1)

Notes: The dependent variable is the availability of medical care in the provinces of European Russia. The standard errors of the coefficients are given in parentheses.

*** p<0,01, ** p<0,05, * p<0,1

When these provinces are removed from the regression equation in Table 3, the explanatory power of all models decreases. It is noticeable that the literacy factor not only acquires positive values of the regression coefficient, but it also becomes significant in one of the combinations. But the main difference from the previous version of the regression equation is that the factor of the zemstvo status of the province becomes the strongest factor – and besides, if it is available, the model has a significantly better explanation of the variance of the conversion rate than models with the included factor of the share of the Orthodox population. In general, models 1 and 5 show the best R2 results, that is, whether the province is a zemstvo or not, as well as the financing of health care and the provision of the population with medical staff had the greatest impact on the level of the population seeking medical care in the provinces of European Russia from the factors we considered.

Table 3. Results of regression analysis of the appeal in European Russia, 1902-1904(1)

Notes: The dependent variable is the availability of medical care in the provinces of European Russia. The standard errors of the coefficients are given in parentheses.

*** p<0,01, ** p<0,05, * p<0,1

Such data suggest that the hypothesis about the prevailing role of zemstvo medicine in the Russian Empire is also expressed at the level of medical care in 1902-1904. However, it would be premature to draw conclusions that zemstvos influence not only the organizational level of medical institutions, but also the nature of the interaction of the population with them – however, it would be just as premature to deny the existence of such a connection. 

The appeal for medical care is a statistical indicator, and the appeal as a unit of this indicator is recorded by a competent person or agency. In this regard, there are a number of research problems associated with the imperfect nature of the collection of statistics, including medical. In the “Reports ...” ^{[24, p. 9]} it is explicitly stated that the statistics of private admission and circulation in cities are incomplete. The level of completeness of statistics is influenced by many factors, including the administrative capabilities of the bureaucracy, which, in turn, also depends on many factors. Partial incompleteness of statistical data can lead to significant errors in the analysis of these statistics. Because of this, due to the alleged incompleteness of information, it is necessary to assume that the statistical indicator of circulation may not be equal to the real level of circulation. In this regard, the most attention is attracted by the Privislinsky and Ostzey provinces, in which the level of circulation recorded in the “Reports ...” is much lower than in the rest of European Russia, which is quite paradoxical, since these regions were distinguished by a higher level of social and economic development. In this regard, there is a possibility to doubt the level of adequacy of reflecting the level of circulation in these regions in statistical reports. The Ostzei and especially the Privislinsky provinces had a complex history of relations with St. Petersburg, and this could also affect the bureaucratic interaction of the Center and the Outskirts, including in the field of medical statistics – however, it is not possible to provide unambiguous confirmation of such an assumption, since this requires a separate in-depth study of the complex problem of the relationship between the Center and the Outskirts in the empire. 

The Ostzey and Privislinsky provinces, characterized by a low level of conversion, did not have the status of zemstvo, including therefore, in the variants of regression models in which they are included, the factor of zemstvo status (as well as the factor of the proportion of Orthodox) explains the variance of conversion much better. In this regard, in the study, each regression model is accompanied by two variants: with the inclusion of the Privislinsky and Ostzey provinces and with their exclusion (60 and 47 provinces).

To check whether the factor of zemstvo status is significant and stable in determining the distribution of circulation, a regression analysis was carried out for the other three time periods – from 1905 to 1913. The factors of literacy and the proportion of the Orthodox population have been removed from the regression equation, since the data for 1897 are becoming increasingly irrelevant over time. The removal of the factor of the share of the Orthodox population is also due to the fact that it actually duplicates the factor of the zemstvo status and at the same time makes a smaller contribution to the explanation of the variance of the conversion rate. Moreover, the dependent factor is divided according to the city/county principle, since both organizationally and infrastructurally urban and provincial medicine differed significantly from each other, which could not but affect the patterns of circulation processes. Because of this, the factor of financing health care is excluded from the equation, since there is no detailed data on it in the source, as well as the factor of the share of the urban population.

