Short History of Bulgarian Medicine1

Part I ~ Ancient and Medieval Evidences for medicine on the Bulgarian Lands

1. Introduction

2. Thracian medicine

3. Slavic medicine

4. Proto-Bulgarian medicine

5. Bulgarian medicine in the Middle Ages

6. Bulgarian medicine under Ottoman rule (14th-19th century)

7. Medicine during the Bulgarian National Revival (1796-1877)

Part II ~ Famous Bulgarian medical man during the Revival Period

1. Dr. Petar Beron 1800-1871

2. Dr. Ivan Seliminsky 1799-1867

3. Dr. Nicola Piccolo 1792-1865

4. Dr. Atanas Bogoridi 1788-1826

5. Dr. Marko Pavlov 1786-1864

6. Dr. Ivan Bogorov 1820-1892

7. Dr. Vasil Beron 1824-1909

8. Dr. Stoyan Chomakov 1819-1893

9. Dr. Christo Stambolsky 1843-1932

10. Dr. Georgi Vulkovich 1833-1893

11. Mr. Sava Dobroplodni 1820-1894

12. Mr. Zahary Knyazeski 1810-1877

13. Dr. Dimitar Mollov 1845-1914

1 Copyright © by the author - 2007.

14. Dr. Kirko Kirkovich 1840-1877

15. Dr. Atanas Granitski 1825-1879

16. Dr. Zachari Strumski 1820-1869

17. Dr. Georgi Atanasovich 1821-1892

18. Dr. Petar Protich 1822-1881

19. Dr. Nacho Planinski 1847-1895

20. Dr. Dimitar Nachev 1850-1903

Part III ~ Modern Period of Bulgarian medical science

1. Organization of medical services during the provisional Russian administration

2. Medical services during coup d'etat of the Russian generals

3. Sanitary work in Eastern Rumelia

4. Sanitary Law from 1888

5. Advancement of health care in administration of the Liberal Party /1903-1920/

6. Health 1921-1945

7. Health 1921-1945, part 2

8. Health 1921-1945, part 3

9. Health 1921-1945, part 4

10. Health 1921-1945, part 5

11. Health since 1945: Transition period

12. Health since 1945: Transition period, part 2

13. Health since 1945: Transition period, part 3

14. Health since 1945: Transition period, part 4

15. Health since 1945: Institutionalization period

16. Health since 1945: Institutionalization period, part 2

17. Health since 1945: Institutionalization period, part 3

18. Health since 1945: Institutionalization period, part 4

19. Health since 1945: Institutionalization period, part 5

20. Health since 1945: Institutionalization period, part 6

Part IV ~ Health Care in Bulgaria from 1989 up-to-date /financing and delivery through a transition period/

1. New Laws Regulate the Problems of Organization, Management and Financing

2. The Crisis in Bulgarian Public Health Services

3. Paid Medical Care — with Preperence and at One’s Choice and Will

4. National Health Insurance Fund – 1

5. National Health Insurance Fund – 2

6. National Health Insurance Fund – 3

PART I: ANCIENT AND MEDIEVAL EVIDENCES FOR MEDICINE ON THE BULGARIAN LAND /FROM 100 000 B.C. TO 1878/ ~ AN OUTLINE

From: Zlatka Dimitrova. The Heirs of Orpheus: Bulgarian Medicine and Pharmacy over the Centuries. In: Pötzsch, R (editor). The Pharmacy ~ Windows on History. Basel: Editiones Roche, 1996.

Introduction

The Balkan Peninsula’s highly distinctive traditions of medicine and public healthcare have always been linked: the region’s relatively high standard of living and cultural life dating back several thousand years BC. Paleolithic and Neolithic man in the Balkans appears to have had a good knowledge and awareness of health matters. Miniature models of ancient dwellings found near me town of Rouse show, for instance, the existence of waste pits (the first evidence we have of sanitation in neolithic times). The excavation of the Varna Necropolis from 1972 /Picture 1/, revealed the world’s oldest horde of gold (dating back to 4600-4200 BC) - the work of exceptionally skilful pre-Thracian craftsmen and reflecting a high standard of social and economic development (Venedikov et al., 1973).

Ancient Bulgarian medicine was shaped primarily by the practices of the three tribal communities who formed the basis of the Bulgarian nation: the Thracians, Slavs and Proto-Bulgarians.

Figure 1: Objects of pure gold discovered in the Varna necropolis. Historical Museum, Varna.

Thracian medicine

The Thracians, who belonged to the Indo-European ethno-linguistic community, were one of the most ancient of peoples and can be traced as far back as the Bronze Age. They inhabited the lands between the lower reaches of the Danube, the Black Sea, the Sea of Marmora, the Aegean and the River Strouma, as well as entire regions of Asia Minor. The distinctive nature of Tracian civilization and craftsmanship was firmly established by the second millennium BC. Thracian culture flourished particularly strongly between the 6th and the 4th century BC in the state of Odrysae, whose rulers built citadels and towns,

minted coins and constructed palaces and monumental burial mounds. At the end of the 4th century BC, Seuthes III, the ruler of the state of Odrysae, built his capital, Seuthopolis, which survived until the 2nd century BC, on a fifty-hectare site not far from the present-day city of Kazanlak. As excavations at Seuthopolis show, the Thracians had the technical knowledge to build the public sanitation facilities typical of the period. Seuthopolis had a water-supply and sewage network. Freshwater was drawn from wells, and wastewater was drained from the houses through clay pipes which were connected up to the central sewage system. The sewers ran outside the city walls where the sewage was deposited in the River Toundja, which encircled the city on three sides.

The Thracians were renowned for their progressive views on hygiene. The priests, in their capacity as physicians, would gather the people together in the town squares and teach them rules of hygiene which these would then have to repeat in chorus. According to some authors, Thracian nobles were free from intestinal worms because, besides knowing how to treat these parasites with male fern roots (Rh. Fillicis maris), they had such high levels of personal hygiene (Miteva, 1985).

Figure 2: Sculpture portraying the Thracian horseman. Found at Glava Panega

Thracian civilization owes its distinctive nature to the great structural diversity of its society and beliefs and to its relations with the four major civilizations of the time: the Persians, Greeks, Celts and Scythians.

The Celtic and Roman invasions of the 4th to the 1st century BC and the devastating epidemics of plague and other infectious diseases which periodically swept through the country (such as the pandemic plague of the 5th century BC or those of the 1st and 2nd centuries AD) led to a general decline in Thracian civilization.

Gods, goddesses and demi-gods constituted the Thracian pantheon, all of whom had some bearing on the nation’s health. Heros (the Thracian Horseman) was the Thracian god most commonly cited as being the god of life, death, hunting and fertility /Picture 2/. His followers believed him to be omnipotent, possessing the power to bring happiness not only to people on earth but also to those in the afterlife. Heros the horseman ‘protected’ people from sickness and evil. Heros the healer was depicted as a hunter slaying a wild boar, which symbolized disease and all things fatal to man. Extant votive tablets refer to him as ‘the great and benevolent Heros’ and ‘the patron saint of mining’.

The Thracian healer Orpheus, who most probably lived during the 6th century BC, was another popular figure. Said to be descended from the tribe of the Cicones, there is disagreement among historians whether he was a real historical figure or simply a myth. He was celebrated as a great singer, musician, tsar, god, physician, pharmacist and philosopher. On vases, coins and sundials from the Classical and Hellenistic period, he is often depicted playing a lyre, surrounded by Thracians or wild animals tamed by the magical powers of his music. It was Orpheus who first suggested using music as a healing aid. He employed a variety of techniques involving music, songs and fables, and left a legacy of tablets inscribed with remedies for numerous illnesses.

Figure 3: Orpheus making music, surrounded by Thracians wearing coloured hooded capes and leather hats. Red-figured Attic crater, second half of 5th century BC. Antiquities Collection, State Museums, Berlin.

Orpheus was famous for his herbal remedies. He was associated in particular with Heberlia Rhodopensis, ‘Orpheus’ flower’ or silivraka, perhaps mainly because it was found in the Rhodopes Mountains from which he is said to have originated. This plant is anabiotic, meaning that dried samples can be preserved for up to eighteen months and then brought back to life by being planted in the right environment. In most European countries, Orpheus is considered to be the patron saint of pharmacy (Dimitrova, 1990).

Orpheus was the founder of the philosophy later named after him, Orphism /Picture 3/. He was considered responsible for the Thracian and Ancient Greek theories of the origin of the universe and the origins of man. His philosophy was linked to the belief that the soul is immortal, and promoted a simple lifestyle close to nature. His acts of healing are reported in the writings of many ancient authors. According to Pausanias, ‘Orpheus surpassed everybody and possessed great powers since he was able to discover the secrets of the gods and produce remedies for illnesses which preserved one from their wrath’ (Vasilev, 1975).

Orpheus’ contemporary, the physician, priest and demi-god Zalmoxis, was an important figure in Thracian spiritual life. Before being endowed with divine powers, he had been the leader and priest of the Thracian Geti tribe who inhabited both banks of the Danube delta. Herodotus (5th century BC), the earliest writer to mention Zalmoxis, relates the story of Zalmoxis’ resurrection, when he returns from the afterlife to teach the Thracians about the immortality of the soul. This clearly identifies him as a follower of Orpheus. We can also deduce something of Zalmoxis’ beliefs from the following extract from the Charmides dialogue of Plato (427—347 BC): ‘Well, that’s how matters stand,

Charmides. They use recitation. I discovered this from a Thracian physician during manoeuvres, who was taught by Zalmoxis, and who, presumably, believes in the immortality of the soul. This Thracian said that the Greeks had a right to talk about what I’ve just told you. He also said that their king, Zalmoxis, himself a god, maintains that, just as one would not cure the eyes without curing the body, one should not cure the body without curing the soul. Apparently the reason why the Greeks have so much difficulty treating so many illnesses is that they do not treat the body as a whole. They fail to recognize that the health of one part of the body depends on the health of the other parts. The soul, he continued, is the font from which all the good and evil present in the body, and in the person as a whole, flow. The head performs a similar function for the eyes. So it is of paramount importance that we treat the soul first, in order that the head and the other parts of the body should be healthy. The way to treat the soul, my dear, is by recitation, by reciting good advice. The soul learns wisdom from this advice. Once the soul has accepted this wisdom, it is easy to treat the head and the remainder of the body.’

Zalmoxis is shown here as the founder of a school of thought that embraces both man and nature. Its very essence was the Orphic concept of the afterlife and the belief that body and soul formed an integral whole as did all of man’s individual functions. It is clear from the Charmides dialogue that the Thracian followers of Zalmoxis were critical of the Greeks, who did not accept the idea of the body as a unified whole in which ‘the health of one part depends on the health of the other parts’. Later on, Hippocrates (460—377 BC), the Father of Medicine, was to see nature as a united and indivisible whole, and man as a harmonious unity of physical and spiritual functions.

Herbal remedies were common in Thracian medicine. Theophrastus of Eresus (3rd century BC) notes that the Thracians used wormwood (Artemisia absinthium), hellebore (Veratrum album), bindweed (Convolvulus arvensis), elder (Sambucus nigra) to stop bleeding, wild thyme (Thymus serpillum) and other herbal remedies. In his treatise entitled De Materia Medica, the Roman physician Pedanius Dioscorides (1st century AD) refers to the use of greater celandine (Chelidonium majus), male fern (Dryopteris filix-mas), colt’s foot (Tussilago farfara), blackberry (Rubus fructicosus), creeping tormentil (Potentillla erecta) and other medicinal plants by the Thracians. The Thracians also used remedies containing calamine (zinc oxide), alum and other mineral extracts. The remedies of Dioscorides were used widely by Galen (129—200 AD) and even by Avicenna (979—1037 AD) and other medieval physicians.

Yoghurt was used by the Thracians to treat burns, scalds and other wounds, and later came to be known as the ‘Thracian elixir’. It was used by the women of the tribe of the Cicones for cosmetic purposes.

Figure 4: Votive tablet depicting the gods of medicine, first half of 3rd century. National Archeological Museum, Sofia.

Under Roman rule, interest in the cult of Aesculapius grew significantly in Thracian civilization. Aesculapius was the god of medicine and, in typical Thracian fashion, was usually depicted as a horseman with the face of a young man and a head of curly hair. At Glava Panega, we also find Aesculapius portrayed in typical Greek fashion /Picture 4/. He has a mantle thrown over him and is holding an egg in his hand with a snake entwined around his staff. On his left, his daughter Hygieia is depicted as a symbol of the sick person’s soul being nourished with health-giving juices, and on his right is Telesphorus, the god of children’s health.

The origin of the cult of Aesculapius is disputed. Those who claim it is of Thracian origin point to the fact that Aesculapius is often depicted with Bendida, the Thracian goddess of hunting. In addition, his name and that of his daughter Panacea are Thracian, and his cult enjoyed exceptional popularity in areas considered to be Thracian. Most of the sanctuaries dedicated to him have been found in areas of present-day Bulgaria which were formerly populated by the Thracians. Those who attribute a Greek origin to the cult point out that there is no written or epigraphic evidence on any statue or relief which directly or indirectly refers to the Thracian origins of Aesculapius or Panacea.

The numerous sanctuaries which appeared at the beginning of the 1st century AD bear witness to the widespread popularity of the Aesculapius cult. They were situated near the mineral springs of all the larger towns and villages and served as public health centres. The earliest reference to mineral water being used in the treatment of skin complaints is found in Herodotus’ description of the military manoeuvres of Darius I in Thracian lands during the 5th century BC. The use of mineral waters and other natural forms of therapy from Thracian times such as herbal remedies, music therapy and ‘good advice’ is as much a feature of Bulgarian medicine today as it was in the past.

Votive tablets dedicated to Aesculapius were donated by people who had been cured by such treatment. One such tablet was found during excavations at the village of Batkoun in the Pazardjik region (the original and a copy are now on display in Plovdiv’s Archeological Museum and Pharmacy Museum respectively). One of the largest tablets of its kind from that period depicts Aesculapius and Hygieia with the Thracian horseman, testifying to the link between Thracian, Greek and Roman mythology /Picture 5/.

A frieze of the health-bearing Thracian deities was discovered during excavations at Plovdiv in 1921. The original is in the Archeological Museum at Plovdiv and a copy is on display in the Pharmacy Museum. The frieze is one of the most important finds from Thrace during the Roman period (the first half of the 3rd century AD) It depicts eight figures, including Aesculapius, the god of medicine, his daughters Hygieia and Panacea, and Telesphorus, the god of children’s health.

Figure 5: Relief depicting Aesculapius, Hygieia and the Thracian horseman found at Batkun. Pharmacy Museum, Plovdiv.

The relationship which existed between Ancient Thrace, Greece and Rome is of great historical interest. The Thracians participated in the birth of Greek civilization and their influence was strongly felt in early Greek history. Certain religious cults of Thracian origin (the cult of Bacchus, for instance) sprang up amongst the Greeks very early on. The cult of Orpheus was the ideology which the poverty-stricken peasants and slaves of the 6th century BC embraced. This cult had a great impact on the way ancient civilization developed and on Ionian philosophical thinking in particular. In return, there is no doubt that Greek and Roman medical and pharmaceutical practice had an important impact on those lands that were later to become known as Bulgaria. As far back as the 7th century BC, the Greeks had established small towns and colonies on the Black Sea coast, e.g. Appolonia Pontica (Sozopol), Odessos (Varna), Mesembria (Nesebur), Anchialos (Pomorie), Dionysopolis (Balchik) and Bizone (Kavarna). But by 46 BC, the Balkan Peninsula was under the complete control of the Romans, who introduced high standards of sanitation. They built new towns and improved the sanitation of the old ones. They constructed baths and reservoirs near the mineral springs, which were used not only by the Imperial families, but also by the sick from the shores of the Aegean, Asia Minor and Egypt.

Advances in almost all branches of medicine were achieved during the first four centuries AD. At excavations near the village of Lyublen, the burial tomb of an eminent Thracian physician of the Roman period yielded such finds as medicine bottles, silver and silver-plated bronze dosage spoons and a silver-plated set of six surgical instruments with elaborately worked silver handles. This physician had probably been a priest from the nearby sanctuary of the Thracian horseman.

During excavations at Bansko in 1970, a large number of surgical instruments were discovered in the grave of a physician from the Roman period. The grave also contained two bronze vessels, a medicine box with a bronze spoon, twenty mineral-based tablets of varying colour, shape and size (up to 11 mm) and a boot which had probably contained fragrant oils (Apostolov et al., 1974).

After the fall of the Roman Empire (378 AD), these lands which were later to constitute Bulgaria became part of Byzantium.

Slavic medicine

Though migration of the Slavs began in the 2nd century AD, it only really got under way in the third and fourth centuries after the Celtic and Hun invasions. Incursions by the southern Slavonic group into Byzantium began at the end of the fifth century when they attacked the provinces south of the Danube and reached the Peloponnese peninsula, Thessaly and Epirus. From the mid-sixth century on, they settled permanently in these regions and mixed with the local Thracian population.

Perceptions of health and sickness in the medicine of these Slavic peoples contained elements of magic. Nevertheless, some treatments involved the use of plant remedies such as birch, willow, lime, sycamore and pine. They coated the tips of their arrows with hellebore (Veratrum album), used hemp and poppy for anesthetics, and ivy to cure vomiting.

Slavic religion was polytheistic, but slowly the belief in one supreme god, Perun, the god of lightning, began to gain ground. The beautiful Pirin mountain is named after this god and is considered to have been his main sanctuary.

Proto-Bulgarian medicine

The Proto-Bulgarians belong to the Turkic linguistic and ethnic community. Originally from Central Asia, they migrated towards Europe in the second century and, from the fourth century onwards, lived in the Caucasian Mountains. During the period known as the great migration of peoples, the Proto-Bulgarians were drawn into the Hun tribal union. When this disintegrated, they established themselves on the lands between the Danube and the Dniester rivers. At the end of the sixth century, the chieftain Khan Koubrat formed the Proto-Bulgarian tribal confederation on what is now southern Russia and was called Great Bulgaria by Byzantine writers. After Koubrat’s death in 651, the confederation was invaded by the Khazars and then broke up. Asparukh (641-700), one of Koubrat’s sons, became ruler of one of the Proto-Bulgarian tribes, the Onogurs, who moved West to the Danube delta. The unsuccessful attempts of the Byzantine Emperor Constantine IV Pogonatus (652-685) to quell the incursions by Asparukh’s Proto-Bulgarians forced him to make peace with them in 681 and officially recognize Bulgar control of the area. This is considered to be the starting point of the Bulgarian state /Picture 6/.

Figure 6: Relief depicting a victorious Bulgarian soldier on the medallion of an 11th century gold ewer from the treasure of Nagi St. Miklosh in Rumania. Historical Museum, Vienna.

The Proto-Bulgarians believed in just one god, Tangra (from the Turkic word tangri meaning sky). However, they also held water, stones and other objects in esteem, believing them to have magical powers.

From the time of the first Bulgarian state, the book containing the answers of Pope Nicholas I (800-867) to the 118 questions set by Boris I in 862 has been preserved (unfortunately, the actual questions have been lost). When examining papal answer 62, regarding the cult worship of a certain healing stone, we must bear in mind that stone worship was also prevalent amongst certain Turkic tribes. Interestingly enough, up to the end of the last century and possibly even later, crushed red stones (Argilla rubra), mixed with water or wine, were used in Bulgarian folk medicine to treat the frail and the bewitched. The healing power of these stones is due to their content of iron and alum, which have anti-inflammatory properties.

Pope Nicholas I’s sixth answer states, ‘.. . You mention later that the Greeks say you must not bathe on Wednesdays and Fridays’. This short extract clearly shows that the Proto-Bulgarians bathed frequently and that they could not accept the Greek priests’ recommendation not to bathe on Wednesdays or Fridays. The Proto-Bulgarians believed in the prophylactic and purgative power of water and erected buildings to accommodate baths. In times of war, baths made out of leather were set up in special military bathing tents, where the soldiers were sprinkled with water before going into battle. The ground was also doused with water after sacrificial ceremonies had taken place. Open-air pools and baths, with air-heating and complex sewage and drainage systems, were found at Pliska, Madara and Preslav and in the palace of Khan Omourtag (died 831), testifying to the Proto-Bulgarians’ high standards of public and personal hygiene.

Of particular interest in Proto-Bulgarian medicine are the (real and symbolic) trepanations which were performed (Boev, 1964). The rough-and-ready implements used in trepanation (flints, antlers, shells) were gradually replaced by a more sophisticated technique which involved grinding and scorching the cranial bone. This practice was known as moxa, and was performed using wool dipped in hot tallow, fat or other such substance.

Many of the healing practices of the Proto-Bulgarians were assimilated into the folk medicine of the Slav- Bulgarian state, which already drew upon a wide variety of Thracian and Slav medical practices.

Bulgarian medicine in the Middle Ages

The Middle Ages represent the period from the creation of the first Bulgarian state in 681 to its subjugation under the Ottoman yoke in 1396. The adoption of Christianity in 865 and the spread of the Slavonic alphabet in the 9th and 10th centuries allowed Bulgaria to establish its authority as one of the most culturally advanced states. Knyaz Boris I, with help from disciples of St Cyril and St Methodius and from St Naum and St Clement, established the universities of Preslav and Ohrid, where theology and science were taught in Bulgarian /Picture 7/.

Figure 7: Synodicon issued by King Boris I. Cyril and Methodius Nation Library, Sofia.

At the end of the 9th and the beginning of the 10th century, knowledge of the natural sciences and medicine in Bulgaria was comparable with that in Byzantium. The natural-history and medical writings of Bulgarian scholars such as John the Exarch, Clement of Ohrid, Chernorizets the Hrabur circulated throughout all the Slavonic countries, Kievan Russia and Western Europe. In comparison, the 9th and 10th century scholastic writings of the Germans, French and Italians were purely religious in nature. The Bulgarian language was also used along with Greek, Hebrew and Latin in the churches of the time, a privilege not granted to any other European language.

John the Exarch (who lived some time during the 8th and 9th centuries), a great scholar from the Golden Age of Bulgarian literature, was one of the most influential people in medieval literature and natural science. His second work, Shestodnev (The Six’ Days of Creation) (John Exarch, 1981), written especially for Tsar Simeon I, the Great (863-927), was the first medieval Bulgarian textbook on the natural sciences and contains interesting descriptions of the human body /Picture 8/. Though medical texts of the time were usually in Latin, Hebrew or Greek, it was not written in any of these languages. By way of comparison, the first translation of the Bible into French did not appear until the 13th century and ecclesiastical writings in English only in the 15th century.

Though John the Exarch did not think of himself as a physician, his knowledge of medicine was wide-ranging. He was the first to translate the concept of pharmaceuticals into Bulgarian, referring to ‘root phenomena’, which could be construed as herbal

remedies. Using medicinal plants as examples, he developed a philosophical theory of the origin of life. ‘Nothing which is created exists in vain. A plant is either there to feed the cattle or it is there to alleviate our lives and help cure the sick. Crickets eat hemlock but, because of their body structure, its poison does not harm them... Quails feed off hellebore but their organism is such that they are not harmed by its poison. These plants can also be of benefit to us. Opium soothes and alleviates strong pain. Others use hemlock to control and quell their passions and desires. Hellebore relieves long-drawn-out suffering.’ John the Exarch also had a thorough grasp of the methods used to modify the active ingredients present in medicinal plants. ‘Pomegranates are sour and almonds bitter. To make them sweet, a farmer car pierce the tree trunk at the roots and drive in a tarred pine wedge...’ (John Exarch, 1981).

Figure 8: Cover page of the Shestodnev of John the Exarch, 13th century manuscript. National Museum of History, Moscow.

In the second half of the 9th century, the most renowned medical centre of the day was that established by Clement of Ohrid (840-916) at the monaster, in Ohrid, which did not charge for its services. It was here that the eminent medieval physician and Bogomil leader Vasilii Vrach (1028-1111) received his medical training.

In the early 10th century, Ivan Rilski (880—946) of the Rila Monastery became widely known for his treatment of various illnesses, particularly mental illness. Hospitals were later established at the Bachkovski, Troyanski and Bitolski monasteries. After Bulgaria’s conversion to Christianity in 865, ecclesiastical and monastic medicine evolved on the basis of the following therapeutic practices: oral stimulation through the use of prayers, sermons and confession; music therapy; herbal remedies; stress or shock therapy, such as dipping people into cold water or locking them in the monastery cellars; healing by the use of holy relics; treatment with water from sacred springs; healing with consecrated food (bread, fruit, wine, etc.).

The distinctive nature of medieval Bulgarian medicine was strengthened by the emergence of the Bogomils (a dualist religious sect) during the reign of Tsar Peter (died 970). These highly humane heretics, who shook the foundations of the feudal system in Europe, were excellent herbalists and psychotherapists. One exceptionally valuable source of medical information is the Bogomil tract entitled Zeleinik, written in the 10th or 11th century It contains instructions on how to cure such conditions as eye and skin complaints, stomach-ache, poisoning, septic wounds and nosebleeds with herbs or honey, or through diet or psychotherapy. Bogomil writings and practices of the time give us an

insight into the use of different types of therapy such as infusions, baths and ointments (Ivanov, 1970).

The wide popularity enjoyed by Vasilii Vrach, his knowledge of theology, philosophy and medicine and his eloquence and progressive ideas made him a threat to the Byzantine authorities. The Emperor Alexius I Comnenus (1048-1118) waged a successful campaign against the Bogomils aimed at liquidating its leader. Vasilii Vrach was burnt at the stake in Constantinople in 1111. He had become the driving force and intellectual leader of the Bogomil Movement after the death of Father Bogomil in the early 12th century. Persecution forced several Bogomil activists - possibly including Hodja Bulgar (died 964), who came to be known throughout Afghanistan and Northern India - to seek sanctuary in the East. Bogomilism came to be widely accepted throughout the Balkan Peninsula and its influence was strongly felt in Western Europe, especially in Northern Italy and Southern France. Through the Bogomil movement and doctrine, Bulgaria undoubtedly made a significant contribution to the development of medieval religious, philosophical and social thought.

The close link existing between historical and medical developments was severed when Bulgaria came under Turkish domination. From 1396 onwards, the economic, spiritual and intellectual life of the Bulgarian people that had evolved over centuries was ruthlessly suppressed.

Bulgarian medicine under Ottoman rule (14th-19th century)

The Ottoman invaders established a feudal system of government by spahi (Turkish warriors) and curtailed the intellectual and spiritual development of the Bulgarian people. Some educated Bulgarians adapted to the Turkish way of life, while others were killed, or driven to exile in Italy, France and other countries.

The travel reports of Europeans who visited Bulgaria during the period known as the ‘Turkish yoke’ are a valuable source of information regarding Bulgarian medicine. They often present a picture of a depopulated country. A doctor at the British Military Mission in the Ottoman Empire, wrote, ‘From Varna to Rouschouk, on the eastern shore of the Danube, our route took us through hilly and forested localities. We passed the occasional squalid and solitary hut whose inhabitants nevertheless, looked quite healthy and strong...’ (English Travel Notes, 1987).

Squalid living conditions, suppression of the rights of the rayah (non-Muslim subjects), excessive taxes and frequent wars were all determining factors in the poor standard of hygiene existing amongst the people. There were devastating epidemics of smallpox, malaria and plague. Acording to a French diplomat, ‘The area around Silistra is covered in freshly dug graves. They look empty and mournful, and one’s imagination conjures up a picture of death itself, surrounded by dead bodies and dying people with the poisons of the infectious plague spewing out of their repulsive mouths’ (French Travel Notes, 1981).

No Bulgarian physicians or pharmacists were trained during this period of political and social oppression, and the healthcare situation amongst the Bulgarian population was correspondingly deplorable. Yosip Boshkovich recounts the tale of a sick, elderly Armenian who was taken to see the doctor in Dobrich, a relatively large town. ‘The doctor prescribed him medicines but the interpreter could not explain the prescription to the old man and the town had no pharmacist to whom he could go for help... We were told, however, that even there had been a pharmacist, he would not have been capable of understanding the prescription. Here, as elsewhere, the only alternative for the sick seems to be that they either get better and live a while longer, or they die.’ (Boshkovich, 1975).

Another traveler produced a list of medicines Europeans needed to carry with them when in Bulgaria ‘Wine vinegar to stop vomiting; mercuric chloride (a strong purgative) ... laxative salts; rhubarb because of its laxative and fortifying properties... gentian for the stomach; quinine sulphate for fever; mallow as an emollient; cantharides beetles for blisters; camphor or opodeldoc for massaging rheumatic pains; elder for high temperatures; lime blossom and camomile... No traveler can survive long in Turkey, without falling ill. This is due to the fact that the country has no public sanitation system. During our travels, we were constantly having to resort to our medical supplies. On our last trip, we came across so many people who were ill with fever that we had to replenish our stocks of quinine and other medicines’ (French Travel Notes, 1981).

Figure 9: The Hippocrates Pharmacy on Maxim-Gorki Street in Plovdiv.

The French naturalist, doctor and traveler, Pierre Belon, wrote extensively about the medicines and different types of medicinal plants found in Turkey. ‘Most of the doctors practicing in Turkey, Egypt and Syria are Jewish... The pharmacists and chemists selling medicines in the Turkish towns are also Jewish... When a doctor writes a prescription, he sends it to the pharmacist to get the medicine he wants /Picture 9/. Pharmacists as we know them do not exist...’ (French Travel Notes, 1981).

Jewish doctors driven out of Spain in 1492 and Portuguese Jews expelled from Portugal in 1496 came to Turkey, introducing Western medical ideas and Arab and Jewish medicine into the Balkans and Bulgaria.

The rayah were cared for mostly by folk healers who preserved and fostered the popular traditions of medicine. More often than not, they used herbal remedies made from the medicinal plants which flourished in such abundance in Bulgaria. About the area around the town of Shoumen, one traveller wrote: ‘Every year, large numbers of people from

Hadrianople (Edirne) come to this area to gather the seeds and seedlings they need for their medicines’ (English Travel Notes, 1987).

According to the Turkish traveler Evliya Chelebi, Bulgarian alum was very beneficial. It was found in the River Moushtanlii. ‘An amount equivalent to the size of two chick-peas, taken on an empty stomach, is sufficient to stop even the most acute diarrhea immediately. However, taken in excess, alum causes heart complaints.’ Evliya Chelebi, among others, mentions that Bulgaria’s numerous mineral springs were used in the treatment of certain illnesses (Chelebi, 1972).

During the first four centuries of Ottoman rule, vitually no healthcare or sanitation existed in Bulgaria. The only medical assistance the Bulgarian population received was from folk healers and monks. The lack of doctors in 19th century Bulgaria prompted the emergence of a variety of self-proclaimed physicians, amongst them hekimi (self-proclaimed doctors), djerahi (surgeons), bileri (Greek healers), ahtari (druggists) and spitseri (unqualified pharmacists who had learnt their trade from a doctor who owned a pharmacy). In the dictionary compiled by Naiden Gerov (1823-1900), the word ahtarnitsa is defined as a place which sold herbal remedies, animal- and mineral-based healing potions and other items. Ahtarnitsi still existed in Bulgaria after Turkish rule ended. Contemporary publications reveal that the ahtarnitsi sold raw medicinal ingredients, pre-prepared medicines, herbs, surgical instruments, paint, coffee, tea, sugar, cups, plates and other items, thus making this prototype chemist’s shop sound very much like a general store. The ahtarnitsa of the Hippocrates Pharmacy Museum has many healthcare items of the period on display.

Medicine during the Bulgarian National Revival (1796—1877)

During the period known as the National Revival, qualified doctors of all nationalities, including Greeks, Jews, Turks, Germans, Austrians, French, Armenians, Italians, Russians and Serbians, came to Bulgaria. They were, however, poorly paid. ‘In Iskoub, we met a Dalmatian doctor, Dr Petrovich, who had settled and married in Melnik. He was a practicing physician but was also involved in the sale of leeches and cotton-wool. Unfortunately, circumstances in Turkey forced him to do this so that he would be able to leave his children some sort of inheritance’ (French Travel Notes, 1981).

Bulgarian doctors were first mentioned in the early 19th century, Marko Pavlov (1784-1864) was the first trained Bulgarian doctor He qualified in Paris in 1811 and opened the first doctor’s surgery in Bulgaria in 1823, in the town of Veliko Tarnovo. Pavlov’s surgery was supplied with medicines by the local pharmacy. Dr Pavlov’s surgery is now a working museum which sells medicines to the public.

Figure 10: Instruments used at the Hippocrates Pharmacy for making medicines.

The first medical school in the Balkan Peninsula was established in Athens in 1829. The first pharmacies were run by qualified doctors; one of them, that of Dr Rashko Petrov, now houses the Hippocrates Pharmacy Museum in Plovdiv /Picture 10/. The oldest exhibit on display is an earthenware filter made in Manchester in 1830, which was used for herbal infusions. Different filters were used depending on the purity of the drug.

The second group of pharmacies were run by pharmacists who had qualified abroad. Graduates from the pharmaceutical faculty of Tsarigrad medical school were referred to as spitseri (spicers). The first spitseriya in Bulgaria was opened by Mavrodiya Kourtev in Sliven in the 1820s. In 1865, the Sultan’s Council of Physicians issued a decree stating that the title spitseri could only be used by suitably qualified persons, and only these people could run a spitseriya. All unqualified spitseri who wished to continue practicing had to pass the necessary examinations.

Pharmacies gradually spread throughout the country. By the time Bulgaria had been liberated, there were 32 in all, not including those attached to the Turkish military hospitals. Public pharmacies whose main purpose was to supply the poor with free medicines also began to appear, alongside the private pharmacies run by doctors and spitseri. The first such pharmacy was opened in 1876 in Rouse, and their number gradually increased.

Folk medicine continued to play a very important role in the lives of the vast majority of the population. Over twenty manuscripts of collections of remedies have survived for scholars to study. These were copied over and over again and handed down from generation to generation. Even towards the end of the 19th century the services of the folk healers Hadji Evtimii (1800-1880), the abbot of Glyuzhenski Monastery, and Father Matei Preobrazhenski (1825-1875) were still much sought after.

Many of Bulgaria’s first healers and pharmacists were also actively involved in the struggle to liberate the people from spiritual and political oppression. During the National Revival period, moreover, Bulgaria’s first group of doctors were also eminent writers (Dr Petar Beron, Dr Ivan Seliminski, Dr Ivan Bogorov, Dr Nikola Pikolo and Dr Vasil Beron) who not only contributed to literature but were also involved in the struggle for an independent Church.

Figure 11: Workshop of the Hippocrates Pharmacy. In the background, the herb mill for grinding medicinal plants.

The second group of Bulgarian doctors, pharmacists and spitseri were - besides being writers - also involved in revolutionary activities /Picture 11/. Dr Kiro Popov, Dr Vasil Sokolski, Spas lvanov, Vasil Petleshev and others were hanged by the Turks for their part in the April Uprising. There seems to have been a very fine divide between the humane act of caring for the health of the people, and fighting for their liberation.

The folk healer Ivan Raev (1876-1938) achieved wide international acclaim. In 1922, he successfully used a solution extracted from the roots of deadly nightshade (Atropa belladonna) in the treatment of Parkinson’s disease. This treatment was later accepted by the medical establishment and is referred to as the Cura Bulgara. The clinic set up in Rome by the Italian queen, Elena of Savoy, where Raev’s drug was clinically tested, was later turned into an educational institute bearing his name. Though new and more effective drugs are now available for the treatment of Parkinson’s disease, Ivan Raev is still remembered with respect and his treatment is accepted throughout the world.

As the 19th century progressed, healthcare in the Ottoman-dominated lands gradually improved. Public health services were established and the first municipal hospitals and private and public pharmacies opened. The first sanitation laws were passed in an attempt to combat epidemics and establish sanitary control and quarantine.

The Russo-Turkish War of Liberation (1877-1878) put an end to almost five hundred years of Ottoman rule and left Bulgarian medicine with a great deal of catching up to do. Subsequent healthcare developments in the liberated Bulgaria of the late 19th century were influenced not only by the country’s own revolutionary and democratic traditions but also by the progressive, democratic ideas of popular Russian medicine.

References

Note: Most of the following publications are Bulgarian originals. The titles are translated here for information purposes.

1. Apostolov M, Atanasova S: A Study of the Composition of Medicines found in

Roman Tomb near Bansko, Aesculapius (Russian original), pp 55-56. Sofia:

Meditsina i Fizkoultura, 1974.

2. Boev P: Symbolic Trepanation in Bulgaria, Bulgarian Academy of Sciences,

News Bulletin, vols 9-10, 1964.

3. Boshkovich R: Diary of a Journey, p 57. Sofia: Otechestven Front, 1975

4. Chelebi E: Travel Notes, pp 24, 28-29, 48, 287. Sofia: Otechestven Front, 1972.

5. Dernschwam H: The Diary of Hans Dernschwam on his Journey to Tsarigrad

during 1553-1555, pp 155-156, 185. Sofia: Naouka i Izkoustvo, 1970.

6. Dimitrova Z: Introduction to the Subject, pp 16-18. Sofia: Meditsina i

Fizkoultura, 1990.

7. Ivanov I: Bogomil Books and Legends. Sofia: Naouka i Izkoustvo, 1970.

8. John the Exarch: Shestodnev Sofia: Naouka i Izkoustvo, 1981.

9. Kitanov C: The Bulgarian Treatment of Parkinsonism, vol 5, p 23 Sofia: Priroda i

Znanie Magazine, 1982.

10. Miteva N: Thracian Beliefs and their Connection with Medicine, II National

Congress on the History of Medicine, Veliko Tarnovo, 1-4 November 1985.

11. Plato: Charmides (Ancient Greek original). Sofia: Naouka i Izkoustvo, 1986.

12. Rogev B: The Astronomical Basis of the Proto-Bulgarian System of Chronology,

Bulgarian Academy of Sciences, p 92 (Russian original). Sofia: 1974.

13. Vasilev V: Ancient Thracian Medicine, p 104. Sofia: Meditsina i Fizkoultura,

1975.

14. Venedikov I, Gerasimov T: Thracian Art, p 407. Sofia: Bulgarski Houdozhnik,

1973.

15. English Travel Notes in the Balkans (14th Century to 1930), vol 7, pp 387-388,

644. Sofia: Naouka i Izkoustvo, 1987.

16. French Travel Notes in the Balkans (l5th-l8th Century) vol 4, pp 106, 187, 248,

253, 271-272, 337, 341, 482. Sofia: Naouka i Izkoustvo, 1981.

PART II: LIST OF BULGARIAN MEDICAL MAN

1. Dr. Petar Beron 1800-1871

2. Dr. Ivan Seliminsky 1799-1867

3. Dr. Nicola Piccolo 1792-1865

4. Dr. Atanas Bogoridi 1788-1826

5. Dr. Marko Pavlov 1786-1864

6. Dr. Ivan Bogorov 1820-1892

7. Dr. Vasil Beron 1824-1909

8. Dr. Stoyan Chomakov 1819-1893

9. Dr. Christo Stambolsky 1843-1932

10. Dr. Georgi Vulkovich 1833-1893

11. Mr. Sava Dobroplodni 1820-1894

12. Mr. Zahary Knyazeski 1810-1877

13. Dr. Dimitar Mollov 1845-1914

14. Dr. Kirko Kirkovich 1840-1877

15. Dr. Atanas Granitski 1825-1879

16. Dr. Zachari Strumski 1820-1869

17. Dr. Georgi Atanasovich 1821-1892

18. Dr. Petar Protich 1822-1881

19. Dr. Nacho Planinski 1847-1895

20. Dr. Dimitar Nachev 1850-1903

NATURPHILOSOPHY SYSTEM OF DR. P. BERON

Petar Beron is born at 1800 in the town Kotel, “a miniature of Nuremberg”, in a rich family of handcrafts and merchants. In Kotel he receives his primary education at the cell school of Stoiko Vladislavov and Raino Popovich. Further he goes to Bucharest where he enters the school of Greek educator Konstantin Vardalach. The latter, a famous for his time pedagogist and encyclopedist, has influenced a lot for the formation of Beron as scientist and philosopher.

