KEYWORDS

DDR
Health
Healthcare
Hospital
Polyclinic
Care
Occupational health care
Prophylaxis
Preventive care
Vaccination
Internationalism
Brain drain

“SOCIALISM IS THE BEST PROPHYLAXIS”

The German Democratic Republic’s Health Care System 

ABSTRACT

Although it exis­ted for only 40 years, the German Demo­cra­tic Repu­blic (DDR) was able to cons­truct and advance a funda­men­tally diffe­rent health care system. The medi­cal approach known as prophy­la­xis, which seeks to prevent dise­ase before it mani­fests, became the leit­mo­tif of health policy in the DDR. Buil­ding on progres­sive medi­cal tradi­ti­ons and socia­list property rela­ti­ons, the DDR was able to elimi­nate the profit motive from medi­cine and cons­truct a unitary health care system that opera­ted in all areas of society. This study inves­ti­ga­tes the poli­ti­cal empha­sis placed on social medi­cine in East Germany, which sought to syste­ma­ti­cally reco­g­nise and combat the living and working condi­ti­ons contri­bu­ting to illness rather than merely focu­sing on treat­ment at the indi­vi­dual level. Further­more, it looks at the insti­tu­ti­ons that supported this approach, such as the trans­for­ma­tive outpa­ti­ent network of poly­cli­nics and the field of occu­pa­tio­nal medi­cine, along­side the compre­hen­sive inte­gra­tion of child­care and health services and the medi­cal inter­na­tio­na­lism of the DDR.

 

In the face of limi­ted econo­mic resour­ces and fierce compe­ti­tion with the capi­ta­list world, the socia­list DDR proved that preven­tive care, effec­tive treat­ment, and digni­fied employ­ment can be guaran­teed for all. By looking at the factors behind both the succes­ses and chal­lenges that confron­ted East Germany, this study seeks to outline a frame of refe­rence for those strugg­ling towards a society orga­nised for and by working people.

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TABLE OF CONTENTS

1. Health Care in a Sick System

 

2. Histo­ri­cal Condi­ti­ons in the Years Prece­ding the DDR

 

3. The DDR’s Compre­hen­sive Approach to Health Care 

 

4. Contra­dic­tions and Challenges

 

5.The Poly­cli­nic: A Modern Approach to Outpa­ti­ent Care

 

5.1. From Private Prac­tice to Polyclinics

 

5.2. The Opera­tion of Polyclinics

 

5.3. An Over­view of the Outpa­ti­ent Sector

 

6. Protec­ting Health in the Workplace

 

7. Health Care for Mothers and Children

 

8. Vacci­na­tion Strategies

 

9. The DDR’s Inter­na­tio­nal Coope­ra­tion and Medi­cal Solidarity

 

10. Why Is Socia­lism the Best Prophylaxis?

 

11. Sources

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The Prole­ta­rian Health Service (PGD) was a self-orga­nised health service that opera­ted from 1921 to 1926. It was expli­citly poli­ti­cal and contin­ued the tradi­tion of public health by, for instance, support­ing the nutri­tion of school­child­ren and the labour strug­gles to main­tain the eight-hour day, espe­ci­ally in the mining indus­try and chemi­cal facto­ries. It further advo­ca­ted for the socia­li­sa­tion of health care and orga­nised concrete, prac­ti­cal assis­tance by provi­ding health care trai­ning and educa­tion, acci­dent preven­tion, and first aid. The PGD also worked closely with the workers’ sports move­ment to promote fitness.

1945: Estab­li­shing the Central Health Admi­nis­tra­tion and the Health Offices (Order No. 17).

 

1946: Repe­al­ing the racist laws and other Nazi legal provi­si­ons (No. 6) and passing an order to combat tuber­cu­lo­sis (No. 297).

 

1947: Intro­du­cing a uniform system of social insu­rance (No. 28); estab­li­shing a work­place health system (No. 234); and orde­ring the estab­lish­ment of outpa­ti­ent centres and poly­cli­nics (No. 272).

 

Other orders were concer­ned with control­ling indi­vi­dual infec­tious dise­a­ses and estab­li­shing medi­cal and scien­ti­fic institutions.

“Since the full deve­lo­p­ment of the health service will only be guaran­teed in a socia­list society, there is nevert­hel­ess a way for demo­cra­tic Germany as well. […] This is the natio­na­li­sa­tion of the health service. Only in this way can physi­ci­ans, enjoy­ing econo­mic­ally secure posi­ti­ons as well as resour­ces guaran­teed by the state, devote them­sel­ves enti­rely to their duties. Only in this way can the achie­ve­ments of medi­cal science be made available to the entire popu­la­tion. […] The preser­va­tion of the health and the produc­tive capa­city of working people is one of the nation’s most important tasks and a prere­qui­site for recon­s­truc­tion. […] Hence, health protec­tion must be made a matter for the state and thus for the people as a whole. The aim must be one of secu­ring for ever­yone the protec­tion of his or her health as the basis of vita­lity and physi­cal fitness”.

 

A district health inspec­tor measu­res sound frequen­cies in a resi­den­tial area in order to deve­lop methods for redu­cing noise pollu­tion. The medi­cal fields of social, occu­pa­tio­nal, and commu­nal health were respon­si­ble for moni­to­ring and safe­guar­ding the health stan­dards of the population’s working and living conditions.
  1. Every citi­zen of the German Demo­cra­tic Repu­blic shall have the right to the protec­tion of his or her health and labour power.
  2. This right shall be guaran­teed through the plan­ned impro­ve­ment of working and living condi­ti­ons; the foste­ring of public health; the imple­men­ta­tion of compre­hen­sive welfare poli­cies; and the promo­tion of physi­cal acti­vity, school and popu­lar sports, and tourism.
  3. In the event of illness or acci­dent, the loss of income and the costs of medi­cal care, medi­ci­nes, and other medi­cal services shall be provi­ded through a social insu­rance system.
In 1950, there were 1,694 phar­macies in the DDR, of which 1,266 were priva­tely owned. By 1989, there were 24 private phar­macies and 2,002 public phar­macies mana­ged by the Minis­try of Health. Each of the DDR’s 15 regi­ons was over­seen by a head doctor and head phar­macist. On the district level, local phar­macists were respon­si­ble for moni­to­ring the distri­bu­tion of medi­cine accor­ding to unified standards.
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Dr. Hein­rich Niemann remem­bers: ‘At the begin­ning of the 1980s, the large Dr. Karl Koll­witz Poly­cli­nic was built in the working-class district of Prenz­lauer Berg in Berlin. The doctors who had alre­ady been working there in private prac­ti­ces did not go into poly­cli­nics with flying colours. Of course, they knew that the moment they worked in such a large faci­lity, a diffe­rent mode of opera­tion, a new way of working toge­ther would be neces­sary. […] Yet, this is the only way that a unity can be estab­lished between thera­peu­tic, reha­bi­li­ta­tive, and preven­tive measu­res. Still today, a private prac­tice can only achieve this to a limi­ted extent’.
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Commu­nity nursing was a highly skil­led and valued profes­sion. The nurses were well acquain­ted with the resi­dents in their region and perfor­med important medi­cal services during house visits such as carry­ing out exami­na­ti­ons, dres­sing wounds, admi­nis­te­ring medi­ci­nes and injec­tions, and arran­ging for a doctor’s assis­tance when necessary.

§2 (4) Labour law is aimed at impro­ving, in a plan­ned manner, the working and living condi­ti­ons of employees in the enter­pri­ses: speci­fi­cally, to expand health protec­tion; to enhance labour power; to improve social, health, intellec­tual and cultu­ral program­mes; and to increase the workers’ oppor­tu­ni­ties for meaningful leisure time and recrea­tion. It guaran­tees working people mate­rial secu­rity in the case of illness, disa­bi­lity, and old age.

 

§ 17 (1) Enter­pri­ses as defi­ned by this law are all state-owned estab­lish­ments and combi­nes as well as socia­list cooperatives.

 

§74 (3) The enter­prise shall syste­ma­ti­cally reduce hazar­dous working condi­ti­ons and limit the amount of physi­cally diffi­cult and mono­to­nous work.

 

§201 (1) It shall be the duty of the enter­prise to ensure the protec­tion of the health and labour power of working people prima­rily by orga­ni­s­ing and main­tai­ning safe working condi­ti­ons that are free from hard­ship and condu­cive to health and efficiency.

 

§207 Workers who are to under­take work which is physi­cally deman­ding or hazar­dous to health shall be medi­cally exami­ned free of charge before employ­ment and at regu­lar inter­vals in accordance with legislation.

 

§293 (1) The super­vi­sion of occu­pa­tio­nal health in enter­pri­ses shall be conduc­ted by the Free German Trade Union Fede­ra­tion (FDGB) through health and safety inspections.

An occu­pa­tio­nal health inspec­tion measu­res noise, tempe­ra­ture, humi­dity, and light­ing condi­ti­ons. In 1981, a strict obli­ga­tion was placed on enter­pri­ses to report on the condi­ti­ons of high-risk work­places and to take measu­res to reduce these risks. Toge­ther, these reports crea­ted a solid data­base through which affec­ted employees could be moni­to­red, protec­ted, and provi­ded with targe­ted care. The data was also used to exert grea­ter pres­sure on poli­ti­ci­ans and enter­pri­ses to reduce and, if possi­ble, prevent the harmful side effects of work.
In the DDR, strict norms were deve­lo­ped and enforced to ensure appro­priate pedago­gi­cal methods, infra­struc­ture, and open spaces at children’s faci­li­ties. New housing deve­lo­p­ments, such as the one in Rostock featured here, were requi­red to include large open spaces for children.
A paed­ia­tri­cian carries out an exami­na­tion in a rural outpa­ti­ent clinic. In addi­tion to the early detec­tion of health abnor­ma­li­ties, the assess­ment of a child’s prepared­ness for school was also part of the preven­tive scree­nings. Confi­den­tial docu­men­ta­tion of all such exami­na­ti­ons and findings on health and deve­lo­p­ment accom­pa­nied child­ren from birth to graduation.
Vacci­na­ti­ons were a part of the regu­lar medi­cal scree­nings that accom­pa­nied child­ren from birth to adult­hood. Health care was guaran­teed in crèches, kinder­gar­tens, schools, and holi­day camps, right through to appren­ti­ce­ships and univer­sity studies. This photo­graph docu­ments the admi­nis­te­ring of a new polio oral vaccine in the form of drops.
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In the late 1960s, after a long period of impo­sed diplo­ma­tic isola­tion, an incre­asing number of count­ries (mostly from the Global South) announ­ced offi­cial rela­ti­ons with the DDR. In 1973, the DDR was admit­ted to the United Nati­ons and parti­ci­pa­ted cons­truc­tively in its various bodies and orga­ni­sa­ti­ons such as UNESCO and the World Health Organisation.
In this article, copied from an entry in Dr. Rüdi­ger Feltz’s Nica­ra­gua diary on 15 March 1986, the Nica­ra­guan press reports on the cons­truc­tion of the Carlos Marx Hospi­tal, which star­ted as a triage tent and was soon expan­ded into a fully func­tio­ning hospi­tal. The hospital’s cons­truc­tion as well as the trai­ning of its staff and provi­sion of its equip­ment and medi­ci­nes were orga­nised by DDR offi­ci­als and finan­ced by dona­ti­ons from DDR citi­zens. It was one of East Germany’s largest soli­da­rity projects.
The DDR’s Doro­thea Chris­tiane Erxle­ben Medi­cal School, named after Germany’s first female medi­cal doctor, empha­sised medi­cal pedagogy. The objec­tive was to train students so that they could in turn teach trai­nees in their home count­ries, ther­eby promo­ting the deve­lo­p­ment and auto­nomy of local health care systems.

TABLE OF CONTENTS

1. Health Care in a Sick System

 

2. Histo­ri­cal Condi­ti­ons in the Years Prece­ding the DDR

 

3. The DDR’s Compre­hen­sive Approach to Health Care 

 

4. Contra­dic­tions and Challenges

 

5.The Poly­cli­nic: A Modern Approach to Outpa­ti­ent Care

 

5.1. From Private Prac­tice to Polyclinics

 

5.2. The Opera­tion of Polyclinics

 

5.3. An Over­view of the Outpa­ti­ent Sector

 

6. Protec­ting Health in the Workplace

 

7. Health Care for Mothers and Children

 

8. Vacci­na­tion Strategies

 

9. The DDR’s Inter­na­tio­nal Coope­ra­tion and Medi­cal Solidarity

 

10. Why Is Socia­lism the Best Prophylaxis?

 

11. Sources

1. Health Care in a Sick System

The manner in which a society approa­ches issues of health reve­als much about its gene­ral charac­ter. The prio­rity given to people’s health, the degree to which indi­vi­du­als are protec­ted and trea­ted equally, and the extent to which health care is geared towards people’s real needs paints a picture of the exis­ting social and poli­ti­cal conditions.

 

Health policy cannot, howe­ver, be redu­ced to the system of medi­cal care alone. It is inse­pa­ra­ble from working condi­ti­ons, nutri­tion, housing, and educa­tion; the charac­ter of social rela­ti­onships; leisure and cultu­ral beha­viour; and a number of other factors that form the basis upon which people’s physi­cal and mental health deve­lop. The inter­re­la­ti­onship between these elements was alre­ady being discus­sed in Germany during the early deve­lo­p­ment of capi­ta­lism. An exam­ple of this was the work of the German physi­cian Rudolf Virchow (1821–1902), the foun­der of modern patho­logy and a pioneer of what was then refer­red to as ‘social hygiene’ (Sozi­al­hy­giene). This field, now asso­cia­ted with the terms social medi­cine or public health, inves­ti­ga­tes the inter­ac­tion between people’s health and their social condi­ti­ons. Fried­rich Engels, too, provi­ded evidence of this connec­tion in his early work on the condi­tion of the working class in England.

“All conceiva­ble evils are heaped upon the heads of the poor. If the popu­la­tion of great cities is too dense in gene­ral, it is they in parti­cu­lar who are packed into the least space. […] They are given damp dwel­lings, cellar dens that are not water­proof from below, or garrets that leak from above. Their houses are so built that the clammy air cannot escape. They are supplied bad, tatte­red, or rotten clot­hing, adul­tera­ted and indi­ges­ti­ble food. […] And, if they surmount all this, they fall victim to want of work in a crisis when all the little is taken from them that had hitherto been vouch­sa­fed them.

 

How is it possi­ble, under such condi­ti­ons, for the lower class to be healthy and long lived? What else can be expec­ted than exces­sive morta­lity, an unbro­ken series of epide­mics, a progres­sive dete­rio­ra­tion in the physi­que of the working population?”

