Socialist medicine, its priorities, healthcare organization, and underpinning ideology was an important aspect of the Cold War world, through which East and West set themselves apart. Following Western medical tourists who studied the new Soviet system in the first half of the twentieth century – among them Henry Sigerist – the geopolitical divisions of the post-First World War era accentuated the marked differences in approaches to health, even as overlaps remained in basic concepts. Through an Eastern European lens, this chapter explores the definition of socialist medicine in tandem with that of social medicine to ask if the difference between social and socialist that became more and more stark in the Cold War, was in name only, or if it represented different historical pathways.

Social medicine and its relation to socialist medicine occupies a particularly useful analytical terrain on the boundaries of the political and professional and the medical and social. Taking together the social and socialist, we can situate health and medicine in (state) socialist contexts into broader conversations around definitions of health, responsibilities for and methods of maintaining it, and on guiding concepts behind healthcare structures. Integrating socialist health into the history of social medicine challenges conventional Cold War divisions in separate “Western” and “Eastern” narratives in the politics of health, broadening an understanding not only of how we approach social medicine and its meanings, but also of what the Cold War itself meant in terms of health and its politics.

The intertwined ideas of social and socialist medicine lead us to further reconsiderations of how we can understand socialist medicine as a phenomenon and, more broadly, where we place the role of ideology within it. Historian Mat Savelli, in his analysis of Yugoslav psychiatry, differentiates between “socialist by design” and “socialist by default.”Footnote ¹ The former refers to practices and concepts that were ideologically infused, engaging some way with socialist ideas and aims – these did not necessarily need to be in socialist countries. Socialist by default, in turn, refers to medicine and health in state socialist contexts that do not necessarily have anything to do with ideology or particular political and social infrastructure – they just happen to be in state socialist countries. What we can see in the overlaps of, and interactions between, social and socialist medicine is the combination of the two: continuities in social medicine that are then framed and molded in a particularly socialist, ideology-infused manner.

Social Medicine before State Socialism

Social medicine has always been an explicitly political project. In Eastern Europe, the interwar era became a high point in the expansion of social medicine, as new states and regimes struggled with redefining nation and health on the ruins of empires. Eastern European pioneers of social medicine were in continuous exchange and conversation with their Western counterparts and had a significant global impact through international organizations. As Patrick Zylberman points out, social medicine in the East and the West were not very far apart but it was more incendiary in the East, as it quickly gained an overall aim of modernization (economy, society, the nation on the whole) instead of its Western, more modest aims of reforming medicine as a field.Footnote ² At its conception and development, however, Eastern ideas about social medicine and social hygiene and Western concepts and practices were fundamentally connected.

Building on ongoing reform in hygiene reaching back to the nineteenth century, social hygiene became a distinct field in the Soviet Union shortly after the Russian Revolution of 1917, with dedicated departments in medical schools starting to appear in 1922. Soviet social hygienists were proponents of the well-being of the whole population, positioning themselves between a sociological and a biological approach. They focused on the description of social factors that contributed to ill health and proposed social measures as disease prevention. The field as such was heavily supported by the revolutionary government, which eventually put social hygienists in an uncomfortable position: they were, in essence, paid by the state to point to its shortcomings and call out the lack of promised social reforms.Footnote ³

Soviet social hygienists did not work in isolation. They followed closely, adapted ideas from, and were in conversation with key figures in German social medicine via medical journals and personal correspondence and translated many influential works into Russian.Footnote ⁴ Historian Susan Solomon argues, however, that Soviet social hygienists saw their work as differing from that of the Germans as it was animated by a “social thrust”, and they also set themselves apart from previous Russian efforts as the units of analysis were class-based, rather than territorial.Footnote ⁵ At the same time, soviet hygienists were, at least in the early Soviet Union, working in a very international environment.Footnote ⁶ Soviet healthcare became an object of intense international attention, its underpinning ideas and system held up as exemplary by many who visited there in the 1920s and 1930s, publishing their praises of social and socialized medicine in the Soviet Union. The most well-known among them are Arthur Newsholme’s Red Medicine and Henry Sigerist’s Socialized Medicine in the Soviet Union.Footnote ⁷

Experiments in social hygiene and medicine were rife elsewhere in Eastern Europe in the interwar era as well, although not all social hygiene experiments were successful. In Czechoslovakia, for instance, a pilot project in Prague to coordinate social and health work failed in a combination of the ageing of the main protagonists driving the project, the loss of the Rockefeller Foundation’s support, and the rapidly changing national and geopolitical circumstances.Footnote ⁸ Still, Eastern European social medicine and social hygiene models created a significant impact and the region became an international leader in social hygiene, rural health, and healthcare reform.

