Hospital provision in interwar Central Europe: a review of the field

ABSTRACT

This article provides a comparative assessment of the provision of hospital services in interwar Central Europe. It presents the findings of a project to review the primary and secondary sources available for the study of healthcare in Czechoslovakia, Poland and Hungary 1918–38 and to provide initial conclusions about how these new states embarked on the task of constructing an institutional infrastructure. The historiographical and archival review demonstrates some of the problems inherent in comparative history, especially the diverse, and often patchy, range of sources available. Building on this it explores three themes: provision and growth of the hospitals of each nation; the impact of geography, especially urban and rural and western and eastern divides, on that infrastructure; and the modes and problems of funding institutional care. It considers the problems each nation faced in constructing a new national healthcare system out of two or even three existing modes of delivery and the barriers faced by largely rural nations when attempting to construct and fund a modern institutional infrastructure.

KEYWORDS:

• Hospitals
• Healthcare
• Central Europe
• Poland
• Czechoslovakia
• Hungary

This article offers a comparative history of hospital provision in three post-imperial states in early twentieth-century Europe: Poland, Hungary and Czechoslovakia. It adopts this approach to a theme and a location rarely explored by historians of medicine. National histories are deep, but they are also unique: comparing and contrasting tests the peculiarity of the local and in the process encourages new ways of thinking about problems in the past. In approach and structure, this article is inspired by Ilana Löwy’s 2007 article in Social History of Medicine, which gives us an important blueprint and justification for pursuing comparative history – despite its many challenges. As she notes, the key benefit of comparative history is the way it can create new understandings of established national stories and broaden our awareness of similarity and difference:

Trans-national comparisons may display unexpected differences and/or surprising similarities; questions initially studied in one context can acquire a different meaning when transposed to another situation; a juxtaposition of developments in several sites can provide information impossible to obtain in single-site studies. To sum up, comparative studies can open new questions on interactions between medicine and society, and deepen our understanding of already existing ones. They can also help to make the social history of medicine more stimulating, intriguing and enjoyable.¹

To date, medical historians have been slow to respond to Löwy’s call for more comparative history of healthcare provision. Undoubtedly the last 20 years have seen a flourishing of national research into medical institutions, especially in Britain, and, to a lesser extent, in North America and Western Europe.² The first key theme emerging from this research is how to measure the scale of hospital provision and its growth over time – although less has been said about different types of hospital and how these developed.³ The issue of provision is intimately connected to discussions of who controlled these institutions, in particular the role of the national state, local authorities, charity and philanthropic organizations, business and religion. The balance between these sectors varied across nations and between different types of institution and patient.⁴ The second theme to emerge from national historiographies is spatial distribution, especially the differences apparent between town and city; urban and rural; and core and periphery.⁵ The third theme, and the one which has dominated recent national historiographies, is finance. Closely linked to both who owned and who could access a hospital, the funding mix varied from nation to nation with a commensurate impact on who received treatment.⁶

These national stories are only gradually being filled out by comparative studies. There has been a growing literature comparing health systems, especially from Martin Gorsky,⁷ while George Weisz has made a major contribution by examining both health professionalization and the structures of chronic care in the United States, Britain and France.⁸ Comparative explorations of welfare, including health, have received the attention of E.P. Hennock in relation to Germany and England and Paul Dutton on the United States and France.⁹ However, there has been relatively little work focusing on hospitals – with Gorsky again assessing differences in financing in the UK and the United States, and Doyle analysing provision in early twentieth-century England and France,¹⁰ while Pérez has made a very significant contribution that offers a global comparison of hospital management in the late nineteenth and early twentieth centuries. Utilizing the ideas of Taylorism, she examines the application of new systems of control across the hospitals of Europe, the United States, Latin America and Russia, culminating in a case study of the city of Barcelona.¹¹ These integrated comparisons have been supported by a growing number of collections that bring together national studies connected by theme and editors’ introduction. Works like Crossman and Lucey, which includes chapters on Britain and Ireland and the UK and Dominions,¹² Gorsky, Rodriguez and Pons on the political economy of the modern hospital, with its chapters from Europe, North and South America and China, and the special issue of Business History examining the business of healthcare in a global context, edited by Donze and Perez,¹³ offer side-by-side comparison of national cases shaped by a common concern.

But why is there not more comparative history? In the main it is because comparison is difficult. Doing good history depends upon a sound knowledge of the topic and the place and acquiring those for more than one location is a challenge. This is compounded when the comparison requires a mastery – or at least a working knowledge – of a second language or even a third. This project sought to meet these challenges by employing early career researchers with the language skills and background knowledge of the nations under examination to work on a brief set by an experienced historian of hospitals. Initially prompted by the relative paucity of comparative research into health services it aimed, in particular, to ascertain the current state of research into hospital history in Central Europe between the wars to enhance the team leader’s work on France and England. It aimed to identify the current state of knowledge on interwar institutional provision in Poland, Hungary and Czechoslovakia, to survey archival and contemporary published sources and to identify key issues for research. These nations were chosen because they provided an opportunity to explore how post-imperial nations managed the healthcare legacy of their imperial predecessors as well as how they utilized healthcare in nation building. They were also deemed important and relevant as there has been relatively little research published in English on their health services before the Second World War. The focus of the fieldwork was on creating a bibliography of work published in the study countries about their hospital services and a sampling of the archives to identify a broad spread of sources and source types. This included collections in the respective national archives and a range of city and county level repositories with the aim of ascertaining the kinds of archive collections available and how these can help us understand how the different hospital systems functioned. The project also made use of the International Health Yearbooks of the League of Nations from the 1920s as well as published material from the International Labour Office¹⁴ and the International Health Board of the Rockefeller Foundation.¹⁵ However, these sources have been more widely used in another project article.¹⁶

Poland, Czechoslovakia and Hungary emerged from the collapse of Europe’s mainland empires at the end of the First World War. Two (Poland and Czechoslovakia) were victorious nations; one (Hungary) had been defeated. In the case of the former two states there was a need to bring together different systems, ethnicities and social and economic cultures, while in the latter the issue was coming to terms with significant spatial and economic reduction. Czechoslovakia was broadly stable and democratic (or so the standard historiography suggests), and Poland politically fairly stable but autocratic, but in Hungary, a right-wing autocracy installed itself fairly quickly after a failed socialist revolution.¹⁷

The historiography of Central European health extant in English was, indeed, limited. The main focus was in four areas: international agencies, in particular the Rockefeller Foundation¹⁸; eugenics, especially in the case of Hungary and Romania as explored by Marius Turda¹⁹; a growing body of work coming out of Central European University covering specialist health interventions, in particular the ‘social diseases’ that dominated health thinking between the wars²⁰; and an expanding body of work on the Socialist era, especially psychiatry.²¹ There has been little comparative work on the general health of these nations and nothing assessing their hospital provision in a national or international context.²² This article will address some of these gaps by providing a survey of the current historiography of interwar healthcare in the region, and especially hospitals; a brief overview of archival holdings; and, drawing on Lowy’s methodology, three case studies. As identified earlier, these will explore: the provision and growth of hospitals; geographic disparities; and the financing of institutions.

Historiography

A key objective of comparative history and one of its biggest obstacles is accessing and understanding the historiography of a range of countries, especially if they are produced in diverse languages. This section will highlight some of the key features of the literature on interwar health services, and especially hospital provision, in our three nations.