Under capi­ta­lism, health protec­tions must be fought for in a constant struggle against econo­mic inte­rests. Public health poli­cies are prima­rily deter­mi­ned by the private sector and are incre­asingly being reshaped by market forces. The COVID-19 pande­mic has drasti­cally reve­a­led the serious defi­ci­en­cies and unsol­ved chal­lenges of health care systems today. Many states lack clear, scien­ti­fi­cally groun­ded decis­ion-making struc­tures. Soli­da­rity-driven coope­ra­tion within and between states is blocked above all by private econo­mic inte­rests. Deaths are shame­l­essly weig­hed against econo­mic losses by poli­ti­cal and busi­ness leaders. Throug­hout the world, the living and working condi­ti­ons of the lowest earners make them the most vulnerable to the pande­mic. In many cases, they are denied access to vacci­nes and medi­ci­nes. The protec­tion of private patent rights is prio­ri­ti­sed over compre­hen­sive care for the people. The popu­la­ti­ons of the Global South are left almost enti­rely empty-handed.

 

The over­all effi­cacy of health care systems in the Global North is touted as an indi­ca­tion of their supe­rio­rity, yet their poten­tial is not fully exploi­ted, nor is their effi­cacy due solely to econo­mic strength or posi­tive medi­cal tradi­ti­ons. Instead, it is the deca­des-long struggle of trade unions and other demo­cra­tic forces that has estab­lished mini­mum stan­dards and basic care. The same forces have there­af­ter been compel­led to defend these gains from the constant pres­su­res of the private sector. Further, the health care systems of wealt­hier states are bols­te­red by medi­cal person­nel who have been lured away from econo­mic­ally weaker count­ries. This – coupled with the contin­ued explo­ita­tion of the Global South – further exacer­ba­tes unequal deve­lo­p­ment between the North and South. Today, the private capi­ta­list sector is conso­li­da­ting its grip on health care systems, parti­cu­larly in Western econo­mies, leading health and illness to become incre­asingly commo­di­fied and subor­di­na­ted to profit-driven motives.

“Health care, instead of being an accoun­ta­ble system, has grown into a hodge­podge of corpo­rate fief­doms whose central aim is to maxi­mise profi­ta­bi­lity for venture capi­tal inves­tors. A profit-orien­ted health care system requi­res the physi­cian to act as a kind of gate­kee­per, deci­ding whether to grant or deny health care. A profit-orien­ted health care system is an oxymo­ron, a contra­dic­tion in terms. As soon as care serves profit, it is no longer true care”.

Since 1991, the propor­tion of private hospi­tals and beds in Germany has increased tremen­dously, conti­nuing a trend of the incre­asing commer­cia­li­sa­tion of inpa­ti­ent care which began in the Fede­ral Repu­blic of Germany (FRG, commonly refer­red to as West Germany) in the mid-1980s. This deve­lo­p­ment gained addi­tio­nal momen­tum in 2003 with the intro­duc­tion of the US-inspi­red billing system based on diagno­sis-rela­ted groups. Under this system, hospi­tal cases are clas­si­fied into diffe­rent groups to iden­tify the ‘products’ that pati­ents receive and to deter­mine payment. As such, decis­i­ons regar­ding the treat­ment and length of hospi­tal stays are incre­asingly made on the basis of what can be billed profi­ta­bly rather than on the basis of medi­cal crite­ria. The quality of health care is thus being eroded, as treat­ment beco­mes ever more depen­dent on pati­ent income and public health services are slashed.

 

The antago­nism between private-sector inte­rests and compre­hen­sive health care for all members of society had alre­ady been reco­g­nised in the early days of the German Demo­cra­tic Repu­blic (commonly refer­red to as East Germany). Throug­hout its 40-year exis­tence, the DDR was able to cons­truct and advance a funda­men­tally diffe­rent health care system. From an initial posi­tion of great econo­mic disad­van­tage, the DDR came to be ranked among the 20 largest indus­tria­li­sed count­ries in terms of econo­mic produc­tion and living stan­dards by the end of the 1980s. The well-being of its 16 million inha­bi­tants was reflec­ted by favoura­ble, even leading values accor­ding to certain World Health Orga­ni­sa­tion measu­res such as the physi­cian-to-popu­la­tion ratio, infant morta­lity, and the reduc­tion of tuber­cu­lo­sis. This was despite the subop­ti­mal struc­tu­ral condi­tion of many health faci­li­ties, the scar­city of medi­cal supplies, and rest­ric­tions on the import of medi­cine and tech­no­logy – much of which was the result of econo­mic sanc­tions impo­sed by the West.

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The DDR was able to achieve signi­fi­cant advan­ces in health care both due to the influence of progres­sive tradi­ti­ons passed down from the 19th century and the Weimar Repu­blic (1918–1933) and due to a radi­cal trans­for­ma­tion of the econo­mic and poli­ti­cal condi­ti­ons in the DDR. This trans­for­ma­tion enab­led the young state to reori­ent the objec­ti­ves and struc­ture of health care around social prin­ci­ples while also crea­ting new socia­list rela­ti­ons in and outside of the work­place that impro­ved the population’s health.

 

This study asses­ses the DDR’s health care system and traces seve­ral of its central elements, exami­ning the signi­fi­cance of the DDR’s socia­list charac­ter in the cons­truc­tion of a health care system based prima­rily on preven­tive prin­ci­ples. This endea­vour did not proceed without its diffi­cul­ties and contra­dic­tions, and the insights gained from this process of buil­ding an effec­tive, acces­si­ble health care system within the context of limi­ted econo­mic resour­ces can serve as a refe­rence for strug­gles world­wide. The title, Socia­lism Is the Best Prophy­la­xis, pays tribute to a well-known quote of Maxim Zetkin (1883–1965), a physi­cian, poli­ti­cian, and son of the inter­na­tio­nal women’s rights acti­vist and commu­nist Clara Zetkin (1857–1933), that became a slogan in the DDR. In line with the focus of the DDR’s health care system, this slogan refers to the medi­cal approach known as prophy­la­xis that seeks to prevent dise­ase before it manifests.

2. Historical Conditions in the Years Preceding the DDR 

Devas­ta­ting social and health condi­ti­ons for the urban prole­ta­riat arose against the back­ground of indus­tria­li­sa­tion in the German Empire (1871–1918). After years of campaig­ning, revo­lu­tio­nary social demo­cracy succee­ded in intro­du­cing social health insu­rance in 1883. While then German Chan­cellor Otto von Bismarck is remem­be­red as the foun­ding father of state-orga­nised social insu­rance, it was in fact the strug­gles of the working class that deman­ded and won conces­si­ons from the govern­ment. Bismarck never made a secret of the fact that he sought to push back the poli­ti­cal influence of the socia­list labour move­ment. During a session of the Reichs­tag, he remarked, ‘Without social demo­cracy and without the fear that it gene­ra­tes in a great many people, we would not have made the modest social reforms that we had to grant today’. The intro­duc­tion of this health insu­rance system helped to parti­ally cover the cost of treat­ment, but inade­quacies remained as working condi­ti­ons had not impro­ved and the workers had to pay two-thirds of the premi­ums. As a result, self-orga­nised health care orga­ni­sa­ti­ons such as the Workers’ Sama­ri­tan Fede­ra­tion (ASB) and the Prole­ta­rian Health Service (PGD) emer­ged, comple­men­ting the work of the Social Demo­cra­tic Party of Germany (SPD) and the Commu­nist Party of Germany (KPD) respec­tively during the Weimar Repu­blic. These orga­ni­sa­ti­ons empha­ti­cally deman­ded the further expan­sion of public health care.

The Prole­ta­rian Health Service (PGD) was a self-orga­nised health service that opera­ted from 1921 to 1926. It was expli­citly poli­ti­cal and contin­ued the tradi­tion of public health by, for instance, support­ing the nutri­tion of school­child­ren and the labour strug­gles to main­tain the eight-hour day, espe­ci­ally in the mining indus­try and chemi­cal facto­ries. It further advo­ca­ted for the socia­li­sa­tion of health care and orga­nised concrete, prac­ti­cal assis­tance by provi­ding health care trai­ning and educa­tion, acci­dent preven­tion, and first aid. The PGD also worked closely with the workers’ sports move­ment to promote fitness.

After German fascism came to power in 1933, the Nazis began misu­s­ing medi­cine to enforce their racist and anti-Semi­tic ideo­logy against people whom they alle­ged were infe­rior, commit­ting crimes against huma­nity on an unpre­ce­den­ted scale. Follo­wing the uncon­di­tio­nal defeat of Nazi Germany in 1945, a cata­stro­phic health crisis hit the German popu­la­tion. The preva­lence of epide­mics, dise­a­ses, and inju­ries reve­a­led how wars conti­nue to produce many casu­al­ties long after the end of mili­tary combat. Hospi­tals, sana­to­ri­ums, and the entire health care system had been destroyed in what then became the Soviet Occu­pa­tion Zone (SOZ). The supply of medi­ci­nes collap­sed, and epide­mics spread uncon­troll­ably, inten­si­fied by a large influx of refu­gees and resett­led people arri­ving from Eastern Europe. Deaths from tuber­cu­lo­sis in this period were twice as high as they had been prior to the war. Typhus, cholera, dysen­tery, vene­real infec­tions, and child­hood dise­a­ses rava­ged the popu­la­tion. The number of doctors halved compared to pre-war levels, and the trai­ning of new physi­ci­ans was inter­rupted by the closure of universities.

 

From the defeat of the Nazi regime in 1945 to the foun­ding of the DDR in 1949, the health poli­cies of the SOZ were shaped based on 30 orders issued by the Soviet Mili­tary Admi­nis­tra­tion (SMAD), which gover­ned the SOZ from the end of the Second World War until the DDR was estab­lished in 1949. The poli­cies were then imple­men­ted by the German Econo­mic Commis­sion (the central German admi­nis­tra­tive body in the SOZ) along with the newly crea­ted Central Admi­nis­tra­tion for Health Care and the five regio­nal govern­ments in Eastern Germany. An imme­diate ques­tion confron­ting the SMAD was how to deal with the doctors and other health profes­sio­nals who had supported the fascist system. Roughly 45 per cent of physi­ci­ans had been Nazi Party members, many of them invol­ved in eutha­na­sia and the other atro­ci­ties that took place in concen­tra­tion camps. Many of these indi­vi­du­als fled the SOZ, knowing that they would be trea­ted more leni­ently in the West. The doctors who stayed posed a poli­ti­cally and morally diffi­cult dilemma: enac­ting a blan­ket dismis­sal of health profes­sio­nals – as had been carried out among judges and teachers for good reason – was out of the ques­tion, if only because of the health crisis facing the coun­try. As a result, doctors who had not been found guilty of any crimes were allo­wed to conti­nue their work, and many of them later made them­sel­ves fully available to the new health system.

1945: Estab­li­shing the Central Health Admi­nis­tra­tion and the Health Offices (Order No. 17).

 

1946: Repe­al­ing the racist laws and other Nazi legal provi­si­ons (No. 6) and passing an order to combat tuber­cu­lo­sis (No. 297).

 

1947: Intro­du­cing a uniform system of social insu­rance (No. 28); estab­li­shing a work­place health system (No. 234); and orde­ring the estab­lish­ment of outpa­ti­ent centres and poly­cli­nics (No. 272).

 

Other orders were concer­ned with control­ling indi­vi­dual infec­tious dise­a­ses and estab­li­shing medi­cal and scien­ti­fic institutions.

Many of the doctors and health workers who were entrus­ted with admi­nis­tra­tive posi­ti­ons in the SOZ’s gene­ral admi­nis­tra­tion were those who had been enga­ged in resis­tance or had emigra­ted or been impri­so­ned under the Nazi regime. Their imme­diate tasks were dicta­ted by the decis­i­ons of the Allied powers in the Pots­dam Agree­ment of 1945 and the newly lega­li­sed poli­ti­cal parties in the SOZ. The Socia­list Unity Party of Germany (SED) formed in 1946, unify­ing the two working class parties – the Commu­nist Party of Germany (KPD) and the Social Demo­cra­tic Party of Germany (SPD) – into a single party in the SOZ and reco­g­nised the need for new health struc­tures, espe­ci­ally in outpa­ti­ent care. When draf­ting social and health policy program­mes for a new, demo­cra­tic Germany, the autho­ri­ties in the SOZ drew on the progres­sive demands and expe­ri­en­ces of the Weimar Repu­blic period.

“Since the full deve­lo­p­ment of the health service will only be guaran­teed in a socia­list society, there is nevert­hel­ess a way for demo­cra­tic Germany as well. […] This is the natio­na­li­sa­tion of the health service. Only in this way can physi­ci­ans, enjoy­ing econo­mic­ally secure posi­ti­ons as well as resour­ces guaran­teed by the state, devote them­sel­ves enti­rely to their duties. Only in this way can the achie­ve­ments of medi­cal science be made available to the entire popu­la­tion. […] The preser­va­tion of the health and the produc­tive capa­city of working people is one of the nation’s most important tasks and a prere­qui­site for recon­s­truc­tion. […] Hence, health protec­tion must be made a matter for the state and thus for the people as a whole. The aim must be one of secu­ring for ever­yone the protec­tion of his or her health as the basis of vita­lity and physi­cal fitness”.

 

The task was now to estab­lish a func­tio­ning health care system. This requi­red natio­na­li­sing health care insti­tu­ti­ons and guaran­te­e­ing the right to health care. Free medi­cal treat­ment was provi­ded through a univer­sal health care system, and the protec­tion of health was unders­tood as a task for all sectors of society. Sepa­ra­ting people’s medi­cal needs from the private inte­rests of capi­tal was a decisive, central idea in provi­ding health care for all; it was reco­g­nised that busi­ness conside­ra­ti­ons, parti­cu­larly regar­ding free­lance doctors working in private prac­ti­ces, ran coun­ter to the progres­sive deve­lo­p­ment of medi­cine. This obser­va­tion had alre­ady been put forth by the League of Nati­ons, an inter­na­tio­nal asso­cia­tion of states foun­ded after the First World War and the forerun­ner of the United Nations.