Contrary to usual historical representations of the region as isolated, participation in international medical networks in Eastern Europe was very much part of forming nationhood. Katharina Kreuder-Sonnen applies Geert Somsen’s term “Olympic Internationalism” to describe this interwar transnational medical mobility through the case of Poland.Footnote ⁹ Social hygiene became central to international health, specifically the League of Nations Health Organization and later informed basic tenets or the World Health Organization through key Eastern European actors: the Polish Ludwik Rajchman and the Yugoslav Andrija Štampar.Footnote ¹⁰

Intertwining of the socialist, social, and socialized emerged in the interwar era with various configurations. Sara Silverstein points out that Andrija Štampar was, already in the 1930s, a critic of the American private health system and saw that social and socialized went hand in hand. Štampar argued that applied sociology in health would lead to “an understanding of society that would form the basis for establishing egalitarian access to health services.”Footnote ¹¹ The centrality of socioeconomic development and equality in accessing health coupled in convenient and logical ways, whether as part of a nation-building, democratic project in Yugoslavia or as part of flagship projects of new and groundbreaking ideas in healthcare in the Soviet Union.

Socialist Medicine

The stark distinction between social and socialist medicine is partly the product of Cold War politics. After the Second World War, newly established communist governments and officials consistently narrated their policies and the reconfiguration of the state which was set up against both the interwar period and the West. Furthermore, the self-distancing from social medicine could serve as a way to skirt around social hygiene’s uncomfortable history with eugenics.Footnote ¹² On the Western side, the thought that very similar ideas in Eastern European authoritarian regimes might underpin health movements that have been constituted as “progressive” in the West could have been troubling enough to reinforce the distinction between the two political contexts. Before turning to the question of overlaps and differences between social and socialist medicine, we need to take a look at how health and medicine was imagined in socialist contexts, what ideas guided healthcare organization, and what frameworks set priorities in building new health infrastructures.

Socialist health and medicine in Eastern Europe – and beyond – was far from uniform in practice and concepts, just as approaches to and practices of socialism varied widely across the world. Moreover, socialist state structures, ideologies, and socialist networks shifted and changed over time, with their timelines peppered with revolutions, retributions, freezes, and thaws, or with intermittent socialisms appearing and disappearing as organizing forces (either in state or health care) beyond the Soviet Bloc, for instance in Ghana, Chile, or even in England, where the Socialist Medical Association played an important role in what became the National Health Service but had been side-lined in the process.Footnote ¹³

As fragmented as the socialist world may seem, ideologically, geographically, and temporally, we can identify certain fundamental approaches that connected the various healthcare structures. Some of these concepts stem from core ideas underpinning a wide range of ideologies on the left, which aim to further the well-being of the masses – workers and peasants, whether formulated by Engels or Mao. Furthermore, the movement and exchanges of people, materials, ideas, and practices continued throughout the Cold War era. A Cuban mission toured Eastern Europe to search for applicable models in the development of the new revolutionary healthcare system and Eastern European physicians and nurses helped the Cuban government in providing rural healthcare in the early 1960s, while Soviet and Czechoslovak researchers participated in setting up polio-vaccination efforts that became a calling card of early Cuban health policy.Footnote ¹⁴ From the first dispatch of Chinese medical experts to Algeria in 1963, Chinese medical assistance expanded to twenty-two African countries by the 1970s.Footnote ¹⁵ In the immediate post-war era, Eastern European countries, together with China, collaborated and provided medical aid in the form of pharmaceuticals, medical care, and hospital-building in North Korea and later, in Vietnam.Footnote ¹⁶ From the 1950s onward, socialist states’ health ministers, including those of Mongolia, Cuba, Vietnam, and Eastern European countries, met annually to align healthcare policies and international health strategies and develop exchanges in training, technical assistance, and medical technology.Footnote ¹⁷ Thus, common threads among the very diverse set of actors were partly due to common ideological underpinnings but were also shaped by various collaborations among members of socialist networks.