The history of medicine in the Czech Lands has always been a small and specialized area of study, written largely by medical professionals and focused on medical specialities and leading practitioners.²³ The arrival of the Communist regime in 1948 saw the introduction of censorship, thus effectively putting historical writing during much of the next 40 years at the service of official state ideology.²⁴ This was especially true of Soviet studies of the interwar democratic period which emphasized social inequality and working class exploitation, the inequities of interwar sickness insurance, and the assistance given to Czechoslovakia’s public health by the left-leaning, internationalist Rockefeller Foundation.²⁵

The history of healthcare and hospitals in interwar Czechoslovakia expanded with the end of Communism in the late 1980s, leading to a diversification of topics and an increase in regional studies and individual institutional histories.²⁶ In the following two decades, notable contributions were made by Ladislav Niklíček, focusing on sickness insurance, as well as by Ludmila Hlaváčková and Petr Svobodný, charting histories of medical faculties and hospitals in Prague along with ‘the first modern comprehensive Czech history of medicine’ in 2004.²⁷ The break-up of Czechoslovakia in 1992 fuelled the production of separate national historiographies, including Anna Falisová’s work on the history of interwar Slovak hospitals.²⁸ However, it is Hana Mášová who dominates the history of interwar healthcare. Her textbook, The Issue of Hospitals in Interwar Czechoslovakia (2005), provides a general overview of the institutional healthcare system, while her other contributions have ranged across healthcare policy and reform, regional differences, prominent hospitals and influential medical personalities.²⁹ Another important strand of research has examined the involvement of the Rockefeller Foundation in Czechoslovakia, where the organization co-financed the State Health Institute and other public hygiene and research initiatives.³⁰ Czechia has no scholarly medical history periodicals, with most contributions appearing in Dějiny věd a techniky, the journal specializing in the history of natural sciences and technology. Although contributions in English by Czech medical historians have been limited, Svobodný and Mášová have recently reversed this trend.³¹

Modern Hungarian medical historiography was institutionalized in 1951 with the establishment of the National Medical History Library, its periodical in 1955, and, further still, with the formation of the Hungarian Medical History Society in 1966, which still runs the Hungarian Medical History Library, Museum and Archives.³² As elsewhere in Central Europe, current medical historiography is dominated by biographies of famous doctors, and an extraordinarily strong field of military medical history. Yet, some excellent research has been completed in the social history of medicine in recent years, especially by Lilla Krasz, who has produced an important body of work on obstetrics and maternity in eighteenth-century Hungary.³³ Reflecting the situation in other nations, the history of hospitals is a limited field, largely restricted to centenary and jubilee histories. There are excellent publications relating to the social history of public health and to the growth of insurance systems, especially the work of Béla Tomka and Tomasz Inglot, but they do not focus on the development of hospitals per se.³⁴ This work is extended by the research of Zoltán Cora in this special issue.³⁵

The literature on interwar Polish hospital systems leaves much room for development. Monographs on the topic are very sparse, with just three general histories, one of health care and two of public health, each with a chapter dedicated to the interwar period.³⁶ There are also histories of hospital systems in Warsaw and health care in Łódź that cover several centuries up to 1945.³⁷ The majority of published research on interwar Polish healthcare and hospitals is found in scholarly journals, among which two dominate: Archiwum Historii i Filozofii Medycyny (Archives of the History & Philosophy of Medicine) published by Polskie Towarzystwo Przyjaciół Nauk (Poznań Society for Friends of Science) and Archiwum Historii Medycyny (Archives of Medical History) published by Polskie Towarzystwo Historii Medycyny i Farmacji (Polish Society of Medical and Pharmaceutical History). The former includes local case studies of hospitals and healthcare, physician biographies and articles on the development of medical and nursing education, while the latter publishes more bibliographies, and articles on sources and developments in the field of medical history.³⁸

The local case study dominates the historical scholarship on Polish hospital developments for the interwar period. Białystok and Łódź have received the most coverage, followed by Warsaw and a smattering of other smaller cities.³⁹ One recent trend that shows promise is a focus on hospital care in Poland’s less developed Eastern borderlands.⁴⁰ A second trend relates to Jewish contributions to Polish medicine. Coverage of these topics is found mainly in the Biuletyn Żydowskiego Instytutu Historycznego w Polsce (Bulletin of the Jewish Historical Institute), based in Warsaw, and Polin: Studies in Polish Jewish History, based in Liverpool, as well as a handful of book-length publications.⁴¹ Unfortunately the two literatures – Polish and Polish-Jewish – remain very separate and have not been put into conversation with one another.

Archival sources for hospital history

As is the case in almost any country before the Second World War, national archives contain relatively little about the operation of hospitals, though rather more about their funding and policy environment. To analyse the day-to-day operation of hospitals we need to look to the local archive and the records of individual hospitals and their governing structures. Equally, to interpret national policy and its change over time we need the commentary produced by professional associations and interested observers through the wide range of national and international journals they produced across the interwar years.

Czechoslovak Ministry of Healthcare and Physical Education records deposited at the National Archives of the Czech Republic in Prague contain material of varying depth and substance.⁴² Whilst some collections cover a wide range of aspects of hospital provision in detail, others are more fragmentary, thus limiting opportunities for accurate comparison. The collection contains material reflecting contemporary public health concerns such as the battle against infectious and ‘social diseases’ (tuberculosis, venereal diseases, alcoholism and infant mortality) along with other information on the consolidation of hospital administration and control, especially financial oversight.⁴³ The latter includes: inspection reports and financial audits, budgets and accounts; performance-focused statistics and staff records; subvention requests and applications to refund uncollected treatment fees; and detailed building programmes and plans. Information on state hospitals, under the direct control of the Ministry, is more extensive than that for municipal or private institutions.⁴⁴ Also included are records providing an insight into day-to-day hospital operations such as patient records, photographs and complaints that shed interesting light on local conditions, as well as other correspondence between the locality and the centre in Prague, for example, in relation to the service in Subcarpathian Ruthenia.⁴⁵

Similarly, the collections in local archives vary in extent. For instance, while the holdings for St Elizabeth Women’s Hospital Na Slupi in Prague include medical reports and personal health records, receipts for treatment, some handwritten statistics, correspondence between patients and the hospital, and contemporary documentary material, the material is incomplete with uneven time coverage.⁴⁶ On the other hand, the extensive records for the Baťa Works Hospital in Zlín provide a much fuller picture. The collection includes individual building plans and health statistics, hospital finances and patient records, along with specialist publications by the hospital’s medical staff and other contemporary material, reflecting the ambition of the project from its conception in 1926 through to its expansion in the later 1930s.⁴⁷ In addition to these archival resources, the publication of specialist periodicals burgeoned during the interwar period, especially following the consolidation of Czechoslovakia’s administrative system in 1928. Most notably, Československá nemocnice (Czechoslovak Hospital Journal) was at the forefront of wide debates on the modernization of the national hospital system.⁴⁸ These culminated in the publication of the ground-breaking Albert-Trapl Plan of 1933 that envisaged hospitals as both curative and preventative healthcare institutions.⁴⁹

For Poland, the archival sources were less extensive. Significant war damage in Warsaw led to the destruction of much of the routine government level material found for Czechoslovakia and Hungary. What has survived in the Archiwum Akt Nowych w Warszawie (Modern Records Archive, AAN) is predominantly focused on dealing with infectious and epidemic diseases, especially in the east, as well as with building an infrastructure to tackle social diseases like tuberculosis. For example, there are details of the TB pavilion and Infectious Diseases institution in Galicia and a quarantine hospital near the port of Gdynia.⁵⁰ There are also important reports on the development of the health centre system, including funding details, along with other significant material on healthcare finances.⁵¹ But the richest sources are the proceedings of regional medical societies, such as those in Krakow and Vilna, which provide both information and opinion on the workings of the hospital system on the ground.⁵² Finally, there are some reports on the hospital system in specific localities, particularly Warsaw.⁵³ Regional archives do offer more in terms of sources for the operation of Polish hospitals. The regional archive in Łódź holds an extensive collection relating to the Anna Maria children’s hospital, including minutes, correspondence and accounts⁵⁴ while the archive at Katowice contains reports on hospitals in Silesia, including data on medical staff and an intriguing survey of opinions on the nursing staff.⁵⁵