 

The DDR’s emer­ging health care system was shaped by the expe­ri­en­ces of the Soviet Union and its health system, the archi­tects of which had them­sel­ves been inspi­red by the policy posi­ti­ons of the German Left during the Weimar period (1918–33). After the 1917 Russian Revo­lu­tion and the Civil War (1917–22), the young Soviet Union became the first state in world history to build a health care system that guaran­teed free, univer­sal health care to the entire popu­la­tion, enshri­ning the right to free medi­cal care in the Soviet Consti­tu­tion of 1936 as one of the funda­men­tal rights of the Soviet people. Under the model intro­du­ced by Niko­lai Semashko (the People’s Commis­sar for Health from 1918–30), medi­cal faci­li­ties and services were comple­tely state funded and centrally mana­ged, and a multi­le­vel system of hospi­tals, specialty clinics, and sana­to­ria opera­ted at the natio­nal, regio­nal, city, and district levels. While aspects of the Soviet model influen­ced the trans­for­ma­tion of the health care system in the SOZ, it was not simply repli­ca­ted. Some of the ways in which the DDR’s system diffe­red, for exam­ple, were the degree of central orga­ni­sa­tion and the fact that it was not finan­ced solely by the state. 

3. The DDR’s Comprehensive Approach to Health Care

“Health policy in the DDR was unders­tood as a tota­lity of ideo­lo­gi­cal, cultu­ral, econo­mic, social, and medi­cal measu­res concei­ved of and prac­ti­ced with vary­ing inten­sity and quality within the public sphere. The aim was to help shape and opti­mise the envi­ron­men­tal condi­ti­ons of peop­les’ lives in a way that both protects and fosters their health. Pati­ents were to be trea­ted and cared for using the know­ledge and expe­ri­ence of modern medi­cine. Life was to be steadily and progres­si­vely extended”.

The crea­tion of socia­list property rela­ti­ons was a crucial precon­di­tion for the DDR’s preven­tive approach to health care. Health-rela­ted matters such as working condi­ti­ons, housing, nutri­tion, and educa­tion could ther­e­fore be mana­ged by the state and its demo­cra­tic decis­ion-making struc­tures. The compre­hen­sive plan­ning of publicly owned insti­tu­ti­ons made it possi­ble to inves­ti­gate and tackle ever­y­day health risks. In this endea­vour, the DDR built upon the tradi­ti­ons of social medi­cine, which approa­ched health from a socio-poli­ti­cal perspec­tive and focu­sed on the inter­ac­tion between people’s welfare and their over­all living and working condi­ti­ons. In parti­cu­lar, the focus on preven­tive care in the work­place and for child­ren, along with a modern concept of outpa­ti­ent care, demons­tra­ted the inte­gra­ted and holi­stic charac­ter of the DDR’s health policies.

A district health inspec­tor measu­res sound frequen­cies in a resi­den­tial area in order to deve­lop methods for redu­cing noise pollu­tion. The medi­cal fields of social, occu­pa­tio­nal, and commu­nal health were respon­si­ble for moni­to­ring and safe­guar­ding the health stan­dards of the population’s working and living conditions.

By orga­ni­s­ing health care insti­tu­ti­ons as state-owned enti­ties, the DDR over­came the sepa­ra­tion found in many capi­ta­list count­ries today between publicly funded health services and the large, priva­tely orga­nised sector of outpa­ti­ent and hospi­tal care. The elimi­na­tion of private forms of owner­ship enab­led the inte­gra­tion of preven­tive, thera­peu­tic, and after­care measu­res that yiel­ded better results for pati­ents. Further­more, the country’s nume­rous and diverse medi­cal insti­tu­ti­ons – from hospi­tals and clinics to phar­macies and rese­arch centres – could now coope­rate with one another as part of a unified network led by the Minis­try of Health.

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The hospi­tal network in the DDR was steadily expan­ded to improve acces­si­bi­lity for citi­zens throug­hout the coun­try. The tiered system, made up of the commu­nal, muni­ci­pal, and regio­nal admi­nis­tra­tive divi­si­ons, sought to provide basic care in muni­ci­pal hospi­tals, while specia­li­sed treat­ment would be admi­nis­te­red in regio­nal hospi­tals or natio­nal insti­tu­ti­ons and univer­si­ties. Prior to the Second World War, churches played a signi­fi­cant role in main­tai­ning and opera­ting hospi­tals throug­hout Germany. Rather than dismant­ling these struc­tures, the DDR worked with the clergy to ensure that emer­gency health care would be available in all areas of the coun­try. Thus, of the 539 hospi­tals in East Germany in 1989, 75 remained under the juris­dic­tion of churches, though they too were inte­gra­ted into the state’s plan­ning system.

 

The DDR also sought to over­come the histo­ri­cally uneven distri­bu­tion of doctors across rural and urban areas. After gradua­tion, every physi­cian recei­ved both their licence to prac­tice and secure paid employ­ment and was requi­red to work for seve­ral years in an area where doctors were parti­cu­larly scarce based on a commit­ment made at the begin­ning of their studies. This policy, refer­red to as the stee­ring of gradua­tes (Absol­ven­ten­len­kung), was the DDR’s solu­tion to a serious problem that still besets many count­ries today.

“There came a point when we were told: “ You have commit­ted yours­elf to serve where society needs you”. Many who studied in Berlin then tried ever­y­thing possi­ble to stay in Berlin to avoid going to Cott­bus or Bitter­feld, for exam­ple, into the brown coal district, into the dirt. I said to myself: “Well, these are people who have a right to adequate medi­cal care. They shouldn’t be aban­do­ned there, so I’ll do it”. For me, it was fulfil­ling a promise that I had made in return for being able to study free of charge. We even recei­ved a scho­lar­ship that allo­wed us to study without finan­cial diffi­cul­ties. Such an obli­ga­tion does not contra­dict my under­stan­ding of fair­ness in any way, even today. It was perfectly accep­ta­ble to me”.

To finance its health care system, the DDR intro­du­ced a broad social secu­rity scheme that covered health, acci­dent, and pension insu­rance and was mana­ged by the workers them­sel­ves through the Free German Trade Union Fede­ra­tion. This inte­gra­ted, state-orga­nised model repla­ced the frag­men­ted and profit-orien­ted insu­rance systems that still operate in many capi­ta­list count­ries today. Indi­vi­du­als in the DDR paid up to 10 per cent of their monthly wages to the scheme, though contri­bu­ti­ons were capped at 60 Marks per month for workers. Enter­pri­ses then matched the contri­bu­ti­ons of their employees, and addi­tio­nal state subsi­dies covered any shortfalls.

 

The poli­ti­cal weight given to health care in the DDR is also illus­tra­ted by the country’s exten­sive legis­la­tion on this issue. The univer­sal right to health care regard­less of one’s social situa­tion (which had alre­ady been ancho­red in the DDR’s first consti­tu­tion in 1949) was enshri­ned in the two subse­quent consti­tu­ti­ons of 1968 and 1974. The DDR ther­eby reali­sed Article 25 of the UN Univer­sal Decla­ra­tion of Human Rights, which states that every human being has ‘the right to a stan­dard of living adequate for health and well-being […] inclu­ding food, clot­hing, housing, medi­cal care, and neces­sary social services and the right to secu­rity in the event of unem­ploy­ment, sick­ness, disa­bi­lity, widow­hood, old age, or other lack of liveli­hood in circum­s­tances beyond his control’. 

  1. Every citi­zen of the German Demo­cra­tic Repu­blic shall have the right to the protec­tion of his or her health and labour power.
  2. This right shall be guaran­teed through the plan­ned impro­ve­ment of working and living condi­ti­ons; the foste­ring of public health; the imple­men­ta­tion of compre­hen­sive welfare poli­cies; and the promo­tion of physi­cal acti­vity, school and popu­lar sports, and tourism.
  3. In the event of illness or acci­dent, the loss of income and the costs of medi­cal care, medi­ci­nes, and other medi­cal services shall be provi­ded through a social insu­rance system.

The DDR guaran­teed not only basic health-rela­ted rights and duties in the sphere of medi­cal care, but also in the sphe­res of work and educa­tion. Equal rights for women as well as health protec­tion for child­ren, youth, and the elderly were also codi­fied. This included inter­na­tio­nally commen­ded legis­la­tion that decri­mi­na­li­sed homo­se­xual acts in 1968 (though they had alre­ady been exempt from legal prose­cu­tion since the 1950s) and lega­li­sed abor­tion in 1972. Other signi­fi­cant statu­tes included the intro­duc­tion of state liabi­lity for health dama­ges caused by medi­cal proce­du­res (1987) and the ‘dissent solu­tion’ for organ trans­plants (1975), which estab­lished a presu­med consent model for organ dona­tion that requi­red indi­vi­du­als to opt out.

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The DDR’s health care system was a highly complex sector that was gradu­ally and syste­ma­ti­cally deve­lo­ped over the course of four deca­des, employ­ing nearly 600,000 people – roughly 7 per cent of the total work­force – by 1989. In addi­tion to hospi­tals and outpa­ti­ent clinics, this sector included medi­cal teaching and rese­arch faci­li­ties; specia­list insti­tu­tes; emer­gency services; scien­ti­fic socie­ties; medi­cal publishers and jour­nals; health educa­tion faci­li­ties; and, last but not least, an exten­sive phar­maceu­ti­cal indus­try. With thir­teen enter­pri­ses, three rese­arch insti­tu­tes, and appro­xi­m­ately 15,000 employees, the Kombi­nat GERMED – meaning ‘combine’, a sort of socia­list corpo­ra­tion – produ­ced some 1,300 diffe­rent medi­cal products, meeting 80–90 per cent of the DDR’s phar­maceu­ti­cal needs while also export­ing medi­cal products to the Soviet Union and other socia­list count­ries. The dome­stic demand for medi­ci­nes was commu­ni­ca­ted to suppli­ers not through market forces but through the calcu­la­ti­ons of district phar­macists. Phar­macists, like physi­ci­ans, were free from profit-orien­ted conside­ra­ti­ons in their work, and medi­ci­nes were provi­ded free of charge to all citi­zens. Close colla­bo­ra­tion between phar­macists and physi­ci­ans enab­led them to tailor pati­ent care and adjust medi­ca­ti­ons if supply shorta­ges occurred.

In 1950, there were 1,694 phar­macies in the DDR, of which 1,266 were priva­tely owned. By 1989, there were 24 private phar­macies and 2,002 public phar­macies mana­ged by the Minis­try of Health. Each of the DDR’s 15 regi­ons was over­seen by a head doctor and head phar­macist. On the district level, local phar­macists were respon­si­ble for moni­to­ring the distri­bu­tion of medi­cine accor­ding to unified standards.

4. Contradictions and Challenges

The deve­lo­p­ment of the DDR’s health care system was not free from conflicts and chal­lenges. Contra­dic­tions between the country’s health care objec­ti­ves and its econo­mic capa­city meant that stated goals and aspi­ra­ti­ons could not always be achie­ved. Health poli­cies reflec­ted both the econo­mic diffi­cul­ties facing the coun­try and shifts in poli­ti­cal prio­ri­ties. For exam­ple, when the Unity of Econo­mic and Social Policy was intro­du­ced in 1971 to increase access to consu­mer goods and services, the health sector initi­ally bene­fi­ted from extra funding. Yet this shift in invest­ment policy away from the indus­trial sector crea­ted imba­lan­ces in the plan­ned economy that were ulti­m­ately felt in the health sector, too. This was appa­rent, for instance, in the wear and tear on hospi­tals and the scar­city of certain medi­cal supplies and equip­ment, which made health workers’ day to day tasks more diffi­cult. In its final years, the DDR was no longer able to import modern medi­cal tech­no­logy deve­lo­ped in Western indus­tria­li­sed count­ries to the extent needed, in part due to the embargo impo­sed by the West. While inno­va­tive diagno­stic and thera­peu­tic methods enab­led the DDR to make progress against certain dise­a­ses that had previously proven diffi­cult or impos­si­ble to treat by conven­tio­nal methods, these efforts were often hampe­red by a lack of equipment.

In the 1980s, bott­len­ecks in the supply of mate­ri­als as well as diffe­ring views on how to tackle urgent health issues led to inten­si­fied policy deba­tes. The preven­tive approach to care and the convic­tion that all social sectors had a role to play in public health remained decisive under­pin­nings of govern­ment poli­cies. Yet, dispu­tes arose around the ques­tion of which dise­ase-caus­ing condi­ti­ons could and should be prio­ri­ti­sed. For instance, at times there was an empha­sis placed on measu­res that sought to change unhe­althy beha­viours in order to combat problems such as obesity, alco­hol abuse, and an increase in smoking amongst the youth. This approach of focu­sing on indi­vi­dual beha­viours that contri­bute to health issues was criti­cised by social medi­cine specia­lists, who instead focu­sed on impro­ving the population’s over­all living and working condi­ti­ons. Such deba­tes reveal that ever­y­day diffi­cul­ties and stra­te­gic ques­ti­ons were open to poli­ti­cal discus­sion, which often took place in bimonthly regio­nal physi­ci­ans’ meetings and bian­nual muni­ci­pal physi­ci­ans’ confe­ren­ces, among other venues.

 

The West’s hosti­lity towards the DDR affec­ted the deve­lo­p­ment of its health system in many ways, exer­ting an ideo­lo­gi­cal, poli­ti­cal, and econo­mic influence on the DDR’s health workers and struc­tures. This had a parti­cu­larly nota­ble impact on the country’s access to medi­cal and tech­ni­cal mate­rial as well as inter­na­tio­nal rese­arch initia­ti­ves. In addi­tion, West Germany actively poached East German doctors by encou­ra­ging them to migrate west­ward. Physi­ci­ans who had enjoyed cost-free educa­tion and trai­ning in the DDR were attrac­ted to the West by better pay or by their reluc­tance to parti­ci­pate in the social trans­for­ma­ti­ons under­way in the East. This dyna­mic impac­ted the DDR from the outset: the exodus of doctors follo­wing the Second World War was so massive that it would have requi­red at least five addi­tio­nal gradua­ting clas­ses of all DDR medi­cal schools to compen­sate for the loss. This was simi­lar to the situa­tion in Cuba, where – apart from doctors like Che Guevara who commit­ted them­sel­ves to the revo­lu­tion – many doctors left the island for the United States after 1959. This pheno­me­non of ‘brain drain’ – in which physi­ci­ans and other highly educa­ted or skil­led profes­sio­nals emigrate from those count­ries where they are most needed – and its conse­quen­ces for the Global South are gene­rally brushed off or sold as a posi­tive aspect of globalisation.

