N.A. Semashko and his role in the development of the soviet system for the protection of motherhood and infancy

G.L. Mikirtichan
Saint-Petersburg State Pediatric Medical University, The Ministry of Health of the Russian Federation

The article describes the activity of the first People's Commissar of Health (1918–1930) Nikolai Alexandrovich Semashko (1874–1949) and his role in the creation of the state system for the protection of motherhood and infancy in our country. His contribution into attracting and engaging all persons concerned about the protection of maternal and child health, and the development of preventive care and dispensary observation, which is fundamental for pediatric prevention and treatment facilities, is shown. As a Chairman of the Children’s Commission at the All-Russian Central Executive Committee (1930–1936), N.A. Semashko worked hard on the problem of homeless and abandoned children. His efforts to develop the Soviet school hygiene (the field where he was one of the prime movers) and work relating to the improvement children’s’ health, as well as achievements and shortcomings of child care are described.

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Semashko (1874-1949) was one of those doctors whose job was difficult but very important – to create a national system of Soviet public healthcare and to develop its theoretical foundations and principles. He was the head of  the People's Commissariat of Health of the RSFSR from 1918 to 1930 – a body which had no analogue in any country of the world.

Since the beginning of the Soviet state, the healthcare of women and children was proclaimed to be one of the most important task. In the multi-faceted creative work of Semashko, the problems of maternal and child health (MCH) held a special place. All his speeches, decisions and actions regarding this issue ensued from one statement of his: "Maternal and child healthcare is a necessary condition for recovery of mankind." Well aware of the value of MCH for a young state, N.A. Semashko brought up three aspects of its development: political, "as it shows the most backward worker and peasant the real, living example of how Soviet government cares about their vital interests", social and economic "as a mother's health and the health of the next generation is the main basis for preserving the living resources of our country, and the living labor force is the basis of the existence of our worker’s Republic'', sanitary and hygienic, "as the health condition of the public must begin with mother and child". [1] He spent many years performing all these tasks.

The initial task of the healthcare system of the new state was to unite all medical matters into a single governing body. The Council of Medical Colleagues, established January 24, 1918, was the first to do this, followed by the People's Commissariat of Healthcare of the RSFSR (PCH), who continued “collecting medicine” according to the figurative expression of N.A. Semashko. It "was removed from the other departments and concentrated in the PCH. It was a matter of further historical development to assimilate departmental divisions inside the body and absorb departmental traditions in the course of work" [2, p. 11].

Pediatricians did not oppose proclamations of MCH as a state objective of the young Soviet Republic and nationalization of childcare institutions. This was due to the fact that, despite the widespread development of public and private charity, social assistance in pre-revolutionary Russia was not regular and could not cover all the needs of the population, as groups of people who had the right to get assistance were not specified at the state level, the sources of financing social assistance were not identified, and the responsibilities of government agencies and local government agencies and charities were not delineated. [3] This was due to the general political and economic situation in Russia at the beginning of XX century, characterized by growing political confrontation, wars, revolutions and emerging national crisis. In Western Europe during this period, as well as in Russia, public care and charity were based on the initiative of citizens and society. However, in such countries as France, Germany and England, there was greater state involvement in childcare.

Public initiatives aimed at fighting child mortality, including establishing various Russian societies and institutions for children, health education, smallpox vaccination, suppling children with quality milk, had little effect due to the precarious financial situation and ineffectiveness of these structures, as well as the lack of unity in their work. Existing measures could not mitigate the impact of severe social and economic conditions (low health rate, poor physical development and health culture of the population; malnutrition, uninformed methods of care and breastfeeding children, poor accessibility to health care, small MCH networks, lack of doctors and midwives, impossibility of implementing theoretical developments, especially in the areas of prevention, etc.), which was typical of poor people in many European countries. One advantage of Russia was that the countryside was organized in the form of zemstvos. Country doctors paid attention to the organization of shelters, day nurseries, education for orphans. Questions of charity for children in zemstvos were discussed at local congresses and in the press. Additionally, special committees were set up for organizing educational, healthcare and proper breastfeeding of children.

Despite significant scientific achievements in pediatrics and the energy and talent of many pediatricians, according to Russian historiography at the beginning of the XX century, a significant reduction in morbidity and mortality of children was not achieved. Thus the famous physician and statistician, P.I. Kurkin, quoted the following rates of infant mortality in the European section of Russia in 1901-1905: 263 out of 1,000 births, [4, p. 9] prominent statistician and demographerS.A. Novoselskiy pointed out that the infant mortality rate in Russia in 1908 was 24.4 ‰, in 1912 – 27.4 ‰ [5], even in Moscow the rate was 29.6‰ in 1910, 185 ‰ in 1913, in St. Petersburg 261 and 27.9 ‰ accordingly [6] The results of the comparative analysis of the data on infant mortality indicated that its level in Russia was higher than in European countries [7, 8]. Every year the country lost about two million children, with the highest percentage of deaths among children under the age of one. [9] Many of the children were physically undeveloped, child infectious diseases were widespread: tuberculosis, severe rickets, gastrointestinal diseases, diseases of skin and subcutaneous tissue, lung diseases. According to a study on the morbidity of babies under the age of one, conducted by country doctors of Moscow Province and generalized by P.I. Kurkin, in the early 1900s, the morbidity of boys totaled 1,485.1 cases out of 1000 children  [10].

