| Berlin polyclinic in 1986 Photo Steffen RitterGerman Federal Archive | MR Online Berlin polyclinic in 1986. (Photo: Steffen Ritter/German Federal Archive)

A brutal system replaced socialist health care in Europe

Originally published: Peoples Dispatch on April 21, 2023 by Peoples Health Dispatch (more by Peoples Dispatch)  | (Posted Apr 24, 2023)

Socialist health systems are often ignored in today’s discussions on improving health care and health policy. This is the case in East Europe, where socialism has been exposed to an intense defamation campaign over the past 30 years. Still, the organization of health care in countries like in the German Democratic Republic (DDR/East Germany) and Yugoslavia should be taken as an important source of inspiration, as it increased access to care, opened health professions to the working class and peasants, and fostered international cooperation to strengthen health systems all over the Global South.

Ana Vračar of People’s Health Dispatch talked to Matthew Read, researcher at the Internationale Forschungsstelle DDR (IF DDR), about the health system in DDR, its achievements, and its similarities to the health system in Yugoslavia. The IF DDR and Tricontinental: Institute for Social Research recently published ‘Socialism Is the Best Prophylaxis’: The German Democratic Republic’s Health Care System.

Ana Vračar (AV): Today we hear a lot of policymakers talking about patient-centered policies. But when I think of health care in Yugoslavia, the term which comes to mind instead is community-centered. It was a health system built around developing health infrastructure in the community. Not only in neighborhoods, but also in schools and workplaces. Later, that took another dimension through the attempt of building self-management in health. Was there this kind of community element in health in the DDR?

Matthew Read (MR): Yes, one of the things that we discovered in our research was that the emphasis in terms of protecting health was no longer placed on the individual, but it was really a social responsibility to protect health. The basic approach to realize that was having this vast outpatient sector, because that’s where you receive care without being admitted to the hospital. The idea was that, for this outpatient care to be effective, it has to be directly available where people live and where they work. There were polyclinics or outpatient centers within neighborhoods, within the workplace, and connected to schools. This made it possible to distribute health tasks amongst different sectors of society. For example, a pediatrician conducted regular on-site visits to kindergartens. Together with the management of the kindergarten, health institutions were able to organize vaccines and regular checkups for the children, so it wasn’t up to the parents alone to deal with this kind of stuff. Also, in terms of reaching communities, there was definitely a big effort in the DDR to reach remote areas. There was a community nurse system where nurses would basically drive around on mopeds to distant regions, and carry all their equipment and expertise with them. They would have regular patient check ups to prevent illnesses in remote regions.

AV: The community nurses’ program is actually one thing that we have left from the socialist model in Croatia’s health system today. Each community nurse has approximately 5000 people in their care, either in a city or in a rural area. Regardless of where they work, you still hear the stories of how they drive through the snow to get to old people who don’t have wood to get them wood. Their job is not only about delivering health care, but delivering food and fuel. It’s delivering all of those things that the community needs, but has no access to right now.

MR: Unfortunately, they dismantled the system here, so there are no community nurses anymore. They were all laid off after the transition. We still have midwives that do this kind of stuff, but in terms of regularly checking up on people outside of the urban centers–they’re on their own.

AV: Your research zoomed in a lot on the polyclinic model in the DDR. Yugoslavia had a similar experience in primary health care with the introduction of community health centers and ambulatories. Since the 1990s, this system has undergone an intense process of dismantlement, but it’s not possible to ignore the fact that it completely changed how people perceived health and their right to health–including health workers. How did the introduction of the polyclinic change health care in the DDR?

MR: It’s important to note that the polyclinic was not a new concept that the DDR developed. Polyclinics were being discussed in the 1920s, in the Weimar era in Germany, because a lot of progressive doctors realized that, if you’re going to try to actually treat patients, it doesn’t make sense to have doctors working in private practices. If doctors are financially incentivized to treat patients, they’re not incentivized to prevent diseases. They earn their money by prescribing medicine and by having consultations, so they’re actually interested in people coming back rather than staying away. At the same time, there was also the recognition that we have all these advancements in medicine and technology, so it doesn’t make sense to have individual doctors within their offices, because they would make most of the advancements if they were to consult with other doctors, have a more holistic approach.