Three common themes emerge more strongly than others in approaches to health in socialist contexts. First, all health was seen as public. While in practical terms, public health as a term officially retained its focus of engaging with living and working conditions and epidemiology, it was clear that there was no distinction between private and public health – all aspects of health became a public concern in a socialist society, which the state was responsible for, therefore achieving the true meaning of public health.Footnote ¹⁸ Second, socialist medicine placed a strong emphasis on prevention and its integration with therapy. Third, socialist medicine was statist medicine, in other words, socialized. The aim was to provide equal healthcare access to all members of society without cost, in a system where all health institutions are organized, managed, and financed by the state and in which medical professionals are all state employees.

Historian Bradley Moore argues that Czechoslovak hygienists saw Western medicine as reductionist, which “biologised” the social and environmental determinants of health.Footnote ¹⁹ Socialist medicine presented itself as an alternative. Emphasis lay on the integration of health and medicine in the workplace, the home, in education, and to address factors external to the body, placing special focus on prevention. Since health was a social and political project, this approach was seen as inseparable from what the West termed as socialized medicine, that is free and universal access to healthcare for everyone. Health thus became an integral part of the revolutionary process. As society’s ailments were caused primarily by social ills (hunger, poverty, dire working conditions, environmental factors, etc.), society itself needed to transform along with healthcare structures and priorities.

In an article providing an overview of the history of healthcare organization in the Soviet Union published in the main Hungarian medical journal Orvosi Hetilap, the essence of health was laid out: “First, we have to mention the healthcare’s state characteristic, the organic and inseparable connection of health to the building of socialism [építőmunka]. The prophylactic direction of medicine and health – the other most important conceptual trait – is the consequence of soviet healthcare’s stateist characteristic, it originates from the socialist state’s nature.”Footnote ²⁰ The heavy (or nearly exclusive) involvement of the state and the focus on prevention were intertwined with the ideology that underpinned the system.

The article also emphasized that therapy and hygiene must be connected. Here, Boris Dmitrievich Petrov, a Soviet historian of medicine who had widely published on the history of Soviet public health, pit Virchow against Pavlov. Virchow, in his understanding, has furthered the specialization of medical knowledge and its separation based on the locality of the body (organs, tissues, cells), thus did not allow for the unity of therapy and hygiene and disregarded the importance of the environment in health. Pavlov, on the other hand, placed emphasis on prevention, as illness forms in the body of the patient before they would encounter medical examination. Therefore, the main goal of medicine was to address the factors that caused illness and disease in the first place.

The concept of a legal right to health was just as fundamental to the socialist state and society and a key aspect of the role of socialist health in the revolutionary project. The new Polish constitution of 1952 stated that the state will ensure the continuous improvement of the standard of health protection and culture and stipulates that this health protection is a legal right of citizens and must be achieved through preventative measures.Footnote ²¹ In a similar vein, the 1949 Hungarian constitution declared the protection of citizens’ health to be an obligation of the state through the organization of healthcare and wide social security.Footnote ²² This concept was very much verbalized in early interactions between Eastern European countries and international organizations as the right to health, coupled with the right to relief in a postwar environment,Footnote ²³ and framed expectations from, and frustrations with, international organizations such as the World Health Organization (WHO).Footnote ²⁴

Eastern European and state socialist healthcare systems always clearly presented the intertwining of medicine and politics in the foreground, not merely as priorities and policies that are underpinned by politically informed views of society, but as direct and explicit political projects that are instrumentalized by the state, party, or political models of the Cold War East.

