Professor A. V. Molkov, Honored Scientist

25 Years of School Health Services in the USSR

Before the October Revolution, school health services in Russia, like public education, were in an embryonic state. There was no unified system for their organization. In the cities, especially the capitals and other large cities, they were administered by the various departments responsible for secondary schools—the ministries of education and war, the Empress Maria’s department, and others—but in most cases this oversight was merely nominal. Physicians were “assigned” to various secondary schools, for the most part receiving no payment for their work and serving in order to obtain ranks and decorations. These physicians were united by absolutely nothing and under no common authority. Only in Moscow and St. Petersburg did the municipal authorities establish organizations of school physicians. In 1906 there were 48 school physicians in St. Petersburg and 12 in Moscow; by the beginning of the imperialist war, 50 Russian cities had school physicians. In a few progressive zemstvos, district physicians, under the direction of the very few sanitary physicians, conducted sanitary inspections of primary schools, but of course on a far from adequate scale.

The Pirogov Congresses devoted considerable attention to school hygiene. A commission on school hygiene and the dissemination of hygienic knowledge was established under the society’s governing board. Among the scientists and prominent sanitary physicians working in the field of school sanitation were Professors Erisman and Khlopin and the physicians Bekaryukov, Nikitin, Mikhailov, Kastorsky, Molkov, Lebedev, Durnovo, and several others. Bekaryukov’s well-known book, Fundamentals of School Hygiene, remains valuable to this day. Under Professor Khlopin’s direction, Dr. Nikitin established the first school hygiene museum and published the first Handbook for School Physicians, containing instructional and methodological materials. Under their joint editorship, a number of works were also translated into Russian

manuals, including the comprehensive manual on school hygiene by Professor Leo Burgerstein and Dr. A. Netolitsky.

Such were the first tentative beginnings of school hygiene in tsarist Russia.

A sharp change in the care of children became apparent immediately after power passed into the hands of the Soviets. Despite enormous food shortages, V. I. Lenin ordered that children be given the best products from the meager supplies then available. On his initiative, a number of laws of immense importance to children’s health were enacted, including a law on compulsory smallpox vaccination. Lenin himself played an enormous part in organizing a number of institutions devoted to education and health, creating the Pioneer movement, defining the role and responsibilities of the Komsomol in the education and health of children, organizing Pioneer camps, and so forth.

The involvement of medical personnel in the complex and responsible work of school education first acquired an organizational form within the system of the People’s Commissariat of Education, where, under the leadership of the late V. M. Bonch-Bruyevich (Velichkina), clear directions were laid out for developing links between medicine and pedagogy. School physician posts were established, and a number of model preventive clinics were created. Their task was the comprehensive study of the child as a basis for properly organizing the educational process.

These clinics and the school physicians of the People’s Commissariat of Education who relied on them did not perform therapeutic or preventive functions, which already fell within the competence of the People’s Commissariat of Health. The resulting separation between medical study and medical care of the child persisted for some time even after the medical institutions of the People’s Commissariat of Education were transferred to the People’s Commissariat of Health in 1918.

At first, work here proceeded under the misguided slogan: “We do not need the old school health physician; the Soviet school needs an entirely new physician—a teacher-pedologist.” Representatives of this tendency (Radin, Zalkind, Gelfer, Tutyshkin, and others) even secured the opening of a special medical-pedological institution of higher education to train such “new” workers, although it did not exist for long. The struggle against this tendency was launched at the same time by representatives of the State Institute of Social Hygiene and the departments of school hygiene at Moscow medical institutes that relied on it.

School health work took a decisive and sharp turn onto the correct path of development following the historic 1936 resolution of the Central Committee of the All-Union Communist Party (Bolsheviks), “On Pedological Perversions in the System of People’s Commissariats of Education.” This resolution, which put an end to the pseudoscientific “theory” and practice of “pedology” in the public education authorities, also prompted a reorganization of school health work within the People’s Commissariat of Health. It was established that the school physician’s chief task should be to provide medical care and create favorable sanitary conditions for the growth and development of every Soviet child. This led to the creation of the coherent system of therapeutic and preventive care for children and adolescents now being put into practice, under which the separation of the study of the child from the provision of medical and sanitary care has been completely eliminated.

This system was founded on three basic organizational principles: comprehensive coverage of the country’s entire population of many millions of children and adolescents with highly qualified therapeutic and preventive care; a close link between the therapeutic and preventive services provided to pupils in educational institutions—nurseries, kindergartens, schools, boarding schools, and so on—and the medical care they receive from clinics, district pediatricians, hospitals, sanatoriums, and the like; and the closest possible coordination of health measures with educational work.

