By Raia Apostolova
I remember when I first realized that Covid represents an undeniable, concrete danger. My first thought was: here, in Bulgaria, we are screwed. Just as Amber Jamilla Musser did, I sweated. A lot. And how couldn’t I? Bulgaria is the poorest member state in the EU and the country’s life expectancy is the lowest among EU member states. The healthcare system in the country has undergone, and continues to go through dramatic neoliberal reforms that have resulted in worsened material conditions in medical institutions and the shutting down of many state and municipal hospitals throughout the country. The territorial distribution and the access to hospital beds are highly unequal. In 2018 the absolute number of hospital beds was 53 173, with 10 274 of them concentrated in the capital Sofia alone. Most of the medical workers have left for Germany, the U.K., Italy, and the United States in the past three decades. It was as if the historical developments from the past thirty years could inevitably mean only one thing: “you are all screwed”. *
As of May 17th, I can say that Bulgaria is doing better than most other European countries.* There seems to be a consensus expressed by various commentators that the striking difference in Covid19-related infection and death rates between the West and the East is due to the later arrival of the virus in Eastern Europe. James Shotter and Sam Jones call thе late arrival “good fortune” that allowed Eastern Europe to introduce lockdowns, restrict mass events and impose compulsory mask-wearing at public spaces early on.* Ani Kodzhaivanova follows a similar line and accords the difference to a supposedly lower international mobility on part of Eastern Europeans; lack of attractive winter tourist destinations; smaller population density in urban areas. In my view, some of the explanations offered above are limited and often lack a sociological and historical understanding of mobility patterns, urban development, and the course social reproduction modes have taken in the past years and their relation to the possible spread of diseases.
In the existing political conjuncture of structural racism, the world is once again looking at the West and the way it manages the mounting health crisis, rarely telling the success stories of non-white nations. God forbid, Europe pays any attention to the Kerala communist mayor who “slayed” Covid-19. Of course, the question of how and to what degree viruses spread is not simply technical but it is above all, political. As such, epidemiology – as a science that deals with the control of diseases – requires a reading that animates a history of struggles. In other words, to know the politics of epidemiology we must know its history. My aim is not to provide an overall history of the science but to merely explore two episodes of its historical development in socialist Bulgaria. First, I turn to the construction of epidemiology as a mass political movement and second, I explore a hegemonic fight that broke out between two party factions in the late 1960s on questions that concern the relationship between epidemiology, democratic principles and the commons. Only a historical look will guide us out of the never outdated image of a “backward” Eastern Europe, which is now being reproduced through stories of its fortune of late contamination but never delves into the historical production of epidemiological knowledge and networks to fight off diseases.
As conspiracy theorists, neoliberal ideologues, and business lobbies are engaged in a constant effort to turn things “back to normal”, getting ready for the next Covid wave, or any epidemic for that matter, we must insist on never returning to that normal, which makes our living and working conditions into a reservoir of diseases. The following piece, I hope, unambiguously shows that history is on our side.
The postwar decade: epidemiology as a mass movement*
According to Nikola Konstantinov (2006) the healthcare material base in Bulgaria immediately after WWII was meager.* On September 9th, 1944 – when the Fatherland Front assumed power – a Ministry of People’s Health was established.* At the time there were 74 state hospitals (with 7905 beds) and 87 private hospitals (counting 1764 beds), or 1,78 beds per 1000 people (including hospital beds that were run by institutions such as the Bulgarian Red Cross, the Bulgarian National Bank and the Bulgarian Agricultural and Cooperative Bank, the Ministry of Transport, and others). Health facilities in small towns and villages were scant, while private hospitals specialized solely in surgical interventions, gynecological and internal diseases. The Sofia bombings of 1940-41 left many of the hospitals practically non-functional. However, even without the bombings the hospital base was already obsolete. According to Miladin Apostolov (cited in Panayotov 1999), the first five years right after the war were characterized by heavy restorative activities whose aim was to eliminate the poor health heritage from previous years.* The reforms in healthcare were numerous and far reaching. In 1945, a special ordinance provided free ambulatory and hospital services for workers, pensioners and their families; in 1946 a Law on Cooperative Construction of Hospitals was passed; that same year a massive system of prevention and treatment was established; 1947 saw the creation of a State Sanitary and Pharmaceutical Enterprise, which succeeded in the overcoming of a mounting at the time drug crisis; Sofia university created 12 more medical departments; Plovdiv University founded a medical faculty and 15 medical high schools (Panayotov 1999).