Social and Socialist

Even as social hygiene was central to socialist medicine and Western engagement and influence on it was openly discussed already in the interwar era, it also set itself apart from Western social medicine in various ways. One central element to this difference was the relationship between biomedical and social, which in many understandings of social medicine are oppositional. In the socialist mindset, they were inseparable parts of medicine and health, in postwar Eastern European contexts and across the wider socialist world, as Sean Brotherton demonstrates in the case of Cuba in this volume. The explanation for the socialist intertwining of the biomedical and the social is situated in the particular political understanding of health on the one hand and the immediate effects of war, destruction, and economic hardship, on the other.

While there was a new and pronounced distancing from Western approaches to medicine with the emergence of the Cold War, continuities with interwar social hygiene projects remained influential. Moore in his work on Czechoslovak social hygienists puts forth that rather than a product of Sovietization and the enforcement of Soviet or socialist models on a profession externally, social hygienists in Czechoslovakia took advantage of the new political emphasis on concerns with environmental and social factors in medicine and of the new state support to realize goals they had been unable to achieve before the war.Footnote ²⁵ It was not the result of a clear-cut or even hazy case of Sovietization, but the realization of longer standing goals of social hygienists taking on board the ideological and organizational framework of state socialism, which fit well with their existing intentions.

Continuities in concepts and, indeed, people involved in social medicine and social hygiene were not particular to the Czechoslovak case. In 1966, István Simonovits, a key member of the Ministry of Health between 1945–63 and later head of the Health Organization Institute at Semmelweis University, published a medical textbook titled Social Hygiene and Health Organization Studies. In its historical overview, Simonovits clearly connected Virchow’s attention to social contexts in health and Grotjahn’s social hygiene with “nervismus” (Pavlov’s theories) and functionalist approaches that privilege the focus on environment (mentioning Edwin Chadwick) and with hygienists such as Max Joseph von Pettenkofer.

In theory, Simonovits extrapolates, social hygiene and health organization studies are distinct. Social hygiene or social medicine (treated as synonyms in Hungarian) is on the boundary of social sciences and medicine and sees beyond the biological unit of the human body to look to the social unit: in other words, it investigates the interaction between people’s social status, living and working conditions, and their health. “Health organization studies emerges to the scene with socialism, in the active phase of establishing socialist health, as a further development of social hygiene,” Simonovits argues. Its goal is to provide scientific base for the effective and economic development and operation of healthcare. This is only achievable by keeping in mind the social conditions, therefore, naturally, it is permeated by social hygiene.Footnote ²⁶ The two, then, are actually connected and complementary and combine a top-down, biomedical organization that integrates the ground-level social, rather than the Western bottom-up, approach of social medicine.

Continuities between social and socialist, with the latter encompassing the biomedical and hierarchical, was widespread in Eastern Europe and at least partly utilitarian. Gabriele Moser, in her analysis of social hygiene and public health in the Weimar Republic and early German Democratic Republic points to continuities between the two, following an older generation of social hygienists’ role in establishing new healthcare structures. Moser argues that ideas of social hygiene from the 1920s had resurfaced in the immediate postwar era, although these were somewhat stifled by the “crisis medicine” to address the immediate challenges of wartime destruction and epidemic outbreaks and which favored the microbiological approach over a focus on social aspects.Footnote ²⁷ Historian Donna Harsch sees this strong presence of the biomedical as a deviation from social medicine: a “medicalized social hygiene,” a blend of medical treatment instead of preventative social interventions, and social hygienic concerns instead of a focus on individual rights.Footnote ²⁸

First, “crisis medicine” and its necessary foregrounding of biomedical approaches cannot be understated and is valid across Eastern Europe. The Second World War had left the region devastated and much of health infrastructure was destroyed or had to be repurposed. For instance, according to a report from 1948, in Pest-Solt-Kiskun county in Hungary, hospital beds were down by 28 percent compared to before the war and nearly three times as many beds were needed in the region to reach the national, prewar average. Many hospitals were damaged, while 45 villages were left without any access to healthcare.Footnote ²⁹

Addressing immediate and urgent needs had to be combined with a revolutionary project that aimed to solve those same needs in the longer term. In a 1986 article, Patricia Kullerberg argued that in the Hungarian case, several reasons led to the process in which scientific medicine was uncontested in the transition in which social and socialist ideas merged in the postwar era. She cited the inefficiency of political indoctrination in vulgar Marxist courses at medical schools; the utility of a narrower concept of disease for economic development and political control of the state; the enforcement of scientific medicine as an avenue to retain physicians’ control and power; and the indestructible avenue for private medical care that was (and has been ever since) an unofficial part of the healthcare system.Footnote ³⁰ The conclusion, then, is that biomedicine as a remainder from the interwar era persisted due to economic concerns and the continuity of capitalist structures in the medical profession.