Children’s polyclinics were to play the leading role in providing comprehensive medical care to children and adolescents in every district, city, and region—that is, in every distinct territorial area. These polyclinics included school physicians and district pediatricians and, in some cases, “unified pediatricians,” who cared for children both at school (or, more generally, in children’s institutions) and at home.

In addition to a wide range of therapeutic and preventive duties, pediatricians in children’s institutions were entrusted with routine, day-to-day sanitary work. In cities, they carried this out with the help of auxiliary medical staff and the assistance of the state school sanitary inspector. In rural areas, all these functions were assigned to local physicians, district pediatricians, and district state sanitary inspectors.

The number of physicians serving schools and children’s institutions grew from several hundred in 1918 to 1,500 in 1924 and more than 3,500 in 1940. From 1936 onward, this network was replenished annually by graduates of specialized pediatric faculties: 26 faculties graduating up to 2,000 physicians each year. Beginning in 1935, approximately 300 graduates of sanitary faculties were assigned as state sanitary inspectors in cities to direct school sanitary supervision.

The state school sanitary inspectorate—one of the independent branches of state sanitary control established by the decree of the Council of People’s Commissars of the RSFSR of 20 March 1934—was organized within the Chief State Sanitary Inspectorate and the state sanitary inspectorates of Moscow and Leningrad from late 1934, and within the regional and territorial city sanitary inspectorates from January 1935. Until 1937, schools, children’s homes, and kindergartens were the principal institutions subject to state school sanitary control. Its scope subsequently expanded to include first out-of-school institutions (Pioneer camps, children’s parks, cinemas, and so forth), then early childhood institutions (nurseries, child health clinics, and so forth), and, from 1940, schools for the training of labor reserves as well.

Thus, the state sanitary inspectorate is now responsible for ensuring proper sanitary conditions in all children’s institutions in the country and, consequently, for the sanitary welfare not only of schoolchildren but of all children and adolescents. The term “school sanitary supervision” is now merely a conventional name inherited from the past.

More complex establishments are served by a team of state sanitary inspectors. For example, trade and railway schools housed in separate buildings, as well as student dormitories, fall under state school sanitary control; production workshops fall under the industrial state sanitary inspector; and food establishments, dining halls, cafeterias, and kitchens fall under the state food sanitary inspector. With respect to the sanitary functions of school and “unified” pediatricians (see above), the state school sanitary inspector, in addition to organizational and supervisory duties, assesses the effectiveness of the measures they implement and analyzes the anthropometric and other sanitary-statistical data they collect. Where necessary, the state school sanitary inspector organizes complex, comprehensive sanitary and hygienic investigations, establishing special laboratories for this purpose, analyzing the relevant data, and drawing practical conclusions from them.

Over 25 years, the principal areas of practical and theoretical work in school sanitary supervision have been the development of statutory and regulatory materials on the construction, equipment, and sanitary improvement of schools and children’s institutions; the hygienic basis for children’s and adolescents’ daily routines and nutrition; and the organization of record-keeping on the social factors affecting the health and physical development of the child population. Work on the sanitary improvement of children’s institutions began in 1923 with a study of the best

examples of school and children’s institution construction in foreign countries. To this end, in addition to obtaining specialized literature, staff members of the People’s Commissariats of Health and Education were sent abroad. Later, at the beginning of the First Five-Year Plan, several architects responsible for children’s institution buildings constructed in a number of Western cities were also invited, along with other foreign architects and engineers.

Regulatory guidelines for the construction of children’s institutions were prepared in 1924–1928 at research institutes of the People’s Commissariat of Health, principally the Institute of Social Hygiene and the Institute for the Protection of Motherhood and Infancy, by specially appointed commissions with the participation of representatives of the agencies concerned. This work resulted in the publication of the first collections of materials: one on the construction of schools and kindergartens by the People’s Commissariat of Education, and another on the construction of nurseries by the People’s Commissariat of Health.

The next stage of this work was a detailed study of new school and children’s institution buildings constructed in cities in 1928–1935. A number of hygiene standards were tested and refined at these sites through instrumental studies of artificial lighting, ventilation, airborne dust, and other conditions. At the same time, work began to establish a hygienic basis for school furniture, clothing, textbooks, toys, and teaching aids. Thus, detailed studies of the dimensions and body proportions of children and adolescents, using specialized anthropometric methods, led to the development of size standards for furniture (M. Korsunskaya) and clothing (Krasnobaeva, Nazarova, and others) for children of all ages. The types of children’s furniture and clothing developed with the participation of physicians and educators were tested in children’s institutions and formed the basis for the mass production of these items. This work received extensive coverage in the press and in specialized instructional materials issued by the People’s Commissariats of Education and Health.