More and more physicians and public leaders declared the need for state involvement in maternal and 

child protection: N.I. Bystrov,N.P. Gundobin, V.O. Gubert, D.A. Sokolov,P.S. Medovikov, G.N. Speranskiy, N.A. Russkih and others. [11]. Among them was the famous Russian pediatrician K.A. Rauhfus who initiated the establishment of the "All-Russian Guardianship of Maternity and Infancy", believing that the if the society was under the patronage of the imperial house, it would have a state character, greater rights, and most importantly, financial security. According to K.A. Rauhfus, the establishment of the Guardianship was to prove the fact of "Russia's fight against child mortality, and that maternal and infant protection were acknowledged as a matter of high national importance" [12].

Guardianship, which lasted for 4 years and 4 months during the country’s most difficult years in the First World War and the revolutionary upheavals, failed to fully fulfill its broad objectives. This was primarily due to a lack of government funding (the activities of the Guardianship departments was still dependent on public and private initiatives and in certain places it was based on charity), which contradicted the objectives of national importance previously established.

At the outbreak of the First World War, the category of the needy was expanded to sick and wounded soldiers, their families and refugees. However, it was the state, which represent them through central and local authorities that should have taken them under their care. It was then when the idea was established that social assistance to citizens who had fallen into poverty was not mercy or kindness, but the duty of the state and society. However, the harm, caused by the war was so huge, that many of the needy children could not get financial aid, clothes, food, and sometimes even a place in a shelter; crime and prostitution of minors increased, the number of the homeless was growing.

Many pediatricians got involved in the creation of the state system of the MCH under the auspices of the People's Commissariat of Health, using their own experience in the organization of care for mothers and children. They fought against child mortality and the forms and methods of various children’s institutions and health education methods, adapting them to new ideological, political and economic conditions. Experience in the organization of child institutions in the pre-revolutionary period was skillfully used in the creation of the Soviet System of the MCH. No less important was the union of various professionals interested in the MCH. Being the head of the PCH of the RSFSR, N.A. Semashko paid much attention to this issue. After the revolution, MCH issues were dealt with by different departments: commissariats of health, public charities, education, labor and others; this contradicted the general centralization plan, hampered the introduction of new institutional work regulations and monitoring of their implementation. 

Until the 1940s, child healthcare in the Soviet Union was divided into two branches – protection of  maternity and infancy (PMI), and protection of the health of children and adolescents. Accordingly, the age of children was the basis of this division.

The centralization greatly assisted the well know N.A. Semashko’s experience in Petrograd, where there was also scattered management of the MCH, but the health authorities played a leadingrole in the struggle for unity. After the Soviet government was transferred to Moscow (March 1918), the Commissar of Health of the Northern Commune, E.P. Pervukhin, and the Board of the Commissariat of Health, established the Council for the PMI. It lasted until 1921 and included pediatricians, lawyers, teachers, representatives of the Commissariats of Labour, Commissariats of Food and other interested agencies. The Council management in Petrograd conducted theoretical and practical developments of activities in the field of the PMI, which by order of the Council had to be united. This was the slogan of the Council. All institutions servicing mother and child had to be merged into one governing center [13].

The activities of the Council for PMI were approved by N.A. Semashko, as evidenced by the archival document of 1919: "Comrade Semashko and his business manager N.R. Freyberg reported that the Central Commissariat of Health had not yet been sorted out these issues and that these issues were the next to be discussed and that the work of the …. Council was not only authorized and approved, but was encouraged and would be further encouraged in the Center on and supported by all means"[14].

In 1919, with the reorganization of certain Commissariats in Moscow, there was a question about the distribution of childcare institutions between the Commissariats of Labour, Social Affairs and Healthcare. A corresponding order was obtained in Petrograd. It caused confusion and protest from the heads of the Health Department in Petrograd, as they had been putting all their efforts into merging all children's institutions with the health authorities.