Unlike Poland, where wartime destruction has left little pre-war material in the central repositories, the Hungarian National Archive is better stocked. The collections of the Ministry of Public Welfare and Labour, the Ministry of Interior, and the Ministry of Education and Religious Issues hold a wide range of material relevant to the highest level administration of public health. However, since all public hospitals were run by municipalities or county administrations in the interwar period, local branches of the National Archive are much more relevant for the study of Hungarian hospital history. For this study we explored four local collections: the Budapest Metropolitan Archives (BFL); the Szeged and Hódmezővásárhely Municipal Archives in Csongrád County (CSML-SZL and CSML-HL); and the Mosonmagyaróvár Municipal Archives (GYMSML-ML). In all the archives we visited the archivists stated that we were the first researchers to ask for hospital materials! While Budapest and Szeged proved to be rather disappointing (with hospital files lost or sporadic), the two smaller local archives offered excellent sources for the study of medical institutions. Hospital Committees were obligatory for every local administration (city, town or county), with their minutes showing discussions and decisions about the general operation of the hospital, its renovation, the building of new departments, how and when debts were to be paid and other operational themes.

Contemporary published material also provides us with a wide range of information at national and local levels. Sources such as healthcare yearbooks and hospital journals offer consistent and comparable data for the period of the 1930s. This can underpin a quantitative picture of hospital provision across these nations, including the number of institutions and type of provider, numbers of hospital beds, patients, staff and treatment days, and the cost of treatment in the different hospital classes.⁵⁶

There were around two dozen journals and magazines related to public health published in Hungary during the interwar period, many of them directly interested in hospital issues. Apart from economic and statistical reviews, some published hospital-related articles. Two periodicals were especially useful. The monthly Hungarian Hospital (Magyar Kórház), published by the Hungarian Hospital Association from 1932, contains very valuable articles on every possible aspect of hospitals. In 1934 it published a Yearbook of Hungarian Health Care Institutions which contained extensive data on every Hungarian hospital (public, private, state, university and so on).⁵⁷ The journal regularly published a supplement entitled ‘Register of Hungarian Hospitals’, a serial with statistical data, some historical background, and photos of numerous hospitals. Equally significant was the Review of Health Policy (Egészségpolitikai Szemle), with important articles covering the hospitals’ role in the overall public health system.

Although there were a number of useful reports produced, especially those at the beginning and the end of the period, the published secondary material for Poland is not as rich as that for Hungary or Czechoslovakia.⁵⁸ However, these national periodicals can be supplemented by international journals like Nosokomeion. Published quarterly from 1930 to 1939 in English, German, French and Italian by the International Hospital Association, it used a combination of regular and themed issues to give an insight into contemporary national and international debates about the role of hospitals, including specialized aspects of institutional healthcare, from hospital kitchens and libraries to hospital legislation and architecture.⁵⁹

Hospital provision and growth

Who provided hospitals in these three nations, and how did the imperial legacy and the ambitions of the new states shape the institutional profile? In both Poland and Czechoslovakia there were multiple systems inherited from the former empires with the result that a complex patchwork of hospital finance and administration emerged. Across all three countries, hospitals were classified as either public or private, with institutional care provided by a mixed economy of public sources, social insurance funds, and social/congregational funds including charities and religious communities. For Poland, a decree of 1926 meant local governments such as cities, counties (powiaty) and communes (gminy) made up the largest percentage of public providers for general care.⁶⁰ Districts (wojewódzstwa) took on the task of mental health care, while the national government ran a handful of epidemic hospitals. In addition to public providers, private providers included the Polish Red Cross and local Jewish communities. In certain areas, rural and municipal sick funds (Kasy Chorych) or miners’ fraternal organizations, such as the Spółka Bracka in Silesia, also provided hospital care.⁶¹

Following Polish independence, the need for growth was urgent, driven by concerns about epidemics and social diseases as well as the minimal provision found in many eastern areas. In the early post-war period, epidemics flourished throughout Poland, but especially in eastern districts, so that building a network of hospitals to assure care and treatment, the isolation of infectious diseases, and the lowering of the death rates became a priority.⁶² Between 1920 and 1923, a Supreme Emergency Commissioner for Epidemic Control (NKK) played the main role in the creation of a network of new hospitals. At its peak in 1921–22, NKK commissioned as many as 1100 epidemic hospital beds in Nowogródek Voivodeship alone, while a similar number of hospital beds were established for repatriates in the city of Baranowicze.⁶³ This policy produced erratic temporary spikes in the number of beds available, for example, in the Tarnopol district in 1924 or Polesie the following year. Most of the NKK hospitals later closed, some were reorganized into state-regulated hospitals for epidemic control, and many were transferred to local government control.⁶⁴

In Poland, it was recognized that running a large network of many small hospitals was not financially viable. In response, the state worked to create a system of fewer, larger hospitals that could be better equipped with supplies and trained personnel. It eliminated hospitals where occupancy did not exceed six to 10 beds, a process that involved merging wards or even combining two hospitals into one building. In the town of Suwalki, the Jewish hospital merged with the Hospital of St Peter and Paul, as they already occupied the same premises.⁶⁵ As a result, between 1927 and 1937, the total number of hospitals increased from 656 to just 677, but bed numbers rose by 11,032. Overall, from 1920 to 1937, the number of beds rose by approximately 70%, although this still fell short of the government’s projected goals. Although the closure and merger of many institutions allowed Polish hospitals to utilize personnel and resources more effectively, it still proved insufficient. Moreover, problems with the financing of hospitals meant the system could not work at full capacity and at various points across the period the inability of large groups of people to afford the cost of treatment resulted in empty hospital beds. In the mid-1920s the towns of Szczuczyn and Ejszyszki in Lida county were using only 29.5% and 36.5% respectively of their beds annually.⁶⁶

Hospitals in Hungary were divided into eight categories: state hospitals; state and private mental hospitals; university hospitals and midwifery schools; public hospitals; private hospitals open to the public; non-public private hospitals; hospitals of the Pious Order; and prison hospitals. However, general public hospitals were divided further. In 1932, there were 26 public hospitals provided by municipalities, 19 by county administration, one jointly by a municipality and the county, and two directly by the state, while of the ten voluntary public hospitals, two were provided by religious groups, one by a noble family and one by the Stefania Association, a state-supported public health organization. The Pious Order had four public general hospitals.⁶⁷ Most counties had at least one County Public Hospital, often in a minor town, as in Csongrád County, where the two major towns (Szeged and Hódmezővásárhely) ran municipal hospitals, while the much smaller Szentes had the county hospital. These public (community) hospitals were obliged to accept patients from anywhere (including paying patients from abroad),⁶⁸ a system that led to competition between public hospitals to attract more paying patients, especially from insurance companies.⁶⁹

Hospital reform in Hungary began in the late 1920s, when membership of the League of Nations opened up international loans, with 48 Hungarian towns running up large debts to invest in infrastructure.⁷⁰ There were relatively few new hospitals built (for example Berettyóujfalu, Mátészalka), while some existing voluntary hospitals were transferred to public ownership (like Debrecen and Cegléd). Although dozens of public hospitals were extended and/or renovated, vast areas southeast of Lake Balaton, and the Eastern region along the River Tisza, were still without any public hospital in the mid-1930s (Figure 1).

