Honored Scientist Professor A. V. Molkov

25 Years of School Health Services in the USSR

Before the October Revolution, school health services in Russia, like public education itself, were in their infancy. There was no unified system for their organization. In cities, especially the capitals and other large cities, they were administered by the various departments responsible for secondary schools—the Ministry of Education, the War Ministry, the Department of Empress Maria, and others—but in most cases this oversight was merely nominal. Physicians were “attached” to various secondary schools, usually receiving no pay for their work and serving in order to obtain ranks and decorations. These physicians were not united in any way or under anyone’s authority. Only in Moscow and St. Petersburg did the municipal governments 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 public health physicians, exercised sanitary supervision over primary schools, though 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 organized under the society’s governing board. Among the scholars and prominent public health physicians who worked in school health 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 guidance, Dr. Nikitin laid the foundations of a 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 feeble beginnings of school hygiene in tsarist Russia.

A sharp change in the care of children came immediately after power passed into the hands of the Soviets. Despite the enormous food shortages, V. I. Lenin ordered that children be given the best food from the meager supplies then available. At his initiative, a number of laws of enormous importance to children’s health were enacted, including a law mandating smallpox vaccination. Lenin played a direct and immense role in organizing a number of educational and health institutions, establishing the Pioneer movement, defining the Komsomol’s role and responsibilities in the education and health of children, organizing Pioneer camps, and so forth.

The involvement of medical personnel in the complex and responsible task of school education first took organizational form within the People’s Commissariat of Education, where, under the leadership of the late V. M. Bonch-Bruevich (Velichkina), clear directions were laid out for developing ties between medicine and education. School physician posts were established, and a number of model preventive clinics were created. Their task was to study the child comprehensively so that the educational process could be properly organized.

These clinics and the school physicians of the People’s Commissariat of Education who relied on them did not perform curative or preventive functions, which already fell within the remit of the People’s Commissariat of Health. The resulting division between the medical study of the child and the provision of medical care 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 there proceeded under the misguided slogan: “We do not need the old school sanitary physician; the Soviet school needs an entirely new kind of physician—a pedagogue-pedologist.” The proponents of this movement (Radin, Zalkind, Gelfer, Tutyshkin, and others) even succeeded in establishing a special medical-pedological institute of higher education to train such “new” workers, although it did not last long. Representatives of the State Institute of Social Hygiene and the departments of school hygiene at Moscow medical institutes associated with it immediately began to oppose this movement.

School health services took a decisive and sharp turn onto the right path of development after the historic 1936 decision of the Central Committee of the All-Union Communist Party (Bolsheviks), “On Pedological Perversions in the System of People’s Commissariats of Education.” This decision, which eliminated the pseudoscientific “theory” and practice of “pedology” in the public education system, also prompted a reorganization of school health services within the People’s Commissariat of Health. It was established that the school physician’s principal 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 curative 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 all the country’s many millions of children and adolescents with highly qualified curative and preventive care; close coordination between the curative and preventive care provided to pupils in educational institutions (nurseries, kindergartens, schools, boarding schools, and so forth) and the medical care they receive from clinics, district pediatricians, hospitals, sanatoriums, and so on; and the closest possible integration of health measures with educational and instructional activities.

Children’s outpatient clinics were to play the leading role in providing comprehensive medical care for children and adolescents in every district, city, region—in short, every distinct territorial area. Their staff included both school physicians and district pediatricians and, in some cases, “unified pediatricians,” who cared for children both at school (or other children’s institutions) and at home.

Alongside a wide range of therapeutic and preventive duties, pediatricians at children’s institutions were also responsible for routine day-to-day sanitary work, which they carried out in cities with the help of nursing and other mid-level medical personnel and with the assistance of the school state sanitary inspector. In rural areas, all these functions were entrusted to local physicians, district pediatricians, and district state sanitary inspectors.