In March 1919, E.P. Pervukhin sent the following telegram to N.A. Semashko: "Dear Nikolai Alexandrovich, due to the merger of the Commissariat of Social Services with Commissariat of Labor, the latter will also adopt the PMI department from the Commissariat of Social Services (St. Petersburg Social Services only had Drops of Milk). Thus our annual work is set and growing more and more. It will certainly collapse if we are deprived of the basics in the form of advice and Drops of Milk. Telegraph me, firstly, am I required to give everything to the Commissariat of Labor and, secondly, talk it over with Central and take it all from Moscow. Leave 

Drops of Milk under my jurisdiction instead of the Commissariat of Labor. We should not build any duplicate agencies or tear them apart, should we? All the best and I shake your hand. E. Pervukhin" [15].

The response telegram from N.A. Semashko ran as follows: "Commissariat of Healthcare. To Pervukhin. 

Stop the transfer of the child healthcare institutions to the Commissariat of Labor. The Center is discussing concentrating them in the People's Commissariat of Health. Commissariat of Health. Semashko" [16].

In Moscow, the Department of PMI of the Commissariat of Public Charity had been headed by V.P. Lebedeva since March 1918. She was also well aware of the fact that the success of PMI development 

depended on the concentration of all activities in one Commissariat, specifically, in the Commissariat of Health. However, it was not easy to achieve that unity. There was not even a sufficiently positive opinion of N.A. Semashko. Then, Vera Pavlovna consulted with Prime Minister V.I. Lenin, who supported her arguments about the concentration of all activities regarding PMI in the People's Commissariat of Health. The result of the collaborative effort was the transfer of all the agencies dealing with PMI to the public healthcare system in May 1920. The People's Commissariat of Health of the RSFSR the Department of PMI was established at this time;V.P. Lebedeva headed it until 1930. Based on her involvement, much was accomplished to establish the Soviet system of PMI [17]. V.P. Lebedeva managed to attract outstanding scientists, obstetricians and pediatricians, to work with the department of PMI. V.M. Velichkina-Bonch- Bruevich, A.I. Lagutyaeva, G.N. Speranskiy,A.A. Kisel, A.N. Rakhmanov, O.P. Nogina, E.G. Karmanova, M.S. Maslov, A.F. Tour, Z.O. Michnik, A.N. Antonov, M.G. Danilevich,E.L. Sklovsky and others were among the first active organizers of the MCH Soviet.They developed new ways of preventive and curative care under extremely difficult conditions of devastation.

In the 1920s, local nurseries, clinics, mother and child shelters and new staff training played leading roles in the work of the Department of PMI. Special courses on MCH and fighting child mortality were initiated for doctors. There werealso courses for nursery governesses who took care of infant children, training courses for personnel, organizers of MCH employees.

Healthcare objectives for older children were originally assigned to the People's Commissariat of Education and in 1917 a school hygiene department under the direction of V.M. Velichkina (Bonch-Bruevich) was instituted there. On July 11, 1918, the school hygiene department was renamed as the Department of Healthcare for children and adolescents, and it was taken over by the People's Commissariat of Health [18]. This department created systems of polyclinics for children, school-sanatoriums for handicapped children, establish the school doctor's goals, and developed methods to help children with mental and physical disabilities.

Thus, by 1921, MCH management had been brought under the control of the health authorities.

Due to the increasing number of institutions for children, the problem of insufficent skilled staff specialized in PMI became very acute. The courses lacked organizational coherence, different programs were used, and there were different periods of training. In addition, not all doctors understood the essence of the PMI system, or the importance of arranging wide spread social- preventive events; they associated maternity protection only with childbirth assistance and the protection of the infant, only with the treatment of children's diseases.

In 1920 this resulted in the organization of special PMY institutions of for training personnel of all levels, including postgraduate pediatricians, for studying the causes of child and maternal mortality and morbidity, and for developing the scientific basis for organizing medical and preventive care for women and children. By 1930, they had been opened in 8 cities of the country. A particularly important role was played by the Central Institute of PMI (Moscow, 1922, now the Scientific Center of Children's Health of the Russian Academy of Medical Science) and Practical Scientific Institute of PMI in Leningrad (1925, now St. Petersburg State Medical University). In the Central Institute of PMI, 500 doctors were trained in 1922-1930, and in 1925-1931 there were 1272 doctors trained in the Practical Scientific Institute in Leningrad.

Building the MCH system in those years was complicated by military intervention, civil war, devastation, famine, epidemics and lack of medical personnel.