In 1824 he is compelled to leave Bucharest, because he participated in a “Greek plot”, and goes to Brashov, another Rumanian town, where he compiles “The Fish Primer”. This book is fundamental for the Reformation in Bulgaria and an

achievement for the young scholar. In 1825 P. Beron enrolls as a student in Heidelberg University where he proceeds philosophy until two years later when he transfers to Munich to study medicine. On the 9 July 1831 after successfully defending a doctoral dissertation Beron is promoted Doctor in Medicine. Dissertation is in Latin and concerns a methodology of obstetrics and gynecology.

The young physician works in Bucharest and Kraiova but after several years of general practice he quits his job and starts merchandise. After fifteen years he makes a fortune and goes to Paris where he lives as a renter. Here he starts a real scientific career. His scope is to entail all the human knowledge by that time and to make a naturphilosophical evaluation by creating a new “Panepisteme”. His encyclopedism is remarkable. Dr. Beron spoke nine languages and wrote about 30 volumes not regarding two dictionaries, one atlas, his doctoral dissertation and the “Fish Primer”.

There are certain facts, which come to show that Dr. Beron was appreciated by his contemporary scientific community. On the session of the Royal Academy of Science in London, held on the 20 June 1850, Sir John Lee presents his work “On the system of atmospherology” and gives tribute to Beron’s activity. In 1853 Dr. Beron is invited by the Association of Natural Sciences in Athens where he reads an article “Earth before the Deluge”. In 1955 he publishes in German language his “Slavic philosophy” where an

outline of his Panepisteme is featured. In 1858 is printed in French language “Origins of physical and natural sciences and of metaphysical and moral sciences”. Next two years are devoted to a huge cosmographical atlas with text. The maps in the atlas were designed by the famous bulgarian painter Nicolaus Pavlovich. But the height of his scientific endeavors is the “Panepisteme”, in seven volumes, which is published in French starting 1961. Until the end of his life on 21 March 1871 he is devoted to this interesting and creative task.

Dr. Beron has spent certainly 25 years of his life in Paris and other European cities. He has seriously and systematically studied western philosophy and culture. He witnessed the endeavors of classical positivism, most obviously in his contemporary Auguste Comte, to replace materialism and idealism with a third line in philosophy. However Beron sincerely believed in the independence of his philosophy Panepisteme. The only scholar whom he accepts as authority is Aristotle. These are the principal ends of his theoretical and logical views.

Addendum: If we make an inquiry, about, the most infamous bulgarian - that, will be our man. It is so, because, bulgarians are worldwide known as a nation not producing celebrities. It is not so, because, no one in Europe during the end of the XIXc. regarded Dr. Petar Beron as a bulgarian. One thing is sure, that, a doctor remain in his heart a bulgarian and belonged to the Slavdom. Even, his heart was sent back to a newly liberated Bulgaria, in 1978, to be berried in his native town Kotel. Today, this embalmed heart could still be found in his House Museum in town.

We wanted to make this extension on Petar Beron for several reasons. The literature on that famous Renaissance man is vast. While, looking here and there in the process of gathering materials for this review, there, we turn on page after page of the life and works of a rare genius. This statement could not be disproved - not only, because, his literary heritage comprise more than 10 000 pages. He could have been another Alexander von Humboldt for the Slav Nations - certainly, the multivolume "Panepisteme" could stand hand in hand with Humboldt's "Cosmos". But, it is still that we don't have this major opus in Bulgarian.

Otherwise, bulgarians keep a good tradition for this man, because, of his "Fish Primer" - allegedly, the first bulgarian secular textbook /in modern times and in new bulgarian script !/. We put an emphasis on this because in Medieval Bulgaria - First and Second Bulgarian Kingdoms - there, existed many examples of early secular literature. This, however, remains in the shadows of the Byzantium Literature /Vth to XVth cc./. The later high development of the Russian Empire and other eastern nationalities, consistently, was preceded by the Golden Bulgarian Age. No more comments.

So, how are we going to proceed with a critique on P. Beron's philosophy. We have been trying to view the question from many angles. First, there are several good monographs reviewing his outlooks - but, it is necessary to abridge all that stuff. Second, if there are

other major works on that scholar in languages other than bulgarian - but, we don't have an idea on such works and don't have a necessary access. Thirdly, if there are living ancestors of the scholar - but, there is no evidence for such an archive existing and not yet.

In such case, fortunately, we believe that an interested reader will excuse our efforts. As time goes on and an open access to a "corpus habeum" will be available on that author - for free access. Until then our project will keep in touch for any fresh assets on the topic!

See for further details *

PHILOSOPHICAL AND SOCIOECONOMIC OUTLOOK OF DR. IVAN SELIMINSKY

Ivan Seliminsky is born on 24 december 1799 in Sliven. His inborn name is Yordan Georgiev Christov. His father was cattle merchant but was massacred by a turk one year after his son was born. In 1812 his whole family perished from plague. Thus in august 1814 Seliminsky departs for Jerusalem as a pilgrim. On his return he stays in the city of Kidonia /Minor Asia/ where he enters the local high school sponsored for five years by Kazanluk merchant Christo hadji Petrov. As all bulgarian youths studying in Greek schools he changed his name to hide his origin.

Ivan Seliminsky studied in Kidonia till the Greek uprising in 1821. The turks started mass massacre of infidels, mainly the men who took part in the insurrection, but also

woman and children which were sold as slaves. Seliminsky succeeded to escape and next three years /1821-1823/ enrolls as soldier and officer with the Greek army and takes part in many battles. In 1824 we see him in Brashov /Romania/. The bulgarian colony there includes many compatriots and young Seliminsky aquainted with way of life, socioeconomic and intellectual progress in western nations partakes actively with the life of the bulgarian settlement. The objective conditions and spiritual freedom еxite the bulgarians in exile towards liberty of ideas and actions to improve the fate of their motherland. At meetings of bulgarian colony Seliminsky explains that freedom of Bulgaria needs a national fraternity to unite all fighters and to apply in practice the act of liberty. Thus Seliminsky is chosen a leader of the emmigrees.

In 1825 Ivan Seliminsky returns in native city of Sliven. There he finds a Secret Society. Members are common people from the class of “non-nobility, the torlaks”. Seliminsky organizes also the first bulgarian school where mathematics, physics, geography and bulgarian language are studied.

The Odrin peace agreement in 1829 and the retreat of Russian troops from Bulgaria makes the population from Northeastern parts of the country to flee away in Russia afraid

from the revenge of the turks. The leader of the refugees is Seliminsky. He stays some time in Galatz then works as a teacher in Greek language at Bucharest and other places.

Now from 1840 until 1844 Ivan Seliminsky studies medicine at Athens University. After graduating he transfers to Sienna in Italy where he specializes in the fields and receives the title Doctor in Medicine and Surgery. The promoted doctor returns to Braila where he spent several years working as district physician. In 1853 he leaves work to actively join the bulgarian volunteer battalion with which he serves in the Crimean war as battalion physician. There he is honorably gifted and receives two silver medals from the Russian government. The end of the war finds him in Bolgrad where he works as a district physician, with some intermissions, to his death in 1867.

Dr. Ivan Seliminsky forms his naturalistic and social views amidst a community of economic progress in the first half of XIX century. Great influence has his acquaintance with the cultural advancement of western countries. This is a time when industry and trade prosper in Bulgaria – the national bourgeoisie becomes the embodiment of the idea for democratic reform and for liberation of the masses. In his brochure “The national fraternity in Sliven and the great migration in 1830” Seliminsky outlines correctly the social stratification in bulgarian society. He depicts the class of nobility, i.e. those bulgarians who call themselves “greeks” and on the other hand the class of non-nobility, the common people or “torlaks”. The “greeks” are a caste totally favored by the greek clergy and turkish rulers and they play a role absolutely reactionary against the liberation of the country. The moral and national character of the land is preserved pure among the natives of the population. It is for them that the young bulgarian bourgeoisie is interested for national and political freedom.

As a student in Kidonia and later in Athens Seliminsky studies the Greek philosophers – Socrates, Plato, Aristotle, Democritus and cites them in his works. A major influence over his views is brought by the French reformators and materialists from the XVIII century – Rousseau, Montesquieu, Helvetius, Condorcet etc., also the influence of the naturalists is great – Lamark, Humboldt etc. As an emigree in Romania Seliminsky reads Yury Venelin’s work “Ancient and contemporary bulgarians” where deeds of the ancestors are narrated. This book creates an urge to study history after 500 years of lethargy.

So far, the epoch where Ivan Seliminsky lives and works is time of enlightenment and self-consciousness of the bulgarian people. The overall public and historical backwardness, immaturity and hesitance of bulgarian bourgeoisie and poor scientific and ideological atmosphere are all reflected in the outlook of Dr. Seliminsky.

Addendum: Let me say few words about the literary heritage of that man. The most important part of his works are the memoirs - "Historical Recall". Those papers are written in greek language during 1855-57 and in a state of depression after the failure of the Crimean War. In his memoirs, Dr. Seliminsky narrates the fate of the bulgarian

people after falling under Turkish bondage and by the middle of the XIX c., when, a bulgarian revival movement developed with differed social factors evolving in the enslaved bulgarian land. The memoirs are written in a lively manner, with good historical accuracy and are a real relic of its time.

Another field of his works are the essays - papers with a direct thematic narrative, i. e. "Bulgarians Attitude towards the Neighboring Christian Nations" (1856), "Politics of Russia and the European Concert against Turkey with its enslaved nationalities" (1859), "Bulgarians and the Church Question" (1862), etc. Some other essays are written with a popular inclination and in the natural, ethical, philosophical sciences. For instance, in the "Natural Development of the Man" (1843), he reflects on the idea of the human mind and the development of the brain according the natural and social conditions. During the period 1843-64, Dr. Seliminsky write a number of studies on the topic of religion, blasphemy, sacrilege and marriage, i. e. "Origin of the religions", "Religion, Priesthood and Church Problems", "On the clergy and its origin", "Main Economic, Social and Moral Laws", "On Matrimony", etc.

Still important is the epistolary heritage. His correspondence with different bulgarian activists from the revival period highlighted many a forgotten details, i. e. letters to and from V. Aprilov, P. Beron, G. Zolotovich, A. Ivanov, etc.

So, let us recapitulate. Dr. I. Seliminsky's literary work comprised about 1000 written materials - mainly, in the Greek language. Nothing, so far, has been available in its original form - viz., books, journals and other printed matter. If something exist on the Greek side, equalizingly, we are not aware. If an archive is available with his descendants, unfortunately, we don't know them.

On the Bulgarian side remains his legacy, formally, handwritten testament carried on by his compatriots in Bessarabia /nowadays, southern Moldova and parts of Ukraine/. This handwritten materials were transported, somehow, to Bulgaria and donated to the Ministry of Education. Later, they were published in the form of XIV volumes in the period 1904-1931 - edited by P. Chilev and E. Pazheva. Still in the 70s of the past century, two books with materials from Dr. I. Seliminsky appeared, allegedly, with collaboration from Athens University, Greece.

Numerous are the secondary sources about Seliminsky, mainly, in bulgarian language. We could recommend 2-3 major monographs, which, contain wealth of information collected from first hand witnesses in Sliven, Bolgrad /Bessarabia/ and other places. The rest of the work on the topic remains. We engage in presenting to the reader and in a digestible form, what, would appear to be appropriate for the format of this project.

See for further details *

THE HUMANITARIAN DR. NICOLA SAVA PICCOLO

N. S. Piccolo is born in Veliko Turnovo from both parents bulgarians. He completes his secondary education in Bucharest with the school of Vardalach who becomes his intellectual father. In 1811 Nicola takes the post of a teacher in French languages at Vardalach’s school. Next we see him as a medicine graduate from Padua /Italy/ and in 1817 as a lecturer at the university of the Chios Isles. On the next year Piccolo together with a group of greek rebels transfers to Odessa where G. Lissani & Co. had a small theater and there three of his plays are performed. Among others “Demosten and Kalauria” had the greatest success.

Now in 1820 Piccolo immigrates to Paris where he meets Dr. A. Corais, an eminent greek naturalist and philosopher, and joins his group. Here studying medicine he also becomes a member of “Philiki eteria”- the Greek revolutionary organization for freedom of turkish yoke. In an appeal to the American people for help in their struggle we see Piccolo's signature in a row with greek revolutionaries. Meanwhile the young scholar continues his work in literature and medicine. In 1823 Lord Guilford, a helenophil and philologist, invites him for a track in philosophy at the University of Corfu Isles. There Piccolo teaches till 1827 and among other activities translates in greek Decartes “Discourse on the method”.

After the liberation of Greece and the Odrins peace treaty Count Pavel Kisselov, russian governor of the Danubian Principalities, appoints him as inspector general of schools and hospitals /1929/. At his new post in Bucharest Piccolo excels as talented administrator. He establishes modern tuition scheme, substitutes Greek language for Rumanian and introduces studies of natural sciences. Further he organizes sanitary affairs and hospitals, creates quarantine checkpoints on Danube’s harbors and engages in political activities. It is with Piccolo's intercession to Prince Stephan Begird that the idea of an autonomous principality of Bulgarians is created in Dobruja, however, a cholera epidemia hinders the project.

In 1839 Dr. Piccolo resides in Paris. There he becomes active member of bulgarian emigrant community. He partakes in many political debates and campaigns. During piece conference in Paris after the Crimean war, Dr. Piccolo and Dr. Beron work out a special petition which demands autonomy of Bulgaria together with the other Balkan nations. It is a serious fact, among others, that common truth at that times was the thesis of the Slavic origin of the greek people. Nevertheless, Piccolo never mastered the bulgarian language. He also was an atheist which is evident from the fact that only 1500 golden francs from his testament were dedicated to the church.

As a man of letters Nicola Piccolo was a follower of a Cartesian philosophy, rationalist and eclecticist. He has definitive role in the formation of modern Greek literary history. He is also one of the eminent figures of bulgarian national revival.

DR. ATANAS TZONKOV BOGORIDI AND FIRST BULGARIAN DISSERTATION IN MEDICINE

A. Tz. Bogoridi is from a famous bulgarian renaissance family - grandson of Sophroni Vrazanski and brother of Stephan Bogoridi. He was born in Kotel about 1788 but settled in Arbanasi, a village in Turnovo region. Bogoridi graduated the Greek academy in Bucharest in the class of Lambroso Votiadi. Being a talented student afterwards he was appointed a professorship in classical languages in the same school. In 1811 he departs for Vienna to study medicine. At the same time he becomes active member of greek revolutionary movement “Philiki Eteria” and consequently the city council authorities expelled him from town and Bogoridi departs for Wьrzburg, Germany to continue his studies. In 1816 after a successful promotion he graduates with a doctoral dissertation “On the problems of digestion in human stomach”. Next year the monograph is printed by Frans Ernst & Publishers.

In a while Bogoridi departs for Valachia, the city of Yash, where he works for some time general practice but afterwards he moves to Vienna and still later to Paris with the intention to specialize in hospitals. Meanwhile he regularly contributes to scholarly journals. Unfortunately, on 1 Mart 1826 Bogoridi dies after short illness in the prime of his life. On this occasion his close friend Teoklit Farmanidis writes an obituary, with notes on his life and activities, published in the official organ of “Philiki Eteria” at the city of Navlion, Greece. Another Greek scholar, Moschopulos writes accordingly: We have to mark down that Atanas Bogoridi was one of the greatest bulgarian scholars and patriots from the beginning of XIX century. He was an active contributor to the journal “Logios Hermes”, published in Vienna. Further we see an acknowledgement for his work in the words of Bulgarian penman Grigor Purlichev when the latter polemizes with Greek professor Orfanidis in 1860, namely: Bulgarian Atanas Bogoridi was the energetic apostle of “Eteria” during his stay in Vienna. He was always exposed to the danger of being arrested by the Austrian police.

A closer look at the dissertation of A. Bogoridi reveals 55 pages written in German alphabet. We see that the process of digestion is examined in details with good knowledge of the anatomy of abdomen and intestines, however, physiological processes are poorly described and he uses naturphilosophical speculations… The author considers water a common nutritional substance as is evident from empirical evidence that plants subside on water and animals subside directly or indirectly on plants – ergo, water is a prime mechanism for existence of life and plants and animals are confined in a repeated metamorphosis of water. He further makes guesses on the role of saliva in mouth and comparing with gastro-intestinal juices makes a difference. Then he tries to explain mechanism of digestion with chemical, mechanical and thermal factors, however, not knowing its constituents /i.e. enzymes/ he entails in different speculations on material substratum rather than some supreme, abstract vital force. One way or another his discussion rests on mechanistic not idealistic concepts and correspond to the matter of science of the day.

Finally, we can say that a short life did not give opportunity to this talented Bulgarian scholar and man of the revival period to fully manifest his versatile abilities.

DR. MARKO PAVLOV - FIRST BULGARIAN MEDICAL DOCTOR

Marko Pavlov is born in the town of Sveshti, district Tetovo, a. 1785-1786. He remains orphan as a kid so an Italian wheat merchant take care of him. Firstly, a primary tuition M. Pavlov acquired in the Greek school at Turnovo. Next, he moved to live with his Italian benefactor in Venice where he graduated secondary studies. Afterwards, Pavlov continues his education in France, in the University of Monpelie where he enrolls to the medical faculty. We know from a checkpoint in the university archives that a student with such name figured in the register at the end of XVIII c. Further, because we don’t see his name later than year 1808, we can conclude that Dr. Marko Pavlov received his Medical Diploma a. 1807-1808.

It was a time of revolution and turmoil when Napoleons army conquered the world. Young doctor Pavlov enlisted a volunteer in the medical brigade. According to one of Napoleons niece Dr. M. Pavlov was adjunct physician to Marechal Ney, Prince de la Moskowa, Duc d'Elchingen /1769-1815/. After the defeat of the French army Pavlov migrates to the Ionic islands where we see him now as member of Greek rebellion from 1821-1822. The cause of Greek independence pending, Dr. Marko Pavlov transfers to an ordinance with the turks and is at medical service with the military. He travels there to Tunisia and Marocco.

We don’t know exactly when Dr. Pavlov establishes back in Bulgaria, but it is a fact that he was honored to be a private physician to the Pasha of Philibe. Obviously, this was a reward for good medical practice on his retirement from the Turkish army. When the Pasha leaves the town Dr. Pavlov goes with him to a new destination. Finally, they reside in the city of Turnovo where Marko Pavlov spent his youth. At that time it is said that the town had not a qualified medical doctor, yet, people look for help at folk healers. He opens a drug store and stays with his family in Turnovo. Dr. M. Pavlov dies on 18 January 1864.

This is scarcely what we know about life and work of M. Pavlov, eminent figure from bulgarian enlightenment. Here are two more facts which are worth discussing when we speak about Dr. Pavlov. He is said to be first M.D. with a private drug store functioning about 1856. Bogomil Vachev, a scientific researcher in pharmacy, finds in the municipal archives of Suchindol /district Veliko Turnovo/ a literature fund in French from the past century. A revision in 1981 shows this to be the apothecary documentation - so called "vasaria" or "lekarnia". The data are arranged in a museum collection.

The family of Dr. Marko Pavlov had three sons - two of them graduated medicine, one graduated pharmacy, all of them from the Military Medical School in Tzarigrad. Dr. Pavel Markov /1824-1880/ is military physician in the Turkish army and works in Badgered, Tzarigrad and Yemen. Dr. Charalampi Markov /1831-1881/ works as city physician in the town of Razgrad. Dr. Georgi Markov - Markidis /1835-1903/ graduates

pharmacy and inherits his fathers apothecary until 1886 when its sold to Panayot Slavkov. No one of the three sons claim to have heirs.

THE VERSATILE BOOKMAN DR. I. A. BOGOROV

Ivan Bogorov is born in the town of Karlovo. His birthday, according to the transfer from the Julian to the Gregorian calendar, is a. Dec 1820 to Jan 1821. His primary education he received with the famous revival elinist Paino Popovich at his hometown. At 18 years he goes to Tzarigrad to study in the Magnus Schola at Kuru Cheshma, namely for the Greek patriarchate as was the option for many bulgarian youth. Bogorov stays there until 1841 when he moves to Odessa at the French Gymnasium, to the name of Duc Armand Jean du Plessis de Richelieu /1852-1642/ - founder of the French Academy of Sciences.

In Odessa he meets with other bright bulgarians of the time, viz. N. Gerov, N. Michailovski, D. Chintulov. With some saved money, the young scholar is tempted to continue his education so he travels to Leipzig in 1845. There, while still studying chemistry, Bogorov supports himself by editing a newspaper "Bulgarian Eagle" in the period 1846-1847. Now, in 1847 we see him back in Tzarigrad where he participates in the issues of "Tzarigradski vestnik" and from there he moves to Romania where he stays until 1853.

In Romania it is supposed that he is involved with the activities of the "Dobrodetelna Druzhina" movement; for which he is persecuted from the government. At the eve of the Crimean War /1853-1856/, Bogorov is sponsored by maecenas Christo Georgiev to study medicine in Paris. Five years he spent there and in 1858 we see the newly qualified physician back in Tzarigrad. Later he corresponds to a friend that while studying in Paris he contributed regularly to different medical journals with articles, however, since those materials were anonymous their origin could not be traced. One way or another, after not being able to find a job in Tzarigrad as a physician but editing instead another newspaper "Bulgarski knizhitzi", Bogorov decides to return to his hometown Plovdiv.

In Plovdiv he establishes a private practice and parallel with that he becomes member of the City Municipal Council for three years. For the purposes of his medical practice Bogorov is endowed with a haberdashery /"achtarnitza"/; for which he supplied from Paris. No sooner than 1865 his restless spirit dashes him on another trial - he makes a great roundtrip in the country and in 1868 he publishes a travel diary "My trip round the Bulgarskite Mesta. Bukarest: RaduleskuPrint, 1868". The second one is "My trip round the Stara Planina" by Panayot Hitov - 1872.

In his early fifties Dr. Bogorov has a new attire. This time he goes to Russia to specialize in commodity circulation; a very challenging task for the time. Somewhere about 1873, maybe as early as 1869, he resides back in Tzarigrad and becomes co-editor of financial column /"listak"/ in the politeconomical journal "The Turkije". We will not dwell on his activities in the field, only suffice to say, Dr. Bogorov is author of two monographs and numerous articles in politeconomy.

In the course of the Serbian-Turkish conflict we see Dr. Bogorov engaged, again, as a military physician at station "Javor". During that period he writes his famous treatise "The Village Physician. Vienna: Yanko KovachevPrint, 1875". The book has a short introduction /"obazhdane"/ and three principal parts: 1. On how to prevent our health; 2. On how to make a diagnosis and give a proper medication; 3. On how to beware our animal from illness and to take care when it is sick, etc. The book received a fair response from the medical community, no matter the fact that it was an attempt to introduce a unified medical terminology. This was second in a row, the first being a work from Atanas Granitski twenty years earlier. The book received, also, an alternative response from publicist Luben Karavelov who admitted, in a sense, that it was written by a self-styled charlatan who advocated more on industry than on health matters.

In 1877 when the Rusko-Tursko War is waged, Dr. Bogorov is appointed interpreter in Svishtov. After the liberation Bogorov remains somewhat in neglect, however, he is made honorary member of Bulgarian Academy of Sciences. Still, the old tycoon remains faithful to his lifetime obligation as a "purist" of Bulgarian language. The list of his works in philology is enormous; more than 200 titles. Thusfar, at the age of 72, on 20 October 1892 he dies from apoplexy in Alexanders hospital in Sofia.

MYSTIC-IDEALIST PHILOSOPHY OF DR. V. BERON

Vasil Beron is born in Kotel in the year 1824 from a family of rich cattle breeder. His maiden name is Jellalsky and he is sisterly son of Dr. Petar Beron, famous figure from Bulgarian Enlightenment. His primary education he received at birth-place while in 1839 he departs for Krayova /Romania/ to join his uncle. After completing courses in Greek and French languages young Vasil enrolls in Tzarigrad's Patriarchal School at Kurucheshme. There he studies two years and transfers to Odessa's Richelieu Lyceum and graduates with honors in 1846.

Twenty two years old Beron is supposed to continue his father as a merchant, but luckily being a favorite and mentored again by Dr. Petar Beron - the latter already on a profitable practice in Paris - to continue his education in a university, Vasil enrolls as a student in medicine at Munich. Next, he goes to Wurzburg and in the year 1852 graduates with a doctoral dissertation "Uber den Startkrampf und den Indishen Hanf als Heilmittel Gegen Denselben", viz. on the pathology, diagnosis and prognosis of "tetanus" or lock-jaw, inclusive, a case study on healing properties of "indian hemp" or Cannabis Sativa from Family Moraceae. Note: the dried leaves is called "marijuana" and the dried flowers is called "hashish", both contain as their principal component narcotic resins.

Now, having received solid education Dr. Vasil Beron moves to Vienna to strengthen his clinical experience. There he had the opportunity to attend lectures from such famous medical celebrities as Josef Skoda /1805-1881/ and Karl Rokitanky /1804-1878/. Unfortunately, his work was hampered by the outbreak of the Crimean War. Dr. Beron is mobilized at the Russian Military Hospital in Bucharest, Romania.

By the end of the war we see the young patriot dispatched to Turnovo, Bulgaria. Here Dr. Beron is acclaimed as a leader. He has been city physician, but also chairman of church's and teacher's community. In ideological light Beron stand on progressist and evolutionist position. Some facts, however, show that he has not been totally impartial towards the revolutionary struggle of his people. This is evidenced by few reports from the Austrian council from Russe to the Turkish authorities. Having troubles with the Turks makes him flee to Bessarabia, in Bolgrad. On 4 December 1864 Dr. Beron is appointed Principal to the local community school. He is engaged in natural history, pedagogic and sanitary control. The patriot, again, excels in nationality activities by means of public oration. He is famous for propagation of the ideas of brothers Cyril and Metodius, creators of the slavic alphabet.

Some historians say that Dr. Beron was back in the capital city Turnova before the Liberation Day. This is, however, highly improbable as is evidenced by the memoirs of revivalists M. Keffalov and P. Kissimov. One way or another, Beron is back in his native country and is welcomed with respect. He is elected member of Parliament and takes different administrative-political duties in the Office, as well as, other non-governmental positions as a physician, educator and secularist. Most notably he is president of the

Archaeological Society in Turnovo /1884/; associate /1870/ and full /1884/ member of the Bulgarian Literary Society which is the forerunner of the Bulgarian Academy of Sciences; receiver of medal "For Civic Valor", 3rd degree /1902/. Beron dies on 24 September 1909 in Sofia.

Viewpoints on Dr. Vasil Beron's versatile heritage reveal a rare genius. It is hand in hand with the creative work of his uncle Dr. Petar Beron, author of the encyclopedic "Panepisteme", that we can rank the Beron family as exceptional. People does not choose their ancestors, but here we see a lineage that continues to give a series of professors even up to our own day. Superlative aside, a source for studying V. Beron's philosophical concepts are unequivocal. His most famous works are: "Logic. Vienna: L. Somer Printers, 1861", "Natural history. Bolgrad: Central School Printers, 1870", "Archeological and Historical Reports. Turnovo: P. H. Panayotov Printers, 1886", etc.

Dr. Vasil Beron makes a worthy contribution to the development of bulgarian scentific thought in the period of the Enlightenment and the first decades after the Liberation in 1878 and in the beginning of the modern Bulgarian State. It is far more precious that all his works are written in a bulgarian language. Thus, by directly offering the wisdom of a worlds treasure he makes an advancement in literary aspect as well. This is evidence that the bulgarian nation has the potential to be abreast with those who are ahead in progress and peace.

DR. STOYAN CHOMAKOV - LEADER FOR SECULAR FREEDOM

Born in the year 1819, from Koprivtiza in Orta Dag region. His linkage is from two of the most wealthy and influential families in the town: Chomakov's and Chalukov's - both authorized tax dealers on cattle trade /"beglikjii" and "dgelepjii"/. His elderly brother, Salcho Chomakov, had connections with the Sultan's court and it is owing to him that young Stoyan got reference for a job in Tzarigrad during the 60's and 70's.

After receiving his primary education in Plovdiv, in 1832 Chomakov is sent to study at Andros Island School in Cyclades Archipelagos, Aegean Sea. This is homeplace of greek revivalist Teophil Cairo /1784-1853/. The latter is famous admirer of French Rationalism and becomes founder and

propagator of a heresy - teaching blaspheme and theosophy. His school is banned in 1839 from the Greek authorities. However, Stoyan Chomakov is influenced by him and later applies his studies in solution for the Bulgarian Church Question.

His next step is to study medicine. After graduating his secondary education in Athens in 1838 young Stoyan is sent to Pizza and Florence in Italy. Here he get his medical diploma and in year 1846 is transferred to Paris for a two year specialization in surgery. His stay in Paris has an utmost importance for formation of his political sympathies and antipathies.

The major waves of revolution occurring in the first half of the 19th century had its repercussions in 1848. The Polish cause was led from emigration by Prince Adam Czartorysky /1770-1861/: fighting the Russian subjugation of the Poles from September 1831. Although not of Polish identity Dr. Chomakov was close to Prince Adam and his circle /i.e. Mikhail Chaikovsky and others/ and thisway is connected with the life and deeds of another great bulgarian Patriarch Neophit Bosveli /1785-1848/. Bosveli is a titan from the Bulgarian Revival and Church Independence War with the Greek Fanariote but we will refer to the question later.

Thusfar, Dr. Stoyan Chomakov is back in Plovdiv as a municipal physician. At that time in the early 50s he was the first medical doctor in the region and his work gained him the

image of a skillful operator. Dr. Chomakov performed three operations in Plovdiv which were debated even from the medical circles in Tzarigrad. The topic of his work were "Ligatura Oesophagus". The same operation was reported as a case-study by Dr. Panoff in the journal "Bulgarski Knigitsi" from October 1861. Further publications are two articles on cholera in the newspaper "Vreme", in two consecutive issues from August 1865. No more materials on medical themes are printed by Dr. Chomakov, however, he is author of three books and numerous etudes on political and secular history.

The subject matter of his activities as a public figure is versatile. He opened a pharmacy which was later administrated by his brother Salcho. He donated 3000 grosh to the pedagogy school of Daskal Nayden Gerov in 1958 /N.B. I see from the register at that time - 73 grosh make a gold coin/. Last but not least is his political activity, mainly secular, in the face of his protest versus the greek bishop Chrisante who, by the way, calumniated the bulgarians for unrest against the Ottoman Government. In 1861 Dr. Chomakov is chosen for representative of Plovdiv Diocese in Tzarigrad. On his way to the new job he never presumed that this is a turning point in his life, that he would leave his gainful medical practice and would stay for 17 years in the capital to become one of the first professional politicians of modern Bulgaria.

But let us take a look at the geopolitical map of the region from that time. Turkey and her allies England, France and Piedmont won the Crimean War and by the Treaty of Paris in 1856 the Ottoman Empire was considered a European State. Same year the Reform Firman /"Tanzimat"/ was drawn up by the minister of foreign affairs - Mustafa Reshid Pasha - and signed by Sultan Abdul Mejid. The firman provided for equality between the christian and muslim subjects of the realm, but in reality it led to clashes between muslims and non-muslims which soon became an international issue, and which the minister of internal affairs - Fuad Pasha - resolved with firm measures. In the midst of that political turmoil Dr. Chomakov arrived in Tzarigrad with his two daughters. He had to arrange a big and well maintained house as was required by the Exarchate. He had to hold a reception for many foreign ministers and ambassadors which required a staff for the residency, a private secretary and also governant for his daughters. He was so busy with his job that he couldn't go back to Plovdiv to attend his sick wife which subsequently died. His brother, Salcho, also got ill and died. Meanwhile, money which were sent from the diocese were not enough to support himself and on his account a half from his expenses came out from his own pocket. Dr. Chomakov had firmly quitted medical practice so this could not have brought him any income. Even in 1865 some people from the bulgarian community protested against him on refusing to take care on cholera patients when practicing physician Dr. Karakonovsky left the town. This and many other of his behavior makes it difficult to characterize Dr. Stoyan Chomakov on a level hand. When, for instance, we speak of him on the First National Exarchate Assembly on 16 February 1872 and the choice of Exarch Antim I /1816-1888/, it is truly his radical position and he is qualified as "red". Four years later during the April Uprising Dr. Chomakov is turkofill and join the most "reactionary" circles in Tzarigrad. One way or another, his figure was often counterposed to another eminent bulgarian politician - Count Gavril Krustevich, the latter being pro-rusofill and the right hand of Russian

Attache Count Ignatieff. More stuff can be written on his Tzarigrad period but this is item of other story.

In 1878 Dr. Chomakov is back to Plovdiv - capital of liberated Eastern Rumelia. While, in his own words, he went to Tzarigrad with 400 000 grosh in his pocket and on his way back he carried two truckloads of inventory and 60 golden lira from the Exarchate cashier for travel expenses. The new times are hard to live for the old political lion. An attempt to be a "gubernks" physician failed in 1978. Then he was chosen as a delegate in the National assembly of Eastern Rumelia. Meanwhile Dr. Chomakov participated in charity activities and become president of "St. Pantaleimon Charitable Society". After the Unification of Bulgaria he is people's deputy in Vth and VIth Common National Assembly; Minister of education from 28 June - 20 August 1887; Full member of the Bulgarian Literary Society, later Bulgarian Academy of Science, in 1887; Awarded medal "St. Alexander", first degree in 1888. All in all, he becomes one of the favorites in the court of Prince Ferdinant, who often made visits to Plovdiv with Dr. Chomakov. Also, his daughter Maria Chomakova was appointed a court lady. On 14 October 1893 the body of Prince Alexander Batemberg is buried on bulgarian soil. Dr. Chomakov attend the funeral in Sofia but on his way back he get ill. Nine days later he dies in piece. Premier Stambolov and Prince Ferdinant sent him on his last journey.

Addendum: We knew, when, we started this project that many obstacles could hamper our work. By far, the most touchy problem is that of the archives. We are a non-profit organization, whatever, being detached from university curriculum and funding. This being, so we seek secondary access to materials - published and republished. Not that it is the cheapest way, but, for sure it is the steadiest!

Our master list contains many a valuable collectibles. With respect to the legacy of Dr. Chomakov, proudly, we present the latest document for this important revival activist and legalist for church freedom, viz. "Dr Stoyan Tchomakoff ~ Life, Work and Descendants", in two volumes. This is a collective effort from the descendants of the doctor, who, scattered around the world pay their tribute. From their side collaborator is, Sonya Petrova - Chomakova from Italy, grand-granddaughter of Dr. Chomakov. From bulgarian side collaborator is, Museum House of Dr. Chomakov, in Plovdiv.

See for further details *

DR. CHRISTO STAMBOLSKY AND HIS DOCUMENTARY "CHEF D'OEUVRE"

Christo Tanev Stambolsky is born on 8 August 1843 in the town of Kazanluk - situated in the heart of the "valley of the roses". His parents were orthodox christians Tanyo and Dafina Stambolsky. There is a story about his grandparent Stoyan who was one time "muchtar" /mayor/ of Kazanluk. It is said that he traveled for 18 days to the capital of Stambuli and when he was back his fellow-citizens greeted him with the words "Hosh geldin, stambollu" /that is, "Well come, stambuli"/. Here is where the family name comes from. Young Christo studied his primary education in his native town with teacher Ivan Naydenov. In year 1858 he enrolled in the highly prestigious Military Medical Academy in Tzarigrad. There he studied for ten years and in 1868 graduated with a medical degree and

rank "major" in the army.

In the middle of the XIX century Tzarigrad was the most important city in the Ottoman Empire. Christo Stambolsky gets there amidst a whirl of empirial struggle. He is immediately entangled in the fight for autonomous bulgarian church led by nationalist émigré. At that time a popular allusion was that national church liberation should anticipate a much more political freedom of bulgarians. Subsequently, church liberation becomes a first stage in a wide legal movement for national emancipation. Whatever the chronology of that revolutionary events, we see young Stambolsky as one of the initiators of the "Easter Day Liturgy" on 3 April 1860. On that day Bishop Illarion Makariopolski /1812-1875/ denunciates the dependence of the Bulgarian church from the influence of the Greek Patriarchate. But let us take a look at the medical activities of Dr. Stambolsky.

As a medical student Christo demonstrates keen interest in anatomy. Even before graduation he works hard on the elaboration of anatomic terminology in turkic-arabic language and simultaneously reads lectures in the bulgarian community center on topics such as anthropology, physiology and hygiene. Thus, he makes a good impression as a diligent student which gives him a chance to be appointed as an assistant in the High Military Medical Academy after graduation. Next year, he is also ordained the post of Head of Dermato-Venerological Clinic in the same institute. Further, Dr. Christo

Stambolsky works on a part time basis as a surgeon in the clinic of Prof. Karatheodoridi in Tzarigrad. The authorities in the capital appreciate very well the versatile talents of the young medical doctor and assign him the task to compile an anatomical atlas for the needs of education in the institute. This immense work is accomplished in 1874: a book entitled "Meftih tetrih" is published by the empirial printing office in turkic language with arabic script. The work has not been translated and is unknown in Bulgaria.

The aforementioned book comprised in three parts: Part One - text of the atlas; Part Two - the illustrated atlas itself; Part Three - a dictionary of anatomic terminology. In fact, the book is an authorized compilation from a work of French professor in anatomy Prof. Mass - reader from the Medical School in Paris. What is important here is the recognition which a bulgarian received among the Ottoman court and next year 1875 Dr. Stambolsky becomes a full time professor in the Military Medical Academy. There are some articles printed in the newspaper "Napredak", edited by Ivan Naydenov /1834-1910/, that show in 1875 he was already very famous, i.e. the affair with the censoring of some "surras" from the Koran ended with the rehabilitation of the bulgarian doctor and his friend editor Naydenov. The latter is popular as the first translator of Konstantin Irechek's "History of the Bulgarians" /1876/.

What happened in the year 1877 is narrated in some 100 pages at Dr. Stambolsky's memoir. To make the long story short, we see that four bulgarian state employees are accused for pro-russian campaigning during the Russo-Turk War /1877-78/. The great "vizier" Midhat Pasha orders that Bishop Antim, Ivan Naydenov, Doctor Vulkovich and Doctor Stambolsky are sent to exile. The order is without appeal against sentence. So, on 7 September 1877 starts a new period in the life of Dr. Christo Stambolsky - he departs for Sanna, Yemen. On arrival he is appointed chief ordinator in the district hospital.

It is difficult to describe such a change in conditions for someone who is used to live in the relative luxury of capital Stambuli. In a primitive surrounding Dr. Stambolsky practice his medical profession. His main contribution from that period is the study of filariosis epidemics /caused by worm Filaria Medinensis/. From this parasite he makes a preparation which he sends to the Medical School in London together with a referral named "De ver de Medine, par d-r Chr. T. Stambolski, de Kazanlik, Thrace, 1879". Suffice to say, on 10 December 1878 the bulgarian patriot receives an amnesty /"Allah Kerim"/.