The inseparability of the social and biomedical was not merely a pragmatic issue, however. Instead of seeing it as a deviation, the strong biomedical and state organization of health and medical training in Eastern Europe and the Soviet Union may be considered as a particular direction in which social medicine developed. Vilém Škovránek, Chief Officer of Public Hygiene in Czechoslovakia, outlined the importance of the integration of the social and biomedical, making a case that hygiene needs to be seen as a field that brings together specialized scientific branches, such as epidemiology and microbiology, communal hygiene, hygiene of work, children and adolescents, and nutritional hygiene as organized around the same objective, “working out scientific and medically justified precepts for the active guidance of all strata of the population, especially economic and technical experts, as well as ordinary citizens, toward the creation of the most favourable conditions necessary for the consolidation, protection and development of the physical and mental health of people living and working in a certain environment.” This work, according to Škovránek, needed to be harmonized within the medical service and outside it, as public hygiene needed to be “an integral connection with the basic aim and mission of the entire community in the public health welfare.”Footnote ³¹

The biomedical and social were entangled in the Soviet Union as well and the Soviet view of the Alma-Ata Conference in 1978 can be instructive to understand this convergence. Based on Soviet archives, historians Anne-Emanuelle Birn and Nikolai Krementsov argue that Soviet health officials like Deputy Health Minister Dimitri Venediktov had very different ideas about primary healthcare to those of Western colleagues at the WHO, such as its director-general, Halfdan Mahler. While the latter conceptualized community-based medicine as primary healthcare, for the Soviet Union, the point of pride was the ability to provide medical care very much based on biomedical practice in an established healthcare infrastructure that reached the whole population, including rural areas.Footnote ³² While community-based healthcare was a way to overcome and meager resources and lack of access, the socialist aim was to provide the resources to the whole of society instead.

This was a major departure from the way primary and community healthcare was understood in Western non-socialist or other socialist contexts outside of Eastern Europe. In fact, while drawing on drastically different political contexts, socialist models significantly informed the renewed approach to primary healthcare that led to the Alma Ata declaration. One often heralded successful approach was Indian rural medicine in Kerala, where the Communist Party had been in power since 1957 and its primary healthcare system and achievements attracted widespread international attention.Footnote ³³ Another notable approach to improving health in the so-called developing countries was the Chinese model of barefoot doctors, even as China itself did not participate in the Alma-Ata Conference due to growing tensions with the Soviet Union following the Sino-Soviet split that began in 1956.Footnote ³⁴ Chinese healthcare organization and priorities in healthcare delivery shifted in the early 1960s, in the aftermath of the famine recovery process of agricultural production. As Xun Zhou points out, there was a marked shift from the top-down organization of disease eradication to prevention and the provision of basic care, in part to address the dire scarcity of medical provisions and hygienic infrastructure and in part as an opposition to what Mao saw as flawed in the Soviet system: too many specialized doctors, who were, in Mao’s eyes, bourgeois and not needed in great numbers. Instead, public health work was prioritized, particularly in rural areas, which, in the combination of severe shortages of medical staff and the basic tenet of community involvement, eventually led to the development of the barefoot-doctor scheme, integrating the use of Western and Traditional Chinese Medicine.Footnote ³⁵ Thus, the Chinese pursuit of communist utopia in healthcare was at least partly set up against not only Western, but the Soviet socialist model, which they saw as too biomedical. The connecting socialist tissues that remained were a continued focus on prevention as a priority, the view that health is as much a medical as a social and environmental question, and the concept that health and healthcare are integral parts of the revolutionary and political project, even in their nuance.