Food for children was a particularly serious problem. In 1918-1919 N.A. Semashko would make speeches before the Council of People's Commissars (CPC) with reports on improving child nutrition. It was immediately followed by the adoption of the necessary proposals. On 14/09/1918 the Council of People's Commissars (the government) of the RSFSR declared child nutrition a priority and adopted the decree "On improving children's food". N.A. Semashko was entrusted with execution of this proposal. It was necessary to arrange meals for children from 5 to 16 years old in all schools, and where this was not possible, outside schools,for those who did not attend them. It took N.A. Semashko much effort and energy to successfully fulfill the directives of the CPC. On 04/02/1919 V.I. Lenin signed a decree "On the establishment of the Council of the protection of children". On May 4, 1919 at the plenum of the Central Committee of the All- Russian Communist Party (Bolsheviks), following the report of the chairman of the All-Russian Extraordinary Commission F.E. Dzerzhinsky concerning meals for children, it was decided to prepare a special decree; and on May 17, 1919, a decree of the CPC “On free meals for children", signed by V.I. 

Lenin, was released. Under this decree, all food products provided by local food authorities to children up to 14 years inclusive, were to be free (paid for by the state). Execution of all these instructions was the responsibility of N.A. Semashko [19].

Despite of the economic difficulties in 1920, in the People's Commissariat of Health and People's Commissariat of Education alone, 298,060 children able to get free food and 1,500,000 in the entire country. In the following years the number of these children increased.

In the early 1920s, N.A. Semashko signed a Decree of the People's Commissariat of Labor and People's Commissariat of Health of the RSFSR concerning measures of labor and health protection of nursing mothers (of 11.11.1920), a Decree of PCH and the People's Commissariat of Justice of the RSFSR on women's health protection (of 18.11.1920), under which abortion operations were allowed only in hospitals, and several others. According to the Decree some  funds were allocated for organizing maternity and child welfare centers, opening special clinics, forest schools and other institutions for children, especially for those with tuberculosis.

Then, the Peoples Commissar of Health published the decrees signed by N.A. Semashko in bulletins. They clearly indicated his attention to the issue of child protection and for organizing the breastfeeding, infant care, and adolescent healthcare measures. It contained medical directives concerning school children, measures to improve sanitary conditions in children's institutions, to combat childhood infectious diseases, summer work to improve health among preschool and school children, and about regulating school and extra-curricular activities of children.

The difficult political, social and economic situation in the country during 1921 was exacerbated by a poor harvest. 25 million people suffered from hunger, of which 8 million were children [20].

The loss of parents, their deaths, economic collapse, and refugee status spawned mass child homelessness during the First World War and the Civil War. This is evidenced by the theoretical and practical research on the problems of crime and homelessness of children by known lawyers, such as M.N. Gernet and P.I. Lublinskiy, teachers V.I. Kufaeva, E.S. Livshits, doctors L.I. Vasilevsky and N.A. Semashko himself and others. [21-25].

In the 1920s and1930s, there was collectivization, dispossession of the kulaks, repressions, deportations and labor conscription compulsory for all citizens between 16 and 50 years old (of April 10, 1919). As a result, women were sent to work, while their children were left unattended. Mothers were no longer involved in raising their children or looking after them. 

Often this was done in the streets. In addition, the Constitution of the RSFSR in 1918 introduced such a repressive measure as a disenfranchisement. Disfranchised by law were those people who used hired labor for profit, living on unearned income, the clergy, former police and gendarmerie officers, traders, members of the White Movement. Disfranchisement of a breadwinner automatically meant his family dependents were also disenfranchised. The disfranchised were not included in the food and goods supply system. The number of disenfranchised families and children was significant. The latter often became homeless children [26]. All this caused new waves of homelessness.

In the early 1920s, according to various estimates, there were between 4.5 and 7 million homeless children [27].

The end of the Civil War permitted active battle against child homelessness, which the country's government considered one of the most important tasks, systematically devoting significant effort and money to overcome it, constantly seeking for new effective ways to help children.

In 1921, a Commission for child living condition improvement was established in the All-Russian Central Executive Committee (also known as VTsIK, which was the highest legislative, regulatory and supervisory body of state government of the RSFSR). The Chairman of the All-Russian Extraordinary Commission (Cheka) F.E. Dzerzhinsky was appointed the first head of this Commission, since it was believed that such an acute social, political, educational, legal, medical and hygienic problem could be solved only by a sufficiently authoritative organization, vested with large powers and special authority, appointed by the Revolution to crush resistance to the new government. The Committee included representatives from the Commissariats of Education, Health, Food, Workers and Peasants' Inspection, All-Union Central Council of Trade Unions and the Cheka. 

Assistance was provided by trade unions, party organizations, the Soviets, the Komsomol, the pioneers, women's departments. Accounting for the homeless was also done by the police, criminal investigators, transportation departments and other organizations established for social and legal protection of minors. F.E. Dzerzhinsky wrote: "Child homelessness, which often reveals itself in the ugliest, exhausting forms, as well as juvenile delinquency, prostitution, and threatens the younger generation with the most severe consequences and makes us anxiety- ridden" [28].

N.A. Semashko, from the first days of the Commission’s establishment, was actively involved in its work. Due to his authority, the Commission was able to coordinate the work of different departments and agencies in a short time. 