The status of infectious diseases was also worrying. Konstantinov claims that although in 1949 there were less people who have contracted infectious disease as compared to the prewar period (1939 and 1940), their number increased in 1952. Airborne diseases were leading the charts of infections (with 83,22% of all infections in 1949 and 95,23% in 1951). Yet in the period between 1944-1952 there was a growing tendency for a decline in mortality rates due to infectious diseases despite increased contamination. Although Konstantinov (2006: 267) is critical of the socialist regime, he admits that these tendencies were due to the “[central government’s] sympathy with the fight against infectious diseases.”
This sympathy would eventually lead to a reorganization of the state sanitary activities in the 1950s. While 1950 saw the creation of various epidemiological institutions (Directorate of Sanitary and Anti-epidemic Affairs and the State Sanitary Inspection, six research institutes), what makes this period to stand out as particularly important is the creation of sanitary-epidemiological stations (hereafter, sanepids). The task of the sanepids is to organize, conduct, and develop all necessary sanitary and anti-epidemic measures at certain territory (Georgiev 2000).* While in 1950 Bulgaria built 23 sanepids, in 1954 the state increased their number to 115. They were located in all district and county centers as well in cities with large industrial and mine enterprises (Georgiev 2000). Sofia alone had six sanepids. The sanepids had a complex administrative structure. When it comes to their methodical work, the sanepids were vertically subordinated to the Ministry, whereas on a horizontal level, their administration was subordinated to the health departments of the local People’s Councils in each district, county and city region (ibid.). Each of the sanepids had 15 to 30 hygienists at their disposal in time of need (Konstantinov 2006: 267). The administrative structure of the sanepids would undergo numerous changes, but up until the Kalaydzhiev Reform (1965), they remained under the control of the People’s Councils.
According to Panayotov (1999), thanks to this network Bulgaria successfully eliminated malaria in 1965, polio in 1968, and diphtheria in 1971. What helped tremendously was that already in 1951 Bulgaria provided free healthcare for its entire population.
However, the efforts from above were not reduced to new laws and the creation of different institutions. In order for these to work, the Party and numerous socialist doctors articulated the creation of epidemiological knowledge, structures and institutions as inseparable from the building of socialism. The “struggle for sanitary culture” – a movement that started in the Soviet Union – was operationalized in a way so as to penetrate the everyday practices of living and working spaces (Hristov 2013).* As professor Slavkov (1953: 6) of the Hygiene Institute put it, “the main [socialist] law – the law for the maximum satisfaction of the material and cultural needs of the population… [is] the main premise for the development of hygiene and the population’s culture of hygiene,” turning the healthcare efforts of the Party into peoplewide efforts.*
Numerous texts, written at the time, link the building of socialism with the need to introduce better hygiene habits among the population. And better hygiene was the primary help in the anti-epidemic struggle at the time. Momchil Hristov (2013) shows that the notion of “habit” has a specific sociological and political place in the medical topography. It denotes the interconnectivity between the everyday of the collective body and its material surroundings. Thus, two central points are being differentiated “that require a complex political interference – the material environment with its external factors that impact the health, on the one hand, and the population’s behavior, on the other.” (Hristov 2013: 126). Analyzing the biopolitical construction of the living environment and its relation to sanitary strategies and tactics of the state in the socialist context of the 1950s, Hristov makes three important observations: the biopolitical regulation of health was weaved into a “complex system of connections and gears between institutional initiatives from “above”, network initiatives from “below” and practices that are transversal to both levels;” socialist care of the individual and collective health was a popular movement; and that the socialist biopolitics depended on “extensive sanitary solidarity between members of the collective” (2013: 384).
Socialist medics were able to construct “hygiene habits,” the “everyday anti-epidemic efforts,” and the “scientific basis” behind the achievement of the former two, into a socialist praxis, but also into a socialist duty. The anti-epidemic effort and high culture of hygiene became a political project. Having the socialist duty to promote the anti-epidemic efforts of the state, a space opened up for scientists to criticise not only the pre-1944 bourgeois state and its “carelessness”, but also the limited, as many saw them to be, efforts of the Bulgarian Communist Party itself. Moreover, relying on the theorisation of “socialist laws”, scientists were provided with a space to rethink the purpose of their own occupations, demanding more socialism than what the Party was able to offer at the time.