 

Until the border between East and West Germany was closed in 1961, the DDR was also pursuing its pionee­ring health programme in ‘compe­ti­tion’ with the FRG, which preser­ved the private prac­tice model and deli­bera­tely used high sala­ries and privi­le­ges to incen­ti­vise well-trai­ned doctors to leave East Germany. The DDR was thus faced with the same diffi­culty that confron­ted the Bols­he­viks after the Octo­ber Revo­lu­tion: how could the specia­li­sed profes­sio­nals and intel­li­gent­sia, who had been privi­le­ged under capi­ta­lism, be won over to the cons­truc­tion of socia­lism? Given the high levels of emigra­tion, the SED deci­ded to make conces­si­ons to the medi­cal intel­li­gent­sia in the late 1950s, utili­sing mate­rial incen­ti­ves to encou­rage doctors to work and live in the DDR. Despite these chal­lenges, further shifts away from private prac­ti­ces to public employ­ment prevai­led in the follo­wing years. Although seve­ral thousand doctors left the DDR before the Wall was built in 1961, by 1988 the number of physi­ci­ans in the coun­try (around 41,000) had more than tripled since 1949, putting the DDR’s physi­cian-to-popu­la­tion ratio on par with the other indus­tria­li­sed states in Europe.

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As the expe­ri­en­ces of the DDR and other socia­list states have reve­a­led, the socie­tal tran­si­tion beyond capi­ta­lism is never a simple linear deve­lo­p­ment. Cons­truc­ting a compre­hen­sive and people-orien­ted health care system cannot happen over­night. Radi­cal trans­for­ma­ti­ons must cont­end not only with a country’s econo­mic limi­ta­ti­ons, but also with tradi­tio­nal concep­ti­ons of social roles and status. The scale of the brain drain from the DDR, for instance, led the govern­ment to make certain compro­mi­ses in its mission to break the intelligentsia’s long-held mono­poly of the medi­cal profes­sion. When drawing lessons for the future, we cannot isolate such compro­mi­ses and short­co­mings from their histo­ri­cal context. That is what diffe­ren­tia­tes cons­truc­tive and progres­sive analy­ses from those that merely seek to smear and deride socialism.

5. The Polyclinic: A Modern Approach to Outpatient Care

5.1. From Private Practice to Polyclinics

Under the capi­ta­list model of health care, outpa­ti­ent care is commonly provi­ded by inde­pen­dent doctors in indi­vi­dual private prac­ti­ces that are scat­te­red throug­hout cities and towns. Progres­sive medi­cal tradi­ti­ons have, howe­ver, long criti­cised this model as having two signi­fi­cant limi­ta­ti­ons. Firstly, self-employed doctors are econo­mic­ally depen­dent on sick pati­ents seeking out treat­ment. That is, they are finan­ci­ally incen­ti­vi­sed not to prevent dise­ase but to treat symptoms after they mani­fest. Secondly, the rapid advance of science has greatly impro­ved medi­cal diagno­stics and treat­ment capa­bi­li­ties, but these new methods require access to the latest tech­no­logy and exper­tise. Since indi­vi­dual prac­ti­ces cannot house the diverse equip­ment and staff deman­ded by modern medi­cine, pati­ents are refer­red to sepa­rate specia­lists or diagno­stic centres, often crea­ting inef­fi­ci­en­cies and discrepan­cies in diagno­ses. In the DDR, poly­cli­nics were deve­lo­ped to over­come these issues in outpa­ti­ent care.

As the name implies, poly­cli­nics were faci­li­ties in which multi­ple medi­cal special­ties colla­bo­ra­ted under one roof to prevent and treat a wide variety of dise­a­ses. More speci­fi­cally, poly­cli­nics were defi­ned as publicly owned outpa­ti­ent faci­li­ties contai­ning at least the follo­wing six specia­list depart­ments: inter­nal medi­cine, oral medi­cine, gynae­co­logy, surgery, paed­ia­trics, and gene­ral medi­cine. Many poly­cli­nics also housed clini­cal diagno­stic labo­ra­to­ries, physio­the­rapy depart­ments, and medi­cal imaging faci­li­ties. In addi­tion, poly­cli­nics embo­died the convic­tion that, to be effec­tive, outpa­ti­ent medi­cal care had to be severed from perso­nal econo­mic conside­ra­ti­ons. Physi­ci­ans and staff working in poly­cli­nics were publicly employed and thus freed from their tradi­tio­nal econo­mic depen­den­cies on the sick. With a secu­red posi­tion and a reasonable income, doctors could focus first and fore­most on preven­tive care.

It was again the tran­si­tion away from private owner­ship that enab­led this funda­men­tal reori­en­ta­tion of the outpa­ti­ent sector, which plays an important if not decisive role in the capa­city of a health care system to serve the entire popu­la­tion. Effec­tive outpa­ti­ent care ensu­res that the medi­cal help people need is directly and rapidly available where they live, from preven­tion and therapy to after­care and reha­bi­li­ta­tion, which helps to mini­mise inpa­ti­ent stays in hospi­tals and ideally prevents illness in the first place. The clus­te­ring of medi­cal depart­ments, tech­no­logy, and labo­ra­to­ries under one roof helped to over­come bureau­cra­tic and finan­cial obsta­cles that plagued private prac­ti­ces. At the same time, this design faci­li­ta­ted more effec­tive colla­bo­ra­tion between medi­cal profes­sio­nals from diffe­rent fields.

“Does not […] the real free­dom of the physi­cian consist in the fact that they are given the means to secure the health of each indi­vi­dual citi­zen without limi­ta­tion? By buil­ding up the state health system, physi­ci­ans are no longer econo­mic­ally inte­res­ted in people falling ill; they can instead genui­nely act as the guar­di­ans and preser­vers of health”.

Smal­ler insti­tu­ti­ons embo­dy­ing the same approach as the poly­cli­nic were called outpa­ti­ent centres (Ambu­la­to­rien) and typi­cally housed at least three diffe­rent depart­ments: gene­ral medi­cine, inter­nal medi­cine, and paed­ia­trics. More than a third of the outpa­ti­ent faci­li­ties were affi­lia­ted with hospi­tals and univer­sity clinics to promote medi­cal colla­bo­ra­tion. Consul­ta­tion centres and state-owned indi­vi­dual prac­ti­ces opera­ted in more remote loca­ti­ons but were orga­ni­sa­tio­nally linked to poly­cli­nics for support.

 

Trans­forming the outpa­ti­ent sector presen­ted unique chal­lenges both in terms of infra­struc­tu­ral requi­re­ments and the new roles of health care workers, unlike the hospi­tal system, which had a longer history of public owner­ship. There was, for instance, considera­ble scep­ti­cism and even resis­tance to the idea of poly­cli­nics among physi­ci­ans. The radi­cal idea of publicly employ­ing medi­cal specia­lists to work toge­ther under one roof shar­ply contras­ted with the deeply rooted self-percep­tion of the ‘free­lance’ doctor who works for him or herself.

 

Seve­ral forerun­ners of large medi­cal comple­xes served as inspi­ra­tion to the DDR’s poly­cli­nic system, such as the House of Health in Berlin, cons­truc­ted in 1923 during the Weimar Repu­blic. Archi­tects of the DDR’s Bauaka­de­mie (Academy of Civil Engi­nee­ring) began to deve­lop and refine simi­lar projects in the 1950s under the leader­ship of then Presi­dent Kurt Lieb­knecht. When the DDR’s immense housing cons­truc­tion programme was announ­ced in the early 1970s, it speci­fied that poly­cli­nics or outpa­ti­ent centres were to be incor­po­ra­ted into the new estates. Larger poly­cli­nics were built in Berlin as well as in other big cities, each staf­fed with upwards of 50 doctors.

 

Conser­va­tive physi­ci­ans’ asso­cia­ti­ons had alre­ady begun syste­ma­ti­cally oppo­sing calls to estab­lish poly­cli­nics during the Weimar era, and they resu­med this offen­sive after the end of the war in 1945. The DDR’s poli­cy­ma­kers sought to demons­trate the advan­ta­ges of the new model by expan­ding the tech­ni­cal capa­bi­li­ties and labo­ra­to­ries in poly­cli­nics. This was a gradual process; for many years, private prac­ti­ces contin­ued to provide a large portion of outpa­ti­ent care.

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It ulti­m­ately proved possi­ble to gradu­ally win over medi­cal profes­sio­nals to the concept of the poly­cli­nic: by 1970, only 18 per cent of outpa­ti­ent physi­ci­ans were in private prac­tice, compared to well over 50 per cent in 1955. The rapid cons­truc­tion of effi­ci­ent outpa­ti­ent faci­li­ties throug­hout the coun­try made the signi­fi­cant prac­ti­cal advan­ta­ges of the new system evident. The contrast between outpa­ti­ent health care in East and West Germany gradu­ally widened over the four deca­des follo­wing the foun­ding of the DDR: by 1989, the vast majo­rity of West German outpa­ti­ent doctors were still opera­ting in private prac­ti­ces, while almost all of their East German coun­ter­parts were publicly employed by that time.

5.2. The Operation of Polyclinics

Physi­ci­ans and staff working in poly­cli­nics were employed and remu­ne­ra­ted by the state, remo­ving perso­nal econo­mic moti­ves from the doctor-pati­ent rela­ti­onship and the medi­cal decis­ion-making process. In contrast to private prac­ti­ces, poly­cli­nics estab­lished unbu­reau­cra­tic coope­ra­tion between indi­vi­dual special­ties. Under capi­ta­list health care systems, self-employed outpa­ti­ent physi­ci­ans have gene­rally been (and often still are) solely respon­si­ble for medi­cal decis­i­ons, whereas the colla­bo­ra­tive struc­tures in poly­cli­nics made it easier for specia­lists across diffe­rent disci­pli­nes to discuss compli­ca­ted cases or, for instance, the prescrip­tion of new medi­ca­ti­ons and recom­men­da­ti­ons for new types of therapy. This inter­di­sci­pli­nary colla­bo­ra­tion also provi­ded a frame­work in which the rela­ti­onship and commu­ni­ca­tion between preven­tive, thera­peu­tic, and after­care measu­res could be streng­the­ned and brought closer toge­ther. Labo­ra­tory and medi­cal imaging services could be reques­ted imme­dia­tely and were usually available within a short time or even during the consul­ta­tion itself. Poly­cli­nics were also able to house supe­rior medi­cal equip­ment, mainly because common usage was more cost-effec­tive than indi­vi­dual use in private prac­ti­ces, and a uniform filing system for pati­ent records was main­tai­ned to reduce inef­fi­ci­ency and miscom­mu­ni­ca­tion between specialists.

 

On average, poly­cli­nics staf­fed 18 to 19 physi­ci­ans, which allo­wed them to extend hours of opera­tion and conti­nue to provide care even when indi­vi­dual doctors were sick or on holi­day, unlike in private prac­ti­ces. In addi­tion, this allo­wed physi­ci­ans to provide more exten­sive care to their pati­ents, as they could couple their normal consul­ta­tion hours with on-site visits. Paed­ia­tri­ci­ans, for instance, were able to conduct regu­lar check-ups in child­care centres while other doctors took charge of walk-in consul­ta­ti­ons in polyclinics.

“The fact that a doctor always has to worry about how to secure their income and is depen­dent on sick people coming to them cannot be the solu­tion. Another solu­tion must be found. Namely, to under­stand doctors as well-paid employees of the state who can conduct their duties inde­pendently of their income. That was one of the basic ideas in the DDR. A second was that the modern deve­lo­p­ment of science no longer corre­sponds to the model of private prac­tice. I need struc­tures where I can access the labo­ra­tory, X‑ray machi­nes, and specia­lists. These two basic ideas led to the gradual crea­tion of poly­cli­nics, or outpa­ti­ent centres. It was a long process, and one that faced resistance”.

The new model of employ­ment in outpa­ti­ent care greatly impro­ved the colle­gial atmo­sphere in the health sector. Staff were guaran­teed fixed working hours, in-house health care, commu­nally orga­nised meals, and joint holi­day faci­li­ties for them­sel­ves and their fami­lies. Importantly, physi­ci­ans, assistants, and nurses were all employed as staff members; they were trea­ted equally in accordance with labour laws and were orga­nised within the same trade union. These measu­res gradu­ally helped erode profes­sio­nal hierarchies.

Dr. Hein­rich Niemann remem­bers: ‘At the begin­ning of the 1980s, the large Dr. Karl Koll­witz Poly­cli­nic was built in the working-class district of Prenz­lauer Berg in Berlin. The doctors who had alre­ady been working there in private prac­ti­ces did not go into poly­cli­nics with flying colours. Of course, they knew that the moment they worked in such a large faci­lity, a diffe­rent mode of opera­tion, a new way of working toge­ther would be neces­sary. […] Yet, this is the only way that a unity can be estab­lished between thera­peu­tic, reha­bi­li­ta­tive, and preven­tive measu­res. Still today, a private prac­tice can only achieve this to a limi­ted extent’.

5.3. An Overview of the Outpatient Sector

Outpa­ti­ent care was a central compo­nent of the DDR’s preven­tive approach to medi­cine, and its expan­sion and success in ensu­ring that all citi­zens recei­ved medi­cal coverage not only during emer­gen­cies but throug­hout the course of their lives argu­ably repres­ents the most revo­lu­tio­nary aspect of the country’s health care system. In order to achieve this, a vast network of infra­struc­ture was deve­lo­ped in neigh­bour­hoods, work­places, child­care centres, and rural loca­ti­ons. Through public owner­ship and the plan­ned nature of the economy, it became possi­ble to shape living and working condi­ti­ons around health considerations.

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By 1989, this network was made up of 13,690 outpa­ti­ent faci­li­ties, 626 of which were poly­cli­nics. Roughly one in four of these poly­cli­nics opera­ted within indus­trial enter­pri­ses, using the work­place as a site to provide consis­tent, quality, and acces­si­ble health­care to the labour force. Of the almost 19,000 doctors working in the outpa­ti­ent sector by 1980, 60 per cent were employed in poly­cli­nics, 18.5 per cent in the smal­ler outpa­ti­ent centres, and just 11 per cent in indi­vi­dual medi­cal practices.

Commu­nity nursing was a highly skil­led and valued profes­sion. The nurses were well acquain­ted with the resi­dents in their region and perfor­med important medi­cal services during house visits such as carry­ing out exami­na­ti­ons, dres­sing wounds, admi­nis­te­ring medi­ci­nes and injec­tions, and arran­ging for a doctor’s assis­tance when necessary.

In order to extend preven­tive care to rural areas and scat­te­red villa­ges, rural outpa­ti­ent centres were built and staf­fed with up to three doctors, with the number of these faci­li­ties rising from 250 in 1953 to 433 by 1989. In many towns, physi­ci­ans worked in public medi­cal prac­ti­ces or tempo­r­a­rily staf­fed field offices to provide resi­dents with consul­ta­tion hours and home visits, while mobile dental clinics visi­ted remote villa­ges to provide all child­ren with preven­tive care. In addi­tion, the profes­sion of the commu­nity nurse was deve­lo­ped in the early 1950s to alle­viate the initial shortage of doctors in the coun­try­side, with the number of commu­nity nurses expan­ding from 3,571 in 1953 to 5,585 by 1989. This exten­sive rural infra­struc­ture helped to provide less densely popu­la­ted regi­ons with medi­cal services compa­ra­ble to what was available in urban areas.