Organizing regular aid to the starving children demanded intensive work from the Children's Commission, which was conducted in two basic ways: the evacuation of children who were not suffering from hunger into the province, and helping children on the spot. Canteens and meal stations were established for children aged from 6 to 15 years old who were not in school. Mass transportation of children from starving areas to more prosperous ones was begun.

Providing residential care for children and adolescents was the basic form of combating homelessness. A huge network of orphanages was urgently spread throughout the country. Reception and assignment centers were created, whose task was to provide first aid to homeless children, preparing them to join organized groups and distributing them to permanent establishments. In reception and assignment centers, children were kept under the supervision of teachers and doctors for up to four months. During this time, they were sent to children's institutions of permanent residence or employed, and sometimes returned to parents or relatives. In different areas, extracurricular activities with children were organized: the homeless were engaged in school activities, clubs, and amateur performances; there were halls of residence made for single mothers, who also got one- time financial assistance. By the beginning of 1925 in the Russian Federation about 200 labor communes for teens had been founded. The most famous of these was the commune named after A.M. Gorky, organized by A.S. Makarenko near Kharkov.

Fighting homelessness was difficult because of the very poor conditions in orphanages: a lack of qualified workers, food, linen, and on top of everything, there was no money. Because of this, the Children's Commission together with PCH and PCE organized "weeks for children", "weeks for a healthy generation", "and weeks for homeless and sick children". During these "weeks" lectures were given, talks were organized, articles in periodicals were published, as were bulletins and special newspapers (N.A. Sematic often lectured himself), funds were raised, clothes were collected, Saturday events were organized.

For example, on April 30 – May 6, 1923 the Week of Homeless and Sick Child was declared, where cash payments were made everywhere, plates were passed in Moscow theaters, and about 10% tax on buffets revenue was collected.

In 1925, due to the law of the Virk and the People's Commissariat of Education of the RSFSR "On the organization of the case to combat child homelessness" an adoption campaign was started in the country to reduce overcrowding in orphanages. In order to reduce the influx of homeless children from villages, assistance was provided; they were employed, provided patronage and guardianship. In addition, children from orphanages were actively provided assistance and taken into collective farm families.

The results of the persistent work of the Children's Commission of the Virk were obvious. The number of street children was steadily decreasing [29]. If in 1925, according to the official data, there were 343,329 of them, in 1926 there were 123,307 and in 1927 there were 109,761.

After Dzerzhinsky's death, the "Commission for improving lives of children" was headed by N.A. Sematic (1930), who provided great effort. He often involved different departments, public organizations, prominent teachers and doctors in the activities of the Commission. He vigorously put into practice a series of radical measures aimed at the elimination of child homelessness (which was made a main objective in 1931). A significant impetus to work improvement was the November 20, 1930 decision of the Presidium of the Virk for combating child homelessness, adopting the report of the Child Commission of the Virk and PCE of the RSFSR. That resolution was the first to clearly identify the responsibilities of various departments in this area of work, to clearly raise the issue of improving the work of orphanages, the first to draw attention to organizing workshops in orphanages and homesteading as powerful factors for labor education of children.

One of the main objectives of the Child Commission was to improve conditions in orphanages. 

Because of malnutrition, children suffered from anemia. N.A. Sematic fought for the establishment of supply regulations and demanded that those rules be observed everywhere. He often wrote that there was no segregation in orphanages: juvenile offenders were held togetherwith ordinary children, healthy children – with sick ones. That was one of the main reasons for children's fleeing from orphanages.

N.A. Semashko considered labor education of homeless children to be the primary goal in eliminating homelessness He strove to attach each orphanage to a factory or a collective farm, rightly believing that this connection would play a huge role in shaping the Soviet man. In 1935, the number of these adolescents (boys and girls) in child commission establishments was about 15 thousand, including those in Child Commission establishments of the VTsIK was 866 people. All those teens, in addition to studying production processes, also went to school [20, p. 297].

In 1936, N.A. Semashko wrote that collective farms had about 40 thousand children under the guardianship of peasant families. "This is a very complicated and difficult job. Guardianship must necessarily be carried out on a voluntary basis. Children taken to collective farm families under guardianship grow into collective farm families, become members of families, get used to work and receive a proper education. Such children must be watched closely to ensure that they receive proper education, attend school, so that they do not become part of families where education can not be provided" [20, p. 299].