Figure 1. Hospitals in Hungary, 1938.

Source: Map drawn by Balázs Szélinger.

The western and economically more advanced provinces of Czechoslovakia – Bohemia, Moravia and Silesia – had been ruled by Austria, whereas the eastern part, including Slovakia and Subcarpathian Ruthenia, had been controlled by Hungary. This caused problems for the new state as the healthcare systems of the two parts of the dual monarchy were based on different laws (the public healthcare acts of 1870 in Austria and 1878 in Hungary). In Bohemia, hospitals were largely in the hands of the local district authority (okresní nemocnice), and Moravia and Silesia operated provincial and some municipal hospitals (zemské/městské nemocnice), while the administration of Slovakian and Ruthenian hospitals was based on a county system (župy) with an additional sprinkling of municipal hospitals.⁷¹ There was also a large number of small private institutions. Ambitious early plans to nationalize and unify the hospital system proved untenable, but a 1920 law gave the Ministry of Healthcare medical and administrative supervisory powers over all healthcare institutions as well as instituting a network of strategically important state hospitals (státní nemocnice), mostly in the eastern part of the republic, where provision was poor.⁷²

As in other states, there were multiple providers of institutional care in interwar Czechoslovakia: municipalities, districts, counties, provinces, the state and the private sector. These were further divided into two broad categories: general public hospitals (všeobecné veřejné nemocnice), along with state hospitals and clinical/university hospitals (fakultní nemocnice); and private hospitals operated by employers, religious orders, insurance companies or voluntary organizations like the Red Cross.⁷³ The latter accounted for roughly twice the number of institutions as the public hospitals, but only half the number of all hospital beds. They lacked the rights accorded to public provision but were largely financed from public funds. Most offered specialized health and social care such as sanatoria, convalescent homes and homes for pregnant mothers, rather than general medical services.

This broad structure changed slowly across the interwar period with the growth of hospital provision grouped into three phrases: from independence to the late 1920s; the era of the Great Depression; and the mid- to late 1930s.

Geography and ethnicity

Across all three countries, but especially in Poland, differences in provision were apparent from west to east and between rural and urban areas. This was strongly influenced by the pre-independence inheritances of these new nations.

Interwar Poland was made up of three territories formerly occupied by the Prussian, Russian and Austrian empires. Each predecessor state had dramatically different social policies which affected the health-care systems inherited by the Second Republic.⁷⁴ Interwar Poland acquired the highest number of hospitals and the best developed social insurance systems from the former Prussian area, although these institutions were increasingly outdated.⁷⁵ Some of the best facilities were found in Silesia, like the Giesche Mining Company’s ‘most attractive’ modern, light, airy, clean institution. It boasted multiple, specialized services, modern equipment, well-staffed wards with several doctors allocated, and a mixture of trained male and female nurses as well as the usual nuns.⁷⁶

The Austrians had given the Poles relative autonomy, allowing them to create national institutions, including hospitals. But these facilities were severely damaged during the First World War, leaving many of them unusable or in need of significant repair.⁷⁷ The inherited hospital system was worst in Russian Poland. In the late 1890s, the Tsarist authorities had withdrawn all state support for hospitals, leaving philanthropic organizations to fill the gaps.⁷⁸ As a result, most medical institutions in the Congress Kingdom territory (Central Poland, including Warsaw), suffered serious financial difficulties and many could only offer limited services or had to close. Beyond the boundaries of the Congress Kingdom, Poland’s easternmost districts were scarred by war damage and economic underdevelopment. Located at the heart of seven years of fighting (1914–21), these rural districts had suffered much damage and stagnation. Hospitals were few and far between. In the district of Polesia, every hospital was damaged during the wars, and some were burnt to the ground. Those that did remain operated on quite primitive terms. In 1920 there were only 500 beds in ‘permanent hospitals’ in the eastern borderlands and 1657 in ‘temporary hospitals’.⁷⁹

Although a goal of three hospital beds per 1000 persons was set for Poland in 1917, the only districts that met this were Silesia and the city of Warsaw, while some other western districts, where social insurance was well developed, came close. After that, total beds available fell off dramatically and some eastern districts, like Bialystok, did not have a hospital provided by a social insurance scheme until 1933.⁸⁰ Even in the capital city, which boasted the highest number of beds, hospital care was of questionable quality. In 1926, the Warsaw Municipal Department of Health Care ordered an inspection of its hospitals. It revealed a consistent lack of space: in 10 years, the city had only increased its number of hospital beds by 236. One observer described sick patients lying in hallways, bathrooms, cafeterias, bedrooms for service personnel and even hospital offices.⁸¹ Another wrote:

The sick are placed on stretchers, on tables, on straw mattresses laid out on the floor, even on stairs [… . T]his makes an impression that in the Capital there has been some sort of great catastrophe, for which the municipal hospitals were not ready.⁸²

In 1928/29 the Department of Health’s commission reported that the lack of available beds resulted in over 10,000 pages cataloguing patients who had been refused admittance.

In Poland’s rural areas, where over 70% of the population resided, there were very few hospitals. In 1917, Rzętwkowski noted that before the war, hospitals for villages and smaller communities did not exist. Moreover, there were few doctors, with a local newspaper reporting: ‘There is not one village with a doctor in the neighbourhood of Lida.’ Rural medical networks were under-developed, and some ambulatories and feldsher stations had been shut down.⁸³ Indeed, in a push to increase the professionalization of medical staff, a 1927 decree had outlawed feldsher from the list of recognized professions, further exacerbating the shortage of rural medical personnel.

However, the main area of growth in the early 1930s was outpatient health centres (ośrodek zdrowia), which began to appear in the 1920s, especially in the east, and focused on activities aimed at the improvement of public health.⁸⁴ As elsewhere in Europe, the responsibilities of these centres included the prevention of social disease and medical examinations for pregnant women, mothers and children, as well as basic medical assistance.⁸⁵ By focusing on outpatient and preventative medicine, they could reach more patients and were much easier to staff and sustain – with nurses and hygienists supported by regular visits from doctors. However, as Valchuck found, ‘lack of cooperation and interaction between hospitals and Health Centres was a significant disadvantage of their work’.⁸⁶ Moreover, they were often underutilized. In 1937 only 1.5 million out of Poland’s total population of 36 million made use of services provided by local government health centres, while just 2 million people made use of social insurance outpatient clinics.⁸⁷

Hungary also experienced significant urban/rural distinctions – in numbers, quality and distribution of hospitals. In spite of the losses imposed by the Trianon Peace Treaty (1920) following defeat in the First World War (including 57% of the hospitals and 42% of the hospital beds), the reduced size and population of Hungary meant the average number of hospitals and hospital beds actually rose.⁸⁸ However, the distribution of hospitals (and therefore hospital beds) was regionally unbalanced. Trianon left the eastern part of Hungary without any public hospitals (between Nyíregyháza and Békéscsaba), while the situation was relatively good in western and southern Hungary (Figure 1).