“There was no sepa­ra­tion between care work and social work in commu­nity nursing, so it was a comple­tely logi­cal deve­lo­p­ment for the nurses that social services became part of the health sector in 1958. […] In villa­ges where there was no doctor, the commu­nity nurse was respon­si­ble for ever­y­thing rela­ted to health, social, and hygiene matters. Some became members of the local coun­cil, and a few became deputy mayors”.

The DDR’s revo­lu­tion in outpa­ti­ent care went beyond the cons­truc­tion of infra­struc­ture. Compre­hen­sive reform was also carried out in the educa­tio­nal system to break down tradi­tio­nal barriers and hier­ar­chies in the field. This included, among other measures:

 

  • Provi­ding tuition-free educa­tion and fixed stipends to cover students’ living costs and ensure that medi­cine became acces­si­ble to the working class and peasantry.
  • Imple­men­ting socio-poli­ti­cal measu­res such as compre­hen­sive child­care and distance educa­tion program­mes to make medi­cal profes­si­ons more acces­si­ble to women, who, from the late 1970s onwards, often made up more than 50 per cent of medi­cal students in the country.
  • Turning nursing and caret­a­king into highly quali­fied and respec­ted profes­si­ons through inten­sive acade­mic trai­ning programmes.
  • Making higher educa­tion in medi­cal special­ties available to all physicians.

Howe­ver, after 1990, the FRG’s private prac­tice model was rigo­rously impo­sed on East Germany, undo­ing the DDR’s achie­ve­ments in the outpa­ti­ent sector. While many East German profes­sio­nals were strip­ped of their creden­ti­als after the DDR was incor­po­ra­ted into the FRG, no one dared to seriously ques­tion the quali­fi­ca­ti­ons of East German health profes­sio­nals: in cases where they were barred from prac­ti­cing, the motive was almost always poli­ti­cal. Further­more, the liqui­da­tion of the poly­cli­nic system repre­sen­ted ‘the grea­test blun­der in health policy’ after unifi­ca­tion, as Dr. Hein­rich Niemann argued before the Health Commit­tee of the German Parlia­ment in 1991 – an assess­ment corrob­ora­ted by the preca­rious state of the health system in Germany today. While the FRG made it possi­ble in the late 1990s for outpa­ti­ent doctors to work as employees rather than free­lan­cers, these clinics are almost exclu­si­vely under private owner­ship and lack a unified struc­ture, and their commer­cial orien­ta­tion marks a signi­fi­cant regres­sion from the inte­gra­ted and publicly funded outpa­ti­ent faci­li­ties of the DDR.

6. Protecting Health in the Workplace

In East Germany, workers’ health was given great importance from the very begin­ning. In 1947, during the period in which Germany was still occu­p­ied by the four Allied powers, the Soviet Mili­tary Admi­nis­tra­tion issued Order No. 234, which stipu­la­ted that work­places with more than 200 employees were to set up medi­cal stati­ons, while those with more than 5,000 employees were to estab­lish enter­prise poly­cli­nics. Within three years, 36 enter­prise poly­cli­nics had been set up, and by 1989, they numbe­red more than 150. The enter­pri­ses them­sel­ves were respon­si­ble for main­tai­ning the rooms, furnis­hings, and opera­ting costs of these health faci­li­ties while the state health system provi­ded and over­saw the medi­cal staff and equip­ment. This point repres­ents a decisive contrast to the occu­pa­tio­nal health care that is offe­red in some private compa­nies today: in the DDR, the medi­cal profes­sio­nals over­see­ing occu­pa­tio­nal health and safety were employed by the public health system, not the enter­prise within which they worked. As such, it was the inte­rests of the workers, not the employ­ers, that guided their medi­cal decisions.

 

In the DDR’s first consti­tu­tion in 1949, legal protec­tions for workers’ health were laid out along­side the exten­sive social insu­rance system. In the subse­quent consti­tu­ti­ons in 1968 and 1974, these protec­tions were expan­ded, and their imple­men­ta­tion was over­seen by the workers them­sel­ves: the Free German Trade Union Fede­ra­tion, present in all enter­pri­ses and insti­tu­ti­ons of the DDR, was tasked with moni­to­ring the enforce­ment of legal provi­si­ons and report­ing on their effects. By law, the work­place repre­sen­ted much more than merely a source of income. Enter­pri­ses provi­ded the frame­work in which employees could pursue cultu­ral and intellec­tual inte­rests along­side recrea­tio­nal acti­vi­ties. Workers’ briga­des were encou­ra­ged to attend cultu­ral and sport­ing events, discuss poli­ti­cal deve­lo­p­ments, and visit holi­day camps main­tai­ned by the enter­pri­ses. The DDR’s Labour Code of 1977, for instance, contai­ned clau­ses to protect and promote both the physi­cal and mental health of employees. This legis­la­tion further demons­tra­tes that the inte­rests of working people deter­mi­ned the direc­tion of the economy.

§2 (4) Labour law is aimed at impro­ving, in a plan­ned manner, the working and living condi­ti­ons of employees in the enter­pri­ses: speci­fi­cally, to expand health protec­tion; to enhance labour power; to improve social, health, intellec­tual and cultu­ral program­mes; and to increase the workers’ oppor­tu­ni­ties for meaningful leisure time and recrea­tion. It guaran­tees working people mate­rial secu­rity in the case of illness, disa­bi­lity, and old age.

 

§ 17 (1) Enter­pri­ses as defi­ned by this law are all state-owned estab­lish­ments and combi­nes as well as socia­list cooperatives.

 

§74 (3) The enter­prise shall syste­ma­ti­cally reduce hazar­dous working condi­ti­ons and limit the amount of physi­cally diffi­cult and mono­to­nous work.

 

§201 (1) It shall be the duty of the enter­prise to ensure the protec­tion of the health and labour power of working people prima­rily by orga­ni­s­ing and main­tai­ning safe working condi­ti­ons that are free from hard­ship and condu­cive to health and efficiency.

 

§207 Workers who are to under­take work which is physi­cally deman­ding or hazar­dous to health shall be medi­cally exami­ned free of charge before employ­ment and at regu­lar inter­vals in accordance with legislation.

 

§293 (1) The super­vi­sion of occu­pa­tio­nal health in enter­pri­ses shall be conduc­ted by the Free German Trade Union Fede­ra­tion (FDGB) through health and safety inspections.

As with the outpa­ti­ent sector, the system of occu­pa­tio­nal health was gradu­ally expan­ded. By 1989, it covered 7.5 million workers from 21,550 enter­pri­ses, or 87.4 per cent of all working people in the DDR. Insti­tu­ti­ons speci­fi­cally dedi­ca­ted to this field – such as poly­cli­nics, outpa­ti­ent centres, and medi­cal stati­ons opera­ting within enter­pri­ses – employed some 19,000 health care profes­sio­nals. Occu­pa­tio­nal medi­cine was also estab­lished as a major field of study, with appro­xi­m­ately one out of seven outpa­ti­ent doctors specia­li­sing in this field. The Central Insti­tute for Occu­pa­tio­nal Medi­cine employed physi­ci­ans and scien­tists to rese­arch work-rela­ted illnesses and deve­lop preven­tive measu­res, and the importance that this sector carried in the DDR is eviden­ced by the fact that the FRG had only half as many occu­pa­tio­nal health specia­lists, despite the West German labour force being three times larger than its equi­va­lent in the East.

 

In certain profes­si­ons, employees were expo­sed to hazar­dous subs­tances and/or parti­cu­larly arduous physi­cal condi­ti­ons. Health offi­ci­als campai­gned to reduce the number of such jobs, and enter­pri­ses were obli­ged to report on the measu­res they were taking to combat harmful condi­ti­ons. Yet, in certain sectors of the East German economy, such as heavy indus­try, produc­tion proces­ses posed unavo­ida­ble thre­ats to workers’ health. By 1989, roughly 1.69 million workers remained expo­sed to harmful pollut­ants and stres­ses such as exces­sive heat, noise, or vibra­ti­ons. To mini­mize the inju­ries that often resul­ted from such jobs, the DDR provi­ded targe­ted care to expo­sed workers. Of the 7.5 million workers moni­to­red under the occu­pa­tio­nal health system in 1989, roughly 3.34 million recei­ved care that was tail­o­red to the speci­fic condi­ti­ons in which they worked. For exam­ple, regu­lar hearing tests were conduc­ted for those working in cons­truc­tion, while regu­lar lung exami­na­ti­ons were conduc­ted for those employed in chemi­cal plants. Along­side these measu­res, specia­list occu­pa­tio­nal health inspec­to­ra­tes moni­to­red enter­pri­ses’ compli­ance with safety stan­dards and speci­fied limits for harmful subs­tances or work stresses.

An occu­pa­tio­nal health inspec­tion measu­res noise, tempe­ra­ture, humi­dity, and light­ing condi­ti­ons. In 1981, a strict obli­ga­tion was placed on enter­pri­ses to report on the condi­ti­ons of high-risk work­places and to take measu­res to reduce these risks. Toge­ther, these reports crea­ted a solid data­base through which affec­ted employees could be moni­to­red, protec­ted, and provi­ded with targe­ted care. The data was also used to exert grea­ter pres­sure on poli­ti­ci­ans and enter­pri­ses to reduce and, if possi­ble, prevent the harmful side effects of work.

The field of occu­pa­tio­nal health was parti­cu­larly important in the context of the FRG’s trade embargo, which caused the DDR to rely heavily on the only energy source readily available in East Germany: brown coal, a lignite-based subs­tance that emits considera­ble pollu­tion when burned. This econo­mic neces­sity, along­side short­falls in tech­ni­cal moder­ni­sa­tion in some enter­pri­ses, led to special exemp­ti­ons being permit­ted regar­ding harmful expo­sures in some work­places. Occu­pa­tio­nal health and safety thus became a conten­tious field as offi­ci­als deba­ted which prio­ri­ties should be set. Ludwig Meck­lin­ger, the DDR’s minis­ter of health from 1971 to 1989, reco­g­nised this dilemma, stating that health poli­cies were inevi­ta­bly rest­ric­ted by econo­mic neces­si­ties and exter­nal factors.

 

Work-rela­ted mental stress was another key issue in the DDR and became the focus of the field of occu­pa­tio­nal psycho­logy. Here, signi­fi­cant findings were made by the scho­lar Winfried Hacker, who focu­sed his rese­arch on the psycho­lo­gi­cal regu­la­tion of labour acti­vity in the context of socia­list society, where the grea­ter satis­fac­tion of people’s needs requi­res increased labour produc­ti­vity. Accor­ding to Hacker, work should be desi­gned in such a way that not only main­ta­ins workers’ health, but also fosters their psycho­lo­gi­cal deve­lo­p­ment: work that is dull and detached from workers’ lived reali­ties will lead to alien­ation, whereas a healthy rela­ti­onship with work must be multi-dimen­sio­nal and allow workers to deve­lop both them­sel­ves and the products of their labour at the same time. To explore these ideas, Hacker and his team of rese­ar­chers deve­lo­ped methods to iden­tify objec­tive charac­te­ristics in the work­place that posi­tively impac­ted health and psycho­lo­gi­cal deve­lo­p­ment and to measure how they affec­ted subjec­tive percep­ti­ons. Although Hacker’s propo­sals were not imple­men­ted on a large scale, his rese­arch set the stan­dard in occu­pa­tio­nal psycho­logy. Hacker’s work diffe­red from the predo­mi­nant approa­ches to occu­pa­tio­nal psycho­logy under capi­ta­lism, which prio­ri­tise incre­asing the effi­ci­ency of work proces­ses rather than the deve­lo­p­ment of employees’ health and mental state.

 

Today, the weak­e­ning of trade union power and the rise of preca­rious employ­ment has led to a dete­rio­ra­tion in working condi­ti­ons in most capi­ta­list states. While there have been advan­ces in the produc­tion proces­ses them­sel­ves, new health burdens are constantly emer­ging, parti­cu­larly in connec­tion with digi­tal work­places, along with agri­cul­ture and food indus­tries. As such, the importance of occu­pa­tio­nal health has only increased, and the expe­ri­en­ces of the DDR in this field remain rele­vant not only from a medi­cal point of view, but also by demons­t­ra­ting that a funda­men­tally diffe­rent approach to health protec­tion in the work­place is possible.

7. Health Care for Mothers and Children 

In East Germany, women enjoyed access to first-rate health care, compre­hen­sive child­care, and guaran­teed employ­ment. These social achie­ve­ments meant that by 1989, the employ­ment rate among women had reached 92 per cent. At the same time, from the 1970s, East Germany also had a higher birth rate than the West largely due the conti­nuous expan­sion of the country’s social and health infra­struc­ture, which enab­led women to both pursue employ­ment and raise a healthy family.

 

The deve­lo­p­ment of this infra­struc­ture was estab­lished in the DDR’s legis­la­tion, which proved to be consis­t­ently more progres­sive than in the FRG, where patri­ar­chal laws reflec­ted bour­geois fami­lial concepts such as the stay-at-home mother. The DDR’s 1950 Law on Mother and Child Protec­tion and the Rights of Women, for instance, prescri­bed an exten­sive expan­sion of day care and health care faci­li­ties for child­ren, expli­citly support­ing single and working mothers. While in 1956 only 10 per cent of child­ren atten­ded child­care faci­li­ties, by 1990 nearly 80 per cent of eligi­ble child­ren atten­ded a crèche (from the age of 0 to 3) and 94 per cent atten­ded kinder­gar­tens (from ages of 3 to 6). At the time, these were some of the highest rates of child­care coverage in the world. Women’s commit­tees within trade unions were instru­men­tal in intro­du­cing and over­see­ing new laws to address the need to balance family and work respon­si­bi­li­ties. One result, for exam­ple, was the estab­lish­ment of enter­prise kinder­gar­tens directly connec­ted to the work­place. Through the socia­li­sa­tion of child­care respon­si­bi­li­ties, mothers were able to work while also raising child­ren and thus deve­lop econo­mic inde­pen­dence from their part­ners. This was reflec­ted in East Germany’s divorce rate, which remained signi­fi­cantly higher than in the FRG throug­hout the DDR’s 40-year exis­tence. This trend was drama­ti­cally rever­sed after 1990, when women’s employ­ment levels fell shar­ply in the former DDR.