With the mass publication of children’s books and textbooks, the hygiene requirements for their external design were re-examined experimentally (Shapiro, Fredgeim, Grombakh); the same was done for children’s toys (Lyakhovich, Badalov, and others).

All these and other materials formed the basis for sanitary requirements governing school construction and the maintenance and equipping of children’s institutions, which expanded enormously during the Second and Third Five-Year Plans.

The State Sanitary Inspectorate took an active part throughout the country in developing the network of children’s institutions by exercising preventive sanitary oversight of their construction. The principal documents in this field are the joint guidelines issued by the State Sanitary Inspectorate and the People’s Commissariat of Education of the RSFSR, “On the Coordination of Matters Concerning the Construction and Sanitary Improvement of Schools and Children’s Institutions at the Central and Local Levels,” and the State Sanitary Inspectorate’s instructions “On the Acceptance of School and Children’s Institution Buildings,” “On the Supervision of Construction,” and others. With the organization of a network of institutions for training labor reserves, the Regulations on Medical and Sanitary Services for Trade Schools and Factory Training Schools, the Instructions on the Procedure for Opening, Arranging, and Equipping Dormitories, and a number of other documents binding on staff in this network were issued jointly with the Main Administration of Labor Reserves under the Council of People’s Commissars of the USSR. With the participation of school sanitary supervision staff, thematic guidelines are prepared annually on sending children to Pioneer camps and colonies, conducting winter vacations, organizing school breakfasts, and many other matters of local importance. At the central level, general hygiene guidelines issued through the People’s Commissariat of Education have been incorporated into the charters and regulations of schools, kindergartens, children’s homes, boarding schools, and other children’s institutions.

For the purpose of conducting ongoing sanitary supervision, there were devel-

…sanitary regulations were developed and issued for all major types of residential and day institutions for children—schools, kindergartens, children’s homes, and Young Pioneer camps—and, for the first time, sanitary requirements were also developed for out-of-school facilities: school cafeterias, children’s theaters and cinemas, children’s libraries, skating rinks, and winter sports facilities.

These materials serve as the principal guidelines for practical work.

During the Third Five-Year Plan, in addition to the basic mass inspections conducted by state sanitary inspectors—which are valuable in themselves for tracking changes in the sanitary condition of the network of children’s institutions—instrumental and laboratory assessments of various aspects of sanitary conditions in schools and children’s institutions were also introduced. To this end, state sanitary inspectors began to enlist research institutes and sanitary stations extensively. In Leningrad, the first school hygiene laboratory was established in 1939, bringing together all the city’s work in this field under the direction of Professor Gutkin. Similar work began in Moscow in 1940 at two district sanitary stations; one of them, in the Kirov district, also established a citywide school hygiene office. In 1937, portable laboratories were produced for the first time for personnel in outlying areas to conduct basic sanitary investigations.

Among the issues concerning sanitary conditions in children’s institutions, lighting and air exchange received the most thorough attention during the Second and Third Five-Year Plans. This work was incorporated into draft standards for artificial lighting, cubic capacity, and floor area in newly designed buildings.

Particular mention should be made of the work on child nutrition carried out during these years. On the basis of a detailed study of the physiological needs of children, conducted by specialized departments of nutrition institutes, and of the practical arrangements for meals in educational and medical institutions for children, dietary standards were developed under the direction of those institutes for healthy and sick children of all age groups (Professor Molchanova, Maslov, Tur, Associate Professor Balinskaya, and others). Work was also undertaken on the organization of public meal services for children in health and convalescent institutions, specialized children’s cafeterias, and ordinary children’s institutions.

Drawing on the entire record of school sanitary supervision during the Soviet period, a special commission of the People’s Commissariat of Health of the USSR drafted sanitary legislation for schools and children’s institutions in 1939.

Alongside the sanitary investigation and improvement of children’s institutions and the refinement of the forms and methods of medical care provided to children in them, some attention was given to studying trends in the health and physical development of the child population and, in particular, of organized groups of children.

Work on assessing the physical development of the child population had begun as early as 1924 at the Institute of Social Hygiene, in a specialized office and the Central Anthropometric Bureau (TsAB). Using a standardized method, physical development standards for children and adolescents were subsequently developed in all the republics of the Soviet Union. Repeat examinations conducted in a number of places showed positive trends in physical development over this relatively short period. In 1932, basic guidelines were developed for organizing periodic observations, which were subsequently carried out in a number of cities through children’s polyclinics, with the active participation of school sanitary personnel.