Now, in the spring of 1879 Dr. Stambolsky is back in the newly liberated Principality of Bulgaria. First he stays in the town of Gabrovo but soon is elected deputy in the Regional Assembly of Eastern Rumelia. Christo Stambolsky is involved with the conservative elements in the parliament. This causes him great trouble as a prefect in the town of Sliven where he had conflict with the so called "red belts", that is representatives of political jingoism at the time. On July 1881 Dr. Stambolsky is appointed new post - head of "Directorate for Transport and Communications" in Eastern Rumelia. There he stays until 8 December 1883 when a liberal coalition force him to resign. Disappointed from political carrier Dr. Stambolsky returns to the medical field. He goes to native town Kazanluk to start a private medical practice.

The Unification of Bulgaria in the year 1885 finds a doctor in his mid-forties with a rich biography behind himself. This causes him trouble with the regime of Premier Stephan Stambolov /1854-1895/ who registers Dr. Stambolsky in the camp of the "legalists". But in 1893 he is back again with a new carrier as administrative physician in the Alexander's Hospital in Sofia. There he stays until the Balkan War when in the years 1912-1913 he becomes a head of "Directorate of Public Health". After the Great War Dr. Stambolsky retires from public activity.

Towards the year 1918 he starts his work on the memoirs. He toils some 14 years on that "chef d'oeuvre" and we see a work called "Autobiography. Diaries. Recollections" published in three volumes: Volumes 1-2 in 1927; Volume 3 in 1931. This magnum opus is still unpublished in its totality. The archives of Dr. Stambolsky wait to be republished. On 4 June 1932, an old man in his 88s, he dies in Sofia.

Addendum: Recently, we get on some new information on Dr. Stambolsky's memoirs. As we mentioned, above, the archives of the doctor represented extremely valuable source of the Bulgarian Revival. However, it happened that during the bombardments of Sofia in January 1944 from the British Aircraft, and, the archive perished from a bomb fallen at the office "Kazanlukska Druzhba" where it was stored. Pity for such a loss!

Later, I personally checked for the published part of the memoirs - a bulk, from about 1300 pages. It did exist in the catalogue of the National Library, but, on my inquiry they couldn't produce a viable copy for research purposes.

Finally, some time ago, we could get hold of the book. It is an inscribed copy to a grandson of the doctor - someone, Todor Kozaroff from Paris, and we could obtain a photo copy of the whole book.

See for further details *

DR. GEORGI VULKOVICH AND "BULGARIAN EASTER"

Georgi Vulkovich is born in the city of Odrin and the year is 1833. His parents are settlers from Koprivtiza and are from the big and influential Chalukov's family - drovers and retail dealers. In fact, he is little cousin of Dr Christo Chomakov whom we have spoken about earlier. Georgi received solid primary education for the time at the greek community in Odrin and his father - Vulko Kurtovich - did not saved his pocket to educate his son. Thus, according newspaper "Svoboda" in Tzarigrad from 1850, Georgi Vuvkovich is the first bulgarian admitted to study in the Military Medical Academy. In 1857 a young graduate, Dr. Vulkovich entered for an examination in the hospital of Hayder Pasha in the town and is appointed chief ordinator in surgery. Three years later, he depart for Paris to study for a qualification and here is a place to remain for long years and entangle in political activities, as well.

In Paris during the 60s swarms a multitude of people from different nationalities and various creeds. It was an arena for struggle between royalists and republicans and preceding the commune of the Third Republic. Dr. Vulkovich was "not so lazy he could not tie his own shoelaces", as a well known aristocrat Comte de Chambord remarked at that time. He joined an underground organization called "Circle of Faithful Friends" which defended the patriotic rights of Tzarigrad's youth. Via this organization Dr. Vulkovich went to London where he met with russian anarchist Mikhail Bakunin /1814-1876/, a man who fell out with Marx and a tireless yet strangely ineffective revolutionary leader. The latter made a strong influence on the young patriot. Next, in the autumn of 1871 Dr. Vulkovich made an interesting correspondence with bulgarian revolutionary G. S. Rakovsky - founder of First Bulgarian Legion in Belgrade. A letter dated from 14 November 1861 is sent from Rakovsky, saying "… by the way, we need a man who could treat wounds made of guns, swords, etc …". Dr. Georgi Vilkovich with a letter from 27 December 1861, reply "… I accept readily such a honorable position and it is a high time that every patriotic bulgarian should give a token for love in front of his homeland …".

Now, in year 1865 Dr. Vulkovich receive a new assignment. He is transferred to serve in Syria where he becomes chief surgeon in "shamsi villaet" of Damask. We don't have much information about that period of his life but we see him again back in Tzarigrad in 1870. He is already an adjunct professor in surgery at the Military Medical Academy and head of the board of directors at "Hayder Pasha's Hospital". Vulkovich gets a fame as a skilled and able medicus. He had a private practice that was in quest by all foreign attaches in Tzarigrad, as well as, many a local "effendies" or high-stream civilians and their families. This allowed him to excel - he make sharp advance in the army and is promoted to a rank "colonel" with a pay increase. In 1872 Dr. Vulkovich is already a "bey" in the civil administration of the town. In 1876 during the Serbo-Turk War he is raised further to a position of "mirilay-bey" in the occupied territory of Serbia and head of M.A.S.H along the "Nish-Sofia's Strip".

However, during the Russo-Turk War next year everything comes to an abrupt end. Dr. Vulkovich is appointed member of "International Committee on Atrocities of War" and after visiting the destructed villages and towns in Bulgaria and meeting remnants from the partisan's detachments of the April Uprising, consequently, this makes him write a report and send it to the British Council. This act of patriotism, however, is ill appraised. Midhad Pasha's agents make a report which accuse Dr. Vulkovich of betrayal and a sentence is issued that he is exiled in Damask. This episodes from his life are well described in the memoirs of Dr. Christo Stambolsky - another well known bulgarian medicus on service in the turkish army.

So far, on 3 March 1878 the peace treaty in San Stefane, a suburb of Tzarigrad, gives an amnesty to all political prisoners of bulgarian descent. The dawn of modern history in Bulgaria is a fruitful field for progress, especially, for people with a rich biography in administration work. Prince Dondukov-Korsakov, temporary governor of newly liberated bulgarian lands, invites Dr. Vulkovich with a position in the Ist Great National Assembly. Vulkovich join the conservative party and participate actively in the elaboration of the new constitution. Afterwards, he moves to Plovdiv and becomes member of the Regional Assembly. Until the Unification Act in 1885, Dr. Vulkovich occupies different posts in the commanding apparatus of the autonomous region of Eastern Rumelia. This are in chronological order: minister of "Agriculture, Trade and Public Building" /1879/, minister of "Post Office and Telegraph" /1881/, second-time minister of "Agriculture, Trade and Public Building" 1882/, minister of "Foreign Affair and Religion" /1883/. In the parliamentary season 1885-1886, Dr. Vulkovich is appointed Chairman of the National Assembly and next year on March 1887 is sent Bulgarian Diplomatic Attache in Tzarigrad. Accidentally, Dr. Georgi Vulkovich died in the turkish capital on 14 February 1892.

Let us communicate briefly on Dr. Vulkovich's carrier as a politician:

1. He was instrumental in the Kingdom's early statute as an independent nation. Thus, he acquired from the "Great Vizier" of the Golden Horn to make direct contacts with the "harjie" or foreign minister. The acceptance of Bulgaria as a separate unit and not as a privileged province is an important step towards a retribution of Modern Bulgaria and the establishment of the Third Bulgarian Kingdom in 1908.

2. He makes everything possible for achieving cooperation between the Balkan States on a larger scale. This is made by signing mutually beneficial trade and communication conventions with the neighboring countries - Rumania, Serbia, Greece and Turkey. He is first to establish diplomatic relations with Monte Negro. The purpose of the Balkan Federation is double-fold: once, in the strategic interests of each participating county in the region and twice, to fence off the influence of the "Great Concert" in the affairs on the peninsula.

3. He protects bulgarian economical interests from collapse in national and international relations. While it is impossible to enumerate every contribution he made in the administration and legislation field, some more important are: opening an Agricultural

School in Sadovo; opening a Telegraphic School in Sofia; modernization of the harbor in Varna; building new hospitals in Sofia, Silistra and Rouse, etc. So far, the most important asset of Dr. Vulkovich's work is his effort to enhance the communication network of the country, viz. building new roads on a line; transferring new telegraph lines, etc. We must point out his efforts to strengthen the railway system in the country. For instance, he organized the state purchase of the line Rouse-Varna from the Hirsh Co. in Vienna and much more.

MR. SAVA DOBROPLODNI - UNIVERSAL EDUCATOR

Sava Dobroplodni is born on 3 December 1820 (old style calendar), in the town of Sliven. Both his parents were grammar-school teachers, namely, father Ilya and mother Trendphila from the Slavov's genus. After the Russo-Turk War from 1828-1829, the family moves to the walachian city of Ploesti where the father dies from cholera. The mother takes care of the family - brothers Nikola, Haralambo, Hristaki and sister Maria - while they return back to their hometown. Sava receives his primary education with daskal Gavril Krustevich - Kotliyanin. The latter was nephew of bulgarian Prince Bogoridi /1780-1859/, who was himself high turkish official and to continue the lineage, viz. grandfather Sophroni Vrachanski of the town Kotel. So this man, G. Krustevich, was a factor that young Sava should be sent to continue his tuition in Tzarigrad.

In year 1835, we see him as a private student with presbyter Nathanail in Tzarigrad and making a living of translating old greek manuscripts. That is, at the same time he applies for a sponsorship to a group of merchants from his hometown and, finally, receives a ticket for the famous Kuru-Cheshme School in Tzarigrad. Sava Dobroplodni is an excellent student there and makes friend with many a famous bulgarians who study there, also: G. S. Rakovski, I. Bogorov, I. Makariopolski, etc. An interesting episode is left from this time, which Sava narrates in a letter to his friend N. N. from Sliven, Re: "… with the lecturer in classic studies, master Evtivuliss, I made stenographic notes and on the next day I was in a position to answer all his questions, while all my schoolmates - having no such notes - find it difficult to give correct answers. This master E., who was examining us on a bulletin sheets, one day reads my name instead "Savvas Ilyadiss" to "Savvas Evcarpidiss", literally meaning - Sava Know How. Thus my nickname remained "evcarpidiss" …". What the point is, here, an allusion /N.B. the extract is from - Ed. L. Miller. Questions that matter: An invitation to philosophy, 2nd edition. New York: McGraw-Hill, 1987, p. 3./:

"… when Leon the tyrant of Philius asked him who he was, he said, "A philosopher", …"

After graduation, in 1842, master Sava Dobroplofni return back to his homeland. He becomes a schoolteacher for fifty years in a row, almost, to the end of his life. The chronology is better described in his "Short autobiography" from 1893. What the aim of our narrative is to point out the contribution Sava Dobroplodni made to the development of health education in those lands, all-in-all, within the context of Bulgarian Revival. So far, he was grammar-school teacher in Kotel /from 1848 to 1847/ and in Shumen /from 1848 to 1852/. In Shumen, Dobroplodni make friends with Lajos Kossuth /1802-1894/, leader of the 1848 Hungarian Revolution. Kossuth aimed at Hungarian independence from Austria of the Habsburgs. The defeat of his movement in 1849, seen as partly due to Kossuth's harsh policy to the non-Magyar nationalities, led to his exile. Sava Dobroplodni occupied for some time a tenure track with Kossuth's news agency, but soon quit the job to make a roundtrip in Central and Eastern Europe. He visited the city of Zemun in 1853, where he published his "Hygiaenomics, 2nd edition" and "A guide for

grammar schools". During the period 1853-1856, he is college professor in greek languages at Sremska Karlovtsi. The end of the Crimean War finds him back in Shumen, this time for a longer period of time.

Now, master Sava Dobroplodni gets married to Maria Gencheva and a son of his, called Preslav, is born in 1857. Also, this is a time for a fruitful literary activity, when Dobroplodni excels as a playwright. On 15 August 1856, he produced and directed the first Bulgarian comedy play "Michail Mishkoed" and is known to have arranged a theatrical art-school, where some of the furtherers of Bulgarian dramaturgy studied - V. Drumev, D. Voinikov, V. Stoyanov, etc. Following is a long list of his tenures as an educator, which gives him a right place among the figures of Bulgarian Revival: Sliven /1859-1862/, Varna /1862-1864/, Tulca /1864-1867/, Silistra /1867-1872/, Kustendja /1872-1875/.

The Liberation in 1878 finds master Sava Dobroplodni in an active position as a chairmen of the District Administrative Council in Varna. At this mature age, he continues to give a contribution to bulgarian enlightenment: he is a school inspector and, simultaneously, newspaper editor-in-chief of the "New Bulgarian Bee". The state gives a tribute to his wholesome career, accordingly: part time member /from 1881/ and full time member /from 1884/ of Bulgarian Academy of Science; honorary pensioner of the state /from 1887/, etc. Sava Doproplodni dies on 19 April 1894 in Sofia.

Last word should be given to his work in the field of public health education. We have found two medical books written by master Sava Dobroplodni, which put him on the forefront of bulgarian medical science of XIX century:

1. "Hygiaenomics", printed in Tzarigrad, 1846. This book is an authorized translation - from lecturer S. A. Saraccieff Auspice at the "Galata-Saray Medical School" in Tzarigrad. It is written on a prophylactic agenda and contains chapters on rational nutrition, on labour hygiene, on some principles of raising infants, etc.

2. "Viewpoints in healthism", printed in Bolgrad, 1865. This second book is on Hyppocrate's medicine. There are interesting propositions made here how diseases are generated, how to beware of magic id est God has not given power to mortals on making decisions for life and death, how to ignore healthisms coming from medical folklore, like "sueverie", "babi", etc.

MR. ZAHARY KNYAZESKI - ACE TRANSLATOR FOR BULGARIA

In the year 1810, at the vicinity of Stara Zagora town, the eight son of Peter and Sanda Russevi is born. The boy is called Zhivko and, seemingly, nothing comes to indicate that a better future is stemmed for a community of thirty or so dwelling houses, buried in the mud of slavery and with a horizon of secularity not higher than a celebrity for Christmas and Easter. This is the vicinity of "Pishmani", today called "Pokayane", and a place for the early childhood of Zhivko. Poverty makes him turn at ten years of age and go to Stara Zagora as apprentice to daskal Doncho and to learn pottery and soapery /i.e. dialectically called "gruntcharstvo" and "sapundjiistvo"/. The revivalist wave blowing from Europe and the political ideas of bourgeois-democratic revolutions, reflected through the prism of Greek uprising from 1821-1828, give an impetus for development in the bulgarian society, included, cultural live in Stara Zagora. This make young Zhivko to launch on a traditional journey abroad - that is, he travel to Syria, Jerusalem, North Africa, Monte Negro, Serbia, Vlachia and, afterwards, to change his name at Zahary "hadji" Knyazeski.

In 1835, Zahary Knyazeski is, already, in the town of Gabrovo - where the secondary school of Neophit Rilski /1793-1881/ is functioning. Here Zahary excels to the rank of assistant and, subsequently, wins a stipend to the High Theological School in Odessa. From 1839 to 1845, Knyazeski lives and studies in Odessa and it is the bulgarian colony in the town that gives him a warm welcome. We do not aim to give full account for his russian period. It suffice to say that he made a lot of acquaintances for a lifetime and in the first time with famous bulgarian revivalists Vasil Aprilov /1789-1847/ and Nikola "Art" Palauzov /1776-1853/. His numerous letters make him an accepted member in the circle of russian academia and let me mention few of them - Pogodin, Bodyansky, etc. Facts on file is that his library measured in "poods" and "foonts", viz. the old russian metrology: 1 "pood" = 40 "foonts" = 16.38 kilograms. The rest is obsolete and no one knows for sure how this immense library made a transfer back to hometown Stara Zagora. Further, details on Zahary Knyazeski's book-treasure are lost in the mist. Someone said that it was donated to the Monastery of Mugliz but later perished in the fire of April uprising 1876 - personally, I do not know.

Whatever, graduating the Odessa Seminary in 1845, master Zahary Knyazeski traveled around Russia for two years. The year 1847 sees him, together with educator Alexander Exarch-Beyoglu /1810-1891/, to become one of the pillars and true entrepreneur of enlightenment in the town of Stara Zagora. His great influence and authority in Russia become a guarantee for advancement of culture not only in the region but in the country, as well. Main activity for Zahary Knyazeski is girls' erudition through stipend promotion and technical enhancement. This activity has, traditionally, been obliterated in the vast but rotting Ottoman Empire from the XIX c., cf. that the Ottoman Empire had sovereignty over Turkey, much of the Balkans and all the Arab lands except Morocco. Feminism, however, entered the communications parlance not earlier than the 1890s - probably, from France. Backwards as they were, bulgarians, tried their utmost to keep and tolerate maidens rights. So, Knyazeski is maybe one of the patriarchs in that

movement. For instance in 1850, his legendary effort to smuggle two girls disguised as boys at Odessa is well documented, latter, in the autobiography of one Anastasia Tosheva /1837-1919/. The latter is founder of the first Bulgarian Woman Association "Mothers' Love" in 1869 at Gabrovo. More or less, Knyazeski & associates helped some 10 girls go and study midwifery for a period between the 60s and the 70s.

Hard times and broken finances make master Zahary Knyazeski to apply as a translator or "dragoman" at the Russian consulate in Turnovo. The year is 1863 and the region is Russe Villaette of Mithad Pasha. Wait here for a moment and see who Mithad Pasha is and what he did for the bulgarian people. That man, born in Tzarigrad and educated in most of the european capitals of the time, served for 15 years as a secretary in the Tzarigrad's Chancellery. Sometime about 1860, he is appointed governor or "valiya" to the Russe Villaette and here he excels as a bold reformator and organizator. In fact, he is the bulgarian Robert Owen and his co-ops near Russe at "Obraztzov chiflik" is a rudiment like the Rochdale's pioneers in Europe /more/. Well, further for the association between Zahary Knyazeski and Mithhad Pasha one can find in the archives but we must emphasize a point, namely … Zahary Knyazeski was, always, interested in the theory and practice of cooperatives. This is evident from a book he wrote and published - "Practical handbook on silkworn. Tzarigrad, 1859".

Knyazeski does not live to see the liberation. He died on 23 January 1877 in Russe.

We don't have full information whether Zahary Knyazeski had any special medical preparation. Most probably, he was self-educated like other revivalists Savva Dobroplodni, Tzani Ginnchev, etc. What is interesting for the purpose of our presentation are three books written by the author and a number of papers:

1. "The origins of alcoholism" is a small book, six pages in total, published in typography Damianoff at Smirna in 1842. The work centers on the psychological aspects of alcoholism and its reflection on physical beauty of man. Also, given are some symptoms of the alcoholic disease.

2. "On childbirth and how to feed a baby" is transliteration from russian, which, represents a book by french authors Tissot-Furcroa-Salmaud. Published in typography Tzarigradski vestnik at Tzarigrad in 1853. In brief, medical care for pregnancy is a task for grammercy by the parents and not so much a concern by the side of the medical practitioner. The book contains 34 rules for the young couple: how to get dressed, how to eat wholesome food, how to dwell in a spacious room. The author is negative about grandmotherly superstitions.

3. "First aid on syncope" is originally published as a serial in the Tzarigradski vestnik. In 1858 it has a second edition, revised and enlarged. The book is reviewed by G. Krustevich and marked "B".

LIFE STATIONS OF A GENIUS - DR. DIMITAR MOLLOV

Dimitar Mollov is born at the town of Elena, in the Bebrovo Balkan, on 26 December 1845. His father, Petar, was a pastor famous for his sermons in the region and the Turks called him - "molla". Petar Molla had eight children, from which, Dimitar as the eldest son was prepared to be ordained. The child received his early education in the local primary grammar school. As many youngsters of the time, Dimitar started as a private teacher, in order, to make a living. This was a time when he worked in the districts of Eski Djumaya and Shumla. In 1862, his uncle Evstati "Hilendarski" /unknown dates/, takes him to study in Kiev Seminary where Dimitar graduates with a monastic degree in 1867. However, this is not enough for the spiritual endeavors of the young man. Supported by the "Slav Charitable Society", he is first enrolled in the Philology Faculty and, then, in the Medical Faculty of Odessa University as a student.

Graduation year 1873 and Dr. Dimitar Mollov, now as a Russian citizen, remains to a position of an assistant doctor in the surgical clinic of Prof. Gaga. In the next years, we see him to be a prospective young physician - whose, appointments in the clinic of Prof. Bassov in Moskow and publications in the journal "Moskovskje vedomosti", make him well known. In 1876, Dr. Mollov is advanced with his doctoral dissertation: "One modification of chloroform anesthesia a la Clode Bernar" is result from his efforts in the pharmacological laboratory of Prof. Sokolovsky. The central theme of his research is "pre-medication with morphine", recommended, 20-30 min before narcosis and is evaluated as "good" contribution to the developing science of anesthesiology.

The years 1876 and 1877 are crucial for the fate of the Balkan states - former, provinces of the Ottoman Empire. Dr. Mollov is at the frontline of battle. First, during Serbian-Turk War /1876/, his team - six doctors with auxiliary personal - works at a sanitary train and get supplied by the "Moskow Trade Union". Next, during Russian-Turk War /1877/, he volunteers as a member of the "Russian Red Cross" and is, again, team with a sanitary train composition. More details on the two wars are found in the Mollov's archive, which, comprise the story of three generations of the family: Dimitar, son Vasil /physician, professor/ and Vladimir /jurist, community activist/!

Year 1878, the liberation of Bulgaria form Turkish dependence. But before this date, already, Dr. Dimitar Mollov is within the organisational plan of General Governer Cherkasky. He is appointed "gubernks" physician of the newly liberated Vidin sandjak /cf. chap. 1, fasc. 3/. In 1879, the second General Governor Dondukov-Korsakov orders him that a new sanitary structure is necessary - according, his "Temporary rules for administration of medical services in Bulgaria". Meanwhile, the Founding National Assembly is convened in Turnovo and Mollov elected deputy member. On 16 April 1879, he is among 279 national electors ratifying a "new constitution". Dr. Mollov is with the liberals - from the fraction of Petko Karavelov /1843-1903/ - and managing editor of the liberal whip with library "St. Kliment". In the period, from 1878 to 1881, are presented chronicles from the Assembly life and, also, translations from the worlds

classics - Platon, Petrarka, Bayron, Longfellow, Guy de Mopassan, Flobeur, Zolla, Goete, Hayne, Pushkin, Lermontov, Koltzov, Nekrasov, Saltikov-Chtedrin, Tolstoy, Chekov, etc. This journal is in the good traditions of the french "Bibliotheque Utile" and the german "Universal Bibliotek".

The year 1879, also, is landmark for the formation of the "Supreme Medical Council" /SMC/ in Bulgaria. Dr. Dimitar Mollov, it was mentioned before, is chairman of the first SMC and his "Temporary rules …" are in power - with minor revisions - until 1903. While serving his mandate, in the period 7 September 1883 - 29 June 1884, Dr. Mollov is elected Minister of Public Education in the cabinet of Dragan Tzankov. The latter position is continued, in connection to the Serb-Bulgarian War /1885/, with the organization and administration of the "Bulgarian Red Cross". Thus, during the war, the organization comprise two divisions: 1. Hospital team, in the "Alexander's Hospital" and taking care of the wounded in the rearguard; 2. Outpatient team, working as a mobile ambulance sanitary hospital /MASH/ in the hills of Slivnitza. The work of the Bulgarian Red Cross is in accord with an international team from the Red Cross-Red Crescent movement /more details …/. However, Dr. Mollov is always at the frontline of the Bulgarian Red Cross, namely, as a member of the governing body and as one of the few qualified surgeons at that time in Bulgaria.

Simple as that, life for Dr. Mollov has not always been smooth and easy. He is subjected, during period 1891-1894, to persecution from the cabinet of prime-minister Stafan Stambolov. The accusations are to be an accomplice in the murder of finance-minister Christo Belchev, but, they couldn't be proven and he is interned … in his birth place of Bebrovo. The trial, a boost event for the time, ends with 4 people sentenced to death /i.e. Svetoslav Milarov, Konstantin Popov, Toma Georgiev & Alexander Karagyulev/ and some one dozen other people put to prison. The jurisdiction, still, ponders on the effects of this case together with the precedence on criminal law in Bulgaria.

The year is 1894 and Dr. Dimitar Mollov is back on the political stage. This time, as a member of the parliamentary committee investigating the illegal actions of Stambolov's government. Meanwhile, the People's Party submit his candidacy for mayor of Sofia. As such, from 1895 to 1897, Dr. Mollov is very helpful to sanitary reforms in the capital and never shirk from his duties as community activist.

Numerous are his secondary social engagements, but, we will briefly give account for the important ones, namely: 1. Editor for the first bulgarian medical journals, like, "Medizinski Napredak", "Bulgarski Lekar" and others; 2. Associate /1881/ and full /1884/ member of the Bulgarian Academy of Science - former, Bulgarian Literary Association; 3. First chairman of the Bulgarian Medical Association /1901/; 4. Carrier of decorations - "St. Stanislav" II degr., "St. Anna" III degr., "St. Alexander" III degr. with strings, "For Civil Valor" II degr. - also, carrier of many medal attachments; 5. Last but not least, with respect to our primary orientation to public health issues, we must point out one of his many medical publications, namely - "Hygiene, or how to prevent health and maintain good disposition. Vienna: Yanko Kovachev Print, 1878" - further, this being a condensation from a book by Prof. Karl Reklama, Medical University of Leipzig.

Dr. Dimitar Mollov dies on 8 January 1914 in Sofia.

A BURNING DAYLIGHT TO DR. KIRKO KIRKOVICH

Kirko Kirkovich is born in the town of Sopot, year 1840. His family stems from the big Hadji Kirko's genus and is far-away relative to famous penman Ivan Vazov. The later, in his bestseller "Under the yoke", has described a beautiful picture of life in a 19th century bulgarian town - "Akche Klise" or "White Chapel", as the turks called Sopot. Young Kirko first studied with the grammar school of daskal Yordan Nenov in his birthplace town. Then, for some time he was volunteer in a trade company at the city of Plovdiv. But, however hard he worked, Kirkovich always suffered from inadequate material circumstances and until 1860, when, he becomes a bursar from the "Slav-Bulgarian Committee". In Moscow, he spent 10 years and became a Russian citizen. From that time he wears a beard like the russian "raznochintsi" - to make a difference. Anyway, fighting with misery, Dr. Kirko Kirkovich graduated medicine in the year 1870. Subsequently, he spent the next two years as a "zemski" doctor in Orlovska gubernks.

The town of Orel is situated, some, 100 kilometers east of Moscow - on the bank of river Oka, left tributary of Volga. Here is what I found written about "Zemstvo" in a book by traveler D. Mackenzie Wallace, cf. "Russia, vol. II. Leipzig: Bernard Tauchnitz, 1878".

"The Zemstvo is a kind of local administration, which, supplements the action of the rural communes and takes cognisance of those higher public wants, which, individual communes cannot possibly satisfy. Its principal duties are to keep the roads and bridges in proper repair, to provide means of conveyance for the rural police and other officials, to elect the justices of peace, to look after primary education and sanitary affairs, to watch the state of the crops and take measures against approaching famine and in short to undertake, within certain clearly-defined limits, whatever seems likely to increase the material and moral well-being of the population … Every province /"guberniya"/ and each of the districts /"uyezdi"/, into which the province is subdivided, has such an assembly and such a bureau".

Further, in his life Dr. Kirkovich will be back in the town of Orel but for the moment, in 1872, we see him settle in Plovdiv for a position of private medical practice. Here, he becomes active participant in community life and in the upsurge of Enlightenment culture. Dr. Kirkovich is welcomed by the bulgarian high-life in Plovdiv, viz - "masters" P. Gorbanov, D. Blagoev, Chr. Pavlov, etc.; "booksellers" Chr. G. Danov, D. V. Manchev, etc; banker Ivan Evstatiev Geshov and bishop Panaret, among the others. On 2 September 1873, he marries to Rada Gugova - niece to famous enlightener Nayden Gerov, who, is standing for the Russian Consulate in the period from 1857 to 1877. The young family have three children, the second son Stoyan becoming famous professor of internal medicine.

When, in the end of 1874, Dr. Kirkovich leaves Plovdiv and transfers to Sofia - I.E.Geshov remarks: "We lost our best man". Whatever, in Sofia during that times, there were only two physicians working, namely: 1. Dr. Naderne from Moravia; 2. Dr. Hasan

Bey from Anatolia; and Dr. Kirkovich appears to be the first bulgarian doctor working in that town. Here, he is under the auspices of benefactors Sava and Yordanka Philaretoff but, also, with the honors from "chorbadjii" or "nobleman" such as Dim. Hadjikotev, Dim. Traikovich and others. Soon after his arrival and Dr. Kirkovich, already, has a prosperous clientele. He manages to run a private office and a drugstore with a pharmacist - situated, around the place of now-a-day "Vuzraghdane Square". It was a time when motor vehicles were not existent, yet, and Dr. Kirkovich had to make his round-abouts on foot.

Sometime, about year 1875, great turmoil stirred on the Balkans. The conflict elevated from the "sandjack" of Bosnia-Hercegovina. Mass conversions to Islam and its intermediate position between Catholic Croatia and Orthodox Serbia, accounted, for the complex religious and ethnic structure of the region. Independent principalities existed in the region since the 14th century and the revolts from 1875-8 assumed the character of a national independence struggle. We will mention, beforehand, that this led to the Treaty of Berlin /July 1878/ and its major accomplishments, namely: 1. Division of Bulgaria into three parts; 2. Permission for Austria-Hungary to occupy Bosnia-Hercegovina; 3. Recognition of the independence for Serbia, Montenegro and Romania. Within the context of our story we continue by mentioning several facts. First, with the starting of the conflict on the Balkans Dr. Kirkovich lost a tolerance from the side of the turks. Second, being a russofil and wearing a beard, he was in a constant contact with patriots, who, demanded from him to serve as a link in a revolutionary setup. Third, in early 1876 begin the uprisings in South Bulgaria or, so called, "April's Uprising". Thus, in a situation which threatens his life and that of his family, Dr. Kirkovich moves back to Russia and with the help of council Nayden Gerov.

From that time on, until his death from tuberculosis, life proceeded in constant suffering for Dr. Kirkovich. It is narrated, vividly, by his wife Rada Kirkovich in her "Memoirs". A woman of extreme education - graduate with gold medal from "Funduklii Gymnasium" in Kiev /1866/ - she was one of the first woman-translators in Bulgaria. In the last days of her ill husband, Rada Kirkovich was the real support for the family. After a short stay in Odessa and living with the immigrant community, there, Dr. Kirkovich wishes to spent his last days in the town of Orel - where he has started his medical carrier. Unfortunately, "tuberculosis" or "scrofulosis" /i.e., the old name of the disease but almost synonymous in symptoms/ was untreatable for that time and most patients died from pulmonary consumption. The end was, unequivocal, for Dr. Kirko Kirkovich. He died on 22 October 1877. In memoriam

ONE MAN SHOW - DR. ATANAS GRANITSKI

Atanas Granitski, born 1825, in the town of Kotel or "bulgarian Kazan" - as they called it and not to be mistaken with a russian one at the tributary of the rivers Volga and Kama. All we know about the family of Granitski is scarce. He was the son of a priest /"pop"/ Petar, who, stayed as a proto-singer in town. He had also a brother, who, one time was a teacher in the town of Svishtov or so. Supposedly he had a daughter, who, married the eminent scholar and organizer of health care in Bulgaria Dr. Marin Russev /1864-1935/. More than that, Atanas Granitski received his primary education in his birth place town, and, in the town of Sliven. At that time "prince" Stephan Bogoridi /1775-1859/, fellow-citizen and grandson of enlightener Sophroni Vratzanski, rendered a trust to the city council of Kotel. Bogoridi studied diplomacy, and, once made a big carrier in the High Porte - a. he was "kaymakan" in Moldova; b. he was "bey" in Samos Island; c. he was "tanzimat" member to Sultan Abdul Medjit. This bulgarian with a "fez", never, forgot about his origin and contributed greatly for the cultural-spiritual advance of the bulgarians. Thus, due to his guardianship, four students were sent from Kotel to Tzarigrad to continue their education, namely: Gavril Krustevich, Georgi Rakovski, Atanas "Pop Nicola" Izvorski, and, Atanas "Pop Petra" Granitski.

Now, before we continue, let us make a containment. In the data we could gather about Granitski, there, no sure evidence were found whether he graduated medicine - eventually. Thus, not pretending to stir "art of the soluble", we present our pros and cons later in the story.

Young Atanas Granitski, first, entered the "International College" at Kuru Cheshme. While, having an orientation towards humanitarian sciences, Granitski showed a gust with studying languages - italian, english, arabic, greek, latin, etc. His fluency in communications gave him chance to start part-a-time work with the "Serbian Legation" in Tzarigrad. Later, representatives Konstantin Nikolaevich, and, Tasse Nikolaevich will sponsor some of his book publishing - a sign for gratitude to bulgariandom. About year 1848, Granitski entered the "Military Medical School" at Galata Saray. How long he studied, there, we don't know. Obviously, sometime about year 1859, he was in disfavor with the turkish authorities in Tzarigrad and left the capital.

Next, we see Atanas Granitski in the role of a "school teacher". It is well known, that, language tuition was honorary job in many a "class-rooms" in Bulgaria. In order to make a living, Granitski was teacher for long years - Shumen /1859-1863/, Lovech /1863-1864/, Turnovo /1864-1877/. Specifically, he was principal in "St. Cyril and Metodius Grammar School" in Turnovo for 12 years. After the Liberation War /1877-1878/, Granitski fell in neglect. Some of his students recount, that, he suffered from a depression and after a short illness died 23 May 1879. Only, his daughter attended him to the funeral.

So far, we see an unhappy life for one of the most productive writers in the Middle-Bulgarian Revival. A long list of more than 30 books came out from his pen - medicine, theology, fiction, philosophy, commerce, art, reference, etc. We shall give some account, about, literature Granitski wrote on medical themes:

1. "Practical Medicine, vols 1-3. Constantinople: Tadeos Divichian Typographers, 1854, 534 pp". This is a capital work for bulgarian medicine. Translated from italian work of Prof. Pirovo. Includes, an introduction - original - from Granitski, and, second introduction from the author. First volume: on pathology of the human body, viz. head, eyes-nose-throat, neck-thorax, extremities, etc in the light of system diseases; Second volume: on materia medica /i.e. technology of the drugs/, with, a pharmacopoeia; Third volume: on practical aspects of anatomy, physiology, hygiene, dietetics, Hippocratic aphorisms, etc. Granitski is excellent medical encyclopedist, also, good artist - evident from 8 figures in the text drawn from the translator, himself. The importance of this work is threefold, namely: i. as first manual on practical medicine, while, the latter has been still in the bonds of quacks and charlatans robbing the population /"ignorance"?!/; ii. as a book written in philological correct bulgarian, and, understandable both to professional and non-professional; iii. as an early attempt to organize a bulgarian medical nomenclature, which, outdated its time with some hundred years. Could this book, possibly, be written by a non-medic? Let us give the answer to the translator, who, writes in the introduction:

"Better not write a book, rather than, write something that will send you to condemnation"

2. "Reflections on greco-arnaut maggus, and, bille-bozadji hekims. In: Tzarigrad Vestnik, № 266, November 1856". This is a critique, written in verse, against quacks and empirism in medicine. Gets a severe response on the pages of the above-mentioned newspaper.

3. "On the modes of cholera. Tzarigrad: n.d.". Written in the early epidemiologic tradition, but, having no real scientific value.

A BULGARIAN "JATAG" IN COURT OF THE SULTAN - DR. ZACHARI STRUMSKI

The year of his birth is debatable: some say 1815, others - 1820. More probable is the latter as concordant with an age 18-19, when, he was registered as a student in T. Cairo's school on the Island of Andros. At that time - as his schoolmate G. Georgiev recollects - Zachari Strumski deserved the post "chairmen" of the Secret Slavobulgarian Committee. In the mist of ignorance, a young boy from Kyustendil cf. at that time in the sandjack of Northern Macedonia, the greek bishop Artemius at town takes care of the son of poor parents. Some 10 years of age, and, Zachari is sent to continue his education via Tzarigrad to the Archipelago Islands. In year 1839, we see Strumski enrolled as a medical student in Athens, and, from there to Paris to get a diploma in 1847. Ultimately, this is the early age curriculum of a doctor, who, is believed to belong to the "karaman greeks" /i.e., those who are converted bulgarians, but could hardly speak or understand their mother language/. The only other bulgarian in that period - a doctor with "karaman" type of descent is Dr. Ivan Seliminsky.

Sometime about 1847, Dr. Zachari Strumski settles in Tzarigrad and makes a medical residency, while, buying a house in the good quarters of the city. In the capital of the Osmann Empire, Dr. Strumski excels as a an able physician - he was consulted by the bulgarian colony there and by foreigners, as well. He was one of the few practitioners, who, deserved the honor to privately treat the Sultan Abdul Medjid in his palaces at "Top-Kapu Sarai". The latter had deserved the nickname - "the sick man of Europe" - because, he spent his time "feasting-and-drinking". Sultan Abdul Medjid died at age 39, supposedly, from alcoholism and sick lungs. Whatever, by the good will of the sultan, Dr. Strumski was privileged as "... a skillful physician and a good patriot ...".

There is hardly an event within the bulgarian community in Tzarigrad, in the 50s and 60s of the century, that has not involved the name of Dr. Zachari Strumski. He is keenly interested in the bulgarian affairs, within and without the boundaries of the enslaved homeland. He was subscribed for the newspaper "Danube's Swan", published in Belgrad by Georgi Rakovski. He was, also, following with deep concern the conflict with the Greek Patriarchate - the "Phenere Machala" in Tzarigrad. His compatriots from Kyustendil, rejected the archmandrite Ignatius - appointed from Greek Patriarchate - and insisted, that, their mitropolite Avxentius should be sent a representative in Tzarigrad. Dr. Strumski takes the position of a mediator in the conflict - the year 1961. He got this position, because, he was a permanent resident in the capital. Other bulgarian representatives for the "church question" - in Tzarigrad are: Dr. Stoyan Chomakov, Christo Tpcheleshtov, Nicola hadji Minchooglu, etc. We shall continue to pay attention to this canonical struggles, further, in our articles.

By far, the most important activity of Dr. Zachari Strumski is his attitude towards hospital organization in Tzarigrad. In a way, he is the first health care manager for Bulgaria. Even, from the first days of his arrival as a medical practitioner, he realized that

his compatriots are suffering from lack of organized health care, namely the need for a hospital. In year 1851, he writes a series of articles in the "Tzarigrad vestnik". In this writings, he mentioned that "from all nationalities living in the capital, only the bulgarians don't have a hospital". He insisted that, "good health is a fundamental for the wellbeing of human life". Later in the same year Dr. Strumski writes with disappointment that, "his idea for a bulgarian health establishment did not held a good reception"; also, "his compatriots are more interested in material and spiritual investments - namely, churches and schools - while, ignoring the fact that a sick person don't care about whether he can read or write or going to church, etc". This articles are given at a time, when, there was a scandal in Tzarigrad regarding the death of two german citizens. They died because, "from lack of adequate sanitary conditions" - and the german community in town immediately raised some funds for building a hospital. Dr. Zachari Strumski communicated directly with the medical manager of the german hospital in town - Dr. Eugene Choll. Well, in the long run, some 40 years later the idea for a bulgarian hospital is realized, with, help from the euphoria of Eulogy Georgiev. However, the name of Dr. Zachari Strumski remains as a first benefactor for hospital care in Tzarigrad.