Much effort and initiative was shown by N.A. Semashko in the organization of medical care for street children. He initiated the creation of a number of new hospitals and organization of health activities for them. In 1932, the Child Commission funded a clinic for crippled children in Moscow and in 1935, an institute for crippled children near Moscow was established ("Peredelkino" station). Its aim was to provide sanatorium and resort care to the residents of orphanages. The Child Commission rented a sanatorium in Simeiz from PCH. Orphans suffering from bone tuberculosis, were sent to the clinic of prof. G.I. Turner in Leningrad and to the children's sanatorium in Alupka. The Child Commission funded a clinic for children suffering from rheumatism in Moscow, sanatoriums in Leningrad, Gorky, Ufa and other cities; an orphanage for difficult teenage girls, former prostitutes, was established and equipped near Moscow ("Stolbovaya" station). [27] The Child Commission funded assistance to children leaving orphanages, leaving to study and starting work. The graduates needed to be dressed, provided bedding, housing, etc.

N.A. Semashko treated children with great warmth. He knew how to talk and get along with them, how to entertain and motivate them. In the office of N.A. Semashko, one could often see the following: on the big leather couch, huddled together, there were sitting ragged teenagers and with them – N.A. Semashko. He was interested in their lives and interests, "maintained close ties with many members of orphanages and labor communes. He corresponded with the people from Rosniansky orphanage, from the first agricultural commune of North Ossetia, from boarding homes in the Far East and Siberia, from labor communes of Ukraine and Crimea; Nikolai Alexandrovich rejoiced when his wards, former street children, went out on the bright road of life and became exemplary hard workers!" [30].

The PCH and PCE increased number of orphanage workers and employees for building children’s homes. Thus, in 1926-1927, 9 million rubles was spent on fighting child homelessness. [31]. 

Incomplete estimates show that the Child Commission of the VTsIK and local child commissions spent approximate 240 million rubles of their funds on child protection [20, p. 297].

The great work of N.A. Semashko for health protection and assistance of street children was highly valued by the government. On 20.07.1936, he was awarded with the diploma of the Presidium of  the VTsIK, which stated: "... Being one of the oldest workers of the Child Commission of the VTsIK, you deserve sincere respect from the general Soviet public as a friend and protector of children" [27].

In the mid-1930s, the massive child homelessness and neglect was essentially over. Millions of children had beensaved from starvation, vagrancy and gotten their start in life. Annually, about 12-15 thousand children left orphanages. Nikolai Alexandrovich wrote: "There are no more street children in the truest sense of the word, that is, those children whom we could not give “attention”, i.e., shelter and education" [32].

In 1935 a regulation was adopted by the Council of People's Commissars of the USSR and the Central Committee of the All-Russian Communist Party (Bolsheviks) "On the elimination of child homelessness and neglect". This regulation announced the elimination of homelessness and neglect in the USSR, and as a result of its publication there was closure of most organizations whose activities were aimed at combating child homelessness and crime. The People's Commissariat of Internal Affairs a Division of Labor Colonies was established. It organized reception and assignment centers, isolation wards and labor colonies for homeless and young offenders [33]. In the beginning of the 1930s an extensive network of agencies was created and operated. It solved socialization problems, starting from the detection and registration of adolescents in need of social assistance and certain preventive measures, until going to foster care after having served their sentences. After the resolution, this policy towards children changed. There was a change from social education to repressive measures and there was a complete rejection of the idea of transition to comprehensive public education of minors. 

Thus, the problem that the Soviet state had been trying to solve flared up again [34]. On 25.08.1938, the Child Commission of VTsIK, having fulfilled its duties, was eliminated. Despite all the measures taken and some reduction in the total number of neglected minors, this negative social phenomenon was not completely eliminated. The problem had not lost its relevance.

Despite an extensive legislative framework, the government did not manage to develop a clear focused program for the elimination of this issue. The primary emphasis was on issues of class, not the real struggle with homelessness. A coordinated teamwork of state agencies in this field was not organized, nor was a single central authority created. The problems of financing childcare institutions were not solved, there was an acute shortage of qualified staff and caregivers in orphanages. Staff turnover also played a role in this; the educational level was low. The material and technical base of institutions was extremely unsatisfactory. When establishing custody for guardianship, there were no institutions which would monitor custody, which often led to a deterioration in the quality of life for minors and their return to orphanages.

N.A. Semashko's activities in the field of child education and healthcare began when he worked as a medic in Nizhniy Novgorod, and then a doctor in a school for children of Russian political refugees on the outskirts of Paris. In that school he was not only a doctor but also a teacher: he taught history and geography. Combining the work of a doctor and a teacher laid the foundation for the multi-faceted scientific and teaching work of N.A. Semashko, which he did subsequently at the Academy of Pedagogical Sciences (APS). This included his views on the problems of school hygiene. With great responsibility and love, N.A. Semashko did performed another duty: he was a Director of the State Children's Literature  Publishing House ("Detgiz"), organized in 1933 [35].