In an article written in 1953, Dr. Yanev – head of the sanitary department at the Ministry of People’s Health and Social Care – resumed Ivan Pavlov’s theory of the interdependence between the external environment and the organism to argue that this interconnection is the main problem of the sanitary anti-epidemic work.* Dr. Yanev argued that some of the epidemics in 1952 – paratyphoid, dysentery and typhoid – were preventable had the Party and the Ministry directed more efforts into the construction of sewers, water supply pits, and the cleaning of cities and villages. Yanev’s criticisms were targeted in a few directions. According to him, despite the passing of Resolution 537 in 1952 – which aimed at the conduct of sanitary activities such as elimination of polluting factors, correct disposal of animal carcasses, improved water supply in towns throughout the country – the practical implementation of the above had been weak. He stressed that in order for these to work, there needs to be a better connection between the efforts for sanitation of the housings with those for the sanitation of the workplaces. Moreover, Yanev fought for the creation of a comprehensive sanitary network which was to include the rooting of hygiene practices in schools, apartments, food establishments, and in sites of leisure. For Yanev, as for many of the practitioners of the time, Bulgaria had to follow the Soviet “movement of the laborers for a sanitary culture” (1953: 11). The author articulated this movement in the following way: “The huge tasks before us can be solved only with the active involvement of all mass and political organizations, of the entire system of sanitary assets, [and] of all workers (1953: 11),” adding that the administrative efforts would be impossible to sustain without the self-initiative of all labouring people.
Yanev was an optimist. Despite his critiques towards the Ministry, he did not hesitate to praise the people’s efforts in the anti-epidemic struggle. He gave an example with Stanke Dimitrov – a town in southwest Bulgaria. It is here worth quoting at length:
The workers from the health department and the sanitary station in Stanke Dimitrov were the first to take up the instructions… to create a movement for sanitary culture. They analyzed the sanitary and epidemiological situation in their area and, given that there are a number of outbreaks of infectious diseases, they took seriously the organization of a number of sanitary and anti-epidemic measures, challenging the view that to improve the hygiene of settlements large amounts of state funds are needed. The health workers proceeded systematically and persistently to sanitize the villages in the area, focusing at first on the most endangered sites. In a short time, the district of Stanke Dimitrov, with materials at hand, built over 7900 toilets, more than 2700 sanitary manure, over 3100 cesspools, etc. 200 water sources have also been renovated and sanitary protection zones have been built for all centralized water supplies in the area. In addition, other renovative works were carried out – cleaning of canals, paving of streets, landscaping and others (Yanev 1953: Pp. 12-13).
According to Yanev, Stanke Dimitrov was successful as the region approached the task firstly by encouraging an interaction between health workers, the district committee of the Bulgarian Communist Party, the executive committee of the People’s Council, and all the mass and political groups; secondly, thanks to the well developed health-educational agitation; and thirdly because “the health brigades… took into account the suggestions of the workers and used them for wider implementation [of the sanitary efforts]” (1953: 13). Stanke Dimitrov’s efforts spread to other areas as well.
The Bulgarian Red Cross was one of the main drivers of the sanitary educational efforts. In a report issued in 1959, the organization was praised by the Ministry of People’s Health and Social Care because of its provision of preventive and sanitary-health measures (Gospodinov and Golemanov 1959).* From 1949 to 1959, the BRC was able to organise various classes on the topics of hygiene and sanitary action. The ГСО (готов за санитарна отбрана, “ready for a sanitary defense”) classes for example, which consisted in educating workers and high school pupils in basic knowledge regarding hygiene, infectious diseases, and anti-epidemic defense were visited by 2 600 000 people, or 33% of the entire Bulgarian population at the time; the БГСО (бъди готов за санитарна отбрана, “be ready for а sanitary defense”) classes provided basic sanitary and hygiene knowledge for pupils in elementary school, where 400 000 of them passed through such classes; the classes for sanitary squads („санитарни дружиннички“) were visited by 30 000 girls and women, whose knowledge was being refreshed each year; classes were organised in the Pomak and Turkish areas of Bulgaria, where sanitary activists were trained in basic medical knowledge and anti-epidemic defense. In addition to such classes, the BRC was organizing theatre plays, reading groups, exhibitions and other cultural events. These measures were not a one-off effort. Throughout the years, the BRC was able to create a vast network of sanitary posts and to train activists, who were regarded as the “the eyes, the ears, and the tentacle of the health authorities” (Gospodinov and Golemanov 1959: 21).