Table 4 shows the circulation model in the counties of European Russia. Its explanatory power is quite large – both with the inclusion and exclusion of the Ostzei and Privislin provinces – while being quite stable throughout the time period. It is noteworthy that if at the initial stage it is the factor of zemstvo status that makes the greatest contribution to explaining the variance of the dependent variable, then over time this role deviates to the factor of providing the population with medical staff. This is especially noticeable in the variant of the model without the Privislinsky and Ostzey provinces – when they are excluded, the coefficient of the zemstvo status factor becomes significantly less. 

Table 4. Results of regression analysis of the circulation in the counties of European Russia, 1902-1913(1)

Notes: The dependent variable is the access to medical care in the counties of European Russia. The standard errors of the coefficients are given in parentheses.

*** p<0,01, ** p<0,05, * p<0,1

The same parameters were selected for the circulation model in cities as for the model in counties. It shows approximately the same picture as in the previous model – and this is a bit of a paradox, since formally the zemstvo status of the province should not have an impact on the urban medicine sector. This could be attributed to the fact that, probably, the practices of the zemstvo health organization spread within the province, including to the cities. However, it has not been possible to find unambiguous confirmation of this at the moment. Moreover, the level of correlation between circulation in cities and circulation in counties is very low and insignificant throughout the study period. 

The following observation from the analysis of urban circulation: in general, the explanatory power of this model is significantly lower than the county version. The parameters we have chosen explain much worse the variance of circulation in the cities of European Russia – this means that it is influenced by some other factors that were not included in this model. They can range from incomplete statistics, especially in cities, to the effect of other, social, economic and even cultural reasons.

Table 5. Results of regression analysis of the circulation in the cities of European Russia, 1902-1913(1)

Notes: The dependent variable is the availability of medical care in the cities of European Russia. The standard errors of the coefficients are given in parentheses.

*** p<0,01, ** p<0,05, * p<0,1

For the period 1911-1913, an additional parameter was included in the regression model of circulation at the provincial level – the statistics of the savings business collected by M. A. Davydov ^[39]. It is included in order to find out how the conditional level of well-being of the population affects the process of seeking medical care. The number of savings books per 1000 people is entered as an independent variable. This model shows that the number of passbooks does have an effect in explaining the variance of circulation, but only to some extent (R2 is equal to 0.14 and 0.11). Moreover, the level of healthcare financing and the availability of medical staff significantly better determine the distribution of the dependent variable. This suggests that the access to medical care was more dependent on the infrastructural state of health care than on the conditional level of well–being of the population in the chosen model - although the fact of the influence of the latter is present in the model. However, it would be premature to talk about the unambiguous impact of the level of well-being on the level of appeal, since the historiography has practically not investigated the rather complex topic of payment for medical services. In cities, there was a practice of hospital collection (which was carried out rather inconsistently), and in some counties medical care was provided free of charge at all – but the effect of these parameters on the intensity of requests for medical care was not investigated.

Table 6. Results of regression analysis of the appeal in European Russia, 1902-1904(1)

Notes: The dependent variable is the availability of medical care in the provinces of European Russia. The standard errors of the coefficients are given in parentheses.

*** p<0,01, ** p<0,05, * p<0,1

In general, the study showed that it is possible to study the medical treatment at least at three levels: provincial, county and city. There are different patterns of circulation distribution in counties and cities: in counties, the selected factors explain this distribution much better than in cities. At the provincial level, the factors included in the regression analysis also largely determine the variance of the level of circulation, but there is a significant difference between the models with the included and excluded Ostzey and Privislinsky provinces. In addition, there is a gradual change of the most significant factor from the zemstvo status of the province to the infrastructural state of health care.

6.     ConclusionsThe results of the study are as follows: in European Russia, by 1913, the appeal rate had increased to 550 appeals per 1000 people (which is almost 50% of the dynamics since 1902).

The main factors influencing the variance of the circulation index are the level of financing of healthcare and the provision of the population with medical staff (which can be characterized as the infrastructural state of healthcare), as well as the zemstvo status of provinces. A statistically significant relationship with the level of welfare of the population (the level of savings deposits) was also revealed. In the counties and cities of European Russia, different patterns of influence of the studied factors are observed: in cities, the coefficient of determination of the regression model is significantly less than in counties. There is a gradual change of the most significant factor – from the zemstvo status of the province to the infrastructural state of health care.