 

Child­care faci­li­ties also played a central role in the health poli­cies of the DDR. These insti­tu­ti­ons were actively moni­to­red by the Minis­try of Health and, in the case of crèches, even placed directly under its respon­si­bi­lity rather than that of the Minis­try of Educa­tion. This made it possi­ble to create inte­gra­ted social and health stan­dards to further children’s well­be­ing, such as regu­lar paed­ia­tric visits to crèches to carry out vacci­na­ti­ons and peri­odic medi­cal check-ups conduc­ted directly in kinder­gar­tens and schools, making health care an inte­gral part of children’s ever­y­day lives. In this way, main­tai­ning good health and detec­ting poten­tial health issues became a social respon­si­bi­lity that was no longer left to parents alone.

 

In 1965, the Law on the Unified Socia­list Educa­tion System made health a central pillar of educa­tion and laid out quali­fi­ca­tion requi­re­ments for person­nel in crèches, kinder­gar­tens, and schools. Child psycho­logy and pedagogy were empha­sised in trai­ning program­mes for crèche person­nel. Early child­hood deve­lo­p­ment was acutely obser­ved by educa­tors to assess, for instance, children’s adapt­a­tion to their fami­lial and social envi­ron­ment. When neces­sary, crèche person­nel arran­ged for consul­ta­ti­ons with parents to discuss prac­ti­cal recom­men­da­ti­ons for ever­y­day care. The Profes­sio­nal Paed­ia­tric Asso­cia­tion (Medi­zi­ni­schen Fach­ge­sell­schaft für Pädia­trie) also conve­ned regu­lar inter­di­sci­pli­nary working groups toge­ther with child­care person­nel to assess the state of crèches and kinder­gar­tens. These groups drew up policy propo­sals and legis­la­tive amend­ments as well as sugges­ti­ons for pilot projects.

In the DDR, strict norms were deve­lo­ped and enforced to ensure appro­priate pedago­gi­cal methods, infra­struc­ture, and open spaces at children’s faci­li­ties. New housing deve­lo­p­ments, such as the one in Rostock featured here, were requi­red to include large open spaces for children.

In addi­tion to provi­ding free child­care to all fami­lies, the DDR strove to break down cultu­ral taboos and promote the health of women and child­ren, regard­less of their circum­s­tances. The 1965 Family Code, for instance, elimi­na­ted the discri­mi­na­tory legal cate­gory of ‘child­ren born out of wedlock’ while empha­sis­ing the role of both parents in raising a child. The 1972 Law on the Termi­na­tion of Pregnancy also contri­bu­ted to women’s self-deter­mi­na­tion and family plan­ning by intro­du­cing free and legal access to contracep­ti­ves and abor­ti­ons within the first 12 weeks of pregnancy. In contrast, the consti­tu­tion of the Fede­ral Repu­blic of Germany conta­ins a clause crimi­na­li­sing abor­tion to this day, and, since 1976, women have been requi­red to attend a compul­sory coun­sel­ling session in order to receive an exemption.

 

Pregnant women in the DDR were guaran­teed compre­hen­sive pre- and post-natal consul­ta­ti­ons to aid and moni­tor mothers and their child­ren. By 1989, there were more than 850 pregnancy consul­ta­tion centres throug­hout the coun­try to guide expec­tant mothers in medi­cal and social ques­ti­ons. After birth, some 9,700 mate­r­nity consul­ta­tion centres regu­larly exami­ned infants and assis­ted the parents in their new roles. Peri­odic medi­cal exami­na­ti­ons then accom­pa­nied child­ren all the way to adult­hood. Importantly, dental care was also inte­gra­ted into preven­tive scree­nings in kinder­gar­tens and schools, again in contrast to most health systems today in which dental health is not publicly guaran­teed and is instead left to the finan­cial resour­ces and discre­tion of parents. Taken toge­ther, these struc­tures and poli­cies helped to ensure that family plan­ning and child­hood deve­lo­p­ment could unfold inde­pendently of econo­mic considerations.

A paed­ia­tri­cian carries out an exami­na­tion in a rural outpa­ti­ent clinic. In addi­tion to the early detec­tion of health abnor­ma­li­ties, the assess­ment of a child’s prepared­ness for school was also part of the preven­tive scree­nings. Confi­den­tial docu­men­ta­tion of all such exami­na­ti­ons and findings on health and deve­lo­p­ment accom­pa­nied child­ren from birth to graduation.

8. Vaccination Strategies

The COVID-19 pande­mic has reve­a­led the inequa­li­ties and inef­fi­ci­en­cies of vacci­na­tion produc­tion and distri­bu­tion in the capi­ta­list world today. On the one hand, intellec­tual property rights have been prio­ri­ti­sed over public health, leading to vacci­na­tion apart­heid in which count­ries in the Global North have amas­sed enough doses to vacci­nate their popu­la­ti­ons three times over, while most states in the South are preven­ted from repro­du­cing these same vacci­nes them­sel­ves. If it were not for South-South coope­ra­tion headed by count­ries such as Cuba and China, vacci­na­tion rates in poorer states would be far lower than they alre­ady are. On the other hand, in a twist of irony, the same states stock­pi­ling vacci­nes in the Global North strug­g­led to convince a quar­ter or even a third of their popu­la­ti­ons of the effi­cacy and safe­ness of immu­ni­sa­tion against COVID-19.

 

As in many other socia­list states, the DDR was able to achieve parti­cu­larly high vacci­na­tion rates during its four deca­des of exis­tence. A clear exam­ple of this was the campaign against the polio virus. In 1961, while West Germany was still regis­tering over 4,600 cases of polio, East Germany had redu­ced its number of cases to less than five. The DDR made use of an oral vaccine produ­ced in the Soviet Union and subse­quently offe­red 3 million doses to the FRG, but the latter decli­ned. While East Germany recor­ded its last polio case in 1962, cases contin­ued to be recor­ded in West Germany until the end of the 1980s.

Vacci­na­ti­ons were a part of the regu­lar medi­cal scree­nings that accom­pa­nied child­ren from birth to adult­hood. Health care was guaran­teed in crèches, kinder­gar­tens, schools, and holi­day camps, right through to appren­ti­ce­ships and univer­sity studies. This photo­graph docu­ments the admi­nis­te­ring of a new polio oral vaccine in the form of drops.

The diffe­ren­ces in the speed and effec­ti­ve­ness with which the two German states tack­led polio stem from two funda­men­tally diffe­rent approa­ches to immu­ni­sa­tion. In the DDR, as in most other socia­list states and some Western count­ries, child­hood vacci­na­ti­ons had been manda­tory since the early 1950s, and all child­ren recei­ved a series of stan­dard vacci­na­ti­ons set by the Minis­try of Health. These vacci­nes were admi­nis­te­red to child­ren directly in crèches and schools, while adults were vacci­na­ted in the work­place. Indi­vi­du­als who did not want to be vacci­na­ted or have their child­ren vacci­na­ted (which prima­rily occur­red for reli­gious reasons) could obtain an exemp­tion after consul­ta­ti­ons with a physi­cian and regio­nal health offi­ci­als. Vacci­na­ti­ons and health care more broadly were thus trea­ted as a social task in the DDR, and a wide range of socie­tal actors, whether doctors, teachers, or parents, ensu­red that all child­ren recei­ved preven­tive medi­cine and care.

 

In the FRG, in contrast, vacci­na­ti­ons were recom­men­ded but not manda­tory, and it was the respon­si­bi­lity of the fami­lies to arrange appoint­ments with their paed­ia­tri­ci­ans for vacci­na­ti­ons. The Stan­ding Commit­tee on Vacci­na­tion (STIKO), an hono­rary commis­sion of medi­cal experts, made vacci­na­tion recom­men­da­ti­ons which doctors were then asked and paid to admi­nis­ter, but public vacci­na­tion program­mes were not imple­men­ted in schools or at the work­place. Hence, for doctors in the FRG, the incen­tive to vacci­nate is prima­rily finan­cial rather than medical.

The focus of today’s poli­ti­cal discourse on the lega­lity of manda­tory vacci­na­ti­ons unde­re­sti­ma­tes and often fails to reco­g­nise the crucial prac­ti­cal ques­tion of how the state can fulfil its obli­ga­tion to orga­nise vacci­na­tion for all citi­zens in an effi­ci­ent and safe manner. Howe­ver, there remains a ques­tion as to whether or not the basic condi­ti­ons for a mass vacci­na­tion programme have been estab­lished in a given society. These include:

 

  • Secu­ring the resour­ces to ensure that all citi­zens can be vacci­na­ted. More speci­fi­cally, this means produ­cing or acqui­ring enough doses for all citi­zens, ensu­ring that faci­li­ties are safe and acces­si­ble, and employ­ing enough medi­cal person­nel to admi­nis­ter the vaccines.
  • Coor­di­na­ting and moni­to­ring vacci­na­ti­ons in an inte­gra­ted system. One of the reasons why certain dise­a­ses conti­nue to spread despite vacci­na­tion campaigns is that indi­vi­du­als forget to arrange a second or third vacci­na­tion neces­sary for full immu­ni­sa­tion. This is a serious limi­ta­tion of volun­t­ary-based immu­ni­sa­tion stra­te­gies in which indi­vi­du­als must keep track of and arrange their boos­ter shots themselves.
  • Main­tai­ning the public’s trust in vacci­na­ti­ons and in the insti­tu­ti­ons and actors that provide them – that is, the state, phar­maceu­ti­cal produ­cers, and medi­cal profes­sio­nals. For instance, are private compa­nies recei­ving public funding to deve­lop vacci­nes that they will then patent and profit from, or is the state rese­ar­ching and deve­lo­ping vacci­nes that will be acces­si­ble and bene­fi­cial to all?

Manda­tory vacci­na­ti­ons in the DDR were ulti­m­ately met by a public that was highly willing to be vacci­na­ted. The use of coer­cion to increase vacci­na­tion rates – a hotly deba­ted issue today – was thus not an issue in East Germany. Simi­lar circum­s­tances are evident in Cuba today, where the COVID-19 vacci­na­tion rate (roughly 90 per cent of the popu­la­tion) is one of the highest in the world, and yet no coer­cive measu­res have been employed.

 

Manda­tory vacci­na­tion was unders­tood in socia­list East Germany not as a one-sided legal obli­ga­tion for the citi­zen, but as the duty of the state and its medi­cal insti­tu­ti­ons. Moni­to­ring and achie­ving vacci­na­tion coverage to the grea­test extent possi­ble was a central prio­rity for health care profes­sio­nals, espe­ci­ally for physi­ci­ans and autho­ri­ties at the muni­ci­pal level. Along­side the immu­ni­sa­tion services that were inte­gra­ted into work­places, kinder­gar­tens, crèches, and schools, perma­nent vacci­na­tion centres were estab­lished where citi­zens could obtain infor­ma­tion and sche­dule appoint­ments for addi­tio­nal volun­t­ary vacci­na­ti­ons, such as against influ­enza viru­ses. To this day, the willing­ness to be vacci­na­ted against influ­enza remains signi­fi­cantly higher in East Germany than in the West.

 

Despite tempo­rary diffi­cul­ties in the produc­tion or import of vacci­nes, the DDR guaran­teed univer­sal child immu­ni­sa­tion up to its disso­lu­tion in 1990. Further­more, the number of diph­the­ria cases was drasti­cally redu­ced, the fight against meas­les was advan­ced through boos­ter jabs despite tempo­rary setbacks, and the intro­duc­tion of a vacci­na­tion against tuber­cu­lo­sis for all new-borns helped to signi­fi­cantly reduce the number of cases. The FRG, which had always been in a stron­ger finan­cial posi­tion than the DDR, was also able to eradi­cate many child­hood dise­a­ses, but its campaigns often progres­sed far more slowly than in East Germany, as is evident with the poliovirus.

Click to enlarge

The dismant­ling of the DDR’s health care system after 1990 was accom­pa­nied by a decline in the willing­ness to be vacci­na­ted and a rising preva­lence of dise­a­ses that had previously been in decline. With the tran­si­tion to a health care system orien­ted around the private sector, immu­ni­sa­tion has once again become an indi­vi­dual respon­si­bi­lity left to the discre­tion of pati­ents and their gene­ral prac­ti­tio­ners rather than centrally orga­nised state insti­tu­ti­ons. Though various factors contri­bute to the emer­gence of epide­mics, the reap­pearance of tuber­cu­lo­sis and meas­les cases in the East of unified Germany after 1990 is tragic proof of the effi­cacy of the DDR’s vacci­na­tion stra­tegy. So too is the parti­cu­larly low vacci­na­tion rate against COVID-19 in Eastern Germany today, which is largely a product of a crisis of confi­dence in the govern­ment and the wider health sector.

9. The DDR’s International Cooperation and Medical Solidarity 

In the late 1960s, after a long period of impo­sed diplo­ma­tic isola­tion, an incre­asing number of count­ries (mostly from the Global South) announ­ced offi­cial rela­ti­ons with the DDR. In 1973, the DDR was admit­ted to the United Nati­ons and parti­ci­pa­ted cons­truc­tively in its various bodies and orga­ni­sa­ti­ons such as UNESCO and the World Health Organisation.

On 8 May 1973, the DDR became a reco­g­nised, equal, and active member of the World Health Orga­ni­sa­tion (WHO) along­side 145 other states. The FRG had been a member of the WHO since 1951 and with its claim to be the sole repre­sen­ta­tive of Germany had hinde­red the DDR’s inter­na­tio­nal coope­ra­tion in the field of health and its access to inter­na­tio­nal resour­ces. Follo­wing its admis­sion in 1973, the DDR became a proac­tive contri­bu­tor to the WHO, hosting the organisation’s 1981 Regio­nal Meeting for Europe along with nume­rous WHO work­shops. It was also actively invol­ved in the WHO’s Health for All by the Year 2000 programme, espe­ci­ally on the concept of primary health care at the 1978 Inter­na­tio­nal Confe­rence in Alma-Ata. DDR experts were sent to the WHO as dele­ga­tes, while foreign students came to study in the DDR on WHO scho­lar­ships. Further­more, fifteen medi­cal insti­tu­ti­ons and projects in the DDR were certi­fied as WHO Colla­bo­ra­ting Centres, which supported the WHO’s global program­mes by conduc­ting rese­arch, coll­ec­ting data, and foste­ring the exch­ange of scien­ti­fic and prac­ti­cal experience.

 

In addi­tion, coope­ra­tion between the socia­list states was inten­sive but also limi­ted by diffe­ren­ces in each country’s capa­bi­li­ties. The DDR, for instance, supplied many medi­ci­nes as well as medi­cal equip­ment to the Soviet Union and its allies, while seve­ral thousand doctors from the DDR recei­ved specia­list trai­ning in these countries.