With time, the anti-epidemic efforts and the sanitary movement became a type of a popular front, where numerous towns and villages were organising countless campaigns, public lectures, sanitary competitions, and educational sessions in a joint effort between workers, labour’s intelligentsia, villagers, people’s councils, health brigades, and executive committees. This is how the institution of образцови села, домове, входове (exemplary villages, homes, entrances in apartment buildings) came into existence.* They are not some funny quirk of socialist nonsense, as anti-communists joke today, but a symbol of the efforts of the people in their fight for sanitary culture and anti-epidemic efforts.
In the early years of socialism in Bulgaria, epidemiology was conceived as a struggle. Not a struggle against an invisible enemy, as we often hear today, but a struggle against the very visible and structural problems that towns, workplaces, vacation homes, personal dwellings, and food enterprises exhibited. The popular front of the sanitary movement was able to make visible what today’s capitalist forms of political organisation attempt to hide from our sight – bad working conditions, poor and underfunded public health institutions, densely populated cities and small-sized dwellings, complete disregard of sanitary models that are able to save lives, apathy towards science, and more importantly, that health is a people’s movement.
The Kalaydzhiev Reform: centralization or democracy, profit or a common?
A long-time member of the Workers Youth League, in 1940 Vladimir Kalaydzhiev decided to cease his studies at the Sofia University Medical Department in order to join the partisan movement and later on the Eastern Front (Kalaydzhieva, Georgiev and Tsonov 2015).* After the war he specialized in microbiology at Sofia University and in the Military Medical Academy in Leningrad, followed by a specialisation in Immunology and Allergology in France and Great Britain (ibid.). His role in the development of epidemiology in Bulgaria was tremendous. Not only because of the numerous reforms he managed to pass – and that, within a very brief period of time – but also because his work presents us with a curious paradox. In 1962 he assumed the position of a Deputy-Minister at the Ministry of People’s Health and Social Care and was appointed a Chief Sanitary Inspector of the Republic. At the same time, a reformist wing in Bulgaria was pushing for an intensification of the economy (increased labor productivity, self-sufficiency of enterprises, grant-like financing, implementation of Liberman’s doctrine). Kalaydzhiev was a proponent of these developments and pushed for similar reforms in the health sector. Although Todor Zhivkov supported these processes in the economic sphere, Kalaydzhiev’s reform was met with strong resistance in the Ministry and by Zhivkov himself. *
In 1965, Kalaidzhiev stepped in to enact the largest reform in the epidemiological sector not only in Bulgaria, but perhaps even worldwide. In an article from 1965 for the Health Front (Zdraven Front) newspaper, Kalaydzhiev harshly criticised the model of preventive medicine existing at the time. His words were harsh: “fragmentation, local subordination, lack of coordination, primitive activity, low qualification” (Kalaydzhieva, Georgiev and Tsonov 2015). With only one stroke, Kalaydzhiev drove the health establishment to their knees. His main focus was to reform the organisation and the societal purpose of the Sanitary-epidemiological stations (the sanepids from above). Kalaydzhiev’s (1965) article was a systematic attempt to think through the new realities of socialism in Bulgaria and their relation to the role of epidemiology as one that should be oriented towards strengthening the life and health of the working populations.*
Kalaydzhiev starts off by working his way through the changing conditions of the external environment and their relation to people’s health. The development of metallurgy, of chemical production, mechanical engineering and other heavy industry sectors, in addition to the increasing role of food processing, leads him to conclude that the epidemiological measures in place of the time were not enough to match the “diversity and the complexity of the external environment”. For him the major problems of the sanepids were seven-fold: 1) impossibility to assure health security in the changing environment of socialist production; 2) too much focus on technical epidemiological aspects at the expense of the medical aspects of the science; 3) the struggle of the sanepids was directed exclusively towards infectious and parasitic diseases, disregarding the growing importance of diseases such as rheumatism, cardiovascular and respiratory conditions caused and/or aggravated by social factors; 4) necessity of interdisciplinary approach, in which epidemiologists would work closely with chemists, physicists, engineers, microbiologists and other professionals; 5) not enough laboratories and research centers at the level of the polyclinics as well as insufficient interaction between the sanepids and the doctors who are stationed at production plants and schools; 6) high relative share of the social organisational work at the expense of more qualified control; 7) the desire to build a large number of equivalent medical institutions had led to a lack of specialized institutions, which was a result of the excessive territorial scope of the sanepids. Instead, Kalaydzhiev proposed a model according to which the function of the sanepids was to study the working and living conditions and their relation to people’s health; to examine the social diseases from a hygienic point of view and to carry out preliminary and ongoing sanitary control; as well as to methodically govern the hygienic work of the entire health network.