In 1922 N.A. Semashko organized and headed the department of social hygiene at the medical faculty of Moscow University. It is here that the Soviet school of hygiene was started and began to develop. In 1926 he established the Department of School Hygiene of the Ist Moscow Medical Institute, which is separated from the Department of Social Hygiene. It was headed by ProfessorA.V. Molkov. The Department of School Hygiene developed the basic ideas of N.A. Semashko – the founder of the Soviet school hygiene.

During the long years of his scientific and social activities N.A. Semashko published more than 200 works, 32 of which were devoted to school hygiene. He defined the school hygiene the following way: 

"This is a hygienic discipline that studies the influence of different conditions on health of children and adolescents and develops measures to improve health of the younger generation" [36].

Unlike other hygienic disciplines, school hygiene, as N.A. Semashko claimed, studies all aspects of life and activities of the child; it is a complex hygienic science. It uses data from municipal hygiene (planning, construction and improvement of schools), food hygiene (baby food), labor hygiene and epidemiology. Based upon this premise, N.A. Semashko developed views on school hygiene as a medical discipline that is closely related to physiology, morphology, psychology and pedagogy.

For the scientific development of health problems in older children, the State Scientific Research Institute of Child and Adolescent Health Protection of the PCH of the RSFSR (now Pirogov Russian National Research Medical University (RNRMU) of the Russian Ministry of Health) was founded in Moscow on October 1927. Later, similar institutions were founded in Leningrad (now Scientific Research Institute of Child Infections of the Federal Medical and Biological Agency of Russia), Gorky, Kiev, Kharkov, Novosibirsk, Rostov-on-Don and others.

The following physicians and hygienists took part in the formation of the Soviet healthcare system of children and adolescents and school hygiene: D.D. Bekaryukov, A.G. Zeitlin,L.A. Syrkin, A.Y. Gutkin, S.S. Poznanskiy,E.P. Radin, N.A. Glagoleva and others.

One of the main requirements of N.A.Semashko was to have a doctor in every school. His work "Basic issues of school hygiene" (1949) included the requirements of a school doctor. According to him, school doctors had to be a pediatrician and a hygienist in a broad sense, they had to know all the branches of hygiene and had to be able to use the data of all the hygienic disciplines in their work. They had to intervene in the school day schedule in terms of hygiene, pay attention to the alternation of difficult and easy lessons and breaks, how food is organized in school, participate in drafting programs, preventing them from being overloaded [37, p. 213].

N.A. Semashko was proud and happy when the Institute of School Hygiene was founded in the Academy of Pedagogical Sciences. He said: "The Institute was built and is now run as a new type of establishment, which has never existed in Russia before and which does not exist anywhere abroad. We had institutes of child and adolescent healthcare. They performed well in the healthcare system. But issues of pedagogy related to the teaching process remained unenlightened. The new institute is biased towards pedagogy, which is clear. That is why from the moment of its foundation, the main defining role in the structure of the institute was played by two branches: sanitary-hygienic and physiological" [36, p. 200].N.A. Semashko headed the institution from 1945 to 1949.

Based on the initiative of N.A. Semashko, the Institute of School Hygiene in the Academy of Pedagogical Sciences in 1946 held a questionnaire survey of various areas in 114 schools; the number of students surveyed was 86,619. Shortcomings in medical and sanitary work of schools were revealed. In order to eliminate them, on 07/15/1946 The Ministry of Health issued a decree "On the improvement of health services for schoolchildren and kindergarten children in towns", which caused a dramatic change in medical help for schoolchildren. This order entrusted special school doctors with school caretaking. It was recommended that a comprehensive plan for recreational activities in children's institutions be developed. An important provision of the decree was an order to take into account 7 year old chronically ill and physically impaired children, since they require special attention because of the switch from the kindergarten schedule to the school schedule.

The achievements of N.A. Semashko in the field of school hygiene research were acknowledged by the government: in 1945 he was appointed a full member of the USSR Academy of Pedagogical Sciences.

In 1923 N.A. Semashko was appointed the first chairman of the Supreme Council of Physical Education of the VTsIK of the RSFSR. He worked successfully there, as in his other positions. He emphasized the preventive value of physical education and believed that the concept of "physical education" was close to the notion of "physical recovery", he encouraged the widespread use of physical education for the training and education of the younger generation, its harmonious development. His remark that the main goal is not records but health remains true. He talked about injury prevention, good sanitary and hygienic conditions of sports facilities, load control during exercise and sports, which was to be carried out by qualified doctors and physical education teachers [38].