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

The School State Sanitary Inspectorate, one of the independent branches of state sanitary control established by a resolution of the Council of People’s Commissars of the RSFSR on March 20, 1934, was organized within the Chief State Sanitary Inspectorate and the state sanitary inspectorates of Moscow and Leningrad from the end of 1934, and within the regional and territorial city sanitary inspectorates from January 1935. Until 1937, the principal institutions subject to state school sanitary control were schools, children’s homes, and kindergartens. Thereafter, its scope expanded to include first out-of-school institutions—Young Pioneer camps, children’s parks, cinemas, and so on—and then early childhood institutions—nurseries, child health consultation centers, and so on. From 1940, it also included schools for training labor reserves.

Thus, the State Sanitary Inspectorate is now responsible for the sanitary conditions of all children’s institutions in the country and, consequently, for the sanitary well-being not only of schoolchildren but of all children and adolescents. The term “school sanitary supervision” itself is now 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, buffets, and kitchens fall under the state sanitary inspector for food. With respect to the sanitary duties of school and “unified” pediatricians (see above), the school state sanitary inspector, in addition to organizational and supervisory tasks, assesses the effectiveness of the measures they carry out and analyzes the anthropometric and other sanitary-statistical data they collect. When necessary, the school state sanitary inspector organizes complex, comprehensive sanitary and hygiene studies, establishing special laboratories for this purpose, analyzing the relevant material, and drawing practical conclusions from it.

Over 25 years, the principal directions of practical and theoretical work in school sanitary supervision have consisted in developing statutory and regulatory provisions governing the construction, equipment, and sanitary improvement of schools and children’s institutions; establishing hygienic principles for the daily routines and nutrition of children and adolescents; and organizing the recording of 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 child-care facility construction in foreign countries. To this end, in addition to obtaining specialized literature, staff of the People’s Commissariats of Health and Education were sent abroad. (Later, at the beginning of the first Five-Year Plan, some of the architects who had designed child-care facilities built in a number of Western cities were invited to the USSR, along with other foreign architects and engineers.)

From 1924 to 1928, regulatory guidelines for the construction of child-care facilities were drafted at research institutes of the People’s Commissariat of Health, chiefly the Institute of Social Hygiene and the Institute for the Protection of Motherhood and Infancy, by specially appointed commissions that included representatives of the departments concerned. This work resulted in the publication of the first collections of materials: by the People’s Commissariat of Education on the construction of schools and kindergartens, and by the People’s Commissariat of Health on the construction of nurseries.

The next stage of this work was a detailed study of new school and child-care facility buildings constructed in cities between 1928 and 1935. At these sites, a number of hygiene standards were tested and refined through instrumental investigations 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 body measurements and proportions of children and adolescents, using special 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 designs for children’s furniture and clothing, developed with the participation of physicians and educators, were tested in child-care facilities and became the basis for mass production. This work received extensive coverage in the press and in special instructional materials issued by the People’s Commissariats of Education and Health.

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

All these and other materials provided the basis for sanitary requirements governing school construction and the maintenance and equipment of child-care facilities, which expanded on a tremendous scale during the second and third Five-Year Plans.

The State Sanitary Inspectorate took an active part throughout the country in expanding the network of child-care facilities by exercising preventive sanitary oversight of their construction. The principal documents in this field are the joint guidelines of the State Sanitary Inspectorate and the People’s Commissariat of Education of the RSFSR, “On Coordinating Matters of Construction and Sanitary Improvement of Schools and Child-Care Facilities at the Central and Local Levels”; the State Sanitary Inspectorate’s instructions “On the Acceptance of School and Child-Care Facility Buildings” and “On Construction Oversight”; and others. With the establishment of a network of institutions for training labor reserves, the People’s Commissariat of Health and the Main Administration of Labor Reserves under the Council of People’s Commissars of the USSR jointly issued the Regulations on Medical and Sanitary Services for Trade Schools and Factory and Plant Training Schools, the Instructions on the Procedure for Opening, Arranging, and Equipping Dormitories, and a number of other documents binding on personnel in this network. Each year, staff responsible for school sanitary supervision help prepare guidelines on specific subjects: sending children to Young Pioneer camps and colonies, organizing winter holidays, arranging school breakfasts, and many other matters of local significance. At the central level, general hygiene guidelines under the authority of the People’s Commissariat of Education have been incorporated into the statutes and regulations of schools, kindergartens, children’s homes, school boarding facilities, and other child-care institutions.