At the time the sanepids were subordinated to the local People’s councils, which, for Kalaydzhiev (1965) meant that “the controlling administration is subordinated to the controlled administration.” Instead, Kalaydzhiev’s reform foresaw a unified hierarchical structure, independent of the People’s councils and headed by the Central Institute for Public Healthcare. The new structure was meant to include 10 regional Hygienic and Epidemiological Institutes (HEI) based in the central economic regions. The rest of the regional cities would have structural branches (Hinkov 2015).*
The reform was launched in 1965. Support for it came not only from home, but also from abroad. The World Health Organization saw the significance of Kalaydzhiev’s Reform and recognized the new centralized Institute as “an international model” to be followed elsewhere (Kalaydzhieva, Georgiev and Tsonov 2015). The WTO wanted to turn the Central Institute into a center for training of cadres from Africa, the Near East, and Southeastern Europe in epidemiological models of preventive medicine. The United Nations’ Development Program financed the reform with 1 272 400 USD (today’s equivalent of 8 650 000 USD); a sum that went into the training of cadres, the purchase of material equipment and international consultations. According to Kalaydzhieva, Georgiev and Tsonov (2015) the results could be seen in 12 aspects: (1) establishment of strong preliminary sanitary control in the industries and in the communal building; (2) the development of a program that ensures the preservation of water, soil and air purity (implemented between 1971 and 1975); (3) 130 industry sites achieved basic sanitary indexes; (4) development of strong sanitary control in mine, foundry, accumulator, glass and cement production plants; (5) sanitary conditions in meat and milk processing industries, as well as in food processing and trade enterprises were improved; (6) between 1966 and 1968 4.5 times more production plants were temporarily or permanently closed as compared to the 1963-1965 period; (7) establishment of highly hygienic tourist places; (8) effective and quick supply of bioproducts and efficient regulation of planned activities; (9) a model, according to which scientific research started relying on funding through grants; (10) the establishment of a unified system in the management of preventive medicine; (11) the development of an avant-garde National Automated Control System for Prophylactic Immunisations (NASUPI) and a complete register of information regarding the population’s past infectious diseases, immunisations and a plan for upcoming immunisations; (12) independence from the local people’s councils.
Undoubtedly, Kalaydzhiev’s Reform had a formidable impact on the development of epidemiology in Bulgaria. However, certain aspects of the Reform were not met with celebratory approval by the entire medical community. Party cadres, including the Minister of People’s Health and Social Care, Kiril Ignatov and the deputy ministers Georgi Nastev and Sibila Radeva opposed the Reform in two major aspects.* They wanted to retain power in the hands of the People’s Councils and scratch Kalaydzhiev’s proposition of applying stopanska smetka as a financial mechanism and self-sufficiency as the basis for an administrative organization of the health units.*
What Kalaydzhiev was suggesting was for the Reform to allow for certain economic mechanisms that were gaining traction at the time to enter the health sphere. As mentioned, the 1960s was a period when the state was looking for ways to intensify the economy through the introduction of market mechanisms into the economic sphere: increasing labour productivity, decentralisation in decision-making, linking wages to the accomplished sale of products, and introduction of profit as a motivational technique (Marcheva 2012).* In a document published in 1969, written by Kalaydzhiev – “Fundamental differences in the views regarding the organization and the content of the hygienic-epidemiological services” – one can see that the main opposition was linked to the concerns voiced out by Ignatov, Nastev and Radeva that a concentration of power in the HEI alone would lead to a disruption in the democratic principles. They also argued that the application of intensification mechanisms would be detrimental to the socialist organisation of health.*
Let us take a quote from an article of theirs published in 1969 and cited by Kalaydzhieva, Georgiev and Tsonov (2015: 5):
[We] cannot step back from the postulate of unity between treatment-and-prevention and the anti-epidemic network and this is guaranteed only by collecting [information] in places and in the hands of the People’s Councils that should appoint and finance [activities]; [otherwise,] the hygiene-epidemiological network would close in on itself and the democratic principle will be violated; there would be a lack of interest and even resistance on part of the People’s Councils against issues of hygiene…; the application of a stopanska smetka is amoral and it does not correspond to the principles of socialist healthcare; we also voice a disagreement with the creation of a Central Institute for Public Healthcare.