Immense are the contributions of Dr. Strumski as a medical essayist and translator, as well. Here is a place to make another point. As a "karaman" type, he could not read or write bulgarin. All his articles are written in turkish language, but, on the pages of "Tzarigrad Vestnik" which is a bilingual edition. Thus, an important publicist, remained relatively unknown to the bulgarian public - his writings widely popular from his time await to be translated in bulgarian. We shall give a short list from his most important works /N.B. all his works are dispersed in issues of "Tzarigrad Vestnik" from 1851-1861/:

1. "Manual on Hygiene", Tzarigrad Vestnik from 1851 - translation from a book by Prof. E. Orphille, rector of medical academy in Paris.

2. "Magnetism and spiritism", Tzarigrad Vestnik from 1856.

3. "The seven races of man", Tzarigrad Vestnik from 1852.

4. "Manual on Snake Poisoning with instructions for self-treatment", Tzarigrad Vestnik from 1853.

5. "On how to prevent from hair loss", Tzarigrad Vestnik from 1856.

Dr. Zachari Strumski was a man of good character. He was respected by his compatriots and fellow citizen. He married a lady from a British descent, and, had two daughters and a son. For the good disposition of the foreign community, evident are two letters form the russian consul in town Alexei Lobanov-Rostovski - namely, to attend a dance ball on the Island of Chalki at 20. I. and 03. II. 1860.

Stephan Strumski, his son, attended from 1867 a Medical School in Tzarigrad. From 1869, after the death of his father, he transfers to Paris to continue his education. This

brave young man could not live to see the liberty, he dies on the barricades of the Paris Commune /18. III. - 28.V. 1871/.

During the cholera epidemics in Tzarigrad at 1864, dies the wife of Dr. Strumski - at an effort to save the suffering with the English Red Cross mission. Dr. Strumski, himself, was not present in town - he was on a military mission in Anadola. The russian newspaper "Vremya" writes, that at the same epidemics perished, also, the wives of Nicola Minchooglu and Constantine Raynov.

Four years later, on 20 April 1869, dies a devastated Dr. Zachari Strumski. The greatest chronograph of the bulgarian life from that times in Tzarigrad, Dr. Christo Stambolsky writes in his memoirs: ... on the edge of Easter, came the gruesome news for the death of Dr. Z. Strumski. He was a long time activist on bulgarian affairs in town ...". At the funeral, there, thousands of people come to give their last tribute. The funeral service comes to an end by mitropolite Ilarion Lovechki /1802-1884/. In memoriam.

GEORGI ATANASOVICH - MEDICAL PROFESSOR IN ROMANIA

We have the privilage to present the first university lecturer for Bulgaria. Georgi Atanasovich is born in the town of Svishtov, at the river Danube - 10 March 1821. His primary education Georgi received in town, with the distinguished revivalist and pedagogue Emanuil Vaskidovich. The latter co-edited, with Neophyte Boswelli, six volumes of "The Slavbulgarian syllabus for children" which was published under the auspice of serbian prince Mikhail "Milosh" Obrenovich in 1835. Further, Georgi Atanasovich continued his education in the school of Teophil Cairo - at Andros Island from 1836 to 1843. The next five years are spent in Paris, studying medicine and graduating in year 1848 with a doctorate, namely: "De l'hemoragie uterine dependant

du decollement du placenta, consideree dans les derniers temps de la grossesse et pendant le travail de l'accduchement".

Dr. Georgi Atanasovich started a job as a toxicologist in Bucarest - year 1849. During the Crimean War /1853-56/, he excells as a physician in the Russian Army at the battlefields of Romania. Roughly from that time begin, and flow parallel to his medical carrier, another occupation of his and which make him even more well-known - Dr. Atanasovich become member of the Benevolent Society /N.B., founded in 1854 as a Central Bulgarian Trusteeship/. While there are many pages written in bulgarian history regarding the Benevolent Society, we shall give a slight touch by what is written in "Bulgarian Academy of Science /editors/. Information Bulgaria. Sofia-Oxford, 1985, p. 189":

"... Political liberation of Bulgaria was set as the key goal of the struggle, which, spread throughout the Bulgarian lands and involved the emigration in Romania, Russia, Serbia and the Bulgarian colony in Cinstantinople. Various social and political forces were active in the liberation movement, and their views are recorded in the periodicals and in a number of programme documents of the Revival Period. The Russophiles, among the "haute bourgeoisie" in Romania, Russia, Constantinople and at home were represented by the Benevolent Society and by the Bulgarian Trusteeship in Odessa. These placed their hopes for Bulgarian liberation chiefly in Russia's intervention, either diplomatic or military, once the international situation was right. Heterogeneous in social composition and inconsistent in its political outlook, they objected on principle to all revolutionary methods ..."

At this point, we are not in a position to further elaborate on Dr. Atanasovich's activities as a member of the Benevolent Society. Enough is to say, that, his signature is evident on many of the official documents of the society - else, this is a job to be done by the archivists. Continuing with his political agenda, we shall give an extract from the memmoirs of his relative Petar Neykov, distinguished bulgarian diplomat from the first half of the 20th century. The latter narrates in his book "Yesterday and the day before yesterday ...", published in Sofia - 1959, p.35:

"... My uncle exceled in his efforts, together with other emminent bulgarians in Romania, to establish a cultural center with educational purposes. This organization would later become known as Bulgarian Literary Association ..."

In reality, the long time desired dream to have their own cultural institution was realized on 29 September 1869, when, a statute of the association is voted in Braila. Dr. Atanasovich was an active member of the founding fathers of the association, although, he is not directly elected as a member of the syndic. Neverthless, we find his name in the efforts to make scientific contacts of the newly found asociation with another "Slavic Academies", i.e., the so called "Matitzas" of Serbia, Slovenia, Chroatia, Czekia, etc. It was a time of everlasting enthusiasm, which, finaly led to the accreditation of the Bulgarian Academy of Science in 1911 - an institution with international recognition.

Let us return to the medical activity of Dr. Georgi Atanasovich. It is amazing, how, versatile is his work in the medical field - considering the fact that he was overburdened with political engagements, as well. From 1856, he is appointed professor of pathology in the "Bucarest Medical School". From 1858, member of the Supreme Medical Council of Romania and until year 1879. From 1869, take the position of adjunct professor of obstetrics and gynecology - namely, without department or salary. There are a number of medical articles, which, Dr. Atanasovich published during his Romanian period, viz. "Forensic medical expertise", "Poisoning with arsenic", "On the organization of infant hospital", On the epidemics of dyphteria from 1872", etc and all of them written in Romanian. Naturally, when the Russian-Turk War from 1877-78 is waged, he is among those who join the chief command of the Danubian Army.

The liberation of the country find Dr. Atanasovich a man of high prestige. From July 1879 to November 1879, he is appointed Minister of Education in the government of premier Todor Burmov. Here is what we find written in the "Bulgarian Diary, vol. 1" by Konstantin Yiretchek, on page 22:

... I went in the Ministry of Education, all of it in a single room. There was a minister sitting at a table, much like a turkish pasha, and around him on two other chairs were the clerks. I understood that the minister is someone Dr. G. Atanasovich from Svishtov, formerly professor from the Medical Faculty in Bucarest; he was a middle-aged man with greyish hair, whiskers and moustache, with a small stature but with obviously important behavior and all the time looking sharp eyed. My first impression - this gentleman is not a nice guy. Latter, I understood that he was of pure character, true patriot, a man with a clasical school of education and who has left the sure thing in a medical practice with a

carrier as a diplomat - something, which cost him not a few and the loss of his pension ..."

We shall try to give some final touches to the portrait of this great bulgarin. From 1883 to 1885 he was chairman of the Third Medical Council in Bulgaria. Introducing a project for a Sanitary Law - to be later voted in 1888. Adjunct /1881/ and full /1884/ member of the New Bulgarian Literary Society /BLS/. Rewarded medal "St. Alexander III" /1885. Owner of a rich personal library - donated to the BLS. The last years of his life, with ill health, he spent with his family in Bucarest. He dies on 26 February 1892. In memoriam.

PETAR PROTICH - SECOND MEDICAL PROFESSOR IN ROMANIA

The genealogy of the Protich family is fairly old. They come from the town of Kratovo, in Macedonia. The grand-grandfather was "prota" or senior clergyman in town, hence, where the family name come from. The grandfather served as a bishop in the nearby Lesnovsky Monastery and was sponsor for the first old-style bulgarian book from the district - "The Miracles of the Virgin Mary" from Yakim Kurchovski. One of his sons - Dimiter - settled in Turnovo at the nearby village of Arbanasi and started a business as a "beglikchia" or tax collector on cattle. Petar is his son, while, from the mother's side he is relative to well-known bulgarian academician Dr. Nicola Piccolo /cf. chapter in biography list/.

Petar Protich was born on 12 March 1822. His primer education is received at greek school in town and from year 1839 we see his as a sophomore in Athens Gymnasium. He studies well, there, an is consequently admitted a student in medicine from 1844. Next year we see him transfer to Paris, with the help of his uncle Dr. Piccolo, studying for a medical degree until 1852. From that period of his life, mention deserve contacts with polish emigrants and Adam Mickiewicz /1798-1855/ - specifically, a romantic poet with dreams for "messianic" restoration of a great nation for the Poles. This company left a reflection in the life of the young scholar.

In year 1850, Dr. Petar Protich graduates medicine with a doctoral thesis: "Des phlegmons de la fosse iliaque interne". With a diploma in his pocket and a solid load of medical knowledge, the young doctor settles in Romania - a free state at that time with better opportunities for work than Bulgaria, supposedly. Now, first thing first, Dr. Protich starts a job as a sanitary inspector for the "Muntenja Prisons", in Bucharest. From 1854 to 1860, he is chief ordinator in the "Murkutza Hospital", Bucharest - with a major in psychiatry, which, makes him the first bulgarian with a degree in mental health. During the Crimea War /1853-1856/, he works in the home front and is responsible for volunteer recruitment. After the war, Dr. Protich becomes a member for the Benevolent Society of Bulgaria. Much like his colleague and friend Dr. Atanasovich, he is executive for many missions of that pre-liberation patriotic organization. However, the full stardom of our subject for this narrative is associated with the work for the Medical Faculty of Bucharest, where, Petar Protich is appointed professor of surgery from 1857, i.e., external pathology as the discipline was recognized from that time. Let us elaborate on

the topic for a while. The data is taken from, namely: "B. Dutescu and N. Marcu. Romanian Medical Science. Bucharest: Meridiane, 1970, p 21."

"... The revolution of 1848 in the Romanian countries, the union of the Romanian principalities /1859/, the Land Reform Act /1864/ and the conquest of National Independence were the main political and social events that formed the background of these decades of important achievements in the organization of public health in Romania. This period of the organization stage in the history of Romanian medicine is called the "era of Carol Davila". Possessing a comprehensive understanding of the tendencies of his time and of the aspirations of his nation, of which he was a brilliant exponent himself, the energetic and clearsighted Carol Davila /1828-1884/, assisted by physicians with advanced ideas, such as Nicolae Kretzulescu, Iacob Felix, etc. successfully reorganized and unified the military and public health services in the Principalities, initiated Romanian higher medical and pharmaceutic teaching, established the organizational framework of modern Romanian medicine and paved the way to the following period of scientific creation in Romanian medicine.

The union of the Principalities and the double election of Alexandru Ioan Cuza as sovereign both in Moldavia and Wallachia /January 1859/ did not result in an immediate and automatic unification of the public health services of the two Principalities. The first step in this direction was taken in the decree regulating the free medical practice in Wallachia and Moldavia /28 January 1862/. In September 1862 the office of Director General of the Public Health Service in the whole of Romania was taken over by Carol Davila. He was assisted by the hygienist Iacob Felix, who devised and applied an ample programme of public health reforms with a view to unifying the public health offices in Moldavia and Wallachia and at the same time achieving definite progress in public health protection.

The period also represents a decisive stage in the development of medical teaching in Romania. The National School of Medicine and Pharmacy of Bucharest, founded in 1857, became a renowned centre of medical teaching and attracted students not only from all Romanian provinces but from other Balkan countries as well, especially Bulgaria. In 1861/1862 for instance, out of 188 students 46 were from Bulgaria.

In 1869, after 12 years of important achievements, the National School was substituted by the Faculty of Medicine of Bucharest, a university institution entitled to confer the title of doctor of medicine and surgery ..."

Insofar as Dr. Protich's career is concerned, some, further points are of special interest. He was member of the Medical Council of Romania - holding a position as a department head in the Faculty of Medicine, from 1869. He was editor-in-chief of the scientific journal "Romanian Physician", where, many articles were published with his collaboration. Unfortunately, those works written in romanian have received by now an undeservedly small attention - waiting to be reanalyzed. Dr. Protich, in his romanian period, was an ardent poet as an influence from his Paris education and contacts with polish emigrants. He published two collections with poems, namely /N.B. those verses

were written in french and romanian/: 1. "Poesii. Bucuresti: Nouva typographie nationala, prop. C. N. Radulescu, 1875"; 2. "La voix de Bulgarie. Bucuresti: Nouva typographie nationala, prop. C. N. Radulescu, 1879". Else, I see in his bibliography more poems published earlier in "Tzarigradski vestnik" about 1857, however, these works are difficult to obtain in visu.

The Russo-Turk War of Liberation find the old tycoon in congratulations for the Bulgarians. We have no information, whether, he get married by that time and if so, whether, he had any children. Nevertheless, we see Dr. Protich as a medical resident in Sofia from 1879. On March 1879, he is appointed member of the "First Medical Council" in the Principality of Bulgaria. Before that, on 1 February 1879, are ratified the so-called "Temporary Rules for the Medical Service" /cf. chapter in history highlight/. The FMC during the provisional Russian administration has the following participants, namely: 1. Dr. Dimitar Mollov, chairman; 2. Dr. Assen Shishmanov, Dr. Yordan Bradel, Dr. Petar Protich, Dr. Dimitar Kalevich and Dr. Konstantin Bonev, council members. Further, the work of the medical council during the period 1879-1880 is a subject of separate study.

After retirement from the work with the council, Dr. Protich continues his activities among friends and relatives. He becomes adjunct member of the Bulgarian Literary Society, now the Bulgarian Academy of Science /1881/. He is awarded with medals "St. Stanislav, IV degree" and "St. Anna, III degree". He dies from stroke on 24 September 1881. This is what prime-minister Todor Burmov says on his funeral:

"... He was one of those rare bulgarians, who, made his living busting and toiling. He was a fair man in times, when, to be a towering personality was something unthinkable - specifically, for a man of medicine ..."

NACHO PLANINSKI - A MAN OF NOTE

Nacho Planinski was born on 20 July 1847. In the town of Stara Zagora he completes some classroom studies until his age of seventeen. From 1864, with a stipend from the church syndics in town, he is send for medical studies in Bucharest. There he enrolls as a student in the High Medical School, where, head is Prof. Carol Davila. We don't have much information about Planinski's achievements as a student. Probably, he performed well there, as is evident by his "Forte Binne" award on his graduation. However, he left more traces with his public activity in Romania.

Bucharest in the 60s was a center for the national-liberation struggles of the bulgarian people. Noted revolutionary like G. S. Rakovsky introduces him in the circles, and, soon young Nacho Planinski begins to publish a fly-sheet with revolutionary content. He becomes the initiator for the establishment of a local community center with reading rooms - the so-called "chitalishte". Such educational centers were something new for the bulgarian revival period, and, deservedly Planinski is acclaimed one of the forerunners for this small scale educational facilities - accordingly, this is from the words of great bulgarian statesman Stilian Chilingirov. Another famous bulgarian statesman and writer - Zachary Stoyanov - narrates about bulgarian "chitalishte" in Bucharest, from his "Notes about the Bulgarian Uprisings":

"... in this classroom, Nacho Planinski served his compatriots with making presentations on various topics in the fields of physics, chemistry, sociology, hygiene, etc. He always emphasized that, some people still live in the age of barbarism and that the only way out from this stage is to work "hand-in-hand", together, for the progress of the whole humanity ..."

With some friends of his, notably Marin Drinov, Vassil Drumev and others, Planinski becomes one of the co-founders of Bulgarian Literary Society in Braila. Fact is, that, he was a corresponding member of "Branch for Natural and Medical Sciences" from year 1869. From 1875 he is full member but after liberation period he neglected his activities with the Society, these, for reasons unexplained by the historical community.

In the year 1870, with his graduate medical diploma, Dr. Nacho Planinski establishes for a private practice in his native town. Some people from his Bucharest period witnessed, that, he had served medical aid even before finishing his medical studies. These are people from the rebel detachment of voivoda Panayot Hitov - the latter, a legendary fighter for national freedom and author of a book with memoirs, notably the "My traveling on the Balkan Mountains" /i.e., supposed to be the first memoir book in the bulgarian literature/. Whatever, we engage very little in literature questions here and our aim is to give brief autobiography sketch of some eminent bulgarian medics.

In Stara Zagora, he stays for two years but disappointedly so. The local town leaders - "chorbadjii" - harm with his medical practice. So, Dr. Planinski devotes to other activities

and most of all to drama. He stages and produces, here, the play "A tormented Genevieve" and some other plays. He also engages in some educational activities in the local "chitalishte". However, in 1872 Nacho Planinski transfers to another bulgarian town with good revivalist traditions - the town of Sliven.

This time he receives a good welcome from the town community. Even from the first days of his arrival he is involved in a political event with the bulgarian eparchy in town. The initiated protest meeting demands, that, the bulgarian bishops shouldn't be sent to exile - accordingly, to a sultans "firman" from Tzarigrad. The Sliven's "myufti-sarafin" Ali Bey attends the meeting, and, being greeted by the crowd with exclamations: "Padishah chock yasha", that is "Long live the Sultan". And, Ali Bey is flattered so that he sends a telegram to the grand vizier in Tzarigrad, and, some days later the order for exile is revoked with the bulgarian bishops being able to go back to their native eparchies. The date is 28 January 1872.

Further, Dr. Nacho Planinski is able to practice his profession for 5 years in Sliven. For his work, he receives good credit in the bulgarian circles, and, for some time an advertisement for his medical skills runs in the newspaper "Eastern Times". But Dr. Planinski never put aside his links with the revolutionary process in the country. In the turmoil of the April Uprising from 1876, he is among those who renders help to the rebels - with money and medical consummative - also, he is known to have accepted for treatment some wounded rebels in his own house. His most well-known enterprise is, notably, some months after the suppression of the uprising. On 24 December 1876, Lady Stanford from Edinburgh is visiting the town of Sliven on occasion of the reported atrocities with christian population. Dr. Planinski and Mihail Ikonomov are two bulgarians, who, dare to join the group of Lady Stanford to the demolished village of Boyadjick. Later, the lady advocates in front of the liberal government of Gladstone - namely, to send thousands of pounds sterling to help the victims from the uprising. The literature for the protest of the English government to the atrocities of the April Uprising is vast, and, we couldn't list here all the sources. Maybe in some other expose, it will be possible to give a fuller account.

Dr. Nacho Planinski is one of the victims from the uprising, also. Together with another 20 bulgarian notables from Sliven, he is arrested and sent to trial in Tzarigrad. There, the defense of Dr. Planinski argues that the doctor has been helping all people suffering from the disasters of the uprising, and, evidently turks who had also been wounded by the rebels. But the prosecutor Saduk Bey is firm in his accusations, saying: "... those pezevenks /i.e. traitors/ helped the commits and are dangerous for the empire.". Sometime in December 1877, Dr. Planinski is sentenced and sent to exile in Mala Asia - in the town of Bollu. This place, tough for dwelling, hardens the experience of the doctor. But, luckily Dr. Planinski is enabled to practice medicine in that remote place and that makes it easier to await the victory of the russian army in the ensuing war.

With the signing of the San Stefan treaty, Dr. Planinski is back in Sliven. Like many other significant revolutionaries, he is granted deserved honor for the rest of his life. He is considerably young, when, elected district physician of the town of Sliven and director

of the city hospital - only, 31 years of age. Next year, he is elected member of parliament for Eastern Rumelia /1879-1882/. He participates actively in the public life of the country. Thus, Dr. Planinski is in the accrediting board of the association "Saint Pantaleimon" in Plovdiv. This benevolent society have the task to help and organize the network of hospital care in Eastern Rumelia - based, on the material resources left by the russian army. Later, this society is a foundation for the Bulgarian Red Cross.

In the year 1885 is waged the Bulgarian-Serb War, on occasion of the unification for the two Bulgarian principalities. Dr. Planinski participates as a sanitary major in this war. For his courage in helping the wounded, he is awarded medals "Saint Alexander", IVth and Vth degrees. After demobilization from war, he is elected consecutively member of parliament for the Third, Fourth and Fifth National Assembly. During that period, Dr. Planinski actively cooperate for the well-being of his electors. The citizens of Sliven remember him as a men with encyclopedic erudition, and, this is how the public activist Atanas Iliev remembers about him in his memoirs. Dr. Planinski is the one who puts a beginning to organized variola vaccination in the region. He also writes profusely in the local newspapers.

The year 1887 is an end for the political carrier of Nacho Planinski. He participates unsuccessfully for the royal election campaign of Alexander Exarches /1810-1891/. Later, he writes a book about that bulgarian public activist. Dr. Planinski is also author of two other textbooks: 1. A textbook of zoology; 2. A textbook of gynecology. These books are difficult to obtain. We couldn't find them catalogued in any public library. Perhaps, they exist in the collection of a private person. While trying to be parsimonious, we should recommend that a new bibliography is necessary for many of the revivalist scholars and men of letters from that period in Bulgaria.

Dr. Nacho Planinski dies from typhus on 8 November 1895, only 48 years of age. In memoriam

ON HYGIENE - DR. DIMITAR NACHEV

We intend to make a small presentation on the life and work of Dr. Dimitar Nachev. A more lengthy exposition is out from the scope of our agenda, right for the moment. We shall start with a short description of the region Bessarabia - nowadays, a westernmost part of Ukraine.

The bulgarian population in Bessarabia has been dislocated in the southern part of this region, known from historical sources under the name "Onglum" (ο η γ λ ο ζ ). In a time, when Khan Nogai's tatars came to the region /a. 1560/, it changed the name to "Budjack" - which, comes from the turkish translation of the name. Both, proto-bulgarian and turkish names are derived from the meaning "angle, corner". See the geographical situation of the region on Map 1. It is limited: west - by the river Prut; south - by the delta of the river Danube; southeast - by Black Sea until the river Dnestur; northwest - by the upper Trayan's wall, which is in Moldova.

The bulgarians in Bessarabia are supposed to be refugees from the European part of the Turkish Empire - which, took part from the second part of the XVIII century /a. 1752/. They do not consider themselves true bulgarians, although, they have retained their bulgarian names. After the successes of the Russo-Turkish Wars, on 29 December 1819 the region was given an autonomy from the russian emperor Alexander I. This was certified with an "Emperor's Edict", called: 'Statutele colonilor bulgare din Bessarabia' or 'Edict for the bulgarian colonies in Bessarabia'.

From 1857 to 1878, Bessarabia was a Romanian domain - truly, from the resolutions from the end of Crimea War on 4 March 1856. But the Bessarabians had their own Governor, in the face of Prince Nikolai Bogoridi, and their own nobility. They regard this period the most prosperous in their existence.

However, the Berlin Treaty from 1878 gave back the territories to the russians, which, had to withdrawn their forces from the occupied northern part of Dobrudja. The later was given to the Romanians, against the protests of the Bulgarians. The bessarabians from that period, showed a negative attitude towards the russification of the region. Some of them chose to emigrate back to the places of their ancestors - in Bulgaria and Eastern Rumelia.

A new impetus was given after the October Socialist Revolution in 1917. The region was joined in the new Federation as a part of Southern Moldova. And after World War II, it became an autonomous region in the boundaries of Ukraine - a statute which has been retained until now.

Map 1: Autonomous region Bessarabia, Ukraine

We made this historical excursion to add some flavor to the biography of Dr. Nachev. He was born at the town of Bolgrad /or Bolhrad, see on the map/ - in the year 1850. His family were settlers from Bulgaria, probably making their living in the trade with "abbyy" /i.e., a coarse woolen cloth/. Dimitar had his primary and secondary studies at his native town gymnasium "St. Cyril and Metodius". In 1865, he won a stipendium from the local authorities and went to study medicine in Paris. Later he moved to study in Berlin and in Wurzburg, where he graduated in 1873. No more information is available on this period of his life, except, that he participated as volunteer in the French-Prussian War /1870-1871/. The conflict was imminent after the process for Unification of Germany and the politics of "iron and blood" by chancellor Otto von Bismarck /1815-1898/.

Dr. Dimitar Nachev's coming back to Bolgrad is uneventful. He is appointed a lecturer on Natural History and Hygiene, at the Central Bulgarian School - Bolgrad. Let us say few words about this first educational institution for Bulgarians in the Revival Period. The school was accredited on 10 June 1858, under the auspices of Prince Nikolai Bogoridi. Saying the later in front of the bulgarian colonists:

"The idea for such educational establishment has existed for some time earlier. But, the former Russian government and the waging wars in the region hampered out initiative. Now, when the obstacles have been overdone, it is time to realize our intentions. Together with our brothers from the Izmail's region we intend to work hard for the

prosperity of our native language. At the same time classes will be ruled out in the vernacular /i.e., Moldavian/... We have appointed, for the support of the academic activities, reimbursements from our colonial lands, namely: 1. from fishing in the lakes of the territories; 2. from taxes on the fords in the region; 3. from rents at the inn's in the region, etc..."

The curriculum was regulated under the Ministry of Education, at the Romanian Government, and signed by Prince Alexander Yoan I. At the end of the period under survey, curriculum was signed by His Royal Majesty King Carol I of Romania. From 1878 on, when the territories were given back to the Russian Empire, school authorities were under the inspectorates of the emperor's court. After 1917 and the Socialist Revolution - in fact, Bolgrad Central School ceased its existence. The building was ceded to a Romanian Lyceum and it stayed there until now.

The city of Bolgrad attracted a pleiad of bulgarian scholars in the vicinities of the Central School. It will be impossible within the limits of our exposition to pay tribute on all of them. This may be a theme for another presentation. Suffice to say that Dr. Dimitar Nachev started a job on a solid background and a good academic surrounding. He practiced his teaching obligations until the year 1878. After reformation of the school authorities, Dr. Nachev was appointed medical director in the city hospital, Bolgrad. This period of his life, unfortunately, is poorly exploited in the literature. Perhaps, his archives still exist in some private library or are withheld by his successors. We return to our work on Dr. Nachev's contribution as first lecturer on a hygienic curriculum.

His first and only remaining book, as far as we know, is: "Nachev, D. On hygiene or lectures for the Bolgrad Central School. Bolgrad, Central School Printers, 1875".

In the introduction, Dimitar Nachev relays his motives for writing the book. It is remarked, unreservedly, that it has been on a facultative agenda and existed to cover a gap in the curriculum. Following, he gives a definition on hygiene: "Hygiene is a science for the prevention of health." From this definition, he extrapolates on the functions of the human body in a state of health, namely: "Health is a mode of functioning for the human body, when, all activities for the support of a living condition are regularly executed."

Next, outlined in some seven chapters, come the body of the text:

Chapter One: Here some basic information is given on the climate and its influence on health. D. Nachev gives information on the seasonal variations of a number of diseases, in a row: typhus, smallpox, rheumatism. Special attention is paid on malaria. He says that it is caused by "miasma" evaporation, and, that the clinics of the disease is influenced by quinine.

Chapter Two: Given is a debate on the role of the building construction as an exponent of school hygiene. He argues on the place, where, a school should be situated; what, should be its heating system; whether, it should contain a sewage system, etc.

Chapter three: Material is given on nutrition. How is food prepared, what should be a regimen for good nutrition, which are the different types of food, etc.

Chapter Four: Water is a separate topic, its quality and origin. He makes a note on alcohol consumption and its influence on the nervous system.

Chapter Five: Given is information on the hygiene of sensory organs.

Chapter Six: Here Dr. Nachev comments on some functions of the brain. The question of mental activity is compared as a reciprocal to physical activity. He supports the view that both are on a chemical basis of regulation, but, different substances are participating in the processes. He points out the importance of sleep on the conditions of the living body.

Chapter Seven: Debates the role of sport on the health of the organism. He describes some types of sport activity, namely: swimming, riding, fencing, etc.

In a time, the book received good response from the bulgarian community. Christo Botev, poet and revolutionary, commented in his newspaper: "We had the pleasure to read the lectures of our young co-patriot, but, we regret that the scope was too limited for such an interesting discipline. Whatever, Dr. Nachev has presented many popular truths, which are so important for the good education of the bulgarian... the later knows, how to work, but, lacks the secrets of living."

Moreover, Dr. Dimitar Nachev received acknowledgement from the new Bulgarian State. He was associate /1874/ and full member /1902/ of the Bulgarian Literary Society. He died in Bolgrad in 1903.

PART III: OUTLINE OF MODERN BULGARIAN MEDICINE

ORGANIZATION OF MEDICAL SERVICES DURING THE PROVISIONAL RUSSIAN ADMINISTRATION

The Russo-Turkish War of Liberation /1877-78/ is a landmark in modern Bulgarian history. A provisional Russian administration is established for an year and ten months. For East Roumelia /South Bulgaria/ it ends on 31 May 1879 when ruling is transferred to general-governor Alexander Bogoridi while for the Kingdom of Bulgaria it is held on 7 July 1879 when Prince Alexander Batemberg receives power from Russian A. M. Dondukov-Korsakov.

Not regarding the short period for ruling of the newly independent bulgarian lands, the provisional Russian administration of North and South Bulgaria makes deep social, economical and political changes which in their entity equal a real bourgoasian revolution. Three are the basic signs of transformation in bulgarian society: 1/ liquidating the Turkish feudal system 2/ making path for development of trade and commerce and 3/ giving wide political opportunities for the thuswhile mainly peasant masses.

Independence finds Bulgaria entirely backwards in sanitary conditions. There are diploma-registered physicians only in the big cities of the country which hardly could supply the health needs of the population. It is so far the duty of the appointed during the war Prince V. A. Cherkaski to take care of of welfare questions during the advancement of the Russian army. It is to him that is due a plan for administering the medical services. With respect to limited number of physicians an institution of regional /”gubernsk”/ and district /”sanjack”/ care is created. Thus district physician Dr. Stoian Radoslavov is appointed on 5 June 1877 in Svistov. On 1 July Dr. Stat Antonov takes health care of Turnovo and later the same month Dr. Alexis Christov is physician of Gabrovo. In February 1878 Dr. Dimiter Mollov is given post in Vidin sanjack. As a whole 26 district physicians are appointed in the newly liberated lands.

Meanwhile and parallel with regional medical administration a special attention to establishment of hospitals is paid. This is priority of Slav Welfare Association, Russian Red Cross etc. In the end of June 1877 a hospital with 200 beds is established in Turnovo. Later hospital facilities are made in Silistra, Tutrakan, Razgrad, Kazanluk, Plovdiv etc.

With the advancement of war general-governor Prince Dondukov-Korsakov takes rapport. The sector for Internal Affairs of the created provisional Russian government deals with health care questions. General Gresser proposes that an organization of public health services is commissioned in the country with respect to physicians, hospitals and pharmacies with attracting local moral and material resources. The best answer is given by Vidin sanjack physician Dr. Mollov. As a result on 15 August 1878 the latter is commissioned to the provisional Russian administration. His project “Temporary rules for medical administration in Bulgaria” is verified by Prince Dondukov-Korsakov on 1

February 1879. This is a primer official health document which authorizes sanitary law in Bulgaria.

Accordingly, a Supreme Medical Council is set up which includes four physicians with a minister. Structurally it is a body commissioned at the Sector of Internal Affairs, however, functionally it has approximately administrative independence. Within the country a hospital network provides treatment with a mixed scheme of repay. First class hospitals are with 100 beds and second class hospitals are with 50 beds supplied mainly from the military resource. People from both gender can be treated for 1 Fr. the first 10 days and the rest – for Ѕ Fr. per day. In his report to the provisional Russian administration from 14 March 1879 general Gresser remarks that hospitals network function well and it is part of the official Kingdom.

There are lists of physicians authorized to practice in the country – 78 doctors, from which 55 Bulgarians. To compensate the inadequacy of medical personal a school for assistant doctors /”feldsher”/ is opened with two departments – medical and veterinary. This is the foundation for special courses in Sofia, Turnovo and Plovdiv. In a program for 6 to 8 months a group of 150 feldshers graduates. These are the first steps of a national health care system

MEDICAL SERVICES DURING COUP D’ETAT OF THE RUSSIAN GENERALS

On 27 April 1881 prince Batemberg suspended the constitution and appointed a cabinet of Russian generals. Himself he declared that credentials for seven years are wanted otherwise he refuses the crown. One way or another this political situation persisted till 7 September 1883 when the generals left for Russia and the constitution was introduced again for correction at the Great National Assembly.

The organization on the medical part of the kingdom during the period mentioned above is assigned to physician Ivan Vasilievich Grimm of Derpt, Estonia. His post was general-inspector on the medical part together with minister of the Supreme Medical Council. He is directly subordinate to the prince while Dr. D. Mollov, chief commissioner at the Council, gives rapport to the Sector of Internal Affairs. First thing the general-inspector issues is an increase of staff: thus, the Supreme Medical Council numbers six members – Grimm /minister/, Dr. Mollov /senior at Internal Affairs/, Dr. Mirkov /senior at War/, Tegarten /senior at Chemical Laboratory/, Neyman /a military/ and Dr. Bradel /secretary of Council/.

Main points of the new medical services are improvement of legislation, organization and function of health care. In 1882 seven additional sanitary laws are issued to complement the “Temporary rules for medical administration in Bulgaria” from 1879. Here some prophylactic tasks are clarified with respect the role of rural and urban physicians, the

sanitary control in manufactures and schools, the need for health education, etc. Now a foundation for scientific institutions is established with a Chemical Laboratory at the Supreme Medical Council. Head of laboratory is Albert Tegarten and activity extends on analytic, microscopic, pharmacognostic, forensic and other investigations. Another scientific establishment is the Variola Institute at Razgrad district hospital with Dr. Boris Ox as a manager. Applied research and preparation of antivariola vaccine is done here. According special instructions /”prikazi”/ organized psychiatry, obstetrics-gynecology and dermato-venerology help is delivered. Also dental health care is provided for first time.

Statistics in the year 1883 shows a number of one hundred and thirty physicians in the kingdom including еight pharmaceutists and four veterinarians. At the same time on general-inspectors initiative Bulgarian physicians are sent for specialization abroad. First in the list of those allowances is Dr. Stephan Bocharov in the field of military hygiene at Petersburg Academy. Meanwhile in the country new hospitals are opened up – six with 50 beds, four with 20 beds and also in seven towns construction of new hospital buildings is started.

A serious fault in the medical services is lack of scientific associations and a medical community. Scientific information is scarce. A necessary step is publishing of periodicals. First medical journal is “Medicinska Sbirka” /medical antilogy/ with editor Dr. Mirkov and leading article on the antiseptic method of John Lister. Subscription is made to 5 Russian, 4 German, 4 French, 1 English and 1 American journal. A library at Alexander’s Hospital is administered and international book exchange started.

General-inspector Grimm succeeded for his short stay in the kingdom to embrace with a noteworthy consistency all spheres of health care. His indepth evaluations published in “Darzhaven Vestnik” /state paper/ have scholarly character and clarify every aspect of medical services administration.

SANITARY WORK IN EASTERN RUMELIA

The Organic Statutes of Eastern Rumelia /1879-1885/ pay little attention to sanitary work. It has the same features as that during the Provisional Russian Government and is under the control of the Directorate of Internal Affairs. First leader, jurist Gavril Krastevich, is in a difficult position for he is in front of a dilemma to choose between two opposite sanitary variants. According the Russian model health care is totally state powered including ambulatory, hospital, sanitary-epidemiological activities under Supreme Medical Council constituency. The Turkish sanitary organization on the contrary during the Tanzimat period functions in a western manner: all hospital and ambulatory care are excluded from state competency and are under charge of charitable organizations and private practitioners. Thus from the necessity to choose in november

1879 G. Krastevich puts forward at the Regional Assembly a proposal for a Sanitary Law and Statute on the sanitary part. So from the sanitary regulations voted in June 1880 a mixed system of health care is introduced in Rumelia – the state takes care of epidemiological control and ambulatory care while hospital facilities are under private initiative. The higher institution is the Sanitary Council consisting of a minister, three physicians, pharmacist and veterinarian. The governor of Eastern Rumelia A. Bogoridi appoints Dr. Stoian Chomakov for a minister. The Council also includes a balanced staff from professionals with only one foreigner – K. Sostrojonek.

For a six year period in Rumelia the Council resolute sixteen normative documents. Problem legislation decrees the statute of general practice physicians, vaccinations, veterinary control, dead burials, pharmaceutical statute etc. Aside from legislature the Sanitary Council elaborates certain materials like statistics for sickness, hospitalized, diseased; instructions to regional physicians; raports to the Director of Internal Affairs; communications to the press etc. An analysis of appointed medicals in the region reveals 28 district and 6 sector regulars – all of them graduates from France, Roumania, Russia, Turkey which attests a very high standard. As a national proportion we see 25 Bulgarians, 4 Greek, 3 Russian and 2 Armenian physicians. Approximately 20% from the doctors had to change their working place from two to three times. However, unfavorable working conditions are compensated with comparatively high salaries – 1700-1800 grosh; which is half as much the compensation of the sanitary chief. Compared to the police force dismissals are seldom not so much for political reasons as for lack of professional qualifications. Accusations against state physicians are unequivocal: refuse medical help to the peasants, restrain from inspection tours, lack of authority to impose hygienic norms, do not control feldshers work, show ethnic preferences etc. In such information against the Sanitary Council acts according a procedure determined from Director Krastevich /from 1884 superseded by Nachov/ - an inquiry commission is created which report leads to disciplinary sanction or denial with facts in the press. Despite considerable decentralization of sanitary work prevailing statements contain good reference for hygienic, ambulatory and small surgical activities.

Few words concerning pharmaceutical services reveal serious burden for the government: overwhelming are old habits of the population used to receive medical goods without prescription from unqualified sellers. The Pharmaceutical Statute from february 1879 regulates strict control from the state, rules for preparing, preservation and allotment of drugs, conditions for establishing a pharmacy, structure and function of pharmacy etc. The Rumelian pharmacy network consists of 28 mobile units of Ist type /remuneration from the state/ and 12 mobile units of IInd type /private owners/. Greater difficulties are presented by stationary pharmacies – lack of appropriate rooms, professional standing of personal, communication with hospital base – all in all 17 such pharmacies are established. Main depot for medical goods is Pharmaceutical Store in Sofia and a branch in Plovdiv exists headed by member of Sanitary Council chemist K. Sostrojonek /from 1884 A. Naidenovich/.

Hygienic matters in Eastern Rumelia are identical to them in the Principality Bulgaria: main current of diseases are caused by terrible dwelling conditions /houses are built

directly on the soil terrain, no windows or apertures, people and cattle live together/; so this way of life mediates vermin, filth, superstition. Nutrition is unhealthy – uncooked, hard to digest food, rotting food, spring water. Settlements have hardly canalization and sewerage; mud, compost, marshes everywhere; no regular cemetery land etc. What can do the Sanitary Council in the case is, traditionally: health education, distribution of free medication, regulation of whorehouses, vaccination. In case of resistance to vaccination fines are imposed also those are not admitted to school and in the army. The picture of epidemics in Rumelia reveals more significantly some variola epidemics in Plovdiv in 1882, scarlet fever epidemics in Karlovo in 1883, epidemics from syphilis, epidemics from egyptian cholera in 1883. Quarantine function well; desinfection of people and animals is compulsory; people are relieved from anxiety etc.