Interwar Czechoslovakia was ethnically very diverse. The uneven distribution of hospitals and the concentration of the various ethnic populations in specific areas also affected the quality of, and access to, medical care. For instance, Sudetenland, a largely industrial borderland area stretching from Silesia to the west and south of Bohemia and inhabited mostly by a German-speaking population, had a dense hospital network with more beds and physicians than other parts of the country.⁸⁹ Hospitals in the area, including Liberec (Reichenberg) and Ústí nad Labem (Aussig), received ample government support during this period.⁹⁰ In maintaining adequate standards of regional welfare provision, the young state clearly sought to prevent any irredentist feelings. However, tensions occasionally surfaced between ethnic groups, such as at the 1500-bed General University Hospital in Prague, which was divided into German and Czech clinics where the German staff failed to speak the new national language, leading to complaints from some of the patients.⁹¹

Services in the east, conversely, were poor or non-existent, encouraging the government to take an interest in provision, especially in Subcarpathian Ruthenia.⁹² This absence of proper healthcare infrastructure and necessity to cooperate with voluntary organizations enabled Dr Bohuslav Albert, a young physician in charge of Mukačevo Hospital, to develop innovative approaches to hospital care. Albert, mentored by Professor Rudolf Jedlička and inspired by the Mayo Clinic’s practices, later became one of the key proponents of hospital reform in Czechoslovakia.⁹³ Following his relocation to Moravian Zlín in 1927, however, and given the effects of the Great Depression, the government investment in Mukačevo Hospital came to a halt.⁹⁴ By the late 1930s, parts of it were on the brink of collapse as the following staff reflection attests:

There is a great resistance amongst local people against using Mukačevo state hospital. This is not surprising given the conditions at the isolation ward. The building can no longer hold so many patients. We need three times more staff … beds are infested with various insects, especially lice … the internal medicine ward is in such disrepair that the ceiling had to be supported by wooden beams in order for it not to collapse.⁹⁵

Jewish identity, especially Orthodox Judaism, was also important for access to healthcare, especially in the Jewish hospitals in the east of the country. Evidence from the Ruthenian town of Užhorod suggests that, unsurprisingly, local Orthodox Jews preferred to forego treatment rather than eat non-kosher food in the main hospital. Moreover, faced with the dilapidated annexe attached to Užhorod Municipal Hospital for their co-religionists, in 1930 the Jewish Burial Society, Chevra Kadisha, campaigned successfully for a subvention for a new Jewish pavilion.⁹⁶

Funding and finances

The third theme to explore is the funding of hospitals. All three nations inherited partial health insurance systems from their imperial predecessors and each attempted to extend and unify this provision. However, fairly quickly it became evident this was a big challenge and by the outbreak of the Second World War they still had very patchy cover.⁹⁷ As in other nations, many of Poland’s workers were excluded from social insurance, leaving a substantial proportion of the population and whole geographical areas medically underserved. Even in 1938, only 14.7% of the population had sickness insurance because rural workers – 70% of the population – were excluded. In Lida, a rapidly expanding district of northeast Poland, local peasants rarely sought medical help except for surgery, complicated labour or when facing imminent death – nor could they pay cash for fees at large municipal medical facilities.⁹⁸ The interwar press and medical profession promoted plans to form benevolent societies or to institute mandatory medical aid where peasants could pay in kind with produce.⁹⁹ But these came to nothing and services remained sparse and expensive. Indeed, tensions were ever present between the national and the local funders and between the insurance funds and the hospital providers, especially in Hungary and in former Hungarian areas.

The social insurance system in Hungary was more extensive than that in Poland.¹⁰⁰ About one-quarter (24.8%) of active earners were eligible for sick pay, most of them in compulsory insurance schemes.¹⁰¹ In 1927 the government centralized the system by unifying the numerous local insurance companies into a National Social Insurance Institute (Országos Társadalombiztosító Intézet, OTI), although the insurance companies of the National Railways, the Hungarian Royal Post, and the Insurance Institution of the Self Employed maintained their independence.¹⁰² As in Poland, agricultural workers were almost totally excluded from the compulsory schemes. Explaining the shape of Hungary’s system, Bela Tomka pointed to the importance of Catholicism in politics, the privileged position of state employees and the continued power of large landowners as significant determining factors.¹⁰³ This resulted in notable differences between hospitals in the number of insured patients treated. In 1932 the proportion treated in rural hospitals varied from 40.9% (Esztergom) to 1.1% (Kőszeg), with a national average of 14.3%,¹⁰⁴ while in the urban Újpest voluntary public hospital, insured patients accounted for 53.5% of the treatment days.¹⁰⁵

The new Czechoslovak state had the most extensive coverage. It set out to unify, simplify and improve the inadequacies of the old Austrian and Hungarian systems, which had excluded a large proportion of the population from insurance schemes. Between 1919 and 1925, health insurance cover was extended to forestry and agricultural workers, all contract workers and all public servants.¹⁰⁶ By the end of the interwar period, nearly half of the population of Czechoslovakia had been covered by sickness insurance. Insured clients could be admitted to hospital for a period of up to four weeks, although hospital treatment for family members was excluded from the compulsory cover.¹⁰⁷ Unlike Poland, the insurance companies became large-scale providers of institutional services and by the end of the period had established around 1300 specialized ambulatory centres and diagnostic surgeries around the country, together with 150 private hospitals, sanatoria and spa houses.¹⁰⁸ Extensive social insurance coverage not only financed a large proportion of hospital activity; it also led to the rapid development and modernization of hospitals.¹⁰⁹

Hospitals were funded from a variety of sources, with the majority of their budgets coming not from health insurance, but from local government and state subventions. The finances of hospitals in Hungary were complex and unstable. Building on previous legislation, a Hungarian Act of 1876 instituted free medical treatment for the poor, with legislation of 1898 defining who should be considered ‘poor’ and therefore eligible for free treatment. The bulk of the public hospitals and their poor patients were paid for by the Ministry of Public Welfare and Labour from the Public Patient Care Fund established in 1908. Private and voluntary hospitals were financed by the local elites in various forms, ranging from individual one-doctor sanatoria to charity organizations and religious orders, while university hospitals and midwifery schools were supported by the Ministry of Religious Issues and Education. To make the system more complicated, the establishment of the OTI in 1927 promoted the growth of insurance company institutions.

Patient treatment fees could be paid in three different ways. A private payment was necessary if the patient was not insured or could not provide a poor certificate. As elsewhere, there were three classes of private patients – first, second and third – with accommodation, treatment and catering fees set accordingly. In a trend seen elsewhere, from the late 1920s a growing number of people were indebted to hospital providers, and these sums were never recovered in most cases. In 1934, the Erzsébet (Elizabeth) Public Hospital of Hódmezővásárhely had nearly 60,000 Pengős (ca. 11,516 USD) in outstanding fees dating back to 1927.¹¹⁰ But it was not just private patients who struggled. As insurance only covered 28 days of hospital treatment in each year, there were an increasing number of insured patients indebted to public hospitals. In one hospital, the number of insured owing money rose to around half of all debtors by 1938.¹¹¹

The cost of poor patients, which in 1932 averaged 67.7% of public hospital patients, rising to over 80% in nine public hospitals, was met from the Public Patient Care Fund, with the state treasury covering any difference.¹¹² The system worked relatively well until the Great Depression, when dramatically reduced tax revenues forced the state to change from a per capita system of payment for patient treatment to an average flat rate given to public hospitals, reducing incomes by as much as 30%. As the state contribution to the overall income of hospitals like Magyaróvár fell, many public hospitals became heavily indebted.¹¹³ Faced with the crisis in state support, some responded by closing hospital beds (whole wards in many cases), with the director of the public hospital of Somogy County in Kaposvár stating:

Our hospital which has 612 beds can only accept 220 toll-free patients due to the flat rate system, paying patients may be only 120–150. Thus the sad situation is that 250–270 beds of the hospital are left empty so the institute cannot fulfil its duty against TB, or STDs, nor in child protection, and pregnant care, which otherwise it could, and should do. The fruitful work we did for more than 60 years is disabled, the familiarization of the patients with the hospital was in vain since we have to refuse all those patients in need of treatment who are poor, and we have no more supplies.¹¹⁴