The protest of these medical cadres was soon to reach the People’s Councils and the central administration. Todor Zhivkov, at a session of the Central Committee of the Bulgarian Communist Party in 1969, criticised Kalaydzhiev and expressed an opinion that “Contractual relation and the [application] of stopanska smetka is an unforgivable violation of the principles of socialist healthcare.” Kiril Ignatov, at the same session, was worried that bringing the practice of self-sufficiency in the sanepids would trigger the continuation of the practice in other spheres of the healthcare: “Logically, if we are to continue with the practice then it should follow that other activities shall be paid for as well; for example: blood samples, X-rays, etc. We have this model in Yugoslavia. Our main concern is to care for the people. We cannot allow the economic practice of self-sufficiency to be transported to the field of healthcare.”
In “Conception to Improve the Healthcare of the Population”, Kiril Ignatov and Angel Todorov (cited in Kalaydzhieva, Georgiev and Tsonov 2015) attacked the Reform on the account that private healthcare providers and the stopanska smetka must not be allowed in the new Law on People’s Health (that was due to be reformed in 1973) as these practices, again, appeared in striking contradiction with the principle of free healthcare. Instead, they called for expansion of the hospital and the polyclinic network, as well as for double-fold expansion of hospital beds, increase of medical cadres and integration of the scientific medical bodies through the creation of a Medical Academy. Most of all, the authors of the Conception called for re-subordination of the HEI to the Regional People’s Councils.
Kalaydzhiev stroke back and wrote an “Anticonception” (Антиконцепция) whose foundation laid in a model focused on the individual and the family unit instead on the social organisation; the implementation of health insurance; the right of all citizens to choose their own general practitioners; private medical practice; development of the preventive activities (Kalaydzhieva, Georgiev and Tsonov 2015). In time, Kalaydzhiev’s propositions were rejected and he was dismissed from his Ministry position in 1971. However, a couple of decades later, his ideas would eventually be realised . In October of 1989, the state established the Health Insurance Fund, and in November of 1989 the private practices – abolished in 1973 – in the health sector were restored.
What is striking in this episode of socialism in Bulgaria is that party cadres, including Todor Zhivkov, were trying to save healthcare from what was already taking place in the economic sphere, often with the blessing of Zhivkov himself. The intensification of the economy was a conflict-ridden question and even some of its very ideologues, such as Evgeni Mateev, were opposing aspects of it (e.g. Mateev was against the adaptation of the category of profit as an incentive in the enterprises). In the late 1960s the intensification of socialist growth was one of the most discussed theoretical issues among socialist economists and sociologists. Wilczynski (1971) describes the opposition between extensive and intensive economy in the following way: “Extensive growth in its pure form is based on quantitative increase in labor, capital and land, whereas intensive growth is derived from gains in overall productivity, i.e. increasing efficiency in labor and a better utilization of capital and other means of production.” Intensification of the Bulgarian economy was pushed forward by what Marcheva describes as пазарници (marketeurs), or a reformist wing which strove towards market liberalisation. Todor Zhivkov’s position was ambiguous when it came to intensification processes. In a protocol from 1968, the Head of the Party is clear: “the faster and more fully we mobilise and use in our economic life the intensive factors, the more rapidly we can develop the economy and society as a whole.” (Central Archive Sofia 1/35/429, p.6). However, according to Marcheva (2012), Zhivkov was forced to step back from his initial plans because of the Prague events. Yet, in the 1970s, intensification would re-emerge strongly in the political debates and make its way through various reforms.