The name of N.A. Semashko is associated with the development of ideas and implementation of prevention of illnesses in Soviet medicine. "Prevention is a branch of Soviet medicine; clinical examination is the method by which it is carried out", wrote N.A. Semashko. [39]. He understood prevention in narrow and broad sense: in narrow sense, as a sanitary measure, broadly, as rehabilitation and disease prevention. According to N.A. Semashko, the task of every doctor and of the entire system of medical institutions, was not only to cure but also to prevent disease, which was seen as a consequence of adverse social conditions and poor lifestyle. An important measure of prevention, in his view, was vaccination which was all-national for the first time. This helped to eliminate many infectious diseases, and promote healthcare, which was one of the primary means of preventing epidemics and encouraging a healthy lifestyle.

One of the most important achievements of N.A. Semashko was guidance and participation in the development of the principles of Soviet public healthcare: qualified medical care had to have a public nature, a preventative character, be free of charge and available to everyone; there had to be a unity of theory and practice, public participation in matters of health. All these things are important for pediatrics and MCH, but apparently, in no field of medicine is prevention as important as it is in pediatrics. This direction and method helped to significantly improve the health of children and to implement systematic monitoring of healthy and chronically ill children.

In 1942, N.A. Semashko published an article in the journal "Pediatrics” where he listed the tasks which pediatricians faced in wartime: care of the families of soldiers; special monitoring of families who had adopted children, and the full support of this patriotic endeavor; prevention of infectious diseases in childcare institutions; uninterrupted operation of childcare facilities; strict staffing requirements; thorough training and supervision of the work [40].

At the end of 1945, after having been appointed the head of the Commission on the elimination of  sanitary consequences of the war at the Presidium of the Academy of Medical Sciences, N.A. Semashko emphasized the need to study the influence of the Great Patriotic War on the reproduction of the population in Russian, on the morbidity and mortality of children and adolescents, stillbirth and premature birth, on the physical health of children in urban and rural areas [41]. He organized five conferences where prominent clinicians, hygienists and public health policymakers discussed ways of 

post-war reconstruction of the country and the speedy elimination of the medical consequences of the war.

Semashko made mistakes on his way to the creation of  the Soviet health care system in those most difficult years for the country. He wrote about this himself: "A lot of achievements as well as mistakes have been made on the new way. ... We have lived through the difficult years of the country's defense against epidemics. ... We have laid only the foundations for proper organization of public medical care. We have only found the right way to recovery.... We have received only the first results in terms of a significant reduction of epidemic illnesses and the complete elimination of some of them: in terms of a dramatic fall in overall and particularly infant mortality, in terms of the spread of sanitary habits among the population, in terms of physical education of the young, of a healthy generation. But these have been our first steps only. There is still a long and difficult way ahead, to struggle for sanitary culture, which is now linked with the general principles of the Cultural Revolution "[2, p. 116].

In his 1923 article, N.A. Semashko summarizes 5 years of struggle for mother and child, where he compares the care of them with a gentle tree. "This tree has lived through years of the toughest ordeals, through the storms of life and the bad weather. This is not a hothouse plant, cherished under glass in a greenhouse. This is an oak battered in revolutionary storms, firmly rooted into the soil of the republic of labor. What gave the strength to this organization not to fade, but grow in a hail of enemy bullets in the past difficult years? Only two things: 1) the selfless dedication of the leaders of the work at the center and in local institutions, and 2) an active part, energetic help and persistent protection on the part of the public itself" [1, p. 201-292].

In his last major work, "Essays on the theory of the soviet health care organization", and in chapter VI "Maternal and child health," N.A. Semashko shows the achievements in this field, emphasizing that in the USSR there was a thought-out, organized state system of health protection of mother and child with an extensive network of medical, preventive and health agencies: prenatal clinics, maternity hospitals, maternity and child welfare clinics, nurseries, kindergartens, baby clinics, hospitals, sanatoriums and resorts. Therefore, the entire life of the child is looked after and protected, starting with his prenatal state to adolescence [42].

The principles of unity of curative and preventive work, dispensary method and district maintenance were included in the activities of institutions for women and children. Quite good results were achieved in overcoming traditional infectious diseases, a dramatic decline in maternal and infant mortality, and in the prevention of social diseases and health education.

The progress which the MCH made in the prewar period was obvious. State support, community involvement, the responsibility and enthusiasm of pediatricians contributed to it. However, not all of the task performance succeeded. Despite the rapid growth of institutions for women and children, it was not sufficient for a vast country with a high birth rate. Specialized and skilled care was provided to children only in large cities. And, finally, the number of doctors who had received special pediatric education, who could carry out preventive and therapeutic work as full and high level was not enough. However, the forms and methods of work created in those years, contributed to the organization of help and saved lives of children during the World War II and the postwar period. In 1978 at the Alma-Ata World Medical Conference, the world medical community acknowledged the unique organization of the MCH in Russia, the principles of medical and sanitary care were highlighted as a model for the member countries of the World Health Organization. This was due to considerable contribution of Nikolai Alexsandrovich Semashko and his associates.

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