The economic crises of the early 1930s also had a marked negative effect on the Polish hospital system, and by the early 1930s most hospital and municipal budgets were in dire straits.¹¹⁵ As a result of failing budgets a large number of Polish hospitals were shut down, including six in the Bialystok district, while others struggled to secure basic supplies. And it was not only the local state struggling. Because of the crisis many patients could not afford to pay for treatment. Some hospitals and towns found creative ways around this difficulty, with the Mayor of Lida offering to accept payment for treatment in the form of ‘lard, grain, cereal and fuel’.¹¹⁶ Further problems emerged when the Kasa Chorych insurance fund struggled to pay. In Warsaw, the City Health Department was in a ‘constant state of war’ with the fund, which had the right to place its members in hospitals in return for meeting half the cost of treatment. But they did not always pay, and as early as October 1929, owed Warsaw hospitals almost two million zlotys.¹¹⁷ On top of these problems, hospitals had a hard time collecting debt. Officially, the gmina was supposed to pay for the registered poor who went to the hospital. However, in certain communes, especially in former Russian territories, the poor state of local finances made it impossible for hospitals to reclaim funds owed to them after caring for the sick-poor. In 1939, the state was still trying to find a solution to this challenge and a new law to apportion costs between communes, counties and a special district-wide fund was in progress when war broke out.¹¹⁸

The financing of Czechoslovak hospitals was as complex as their control and administration. In order to claim treatment fees from the state, hospitals had to be granted by law ‘the right to public provision’, which then enabled them to carry the title of ‘public hospital’.¹¹⁹ The daily hospital treatment rate was then determined by the provincial government. There was controversy over the allocation of resources to different provinces. As in Poland, the distribution declined from west to east. The most privileged status was enjoyed by Prague, the republic’s capital, which hosted a number of prestigious hospitals, as well as the headquarters of most key medical and humanitarian institutions.

Copying the Hungarian model, the Czechoslovakian government initiated the Public Hospitals Fund in 1921, utilizing money from the Healthcare Surcharge based on a percentage of direct tax.¹²⁰ The fund was focused on covering capital costs, like building works and extensions, as well as reimbursing hospitals for unpaid treatment fees incurred by the poor and foreign nationals.¹²¹ Yet this proved quite problematic, as the scale of untraceable treatment fees accounted for up to 70% of the entire hospital budget in some areas, causing huge problems for hospitals in the east. This was, for instance, the case of Užhorod Municipal Hospital in Subcarpathian Ruthenia, which had to rely on bank loans after the Ministry tightened the rules for claiming back unpaid fees.¹²²

Conclusion

This survey of hospital history in three new Central European nations of the interwar period has demonstrated the perils and possibilities of comparative medical history. Each nation has accrued only a limited historiography, one still dominated by professional and institutional biography. The archival inheritance is more varied, with rich national and local sources to be found for Czechoslovakia; more variable records are available for Hungary, with the local proving more promising than the national. The situation in Poland is disappointing, however, the product of extensive wartime destruction. This unevenness points to a significant barrier in the pursuit of comparative research, although the outcomes of the case studies do point in fruitful directions.

All three nations exhibited a range of similar problems, many drawn from their imperial legacies. Their ambitious plans for modern healthcare systems that would do justice to their new, independent status, stalled because of financial weakness, the predominance of agriculture and the effects of the Great Depression. But they were also restricted by geography, with progress in rural and eastern districts limited by distrust of institutional medicine, underdeveloped cash economies and minimal urbanization. What we can see is that comparisons built on local as well as national sources offer two clear lessons: the first is that the national headline discourse of modernization masks significant differences between and within nations; the second is that the imperial legacy created different problems for each of these nations as they sought to build new nations in a hostile political and economic environment.

Acknowledgements

We would like to thank the University of Huddersfield’s University Research Fund for supporting this research and the Rockefeller Archive Centre for their generous Research Stipend Award, which allowed Barry Doyle to complete research in the Rockefeller Foundation collection. We would also like to thank the researchers on the project, Melissa Hibbard, Balázs Szélinger and Frank Grombir, for their work and input to this article. Translations from Polish are by Melissa Hibbard, from Czech by Frank Grombir and from Hungarian by Balázs Szélinger.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This article and the workshop that forms the basis for this Special Issue received funding from the University of Huddersfield University Research Fund for the project European Healthcare before Welfare States Ref: [URF2015/19].

Notes on contributors

Frank Grombir

Frank Grombir, BA, MA, PGCert, AFHEA specializes in the study of migration, diasporas and national identity in twentieth-century Britain and Central and Eastern Europe. He worked as a research assistant on the European Healthcare before Welfare States project at the University of Huddersfield between 2016 and 2017 and is currently completing a Ph.D. in History at the University of Hull. His public history engagement in the Kirklees area has included numerous history talks and walks, journal editorship, community partnership projects and heritage events.

Barry Doyle

Barry Doyle is Professor of Health History at the University of Huddersfield. He has worked extensively on the history of hospitals in England, France and Central Europe, including a book on urban hospitals in northern England and a recent project on the economics and politics of hospitals in interwar Poland, Czechoslovakia and Hungary funded by the University of Huddersfield. His current work focuses on a history of First Aid in Britain and France with Rosemary Cresswell and a project on hospital care in Britain’s sub-Saharan colonies between the wars.

Melissa Hibbard

Melissa Hibbard, BA, MA, PhD, is a historian of health with a focus on early twentieth-century Poland. She completed her doctorate, “Children of the Polish Republic: Child Health, Welfare, and the Shaping of Modern Poland, 1914–1938,” at the University of Illinois, Chicago, in 2020. Melissa currently works as a history teacher in Montana, USA.

Balázs Szélinger

Balázs Szélinger, PhD. Born into a family of medical doctors and pharmacists, Szélinger studied History and Mediterranean Studies at the University of Szeged, Hungary (MA and PhD). Formerly an Assistant Professor of History at Mekelle University (Tigray, Ethiopia), a freelance journalist, and more besides, he was recently the Economic and Trade Attaché at the Embassy of Hungary in Addis Ababa, Ethiopia and currently works for the Hungarian Ministry of Foreign Affairs. His research interests include the relations between the Horn of Africa and Central Europe, the modern history of Hungary, and the anthropology of hard rock and heavy metal music.

Notes

1. Löwy, “Social History of Medicine,” 446–7.

2. Cherry, Medical Services and the Hospitals; Gorsky, Mohan, and Powell, “Financial Health of Voluntary Hospitals”; Doyle, Politics of Hospital Provision; Domin, Histoire economique de l’hôpital; Vilar-Rodriguez and Pons-Pons, “Competition and Collaboration.”

3. For classic texts on this theme see Abel-Smith, The Hospitals; Imbert, Les Hôpitaux en France; Stevens, In Sickness and in Wealth; Rosenberg, Care of Strangers. For a recent assessment using beds per head of population, see Fernández Pérez, “How to Evaluate the Capacity of Hospital Systems.”

4. Ownership has been a significant feature of recent British historiography and is beginning to appear in French discussions. Pickstone, Medicine and Industrial Society; Doyle, “Competition and Cooperation”; Faure and Dessertine, Les Cliniques Privées.

5. Gorsky, “The Gloucestershire Extension of Medical Services Scheme”; Smith, Creating the Welfare State; Mohan, Planning, Markets and Hospitals.

6. In addition to the works cited in note 2, there have been a number of recent collections including Hüntelmann and Falk, Accounting for Health; Valat, Marchés de la santé; Gorsky, Vilar-Rodríguez and Pons-Pons, Political Economy of the Hospital.