Although a strong supporter of intensification, Todor Zhivkov is far from being seen as a dissident in Bulgaria. This is not the case with Kalaydzhiev, however. According to Kalaydzhieva, Georgiev and Tsonov (2015), Kalaydzhiev was not driven by ideological dogmas, but by common sense. Fifty years later we see that health insurances, private medical practices, reliance on business accounts and the development of a system based on general practitioners are anything but free of ideological assumptions. Kalaydzhiev’s Reform acquired a dissident twist after 1989 and his name is highly celebrated today among members of the medical community. The texts I have relied upon for the writing of this piece are written in this precise setting. Professor Miroslav Popov tells of Kalaydzhiev: “In the 1970s, a Bulgarian doctor could really and publicly advocate for a reform of the Bulgarian healthcare system according to a model radically different from the existing one and from the Soviet model. This gives me reason to believe that historically Dr. Vladimir Kalaydzhiev is the first (or one of the first) dissident doctors in our country.” Professor Simeon Bachev confirms: “Dr. Kalaydzhiev was a dissident among his own.”
The dissident is an exemplary person in an anti-communist context. In her study on Anatomy of Reticence – a text written by Vàclav Havel in 1985 – Mariya Ivancheva (2007) demonstrates how Havel constructs the very essence of the figure of the dissident through his concept of “life in truth”.* “Life in truth” has various political functions for Havel, as Ivancheva shows, but the claim on “truth” it places, has acquired an almost ontological validity for all dissidents. Moreover, Ivancheva continues, “Only as a dissident can Havel claim the genuine opportunity to see things as they are… beyond indoctrination and ideology…” The dissident has to be a visionary as well. “For a few generations of specialists… he is a symbol and an example of high professionalism and moral, of a thinking that is extensive and ahead of its time…”, tells the honorific academician Bogdan Petrunov to the audience at an event dedicated to Kalaydzhiev’s 85th anniversary. And just like that, Kalaydzhiev is not only a “truth holder” but bestowed with an unnatural ability: to see what is ahead of his contemporaries, to see into a future free of ideology.
Our Kalaydzhiev is no Havel but the political mechanisms of the figure of the dissident are retained within how his life and work are narrated today. The way his colleagues and loved ones portray him in their memories is precisely through what supposedly stands in striking opposition to ideology: “truth” and “common sense”. As any other social figure, the dissident is not a static entity: it provides us with the tools to assess and understand a concrete and historical social situation. In our case, the function of Kalaydzhiev’s figure is to construct a medical field, free of conflicts over democratic principles and its public status. As such, the struggles over free healthcare are in turn constructed as a caprice of socialist ideologues who did not display the sober mind of the true visionary. One of the most crucial implications of these constructions is the building of a medical field that is politically neutral and driven by mere technicalities and the acquisition of professional skills. Some of Kalaydzhiev’s achievements mentioned above are indisputable. But we need to free medicine of such supposedly “truth-driven” dissident forms and instead search in it what it really stands for: healthcare is a struggle.
The conflict-ridden context depicted in this article is a lesson that we must not forget: the improvement of our working, living, leisure conditions is only possible through a mass movement that is able to turn and keep healthcare as a common. The movement for sanitary culture and the anti-epidemic efforts from the 1950s, which made visible the structural problems of people’s living and working environments, coupled with the management of healthcare concentrated in the hands of People’s Councils are a striking example of a possible political mobilization. Although Kalaydzhiev’s proponents today describe him as a martyr who resisted the status quo, they dismiss the possibility that his ideas of centralisation, hierarchisation and market financialisation in the most important social reproduction sector were in stark opposition not to the status quo per se, but to what the mass workers’ and medics’ movement from the 1950s strove for: more socialism.
Only a mass movement will be able to achieve what was achieved in the 1950s and what is delicately hidden from sight today: the very conditions in which we work, in which we live, in which we rest, in which we study determine the condition of our health; including the possibility of fighting off the spread of diseases. Today, we are faced with a choice: socialism or epidemy.
Cover image is by: Sergey Vasin