Rural healthcare, which also became a central feature of the revolutionary overhaul of health organization and priorities in Cuba, remained to be an important feature of socialist medicine in Eastern Europe. However, like in the Soviet Union, the organization of healthcare in rural contexts was not based on community, rather on a network of epidemiological and hygiene stations, healthcare organized in workplaces, and schools and was based on local districts and on centralized control of hygienic practices in agriculture. In the 1967 informational volume on public hygiene in Czechoslovakia, Karel Symon from the Public Hygiene Institute of Prague did not even mention community participation in the discussion on rural hygiene. The focus instead was on the improved living conditions of farmers with the establishment of large-scale agricultural production and on the perils of the environmental impact and challenges in pollution that had resulted in the shift to collectives.Footnote ³⁶

In Hungary, Simonovits connected peasants’ improved access to healthcare with the transformation of the agricultural structure and the establishment of cooperatives (which were done mainly through forced collectivization, beginning in the early 1950s) and saw room for improvement in integrating the local and factory healthcare units with the hospital system, while promoting the unity and decentralization of healthcare provision, involving community action and self-care. This latter was to be achieved through education of the population and propaganda, with the active involvement of the Hungarian Red Cross.Footnote ³⁷ Thus, Hungarian healthcare organization saw social hygienic aims to be achieved through a horizontal biomedical infrastructure that is coordinated vertically, along with the organization of local community action in the form of committees and through workers’ unions and schools. However, on the ground, access to healthcare remained a challenge. A 1964 article in the national daily Népszabadság highlighted the development of rural healthcare as a pressing priority, with a lack of doctors in rural areas and calling on aspiring medical students to work in villages and outside of urban areas.Footnote ³⁸

Divergence and Convergence

While we can see definite distinctions among various framings of medicine and health between East and West, engagement with social and socialist medicine did not cease on either side. The Iron Curtain was not impermeable throughout the Cold War era, particularly regarding medicine and biomedical sciences.Footnote ³⁹ Eastern Europeans continued to engage with Western social medicine, while Western experts had a continued interest in socialist medicine.

A clear interest in Western social medicine and its compatibility with socialism is illustrated by an article published in 1964 in, Valóság, the journal of the Hungarian Society for Dissemination of Scientific Knowledge. Titled, “The Sociology of Medicine and Healthcare,” the social psychologist, Béla Buda, provided a lengthy discussion on the importance of integrating a sociological viewpoint into medical theory and practice, relying heavily on American literature.Footnote ⁴⁰ In the closing pages, Buda turned his attention to the particular Hungarian case and lamented the point that research in medical sociology has mainly been conducted in capitalist health contexts, within the methodological and theoretical atmosphere of bourgeois sociology (as opposed to Marxist, materialist sociology).

This has obscured the most important correlations, Buda argued:

Conversely, Hungarian medical professionals have not paid enough attention to the thorough investigation of social factors with the help of sociological methods and theories. This, Buda continues, could be particularly interesting, given the enormous and fundamental changes in social structures within a relatively short time and was especially important, due to cultural differences, the social factors and causal mechanisms of the same diseases based on Western research could not be applicable in places like Hungary.

In this scientific treatise then, Buda formulated critique for both sides and argued for the combination of perspectives among Western social medicine and the socialist view of health. In his understanding, the value of sociology in medicine was undisputed. Furthermore, he acknowledged the leading role particularly American researchers were taking in this discipline and saw the lack of such a strong field in Hungary as a weakness. However, without fundamental political engagement, the Western analysis has been incomplete and this is what socialist medicine brings to the table: it is not possible to improve human health, no matter if there is attention to detail for social factors, if the overarching political structures that frame social ones, among them access to healthcare and distribution of resources, are unaddressed.

On the other side, the most comprehensive source through which Western experts could learn about the healthcare structure and priorities of Eastern European countries was Richard Weinerman’s book Social Medicine in Eastern Europe: The Organization of Health Services and the Education of Medical Personnel in Czechoslovakia, Hungary and Poland, written in collaboration with his wife, Shirley Weinerman, and published in 1969. The Weinermans, advocates of social medicine and Richard being Professor of Public Health and Medicine at Yale University at the time,Footnote ⁴² compiled this book as a follow-up to their earlier one, Social Medicine in Western Europe, published in 1951.Footnote ⁴³ They spent a month in each country in 1967, sponsored by the respective Ministries of Health, and visited national research institutes, schools of medicine, postgraduate-training institution, regional and district health departments, hospitals, local healthcare offices, industrial medical units, and sanitation and epidemiological stations.