For the purpose of carrying out routine sanitary supervision, there were devel-

…sanitary regulations were developed and issued for all principal types of residential and day institutions for children—schools, kindergartens, children’s homes, and Pioneer camps—and, for the first time, sanitary requirements were also developed for facilities outside the classroom: school dining halls, 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 basic large-scale surveys 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 the extensive participation of research institutes and sanitary stations. 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. In Moscow, similar work began in 1940 at two district sanitary stations; at one of them, in the Kirov district, a citywide school hygiene office was also established. In 1937, portable laboratories for carrying out basic sanitary investigations were produced for the first time for workers outside the major centers.

Among the aspects of sanitary conditions in children’s institutions, lighting and air exchange received the most comprehensive attention during the second and third Five-Year Plans. The findings were 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 children’s nutrition carried out during these years. Specialized departments of nutrition institutes conducted detailed studies of the physiological needs of children and of the actual organization of meals in educational and medical institutions for children. Under the direction of these institutes, nutritional standards were developed for healthy and sick children in all age groups (Professors Molchanova, Maslov, and Tur; Associate Professor Balinskaya; and others). Work was also carried out on the organization of collective catering for children in sanitary and health institutions, specialized children’s dining halls, and children’s institutions serving the general population.

On the basis of a review of all school sanitary inspection activities during the Soviet period, a special commission of the People’s Commissariat of Health of the USSR drew up a draft of sanitary legislation for schools and children’s institutions in 1939.

Alongside the sanitary assessment and improvement of children’s institutions and the refinement of the forms and methods of medical care provided in them, attention was also paid to studying changes in the health and physical development of children, particularly those in organized groups.

Work on the assessment of children’s physical development began as early as 1924 at the Institute of Social Hygiene, in a specialized office and the Central Anthropometric Bureau (TsAB). Standards for the physical development of children and adolescents were subsequently established in all the republics of the Soviet Union using a unified methodology. Repeat surveys in a number of places showed positive changes in physical development over this relatively short period. In 1932, basic guidelines were developed for organizing longitudinal observations, which were subsequently carried out in a number of cities through children’s polyclinics, with the active participation of school health personnel.

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

Enormous care was devoted to organized groups of children evacuated from the front-line zone and relocated to areas in the interior of the country. The railway sanitary service, the medical workers accompanying the children’s trains, and local health departments had to be able to take prompt preventive measures to stop the spread of childhood infections—hospitalizing those who were ill and vaccinating children who had been in contact with them, sometimes under extremely difficult travel conditions.

The rural medical network and district state sanitary inspectors made children’s boarding institutions a priority for medical and sanitary services. With the help of local Soviet and Party organizations, these institutions were able to continue caring for children under relatively normal conditions. Detailed instructions on medical and sanitary services for boarding institutions were incorporated into the “Regulations” on boarding institutions 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 raised its requirements for administrators and teachers to maintain proper sanitary conditions in schools and children’s institutions and intensified its efforts to organize volunteer sanitary workers. A system of volunteer sanitary inspectors was established in 1941. Sanitary standards are maintained and children’s meals organized largely with the active participation of members of the children’s institutions’ communities.

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

New forms of student activity—mass participation in agricultural work, work in training and production workshops, and the greatly expanded range of specialized training programs for the labor reserves—have presented the school sanitary inspection service with new responsibilities for overseeing adolescents’ working and living conditions. Basic guidelines have been developed for the selection of students and the exercise of sanitary supervision in factory training schools and trade schools.

The mass entry of women into production led to a substantial expansion of the network of institutions for young children—nurseries, kindergartens, and play centers. Major changes were made in the organization of these institutions: groups attended in shifts during the day, children stayed around the clock, and so forth. All this led to closer sanitary supervision of these institutions, with particular attention to the prevention of childhood infections.