While ambulatory and epidemiological activity is a priority of the state hospital care depends on private initiative. The provisional Russian government, namely General Skobelev and Prince Shachovsky propose to bulgarian intelligence to take care by commissioning a semi-Red Cross association. Under the leadership of the Bulgarian Exarchate on 23 May 1879 an association “St. Pantaleimon” is created. Its statute copies a Russian style – salvation work with no regard to ethnic or religious affiliations, education of health personal, cooperation to vaccinations, establishment of hospitals with drug stores. Presiding the association is head of the Sanitary Council Dr. Chomakov. The board of trustees includes eminent figures, medical doctors Vulcovich, Stambolski, Hakanov as well as deputies and members of regional comities. Funding for the association depends on charities from private persons and on reliefs from the district authorities. Main discrepancies in hospital administration appears to be the conflict for appropriation of possessions left by the Russian army namely the military lasers. However, from 1879 there are hospital functioning in Plovdiv, Burgass, Yambol; from 1880 – in T. Pazarghik; from 1881 – in Sliven, Kazanluk; from 1882 – in N. Zagora; from 1883 – in Chirpan, St. Zagora etc. The income of “St. Pantaleimon” association is distributed proportionally to the hospitals by size, nevertheless, funding is inadequate. The problems are the same as in the Principality Bulgaria: unsuitable buildings; lack of basic appliances i.e. beds, instruments, apparatus; insufficient personal etc. The statistics from the Sanitary Council shows that most of the hospitals have 10-15 beds with approximate rate of 135 patients per bed per year. Obviously that low attendance of hospitals is due to distrust of the system, poor hospital environment, inadequate medical qualification, high mortality rate in hospitals versus home therapy etc. Finally, there is information that as early as 1879 a measure to convert mentally ill from the monasteries is introduced – the first madhouse is assylumed to Plovdivs hospital. As a conclusion to the review of sanitary work in Eastern Rumelia there is evidence that despite considerable decentralization effect of state health care is stable with many achievements of modern medicine gained.

THE SANITARY LAW FROM 1888 The Sanitary Law is entered at the Vth Common National Assembly in the second regular session /15 October – 18 December 1888/. By that time the “Temporary Rules” commissioned by Dr D. Mollov in 1879 were valid and an annex with seven civil sanitary laws were complemented by Dr Iv. Grimm in 1882. This jurisprudence did not spread over Eastern Rumelia where other sanitary decrees were in order. Now there is a controversy aroused here. A contention is that in 1884 a sanitary law was enforced by Dr Georgy Atanasovich, the then health minister of the principality. However, stenographic protocols from the Vth CNA as well as the anniversary book by Dr M. Russev from 1904 show that such law was non-existent. It is true that Dr Atanasovich prepared a draft but the violent developments from 1885 hampered it being considered and approved. Principal cause for the creation of new law is the Unification of North and South Bulgaria – a tempestuous event in the first decade after the Liberation. There was a pressing need to revoke the outdated matters of the previous law and to provide an even development for the newly built country. Prime-minister Stephan Stambolov who was Minister of Interior as well, remark: I would like this new law to be a better one because it belongs to the bulgarian people and we all feel happy when he is well. Further, the particulars were elaborated by Dr Panayot Zhechev – head of the Supreme Medical Council. It was approved by the National Assembly under title”Sanitary Law” and ratified with princely edict /”ukase”/ on 18 December 1888. With the new law health care is included fully in the administrative apparatus of the state. Within the Ministry of Interior is created a Civil Sanitary Directorate which remains a governing body till 9 September 1944. The membership of the Supreme Medical Council is enlarged. It includes the most able and authoritative specialists with a prerequisite for them to be bugarian subject. The Supreme Medical Council is presided by the Minister of Interior but when he is out from the country – by the minister of the Civil Sanitary Directorate. Supreme Medical Council remains the upmost consultative organ. The Sanitary Law defines the liabilities of county, district and municipal doctors. Also county hygienic councils are created as most important local sanitary authorities which function by 9 September 1944. They include managers of administration and health care in the county, namely: the mayor of the central county city, the county physicians, a member from the county hospital, the county veterinary, an engineer, a pharmacist and a military. First time private medical establishments are regulated under state sanitary authorities. Also first time prostitution is put under surveillance. Official Pharmacopoeia until then is unequivocal – under Russian and Austrian supervision. Afterwards, remains only Russian Pharmacopoeia. Encouragement of drugeries is promoted and mainly by bulgarian subjects. A novell act is deliverance of free health care to poor strata of population. This is forerunner of future totally free socialist health care after 9 September 1944. Meanwhile, article 64 from the Sanitary Law, say: Municipal doctors are liable to take care of poor unwell according to a list of names declared poor in the community, tha t is, those people

should be treated for free. This is not superficial state charitable act. Its a critically considered plan answer to the demands of the needy. Also, special committees are formed in the community enforced to support municipal and private physicians. As far as we know, democratic innovations of such kind are not to be found in foreign sanitary legislation. In Russia sporadic cases of free health care for rural population is encountered in some rich gubernks /”zemstva”/. Working class movement in Germany makes Bismark government to create sick hospital funds but this is inconclusive reform. Free medical care for economically week social strata is introduced fully in Western Europe after World War II. More comments on the Sanitary Law from 1888 show that some proponents discuss whether the law was a copy of the actual one in Roumania. Dr Zolotovich points which exactly clauses are captured from it and what is not just a mechanic translation from a backward social origin from our northern neighbor. In fact, the law reflect the new democratic traditions of Bulgarian system of state. As early as 1861 in Tzarigrad an organization for free medical care for poor bulgarians exist. Not without importance is the mere vigor with which the surviving heroes from the fights for National Revival contribute. Chairman of the Vth National Assembly is famous Zachari Stoianov. Members of parliament are Georgi Zhivkov, Dimiter Petkov, Traiko Kitanchev, etc. The architect of the Sanitary Law is Dr Panayot Zhechev /1853-1903/ - graduated medicine in Bucharest, volunteer in the Liberation War as a battalion doctor in a Romanian regiment. All those people work for the moral and spiritual ideals for which they sacrificed. In 1903 enters another public health law which keeps many of the statutes of the previous one. Toma Vassilov, eminent character and contemporary from that period, writes 50 years later: Sanitary Law from 18 December 1888 gave a new and powerful impact towards improvement of sanitary care in the country.

from the Sanitary Council shows that most of the hospitals have 10-15 beds with approximate rate of 135 patients per bed per year. Obviously that low attendance of hospitals is due to distrust of the system, poor hospital environment, inadequate medical qualification, high mortality rate in hospitals versus home therapy etc. Finally, there is information that as early as 1879 a measure to convert mentally ill from the monasteries is introduced – the first madhouse is assylumed to Plovdivs hospital. As a conclusion to the review of sanitary work in Eastern Rumelia there is evidence that despite considerable decentralization effect of state health care is stable with many achievements of modern medicine gained.

ADVANCEMENT OF HEALTH CARE IN THE ADMINISTRATION OF PEOPLE'S LIBERAL PARTY /1903-1920/

The constitution of the People's Liberal Party unites some of the eminent political figures in the country. Among them are veterans from the National Liberation Period - Stephan Stambolov, Zachari Stoianov, Georgi Zhivkov, Dimiter Petkov, Nikola Obretenov etc; also, former members of the Conservative Party of Eastern Rumelia - Dimiter Grekov, Ivan HadjiEnev, Ivan Andonov, Ivan Salabashev etc. Thus, taking the helm of bulgarian administration /1887-1894/, the Party establishes a regime contributing to strengthen the political and economic positions of petty bourgeoisie in Bulgaria. This leads to ascension to the throne of Prince Ferdinand I /b. Vienna 26 February 1861, d. Coburg 10 September 1948/, however, because of weakness of monarchic institute at that historical period, a phrase is coined - "The king reigns but does not rule over". The assassination of S. Stambolov creates a confusion in the Party ranks. Without its authoritative chief the perspectives of a political favorite seamed unhappy, until, on 05 May 1903 the monarch summons the People's Liberal Party in the government. Again, after almost ten years of political lingering, the national destiny and long-term prestige of the country are put on high stake. This time a new political leader excels - Dr. Vasil Radoslavov. In the long run, both the king and the premier will end their life in exile. On such a historical canvass it is tempting to present the health care affairs in the country.

The first session of the National Assembly on 30 December 1903 adopts the "Law on Protection of Public Health", which revokes the Sanitary Law from 29 November 1888 and itself stays in power for the next 26 years. The Law from 1903 has its chief architect in the face of Dr. Marin Russev /1864-1935/. The latter is eminent figure in the ranks of the Bulgarian Doctors Association, one of the foremost balneologists in Bulgaria and author of many surveys on bulgarian health resorts. Now, we have a new Law which postulates an increase of health personnel and creates generally better opportunities for medical service of the population. Instead of 60 000 people per physician a new arrangement is made for 20 000 administered per physician. For this purpose district constituency is subdivided into sanitary districts /"lekarski uchastuk"/ where physicians and feldshers are appointed according number of residents. Next, a popular hygiene

councils /"obshtinski higieni soveti"/ are established on a municipal level with membership from the government and aiming at administrative measures if the need should arise. For instance, the hygiene councils had the power to impose a fine from 10 to 25 lv. to someone trespassing the sanitary norms of cleanness in the environment and the behavior, etc. Another step is, introducing for the first time compulsory vaccination for smallpox to children 1-7 years old and youths 20 years old which is administered by a Central Medical Institute for manufacturing of serum. As a whole, the health care system is ruled over by the Directorate for Protection of Public Health, a department of the Ministry of Interior, which reduces the role of the existing Supreme Medical Council and makes it an appendix to the directorate.

The advancement in the Law stimulates the business of medical drug dealers. They insist, their syndicates, on 01 June 1904 that the government should rise the costs of medications with average 60-70%. This being a fact, the opposition in the face of the agrarians says: People have been already going to medicine-man and fortune-tellers out of poverty and You, from the ruling circles, dare drive him even further by rising the price of medications.

Meanwhile, the problem for covering the newly opened vacancies with licensed physicians persists. This compels the supplement of the "Law for Protection of Public Health" in 1906, saying that military feldshers and sanitary could work for the civil services. It is a dangerous step back in case that quality of medical care should failure but education at that time was affordable only from abroad and for a long period of time. While there is a shortage of medical personal, the inadequacy for hospital establishment is even greater. In the autumn of 1903 the first orthopedic clinic /with a workshop for prosthesis/ is opened. In 1905 a modern pediatric detachment is attributed to Alexander's hospital in Sofia. About that time a complex project to enhance the existing hospital base is launched. On average the logistics is increased by 30-40 beds, while in some big hospitals with 100 beds. Further, the crude number of hospitals rises from 51 in 1903 to 58 in 1908, mainly new establishments in the countryside and financed by the local gentry.

In consideration with the historical period being examined full appreciation by the governing classes was paid to the development of balneologic centers. Most important advance in this direction was the allotted special credit for building of mineral baths at the spas of Kniazhevo, Gorna Bania, Bankia, Merichleri, Varshetz, Hissar etc. On 18 December 1907 the municipality of Balchik is allotted a grant and a terrain for building a healing center at the vicinities of the town. Altogether, competent circles from the country and abroad discuss the opinion that Bulgarian Spas have good future.

If separate attention is paid to the absolute parameters of budget allocations distributed by regions, a constitution will be made that from 177 500 lv. in 1902 the budget jumped 3-4 fold in the next year. Most money are detached for Varna, Sofia, Burgas, Russe, Shumen districts. Still, on a relative scale the health budget is alarmingly low - on average 2.57% from the gross domestic product. The process enters into chaos after the country takes part into the tumultuous years of two Balkan Wars and the First World War.

Finally, words should be said about the opening of Medical Faculty in Sofia. The need for separate medical school is debated by the end of the past century. Thusfore, Alexander's hospital served as a hearth of bulgarian medicine. By 1904 a medical library is bound on the territory of the hospital and by 1906 - a medical museum. The material basis is continuously updated, the wards are enlarged and adapted to host the clinics of the future faculty. In 1907, Alexander's hospital in association with Mother's Home, the other big health care establishment on the territory of Sofia-city, organize three months qualifying courses in surgery, obstetrics&gynecology and ophthalmology. The results are that 17 physicians are sent for specialization abroad, among them several future professors in the faculty: Dr. Stoian Kirkovich /Vienna, internal medicine/, Dr. Atanas Teodorov /Vienna, forensic medicine/, Dr. Toshko Petrov /Tulusa, hygiene/, Dr. Ivan Kiprov /Berlin, eye&ear diseases/, etc. The fourth faculty of Sofia University have its birthday on a regular session of the National Assembly - 20 January 1917. First lectures are given on 10 April 1918. The right hand for the opening of the faculty is most vigorously supported by Dr. Stephan Vatev /1866-1946/, member of the Democratic Party. Thus, a new chapter is open for homeland medicine in Bulgaria.

HEALTH 1921-1945

The world after World War I in which Bulgaria has to appear was of a quite difference. The treaty with the "Entante States" was signed in the Paris suburb of Neuilly on 27 November 1919; - the country slid into a grave economic and political crisis. The puppet communist government of Alexander Stamboliiski with BAU /Bulgarian Agrarian Government/ was an obsolete landmark for the state of affairs. About year 1923 the political parties began a process of consolidation;

- on 9 June 1923 a Popular Alliance /organizing representatives of all bourgeois parties with Military League and Great Masonic Lodge/ facilitated the government;

- on 4 January 1926 a Second Alliance cabinet was formed at the head of which was Andrey Lyapchev /1866-1933/; - on 29 June 1931 a Popular Block won the majority of the votes headed by Alexander Malinov /1867-1938/ and Nicola Mushanov /1872-1951/;

- on 19 May 1934 a Zveno Block overthrew the government and initiated a chain of sinister registration of state officials until the end of World War II.

Aiming to be short, we should not like to omit the political role of other occasional formations like: 1. IMRO /Internal Macedonian Revolutionary Organization/ headed by Vanche Michailov and Menche Kurnicheva; 2. UFC /United Fascist Center/ headed by Alexander Tzankov; 3. Agrarian Union splitting to numerous divisions but most important are "Vrabcha" and "Pladne"; 4. Royal Chancellery ebbing the tide of political

forces. So far, the next page of history is outlined by an organization of Socialist State in Bulgaria.

A comprehensive review of the subject can be found in "Golosmanoff, I. The Public Health Services in Bulgaria. Geneva: Health Section of the Secretariat of the League of Nations, 1926"

/to be continued/.

HEALTH 1921-1945, PART 2

During the period 1921-1945, medicine and health care in Bulgaria develop on a background of complicated national and international political relations, which determine both the tendency and structure of specific socio-medical institutes. As a whole, there is somewhat of a decline from the side of medical and health policy in the country. Progressive bulgarian scholars, like Prof. Assen Zlatarov and Ilya Yanulov, make observations in their works that the very question of deteriorated health indicators of the general population is a reflection of poor labor conditions, i.e. that works as a scissors on life style of the people. Thus, a bread which have a mean price in year 1923: - 5.63 lv /index 100/, costs respectively in year 1924: - 7.04 lv /index 125/ and in year 1927; - 8.30 lv /index 147/. One kilo of butter, respectively, in year 1923: - 34.93 lv /index 100/ and in year 1927: - 37.79 lv /index 105/. Meanwhile, the mean daily wage of a worker is 63.08 lv /index 100/ in year 1923 and is 61.62 lv /index 97/ in year 1927, given that the laborer has, on average, ten days that he is gainfully employed.

On the mainstream, the sharp turn in politics after 9 June 1923 does not reflect on organizations and levels of health care maintenance /?/ in the country. It is true, that head of Directorate of Public Health - Dr. Veliko Georgiev /1872-1924/ quits his position, on grounds that "he would not cooperate with authority uzurping the government". This is not surprising, while he was one of the leaders in premier's Alexandre Stamboliisky "equipe medicalle" to reform the country and the health care, aprtially, on a commune principles. Dr. Georgiev, together with other communist-agrarian reformers like Dr. Yotov, Dr. PopSavov, Dr. Daskalov, Dr. Kaishev, etc. perished in the political turmoil after June 1923 - some died or other emigrated abroad. The post Head of Directorate Public Health is succeeded by progressive Dr. Petar Tzonchev /1867-1947/ from Gabrovo.

The bourgeois political development in Bulgaria, which is in a nutshell radical and democratic, confounds a series of occasional formations playing role in the governing of the country. One such organization is the Bulgarian Medical Union /BMU/, founded in 1903. As a matter of fact, more information on BMU activities can be find in the journal of the organizaton "Annales De L'Union Des Medecins Bulgares", issued volumes I-

XXXVIII. In it's nearly 45th years, the BMU had 26 assemblies but on the XXVI Assembly, held on 23, 24, 25 December 1945, the union came abruptly to an end. It took another 45 years that BMU had its revival under new auspices. Now, it is not our aim to dwell on the history of BMU but to show its role on the political community in the country and in particular, what scientific and technologic support it gave to medicine in Bulgaria. Our main thesis is that BMU played an important role in the historical development and was always on the right hand side to support the decisions of the main ruling medical body - the Supreme Medical Council at the Ministry of Interior and Public Health.

Thus, it hailed the constitutional "Law of State Defense" or LSD received on 4 January 1924. The BMU approved the sanctions taken against those members of the medical community which boycott the change of policy after June 1923, according art.15 of the LSD. Dr. Ivanov of BMU says: "That means LSD has an inverse power … in relationship with the discharges of union members, having in mind that those people have ever had communist convictions". However, the union took in mind the arguments of Dr. Racho Angelov, a social-democrat and council of BMU. The latter resigned from his post but the assembly of BMU, obviously realizing that this is an act of reproachment from an independent member towards the sway of terror and violence in the country, gave him a tribute. Ahead of events Dr. Angelov was right - LSD was abolished on 16 October 1944.

To assume multicollinearity of views it is worth rendering the fact that medico-sanitary insurance represent the "Achilles heel" of health care during that period. Here comes the "Public Health Law" or PHL from 9 March 1929. The PHL aims at centralization of top medical leadership and further specialization and systematization of medical organs. The law transfers all expenditures on local health services to burden the budget of communities and municipalities. The PHL is acknowledged in a moment when the country economy is in a business recession and tax paying from the masses is scarce. Art.18 from PHL says: "Taxes can not be lower than the actual expenditures for the diseased" and accordingly "Expenses for the poor are untowardly met by the communities". This gives some good opportunities for flowering of private stationary and ambulatory cabinets. Art.192 from PHL says: "Every registered physician has the authority to open a hospital or sanatorium … having in mind that he is not under conviction, disciplinary or criminal, connected with his medical service or is pending". The ethical issues connected with this file are not under consideration. The PHL gives access for profitable investment of capitals coming from shareholders and stockholders. This requirements are liberal but still they are looking for compromise between a public and a private mix.

Next moment in health issues of the period is combat with social evils, namely with tuberculosis, alcoholism, prostitution, etc. The socialhygienic elements are based on wade hygienic councils under the operational leadership of the Directorate of Public Health and with the strategic goal of liquidating and eradicating so called "social pathology". This approach was not a new one, while before the WWI there were agitated debates between the two fractions of BMU: Dr. Orahovatz's and Dr. Russev's supporters. On a new scale those fractions were classified by some modern socialhygiene narrators from the 70th and

80th decades as "bolshevik" and "reactionary" but we do not wish to devaluate what was written some 30-40 years ago.

Whatever, on the continuously deteriorating status of the masses we can judge from the reports of the head of the Directorate of Public Health, mimeograph from year 1931: "I would propose to decrease the taxes for delivering health care … while prices of goods from first necessity mark a decline those in health establishments are still high". At that time the prices are: - for ambulatory exam is 20 lv; - for one day stationary treatment is 40-80 lv; - for one day sanatorial treatment is 75-120 lv, etc. In the field of infectious disease prevention: - for desinfection of one kilogram stuff is 5 lv; - for hygienic douche is 5 lv, etc.

/to be continued/.

HEALTH 1921-1945, PART 3

The year is 1934. On 19 May the political power is taken by the military league "Zveno". Head of Directorate of Public Health is appointed Dr. Georgi Ivanov /?/. However, the burden of loose operational leadership has a timely effect on institutional settings. The government is under pressure and legislation, given that all political parties are banned and National Assembly is disrupted, have to deal with co-ops which, in fact, represent the outrageous ordinary masses from the street. Even IMRO had to put an end to its activity and leader Ivan Michailov /1896-1990/ fled away from the country in exile. The picture comes to a rest at the eve of WWII when in December 1939 an election campaign for the XXVth Ordinary National Assembly is held.

Let us examine what's going on with health care. On 22 March 1935 is issued provisional draft for "Law for Compulsory Medical Practice in the Village" or LCMPV. Despite that the number of physicians in the period is increased and there is an evidence for "physicians plethora", meanwhile, in the countryside health is far removed from the population and the individual. The hard mode of life and work in the bulgarian village, their backwardness and timidness, repulses the young practitioners to stay in the ambulatory. In an editorial from 1940 in the "Annales …" we read: "Most of the jobs offers in the village will remain chronically vacant, because the super-pretentious doctor can not get hold there and due to lack of elementary conditions for subsistence - board and lodging".

That is quite different in the city. A greater number from the young medical practitioners are still graduates from abroad, while Medical Faculty in Sofia takes a narrow margin. Those bachelors, naturally, apply the forms and methods of treatment which they have learned in the institutes of their education. For the first time this create a "tower of Babel", a confounding of terminology, classifications, etc. Further, specialization and

post-graduate education is necessary with respect to private clientele and that is organized in two manners: First, the medical doctor is sent abroad - with a stipend - to a western establishment, which issues a document that the specialist has served for "such and such" period and received a title; Second, there is a practical training available in a Bulgarian clinic - without reimbursement - which leads to a certificate for a specialty. Both lines were a matter of debate from the Bulgarian Medical Union. Dr. Robev from the council of BMU remarks: "It is a high time that the Directorate of Public Health stop sending proteges and other partisans… which is a violation of deontological norms and downright laws". Finally, the raising in medico-sanitary hierarchy is organized on the basis of a competition with a maturity exam, commissioned by the Supreme Medical Council. The candidates for a managing post are rated and graded on a percentile scale and the most successful ones are reported to the Council. Usually, the administration of the procedure is supported by high taxes but the benefactor, while every effort was made to prevent the corruption, still remained dim.

We will be back on the professional item of medical life but let us now take a look on the demographic situation in the country. A concentration of main demographic indicators is presented on Table 1:

Table 1: Crude birth rates, crude death rates and natural increase for the period 1921-44 /per 1000 population/.

Year Crude birth rate Crude death rate Natural increase

1921-25

1926-30

1931-35

1936-40

1941-44

39.0

33.1

29.3

23.2

22.1

20.8

17.8

15.5

13.7

13.5

18.2

15.2

13.8

9.6

8.1

We see from the data that total mortality show a tendency for decline, while it is associated with parallel slow down of the numbers for natality and their product limit. Here are some data on a comparative scale for natural increase per 1000 /N.B. The information is for the period before WWI/: Bulgaria /1910-12/ is 19.7; Russia /1912-13/ is 18.4; Serbia /1909-12/ is 14.5; … Spain /1908-13/ is 9.3; Belgium /190-12/ is 7.7; France /1908-13/ is 6.9. Evidently, demographic revolution in Western Europe is some 20-30 years ahead. Or maybe, some experts lament, the existing bureaucratic system in Bulgaria prevent regular registration and/or intensive-extensive mix give misclassification of rates. However, this is a misnomer in the whole civilized world!

Now let us dwell on some international issues concerning health policy of the "League of Nations" /LN/ and "Rockefeller's Foundation" /RF/. The small scope of our study does not allow to give a more detailed picture on those organizations. Suffice to say, from a special committee report presided by Prof. Hecht & Co. entitled: "Raport sur son voyage d'etude dans certin pays d'Europeen. Geneva: Health Section of the Secretariat of the League of Nations, 1924" we see that a project is undertaken for Bulgaria. With the management of "Rockefeller's Foundation", in the period 1931-34, an imposing building for public health activities is mastered in Sofia, Bulgaria. Architect is Dr. K. Koev and the design is the biggest on the Balkan Peninsula, a huge six store building which stays on the "Regentska Street" some 100 meters away from the Mausoleum of Vassil Levsky. It is there that the Directorate of Public Health with Supreme Medical Council transfer its quarters under the name "Institutes for Public Health". It is pity that the archives of the "Institutes …" were ravaged after the World War. I have got some information from a notebook belonging to two members of the "Teetotaler's Association in Bulgaria", namely Dr. Haralambi Neykov and Dr. Dimmo Burilkov. Suggestions for further research on the topic are welcomed.

Addendum: While every effort has been made to be correct in our presentation, sometime, there appear new data to accumulate. In the case we would like to give information on the activities of "Rockefeller's Foundation", where, it was connected with the eradication of malaria in Bulgaria. Three reports are given below from Dr. K. Marcoff, Inspector General for Malaria:

1. K. Marcoff. Malaria in Bulgaria in 1922. Geneva: Health Organization of the League of Nations, 1924 - go to # 11

2. K. Marcoff. The organization of the campaign against malaria in Bulgaria in 1922. Geneva: Health Organization of the League of Nations, 1934 - go to # 3

3. N. H. Swellengrebel. Third Report on the situation of the Bulgarian refugees from the government of Bourgas in relation to malaria. Geneva: Health Organization of the League of Nations, 1928 - go to # 123

/to be continued/.

HEALTH 1921-1945, PART 4

Let us continue our narrative by the beginning of WWII in September 1939. I have read somewhere a statement about Adolf Hitler: "Einem Trompeter gebe die Macht nicht". Whoever said it proved to be politically shortsighted. Hitler's war shaked up the world to

an unmeasureable scale. What happened then is a matter of fact in numerous textbooks and files. We concentrate our attention on Bulgaria's destiny by the period and that is done, purposefully, via a presentation of renegade man Aleksander Tsankov /1879-1959/. Here is an article about him from Encyclopedia Britannica Inc., 1968:

"Bulgarian statesman, born in 1879 in the town of Oriakhovo and studied law at Sofia University, where he became professor of economics. In 1922 he became leader of a small group called the National Concord /Naroden Zgovor/, drawn from the intelligentsia of various political parties and the mass of former officers, which aimed at combining the dispersed national forces for a struggle against the semidictatorship of Aleksander Stamboliski. To him fell the premiership of the coalition government, representing all the political parties except the Communists, that took power on 9 June 1923, after military "coup d'etat", in the preparation of which Tsankov's National Concord had its share. Tsankov remained prime minister until 1926, when he was replaced by Andrei Liapchev. His tenure of office coincided with one of the most tragic periods in modern Bulgaria's history. The disturbance that broke out after Stamboliski's overthrow took thousands of lives.

On 9 September 1944, after Soviet troops had occupied Bulgaria, Tsankov formed a National Bulgarian Government in Austria under German auspices and tried to recruit a volunteer corps. The advance of the Russians put an end to these efforts; Tsankov surrendered to the U.S. forces and, for several months, was interned at Kitzbuhel in Austria. Later, he was released and emigrated to South America.

From 1948 he lived in a suburb of Buenos Aires, Argentina, where he died on 17 July 1959."

Prof. Aleksander Tsankov is important for medico-sanitary historiography because he is, presumingly, the architect of modern social security reform in Bulgaria. On 1 July 1924 is enforced the "Law for Social Security" /LSS/, which cancelled all active decrees by that time. The law makes a reorganization for social security concerning the main bio-social risks by introducing insurance with "Fund for Social Security" /FSS/ which is functioning at the "Ministry of Trade, Industry and Labor". Specific for the new system is the profile administration matrix, i.e. all organizations on state, public and private level are cooperative to a certain degree, given it is not prohibited by a specific other formulation. It is an old system of "leveling" coming from XVII century England, stirred in the Cromwellian army. But we are not going to dwell on the evolution of the concept right now.

The professional medical associations, subject to social security venture, are the Bulgarian Medical Association /BMA/ and the Bulgarian Dental Association /BDA/; they coordinate the operational activity for collecting the prestations and subsequently defend the interest of the insured. Thus, for the period until 1944, the mean number of workers and employees covered with ambulatory, domiciliary and some other services by the "Fund for Social Security" is: 1.24% versus 0.65% for the general population /N. B. these are numbers for services done, not for services paid/. However, towards the end of the

period the costs for rendering such services are unrealistic, because: 1. An increasing devaluation of the bulgarian currency; and 2. The bureaucratization of the organization towards expenditures for administrative purposes.

On the left hand of the system /i.e. the object/ is situated the "Institute for Working-Medical Expertise", decreed with the same law from April 1924. We see here the principle that, whoever treats is the one who determines the length of treatment or "piggy-backing". For the first time the "Institute …" administers: short-term, long-term and whole-term /or invalidity/ expertise on disability and done with the help of trained para-medical personal. Thus, for instance, the measurement for working incapacity /by organo-topographic signs/ is appreciated via percentage estimation and not by reimbursement of unrealized working income. We present here some data on medical examinations of insured people with "Fund …" for the period 1930-1944 /N.B. index is 1939/:

Table 2:

Medical examinations Exams per 1000 insured

Disabled people Year

number index number index number percentage

1930

1931

1935

1936

1937

1938

1939

1940

1941

1942

1943

1944

185 657

209 855

431 410

642 796

752 337

841 369

891 873

778 647

882 158

808 209

671 629

306 865

20.81

23.52

48.37

72.07

84.35

94.33

100.00

87.30

98.91

90.01

75.30

34.40

764.8

1981.3

2169.1

2424.4

2366.4

3629.2

3432.3

3102.0

2903.4

2595.3

2129.4

1472.8

22.28

57.72

63.19

70.63

76.81

106.02

100.00

90.37

84.64

75.61

62.04

42.91

433

425

…

…

…

21 084

21 586

19 023

10 167

952

7706

3577

0.23

0.20

…

…

…

2.50

2.42

2.44

1.23

0.11

1.14

1.16

It is evident from the table that operational activity of "Fund …" is irregular. Also, the curve of medical examinations for the period 1930-1944 appear to have a binomial distribution.

/to be continued/

HEALTH 1921-1945, PART 5

Our review of Health Care Organizations in Bulgaria is towards its end. We shall briefly make a synopsis of the period 1921-1945 before continuing the subject with the reforms following the end of WWII.

The fundamentals of legislation and administration in Bulgaria during the before mentioned period was elaborated at the League of Nations - an international organization set up in 1919 to preserve peace and settle disputes by arbitration. The constitution of the League /"Covenant"/ was adopted by the Paris Peace Conference in April 1919 and written into each of the peace treaties. The League's headquarters were in Geneva but its first secretary-general during the period 1919-32 was the British diplomat, Sir Eric Drummond /1876-1951/. During the Second World War the League maintained its non-political functions. Its remaining responsibilities were handed over to the United Nations in April 1946.

Now, let us make a survey of the General Administration of Bulgaria. The Government consists of the Head of the State, the representatives of the people and the Cabinet. The Head of the State is the King /"Tsar"/. The representatives of the people, who are elected every four years, each deputy representing 20 000 inhabitants, constitute the National Assembly /"Sobranje"/. The cabinet is composed of ten ministers. Bulgaria is divided into 16 provinces, 82 districts and 2391 communes, of which 82 are urban and 2299 rural, the total number of the settlements being 5652. Each province is administered by a prefect, appointed by the Minister of the Interior and assisted by a provincial council and provincial committee. The districts are administered by sub-prefects. At the head of each commune is a major, who is assisted by one or more deputies elected by the municipal council; the council is elected by the inhabitants. Questions of interest to the municipality may be submitted to a referendum at the demand of at least one-sixth of the electors. Sofia possesses a special communal organization.

The legislative power is in the hands of the Crown and the National Assembly. The Government generally draws up laws and takes the initiative in matter of reform. Bills are laid before the National Assembly by the minister of the department responsible for their promulgation. Private members may also introduce bills, which must, however, have

been signed by a quarter of the representatives in the National Assembly. The legislative bodies of the communes are the communal boards. These boards must not, however, issue regulations which are at variance with the national laws. The executive power is in the hands of the Crown, the ministers and the Cabinet. Ministers issue executive regulations under the laws passed by the National Assembly; these regulations must be sanctioned by royal decree. Ministers cannot promulgate new laws or amend, add to, or replace existing ones. In exceptional circumstances, and subject to a decision by the Cabinet, the Crown may publish decrees having the force of law. The prefects, assisted by the provincial councils, are the highest representatives of the executive power in the provinces. They may issue orders, which must not, however, exceed the scope of the national laws. The powers of sub-prefects are purely administrative. In the communes, the executive power is represented by the mayors, whose orders have the force of law.

Finally, the Health Care organizations in Bulgaria are established with a decree № 2 from 7 February 1929 and published in the supplement of the "State Paper", vol. 277 from 9 March 1929; revised with additions according the law, published in the "State Paper", vols. 68/1933 and 76, 178, 223/1935 and 129/1940. Here is an example of the structure of health organization in Bulgaria.

Copyright © 2002.

HEALTH SINCE 1945: TRANSITION PERIOD

It is our privilege to begin a review for a long period of socialist health care in Bulgaria. Our plan comprise of the following materials, divided according time periods in economo-political aspect:

- First, transition period from 1945 to 1960

- Second, institutionalization period from 1960 to 1990

- Third, reconstitution period from 1990 to present time

We begin with the transition period to a socialist economy on the Soviet pattern which took longer than the immediate post-war period. Simply nationalising private industrial enterprises in the period was not enough. A system of long-term central planning to co-ordinate outputs with inputs also had to be set in place. And for such planning to include all production, the collectivisation of small-scale, private agriculture seemed necessary. Bulgarian economists typically identify the date of its completion, 1960, as the end of the transition to the Soviet system.

Each of the first three national plans followed a strategy of extensive growth. Huge amounts of capital and labour were funneled into a few branches of industrial production. These plans honour the Soviet ideology which can be briefly retold. First, the basic Soviet system for central planning is well known. So is Soviet development strategy: rapid growth of heavy industry to be achieved through concentrated investment from the state budget and a labour force augmented by peasant influx. A smaller rural labour force is left on the mechanised collective farms to produce the surplus needed to feed a growing urban population. Bulgaria's post-1948 transition to this planning system and strategy followed the Soviet pattern perhaps more closely than did any of the other Communist governments in Eastern Europe. Second, although its general pattern is familiar, the period of the first three Five-Year Plans is the most neglected in modern Bulgarian economic history. Western and Bulgarian economists have concentrated their efforts on the period since 1960, where reliable statistical evidence is more available and connections to the international economy more important /N.B. Bulgaria published no statistical yearbook in the 1950s/.

Bulgarian political history from 1949 to 1960 also makes a detailed appraisal of these years more difficult. Accompanying several changes in Bulgarian party leadership was the Soviet transition from the Stalin to the Khrushchev eras. The single line of authority from party leadership to economic policy that is a hallmark of Soviet-style economies was doubtless present, but harder for outside observers to discern. Subsequent Bulgarian scholarship has trodden too lightly on these political links to make clear the inner dynamics of economic policy.

The period began with the illness and death of the party's respected leader, Georgi Dimitrov. A sick man at least from 1947 onward, he died in April 1949 after several months of treatment in the Soviet Union. Dimitrov enjoyed international prestige on the left as the eloquent defendant in the Reichstag fire trial, staged unsuccessfully by the Nazis in 1934, and as head of the Comintern thereafter. He kept his position as Bulgarian Prime Minister during the Tito-Stalin split, despite his advocacy with Tito of a Balkan customs union and federation just a few months before the dispute erupted. Traicho Kostov, one of his logical successors and the party leader most responsible for economic policy since 1944, did not survive the purge following the Tito-Stalin split.

The actual successor, Vulko Chervenkov, had been trained in the Soviet Union for party work since his exile there in 1925. He co-ordinated propaganda for the Comintern from the late 1930s, and for the Bulgarian party's Central Committee after his return to the country in 1946. His background did not prepare him well, in other words, for overseeing the first Five-Year Plan. His two decades of Soviet exile did, however, prepare him to follow Stalin's lead after the split with Yugoslavia in 1948, and to reject any further delay in proceeding with rapid industrialisation and forced collectivisation according to the Soviet experience of the 1930s. In addition, Chervenkov came to power during Stalin's last years, when the Soviet Union's own reliance on propaganda slogans and the threat of arbitrary punishment reached its post-war peak. These were distinguishing features of economic policy in both countries from 1950 until Stalin died in 1953. Chervenkov had begun his regime by expelling one-fifth of a party membership that had grown to half a million. Many of those expelled, like half of the party membership, were peasants. So were many of the unknown numbers of suspected "enemies of the people", who were sent to concentration camps in the early 1950s. All this made the atmosphere surrounding further collectivisation ominous, rather than encouraging.

The first challenges to Chervenkov's leadership none the less appeared surprisingly early in the Second Five-Year Plan /1953-1957/. The plan was itself a retreat from the harsh, sometimes counter-productive measures of the first. Criticism of Chervenkov for these excesses appeared in the Bulgarian Politburo as early as 1953, and reappeared in 1955 because of continuing agricultural problems. Khrushchev's 1956 speech exposing Stalin's "mistakes" and his "cult of personality" was perhaps the most important, but not the first step in Chervenkov's demotion. Todor Zhivkov emerged from the new generation of post-war party leaders to become First Secretary in 1954, at the age of 43, and Deputy Prime Minister in 1956. But Chervenkov was to remain the other Deputy Prime Minister until 1961. Anton Iugov, the Interior Minister during the mass arrests of 1949-1950 and one of the older generation of "home Communists" had re-emerged in 1956 as Prime Minister. Zhivkov strengthened his position in this triumvirate as the 1950s drew to a close. The influence of the other two still remained to be reckoned with until the shortcomings of the Third Five-Year Plan had become clear. Bulgarian economic policy did not therefore pass fully into the hands of Zhivkov and his post-war generation until the 1960s.

Now, before continuing to the main body of presentation, we would like to point some attention at a concise outline of the topic under consideration. Specifically, this is "Part

VI" from the monumental work of the Bulgarian Academy of Science /BAS/: "The Editors of BAS. Information Bulgaria - a Short Encyclopaedia of the People's Republic of Bulgaria. Oxford: Pergamon Press, 1985"

/to be continued/.

HEALTH SINCE 1945: TRANSITION PERIOD, PART 2

The first act, which came to reflect the new attitude of the state towards health care, is establishment of the "Ministry of Public Health" /decree № 284 from 9 September 1944/ as a central state institution for co-ordinating health. This is a realization, de facto, one of the main formulary from the health policy of the Party and the progressive medical community - which is the program documents of the expert group "Social Medic", working for long years under the auspice of the Bulgarian Medical Union. Dr. Racho Angelov /1873-1956/ is appointed first minister-of-health and Dr. Konstantin Kusitasev /1900-1955/ to the chair of secretary-in-chief: both well known as consistent public health activists, also, having a long dossier as professional revolutionaries. The new ministry is a split off organization, meaning, it came out as a corollary from the "Ministry of Interior & Public Health" and by right of succession taking its actives and passives.

The main tasks of health care in the transition period are formulated in the "Program of the Fatherland Front" from 17 September 1944. They are elaborated in the form of a State Plan, containing eleven points:

1. Cultural and vital elevation of the living standard of the people

2. Fight against infant mortality and provision of effective measures for combating infant diseases

3. System prevention of tuberculosis and all other infectious and social diseases

4. Sanitary development of dwelling settlements and all other populates

5. Qualification and re-qualification of medical care at all levels

6. Special health care of villages, factories, workshops, schools, etc.

7. Sports and physical activity recreation

8. Social care for adults, adolescents and other outcasts

9. Infiltration of the community with new health education

10. Making a universal medico-social insurance

11. Social care for motherhood

The platform is a demarcation of a new social approach for decision making in medicine, altogether, showing some realization of the principles of socialized medicine. The full project consist a booklet of some 40 pages and is printed in the early 40s but remained concealed by the group "Social Medic", viz. Kusitasev K., Mateev D. Project for State Health Plan. Sofia: Hudojnik Print, 1940.