The processes of seeking medical care in European Russia at the beginning of the XX century developed dynamically: in 12 years, numerically, it has grown by almost half. This already gives reason to believe that the availability of medical care is not directly dependent on the incidence – there is no evidence in the sources of such a significantly increased number of diseases. Reversibility is the result of the action and interaction of many actors and factors, primarily between medical institutions and people themselves. Such a high growth in a relatively short period of time indicates a rather dynamic development not only of the Institute of health care, but also of behavioral practices of seeking medical help. In the research optics of Foucault and Illich, such a phenomenon clearly resembles the development of the process of medicalization: at least in quantitative terms, the degree of interaction of people with medical institutions has been dynamically increasing. However, it would be premature to say unequivocally that this process was accompanied by an increase in power control over the population, in which medical institutions act as a channel for broadcasting this control. 

However, it is difficult to deny the fact of a high positive dynamics of circulation as an indicator of interaction between healthcare and the population in the role of a potential patient. As a result of the regression analysis of the factors of seeking medical care, the following conclusions were formulated.

Most of the factors considered in the study – the infrastructural state of health care and the zemstvo status of the province – largely explain the variance of circulation in European Russia. When detailed, this conclusion becomes more complicated. Firstly, these factors have a much greater degree of determination of the circulation in counties, while in cities their influence is much less. That is, if the appeal rate in the counties was largely explained by how many doctors and paramedics are on the staff of medical institutions, and by whether the province is a zemstvo or not, then in cities, probably, other factors influenced the level of appeal.

Secondly, there is a gradual change of the most significant factor: if at the beginning of the study period the zemstvo status of the province largely determines the appeal, then by 1913, both in counties and in cities, the provision of the population with medical staff better explains the variance. Of particular interest is that the correlation between these factors is low and insignificant. The reason why, whether the province is a zemstvo or not, in 1902, other things being equal, had a greater impact on the number of requests for medical care than the infrastructural ability of healthcare to accept these requests, and why by 1913 this situation had changed, remains unknown. Among the proposed options: features of statistics collection, other behavioral practices of the population – however, this requires separate study.

Thirdly, the level of well-being (in the study presented in the form of the number of savings books in the hands of the population) does have some effect on the distribution of the circulation of the population. However, its effect is much less significant than the influence of the above factors. 

Fourth, in the course of the study, a deep difference in the patterns of distribution of circulation in the Privislinsky and Ostzey provinces is clearly noticeable. The explanation of such a phenomenon requires additional research.

Thus, the need for medical care appears as a rather ambiguous indicator of the interaction of many factors within Russian society at the beginning of the XX century. In quantitative terms, it is quite low, despite the high dynamics. In many ways, the level of appeal in the province depended on the organizational and infrastructural state of health care in this province – however, the case of the urban sector indicates a potentially much more complex composition of factors affecting the population's access to medical care. In general, the data on circulation indicate a significant increase in the sphere of competence of medical institutions, which can be interpreted both as an increase in the "sociality" of the state and society, and as an increasing deprivation of physical secrecy and greater statistical transparency of Russian society.

How do the obtained data on the appeal fit into the broader picture of healthcare? Undoubtedly, the receiving capacity of healthcare has significantly improved, which cannot but be both a consequence of the modernization of the healthcare structure and a driver for its further development, the realization of its potential to turn into a system. On the other hand, on the part of the recipient of health services, the trend of demand for these services is clearly visible: in such a short time, the number of applications has increased by half. This suggests that in European Russia at the beginning of the XX century there was a dynamic process of development of approaches to the issue of preserving public health – not only in the form of some policies emanating from medical and public institutions in general, but also in the plane of the attitude of people – potential patients to the topic of intervention of these institutions in the sphere of their physicality. However, it cannot be said that the potential for the development of Russian healthcare was close to exhaustion – as the study showed, the development of the material base of medicine, as well as the improvement of social, cultural, economic living conditions of the Russian population were necessary conditions for improving healthcare in general.