In the USSR, scientific and methodological guidance for school health work by personnel of all specialties—from pediatricians to representatives of the state sanitary inspectorate—has always been provided through a system of research institutes, academic departments, institutions of higher education, and scientific and methodological centers, including experimental demonstration stations and outpatient clinics.

The first republic-level 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, at which

...where an experimental demonstration school was opened. Problems of child morphology and physiology, clinical pediatrics, neuropsychiatry, and the organization of medical services for children were studied at institutes for the protection of the health of children and adolescents established in a number of major centers of the USSR. The central institutes for the protection of the health of children and adolescents (now pediatric institutes) have experimental demonstration institutions attached to them—schools, physical education grounds, children’s sanatoriums, and so on. Some operational institutions conducting experimental work and scientific research, organized partly by the People’s Commissariat of Education and partly by the People’s Commissariat of Health, also became 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.

Beginning in 1922, a system for teaching school hygiene took shape in higher medical education—initially in Moscow as a lectureship within the Department of Social Hygiene, headed by Professor N. A. Semashko. The teaching of “hygiene of upbringing” was entrusted to the assistant A. V. Molkov. In 1925, the lectureship 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 within them.

A corresponding department was also established at the Central Institute for Advanced Medical Training. School hygiene was introduced into the curricula of 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 they came from among practicing school health workers and then, with the establishment of postgraduate training, from among younger workers who had completed postgraduate study in departments of school hygiene. School health supervision in the USSR came to be headed by researchers: 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, research institutes, departments of school hygiene, individual dissertation researchers, and practitioners carried out a large number of scientific studies. Many were published in condensed form or as abstracts in periodicals; others appeared in collections or as separate monographs. Among periodicals, the journals Social Hygiene, Soviet Pediatrics, Preventive Medicine, Hygiene and Sanitation, Hygiene and Health, and Protection of the Health of Children and Adolescents maintained sections devoted to school hygiene.

The practical achievements in protecting the health of children and adolescents over the past 25 years have been immense. Tangible evidence of this is provided by the tens of thousands of splendidly appointed buildings for children’s institutions, specially constructed not only in major urban centers but also in smaller communities and rural areas.

In the early stages of developing institutions of various kinds for children, the Soviet authorities made use of mansions and luxurious buildings belonging to the bourgeoisie, located in cities and on estates. But this stock was quickly exhausted owing to the enormous scale on which children’s institutions of various kinds were being developed. An acute need for premises arose, especially for schools, 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, cities saw intensive construction of school buildings, often large not only in their capacity—1,500, 2,000, or more pupils—but also in the complexity of their design, which required considerable floor area and building volume. Many rooms were devoted to ancillary facilities: classrooms, laboratories, workshops, museums, recreation halls and gymnasiums, kitchens, dining rooms, and the like. Construction of preschool institutions expanded at the same time. However, the extensive requirements for accommodation 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,” specified maximum standards for ancillary rooms and limits on floor area and building volume per pupil, and established standard school building types. A similar resolution was adopted in 1936 for kindergartens and nurseries.

With physicians acting as consultants (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 provide all the essential conditions for successful educational work and for strengthening children’s health and physical development.

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

The physical condition of children and adolescents in every age group has improved markedly, 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 schoolchildren’s height, weight, and chest circumference were considerably greater in 1927 than those recorded in the extensive studies conducted by Professor Erisman and his pupils in 1885. Studies repeated by Professor Syrkin eight to ten years later revealed further increases in the weight, height, and chest circumference of children and adolescents of all ages. Other researchers have obtained similar findings.

Most convincing of all, however, are the words spoken by Comrade Voroshilov at the Seventh Congress of Soviets of the USSR: “Medical examinations of workers called up for military service showed that in Moscow and Leningrad, the Moscow, Leningrad, and Ivanovo regions, Gorky Territory, and Ukraine, average weight has risen by one and a half to two kilograms over the past six or seven years, while chest circumference has increased by one and a half to two centimeters.” This characterizes the physical condition of the heroic defenders of our homeland and places an increased 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 for the next generation the conditions that will enable our reserves of labor and fighting strength to maintain the high level of physical development they have attained.