During the Great Patriotic War, all sanitary measures were intensified.

Great care was devoted to organized groups of children evacuated from the front-line zone and resettled in the interior of the country. The railway sanitary service, the medical workers accompanying the trains carrying children, and local health departments were called upon to implement preventive measures rapidly to prevent the spread of childhood infections—hospitalizing the sick and vaccinating children who had been exposed, sometimes under extremely difficult conditions in transit.

The rural medical network and district state sanitary inspectors made children’s boarding homes a priority for medical and sanitary services. With the help of local Soviet and Party organizations, these homes were able to continue caring for children under relatively normal conditions. Detailed instructions on medical and sanitary services for the homes were incorporated into the “Regulations” on boarding homes for school-age and preschool children, issued by the People’s Commissariat of Education in agreement with the People’s Commissariat of Health.

Routine sanitary services for schools and children’s institutions passed primarily to mid-level medical personnel. The State Sanitary Inspectorate therefore substantially increased its demands on administrators and teachers to maintain proper sanitary conditions in schools and children’s institutions, and intensified its efforts to organize volunteer sanitary workers. In 1941, a corps of volunteer sanitary inspectors was established. The maintenance of sanitary standards and the organization of children’s meals are carried out chiefly with the active participation of the communities of children’s institutions.

In accordance with instructions from the People’s Commissariats of Health and Education, professional development courses for teachers in childhood hygiene and the control of infections are being held in a number of cities in 1941–42. In accordance with instructions from the Chief State Sanitary Inspectorate, volunteer sanitary inspectors are recruited from among teachers in schools and children’s institutions. They carry out sanitary work under the direction of medical personnel assigned to the schools or of a state sanitary inspector.

New forms of student activity—mass participation in agricultural labor, work in training and production workshops, and the greatly expanded range of specialized training fields for labor reserves—have confronted the school sanitary supervision service with new responsibilities for monitoring adolescents’ working and living conditions. Basic guidelines have been developed for selecting students and conducting sanitary supervision in factory and plant training schools and vocational schools.

The large-scale entry of women into industrial work brought about a substantial expansion of the network of institutions for young children—nurseries, kindergartens, and children’s playgrounds. Significant changes were made in the organization of these institutions: groups were introduced in shifts during the day, children began to stay around the clock, and so forth. All this led to increased sanitary supervision, with particular attention to the prevention of childhood infections.

In the USSR, scientific and methodological guidance for school health work by professionals of every specialty—from pediatricians to representatives of the State Sanitary Inspectorate—has always been provided by a system of research institutes, academic departments, and institutions of higher education, as well as by scientific and methodological centers: experimental demonstration stations and polyclinics.

The first republican scientific and methodological center for school hygiene after the October Revolution was the State Institute of Social Hygiene, which assembled extensive school-hygiene materials in its museums. Issues of physical education for the younger generations were studied at the Institute of Physical Culture, where

where an experimental demonstration school was opened. Problems of child morphology and physiology, clinical pediatrics, neuropsychiatry, and the organization of medical care for children were studied at institutes for the protection of children’s and adolescents’ health that existed in a number of major centers of the USSR. The central institutes for the protection of children’s and adolescents’ health (now pediatric institutes) have experimental demonstration institutions attached to them—schools, physical education grounds, children’s sanatoriums, and the like. Some operating institutions that conducted experimental work and scientific research, established partly by the People’s Commissariat of Education and partly by the People’s Commissariat of Health, also became important methodological centers. Among these were the Timiryazev School in Noginsk, which studied questions of physical education for children and adolescents; the tuberculosis dispensary in Moscow; the Krasnaya Roza tuberculosis sanatorium near Moscow; and the Professor Bobrov Children’s Sanatorium in Alupka, among others.

Beginning in 1922, a system for teaching school hygiene took shape in higher medical education—first in Moscow, in the form of a readership within the Department of Social Hygiene, headed by Professor N. A. Semashko. The teaching of “hygiene of upbringing” was entrusted to Assistant A. V. Molkov. In 1925, the readership at the First Moscow Medical Institute was transformed into an independent Department of Hygiene of Upbringing. Similar departments were organized at a number of medical faculties in the USSR, and with the opening of sanitary and pediatric faculties, departments of “school hygiene” were established in them.

A corresponding department was also established at the Central Institute for Advanced Medical Training. School hygiene began to be taught in medical and pedagogical technical schools (N. I. Sokolov, S. N. Malov, Professor Emelyanov, and others).