Meanwhile, efforts are strained from the new government to overcome the ruins from the WW II. Activities, interest and participation from the side of the general population is shown towards the questions of health care. With voting on 11 July 1946 of the "Law for Cooperative Suffrage of Health Establishments" /LCSHE/, a foundation is laid for intensive development of health care. This is emphasized by minister Angelov on a briefing at the National Assembly: "Evidently, the present state of affairs /N.B. approximately, in the year 1946 the hospital bed supply is 1 per 1000/ need a corrective down-and-up …" The LCSHE arranges the following subjects of cooperation: 1. As a compulsory participants in the face of state and municipalities; 2. As a facultative participants in the face - coops, associations, societies, companies, etc. Consequently, the government emits obligation funds which are cashed unconditionally by the State Exchequer at a limited interest rate. This is, de facto, socialization of health care on a large scale.

Socialization on a small scale is attributed via district physicians principle. Pre-requisite for this act is the adoption of new "Constitution for People's Republic of Bulgaria" /5 December 1947/ - in Art. 81 is written, that: "Liability of the state is to take care of the health of the citizen". Furthermore, with a decree № 43 from 21 December 1949, a new health maintenance organization is arranged, called, "polyclinics" and functioning on the basis of the former municipal health-services, workers health check-points, district ambulatories, etc. What is important here is that, towards, at the end of 1949 some 69,2 % of the total population were covered with "free" medical services. Here, in caveat, let us remark that much speculation has been held on the meaning of the term "free" health care. What is important here is that coverage was eligible for everyone, who, separately is employed in any kind of a state job. Thus, we say that 69.2 % is quite a good index for employment rate. The bad point is that re-imbursement rate often proved wrong and that is what "Marxian" economists could not foresight.

Speaking about "failure" is an issue from quality control. Our job is to give a chronology of events in the years after WW II and in the period of Cold War. Thus, we should try to enumerate briefly what happened in the first five years, something, which for the field of health care could encompass a lot of thick volumes. Firstly, on 12 June 1947 was voted the "Law for Sanitary Pharmaceutical Enterprise" /LSPE/ - enacting a process of nationalization for drug industry and marketing. Secondly, with decree № 4 from 12 May 1948, all private hospitals and clinics were expropriated and put under the umbrella of the Ministry of Public Health. Thirdly, with decree № I-20-874 from 19 August 1949, all

establishments from the "Fund for Social Security" /FSS/ are expropriated and a new institution, under state umbrella, is created - "State Institute for Social Security" /SISS/.

/to be continued/.

HEALTH SINCE 1945: TRANSITION PERIOD, PART 3

In the 50s, already, socialist transformation of health care was marching on a dynamic and rational scale - which, within the frames of the "Second Five-Year Plan" led to a total socialization of state apparatus: cf. Josef Stalin /1879-1953, b. Djugashvili/ and "Stalinism". I turn the pages of an old book, viz. Kolarov P. On socialist transformation of public health care /2nd ed./. Sofia: Nauka i Izkustvo, 1952. The author, Dr. Petar Kolarov /1906-1966/, was architect of socialist reform in health care. Himself, interbrigadier from Spain and U.S.S.R., was appointed minister-of-health on 20 January 1950. Same year, with decree № 2658 from 20 November 1950, was given state jurisdiction to a new nomenclature of health care organisation in the country. The basis of the decision making process, included:

1. Categorization of health care establishments and health care appointments

2. Unification of ambulatory and stationary health care units in academic structures

3. Recreation of Sanitary Epidemiologic Stations /SES/ with prophylactic purpose /N.B. first time, such stations were created during WW I but abolished on a later stage/.

The "Ministry of Public Health", renamed "Ministry of Public Health & Social Care" /MPHSC/ from 29 November 1951, function as a co-ordinating body which organise and run at the head a large network of branch structures - in itself, a replica of the "Directorate of Public Health" before WW II. A "Scientific Medical Council", accredited with ordinance № 911 from 14 April 1950, is the supreme consultative organ of the ministry for planning, research and development. It consist 25 members, all republican specialists in their corresponding working fields, appointed from the minister-of-health and treating different social medical problems with the help of standing committees and commissions.

In the periphery, health care is administered by the local organs of state authority - the public councils. Consequently, with decree № 2822 from 29 November 1951, are established the "Sectors for Public Health" within the district, community and city public councils. The "Sectors …" are responsible for management of hospital and ambulatory care on the territory of the corresponding council, while, some institutions on a national importance are under umbrella jurisdiction of the MPHSC. As a supplement and on a

middle level of management are constituent, also, a network of corollary consultative organs with duplicate functions: see example 1.

Now, medical planning has become particularly important characteristic for socialist health care. Planning is inseparable from budget and market extrapolations of any state economy. It consist from parallel lines of development and truncates to the left. Insofar as medicine is concerned - expenditures, for Ministry and Sector health establishments, are planned within the total republican budget and allocated with the help of corollary consultative organs. This seldom leads to discrepancies, but, once a deficit is settled and it can be reimbursed from the state reserve. In a historical perspective - some, 50 years after WW II and the federation of socialist states collapsed under the burden of state deficit. The question is, no making predictions, what could a wholesome world do if a trend on planning continue and this time in an inverse order under capitalist rules?

Next step, nevertheless, comes the reformation of cadres politics in the country. This is an issue of utmost importance and having in mind that Bulgaria could not boast a plethora of medical workers in year 1950, viz. there are 5164 physicians, 1550 dentists, 2034 nurses in practice. We see that health personnel management is not concerned, so much, with a matter of numbers as to their distribution and category level. Ahead, comes an ordinance № 1124 from 6 March 1951 that proclaims the "Institution for Specialization and Unification of Lectors" /ISUL/ - a doublefould organisation: once, to methodically upbring cadres and twice, to nourish a peripheral structures with personnel on a mapping principle /editor note, understand here "geography"/. Socialist reorganization seemed incomplete, without, ISUL and socialist international co-operation. In the long run, socialist countries, joined World Health Organization /WHO/ and International Classification Diseases /ICD/ - fl. year 1960.

/to be continued/

HEALTH SINCE 1945: TRANSITION PERIOD, PART 4

When Stalin died in March 1953, as we said earlier, the days of his satellite followers were doomed. Thus, Vulko Chervenkov /1900-1980/, himself: - a miner's son, who passed through "Lenin's Institute for International Politics", via Party work in the "committees" for culture, to Party work in the "central" apparatus. Chervenkov slavishly copied Stalin until April 1956, when, he was replaced by Anton Yugov - a Macedonian. However, the real power in Bulgarian political life from 1956 to 1989 was vested with the secretary of the Bulgarian Communist Party, Todor Zhivkov /1911-1998/, and under his direction Bulgaria remained the loyalest supporter of Soviet policy in the Warsaw Pact.

In the mainstream, an intensive social-economic development of the country in the Third Five-Year Plan, led to significant system processes with a reflection on health care, as well. Together with a changing canvas of lifestyle and working, parallely to, a heavy industrialization, a vivid cooperatization, etc - urbanization gained momentum. What we see in Table 1, bellow, the population structure of Bulgaria covering the period 1944-1967:

Towns Villages Year Total

№ % № %

1944

1948

1953

1958

1963

1967

6 913 300

7 162 200

7 385 600

7 766 300

8 111 100

8 335 100

1 665 500

1 888 200

2 241 800

2 732 100

3 306 700

4 043 300

24.1

26.4

30.4

35.2

40.8

48.5

5 247 800

5 274 000

5 143 800

5 034 200

4 804 400

4 291 800

75.9

73.6

69.6

64.8

59.2

51.5

Obviously, the urban population proportion is rapidly increasing and in 1967, 48.5 % of the total number are living in the towns and 51.5 % - in the villages. The migration of peasant population into the towns occurs at the expense, mainly, of the younger population rendered imperative by the industrialization process on a nationwide scale and developing at a very high rate.

The demographic development of the country during the years of people's government is characterized in Table 2, bellow, demographic development of the population of Bulgaria over the period 1944-1967:

Year Marriages

per 1000 inhabitants

Divorces

per 1000 inhabitants

Livebirths

per 1000 inhabitants

Deaths

per 1000 inhabitants

Natural growth

per 1000 inhabitants

Infant mortality

per 1000 livebirths

1944

1948

1953

1958

1963

1967

9.2

11.1

9.3

9.1

8.2

8.7

0.5

0.5

0.6

0.8

1.0

1.2

21.9

24.6

20.9

17.9

16.4

15.0

13.6

12.6

9.3

7.9

8.2

9.0

8.3

12.0

11.6

10.0

8.2

6.0

120.6

118.2

80.8

52.5

35.7

33.1

We see, that, infant mortality rate has sharply lowered - from 120.6 per 1000 born alive in 1944, it falls to 33.1 for year 1967. Ever since 1944, the birthrate on a nationwide scale has augmented, reaching 24.6 per 1000 population in year 1948; thereafter, it showed a tendency for decrease.

On an organizational level, further, were elaborated some aspects of health care network and within the context of town-village controversy. The leading principle was - "bridging over differences between workers and peasants". How to achieve this task? In a long term perspective, this, is a matter of folk psychology and we are not in a position to discuss the question. There is a multitude of literature written in the bulgarian parlance, but, let us stay abreast with our theme. Now, in order to provide a qualified and ready service for the workers in the manufacture - there, decree from "Ministry of Health" on 24 February 1953. The aim was to promote preliminary and periodical medical examinations for the workers, with, expertise for incapacity. These are rudiments of "screening" and "monitoring" procedures, as early as, the 50s in Bulgaria. Within a caveats mentioning, that, even earlier and before the WWII were functioning the "factories for health" - but, let us confess they had their precursors in the utopian literature. In Bulgaria, workers health care grew on a local basis and culminating in the 70s with WHO's project - "Dispensarization model in Gabrovo district, Bulgaria" /editor note, we'll talk about that later/.

In our opinion, socialist transformation of health care in the village is more interesting and deserves a special attention. This was done in a pace, when, collectivization of agriculture accorded such megacomplexes - i.e., TKZS, DZS, MTS, etc /N.B. transliteration is in bulgarian/. The bulgarian village gives good opportunities to sustain

and nourish the labor of the peasants. At first hand, when, urbanization of the country was not advanced and infrastructure roadways, building construction, etc were developed on a smaller scale - there, booming was extensive integration of village "district" health hospices. The number of such establishments was - 92 hospices with 1500 beds in year 1951; 266 hospices with 4028 beds in year 1957, etc. Later in the 60s an involution process began and, subsequently, new structures emerged in the face of "rural policlinics". These numbered, about, 300 in the end of year 1969 and were integrated to the "district" and "regional" hospitals, namely - with limited specialized cabinets.

Another establishments, founded with decree from "Ministry of Health" on 17 July 1953, were called - "Maternity and Infantile Homes" with operation carricula rules. What is given bellow is some statistics for the period 1944-1967, but, we will be back on the issue later to do some reasoning. Whereas during year 1944 there were only 7 "maternity and infantile homes" with 280 beds and not a single public nursery "creches", than, in year 1967 the "maternity and infantile homes" grow up to 31 with 2218 beds. In addition, 674 seasonal "creches" with 17 466 beds were established throughout the country. Thus, favorable conditions were provided for adequate cares and education of the children, enabling the mothers to put their efforts in the production and research. The flagpoints in this type of health care, include:

- complete dispensarization carried out for all pregnant woman, as well as, systematic observation ever since the very first week of gravidance.

- dispensarization by inclusion in special observation lists of all children, as early as, in the first month of life.

- requirement, that, each delivery takes place in a hospital unit or maternity home is of paramount importance for the state and organization of obstetrical aid.

Finally, few words should be said for the geriatric and sanatorial care in the country. They are within the framework of minister Dr. Petar Kolarov, who, held his post in the long summer from 1950 to 1962. Many efforts were made for securing normal life conditions for solitary old people and invalids with severe physical or mental defects. Here is some statistics for period 1944-1967:

- 126 social service units have been established with 9774 beds, against, 26 asylums for old in year 1944.

- 174 sanatorial units with 15 659 beds have been established for providing sanatorial-resort treatment, against, 20 units with 2134 beds during year 1944 - i.e., the sanatorial beds available per 10 000 population has increased from 3 to 19.

HEALTH SINCE 1945: INSTITUTIONALIZATION PERIOD

The Bulgarian transition to economic priorities and institutions, based on the Soviet pattern, was essentially complete by the end of the 1950s. It was on this basis that economic development /i.e., modern growth supported by structural change/ was under way for the first time in Bulgarian history. The concentration of investment capital, and, the arrival of factory labour from a newly collectivized agricultural sector were the key structural changes that sustained rapid growth of heavy industry and modern technology. Bulgarian economic development derived in part from a larger commitment to foreign trade, than, that of the Soviet Union or of any other Eastern European country. Since 1960, moreover, the making of Bulgarian economic policy has been marked by virtually unbroken discussion - about, how to improve the productivity of labour and capital. The discussion has prompted recurring reforms in the initial Soviet system of central planning and ministerial control. More attention was paid to statistical turning-points. Increasingly less attention was paid to discrepancies, between, planned and actual growth; they became less glaring after 1960 and virtually disappear after 1980.

Comparisons across the entire post-war period suggest another important change under way in the Bulgarian economy from about 1960 onward. This has been the transition from extensive to intensive growth, more precisely, from growth based on increased inputs to growth based on greater productivity per input. For labour, the transition was fuelled by massive injections of new fixed capital, and, proceeded more rapidly than anywhere else in Eastern Europe. For capital and other inputs, the growth of productivity has been sporadic and remains illusive. Management and technology have not improved consistently enough to increase the efficiency with which capital, in particular, is used. The concentration of more and more inputs into modern industrial production, however, has continued to be the principal source of structural change in the economy.

Characteristically, the overall rate of Bulgarian economic growth has itself declined. The productivity of capital has failed to keep up, with, that of labour. Raw materials have become more expensive, as they have everywhere in the world. Yet the record of growth remains a remarkable one, particularly, when compared to economies of similar size in Wastern and Eastern Europe. If there was no economic miracle for Bulgaria in the 1960s, neither, was there a serious setback during the 1970s.

Political continuity provides part of the explanation for this relatively stable performance. By the early 1960s, as spelled out earlier, Todor Zhivkov had consolidated his position as party "First Secretary" and had become Prime Minister. In 1971, he exchanged the latter position for the Presidency of the new State Council. Under this reorganization, Zhivkov has retained authority over the Council of Ministers, although, he is no longer its chairman. He was therefore head of state, as well as, head of the party. The collective leadership of Politburo of the party's Central Committee, and, 27 members of the slightly larger Council of Ministers have none the less come to play the wider role in making decisions - whatever, equivalent bodies do in the Soviet Union. Enough younger

members have entered the Politburo to lower the average age to below 60, which, was significantly younger than a Soviet figure.

No independently powerful figure, or, likely successor to Zhivkov emerged /N.B. His daughter Liudmila, though a member of Politburo, was never considered his probable successor nor equal; she was none the less widely mourned at her early death in 1981/. His leadership, until November 1989, constitutes the longest period of unbroken political stability under a single authority in modern Bulgarian history. Among a population whose historical memory of the 20th century was dominated by uncertainty and impermanence, by brief triumphs and enduring defeats, this recent continuity must be of significance. In the rest of Eastern Europe, only Hungary has had a comparable experience.

/to be continued/.

HEALTH SINCE 1945: INSTITUTIONALIZATION PERIOD, PART 2

An important factor, which determines the pace of medical science in Bulgaria from that period, is a drop out from the international isolation of the country - that, has been concomitant since the end of WW II. This is a welcome association with a number of international structures - UN, WHO, UNESCO, etc. - and, an important step forward to following the tendencies and programs of world community, as well as, the cardinal problems of men-environment-disease in the 20th century. This cooperation aside, Bulgaria continued to support intensive contacts with the countries of the CMEA /Council for Mutual Economic Assistance/. This international community of socialist countries, based on economic relations and fraternal cooperation, was created in 1949. It hosted international socialism, and, some non-aligned countries like Finland, Iraq, Mexico on the basis of relevant agreements until dissolved in year 1989 by political liquidation. Whatever the form of cooperation, the bulgarian medics participated actively in the field of health progress. For example, an extremely important project of the WHO and a group of bulgarian clinicists with leader Prof. Alexi Puchlev, was implemented on the research of Balkan Endemic Nephropathy from the early 60s.

Another important feature of medical science was the augmentation of medical cadres. It was evident that post-war Bulgaria lacks the plethora of specialists, necessary, to reform a health care system. Thus a massive trend was established towards production of medics. On 4 August 1945, with decree № 180, was established second medical faculty in Plovdiv. Consecutively, medical faculties were opened in Varna /1960/, Pleven /1964/, Stara Zagora /1982/ and after the conglomeration of the National Medical Academy in 1972, filials were bridged in the towns of Tolbuchin and Pazardjik. Namely, this gave an increase of physicians, from 3 500 in year 1944 to 28 500 in year 1989. The tradition to specialization of cadres abroad continued - as, hundreds of young specialists became

candidates and doctors of medicine in the frame of WHO programs and exchange fellowships with CMEA countries, viz. Soviet Union, GDR, Poland, Czechoslovakia, Hungary. However, the internal aspects of coordination were not neglected. The Bulgarian Medical Union /BMU/, which functioned short after the war, stepped place to an alternative organization - Union of Scientific Medical Associations in Bulgaria /USMAB/, based on a topic principle. Ultimately, the new organization was responsible for a network of internal relations in the forms of congresses and seminars, as well as, for providing an atmosphere of educational and ethical problem solving. This, however, not always gave a positive result - sometime, the principles of so called "democratic centralism" were broken and appeared ugly phenomenons, like, "loss of a job" or "transfer to another place" or "financial penalties", etc. Simultaneously, capitalism was presented with a monster face and the era of senators Mackarthy and Fullbright sentenced to decay. But, those were the realities of the 60s and we are not in a position to debate on the questions of Cold War, right now.

Health care from the beginning of the institutionalization period is characterized by the following features, namely:

1. increased adaptability to the new lines of social-economic progress;

2. more regulation towards the utility of resources, and, mobilization of self-control specifically in the field of prophylaxis;

3. enhanced cooperation of health care with other spheres of the social system, with, regard to complex determining of health and social problems;

4. further democratization of the health care system in accord, with, state and party directives /N.B., understand here development of relations of production, productive forces and surplus product/;

Minister of Health from that period is Dr. Kiril Ignatov /1962-1971/. Most important lines for the development of the state and the party, within frames of the Fourth and Fifth Five-Year Plans, are the decisions of the "9th Congress of BCP" /1966/ and "July Plenum of CC of BCP" /1968/. Now, while trying to be parsimonious with the interpretation of data from that period, we encountered some difficulties in the transfiguration of the material. In a future presentation we shall aim to give a fuller account of the state of health care system for the period. For the moment we have at hand some papers, presented by the Minister of Health in 1968, and, entitled "Cardinal lines of health development in the People's Republic of Bulgaria". Here are some excerpts from the concluding sections of the document:

"... In full accordance with the Thesises of the 9th Congress of the BCP, the main task of the social policy of the BCP is "to assure high vitality of the nation, to affirm a healthy way of life, to build up more favorable conditions for the multilateral manifestation of the human personality". The complex approach to health comprises the accelerated

development and realization of all specific activities, that, affect the solution of the health problems.

... The Party pays a special attention to the establishment of a healthy way of living, and, the nation-wide movement for high health culture. With regard to this, additional efforts will be made for the further development of mass physical culture, sports and tourism, for increasing the sports and tourists base and its using, especially by children and youth.

... Medical science has risen to a new higher level, respectfully, of its function and importance as such on account of the higher criteria and more important role of health care. The leading force of the scientific and technical revolution in our socialist health care is the powerful scientific, educational, production and organizational-methodological potential. The coordination of the research work programs is being improved, as well as, its complex character. The information possibilities are of much better use now ... New forms of immediate transfer of the latest domestic and foreign scientific results to the consumers are organized - the health workers in the practical health network.

... In the political report of the CC of the CPSU, delivered by comrade L. Brezhnev, and in the new edition of the Program of the CPSU enormous attention was paid to the development of health care in the Soviet Union. The political report of the CC of the CPSU states, that "For both man and society there is nothing more valuable than health. The preservation and consolidation of people's health is of primary importance". The problems of health care must be considered and worked out from wide scope social positions, by involving the Councils, the Comsomol, with the public initiative and the activity of the population ... This identity in the Party's outlines for the development of our and Soviet socialist health care is determined by the decades old links and harmony between the BCP and the CPSU, between our countries and nations, between our health care systems. Our socialist health care was created and developed on the Soviet health care model, using all the time its enormous experience and achievements. That is the base on which the identical goals, means and ways of development are formed."

/to be continued/.

HEALTH SINCE 1945: INSTITUTIONALIZATION PERIOD, PART 3

The beginning of the 70s were marked by several important events. On an international plan this is a series of conversations aimed at restraining the arms race, held between Soviet and U.S. representatives - the Strategic Arms Limitation Talks /S.A.L.T. Talks/. The first treaty was signed on May 1972 /S.A.L.T.-1/, limiting defensive anti-ballistic missile systems and agreement was reached over certain other measures. A second agreement /S.A.L.T.-2/ was concluded in June 1979, but, it fell short of American hopes when president Carter administration found it impossible to persuade the Senate to ratify the agreement. At Geneva on 1 July 1982, Soviet and American talks were renewed under the acronym S.T.A.R.T. /Strategic Arms Reduction Talks/ - as an optimistic

substitute for the discredited S.A.L.T. These S.T.A.R.T. Talks paved the way for international agreement in the 90s and continue until now.

As viewed on a national scale, the 70s brought important changes in the structure of the socialist society and in health care in particular. Let us enumerate the items on an agenda, which, will serve as a guide in the following narratives:

1. The tenth congress of BCP /1971/ gives in details the quantitative and qualitative changes in Bulgarian society. A programme is outlined for building an advanced socialist model in the country.

2. A new "Public Health Law" is voted by the sixth Common National Assembly /31 October 1973/. Important aspects of this law are, namely - prohibition of the private medical practice, adoption of a new Moral Codex of the physician, etc.

3. The process of consolidation of medical science finds its height, with, the establishment of Medical Academy as a solid, unified, scientific, therapeutical and organization-methodical complex /article № 921 from 30 April 1972/. The new institution is accredited with statutes and regulations by article № 0-9 from 7 February 1976.

So far, during this period of institutionalization, ministers of health are, namely: Dr. Angel Todorov /1971-1977/, Dr. Radoy Popivanov /1977-1987/ and Dr. Mincho Peychev /1987-1989/. At the end of year 1989, the country falls in sharp political and economical crisis. A long time regime of socialist transformation comes to an end.

We shall follow our agenda with some presentations, which, make every effort to be succinct. Main sources of information should be pin-pointed. Mention will be done, that, while the previous periods in the development of health care were scarce in materials with an international standard and here we have - in the 70s and 80s - quite an abundance from such materials. Our choice has been a matter of personal preference.

From: ***. Health Services in Europe (2nd edition). Copenhagen: WHO - Regional Office for Europe, 1975.

I. Background information

The People's Republic of Bulgaria, situated in the south-east of the Balkan peninsula, has boundaries with Romania in the north across the River Danube, with Yugoslavia in the west, and with Greece and Turkey in the south. Its frontier in the east is the Black Sea. Its territory covers 110 928 square kilometers and the population in 1972 was 8 576 200, i.e. 77.3 persons per square kilometer. The capital, Sofia, had a population of 877 000. The age distribution showed a preponderance of the younger age -groups: under 20 - 30.6 %; 20 to 39 - 29.3 %; 40 to 59 - 25.2 %; 60 and over - 14.9 %. For the period 1965-67 the expectation of life was 68.8 for males and 72.7 for females. The birth rate in 1972 was 15.3 per 1000 and the crude death rate 9.8 per 1000. The natural increase was 0.55 %.

The infant mortality rate, which has been decreasing slightly in recent years, was 26.2 per 1000 live births.

In 1971, the main causes of death , in descending order of incidence, were: diseases of the heart, cerebrovascular diseases, malignant neoplasms and pneumonia. The communicable diseases most frequently notified in 1971 were influenza, dysentery, infectious hepatitis, measles, gonorrhoea, tuberculosis and scarlet fever.

Bulgaria is being rapidly industrialized and industry now provides more than two-thirds of the total national product. Agriculture, which is heavily mechanized, is now fully on a cooperative basis.

Education is free and is compulsory up to 14 years of age.

II. Administrative organization of the health services

The country is divided into 27 provinces ("okrugs") and, in addition, the city of Sofia has the status of province. The provinces are subdivided into urban and rural communes,

There is a unified system of public health services and the Ministry of Public Health, set up in 1944, is the central authority for health matters. Free medical care and health protection are guaranteed by law for the whole population. All medical establishments are State-owned. At the provincial level the health services are directed by the public health departments of the Executive Committees of the People's Councils.

III. Organization of medical care

The basic unit of medical activity is the hospital, which provides both curative and preventive care and is responsible for health education. The hospital physicians also work in the out-patient department and visit patients at their work and at home.

The medical services are developing rapidly, especially in rural areas, which were formerly much neglected. Every rural commune has a health service and nearly every village with a population of over 2000 has its own health service, headed by a physician, There were 1223 such centres in 1970. In smaller settlements and in the more remote localities, care is usually provided by a feldsher working under medical supervision. Each rural health centre has a dental clinic.

Rural health services receive assistance from specialists in the regional hospitals.

In 1970 there were 200 hospitals with 56 009 beds and 185 sanatoria with 16 310 beds. In addition, there were 3587 polyclinics, dispensaries and other out-patient establishments, with a total of 7362 beds. At the end of 1970 there were 9.4 beds per 1000 inhabitants. Of these facilities, 15 rural polyclinics, 181 rural health services, 1127 rural health centres, 1866 health centres directed by feldshers and 903 rural maternity homes, with a total of 3464 beds (including 2569 maternity beds) served rural areas. Industrial workers receive

specialized medical care over and above that provided by the general medical service. Big industrial plants have medical establishments of their own: hospitals, polyclinics, prophylaxis centres, night sanatoria, rest homes, etc.

IV. Organization of preventive services

The standard of hygiene in both urban and rural areas is steadily rising. Guided by the central medical authorities, co-operation between the local authorities and the population is giving good results. Sanitation and epidemiological stations provided with laboratory facilities play a very important role.

Towns, both large and small, and industrial centres have water supply and sewage disposal systems.

At the present time infectious diseases pose no great problem, for Bulgaria is practically free of most epidemic diseases. Although tuberculosis is becoming increasingly less prevalent, the campaign to wipe out this disease continues and the population is subjected to compulsory and systematic X-ray examinations and BCG vaccinations. Treatment for tuberculosis is free, whether in hospitals, sanatoria or at home.

Employed women are entitled to fixed periods of maternity leave, as follows: 120 days for the first child, 150 days for the second and 180 for the third. During pregnancy they are encouraged to undergo medical examinations and to follow special courses. Creches are at the disposal of all working mothers. In 1970 there were 1003 creches with 43 697 places for children.

There is well-developed school health service. Each school doctor is in charge of some 2400 children, who are organized in Red Cross groups.

Mental health dispensaries have been set up throughout the country to prevent and treat mental disorders.

Special attention is paid to health education which is directed, under the Ministry, by the Institute of Health Education in conjunction with the Red Cross.

V. Public health information and research

Research work in all major fields of public health is carried out by 12 central scientific research institutes under the Ministry of Health. Some of these institutes were recently reorganized to form a Scientific Institute of Social Hygiene and Health Organization.

VI. Supply and training of health personnel

In 1971, the breakdown of principal categories of health personnel was as follows:

16 183 physicians (i.e., 1 physician per 530 inhabitants)

3 131 stomatologists (dentists) (i.e., 1 stomatologist per 2739 inhabitants)

5 012 feldshers

2 464 pharmacists

6 016 midwives

26 381 nurses

807 physiotherapists

556 rehabilitation workers (in 1970)

3 847 laboratory assistants

886 X-ray technicians

Three schools of medicine, in Sofia, Plovdiv and Varna, offer a six-year course of training for physicians, who may receive further training at the Institute of Advanced Medical Studies, which has university status. In order to qualify as specialists, physicians must follow special courses and pass a State examination.

Bulgaria also has 17 schools for nurses, feldshers, midwives and laboratory assistants (two-year and three-year courses).

VII. Financing of health services

The cost of medical care is met, either directly or indirectly, by the State.

Fig. 1: Public Health Administration in Bulgaria

/to be continued/.

HEALTH SINCE 1945: INSTITUTIONALIZATION PERIOD, PART 4

From: ***. Primary Health Care in the Bulgarian National Public Health System. Sofia: Medical Scientific Information Centre, 1978.

Going through exclusively difficult stages of development, Bulgarian Public Health nowadays represents a harmonious dynamic system connected functionally with the entire social and economic development of the country, and, related to all spheres of social life. The right of every citizen for good health is guarantied by the Republic's Constitution and by the Public Health Law /31 October 1973/ which rests on the basic socialist principles.

The state character of the public health is the first basic principle. As a social structure, the public health system is built, organized, financed and directed by the State and for that reason it represents and integral part of its politics. The institutional structure of the health network is built on a common hierarchical principle, compulsory for all administrative units in the country. This structural unity is an important stipulation for the even medical care distribution on the whole territory of the country, as well as, for the effective administration of public health activities.

An important characteristic of public health in the People's Republic of Bulgaria /PRB/ is its planning character. The public health plan is an integral part of the uniform national economic plan. It is created on the basis of thorough scientific researches on the alterations of the ecological system "man-environment", the incessantly changing requirements of the population for medical care, the tendencies of the health and demographic state of the country, the agglomeration of the population and the growth of the settlement systems, on the long-term prognostics for the development of productive forces, on the development of the public health resources, etc.

Prophylactics is a main tendency of Bulgarian Public Health. In the endeavor for good health the introduction of this principle is a qualitatively new and higher stage, which, can be realized only when interests of the people and the State coincide and develop in an organic unity. Essential feature of the prophylactics in the PRB is its comprehensive character. The activity sphere of the prophylactic measures is raised on a state level.

The successful social and economic development of the country created favorable conditions for the gradual decrease of the incidence of some and the complete eradication of other infectious and parasitic diseases. Under the organizational and systematic guidance of the "Inspectorates of Hygiene and Epidemiology" with the active participation of all prophylactic and curative establishments, as well as of the population itself, for many years along a planned and comprehensive immunoprophylactics and other antiepidemic measures have been taken.

Another basic principle of public health for the Bulgarian people is the insurance of a mass accessible, free of charge and qualified medical care for the whole population. On the present stage the prophylactic, diagnostic, curative and rehabilitative measures - as well as - some of the social ones for the protection, promotion and restoration of the people's health are realized by a widely spread, hierarchical, state functioning and mutually coordinated system of health establishments covering by their activities the population of the country - as a whole - and every person individually from his birth till

his death. The health structure of a higher level executes a more and more specialized activity and represents an integral part of the uniform public health system.

The basic organizational unit of public health is the team of microregional physicians. The primary health care in all its medical aspects and in some of its social ones is realized by team.

Public health in Bulgaria is build up and developed on the principle for unity of medical science and practice. This principle is realized by the wide development of the fundamental and applied medical scientific researches and by the implication of the latest scientific achievements into practice. The medical science provides the medical workers with modern methods of prophylaxis, diagnostics, treatment and rehabilitation. The insurance of scientific progress in the public health practice is a subject of special care on the part of the health authorities. This contributes to the permanent improvement of the people's health status.

The wide participation of society and of the population in the State activity for the protection, promotion and restoration the health of the population is a fundamental principle of Bulgarian public health. The activity of the population, directed and supported by the state organs, is a powerful stimulating factor for the successful fulfillment of all prophylactic and medico-social measures. The organizational forms of the participation of the population in Public Health are - the Standing Committees at the National Assembly; the district and municipal People's Councils; the health teams at the medical establishments; the members of the health groups organized in factories, schools and agricultural units, etc.

I. Hygiene and epidemiological activities

The hygiene and epidemiological care of the population is organized on different levels, in accordance with the administrative subdivisions of the country and the distributive principle of medical care.

Regional (local) level inspectorates are units and groups of hygiene and epidemiology - operating as branches of the "Inspectorates of Hygiene and Epidemiology". The groups of hygiene and epidemiology are organized in regions with up to 80 000 inhabitants. They are subordinated to the district inspectorates. One group consists of 2-3 physicians, several sanitary inspectors, laboratory technicians, disinfectors and others.

District inspectorates of hygiene and epidemiology are organized in the district towns with a population over 80 000 people. Teams of 18-20 physicians and other specialists with high and secondary medical education - chemists, biologists, sanitary inspectors, laboratory technicians and others are working at them. Some of the district inspectorates of hygiene and epidemiology are charged with national functions, too.

National (central) inspectorates of hygiene and epidemiology is functioning on national level.

The groups of hygiene and epidemiology and the branches of the inspectorates conduct a current sanitary control on public utilities, industrial enterprises, agricultural sites, public catering establishments and children educational institutions. They organize the fulfillment of the antiepidemic measures - immunizations, disinfection, disinsection and deratization.

The district inspectorates of hygiene and epidemiology execute specialized sanitary and epidemiological activities in the sphere of epidemiology, social hygiene, occupational hygiene, hygiene of nutrition, hygiene of children and adolescents, etc. The district services include microbiological, parasitological and chemical laboratories.

The national inspectorates of hygiene and epidemiology exercise a systematic guidance and control over all local medical services, renders practical assistance in the organization and execution of the state sanitary control, conducts a sanitary control over basic problems and over important sites with national significance, realizes the sanitary and technical expertises on standard projects, over sites of national importance, elaborate measures for prophylaxis and reduction of infectious and parasitic morbidity, carries out measures for the medical and sanitary protection of the country against quarantine and especially dangerous infections.

As a result of the close correlation of the services of hygiene and epidemiology and the network of medical services and the active cooperation of society and the population, considerable success was obtained in environmental sanitation on the basis of the respective sanitation programmes. Thus, for example, a number of industrial enterprises polluting the atmosphere were moved out of settlements. At present, 96 % of the population of the country uses pure drinking water from the central water supply system and 3.6 % from controlled local water sources. The number of industrial and agricultural sites reorganized in accordance with the hygienic standards, rules and requirements increase steadily. A great success has been attained in mining dust control and in the sharp reduction of pneumoconioses. The achievements in the limitation of the harmful effect of the chemical substances used in industry and agriculture are also considerable. A number of physiological and ergonomical problems are solved more and more successfully, as for example, the improvement of the regimens of work and rest, the introduction of new forking furniture, industrial equipment, etc. in accordance with the requirements of ergonomics.

Considerable achievements have been obtained in the endeavor for prevention, reduction and eradication of the infectious diseases in Bulgaria. This activity is conducted systematically and purposefully by the inspectorates of hygiene and epidemiology and by the medical establishments with the active participation of the administrative services and the social organizations. A basic role in that respect have the prophylactic immunizations, which, according to the Public Health Law are performed annually in accordance with an adopted immunization calendar. Their wide application permits the attainment of a great progress in the infectious disease control.

Table 1: Achievements in the struggle against the infectious and parasitic diseases in the PRB /morbidity per 100 000 people/

Kinds of infectious and parasitic diseases

1944 1955 1965 1975 1976 1977

1. Acute Poliomyelitis 1.5 1.5 0.0 0.0 0.0 0.0

2. Typhus 22.4 0.5 0.0 0.0 0.0 0.0

3. Diphtheria 57.1 9.6 0.2 0.0 0.0 0.0

4. Malaria 52.7 9.0 0.1 0.5 0.2 0.2

5. Typhoid fever 5.7 2.4 0.4 0.2 0.1 0.1

6. Tetanus 3.3 4.3 1.4 0.3 0.3 0.3

7. Whooping cough 15.3 252.4 18.1 5.6 1.6 15.9

8. Mumps 35.5 151.0 250.9 400.8 179.1 31.1

9. Measles 23.3 408.6 354.1 231.2 193.5 9.2

10. Dysentery 2.0 232.3 127.2 184.8 97.4 179.0

11. Viral Hepatitis 2.0 152.1 233.5 115.7 116.3 134.9

II. Health education

The principles, guiding planning, organization and management of health education activities in Bulgaria derive from the basic principles on which the public health system is organized. The significance of the health education in the public health system is stipulated by its prophylactic tendencies and by the active and mass participation of the population in the versatile activities for the health protection of the people. The health education is a State responsibility realized by its organs and is under its direct management.

Health education activities in the country are directed towards the formation of such health behavior and education, which, will enable every citizen to protect and promote his own health as well as the health of his family and his relatives. On the second place, the health culture stimulates the initiative of the population and of the individual person to participate in the realization of sanitary measures and measures for environmental sanitation, transforming each citizen into an active champion of the people's health and welfare.

In order to realize these activities, specialized services for health education were formed in the framework of the public health system. An "Institute for Health Education" has been created at the Ministry of Public Health, aiming at the organization and scientific guidance of health education in the country. Irrespective of that, department of Health Education were organized in all district inspectorates of hygiene and epidemiology. Their duties were twofold - to carry out health education by their own means and to organize the involvement of all health establishments and medical workers in health educational activities. At the same time, the Institute is responsible for the publication of different materials indispensable for the regular and purposeful direction of health education activities, such as: theses for lectures and meetings, films, slides, placards, exhibitions, leaflets, booklets, etc. Series of health lectures are issued, too - "Library of Health", "Health Lectures for the Worker", "Health Lectures for the Rural Population", Health Lectures for the Pupil", "Nutrition and Health", etc.

The health education in the country is conducted not only by the organs of the public health system, but, also by a number of other state institutions and organizations - the Ministry of Education, the Committee of Culture, the Bulgarian Cinematography, the Trade Unions, the Youth Organization, the Committee of Bulgarian Women, the Committee of Soberness and others. The activity of all these institutions is coordinated and directed systematically by the Ministry of Public Health and the National Council for Health Education, created on social principles at the same Ministry.

The Bulgarian Red Cross also displays widescope activities in the field of health education. Annually, thousands Bulgarian people are trained in different courses organized by this mass organization. In only one year, more than 300 000 people attend the courses on nutrition, on nursing ill people at home, on longevity, on the hygiene of youth, on hygiene of marriage, on hygiene of living conditions and others. Thousands of health posts render first aid and take care of the hygiene and the dissemination of health education on social principles. Especially significant is the activity of the Bulgarian Red Cross in the schools. There, this activity is directed towards the hygiene education of the pupils, including their participation in the struggle against smoking and drinking, their sexual education and their training in the health posts for rendering first aid, etc.

A considerable part of the work for the promotion of population health culture is carried out by the Fatherland Front - the largest social and political mass organization in the country. Through this organization thousands of health lectures and various prophylactic measures are organized annually in towns and villages.

III. Organization of primary medical care

Out-patient and day-patient care is the most mass type of medical care. In the outpatient departments, to a large extent, the problems of prophylactics, diagnostics, treatment, occupation-medical expertise and rehabilitation of the majority of the people in need of medical care are solved. This determines the leading role of the outpatient departments in the solving of the problems connected with the health status of the population.