The idea of the polyclinic is actually quite old, but the socialist states–well, I can speak for the DDR at least–made the decision to create them and to cluster different specialties under one roof. There were a number of practical advantages to this. There’s the medical benefit of being able to have an interdisciplinary collaboration. All of a sudden, you have different doctors discussing one case, understanding what’s going on, instead of just having a very specific targeted understanding of a patient. You also have ready access to laboratory equipment or imaging services. The polyclinic can also stay open longer than a single practice. That means you can have longer working hours, without overburdening workers. It’s easier to cover for doctors if they’re sick or if they’re on holiday. You can even have doctors go and do on-site visits while the polyclinic stays open. You are actually able to achieve much more extensive care than you can with private doctors scattered throughout cities.

The polyclinics weren’t the only outpatient clinics. There were also smaller centers with fewer departments, but which were trying to incorporate this idea of interdisciplinary collaboration. In more remote areas, you still had individual practices. Near the end of the DDR, these were also public practices, just individual. What I’m saying is, it wasn’t just all one big polyclinic that everyone had to go to. You had different layers of outpatient care, and the polyclinic was kind of the culmination point, a kind of central node in this network. But the key was to have the outpatient posts staffed by health workers who are also publicly employed. They are guaranteed fixed working hours, a reasonable income, and everything else that goes along with it, which is very different to the private, self-employed doctor.

AV: How did health workers react to this shift from private practice to public employment? This is something that got a lot of opposition in Yugoslavia when the socialist health system was introduced. But then, with time, everybody grew used to it and started to see the benefits of providing primary health care through a collective. In fact, they grew so accustomed to this type of work that when the first reforms in primary health care were introduced in the early 1990s, bringing it back closer to private practice, even the doctors didn’t want to do that. I mean, it didn’t take them long that this would mean more money for them and return to the old logics, but for a brief moment you had doctors, nurses, and all the health workers in the centers saying, ‘Why would you want to destroy something that works so well? We want to keep this.’

MR: Opposition to this kind of changes went back to the days of the Weimar era, and it was led primarily by conservative physicians’ associations. Because as you say, they realized that if they lose their self-employment status, then they might earn less. One of their other concerns was that, for a long time, medicine was something that was kept in the family. The child would take over the practice from the father, or something like this. There was a very traditional understanding of medicine that physicians were afraid to let go of, a vision which enabled them to have a monopoly on the profession. This didn’t only apply to the practice of medicine, but also to learning medicine and training to become physicians. Once the DDR began to go on the polyclinic path, this sort of resistance reemerged.

At this point, the DDR was in a very precarious situation because the border to West Germany was still open. The doctors who were afraid that they might have to give up their private practice, the doctors who wanted to earn more money, the doctors who took part in Nazi atrocities, they could just pick up and go West. A lot of them did. You had a huge shortage of doctors in the beginning of the DDR. At the same time, doctors were being trained tuition free in East Germany. The East German government was funding medical education to a very high standard just to look people leave, and West Germany was actually actively poaching doctors. It was an instrument in the Cold War, a way of weakening East Germany.

What they tried to do then was to try to demonstrate to the health workers the advantages of the polyclinic model. In the beginning, they also offered some concessions to doctors so they wouldn’t leave, like the possibility of having a private practice. This showed them the medical benefits of the model without forcing them to enter public employment. The situation changed when the border was closed in 1961, but by then you had young doctors who understood the benefits of the new model. You know, you have fixed hours, you have a secure income, you don’t have to do all the administrative stuff like you have to do in your own private practice, this kind of thing. It was possible to gradually win over the medical professionals, but it was not an easy path.