In this article, copied from an entry in Dr. Rüdi­ger Feltz’s Nica­ra­gua diary on 15 March 1986, the Nica­ra­guan press reports on the cons­truc­tion of the Carlos Marx Hospi­tal, which star­ted as a triage tent and was soon expan­ded into a fully func­tio­ning hospi­tal. The hospital’s cons­truc­tion as well as the trai­ning of its staff and provi­sion of its equip­ment and medi­ci­nes were orga­nised by DDR offi­ci­als and finan­ced by dona­ti­ons from DDR citi­zens. It was one of East Germany’s largest soli­da­rity projects.

The DDR’s inter­na­tio­na­list soli­da­rity with count­ries throug­hout the Global South included nume­rous projects in the health sector. There were contrac­tual agree­ments with over 40 count­ries and natio­nal libe­ra­tion orga­ni­sa­ti­ons, such as the South West Afri­can People’s Orga­ni­sa­tion (SWAPO) and the Afri­can Natio­nal Congress (ANC). The spec­trum of the DDR’s medi­cal inter­na­tio­na­lism included supp­ly­ing medi­ci­nes and equip­ment, deploy­ing doctors and nurses over­seas, trai­ning and further educa­ting inter­na­tio­nal person­nel in the DDR, and buil­ding and opera­ting hospi­tals. For example:

 

  • The DDR-Viet­nam Friend­ship Hospi­tal, today the Viet-Duc (German-Viet­na­mese) Hospi­tal, in Hanoi, Viet­nam was supplied with medi­cal mate­ri­als by the DDR as early as 1956.
  • The Carlos Marx Hospi­tal was built in Nica­ra­gua in the 1980s and largely opera­ted by DDR medi­cal and tech­ni­cal experts. By 1989, there were appro­xi­m­ately 90 employees working there, inclu­ding 25 doctors and 23 mid-level medi­cal staff from the DDR.
  • Over 50 doctors and specia­lists from the DDR cons­truc­ted and opera­ted the Metema Tropi­cal Hospi­tal in Ethio­pia from 1987 to 1988 to treat drought victims.
  • Angola recei­ved 27 ambu­lan­ces through DDR soli­da­rity dona­ti­ons in 1975. In a reha­bi­li­ta­tion centre in the capi­tal city of Luanda, DDR medi­cal person­nel trea­ted woun­ded comba­tants of the People’s Move­ment for the Libe­ra­tion of Angola (MPLA). The centre also opera­ted as a school to train local nurses and doctors.
  • The DDR sent specia­lists to Cambo­dia (the 17 April Hospi­tal), Mozam­bi­que (the towns of Chimoio and Tete), Alge­ria (Frenda, Mahdia, and Oran), the People’s Demo­cra­tic Repu­blic of Yemen (Aden), and Guinea (the ortho­pae­dic-tech­ni­cal centre in Cona­kry). DDR paed­ia­tri­ci­ans also trea­ted pati­ents at the Natio­nal Union of Tanga­ny­ika Workers’ clinic in Dar es Salaam, Tanzania.
The DDR’s Doro­thea Chris­tiane Erxle­ben Medi­cal School, named after Germany’s first female medi­cal doctor, empha­sised medi­cal pedagogy. The objec­tive was to train students so that they could in turn teach trai­nees in their home count­ries, ther­eby promo­ting the deve­lo­p­ment and auto­nomy of local health care systems.

Further­more, doctors from count­ries throug­hout Africa, Asia, and Latin America recei­ved specia­list trai­ning in the DDR, and about 700 over­seas pati­ents were trea­ted in the DDR every year. Nurses and other mid-level medi­cal profes­sio­nals also recei­ved trai­ning in the DDR, most often at the Doro­thea Chris­tiane Erxle­ben Medi­cal School, which drew roughly 2,000 students from more than 60 states and natio­nal libe­ra­tion move­ments during its 30-year exis­tence. The DDR’s medi­cal inter­na­tio­na­lism was charac­te­ri­sed by both imme­diate aid and a commit­ment to support­ing the long-term deve­lo­p­ment of self-sustai­ning medi­cal services in the emer­ging nation states.

“Contract workers from Poland, Mozam­bi­que, Mongo­lia, and other count­ries had always been employed in proces­sing plants in the meat indus­try. As a rule, workers should have been exami­ned for fitness in their home count­ries before coming to the DDR. Nevert­hel­ess, during our recruit­ment exami­na­ti­ons, we often detec­ted serious illnesses of the lungs, liver, kidneys, etc. But these pati­ents were never sent back. Instead, they were admit­ted to special clinics where they were trea­ted free of charge, some­ti­mes for months. This was prac­ti­cal soli­da­rity in the DDR. What a huge contrast [with health care] after “reuni­fi­ca­tion” in 1990, when, for exam­ple, a despe­rate father from Russia approa­ched me with his child suffe­ring from a tumour. Doctors from the Charité Hospi­tal were willing to operate on him, but the funds could not be secu­red. In the media today, we often hear people begging for money to help seriously ill child­ren from abroad, which always makes me sad and angry at the same time. The ‘impo­ve­ris­hed’ DDR never had to beg for such huma­ni­stic gestures!”

 

10. Why Is Socialism the Best Prophylaxis?

With the incor­po­ra­tion of East Germany into the FRG in 1990, the DDR’s 40-year endea­vour to cons­truct a funda­men­tally diffe­rent health care system was brought to an end. The medi­cal infra­struc­ture and staff of the former DDR were engul­fed by the West German system, which had itself been caught up in a wave of neoli­be­ral commer­cia­li­sa­tion since the mid-1980s. Corpo­rate hospi­tal chains emer­ged throug­hout Germany in the deca­des that follo­wed, and the private prac­tice model of outpa­ti­ent care was reimpo­sed on the East. The profit motive came to domi­nate the medi­cal profes­sion once again, as Irene, a former nurse employed in one of the DDR’s poly­cli­nics, recoun­ted: ‘By 1993, physi­ci­ans had begun to set up their private prac­ti­ces. After my chief doctor had atten­ded a class on self-employ­ment, she said to us, “I lear­ned today that there are three prin­ci­ples of self-employ­ment in the new system. First, we must always be kind to the pati­ents so that they like to come to us. Second, we must disco­ver what we can earn from the pati­ent. How much reve­nue will they gene­rate for us? And the third prin­ci­ple: We cannot allow them to get healthy”. That was my expe­ri­ence of the system change after 1990, and it has been my over­all feeling in the health sector ever since’.

 

The reimpo­si­tion of commer­ci­ally orien­ted medi­cal prac­ti­ces in East Germany has made the contrast between capi­ta­list and socia­list health care all the clea­rer. While the market turns dise­a­ses into commo­di­ties and pati­ents into custo­mers, socia­list medi­cine seeks to prevent the dise­ase and illness to begin with, making human well-being its guiding prin­ci­ple. As in other socia­list states such as Cuba, preven­tion remained the guiding prin­ci­ple of the DDR’s approach to health care throug­hout its exis­tence. Once the profit motive had been elimi­na­ted from both medi­cine and the economy, there was no reason why indi­vi­du­als and workers should be allo­wed to get sick.

 

In the DDR, poli­ti­cal empha­sis was placed on social medi­cine – that is, the syste­ma­tic reco­gni­tion and comba­ting of the socio-econo­mic deter­mi­nants of health and illness rather than an approach that merely focu­ses on how these mani­fest at the indi­vi­dual level. While both social and indi­vi­dual medi­cine provide crucial perspec­ti­ves for preven­ting and trea­ting illness, poli­cies aimed at impro­ving the population’s health will inevi­ta­bly be rest­ric­ted if the gene­ral social context and root causes of dise­ase are disregarded.

“Throug­hout my poli­ti­cal life… I have seen the world through the eyes of a doctor, for whom poverty, misery, and dise­ase are the main enemies. That’s how I came to commu­nism, and that’s how I was lucky enough to expe­ri­ence in the DDR a health and social system that estab­lished an impres­sive frame­work, a social and health system for the whole popu­la­tion such as I had never seen before. […] I am not uncri­ti­cal of the former DDR and do not glorify its past. […] But one thing I know for sure: it would never have pushed me away from the ideas of socia­lism, for I arri­ved at them via unfor­gettable expe­ri­en­ces under capi­ta­lism. […] The best, most humane and scien­ti­fic medi­cine ulti­m­ately remains help­less under condi­ti­ons of social misery. The state of the world today provi­des the most compel­ling and horri­fic evidence of this. But the reverse is also true: even the best social envi­ron­ment is power­less in the face of dise­ase if it lacks medi­cine of the highest scien­ti­fic and huma­ni­stic order.”

 

Outpa­ti­ent care, which has been a central focus of this study, reflects most strikin­gly the distinc­tion between a capi­ta­list and a socia­list health care system. Outpa­ti­ent faci­li­ties and profes­sio­nals in East Germany were inte­gra­ted into all areas of society, from work­places and schools to urban neigh­bour­hoods and rural villa­ges. The country’s various medi­cal insti­tu­ti­ons were connec­ted through an inte­gra­ted network that promo­ted coope­ra­tion rather than compe­ti­tion. This exten­sive infra­struc­ture func­tioned as an early warning system that could iden­tify and coun­ter­act harmful deve­lo­p­ments where­ver and when­ever they emer­ged. The field of occu­pa­tio­nal health care was parti­cu­larly important in this respect since it allo­wed the links between work and illness to be scru­ti­ni­sed and addres­sed. Simi­larly, the inte­gra­tion of preven­tive care in child­care and educa­tio­nal insti­tu­ti­ons turned health matters into a social respon­si­bi­lity that was should­e­red not only by parents but also by teachers, physi­ci­ans, and public officials.

 

What stands out in the East German context are the achie­ve­ments in health care policy despite the diffi­cul­ties facing DDR society. Situa­ted on the front­li­nes of the Cold War, the coun­try was heavily sanc­tioned and strug­g­led to import modern medi­cal tech­no­logy and equip­ment. At the same time, working condi­ti­ons were strai­ned by the neces­si­ties of reindus­tria­li­sa­tion after 1945, which often entailed arduous labour and expo­sure to brown coal pollu­tion. The DDR’s early years were also marked by a serious labour shortage in the health sector as medi­cal profes­sio­nals were lured west­ward. Yet, despite these chal­lenges, the socia­list state was able to make use of its limi­ted resour­ces to progres­si­vely improve the social situa­tion and health of the popu­la­tion, and, in the process, the medi­cal profes­sion was revo­lu­tio­nised to break down tradi­tio­nal hier­ar­chies. The field of medi­cine was opened up to the working class and peas­an­try, while the tran­si­tion from private prac­ti­ces to poly­cli­nics helped to erode the privi­le­ges of physi­ci­ans over nurses and assistants as former employ­ers and employees became colleagues.

 

These succes­ses were made possi­ble by two major poli­ti­cal deve­lo­p­ments. First, health was made into a socie­tal prio­rity in East Germany after the Second World War. While in the Weimar era health poli­cies had to be fought for by trade unions and conce­ded by the capi­ta­list class, the DDR was a workers’ and peasants’ state; health, social, and cultu­ral rights were enshri­ned in the country’s consti­tu­tion, and the enforce­ment of these rights was over­seen by workers them­sel­ves. The second factor was the socia­li­sa­tion of property rela­ti­ons in East Germany, which crea­ted the frame­work for an inte­gra­ted health care system. The state’s centra­li­sed orga­ni­sa­tion of indus­try, housing, medi­cine, and educa­tion meant that health objec­ti­ves could be discus­sed and imple­men­ted in rela­tion to other social, econo­mic, and poli­ti­cal objec­ti­ves. A compre­hen­sive link was thus estab­lished between health policy and all areas of society, crea­ting for the first time a prac­ti­cal basis for such discus­sions (despite often fierce policy debates) .

 

Today, to justify the priva­tis­a­tion of health care systems world­wide, we are told that markets ensure the most effi­ci­ent allo­ca­tion of resour­ces in society. Yet, as the COVID-19 virus claims milli­ons of lives and rava­ges the enfee­bled health sectors of even the richest states, the inef­fi­ci­ency of the market and inhu­ma­nity of private owner­ship are more evident than ever. The DDR demons­tra­ted that an alter­na­tive is possi­ble – one that places human well-being at its centre, driven and mana­ged by working people. Even under condi­ti­ons of severe econo­mic cons­traint, socia­lism has proven that preven­tive care, effec­tive treat­ment, and digni­fied employ­ment can be guaran­teed for all. Indeed, embarg­oed Cuba conti­nues to prove this point today, not only provi­ding exem­plary health care for its people but also serving those in need around the world. The health care systems of the future will find their blue­prints in the socia­list socie­ties of those states like Cuba and the DDR.

ACKNOWLEDGEMENTS

This study was produ­ced in colla­bo­ra­tion with Dr. Hein­rich Niemann (b. 1944), who worked as a specia­list in social medi­cine in the DDR and served as district coun­cil­lor for health in Marzahn-Hellers­dorf, Berlin during the 1990s. The section on occu­pa­tio­nal psycho­logy was co-autho­red with Dr. Klaus Mucha, an occu­pa­tio­nal psycho­lo­gist. We also recei­ved important inputs from inter­views with Dr. Herbert Krei­bich (b. 1943), a specia­list in occu­pa­tio­nal health care who led the DDR’s Central Insti­tute of Occu­pa­tio­nal Medi­cine from 1983 until 1990; Irene (b. 1940), a former nurse in the DDR who worked in a poly­cli­nic in sports medi­cine prophy­la­xis and in an enter­prise outpa­ti­ent clinic (she has asked for her surname to be with­held for perso­nal reasons); and Dr. Rüdi­ger Feltz (b. 1958), a specia­list in neuro­sur­gery who was a prac­ti­sing physi­cian in the DDR and today in the Fede­ral Repu­blic of Germany. All the inter­views were conduc­ted between May and Novem­ber 2021 in Berlin.

BIBLIOGRAPHY

Bismarck, Otto von. Steno­gra­phi­sche Berichte über die Verhand­lun­gen des Reichs­tags, VI. Legis­la­tur­pe­ri­ode, I. Session 1884/85 [Steno­gra­phic Reports on the Nego­tia­ti­ons in the Reichs­tag, VI. Legis­la­tive Period, I. Session 1884/85]. In Geschichte der deut­schen Arbei­ter­be­we­gung, Band I [History of the German Labour Move­ment, Volume I]. Berlin: Karl Dietz-Verlag, 1970.