7. Gorsky, “The Political Economy of Health Care.”

8. Weisz, Divide and Conquer; Weisz, Chronic Disease.

9. Hennock, Origin of the Welfare State; Dutton, Differential Diagnoses.

10. Gorsky, “Hospitals, Finance, and Health System Reform”; Doyle, “Healthcare before Welfare States.”

11. Fernández Pérez, The Emergence of Modern Hospital Management.

12. Lucey and Crossman, eds., Healthcare in Ireland and Britain.

13. Gorsky Vilar-Rodríguez and Pons-Pons, Political Economy of the Hospital; Donzé and Fernández Pérez, eds., “Health Industries in the Twentieth Century.”

14. League of Nations, International Health Yearbook; International Labour Office, Economic Administration of Health Insurance Benefits.

15. Rockefeller Archive Center, Sleepy Hollow, NY: Rockefeller Foundation Records, International Health Board RG5.

16. Doyle et al., “Hospital Systems in New Nations.”

17. Bideleux, History of Eastern Europe; Prażmowska, History of Poland; Heimann,Czechoslovakia; Molnár, Concise History of Hungary.

18. Löwy and Zylberman, “Medicine as a Social Instrument” and contributions by Balinska, “The Rockefeller Foundation and the National Institute of Hygiene”; Palló, “Rescue and Cordon Sanitaire”; Weindling, “Public Health and Political Stabilisation”; and Page, “The Rockefeller Foundation and Central Europe.”

19. Turda, Eugenics and Nation.

20. Promitzer, Trubeta, and Turda, Health, Hygiene and Eugenics in Southeastern Europe; Karge, Kind-Kovács, and Bernasconi, Midwife’s Bag to the Patient’s File.

21. Vargha, Polio across the Iron Curtain; Marks and Savelli, Psychiatry in Communist Europe.

22. Though Central Europe does feature in Borowy and Gruner, Facing Illness in Troubled Times.

23. Niklíček and Šimberská, “Vývoj a současné problémy” includes a summary in English.

24. An exception to this was Sinkulová’s multi-volume study, with the third volume halted by the Soviet invasion of August 1968. Sinkulová, Dějiny československého lékařství. Also see Niklíček and Šimberská, “Vývoj a současné problémy,” 10.

25. Deyl, “Z historie přípravy a vzniku zákona” includes a summary in German; Deyl, “Vývoj dělnického sociálního pojištění v Československu”, includes a summary in Russian and German; Niklíček, “Založení státního zdravotního ústavu Republiky Československé,” 99, includes a summary in Russian and English.

26. Sajner, Selinger, and Volavý, Dvě století ve službách zdraví; Veselý and Hlaváčková, Fakultní nemocnice v Praze; Hlaváčková, Svobodný, and Bříza, Dějiny všeobecné nemocnice v Praze.

27. Hlaváčková, Svobodný, and Bříza, Dějiny všeobecné nemocnice v Praze; Niklíček, Systém veřejného zdravotnictví a nemocenského; Svobodný and Hlaváčková, Pražské špitály a nemocnice; Svobodný and Hlaváčková, Dějiny lékařství v českých zemích; and Karel Černý, “History of Medicine in the Czech Republic,” 196.

28. Falisová, Zdravotníctvo na Slovensku.

29. Mášová, Nemocniční otázka; Mášová, “Nemocnice v průmyslových centrech Československé republiky”; and Mášová, “Dva pilíře přestavby československého zdravotnictví.

30. Niklíček, “Založení státního zdravotního ústavu Republiky Československé,” 97–108; Niklíček and Šimberská, “Rockefellerova nadace a založení Státního zdravotního”; Weindling, “Public Health and Political Stabilisation”; Weindling, “Philanthropy and World Health”; and Page, “The Rockefeller Foundation and Central Europe.”

31. Svobodný et al., “Continuity and Discontinuity of Health”; Mášová, “Social Hygiene and Social Medicine”; Mášová, “Czechoslovak Hospital Reform”; and Mášová and Svobodný, “Health and Health Care.”

32. Following various name changes, the journal is now called Bulletin of Medical History (Orvostörténeti Közlemények). While the library is of great use to researchers, their archive is relatively poor, holding only the documents of a few famous doctors.

33. Her extensive bibliography in Hungarian, German and English can see be seen here: http://tudasaramlas.btk.elte.hu/en/members/lilla-krasz

34. Ferge, Fejezetek a magyar szegénypolitika; Tomka, Welfare in East and West; and Inglot, Welfare States in East Central Europe.

35. Cora, “Hungarian Health Care in the 1930s and 1940s.”

36. Bunsch-Konopka, Historia ochrony zdrowia w Polsce; Fijałek, Tradycje zdrowia publicznego; and Nosko, Z dziejów zdrowia publicznego.

37. Fijałek and Indulski, Opieka zdrowotna w Łodzi do roku 1945; Podgórska-Klawe, Szpitale Warszawskie.

38. Discussions of source challenges in this field include: Konopka “O źrodłach do dziejów medycyny polskiej”; Syroka, ‘Pojęcie źródeł do historii medycyny.”

39. In addition to Fijałek see Zabłotniak, “Niktóre Wiadomości”; Grassmann, Zemke-Górecka, and Kędra, “Szpitalnictwo cywilne w województwie białostockim”; and Podgórska-Klawe, Szpitale Warszawskie.

40. Tishchenko, “Public Health in the East Voivodeships”; Valchuk, “Opieka medyczno-sanitarna.”

41. Blady-Szwajger and Tasja, I Remember Nothing More; Zabłotniak, “Szpitale Żydowskie”; and Zabłotniak and Kroszczor, “Towarzystwo Ochrony Zdrowia.”

42. Národní archiv [National Archives of the Czech Republic], Records of the Ministry of Public Health and Physical Education 1918–1938. NA 622. Hereafter Czech National Archives, Ministry of Health 622.

43. Czech National Archives, Ministry of Health 622, “Records of the Masaryk League Against Tuberculosis,” Box 748.

44. Czech National Archives, Ministry of Health 622, “Hospital Finances in Slovakia,” Box 51; “Prague Vinohrady State Hospital Staff Records, mid-1930s,” Box 279.

45. Czech National Archives, Ministry of Health 622, “Records of the Ostrava State Hospital,” Boxes 649 and 654; “Mukačevo Hospital Records,” Boxes 646 and 647; and “Užhorod Hospital Records,” Boxes 277, 278 and 280.

46. Prague City Archive, “St. Elizabeth Women’s Hospital Na Slupi, 1826–1983,” Collection 2142.

47. Státní okresní archiv Zlín [Zlín District Archive] “Baťova nemocnice, 1926–1949,” H1140; Mášová, “Sociálně-zdravotní novátorství Baťovy nemocnice.”

48. Edited by Alois Svoboda from Prostějov between 1928 and 1930, it was published by Společnost československých nemocnic (Association of Czechoslovak Hospitals) since 1931 and included contributions by German representatives, thus averting the foundation of a separate German journal. Mášová, Nemocniční otázka.

49. Albert, “Reforma nemocnice”; Albert, “Les efforts tchécoslovaques.”

50. AAN, Ministerstwo Opieki Społecznej (MOS) MOS 123, Project for building a TB pavilion and Marshall Piłsudski Infectious Diseases Hospital in Chrzanowie; MOS 122 Building and Renovation of Quarantine hospital in Babi Dole near Gdynia.

51. For example, MOS 121 Building of Health Centres; MOS 514 Granting Subventions for Institutes of Preventative Health Care, 1938–39.