The Weinermans’ visit was, of course, carefully curated. While they were quick to note that they were not hindered in their movements during the visits in any way, the trips were organized by the ministries, complete with chauffeurs and translators, and held in a select number of institutions. Still, the analysis and observations of the volume provide a relatively thorough analysis of the guiding principles that served as a framework for Eastern European organization of healthcare, highlighting historical roots, local specifications – even if the reality on the ground might have been quite different.

In its general observations, the book identified formulations that characterized all three countries’ guiding principles, among them were emphases on prevention, raising the standard of living through public health, and centrally organized planning with decentralized responsibility.Footnote ⁴⁴ What becomes immediately clear is that the list was written for an American audience, from an American perspective, and four of the seven points – public responsibility for health, free and accessible healthcare, public education and research, and universal social insurance – addressed socialized medicine. An understanding of Eastern European healthcare structures and priorities and the interpretation of what the Weinermans had seen in the three countries therefore needs to be situated in the American context as well: the intense debates in the 1960s about Medicare and Medicaid, resulting in the 1965 legislation.Footnote ⁴⁵ From the early Cold War onward, socialized medicine had increasingly become a symbol of the socialist world and had become vilified in the 1960s, with heavy involvement by the American Medical Association. As one of the first inroads to the world of politics, the young Ronald Reagan recorded a speech in 1961 titled, “Ronald Raegan Speaks Out against Socialized Medicine,” which was available for listening at home, getting the message into households about the dangers of such an approach.Footnote ⁴⁶ As Greene, Podolsky, and Jones point out Chapter 7 in this volume, the blurring of the boundary between social and socialized served the purpose of undermining social medicine in the United States by invoking the Red Scare. However, this was not particular to American distinctions because the blurry boundaries became inconvenient for the same reason elsewhere in the West, too, and the coupling was explicitly pushed back against by proponents of social medicine such as Rene Sand, who proclaimed after the Second World War, setting himself apart from Eastern European counterparts: “Social medicine does not mean socialist or socialized.”Footnote ⁴⁷

Conclusion

Through the lens of Eastern Europe and beyond, we can see defined lines of differentiation along political ideologies but also an ebb and flow of ideas and practices across divisions, which characterized both social and socialist medicine. Looking at the establishment of healthcare systems and medical thought in Eastern Europe and the socialist world in the Cold War era, we can broaden how we understand social medicine itself. Social and socialist were intertwined in their concepts and aims and as historians, we need not necessarily follow Cold War politics in keeping them wholly separate. Rather, instead of a terminology based on mainly Western sources and practitioners and instead of dismissing Eastern European socialist medicine as irrelevant or a deviation, we might include them as a particular direction in which social medicine developed. This can then enable us to move beyond dichotomies set up in a Western understanding. Socialist approaches point to the integration of the biomedical and social in a way that shows them inseparable and as parts of the same political project, rather than opposing sides of medicine. They work with practices that entwine vertical and horizontal interventions in public health and combine a top-down and bottom-up organization of healthcare.

Integrating the particularities of socialist medicine in Eastern Europe, its continuities with and iterations of social hygiene, and health organization studies into a Western history invites us to reconsider what social medicine is on the whole. Along with rural health and the primary healthcare movement, Chinese barefoot doctors and Cuban medical internationalists, the inclusion of Eastern European socialist medicine is important.

Of course, more research is needed to see the changes over time in the approach of socialist medicine and the role and conceptualization of social medicine within, and to investigate, furthermore, how socialist medicine was represented by Eastern Europeans to the so-called Third World and how competing ideas of social medicine were negotiated and integrated into these interactions. This, hopefully, can eventually connect missing pieces that can provide us with a more comprehensive view of social and socialist medicine.