AV: Was it easier with other health workers compared to doctors? I have the feeling we tend to talk about doctors a lot, but nurses and other health workers won important battles during socialism. Nurses in Yugoslavia, for example, weren’t only doctors’ helpers, but a profession in their own right.

MR: We spoke with quite a few nurses during our research, and when you talk to them, especially the older ones who were already working in the early days of the DDR, you see the conditions were not a walk in the park. They had to deal with a lot of difficult situations. I don’t want to paint a rosy picture of health work in the DDR, but what is clear is that they manage to sort of erode these hierarchies between medical professions. There was a focus on continuously upgrading the nursing profession. The state started to finance the training of nurses at quite a rigorous academic level. They ensured that there was a system which would allow nurses to obtain more qualifications over time. Basically, nurses and doctors began to equalize. Again, public employment helped make this happen. When they were all employed in outpatient centers, nurses and doctors were all treated under the same labor laws. They organized within the same trade union. You no longer had physicians’ associations that looked down at nurses and worked only for their own interest.

There was also a big effort to ensure that working class and peasant kids could get into medicine. Again, for a long time, medicine was a profession exclusively for the intelligentsia, so bringing in people from other groups was another way of winning over the medical profession to socialism. If you bring working class and peasant kids to the medical profession, they won’t be so reluctant to go down the polyclinic path, because they don’t have the same private interests people from old doctors’ families have. In terms of training new doctors, there was quite often a prioritization of enrolling working class and peasant students.

AV: That sounds completely different from what we are seeing today in Croatia. Technically, everyone still has access to studying medicine, but it’s mostly doctors’ children going down this path. There is also a reluctance, still, for doctors’ children to pick up other health professions, like nursing. In theory, everyone can be a doctor. In practice, the old hierarchies are still here. There is not really the effort to break these down by fostering real teamwork and retaining the staff that you need. It’s a very different situation to what there was in Yugoslavia, where they made a point of educating health workers, but also developing their own research, development, and production capacities. The things that today we pay millions of euros to Big Pharma corporations, like vaccines, we were able to produce ourselves. For example, the Institute of Immunology in Zagreb was able to develop and produce a very high quality version of the measles, mumps and rubella (MMR) vaccine, in approximately enough quantities to be independent. The DDR was in a worse position than Yugoslavia when it came to the possibility of imports and scarcity of materials, so how did they manage with building their own workforce and production capacities?

MR: Supply issues were definitely a big issue throughout the DDR’s existence. They were very tangible in the case of medical equipment, but also general supplies like bandages. It was not only external problems like the West-imposed blockade that led to this, there were also internal economic difficulties. Essentially, the way that the DDR tried to go around this was similar to what you describe in Yugoslavia. There was a big effort to produce locally, especially pharmaceuticals. There was a very, very large pharmaceutical industry in East Germany. The idea was to integrate that within the wider socialist camp. Let’s say the DDR would produce lots of pharmaceuticals, covering around 80 or 90 percent of its own needs. It would also export a lot of these medicines to other socialist states. In return, these countries would take up a lot of the medical training for nurses or doctors from the DDR. These health workers would then come back to East Germany. It was a little bit like division of labor.

The fact that all health facilities were interconnected also helped with addressing supply issues. To give an example, doctors were in very close communication with pharmacists. So if they had prescribed a medicine to a patient, and the patient couldn’t find this medicine in the pharmacy, it wasn’t up to the patient to go back to the doctor and see what can be done. By having a unitary network that’s not fragmented between private pharmacies and public clinics, you could deal with supply issues much more efficiently than you can in capitalist states.

AV: It’s interesting to see how the perception of what makes sense economically changed over time. Now everybody keeps talking the about the importance of prevention, but if you look at the budgets, that’s not reflected. In Croatia, prevention gets about 3% of the health budget. And this mirrors the shift of priorities that happened during the 1990s, when we let go of primary health care and turned back to the hospital sector. But what I find most bizarre is that while the content of health care has changed, it’s impossible even for the most pro-privatization minister to ignore the good things that have come out of the Yugoslav health system. There are even some elements, some institutions, that were not dismantled completely, although it’s a very hospital-based, private-driven health system we’re seeing today. Did you notice something similar happening in East Germany?