The microregional principle (territorial and occupational) is accepted as a basic principle of primary medical care in the contemporary organization of outpatient care. The microregional system for outpatient medical care reflects in its contents the synthesis of the prophylactic and curative medicine. In Bulgaria the following physician's and dentist's microregions are organized, in accordance with the size and the territory dislocation of the attended contingent:

The village health microregion is organized in one or several villages with a population of 1500 - 3500 people. In such microregions qualified primary medical care is provided to the entire population. Every microregion is attended by a team formed out by a physician, a dentist, a midwife, nurses, physicians's assistants and auxiliary medical personnel. Dispensaries headed by physician's assistants (sometime called feldshers) are organized in order to ensure health care in small constituent villages in the structure of the village health microregions. In them, the physician's assistants work under the guidance of the microregional physician.

The therapeutic microregion organized in the towns and cities is the basic unit in the infrastructure of the outpatient medical care of adults. It covers a territory with adult population of 3000 - 3500 people. A team of physician-general practitioner or specialist in internal medicine, nurses and physician's assistants work there. For the medical care of the nearby villages, the therapeutic microregion includes in its structure physician's assistant's dispensaries in order to provide health care to the inhabitants of the nearby villages.

The enterprise-departmental physician's microregion is organized in enterprises for ensuring medical care for 1200 - 2000 workers. The medical team of the departmental microregion is composed of a physician (G.P.), a dentist, a physician's assistant and a nurse. In enterprises with more than 800 women workers - a midwife is included in the team. Physician's assistants dispensaries are organized in distant departments of the enterprise with more than 200 workers.

The pediatric microregion is organized for the attendance of 1000 children, on an average, aged up to 15. A microregional pediatrician and two nurses - a microregional nurse and a patronage nurse - are included in its structure.

The school health microregion is organized for 200 and more pupils. The necessary pediatric or internal medical care is ensured in accordance with the age of the pupils. There a school physician - pediatrician or internal medicine specialist - is working aiming at the specific medical problems of the rising generation. Nurses and physician's assistants are included in the team.

The obstetric and gynecological microregion is organized on a territory with a total population of 17 000 - 18 000 people or in industrial enterprises with more than 4000 women workers. A primary, specialized obstetric and gynecological care is provided. The team of midwives is headed by an obstetrician-gynecologist. In the rural medical service, in which an obstetric and gynecological microregion is not organized, a maternity health

center is organized and managed by the medical worker in charge of the dispensary. He ensures the prophylactic surveillance only on women with normal pregnancy, while, these with pathologic pregnancy are looked after in the outpatient department of the regional or district hospital.

The stomatological microregion forms an integral part of outpatient medical care and is a constituent part of the dispensary, or of the outpatient department's stomatological ward of the regional (local) hospital, or of the district stomatological outpatient department. It attends on a territorial principle the population elder than 18 years, while, the children and the pupils are attended by profiled children's and school's dentists. In the industrial

enterprises a departmental stomatological microregion is organized.

The types of the health microregions described above, provided the majority of the people with primary medical care in internal medicine, pediatric, obstetric - gynecological and stomatological aspects. Primary medical care in the remaining aspects is provided by the general outpatient departments, in the specialized outpatient departments and in the district stomatological outpatient departments. A successful supplement to the microregional principle in the country is the widespread organizational form of team care /see Fig. 1/. The basic sense and contents of this form is expressed in the following: the microregional

principle becomes essential not only for the internal medicine specialists, pediatricians and obstetrician-gynecologists but also for the other specialists in the outpatient departments. In compliance with the capacity of the establishment - one, two or more teams are organized composed of 5-6 microregional internal disease specialists, pediatricians, obstetric-gynecologists, a surgeon, a neurologist, an eye-specialist, an otorhinolaryngologist and a dermatologist. All these attend patients in a synchronized schedule. That creates a possibility for timeliness, quality and complexity of the diagnostic and curative process.

IV. Structure of the primary medical establishments

The widespread network of outpatient establishments and dispensaries in this country provides the population with free of charge, accessible paramedical help and qualified, specialized medical care. The medical services of general type, that, provide the population with primary medical care classified according to their capacities are the following:

The outpatient departments are complex medical establishments, delivering qualified and specialized primary consultative outpatient medical care - both, to the urban and to the rural population. They are developed as part of the regional, district or labour hospitals and as an independent establishments. The number of the outpatient departments in the towns is in accordance with the number of the inhabitants, and, their dislocation is in conformity with their necessary closeness to the attended population. An outpatient department in the big cities attends about 40 000 people on an average.

The outpatient departments, according to the number of the attended people and the functions they execute, are divided in five types. In them, an assistance of determined specialty is provided in conformity with the type of the outpatient department. The outpatient departments of type I, II and III are organized in the towns and cities. These of types IV and V are organized chiefly in the larger central villages. In the latter, according to prearranged schedules, different specialists are working - surgeons, neurologists, otorhinolaryngologists, ophthalmologists and others coming from the regional or district hospitals with a view to bringing the specialized primary medical care closer to the rural population.

The labour outpatient departments are organized at the industrial sites and complexes with more than 10 000 workers. As a rule, they are included in the structure of the regional or the workers hospitals.

The stations for urgent medical care exist as an independent health establishments only in the largest cities. They provide urgent medical care of the basic and some other specialties, such as: internal medicine, surgery, obstetrics-gynecology, cardiology, reanimation, traumatology, neurology, toxicology and others. The specialists according to their specialty are included in the staff of specialized teams, who, dispose of adequately equipped means of sanitary transportation.

The departments for urgent and emergency care are structurally incorporated into the outpatient departments of the district hospitals. Teams of medical workers with higher college and secondary medical education who are specialists chiefly in internal medicine and pediatrics, together, with specialized teams in conformity with the needs of the population - are working in them. The services for urgent and emergency medical care at the regional hospitals have the same functions but their staff is smaller.

All the stations, services and departments for urgent and emergency medical care use in their routine practice appropriate medical technology for the conduction of life-saving measures on the place of accident and during the transportation of the patient to the health establishment, as well as, modern means of communication: radio-telephone, distant recorder of electrocardiogrammes and others. In the structure of the National Station for Urgent Medical Care in the capital of Bulgaria - Sofia, the service of urgent consultations and medical aviation, disposing of modern transportation means including medical airplanes and helicopters, is included. At the day and night's disposal of this service are 250 habilitated specialists from the Medical Academy.

The dispensaries or so-called "outpatient and inpatient departments", provide primary specialized and consultative medical care on some problem disease in the public health network. Such are pneumophthisiologic, oncologic, psychiatric and dermovenerologic dispensaries. They provide specialized medical care to one or several districts, work in close interaction with health establishments of the general type and guide them systematically according to their specialized work.

Parallel with the insurance of primary medical care by the microregional physicians and by the outpatient departments specialists, the citizens have the possibility to choose - in accordance with their desire and preferences - a free of charge medical care from a highly qualified specialist, such as: head of hospital ward, head of clinic, habilitated specialist, etc. For this purpose scheduled hours for consultations of the patients in the outpatient departments are fixed. In the PRB exists a specially created organizational system, which, permits every person for whom the physician in charge on a given level decides that he needs more qualified and specialized medical care - to be sent to an establishment of a higher level. The system stipulates a special documental exchange of information between the different levels including feed-back of information.

In the activities of the general and specialized outpatient establishments network (the activities of the microregional physician and the different specialists working in those establishments) a basic method is the follow-up. These activities involve:

- planning, organization and carrying out of different kinds of prophylactic examinations of certain age, sex and occupational groups of the population with a view to the early discovery of the risk factors - occupational, communal, hospital - and the diagnostics of the early forms of some diseases which at that stage have the characteristics of mass and problem diseases for the country;

- the exact diagnostics of each individual case, clarification of the health condition of definite priority groups of the population (children, pupils, pregnant women, heavy load workers, etc), prescription of the necessary prophylactic curative and rehabilitative measures, planning and organization of dynamic surveillance of the followed-up patients and of the group of people at risk;

- realization of the planned measures in respect of the protection and sanitation of labour and living environment of man, increasing and strengthening the protective forces and supporting the adaptive mechanisms of the organism, promotion of health knowledge and formation of healthy habits among the population, systematic and active control of the results of the conducted health measures, introduction of eventually imposed corrections of the primary programmes, etc.

More on follow-up method in Bulgaria can be found in the monograph from WHO, namely: "D. K. Sokolov, J. E. Asvall, H. Zollner. The Gabrovo Health Services Model in the People's Republic of Bulgaria. Copenhagen: World Health Organization - Regional Office for Europe /EURO Reports and Studies 27/, 1980."

V. Organization of specialized medical care

The hospital network in Bulgaria is organized as a stage system comprising four levels - regional (local), district and national.

On a regional level, hospital care is provided in the united regional hospital. Its capacity is about 300 - 600 hospital beds. There are wards for internal diseases, pediatrics, surgery, obstetrics-gynecology which are organized obligatory, as well as, some specialized wards such as ophthalmological, otorhinolaryngological, neurological and others.

On a district level the district hospitals with 600 to 1200 hospital beds are organized for satisfying the needs of the population of the corresponding administrative unit (200 000 to 400 000 inhabitants). These are wards according to a broader nomenclature and include cardiologic, endocrynilogic, urologic, orthopedic, traumatologic and other wards.

On a national level specialized centres of pulmo- and cardio- surgery, organ's transplantation, keratoplastics and others are organized.

At the end of 1976, in 184 hospitals of the country 67 220 beds were functioning, which shows that the bed-population ratio was 85 beds per 10 000 people and that the admission rate was 16.4 per cent.

The sanatorium-resort care in Bulgaria disposes of precious resorts. More than 500 mineral sources were discovered with different composition and temperature of the water. Besides, there are firths and peats-bogs sources of curative mud and resorts with favorable climatic conditions. Some of the mineral sources, as these in Hissar, Kyustendil, Sofia and others were discovered and have been used as curative centres as far back as the time of the Roman Empire.

Sanatorium-resort care is considered as a stage in the carrying out of outpatient and hospital care. This type of medical care provides the realization of part of the planned in other medical establishments physioprophylactic, physiotherapeutic and medical rehabilitative measures. A harmonious system of continuity between the sanatorium resorts and the other medical establishments is organized, ensuring the sequence in the realization of the planned medical measures.

In 1976, the sanatorium bed-population ratio was 21 beds per 10 000 people. Considerable part of these beds were determined for the treatment of children and adults.

The medico-social assistance in Bulgaria comprise 15 209 berths in 158 establishments for social assistance - boarding houses for old people, boarding houses for honored revolutionists, homes for disabled people, homes for children and adults with physical impairment or mental disorders, hostels for students in the training and industrial enterprises, etc. In 49 settlements of the country the so-called "Social Home Patronage" is organized, by which different types of services (food delivery, cleaning of the lodgings

and other services) are ensured for old and incapable for self-attendance persons. In order to make life of old people worthwhile, 356 "Clubs of the Pensioner" have been organized in Bulgaria.

VI. Medical science and training of medical staff

Medical science is of special importance for public health in the broad sense of the term, including primary medical care - because - it ensures the outlining, the planning and the conduction of scientifically grounded measures. The scientific investigations about the health of the population and the conditions and the factors that determine it, about the needs of the population in medical care, about the requirements to create an effective health organization, about the clinical diagnostic curative and rehabilitative problems, etc. are of such nature that they can introduce essential changes in the approach to the protection and restoration and promotion of the health of the people. A basic element of science and of the realization of a comprehensive medical care is the medical staff.

All scientific and higher educational institutes in the country are integrated in an uniform scientific and educational complex - the Medical Academy - composed of 24 scientific institutes, 3 medical, 2 stomatological and 1 pharmaceutical Faculties. In this complex, the training of the students in medicine, the post-graduate education of the medical staff and the scientific activities are concentrated.

The paramedical staff is trained in institutes dislocated on the territory of the country. Their training takes 2-3 years depending on the specialty. At present, 19 institutes are functioning in Bulgaria, in which physician's assistants, midwives, nurses, laboratory technicians, X-ray technicians, rehabilitators, assistant pharmaceutists, nutrition inspectors, dental technicians and others are trained.

HEALTH SINCE 1945: INSTITUTIONALIZATION PERIOD, PART 5

From: ***. Bulgaria's Road to "Health for All". Sofia: Publishing House at the Medical Academy, 1987.

1. FOREWORD

The adoption of the goal of "Health for All" by the year 2000 from the member states of the World Health Organization /WHO/ in May 1977 became a turning point in its history and an event with profound long-term implications for the health and social policies of all nations. The challenge of "the attainment by all citizens of the world by the year 2000 of a level of health, that, would enable them to lead socially and economically productive lives" has given birth to a programme of peaceful cooperation and competition between countries of different social and political systems, small or large, developing or

developed. In this, the WHO and its member states have set an example of how different interests, ideologies and political systems can work together in the name of an attainable goal promising well-being and better quality of life to the millions of ordinary people throughout the world.

The past ten years have witnessed some significant progress towards the achievement of this objective, as well as, many difficulties and obstacles. The "International Conference of Primary Health Care", which, took place in Alma Ata, USSR, in 1978 was a major early landmark in the right direction. Under the leadership of Dr. Halfdan Mahler, the Director General of WHO and a dedicated architect of the "Health for All" movement, the WHO secretariat has developed an orderly conceptual and practical system of methodological instruments and guidelines in support of the efforts of the member states. Many countries have succeeded in accomplishing profound structural reforms in their national health care systems and in re-orienting a considerable part of their human, material and other resources towards providing efficient and accessible primary health care, preventing socially significant disease and other health problems, and ensuring social equity in health care. Other countries, however, have experienced serious economic difficulties, often aggravated by natural disasters, hostilities, dependence inherited from the colonial past and lack of a developed infrastructure. But irrespective of such divergences and of the uneven rate of progress towards the common goal, "Health for All" has become a global task, a system of new values and a set of specific strategies within the framework of world health during the last quarter of the XX century.

Bulgarian health workers and the entire Bulgarian society, as well as, the health workers and the peoples of many other countries, are clearly aware of the fact that the achievement of "Health for All" could be significantly accelerated if the world could free itself of the burden of the colossal expenditures on arms. The mere existence of nuclear arsenals having the potential of a global destruction puts in question not only the achievements of "Health for All", but, the very survival of humankind.

The realization of the most human goals of "Health for All", its accompanying system of values and the corresponding strategies, are in full concordance with the ideology and the objectives of the social development of the People's Republic of Bulgaria /PRB/. For forty years the principles underlying Bulgarian socialist health care and social policy have been consonant with the fundamental requirements proclaimed by the WHO in 1977, i.e. accessibility of health care, social equity in the allocation of health resources, government and community responsibility for the health of all citizens and priority of prevention.

At present, an intensive social and economic reorganization is taking place in PRB. It is related to real needs arising in the process of building up a mature socialist society. In the course of this reorganization utmost priority is given to the satisfaction of human needs and to providing the optimal conditions for a harmonious development of the individual person. One of the important prerequisites to the attainment of these objectives is the improvement of the health state of the population, the eradication or control of some

diseases, the significant decrease in the impairments and disabilities resulting from other diseases and the achievement of a harmony between man and his environment.

The intensive international exchange of information and experience and the programme documents and methodological tools produced by WHO, have found a vivid resonance among Bulgarian health workers and health planners, the public opinion and the government. Since 1977, national programmes dealing with key health and social problems have been drafted and adopted in accordance with the "Health for All" principles. Naturally, the time has now come for an overall review of the current state, trends and future projects in the main areas of public health and social development, which, will determine the attainment of the "Health for All" objectives.

The present document - Bulgaria's Road to "Health for All" - has been prepared in response to the unanimous decision of WHO member states for developing national strategies and plans of action in accordance with global and regional "Health for All" strategies. Each section of the paper contains a brief analysis of a particular problem, an outline of the approaches to its solution and a statement of the intermediate and final targets. It is foreseen to set up a Coordination Council /CC/, which, will monitor the implementation of the separate activities within the national strategy and coordinate the work of all the participants in the process. The CC will analyze annually the progress towards the accomplishment of the specific tasks according to an agreed timetable. An overall evaluation of the strategy will be carried out biennially by the "Collegium of the Ministry of Health" and the "Presidium of the Medical Academy". The results of these interim evaluations will be reported to the CC.

2. SYNOPSIS OF OBJECTIVES AND TARGETS

Promotion of healthy lifestyles

• Balanced nutrition

...

• Physical activity

...

• Smoking cessation

...

• Reduction of alcohol consumption

...

Promotion of environmental health

...

Rearing a healthy and harmoniously developed young generation

...

Prevention and control of socially significant disease and related health problems

...

Biomedical science and technology: a prerequisite for achieving "Health for All"

...

Improving the organization and management of health care

...

Financial support of health care

...

Training and development of human resources

...

International cooperation

...

3. HEALTH POLICY OF THE PEOPLE'S REPUBLIC OF BULGARIA

The People's Republic of Bulgaria /area: 111 000 km2 and population: 8 949 618/ is one of the oldest countries in Europe. It was founded in year 681 and in the early Middle Ages became the cradle of the Slavonic script and a major focus of culture. Its stormy history passed through periods of flourishing and decline, through centuries long struggles for national independence and self government.

Already during the first years following the Liberation of the country from the Ottoman rule /in year 1878/, a project for the organization of a national health service was developed by Bulgarian physicians. The first health projects at the time were influenced by the advanced Russian community medicine, which, emphasized prevention and democracy. However, within the framework of the capitalist state, Bulgarian public health policies were subordinated to the interests of the ruling class and gradually yielded to the private capitalist enterprise. Under the conditions of the bourgeois state the solution of national health problems suffered serious neglect.

Immediately after the victory of the Socialist Revolution on 9 September 1944, the new People's government set itself the task to resolve the major problems of public health, which, had been aggravated by the conditions resulting from the Second World War. In that period the health indices for the nation showed high infant mortality rates and high prevalence of communicable diseases, such as, tuberculosis, diphtheria, typhoid fever, exanthematic typhus and malaria. Hospital services were inadequate and restricted to cities and big towns.

The Socialist Revolution proved a turning point in Bulgarian public health. The essence of the health policy of the People's government was phrased in brief by Georgi Dimitrov: "Health and working capacity are the most precious national wealth". According to the "Constitution of PRB", health is "a basic human right safeguarded and promoted by the state and the socialist society". After its establishment, the "Ministry of Health" was assigned the important task to overcome the shortcomings of bourgeois public health and to develop a new system of health promotion and protection.

The first step of the People's government towards the establishment of a new health care system was the putting into practice of the Leninist principles of socialist public health, i.e. to make highly qualified medical care available to the entire population free of charge; to promote prevention as the mainstream of public health; to integrate medical science with medical practice; and to ensure the participation of all the sectors of society and the people's organizations in the implementation of health measures.

The system for preventive and therapeutic care in Bulgaria at present is built up on the territorial principle /residential or occupational/. Its methodology emphasizes strongly the so-called dispensarization approach, i.e. the active medical follow-up of large groups of the population. A network of hygiene and epidemiological monitoring stations were established, as well as, a "State Sanitary Inspectorate". As of year 1951, all the citizens of the country were entitled to medical care free of charge.

A decisive impetus to the advance of public health was given by the "April Plenum of the Central Committee of the Bulgarian Communist Party" in 1956. The supreme principle underlying, what, became known as the April policy of the Party - "Everything in the name of man, everything for the welfare of man" - evolves from the ultimate goal of communism, to promote the free and harmonious development of everybody. This political position ensured a lasting and comprehensive support to public health and laid down the lines for its further development: better coverage with health care, concentration of resources and establishment of health facilities with improved diagnostic and therapeutic potential, promotion of medical science and technology, transfer of the best achievements in world health science and practice, etc.

Within the provision of the "Constitution of PRB", the access to free health care is guaranteed to everybody in Bulgaria. The comprehensive network of health facilities now includes 3851 outpatient and polyclinic services, 187 hospitals with a bed/population ratio of 93 hospital beds for a population of 10 000, 196 sanatoria, 1199 creches and nurseries, 167 social welfare homes, 4644 pharmacies, 29 hygiene and epidemiological

inspectorates, etc. The number of health workers is over 190 000, including 25 665 physicians, 5745 stomatologists, 4209 pharmacists and over 84 000 mid-level health personnel. The annual number of outpatient medical contacts is over 86 million, of hospital admissions - over 2 million, of persons covered by medical follow-up care - over 4 million, etc.

Health care is being brought increasingly closer to the population by constantly strengthening the frontline of primary health care and emphasizing the coordinative role of the district physician. In the field of prevention the measures aiming at the improvement of the living environment become increasingly comprehensive and effective. The dynamic social and economic development, the rising standards of living and the involvement of the community are conductive to a constant improvement of the health status of the population. At present, the average life expectancy is over 71 years /versus 48.4 years in 1944/ and infant mortality has decreased to less than 15 per 1000 live births. Many communicable diseases have been eradicated and there is a trend towards a decrease in temporary and chronic disability; physical fitness and mental health, especially as concerns the younger generations, enjoy a high priority and the well-being of the entire population has been improved. It is foreseen to expand the principle of free medical care in the forthcoming years by providing all the essential drugs to those, who, need them free of charge. On a number of important health indicators the PRB ranks among the highly developed countries.

The advances in public health run in parallel with the progress of Bulgarian medical science. At the "Tenth Congress of the BCP", a new approach towards science and education was adopted, aiming at interlinking them more closely with social, economic and cultural development. The "October Plenum of the CC of the BCP" in 1971 set the task of reorienting science to socially relevant goals and integrating research with training and practical work at all the institutions of higher education. As a result, the Medical Academy was established in 1972. It was entrusted with the following tasks:

• further concentration of the scientific potential in biomedical research and its

integration with medical education and medical care;

• integrated management of research, the development of science, medical

technology and higher education;

• promotion of international collaboration;

The establishment of the Medical Academy led to an efficient concentration of cadres and resources, and, to their orientation towards key health problems. Health research was pursued not only within the Medical Academy, but, also in collaboration with the Bulgarian Academy of Sciences, the Academy of Agriculture and other institutions.

During the past decade 25 biomedical research institutes, 5 higher medical institutes /medical schools/ and 3 centres for applied research and production were established. The

Medical Academy thus became a powerful research, diagnostic and therapeutic complex, which, also has the important function of training highly skilled health workers.

Much of the research potential available at the Medical Academy is engaged in the development of new biomedical technologies, including original pharmaceutical products, advanced medical electronic equipment and other items produced to meet the local needs or for export in both developed countries and developing ones. More than 1600 technological inventions and innovations have been registered by the Medical Academy in the past 5 years. A number of scientific achievements have already been put into practice.

The resolutions of February 1985 and January 1986 Plenums of the CC of the BCP emphasized, that, the further development of Bulgarian society would have to be based on the accelerated advance of science and technology and the application of their products in all spheres of life. The "Thirteenth Congress of the BCP", laid the foundations of a new important stage in the social development of Bulgaria by adopting a national long-term strategy for scientific and technological progress, developed under the guidance of Todor Zhivkov - Secretary General of the CC of the BCP.

The strategy envisages a profound reorganization of science, with the aim of overcoming existing flaws in certain areas and mobilizing the creative potential of the nation. The accelerated implementation of scientific and technological advances and the transfer of leading world expertise, should provide the basis and conditions for a new stage in the promotion of health, prevention of diseases and the overall improvement of the work capacity and quality of life of people. The most important objective is to qualitatively upgrade health care, and, by means of a selective reorganization to direct all the efforts towards the solution of the most significant health problems. Bulgarian society has reached now a stage, when, it becomes possible to carry out a scientific and technological revolution in public health at an accelerated pace. Research into the molecular basis and mechanisms of heredity, of carcinogenesis, of hormonal and central nervous control over the physiological functions, hold out unexpected opportunities for preventing and treating disease and for promoting health. In due cognizance of the key importance of mental health and human behavior and of the role of the brain in the homeostasis of the organism, special attention and resources have been given to an integrated programme of neuroscience and behavioral science research.

In the light of this, the control of socially significant diseases comes to the fore. Due to the high morbidity, mortality and disability and the serious social, economic and psychological impact of cardiovascular, cerebrovascular and respiratory diseases, malignant neoplasms, injuries, diabetes and mental disorders - these conditions have been selected as the targets of a major national programme for primary prevention, treatment and rehabilitation. The programme includes a variety of social, behavioral and medical measures and specifies clearly the responsibilities for their implementation both within and outside the health care system. Dyspensarization will remain a key approach and according to the plan 65 per cent of the population would be covered by active medical follow-up by year 1990.

At this stage it is particularly important to shift the focus from a preoccupation with the treatment of disease, only, towards health promotion and disease prevention, in order to maximize the chances of all the people to enjoy lives free from disease and disability at the highest possible levels of physical fitness and mental activity that are commensurate with their age. In accordance with the Constitution of the WHO, which, emphasizes that "health is a state of complete physical, mental and social well-being and not merely the absence of disease or disability", the activities of the health system will increasingly be directed not only towards the persons who are ill, but, also towards the healthy. An example of the new measures within this comprehensive approach to the promotion of health is the establishment of the so-called "health workshops" in the industrial enterprises and organizations. There is now in Bulgaria a growing awareness, that, in view of the multiple determination of health programmes for health promotion and disease prevention prompt actions by all the state, economic and social bodies and organizations; public health is now clearly seen as a national cause. According to this new approach, health care must begin with health education of the population and participation by the people is required in all programmes dealing with prevention, treatment, rehabilitation and social assistance.

More than forty years have elapsed since the first People's government announced in its programme the strategy for the protection of the people's health. During that period of time fundamental changes have taken place in Bulgaria. The development of the health care system has paralleled the overall economic and cultural advance of the country. In the decades ahead, Bulgarian health workers and the nation as a whole, face major new tasks and challenges clearly outlined in the historic decisions of the "Thirteen Congress of the BCP". These decisions have set the signposts of Bulgaria's road to "Health for All" by the year 2000.

4. CONTEMPORARY STRUCTURE OF THE FRONTLINE OF HEALTH CARE IN BULGARIA

Editor's note: This chapter, essentially, covers the same material given before in chapter 18 from our exposition: sketch

5. PROMOTION OF HEALTHY LIFESTYLES

Balanced nutrition

In the course of implementation of the System for Balanced Nutrition on a national scale, the following objectives will be pursued:

1. By the year 2000, the prevalence of obesity /expressed as overweight exceeding

by 20 per cent or more the optimal weight/ should be reduced to less than 10 per

cent in the male population, and, to less than 20 per cent in the female population;

2. By the year 2000, cholesterol content in the blood serum should be reduced to

under 200 mg/100 ml or 5.17 mmol/l for the age groups 15 to 64 age, and, to

under 150 mg/100 ml or 3.87 mmol/l for children up to 14 years of age;

3. By the year 2000, the mean consumption of table salt per capita should be

reduced to no more than 6-8 g sodium chloride per day, with, a trend towards a

further decrease to 4-6 g per day;

4. The nutrition education of the population should be improved, so that, by the year

1990 no less than 40 per cent of the people from all ages would have adequate

knowledge about the diet appropriate to them; by the year 2000 this percentage

should be at least 60, as ascertained by questionnaire surveys;

5. By the year 2000, the consumption of animal fats should be reduced by 30 per

cent, and, that of sugar and sugar products - by 35 per cent; at the same time, the

consumption of fresh and frozen vegetables, fruit and fish should at least double

and the production of vegetable and fruit juices and mousses additionally enriched

with calcium and potassium should be substantially increased;

6. From 1988 on, obligatory labeling of foodstuffs should be introduced, in order to

inform the consumers about their nutritive and biological value; the concentration

of sodium chloride should be indicated on the packing of commercially available

table salt. By 1987, amendments to the Bulgarian State Standards for processed

and semi-processed foods should be initiated, in order to make them consistent

with up-to-date scientific norms of balanced nutrition;

Physical activity

The most important objectives are as follows:

1. The number of curricular and extracurricular classes for physical activity of

schoolchildren should be increased: for grades I to III up to 13-14 hours weekly;

for grades IV to VII up to 12-13 hours weekly; for grades VIII to XII up to 8-9

hours weekly;

2. There should be at least six obligatory days for walking tours in each school term

and a year round mountain camping base should be provided for about 5000

schoolchildren by 1988;

3. By the year 1990, the proportion of the adult population in age groups 18 to 65

years, who, are engaged in adequate physical fitness activities three or more times

a week should reach 50 per cent, and, by year 2000 - 80 per cent;

4. By the year 1990, no less than 60 per cent, and, by the year 2000 no less than 90

per cent of the adult population in age groups 18 to 65 years should be acquainted

- theoretically and practically - with the scientific norms of optimal physical

fitness and activity;

Smoking cessation

The following specific objectives will be pursued:

1. By the year 1990, the sales of cigarettes should be reduced by 20 per cent as

compared with year 1985, and, by the year 2000 - by further 30 per cent as

compared with 1990;

2. The proportion of smokers in the population should be reduced from 42 per cent

in year 1985, to 35 per cent by year 1990, and, to 25 per cent by year 2000;

3. By the year 1990, the proportion of schoolchildren from 12 to 18 years of age

who learn the smoking habit should be reduced to under 5 per cent, and, by the

year 2000 - to under 1 per cent;

4. By the year 1990, no less than 75 per cent of the adult population should be able

to specify the diseases related to smoking /as ascertained by questionnaire

surveys/; by the year 2000, the proportion of the informed population should be

95 per cent;

5. From 1988 on, the contents of the obligatory warning notice on the packets of

cigarettes about the hazardous effects of smoking should be amended to include

information on the nicotine and tar content and on the amount of carbon

monoxide released in the course of smoking;

6. From 1988 on, short term courses on behavioral therapy aiming at smoking

cessation and overcoming the smoking habit should be available at the outpatient

and polyclinic units and in the "health workshops" attached to industrial

enterprises; such courses should be organized with the support of the relevant

research institutions and the Trade Unions; in order to provide support to all the

smokers who have decided to give up smoking, mutual aid clubs or groups for ex-

smokers should be organized at their place of work;

7. By the year 1990, the smoking habit among all physicians and teachers should be

eradicated on a voluntary basis;

Reduction of alcohol consumption

The most important objectives are:

1. A decrease of mean alcohol consumption per capita from 7.32 l absolute alcohol

in 1985, to less than 5.0 l in 1990 and less than 4.0 l in 2000;

2. By the year 2000, a decrease should be achieved by at least one-third in the

incidence of alcohol related liver disease; the incidence of alcohol related

disorders such as delirium tremens, hallucinosis, Korsakoff's psychosis and fetal

alcoholic syndrome should be reduced to a level that would make it possible to

regard them as clinical rarities;

3. By the year 2000, the proportion of traffic accidents due to alcohol use should be

reduced to under 50 per cent of all accidents;

4. By the year 2000, the number of people of specialized antialcoholic treatment

should be reduced by 50 per cent as compared with their number in 1985;

6. PROMOTION OF ENVIRONMENTAL HEALTH

Measures are adopted by the Committee for the Protection of the Environment:

1. By the end of 1990, at least 2 or 3 settlement systems, and, at least 25 towns and

villages in each province of the country should be developed into models of

sanitation and hygiene;

2. By the end of 1990, 55 per cent of the industrial enterprises /encompassing no less

than 70 per cent of the industrial workforce/ should meet the requirements of

hygienic regulation; by the year 2000, their proportion should exceed 90 per cent;

7. REARING A HEALTHY AND HARMONIOUSLY DEVELOPED YOUNG GENERATION

The basic approaches towards the achievement of this objective are as follows:

1. By the year 2000, the rate of newborns with low birth weight /less than 2500 g/

should be reduced to under 6 per cent;

2. By the year 2000, the incidence of congenital malformation and anomalies,

especially those relating to the neural tube and the cardiovascular system, should

be reduced to 2.5 per 1000 live births;

3. Perinatal mortality from all causes should decrease from 12.3 per 1000 live births

in 1985, to 11 per 1000 live births in 1990 and to less than 8 per 1000 live births

in 2000;

4. A decrease in post-neonatal mortality rate /the mortality of live born children who

die at an age from 1 month to 1 year/ should be attained, from 7.1 per 1000 live

births in 1985, to 5.0 per 1000 live births in 1990 and to less than 3.5 per 1000

live births in 2000;

5. The stillbirth rate should decrease from 6.6 per 1000 births in 1985, to 6.0 per

1000 births in 1990 and to less than 4.0 per 1000 births in 2000;

6. By the year 1990, the infant mortality rates should be reduced to less than 11 per

1000 live births, and, to less than 9 per 1000 live births by the year 2000, with a

trend towards further decrease;

7. By the year 1990, no less than 80 per cent and by the year 2000, no less than 90

per cent of the pregnant woman should be thoroughly familiar with the risk

factors that may affect fetal and infant health;

8. By the year 2000, the proportion of parentless children, who, are adopted or

placed with foster families after a stay in an institution of no more than one year

should increase to 85-90 per cent;

8. PREVENTION AND CONTROL OF SOCIALLY SIGNIFICANT DISEASES AND RELATED HEALTH PROBLEMS

A National Programme for the Prevention and Control of Socially Significant Diseases in Bulgaria has been developed and adopted:

1. Cardiovascular diseases: The national objective is, by the year 2000 to achieve a

decrease in the mortality rate from ischemic heart disease of 24 per cent as

compared to 1985, i.e. to reduce it to 190 per 100 000 total population /all age

groups/, and, to 66 per 100 000 total population for the age groups 45-54; to

decrease the mortality rate from cerebrovascular disease by 30.2 per cent

compared to 1985, i.e. to reduce it to 184 per 100 000 total population;

2. Malignant neoplasms: With a mortality rate of 164.9 per 100 000 total

population /1985/ malignant neoplasms rank second among the main causes of

death in the entire population /all age groups/; and with a mortality rate of 384 per

100 000 total population are the leading cause of death for the age groups over 55

years; it is expected that the implementation of this strategy will result by the year

2000 a decrease in cancer mortality rate of about 16 per cent as compared to 1985,

i.e. will be reduced to 138 per 100 000 total population /all age groups/;

3. Respiratory diseases: With a mortality rate of 92.3 per 100 000 total population,

respiratory diseases account for about 45 per cent of registered disease

prevalence; it can be expected that the successful implementation of measures

will result in a decrease by the year 2000 of the prevalence and mortality of

respiratory diseases by about 25-30 per cent as compared to 1985;

4. Accidents and injuries: In 1985 the mortality rate from accidents and injuries in

Bulgaria was 63.5 per 100 000 total population;

5. Mental disorders: About 1 per cent of the total population /all age groups/ is in

need of therapeutic and rehabilitative care because of chronic or recurrent mental

disorders;

6. Infectious diseases: During 1981-85 the incidence of all infectious diseases

/excluding influenza and acute respiratory diseases/ has been decreases by 21.9

per cent; the incidence of infectious intestinal diseases by 31.6 per cent; and the

incidence of infectious respiratory diseases by 16.8 per cent, as compared with the

previous five year period /1976-1980/;

9. BIOMEDICAL SCIENCE AND TECHNOLOGY: A PREREQUISITE FOR ACHIEVING "HEALTH FOR ALL"

The general aim of health research and the development of new technologies during the following 10-15 years will be to ensure the scientific back-up to the Bulgarian strategy for attaining "Health of All". This presupposes a priority development of those branches and trends of science which will:

1. Guarantee the development and implementation of technologies directly serving

the programmes for promotion of healthy lifestyles, control of the socially

significant diseases, health protection of children and adolescents, environmental

protection and rising the quality and accessibility of health care;

2. Increase knowledge about the patterns and trends of morbidity and health in the

community, with, a view to making predictions, identifying needs and improving

health care management;

10. IMPROVING THE ORGANIZATION AND MANAGEMENT OF HEALTH CARE

The further development of public health in Bulgaria will require certain decisive improvements of the organization and the system of management of health care. The new requirements arise naturally in the course of construction of a mature socialist society, namely:

1. Joint management of the health services by the state and the community;

2. Strengthening the role of the Ministry of Health;

3. Strengthening the role of the Medical Academy;

11. FINANCIAL SUPPORT OF HEALTH CARE

The global trend of rising health care costs also has its effects on health care support in Bulgaria. This is evident from the higher rate of increase of health expenditures in comparison to the growth of national income, viz:

1. While during the period 1970-1980 the average annual rate of national income

growth was 6.9 % and that of the government budget 8.8 %, health expenditures

grew at an annual rate of 10.9 %;

2. In 1985 the health care expenditures amounted to 6.1 % of the national income;

12. TRAINING AND DEVELOPMENT OF HUMAN RESOURCES

The most important objectives, as viewed by the national strategy, are as follows:

1. By year 1990, the number of doctors will increase to 28 235 or 31.3 per 10 000

citizens; the number of dentists will be 6228 or 6.9 per 10 000; and that of the

nursing staff will be 94 223 or 104.6 per 10 000 citizens;

2. By year 1990, the ratio between doctors and dentists on one hand, and, nursing or

supporting medical personnel on the other - will improve, and from 1:2.56 at

present will reach 1:2.62 with a tendency towards further improvement up to

1:3.50, by the year 2000;

3. By year 2000, the number of higher medical staff is expected to be 31 200, thus,

reaching a coverage of 33.7 doctors per 10 000 population; no less than 48 % of

the net increase in the number of doctors will be absorbed by the "front line" of

health care, and, it is expected that by the year 2000 one-half of all doctors will

work in primary health care;

13. INTERNATIONAL COOPERATION

Multilateral cooperation in health is regarded by Bulgaria as being of key importance to the attainment of "Health for All". New proposals will be developed for its qualitative upgrading, both, within the framework of CMEA and WHO programmes:

1. The medium term Collaborative Programme between Bulgaria and WHO will

focus increasingly during the coming years on the specific European targets for

attaining "Health for All" by the year 2000;

2. The Bulgarian institutes designated as WHO Collaborating Centres will play the

principal technical role in the implementation of joint programmes and activities

with the WHO Regional Office for Europe and the WHO Headquarters in

Geneva;

3. The participation of the Bulgarian research institutes in the conception and

implementation of WHO programmes will be expanded and steps will be

undertaken for the establishment of further WHO collaborating and reference

centres in this country;

14. CONCLUDING NOTES

The present document has been prepared by a working group under the guidance of Academician Professor A. Maleev, Associated Professor A. Jablensky and Associated Professor L. Ivanov

HEALTH SINCE 1945: INSTITUTIONALIZATION PERIOD, PART 6

From: The Editors of BAS. Information Bulgaria - a Short Encyclopedia of the People's Republic of Bulgaria. Oxford: Pergamon Press, 1985

SOCIAL SECURITY IN BULGARIA /1945-1989/

Basic Principles and Historical Evaluation.

Social security was first introduced in Bulgaria immediately after the Liberation from Ottoman rule in 1878. At first the social security scheme covered only civil servants as there was a strong desire to consolidate the Bulgarian State. The Turnovo Constitution of 1879, the first Bulgarian Constitution, stipulated that 'civil servants appointed by the Government are entitled to pensions the size of which will be fixed in a stated manner'. With a view to legally regulating the social security scheme, laws on pensions were voted on covering disability pensions, retirement pensions and pensions paid to dependants. Those entitled to these pensions included the military, administrative and police officials, teachers, ministers, clergymen, civil servants and those holding elective posts. The bourgeois State excluded the working-class people from social security, which was the privilege of certain classes. Retirement pensions paid to the military were extremely high. The aim was to prevent civil servants and municipal workers from waging an organized struggle for better working and living conditions and from carrying out joint actions with the workers. When setting up their first trade union organization, workers from the private sector established mutual-aid funds to cover the event of unemployment, sickness and death. This voluntary trade union security failed to provide the necessary social security against labour risks.