 

Bünd­nis Kran­ken­haus statt Fabrik, eds. Das Fall­pau­scha­len­sys­tem und die Ökono­mi­sie­rung der Kran­ken­häu­ser – Kritik und Alter­na­ti­ven [The German Diagno­sis Rela­ted Groups and the Econo­mi­sa­tion of Hospi­tals – Criti­cism and Alter­na­ti­ves]. Main­tal: Bünd­nis Kran­ken­haus statt Fabrik, 2020.

 

Deut­sche Demo­kra­ti­sche Repu­blik [German Demo­cra­tic Repu­blic]. Arbeits­ge­setz­buch der Deut­schen Demo­kra­ti­schen Repu­blik [Labour Code of the German Demo­cra­tic Repu­blic]. 16 June 1977. http://www.verfassungen.de/ddr/arbeitsgesetzbuch77.htm.

 

Deut­sche Demo­kra­ti­sche Repu­blik [German Demo­cra­tic Repu­blic]. ‘Befehle der Sowje­ti­schen Mili­tär­ad­mi­nis­tra­tion in Deutsch­land zum Gesund­heits- und Sozi­al­we­sen’ [Orders of the Soviet Mili­tary Admi­nis­tra­tion in Germany on Health and Social Services]. In Veröf­fent­li­chun­gen des Koor­di­nie­rungs­ra­tes der medi­zi­nisch-wissen­schaft­li­chen Gesell­schaf­ten der DDR [Publi­ca­ti­ons of the Coor­di­na­tion Coun­cil of the DDR’s Medi­cal-Scien­ti­fic Socie­ties]. Berlin: Verlag Volk und Gesund­heit, 1976.

 

Deut­sche Demo­kra­ti­sche Repu­blik [German Demo­cra­tic Repu­blic]. Verfas­sung der Deut­schen Demo­kra­ti­schen Repu­blik [The German Demo­cra­tic Republic’s Consti­tu­tion]. 9 April 1968. http://www.verfassungen.de/ddr/verf68‑i.htm.

 

Deut­sche Demo­kra­ti­sche Repu­blik [German Demo­cra­tic Repu­blic]. Statis­ti­sche Jahr­bü­cher der DDR [Statis­ti­cal Year­books of the DDR]. Berlin: Staats­ver­lag der DDR, 1956–1991.

https://www.digizeitschriften.de/search?access=all&direction=asc&filter%5BZeitschriften%5D%5B4%5D=514402644%7Clog1&from=&mainFrom=1956&mainTo=2003&q=Statistisches%20Jahrbuch%20der%20Deutschen%20Demokratischen%20Republik&scope=all&sorting=_score&to=.

 

Engels, Fried­rich. The Condi­tion of the Working Class in England. London: Panther Books, 1969. https://www.marxists.org/archive/marx/works/download/pdf/condition-working-class-england.pdf.

 

Feltz, R. (specia­list in neuro­sur­gery who was prac­ti­cing physi­cian in the DDR and today in the Fede­ral Repu­blic), in discus­sions with the authors. 28 July 2021. IF DDR office, Berlin.

 

Feltz, R. (specia­list in neuro­sur­gery who was prac­ti­cing physi­cian in the DDR and today in the Fede­ral Repu­blic), Zoom inter­view with the authors. 25 May 2021. Berlin/Erfurt.

 

Reden zur Weima­rer Gesund­heits­kon­fe­renz, Februar 1960. [Spee­ches at the Weimar Health Confe­rence, Febru­ary 1960]. In Für das Wohl des Menschen. Band 2: Doku­mente zur Gesund­heits­po­li­tik der SED [For the Good of the People. Volume 2: Docu­ments on the Health Policy of the SED], edited by Fischer, Erich, Lothar Rohland, and Diet­rich Tutzke. Berlin: Verlag Volk und Gesund­heit, 1979.

 

Irene (former nurse in the DDR who worked in a poly­cli­nic, in sports medi­cine prophy­la­xis and in an enter­prise outpa­ti­ent clinic), in discus­sion with the authors. 21 June 2021. Berlin-Treptow.

 

Krei­bich, H. (specia­list in occu­pa­tio­nal health care who led the DDR’s Central Insti­tute of Occu­pa­tio­nal Medi­cine from 1983 until 1990), in discus­sion with the authors. 30 Novem­ber 2021. Eichwalde.

 

Kupfer­mann, Thomas. Ärzte, Poli­kli­nik, und Gemein­de­schwes­ter [Doctors, Poly­cli­nic, and District Nurse]. Augs­burg: Welt­bild, 2015.

 

Lown, Bernard. The Lost Art of Heal­ing: Prac­ti­cing Compas­sion in Medi­cine. New York: Random House, 1999.

 

Meck­lin­ger, Ludwig, Günter Ewert, and Lothar Rohland, eds. ‘Zur Umset­zung der Gesund­heits­po­li­tik im Gesund­heits- und Sozi­al­we­sen der DDR’ [The Imple­men­ta­tion of Health Policy in the DDR’s Health and Social System]. In Inter­es­sen­ge­mein­schaft Medi­zin und Gesell­schaft e.V. [Inte­rest Group Medi­cine and Society], no. 13–16. Berlin: Eigen­ver­lag, 1998.

 

Niemann, H. (former specia­list in social medi­cine in the DDR and served District Coun­cil­lor for Health in Marzahn-Hellers­dorf, Berlin), in discus­sion with the authors. 2 June 2021. IF DDR office, Berlin.

 

Rapo­port, Inge­borg. Meine ersten drei Leben. [My First Three Lives]. Berlin: Edition Ost, 1997.

 

Schu­bert-Lehn­hardt, Viola and Klaus Thiel­mann. ‘Das Einfa­che, das so schwer zu machen ist: Gute Allge­mein­me­di­zin. Zum Verhält­nis von öffent­li­cher zu indi­vi­du­el­ler Gesund­heits­ver­sor­gung’ [Good Gene­ral Prac­tice: The Simple Thing That Is So Diffi­cult to Do. On the Rela­ti­onship between Public and Indi­vi­dual Health Care]. Ethica, no. 22 (2014): 163–181.

 

Seidel, Karl. Im Dienst am Menschen – Erin­ne­run­gen an den Aufbau des sozia­lis­ti­schen Gesund­heits­we­sens [In the Service of People – Memo­ries of the Buil­ding of the Socia­list Health System]. Berlin: Dietz-Verlag, 1989.

 

Spaar, Horst. ‘Doku­men­ta­tion zur Geschichte des Gesund­heits­we­sens der DDR, Teil I–VI (1945–1989)’ [Docu­men­ta­tion on the History of the Health System in the DDR, Part I–VI (1945–1989)]. In Inter­es­sen­ge­mein­schaft Medi­zin und Gesell­schaft e.V. [Inte­rest Group Medi­cine and Society], no. 3; 5; 17/18; 29/30; 37/38; 46/47. Berlin: Eigen­ver­lag, 1996–2003.

 

World Health Orga­ni­sa­tion. Decla­ra­tion of Alma-Ata. Inter­na­tio­nal Confe­rence on Primary Health Care, Alma-Ata, USSR, 1978.

https://www.who.int/teams/social-determinants-of-health/declaration-of-alma-ata.

 

Zentral­se­kre­ta­riat der SED [Central Secre­ta­riat of the SED]. Gesund­heits­po­li­ti­sche Richt­li­nien der SED [SED Health Policy Guide­lines]. Log no. 87, meeting of the Central Secre­ta­ries, 31 March 1947. http://www.argus.bstu.bundesarchiv.de/dy30zspr/mets/dy30zspr_077/index.htm?target=midosaFraContent&backlink=/dy30zspr/index.htm-kid-11ee9da7-4419–481f-8301-b9e989422683&sign=DY%2030/IV%202/2.1/77#7.

IMAGE CREDITS

 

Cover collage: Woma­cka, Walter. Unser Leben [Our Life]. 1962–1964. Mosaic artwork; Henning and Dorf­ste­cher. 15 Years DDR. 6 Octo­ber 1964. Stamp; Detlef­sen, Hans. German Red Cross DDR. 1972. Stamp; Lüders, Lutz. Inter­na­tio­nal Year of the Child 1979. 1979. Stamp; Henning and Dorf­ste­cher. The World United Against Mala­ria. 1962. Stamp.

 

Logo of the Prole­ta­rian Health Service.

 

Link, Hubert. Berlin, Bersarin­straße, Noise Measu­re­ment. 10 Novem­ber 1976. Photo­graph. Wiki­me­dia Commons / German Fede­ral Archive, image 183-R1011-0320 / CC-BY-SA 3.0.

 

Barto­cha, Benno. Fried­land Phar­macy Prescrip­tion Room. 8 Decem­ber 1975. Photo­graph. Wiki­me­dia Commons / German Fede­ral Archive, image 183-P1208-0025 / CC-BY-SA 3.0.

 

Ritter, Stef­fen. Berlin Poly­cli­nic. 9 Decem­ber 1986. Photo­graph. Wiki­me­dia Commons / German Fede­ral Archive, image 183‑1986-1209–014 / CC-BY-SA 3.0.

 

Paet­zold, Wolfried. Gade­busch District, Commu­nity Nurse. 1 Octo­ber 1982. Photo­graph. Wiki­me­dia Commons / German Fede­ral Archive, image 183‑1982-1101–009 / CC-BY-SA 3.0.

 

Link, Hubert. Berlin, VEB Elek­tro-Appa­rate, Indus­trial Hygiene Inspec­tion. 29 Novem­ber 1978. Photo­graph. Wiki­me­dia Commons / German Fede­ral Archive, image 183-T1129-0319 / CC-BY-SA 3.0.

 

Sinder­mann, Jürgen. Rostock, Lütten Klein Play­ground. 6 Febru­ary 1968. Photo­graph. Wiki­me­dia Commons / German Fede­ral Archive, image 183-G0206-0016–001 / CC-BY-SA 3.0.

 

Paet­zold, Wolfried. Carlow, Pedia­tric Exami­na­tion. 1 Novem­ber 1982. Photo­graph. Wiki­me­dia Commons / German Fede­ral Archive, image 183‑1982-1101–008 / CC-BY-SA 3.0.

 

Löwe, Giso. Kinder­gar­ten, Vacci­na­tion Against Polio. 26 March 1960. Photo­graph. Wiki­me­dia Commons / German Fede­ral Archive, Image 183–71807-0001 / CC-BY-SA 3.0.

 

Lenz, Gudrun. 40 Years World Health Orga­ni­sa­tion. 22 Novem­ber 1988. Photo­graph. Wiki­me­dia Commons.

 

News­pa­per clip­ping. Source: Feltz, Rüdi­ger. Nica­ra­gua Diary. 5 March 1986. Unpu­blished diary. Perso­nal coll­ec­tion of Dr Rüdi­ger Feltz. Acces­sed 20 Novem­ber 2022.

 

Lehmann, Thomas. Qued­lin­burg, Teaching Infant Care. 20 June 1986. Photo­graph. Wiki­me­dia Commons / German Fede­ral Archive, Image 183‑1986-0620–015 / CC-BY-SA 3.0.

 

GRAPHICS

 

Infant morta­lity rate. Sources: Bundes­re­pu­blik Deutsch­land [Fede­ral Repu­blic of Germany]. Gesund­heits­be­richt für Deutsch­land [Germany’s Health Report]. Bonn: Statis­ti­sches Bundes­amt, 1998; Deut­sche Demo­kra­ti­sche Repu­blik [German Demo­cra­tic Repu­blic]. Statis­ti­sche Jahr­bü­cher der DDR [Statis­ti­cal Year­books of the DDR]. Berlin: Staats­ver­lag der DDR, 1956–1991; World Bank Open Data. ‘Morta­lity rate, infant (per 1,000 live births)’. The World Bank Group. Acces­sed 1 Novem­ber 2022. https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?end=2019&locations=GB-US-SE-FR&start=1960&view=chart.

 

Resi­dents per physi­cian in the DDR. Sources: Deut­sche Demo­kra­ti­sche Repu­blik [German Demo­cra­tic Repu­blic]. Statis­ti­sche Jahr­bü­cher der DDR [The DDR’s Statis­ti­cal Year­books]. Berlin: Staats­ver­lag der DDR, 1956–1991.

 

How the DDR’s health care system was orga­nised at the natio­nal level. Source: Niemann, Hein­rich (former specia­list in social medi­cine in the DDR and district coun­cil­lor for health in Marzahn-Hellers­dorf, Berlin). In discus­sion with the authors. 2 June 2021. IF DDR office, Berlin.

 

How the DDR’s health care system was orga­nised at the muni­ci­pal level. Source: Niemann, Hein­rich (former specia­list in social medi­cine in the DDR and district coun­cil­lor for health in Marzahn-Hellers­dorf, Berlin). In discus­sion with the authors. 2 June 2021. IF DDR office, Berlin.

 

Physi­ci­ans per 10,000 resi­dents. Sources: Deut­sche Demo­kra­ti­sche Repu­blik [German Demo­cra­tic Repu­blic]. Statis­ti­sche Jahr­bü­cher der DDR [Statis­ti­cal Year­books of the DDR]. Berlin: Staats­ver­lag der DDR, 1956–1991; Rahlf, Thomas, ed. Deutsch­land in Daten [Germany in Data]. Bonn: Bundes­zen­trale für poli­ti­sche Bildung, 2015; World Bank Open Data. ‘Physi­ci­ans (per 1,000 people)’. The World Bank Group. Acces­sed 1 Novem­ber 2022. https://data.worldbank.org/indicator/SH.MED.PHYS.ZS?locations=US-FR-SE-GB.

 

Public versus private employ­ment of doctors in the DDR’s outpa­ti­ent sector. Source: Deut­sche Demo­kra­ti­sche Repu­blik [German Demo­cra­tic Repu­blic]. Statis­ti­sche Jahr­bü­cher der DDR [Statis­ti­cal Year­books of the DDR]. Berlin: Staats­ver­lag der DDR, 1956–1991.

 

The deve­lo­p­ment of outpa­ti­ent faci­li­ties in the DDR. Source: Deut­sche Demo­kra­ti­sche Repu­blik [German Demo­cra­tic Repu­blic]. Statis­ti­sche Jahr­bü­cher der DDR [The DDR’s Statis­ti­cal Year­books]. Berlin: Staats­ver­lag der DDR, 1956–1991.

 

Tuber­cu­lo­sis cases per 10,000 resi­dents. Sources: Deut­sche Demo­kra­ti­sche Repu­blik [German Demo­cra­tic Repu­blic]. Statis­ti­sche Jahr­bü­cher der DDR [Statis­ti­cal Year­books of the DDR]. Berlin: Staats­ver­lag der DDR, 1956–1991; Rahlf, Thomas, ed. Deutsch­land in Daten [Germany in Data]. Bonn: Bundes­zen­trale für poli­ti­sche Bildung, 2015.