52. MOS 485 Conference of County Doctors from the Krakow District.

53. MOS 726 Activity of the First Health Centre in Warsaw; MOS 736 Short History of Hospital Development in Galicia.

54. Archiwum Państwowe (AP) w Łodzi, LCDT/178 Łódź 1894–1921 Szpital Anny Marii.

55. Archiwum Państwowe (AP) w Katowicach, 27 XI Silesian Department of Public Health: 19 Hospital Reports.

56. Říha, Zdravotnická ročenka Československa [Czechoslovak Healthcare Yearbook].

57. Magyarország gyógyintézeteinek évkönyve.

58. Though see the two reports produced in 1917 and 1939, Rzetkowski, Odbudowa Kraju a Szpitalnictwo; MOS, “Dwadzieścia lat publicznej służby zdrowia.”

59. Nosokomeion: Quarterly Hospital Review/Revue trimestrielle des hôpitaux, Vierteljahrsschrift für Krankenhauswesen was published between 1930 and 1939. A full run is held by the Wellcome Library, London: http://0-www.bmj.com.libsys.wellcome.ac.uk/record=b1312543~S12. Willis, Goad, and Logan, Architecture and the Modern Hospital.

60. 1937 figures: 50% of providers local government, 31% social Insurance, 15% state hospital and 4% small private hospitals. Godycki-Ćwirko, Oleszczyk, and Windak, “Development of Primary Health Care in Poland,” 30.

61. Walsh, Giesche Spółka Akcyjna.

62. Grassmann, Zemke-Górecka, and Kędra, “Szpitalnictwo cywilne w województwie białostockim,” 133–4.

63. Więckowska, “Szpitale Epidemiczne.”

64. Tishchenko, “Public Health in the East Voivodeships,” 86.

65. Grassmann, Zemke-Górecka, and Kędra, “Szpitalnictwo cywilne w województwie białostockim,” 136.

66. Valchuk, “Opieka medyczno-sanitarna.”

67. This calculation is based on Magyarország gyógyintézeteinek évkönyve.

68. The hospital in Magyaróvár treated patients from locations as far as Székesfehérvár and Budapest. Mosonmagyaróvár Municipal Archives GYMSML-ML, 802. 110. At the public hospital of Miskolc in 1938, 46.7% of the patients came from the county which ran the hospital, 33.8% from Miskolc town itself, and 19.5% from other counties.

69. See Hódmezővásárhely Municipal Archives in Csongrád County CSML-HL, VIII. 802. 219/937 which shows that a well-known specialist doctor could attract patients from outside the county.

70. Dobrossy, “Miskolc infrastruktúrájának modernizálása.”

71. Pelc, Organization of the Public Health Services; Mášová, Nemocniční otázka, 119–23.

72. Pelc, Organization of the Public Health Services, 159.

73. Říha, Zdravotnická ročenka Československa, 1929−40.

74. Przywieczerski, “Les Hôpitaux en Pologne.”

75. MOS, “Dwadzieścia lat publicznej,” 96.

76. MOS, “Dwadzieścia lat publicznej,” 60.

77. MOS, “Dwadzieścia lat publicznej,” 96.

78. Przywieczerski, “Les Hôpitaux en Pologne.”

79. MOS, “Dwadzieścia lat publicznej,” 96.

80. Grassmann, Zemke-Górecka, and Kędra, “Szpitalnictwo cywilne w województwie białostockim,” 141–2.

81. Podgorska-Klawe, Szpitale Warszawskie, 287.

82. Podgorska-Klawe, Szpitale Warszawskie, 288.

83. A feldsher is a paramedic or physician assistant found across rural areas of central and eastern Europe until the mid-twentieth century. Though essential in areas with few medical services, they were frequently targeted by professional medical associations as a threat.

84. Tishchenko, “Public Health in the East Voivodeships.”

85. Mogilnicki, “Le role social du medecin”; includes summaries in German, English and Polish; Gruschka, “Die Praventiven Aufgaben Des Krankenhauses”; includes summaries in English and French.

86. Valchuk, “Opieka medyczno-sanitarna,” 13.

87. Sadowska, Świadczenia lecznicze.

88. Ágoston, “A kórházi kapacitások,” 104. See also Doyle et al., “Hospital Systems in New Nations,” 151–4.

89. Mášová, Nemocniční otázka, 78–80.

90. There were also a number of new hospitals built in German-speaking areas, including Německý Brod (Deutschbrod) and Německé Jablonné (Deutsch Gabel).

91. Czech National Archives, Ministry of Health 622, Boxes 58 and 672.

92. Albert, Nemocnice v Mukačevě v letech.

93. Albert and Baudis, “The Association of Czechoslovak Hospitals,” 123; Bakala, Baťova nemocnice ve Zlíně, 17–20; and Mášová, “Účelnost pro vyšší humanitu.”

94. The modernization and development of Ruthenian hospitals did not stop completely. In Berehovo, for example, the provincial hospital was extended to include a new maternity unit and a four-storey surgical block for male and female patients. Veselý, “Rekonstrukce zemské nemocnice v Berehové,” 107–10.

95. Czech National Archives, Ministry of Health 622, September 7, 1938, Box 646.

96. Czech National Archives, Ministry of Health 622, February 6, 1930, Box 739.

97. Inglot, Welfare States in East Central Europe.

98. Gazeta Lekarska, 1923 in Valchuk, “Opieka medyczno-sanitarna.”

99. Valchuk, “Opieka medyczno-sanitarna.”

100. Tomka, Welfare in East and West; and Prónai, Kötelező társadalombiztosítás. For a contemporary reflection on the relation between social security and public hospitals see Szőts, “A közkórházak kapcsolata az Országos Társadalombiztosító Intézettel,” 133–42.

101. Tomka, Welfare in East and West, 73.

102. Igazné, Kötelező társadalombiztosítás, 50–4.

103. Tomka, Welfare in East and West, 108–9.

104. Magyarország gyógyintézeteinek évkönyve, based on 45 hospitals in the countryside.

105. Újpest was still an independent town but virtually belonging to greater Budapest by that point.

106. Pospíšil, “Mezery ve styku nemocnic,” 175–7.

107. ILO, Economic Administration, 147–8; 10 let Československé republiky, 110.

108. Nečas, 20 let sociální péče v Československé republice, 56.

109. Břeský, “Sociální pojištění,” 45–54; Zenkl, “Význam sociálního pojištění,” 90.

110. CSML-VL, VIII. 802. 1. Doboz, 713/936.

111. CSML-HL VIII. 802. Vols 47–48.

112. Magyarország gyógyintézeteinek évkönyve, based on the data of 47 public hospitals in 1932, none of them from Budapest.

113. GYMSML-ML, 802. fond, 110–120: Számadási főkönyvek. See for example Ede, “Milyen befolyást gyakorol a 6000/1931. M.E. sz. Rendelet a klinikák és kórházak üzemére?”, and several comments on it: “Hozzászólások.” Most doctors agreed that the flat-rate system was a mistake.

114. Sándor, “Somogyvármegye Közkórháza Kaposvár.”

115. Valchuk, “Opieka medyczno-sanitarna,” 11.

116. Valchuk, “Opieka medyczno-sanitarna,” 12.

117. Podgórska-Klawe, Szpitale Warszawskie, 292.

118. MOS,“Dwadzieścia lat publicznej,”97.

119. Mášová, Nemocniční otázka, 70–2.

120. Bébr, “Reformní snahy na úpravu poměrů veřejných nemocnic,” 258–65.

121. 10 let Československé republiky, 159.

122. Vovesný, “Příčiny špatného finančního stavu veřejných nemocnic,” 116–18.