MR: I’ve heard from other friends from Yugoslavia that some things were maintained, or slightly changed and continued. Here the key difference between Yugoslavia and the DDR, or East Germany, is that there was not really a gradual transition towards capitalism in East Germany. It was incorporated into West Germany. West Germany just extended its borders, basically, and essentially overnight you had the dismantling of the East German healthcare system. All of the achievements gone, the rigorous re-imposition of the private practice model implemented, the polyclinics just eliminated. The community nurse system was destroyed. The nurses were laid off, they had to find jobs elsewhere. It was moving to talk with all of these former DDR doctors or nurses, because they were really shocked by the transition. They would tell us that, all of a sudden, they’re not referring to patients anymore, but they’re using the word customer to talk about them.

There was one nurse in particular that we spoke to, who was employed in a private practice after 1990. The doctor became her employer. And she told us of this time when the doctor had to go to a course on self-employment to know how to run a private practice. When she came back, she told the nurse, “You know, what I learned there is that we’re not allowed to let the patients get healthy again. We have to make sure that they stay sick, so that they come back and we can prescribe them more medication. That way we can keep consultation hours coming.” She was just shocked, the doctor, that this is her profession now: it’s not about keeping people healthy, it’s about earning money and keeping the private practice running. As tragic as it is, it’s in moments like these when you can really see the contrast between different social systems. You see the difference between the system that’s based on profit and the system that’s based on people’s needs very clearly. In terms of what’s available in Germany today, there’s really nothing left of the DDR system. We have this fragmented system of rather weak public facilities and a number of different private facilities.

Earlier you mentioned doctors being poached from Yugoslavia, or Eastern Europe in general. This is something that’s keeping the German medical system relatively stable. I mean, it’s unstable, but it’s being stabilized by the import of medical professionals from other countries. There is this brain drain from countries who really need their health workers. Instead, they’re coming here because the pay is better and the living conditions are better. It’s the exact opposite of what the DDR and the other socialist states were doing. They had agreements with national liberation movements in former colonies to train health workers in the DDR, who would then return and build their own medical health system. Now, when we train people in Germany, a lot of them stay. There are no agreements to train people from abroad so that they can return and build their own country up. Instead you have this sort of perpetuation of inequalities, which is a huge setback. It’s also very difficult to measure the consequences of that, but we really need to try, because it’s something extremely devastating.

In terms of what you said about aspects of the social system continuing in Yugoslavia today, sometimes they try to do that here as well. For example, there is now this model they call medical centers, which sort of leans on the idea of the polyclinic. Doctors in this kind of institution can be employed rather than self-employed. But these medical centers are private, and they’re subordinated to the idea of profit. In this way, we are seeing something similar to what you describe. But I think it’s not possible to actually take elements of the socialist model, put them into a capitalist state or system, and think that they will be able to reproduce what they are originally meant to do.

AV: I really like your point about international cooperation: it was something that was valued in Yugoslavia as well. Some of the older people who we talked to, young doctors at the time, remember how people from Iran came to Yugoslavia to learn about the primary health system. People from Yugoslavia then traveled to Iran to help build a system which would work there–not merely a reproduction of what was being built in Yugoslavia, but something that Iran needed and wanted. It’s something that’s completely forgotten now.

MR: Absolutely. We spoke with many people who were involved in the training of international students. They train international students in Germany now, too. But like I said, a lot of them stay here. It’s not something that we are doing out of solidarity with other countries, but for our own interest, and at most for these individuals. The people who come to train here mostly come from a certain class, a class which can afford it. This means that the lower classes in other countries are left to fend for themselves. It’s very much a brutal system.

People’s Health Dispatch is a fortnightly bulletin published by the People’s Health Movement and Peoples Dispatch.