The teaching staff for school hygiene in higher and secondary medical education were initially drawn from physicians who had worked on these questions before the revolution; later, from practicing school sanitation workers; and then, with the establishment of postgraduate training, from young workers who had completed postgraduate study in departments of school hygiene. Scientific workers took the lead in school sanitation inspection in the USSR: M. I. Korsunskaya (People’s Commissariat of Health of the USSR), L. N. Zaglukhinskaya (Moscow), A. Ya. Gutkin (Leningrad), Comrade Gudkov (Gorky), A. I. Balandin (Omsk), and others.

During the period under review, scientific institutes, departments of school hygiene, individual dissertation writers, and practitioners carried out a large number of research studies, many of which were published in abbreviated form or as abstracts in periodicals; others appeared in collected volumes or as separate monographs. Among periodicals, the journals Social Hygiene, Soviet Pediatrics, Preventive Medicine, Hygiene and Sanitation, Hygiene and Health, and Protection of Children’s and Adolescents’ Health maintained sections devoted to school hygiene.

Practical achievements in protecting the health of children and adolescents over the past 25 years have been enormous. Tangible evidence of this is provided by the tens of thousands of splendidly designed buildings for children’s institutions, purpose-built not only in major urban centers but also in smaller communities and rural areas.

In the early stages of expanding the various types of children’s institutions, the Soviet government used mansions and luxurious buildings belonging to the bourgeoisie, located in cities and on estates, but this stock was soon exhausted as a result of the enormous scale on which children’s institutions of various kinds were being established. An acute need for premises arose, especially for schools in connection with the introduction of universal—

…of compulsory education through the seven-year level. Schools had to adopt two shifts, and in some places three, making it difficult to maintain proper sanitary conditions.

Extensive new construction of purpose-built schools and children’s institutions began alongside the construction of new cities and settlements. During the reconstruction period, intensive construction of specialized school buildings began in the cities. These buildings were often large not only in scale—accommodating 1,500, 2,000, or more pupils—but also complex in layout, requiring considerable floor area and cubic capacity. Many rooms were set aside for auxiliary facilities of various kinds: classrooms, laboratories, workshops, museums, recreation halls and gymnasiums, kitchens, dining rooms, and so on. At the same time, construction of preschool institutions expanded. However, the increased requirements for the range of rooms and the concentration of large numbers of children in these institutions did not meet the widespread need to expand their network. Accordingly, a special 1935 resolution of the Central Committee of the All-Union Communist Party (Bolsheviks) and the Council of People’s Commissars of the USSR, “On School Construction,” established maximum standards for auxiliary rooms and limits on floor area and cubic capacity per pupil, and specified types of school buildings. A similar resolution was adopted in 1936 for kindergartens and nurseries.

With the advisory participation of physicians—P. M. Ivanovsky, M. I. Korsunskaya, A. Ya. Gutkin, L. N. Zaglukhinskaya, and others—a group of architects developed standard plans for schools and other children’s institutions. During the second and third five-year plans, approximately 24,000 schools and more than 5,500 children’s institutions were built. These bright, spacious buildings provided all the essential conditions for successful educational work and for improving children’s health and physical development.

The extensive data collected in recent years on the physical development of children and adolescents convincingly demonstrate the beneficial effect of the conditions created by Soviet power on the vitality of our young people.

The physical appearance of children and adolescents in all age groups has changed markedly for the better, as has been observed everywhere comparative anthropometric studies have been conducted. Extensive studies carried out by the Institute of Social Hygiene and the Department of School Hygiene under Professor L. A. Syrkin in Moscow, Bogorodsk, Tula, and the Ostashkovo district near Moscow consistently found that in 1927 such measures as height, weight, and chest circumference among schoolchildren were much greater than those established by the extensive studies conducted by Professor Erisman and his pupils in 1885. Studies repeated by Professor Syrkin 8–10 years later revealed further increases in weight, height, and chest circumference among children and adolescents of all ages. Other researchers obtained similar data.

Most compelling of all, however, are the words of Comrade Voroshilov at the Seventh Congress of Soviets of the USSR: “Medical examinations of workers called up for military service showed that, in Moscow, Leningrad, the Moscow, Leningrad, and Ivanovo regions, Gorky Krai, and Ukraine, average weight has increased over the past 6–7 years by one and a half to two kilograms, and chest circumference has grown by one and a half to two centimeters.” This characterizes the physical condition of the heroic defenders of our motherland and places a heightened responsibility on the bodies charged with caring for the rising generation, including school health workers, in these difficult times of the Great Patriotic War: to preserve conditions for the rising generation that will enable our labor and military reserves to maintain the high level of physical development they have attained.