The Bulgarian proletariat launched an organized struggle for mandatory social security for workers, a struggle which achieved the first results, whereby the State was compelled to establish mutual-aid funds and friendly societies. An important role in the proper direction of the workers' demands was played by the Bulgarian Workers' Social Democratic Party which, in the programme adopted at its first congress in 1894, demanded social security for workers as well. A law was adopted in 1905 regulating female and child labour in industrial enterprises and a social security scheme was introduced to cover sickness and industrial injuries for workers from the public building enterprises. The raising of the revolutionary spirit of the working people as a result of the victorious Great October Socialist Revolution, and of the hard conditions on the battle front during World War I led to the introduction in 1918 of compulsory social security covering industrial and office workers in the event of sickness and industrial injuries. The sickness insurance was confined only to low-paid workers, those receiving up to 2,400 levs annually. Provisions were made for treatment of up to six months with the sick person receiving, from the third day of falling sick, compensation amounting to three

quarters of his or her monthly wages when treatment was given at home. In the event of hospital treatment, the corresponding proportion was 50 per cent of the respective wages. The insurance against industrial injuries came to cover, for the first time, all workers and employees at state, public and private enterprises and establishments irrespective of their age, sex, nationality and form of pay. The principle of vocational risk was recognized. It required that the insurance contributions be paid by the respective enterprise, with full compensation being given in the event of any kind of industrial injury, and there was no need to prove who was to blame for the labour accident. Those who suffered industrial injuries were allotted pensions in a statutory way rather then through the court. In 1920 the pensioning scheme covered 62,000 people but insurance was poorly organized and inadequately financed. Under the conditions of the organized struggle of the workers, grouped in powerful trade unions led by the Bulgarian Workers' Party after the suppression of the world's first anti-fascist uprising of September 1923, the bourgeois Government was compelled to initiate a workers' social security scheme. As a result of the 1924 social insurance act, an insurance scheme was introduced covering industrial injuries, occupational diseases, sickness and maternity, disability and old age. An unemployment insurance system was initiated in 1925, while from 1941 onwards insurance came to cover private craftsmen, and from 1943 onwards it included merchants as well. The contributions for the 'labour injury" insurance were paid by the employers, while the contributions for the rest of the insurances were shared equally by those covered by the insurance scheme, the employers and the state.

Bulgaria's experience in introducing insurance for private farmers in 1941 was interesting. That insurance originally covered only men, and from 1946 on women as well. The retirement age for men was 60, for women 55. The size of pensions was not very high. Under the conditions of capitalist development social security was incomplete arid financially unstable, and the size of pensions was insufficient. Social security in those days was characterized by various financial irregularities and bureaucratic administration.

After 9 September 1944 social security became part of Bulgaria's social policy. It was aimed at promoting the working people's health and at raising their living standard. From the first years of the popular regime it was placed on solid foundations. In 1949 all social security schemes were overhauled and were administered by a unified State Social Security Institute. In 1951 free medical care was introduced throughout the whole country and a Labour Code was adopted, regulating state social provisions. Since 1957 pensioning has been regulated by a law, which is still in force, although some amendments and additions have been made to it.

The right to social security is guaranteed by the Constitution. The main principles underlying social security may be summed up as follows: to protect all the working people (all people engaged in socially useful work are covered by the insurance scheme), that is, workers, employees and co-operative farmers who are employed under a labour contract, irrespective of what has necessitated such a contract, as well as part-time workers; and servicemen in the Bulgarian People's Army, re-enlisted officers and sergeants, workers and employees on the regular payroll working half a day, those

vocationally rehabilitated who are on a shorter working day, Bulgarian citizens working abroad, those working in small-scale private shops and farms, members of households and private persons, foreign workers and employees based in Bulgaria, those serving in the Bulgarian Orthodox Church, masters of arts and crafts, writers, journalists, artists and sculptors; to cover all risks against temporary or permanent incapacity for work due to industrial injuries, occupational diseases, general sickness or injuries other than industrial ones, confinement and maternity, quarantine, infectious disease, attending a sick member of the family, disability, old age and death. The insurance contributions are paid by the respective enterprise or establishment (workers and employers pay no contributions, except freelances). The size of the insurance contributions should be sufficient to enable the working people to maintain their living standard even in the event of incapacity for work. The administration of social security should be handled by the workers. Under a 1960 law this administration was entrusted to the trade unions, the largest organization of working people in Bulgaria.

Social security in Bulgaria is based on the insurance contributions paid by enterprises, establishments, cooperatives and public organizations. These contributions are deducted from the wage fund and are paid out of the funds of enterprises and establishments. There has been a great increase in the size of these deductions. This is due to the extension of the population's rights to insurance, mainly through the increase in the size of child allowances, compensation and pensions, and through the extension of maternity leave. In 1973 these contributions amounted to 12.5 per cent, in 1974 the proportion was 20 per cent and in 1980-30 per cent. Social security in Bulgaria is based on the principle of the pure system of distribution. Current expenditures are met by current revenues. No reserves for meeting future payments are formed. Any surplus at the end of the year is deposited in the State Budget, thus restoring any deficit, hence the financial stability of social security in this country.

Insurance in the Event of Temporary Incapacity for Work.

This covers workers who are unable to work because of sickness, industrial injuries, occupational diseases, balneological treatment, urgent medical examinations, quarantine, suspension from work on medical advice, attendance of a sick member of the family, the accompanying of a sick man to a hospital situated in another area, or treatment abroad; and for women workers and employees - in the event of pregnancy, confinement, or maternity leave. Temporary incapacity for work must be certified by the doctor in attendance when it lasts up to twenty days, and by a medical team when its duration is over twenty days. The amount of compensation for temporary incapacity for work due to sickness, accidents other than labour ones, quarantines, for attending a sick member of the family (not including children up to the age of seven) depends on the uninterrupted length of service of the person involved and is calculated as a percentage of the nominal labour remuneration during the month preceding the onset of the incapacity for work. The percentages are differentiated and depend on the number of years worked: 70 per cent of those with ten years of service, 80 per cent for people with service of between ten and fifteen years and 90 per cent for a service of over fifteen years. When temporary incapacity for work continues for more than fifteen days, the size of the compensation

after the fifteenth day is 80 per cent, 90 per cent and again 90 per cent, respectively. The compensation for attending a sick child up to the age of nine is 100 per cent of the nominal wages, and for temporary incapacity for work due to industrial injuries and occupational diseases - 90 per cent. In both these cases the size of the compensation does not depend on the number of years worked. Temporary incapacity for work due to sickness and industrial injuries is considered to have begun from the first day of its onset and runs until the day the person involved is proved to be fit for work again, unless permanent disability is certified, in which case a disability pension is granted. In cases of quarantine, compensation is paid as long as the person involved is under quarantine. When someone is suspended from work for suffering from an infectious disease, for being a germ carrier, or for having been in contact with people suffering from contagious diseases, compensation is paid for 90 days. The duration of the compensation for attending a sick member of the family is ten calendar days per calendar year for each insured person. When attending a sick child under the age of sixteen, or when accompanying him or her to another area for the purpose of undergoing treatment or medical examinations, or when accompanying him or her abroad for the same purpose, the accompanying mother or father is entitled to compensation for up to 60 calendar days per calendar year. In the event of balneological treatment the compensation paid covers the whole period of treatment, plus three days travel allowance to and from the spa.

Insurance in the Event of Pregnancy, Confinement and Care of Young Children.

In 1944 the number of people covered by insurance was 54,000, while in 1982 the corresponding figure was 2 million. Paid leave has been extended and the size of compensation has been raised to 100 per cent of the basic labour remuneration. Insurance coverage may be summarized as follows:

1. Vocational Rehabilitation of Expectant Mothers. With a view to preserving the health of expectant mothers and to ensuring normal pregnancy, every mother-to-be working in conditions harmful or arduous to the pregnancy is transferred to another lighter job corresponding to her health condition and qualifications. A special commission made up of the respective administrative manager, the chairman of the trade union, or trade union representatives, a representative of the Inspectorate of Hygiene and Epidemiology and a doctor from the maternity health centre defines the place of work and posts expectant mothers should not occupy and those to which they can be transferred. This vocational rehabilitation begins from the day pregnancy is confirmed. When the income of expectant mothers has fallen as a result of vocational rehabilitation, the balance of the average monthly nominal wages received during the previous twelve months is restored out of the social security fund. Vocational rehabilitation is carried out on the basis of a medical certificate issued by the respective doctor. It gives the duration of that rehabilitation and the kind of job the expectant mother is capable of doing. Once back to work after the delivery, mothers are entitled to the same job they have held before their vocational rehabilitation.

2. Maternity Leave. All women covered by the insurance scheme are entitled to paid maternity leave. This applies to all those who have been employed, even only for one

day, before going on maternity leave (which begins 45 days before confinement). They too are covered by the insurance scheme and are entitled to cash compensation. Seasonal and other women workers who are not permanently employed are also covered by the insurance scheme. They are required to have been employed for seven consecutive days before going on maternity leave. Mothers enjoy 120 days of paid maternity leave for the first child, 150 days for the second, 180 days for the third and 120 days for each subsequent child. Forty-five days of this leave are given before delivery. Throughout the maternity leave mothers receive cash grants equal to 100 per cent of the nominal wages they have received during the preceding month before going on leave (which is not less than the wage scale and not higher than 120 per cent of that same scale). Adoptive mothers, too, are entitled to the same maternity leave.

3. Paid Leave for Looking after Young Children. If after the paid maternity leave the child is not placed in a nursery or a child-care establishment (this is done of the parents' own free will), mothers (adoptive mothers included) enjoy an additional leave of six months for the first child, seven months for the second, eight months for the third, and six months for each subsequent child; as of 1 July 1985 this leave is extended to 24 months. During that leave mothers receive cash grants equal to their minimum wages, which are fixed throughout the country, and amount to 110 levs a month. When mothers do not wish to take such leave and prefer to return to work, as well as their wages they also receive 50 per cent of the cash grants given to mothers on leave for looking after their children. If a mother (or an adoptive mother) on maternity leave, or on leave to look after her child, is taken ill or dies, the cash grant for looking after the newborn baby is given to the father or to another relative. In addition, mothers enjoy additional unpaid leave until the child is three years old. During that leave they receive ten levs a month in the form of a cash grant. The maternity leave and the leave for looking after the child is not considered an interruption of the length of service, and their jobs are held for them until the child is three years old.

Student mothers are entitled to a 90 lev cash grant per month. This grant is given to them for ten months for the first child, 12 months for the second child, and 14 months for the third child. A decree of the Central Committee of the BCP and the Government, issued in April 1984, provides for this leave to go up to 24 months, irrespective of the number of children born, and the grants will be equal to the country's minimum wages. Only full-time students are entitled to this grant, regardless of whether they are studying in Bulgaria or abroad. Student mothers at all higher educational establishments and at special secondary schools receive a grant of up to 80 levs a month after their maternity grants have terminated. When the husband is employed, the student wife receives 50 per cent of the grant, i.e. 40 levs. Mothers who for one reason or another are not employed and do not study are likewise entitled to maternity grants, and to grants for looking after their children. The period is considered as length of service, which is twelve months for the first child, fourteen months for the second child and eighteen months for the third child.

Family Allowances are paid under the 1951 Decree for Promoting the Birth-rate and Large Families. Family income supplements were first paid in Bulgaria in 1941 to state

employees only. Under legislation currently in effect, able-bodied persons are entitled to a lump-sum cash grant in the event of confinement, to monthly child allowances, and monthly grants for student families and for those of post-graduate student and conscripts. Lump-sum cash grants for live-born children at the rate of 100 levs for a first, a fourth and each additional child, 250 levs for a second and 500 levs for a third child are paid to all Bulgarian women, regardless of whether they are covered by the social security scheme. Foreign nationals giving birth to a child in Bulgaria are not entitled to cash grants. As a rule it is the wife who draws the maternity grant, though in some specific contingencies it can be drawn by the husband or the guardian. During the period 1970-82 the sum total of maternity grants rose from 17.1 million levs to 24.1 million. The monthly child allowance rate is 15 levs for a first, a fourth and each additional child, 25 for a second, and 45 for a third, so that a one-child family receives monthly a 15 levs supplement, a two-child family 40 levs supplement, and a three-child family an 85 levs supplement, amounting respectively to 15, 40 and 85 per cent of the minimum monthly pay. Child allowances are given until the age of 16.

As of 1 July 1985 the monthly allowances for children are set as: for a second child to 30 levs; for a third child to 55 levs; after the birth of a second child, the monthly allowance for the first child increases from 15 levs to 30 levs. The monthly child-care grants for families of students, post-graduate students and conscripts are 30 levs per child. State allocations for child allowances come second after those for pensions, and have grown from 219.8 million levs in 1970 to 504.7 million in 1982.

As of 1 July 1985 young newlyweds are entitled to state loans for the construction or purchase of a flat, up to the sum of 15,000 levs, without having to pay a deposit, and are allowed up to 30 years to repay it. On the birth of a second child (four years after the birth of the first child) 3.000 levs of the loan are remitted, and of a third child - another 4,000 levs are remitted. Apart from the loan for construction or purchase of a flat, young newlywed couples are entitled to a loan of 5,000 levs for other purposes, to be paid off within ten years. For the birth of a second child within four years after the birth of the first child the entire remaining unpaid part of the loan should be remitted.

4. Other Benefits. An employed person falling into a rectified disability class, but not eligible for a disability pension because of incomplete length of service, and who has been re-posted to a job suitable for his health status, can qualify for financial aid starting from the date of disability, to be paid over the course of three months, if he is graded Class 3 disabled, and over the course of six months-if Class 2 or 1. In the event of the death of a member of the insured person's family, a death grant to the rate of 80 levs is payable to the person paying the funeral expenses; in the event of death through an accident at work the sum is 120 levs. Funds allocated for temporary disability indemnities, and especially those of the child allowances, are continually on the increase.

The Pension Scheme.

Bulgaria's pension scheme is one of the most democratic in the world. Especially increased provision was made for pensions following the April 1956 Plenum of the

Central Committee of the BCP. The pension scheme is being systematically improved in compliance with the extensive programme for raising the population's living standards adopted in 1972. Factory and office workers and co-operative farmers come under a unified pension scheme which covers practically all Bulgarian citizens. State expenditure on it keeps growing.

Retirement Pensions. Having completed the specified length of service, the socially insured person of pensionable age is eligible for a retirement pension. The length of service is defined as the time under contract in state, public or co-operative enterprises for which labour remuneration has been paid; for freelances (workers in the arts, journalists, lawyers and others) this is the term during which they have been self-employed, provided they had been paying the necessary contributions. Just as with the length of service, required pensionable age varies with the category of labour. There are three categories in Bulgaria which classify the degrees of hard and harmful labour: Class 1 - very hard and harmful labour, Class 2 - hard and harmful, and Class 3 - labour under normal conditions. In cases where an insured person has worked in more than one of the above-mentioned categories of labour, the rate of his pension is determined according to the class in which he has served the longest. A retirement pension can be claimed under the following terms: Class 1 labour - fifteen years of service, at the age of 50 for men, 45 for women; Class 2-20 years of service, at the age of 55 and 50 respectively; Class 3-25 years of service and at the age of 60 for men, and 20 years of service and at the age of 55 for women. Mothers of five or more children aged eight and over are entitled to a retirement pension after fifteen years of service and 40 years of age in Class 1 labour, and after the same length of service and 45 years of age for classes 2 and 3. Persons of pensionable age not having completed the specified length of service may qualify for a retirement pension with reduced rates, proportional to the length of service they have completed. For those under pensionable age each year of service above the term specified in the Law on Pensions brings an addition of up to 2 per cent to the basic retirement pension; the total rate of such additions cannot, however, exceed 12 per cent. Persons having reached the required pensionable age and completed the specified length of service are entitled to a 6 per cent addition to their basic pension for each extra year of service. The rate of the retirement pension is based on the average nominal monthly pay received during three consecutive years out of the last fifteen years of service as chosen by the person himself, and is deducted as a percentage of the basic remuneration - starting from 80 per cent for the lowest, down to 55 per cent for the highest labour remuneration. Retirement pensions are regularly being up-graded in line with changing economic conditions, so that the pensioner's living standards do not suffer.

Disability Security. Disability pensions can be claimed in the event of partial or complete, temporary or permanent disability. They are granted in cases where the disability was caused in the course of employment, or not later than two years after termination of contract (the former contingency not applying to the congenitally blind or to persons deprived of sight before entering employment, the term of the latter being longer for certain prescribed diseases). When, in spite of treatment, ailments do not improve and the chances of regaining capacity for work are slight or non-existent, the invalid must appear before a Medical Commission on Labour (MCL)-a specialized commission of medical

experts and a representative of the trade unions, authorized to ascertain permanent disability: to pronounce on the degree of disability and the date of disablement; to establish, in cases of occupational diseases. the relation between employment and ailment; and to redeploy persons with partially impaired capacity for work. Three disability classes have been set out in Bulgaria according to the degree of disability: Class 1 includes persons unable to perform any work (the severely disabled); Class 2-persons unable to perform either the job they have been trained for, or any other, but who can work in specially provided conditions; Class 3 includes persons who, because of health considerations, have lowered or been induced to lower, their standard or occupation, or have changed, or been induced to change, their conditions of labour. A disability class is granted permanently when there are no indications that the disability will be cured, or temporarily - in all other cases In the first case the disabled person can claim reassignment to another disability class with more favourable pension terms, in cases when his condition has worsened. Disability pensions fall into the following categories: industrial injury or occupational disease pensions, pensions for general illness or injuries arising from accidents other than labour accidents, and civil acts military disability pensions. Industrial injuries comprise; all injuries arising out of or in the course of employment as well as those resulting from work in emergencies c: under conditions not normal for the respective occupation if it has caused the insured person's temporary disability invalidity or death. Industrial injuries are likewise suffered in performing any service in the interest of the employer, during breaks in work-time, on the way to and from work, in saving a person's life or property, or when taking part in voluntary work-days and sports competitions. An industrial injury is ascertained by the head of the enterprise through an Industrial Injury Certificate, the disability - by the MCL. Occupational diseases fall under the class of industrial injuries. The nature of the disease and the degree of disability are established by the MCL.

The rate of the pensions granted for disability through labour accident or occupational disease is fixed according to the disability class and the basic labour remuneration. The percentage determining the rate of a disability pension grows in direct proportion to the degree of disability established, and in inverse proportion to the basic labour remuneration. Thus Class 1 disability pensions vary from 70 per cent for the highest basic remuneration to 100 per cent for the lowest, for Class 2 the percentage is respectively 55 to 85 and for Class 3-35 and 65. The aim is to ensure that the disabled receive approximately the same income as before the disablement.

Disability pensions are granted in the event of general illness or injuries arising from accidents other than labour accidents to disabled persons pronounced by an expert medical commission on labour to fall into one of the three disability groups and provided that they had completed the specific length of service graded in conformity to the respective age before the pronouncement of disability (up to 20 years of age - regardless of the length of service; up to 25 years of age-with three years of service, over 25 years of age-with five years of service). Disability pensions are payable to congenitally blind persons having been deprived of sight before entering employment with five years of service regardless of their age.

Disability pensions granted in the event of general illness or injuries from accidents other than labour accidents are rated in a percentage based on the basic labour remuneration. The percentage is graded according to the size of labour remuneration and the disability group as follows - for group I - rating from 73 per cent for the lowest to 55 per cent for the highest labour remuneration, for group II-from 65 per cent to 40 per cent and for group III - from 50 per cent to 25 per cent. Persons who fall into disability groups I and II due to general illness are entitled to an addition to the basic pension, the size of which depends on the length of services prior to the date of pronouncement on disability and is fixed according to the basic pension as follows: 5 per cent after ten to fifteen years of service, 10 per cent after fifteen to twenty years of service, 15 per cent after twenty years of service and over. Pensions with 25 years of service, at the age of 55 for men, and 20 years of service and at the age of 50 for women, are granted a 25 per cent addition to the basic pension.

Civil disability pensions are granted to persons injured in the performance of civil or public duties, to members of the auxiliary defense organizations, to members of sports teams injured during training sessions or competitions, to students injured during practical training or studies and to convicts injured in labour accidents. The monthly size of pensions is 65 levs for disability group I, 60 levs for disability group II and 50 levs for disability group III.

Military disability pensions are granted to persons injured while serving in the army, depending on the respective disability group, to regular privates and NCOs in the armed forces, to called-up reservists, to regular servicemen in the engineering corps or to reservists summoned to training, inspection or practical muster roll, regardless of their rank and to persons injured in rendering assistance to troops. The dead and missing also come into this category. If the injured have been socially insured before enlisting in the army, the size of their pensions is fixed on a similar scale to the rating of disability pensions that would have been granted in the event of industrial injuries and occupational diseases, if this is to their benefit.

Disability group

Dependant Pensions (Death Insurance). Dependant pensions secure an income for the heirs to the deceased if he was insured. The major requirement in Bulgaria is for the dependant to have been supported by the deceased prior to his death. The beneficiaries entitled to dependant pensions are the children, brothers, sisters and grandchildren under eighteen, and those studying at educational establishments up to 25 years of age and over if they have lost their capacity for work before reaching 18 or 25 respectively. Students are entitled to dependant pensions after 25 years of age if they have served their regular terms in the army or in the labour corps. This term is extended by as many years as served in the army or in the labour corps. The parents are also entitled to dependant pensions, the husband or wife on reaching the age of 60 for men, 50 for women, or before if disabled; one of the parents or the wife, regardless of their capacity for work or age, if they are unemployed and look after children, or the brothers and sisters of the late head of family, on reaching sixteen; the grandfather and grandmother if they have no other

income or if there are no persons bound by law to support them. The size of dependant pensions is fixed on the basis of the personal pension that had been paid to the deceased: 50 per cent if there is one dependant, 75 per cent if there are two dependants and 100 per cent if there are three dependants. The size of pensions payable to the heirs of a person who has died from industrial injuries is fixed on the basis of group I disability pensions if disability was caused by an accident. Heirs of a person whose death was caused by general disease are entitled to a pension fixed on the basis of the disability pension of group II that had been granted to the deceased. If the deceased had the required length of service entitling him or her to a personal retirement pension, the dependants' pension is fixed on the basis of the former, should this be of benefit to the dependants.

Social pensions were introduced in 1973. They are insignificant in number and are granted to persons who have not been insured or do not have at least half the length of service required for retirement or disability pensions. Such pensions are granted to invalids falling into disability groups I and II (aged over sixteen), and to old people having reached 70 whose annual income is lower than the specified minimum income. These pensions are small and the same for all entitled to them. Social security has been entrusted to the Bulgarian Trade Unions. They draft bills on social security issues and, jointly with other departments concerned, submit them to the National Assembly. Jointly with the Council of Ministers the Trade Unions issue regulations, decrees and instructions.

The Trade Unions are in charge of the social security budget. The remainder of contributions deducted (after the payment of indemnities, monthly child allowances, and maternity lump-sum cash grants) is transferred by enterprises and departments to the bank account of the social security with the Trade Union's Central Council.

Sums for the payment of pensions are drawn from this bank account. The control over the correct deduction and payment of security contributions and over the lawful spending of the social security fund is exercised by the Trade Unions. At enterprises and departments, indemnities cannot be paid without the signature of the Trade Union Chairman or of the person authorized by the former. The planning of social security funds, receipts and expenditures is carried out by the Trade Unions. Pension commissions and expert medical commissions on labour must include representatives of the respective Trade Union bodies. The Trade Unions fulfill their rights and obligations through their specialized bodies: the Social Security Board with the Central Council, the social security departments with the district and city councils, the Trade Unions and the social security commissions set up with them at every enterprise, department and organization.

PART IV: HEALTH CARE IN BULGARIA FROM 1989 UP-TO-DATE /FINANCING AND DELIVERY THROUGH A TRANSITION PERIOD/

NEW LAWS REGULATE THE PROBLEMS OF ORGANIZATION, MANAGEMENT AND FINANCING

From: Almanac Bulgaria 1996

People’s health is a national wealth and prerequisite for the advancement of any nation. It is, as well, a measure of the social, economic and political development of society.

The network of healthcare centers which render medical aid (diagnostics, treatment, rehabilitation, some types of prophylactic activity) in Bulgaria is well distributed, disposes of the necessary basis and a considerable number of academic, college and high-school graduates and other personnel. The macro-scheme of medical aid includes three levels — national, regional and municipal. The public sector comprises 5 higher medical institutes (in Sofia, Plovdiv, Varna, Pleven, Stara Zagora) with a number of faculty clinics, 4 national centers with clinical bases, 287 hospitals and 3,723 ambulatory-clinical units, 917 crèches, 163 sanatorium-recreational establishments, 5 stations for fast and urgent medical aid, and 6 centers of transfusing hematology. The private sector comprises 7,445 medical consulting rooms and 3,692 dental surgeries. Besides, until the end of 1995, 64 private health utilities have also been established, including hospitals, out-door patients clinics (polyclinics), dispensaries, laboratories. The in-patient wards of the hospitals dispose of 90,991 beds (107 beds per 10,000 of the population), in sanatoriums — 19,278 beds (23 per 10,000 of the population). In crèches and nurseries there are 38,340 beds. Children up to 3 years of age are procured with 132,4 beds in crèches per 1,000 children.

Dental aid at national level is procured by a Faculty of Stomatology with a clinic. At regional level operate stomatological polyclinics, at municipal level — dental surgeries in polyclinics and health services in the villages. Here we must mark the fact that in the field of dental aid considerable portion of the necessities are already being covered by privately practicing dentists.

The medical aid network disposes of considerable in number personnel — one physician per 314 persons of the population, and one dentist per 1,487 of the population.

In Bulgaria about 60 per cent of the physicians have recognized specialties. Among therapists the relative share of the specialists is 50.8 per cent, among pediatricians — 55.3 per cent, among obstetricians — 77.5 per cent, among surgeons — 70.8 per cent, among orthopedist-traumatologists — 71.5 per cent. The number of specialists with college and high-school education is increasing.

This highly developed in quantitative respect system operates with funds of state financing. During the last years these funds sharply shrunk. The absolute increase of funds for healthcare in 1995 cannot cover the enormous relative fall-behind on the background of the general increase in the cost of living — medications, consumables, foodstuffs, heating, light, etc. This results in closing hospitals, patients procuring themselves medicines, blood for transfusion, consumables.

The problems in healthcare and inadequate nutrition brought back some forgotten diseases like tuberculosis, hepatitis, abdominal typhoid, rabies, syphilis, etc. Unemployment and stress over the uncertain future led to mass neuroses, psychoses, endocrine disorders. The efforts to overcome this heavy situation are in several directions. But, before all, serious efforts were made to render legislation in conformity with the new conditions.

The actual priority in the Government’s program in the field of healthcare is the drug policy. The Law of Drugs in Human Medicine and of Pharmacies regulates drug supply for some diseases, the treatment of which is life-saving and life-supporting. These diseases are 11 and a hundred-per cent availability of respective drugs, which the patients receive in ambulatory conditions, is guaranteed throughout the whole year. This treatment is carried out under out-patient conditions and is financed directly from the budget of the Ministry of Health. Another 114 diseases are financed from the municipalities’ budgets. Rendering legislative ground of the drug policy in compliance with the contemporary, generally accepted norms of the European Union member countries is considered an achievement of the National Health Strategy.

In 1996 the National Assembly is going to adopt important amendments in the Law of Public Health which will guarantee the right of a free choice of a healer and free medical aid to every Bulgarian citizen. Changes are also envisaged to reflect the transitional period towards health insurance system by virtue of which the health establishments will receive legal independence.

Discussion is being held on the Law of Professional Organizations which will stipulate obligatory membership like it is practiced in almost all European countries. Thus, professional organizations will receive the right, on behalf of all who offer medical aid, to be a party to the conclusion of a national accord. At a final stage is, as well, the preparation for adoption of the Law of Health Insurance, adapted to the already adopted Law of Creation of a National Insurance Fund and Separation of the Social Insurance Fund from the State Budget.

The amendments in the Law of Public Health go parallel with the preparation and adoption of regulations for new organization of pre-hospital medical aid which is correctly distributed by territory in order to guarantee access of all Bulgarian citizens to medical specialists in polyclinic units.

Healthcare is closely linked to prophylaxis, therefore in the National Health Strategy, adopted by the Government and approved by Parliament, a large section is dedicated to

work to prevent disease. Such is the approach of the rich countries — to allocate money for prophylaxis of the healthy person because afterwards much more means will be needed for his healing.

The new organization of pre-hospital medical aid envisages the right of every citizen to choose his personal physician on the territory where he lives. It could be a therapist, a pediatrician (for children), a gynecologist (for women).

The start of the health reform in Bulgaria, which is already a fact, was preceded by a long social and professional discussion. The position of the Ministry of Health is that the valuables of the already achieved must be preserved, all factors to be precisely taken into consideration, including negative ones, so that the country would not lose whatever is already national possession in healthcare.

THE CRISIS IN BULGARIAN PUBLIC HEALTH SERVICES

From: Almanac Bulgaria 1997

From the point of view of public health, the demographic problems in the Republic of Bulgaria continue to go deeper. The trend towards demographic collapse has been deepening since the late 80s and at present. the negative growth of the population is -3.9 (9.3 births and 13.2 deaths per one thousand people). There is a strong tendency to a slight rise in the death rate including the younger ages, and especially among the male part of the population. This increase is most significant among the rural population. Life expectancy begins, although slowly, to go down.

To be explained, these facts should be viewed by considering a great number of factors, such as: the change in the living conditions, the sharp reduction of the nation’s wealth in the last few years, the decrease of the purchasing capacity of the individual — with more than a hundred times for the people of the third age, the chronic stress, the increasing alcohol and smoking abuse, the permanent rise of drug habits, the worsened conditions in the environment, etc.

Bulgaria is a typical representative of a centralized hierarchical system with the hospital sub-system as its dominant part, with surplus of low-paid and discouraged personnel and relatively poorly developed primary health attendance service. It is a system financed only at the entrance without any effective feed-back, that is, certain structures are financed without any actual measurement of the product at the outlet. This kind of systems lack any financial incentives for the working professionals. They lack all the elements of the market and the competition. The signals coming from the system are not considered from the point of view of the general economic theory, that is, there is no search for measures of effectiveness and efficiency, and there is no search, too, for economic instruments that would improve the system. Such a system is financed with low percentage by the GNP, and in Bulgaria in the beginning of 1996 it was 4.2 % with

galloping inflation and lack of flexibility in the budgetary response making it drop to 2.5 %. In addition to this evident deficit of funds, the structure of the system is such that some quite inefficient health care structures are financed. In the country, there are 29 269 working doctors or 34.9 per 10 000 people, which is one of the highest indexes in Europe. The bed space is 10.6 per 1000 people, which is almost twice as much as the average in Europe (5.5 per 1000 people). Ninety-nine per cent of the structures and the activity is state property and less than 1 % is private property.

These are widely known figures and it is clear that there is necessity for serious change in the structure and the functions of the health care system. What is being claimed and done in 1996 in this direction? The implementation of the National Strategy "Health for Bulgaria" began and was developed as a strategy for primary health attendance directed to the establishment of General Practitioners and of every citizens right to choose his/her own physician. Meanwhile, by way of a proposal on behalf of the government, the Parliament passed extremely unpopular measures amending the National Health Act and actually prohibiting to the doctors to practice privately if they work for a public health institution. The Ministry of Health introduced attestation of the directors of hospitals, practice used 20 years ago by the Communist Party. There is a discussion of health policy in that field running in the country in an informal order, as well as, by creation of projects supported by the PHARE program and the EU.

Good teams of specialists give their views and suggestions and this will act as the basis for specific documents, which will outline the aims and the means for their accomplishment. However, the experts opinions are used and altered to the advantage of the political doctrine and not as a response to public interests. An Instruction on Pre-hospitalization Aid was passed. which provided for free choice of a General Practitioner. The campaign was done very hastily without elucidating the people to what this might mean to them and above all, by cosmetic changes in the payment of doctors from whom it is expected to act as GPs and “gatekeepers”. The result is that only about 37 % of the people have been enlisted and have chosen such a doctor. Applied were standards for national health structure long developed by the present team of specialists of the Ministry of Health. These standards do not add any changes to the structure of big hospitals, in which hundreds of beds are not used effectively, and the personnel in the system will not be considerably re-structured.

A new regulation on doctors’ salaries in hospitals and polyclinics was applied, according to which the salary contains a shifting part up to a certain limit, based on the number of treatments and the seriousness in the conditions of the patients treated by them. The regulation is in a process of adoption, but the high rate of inflation “has eaten out” some of its positive elements.

The application of the Law on Medications and the regulation mechanisms of the prices of medicaments, which it introduced, did not achieve their aim to stop the growth of these prices, which continues to outstrip the rate of general inflation in the country. Surprisingly the Government submitted in Parliament a Draught Health Insurance Law and remarkably quickly, breaching all legal procedures, passed it on first reading. All

medical professionals were shocked by the fact that that was not the long discussed project from 1993, but one that could turn health insurance into an appended warehouse to a huge National Insurance Institute, without any structures to stand for the interests of the insured, without any transparency of costs, and without a real process of negotiation between producers and consumers of health services.

In conclusion, the analysis of the activities of the majority in Parliament and the Government leads to the judgment that in progress are activities called reform, which reproduce the structure of the old system and do not change it. The achievements of the transition period as municipal self-government are being replaced by new re-centralization, the working rights of the medical professionals and the right to choose are being restricted, there is a lack of financial incentives and there is no talk of shift of property and consensus-based public agreement.

PAID MEDICAL CARE — WITH PREFERENCE AND AT ONE'S CHOICE AND WILL

From: Almanac Bulgaria 1998

The crisis in Bulgarian health service was provoked by the critical economic situation in the country, as well as, by the inadequate structure of the health system itself. The delayed reform and the established legislative and ruling vacuum deepened seriously the problems facing Bulgarian physicians, health institutions and. ultimately, the patients.

During the years of socialism Bulgarian people grew unused to thinking about the price of healthcare. Everything was just “free”. Therefore the confusion arising when the question of compulsory medical insurance is put forward is natural although the insurance does not cover the multitudinous possibilities in the process of medical treatment. But the government has decided to bring its intentions of rudimentary reform in the health service, to an end.

The system had been surveyed for several months and then began the process of hospital accreditation. The first to be accredited were 80 municipal hospitals, and the number of beds and wards in them were set in compliance with the actual demands of the municipalities. The over 90,000 beds (105 beds per 10.000 people) were reduced by 30,000 which are not used for treatment of those who need to he hospitalized. There is a running reorganization in public health resorts, where practically do not come patients who need treatment. Part of the departmental pre-hospital and hospital network, which only doubled the national one and had been ineffective, was shut down. The accreditation of big district hospitals, university hospitals and national centers is continuing. With regard of the aggravated economic situation, financing priorities have been established: which health institutions and which types of medical care should take priority in funding. The rules of use of that care by people were broadly notified. There was created a possibility for alternative use of the system (without observing the established order and

without waiting — in return for immediate payment) by patients who would like to choose a doctor and a hospital by themselves. This temporary measure has been taken until the introduction of health insurance takes place in order to restrain the black market of health services. There are training courses where hospital managers are being educated. The programs for these courses have been developed in collaboration with EU experts and they include modern methods of management in the circumstances of market economy, public healthcare and health policy. All directors of hospitals, diagnostic centers, emergency aid centers and municipal health administration do such courses. A National Case-mix Office will ill he established, where information about treatment of patients from all hospitals in the country will be collected, and it will indicate tariffs and effectiveness of hospital production. The creation of a case-mix index for all hospitals in the country will allow for planning and fair distribution of the necessary resources in accordance with the work done, and for equality of use of health services throughout the hole country as well as a guarantee for good quality. The hospital product evaluation system (Bulgarian variant of Diagnostic Related Groups) will be utilized by the health insurance system for payment of the medical service done to the insured.

The institution of “General Practitioners” was adopted for pre-hospital aid. They will look after the health of patients and whole families who have chosen them. It is intended to stimulate those doctors so that they could be able to serve as “gatekeepers” and restrict the cases of unnecessary hospitalization The former system of socialist healthcare was mainly hospital-oriented and very often patients were needlessly hospitalized for minor reasons and had to stay in hospital for a long time. There was no organization of medical treatment at home. This resulted in the creation of many narrow specialists in the hospitals and the term “family doctor” was deprived of any meaning, thus increasing the share of costly hospital aid within the overall framework of health care. Family doctors will also take prophylactic measures in protecting and recovering people’s health.

The legislative program permitting the transition to a self-governing system of health care is being implemented, too. In Parliament was discussed and adopted the Law on Health Insurance. A plan for the introduction of a health insurance system was designed, which envisages a preparatory period of a year and a half necessary to build administration, an information system, to establish the controlling mechanisms, the methods of bargaining and payment of health services. It is essential to find redirecting and retraining solutions for that medical manpower whose jobs will be made redundant. The big problem is to accomplish the reform in a way that the social price in the transition period should be as low as possible.

Reform in the educational system also began. Medical universities in the country will he consolidated, and the state commission for admission of medical students has been reduced. There are new specialties at university for nurses and health managers. The role of the Ministry of Health will gradually shift from governing to directing, coordinating, controlling and planning.

The role of the municipalities in setting the regional schemes of health care will increase in the process of decentralization. The health institutes will function in a competing environment in respect with public funds, and with strictly established rules of the game.

The aim of all undertaken activities is to reform the health care system so that it should function in the circumstances of regulated market and competition, and turn into a dynamically developing industry, which will introduce new technologies quickly, where patients will be able on an equal and free basis to choose their own doctor, and, ultimately, increase the quality of health services. That means matched access of all in need to medical services of good quality and effect. The system will receive revenue from more than one source, it will allow the opportunity of choice of different schemes according to the variety of individual and group necessities. Simultaneously, the regulated market will permit planning of needs and resources and their correct distribution, and it will hold the increase of expenditure through mechanisms similar to the so called managed care.

Health care intensification is intended as a result of economic intensification, but it has an immediate effect on the economy itself, which is often forgotten. In the developed countries approximately 17-18 % of the economy works for health care providing raw materials and resources, and this means more jobs and higher incomes. According to governmental forecasts, 1998 will lay the foundations of a real economized financing system for health care, which in 2 years’ time will spend nearly 7 % of GDP, it will engage about 10 % of industry and will fit the health care system in the normal proportions of public revenue distribution.

NATIONAL HEALTH INSURANCE FUND - 1

From: Almanac Bulgaria 2000

The Health Insurance Act was adopted in July 1998 and so the compulsory and the voluntary health insurance was introduced in Bulgaria. The compulsory health insurance is a system for health protection of the population, guaranteeing a package of health-related services, and is administered by a National Health Insurance Fund. The Act regulates the signing of a National Framework contract between the NHIF and the professional associations of the healthcare providers.

At present we are facing the challenge to build a brand new organization with more than 280 territorial structures and 4500 employees throughout the whole country.

The Bulgarian health insurance system has a three level structure - national (NHIF), regional (RHIF) and local (local health insurance services). The authorities of the NHIF are the Assembly of Representatives, the Governing Board and the Supervisory Board and Director.

The Assembly of Representatives includes representatives of employers elected for a period of 4 years on quota principle, insured persons and the state. The Assembly adopts and amends the Regulations on the structure and activities of the NHIF and the RHIF. In addition to that it appoints and releases members of the Governing Board and the Supervisory Board, approves the draft annual budget of the NHIF and its annual report.

The Governing Board together with the Director of the NHIF represents the Fund at the negotiations on the preparation of the National Framework contract and signs it. The Board prepares the annual budget and the annual report of the Fund and takes decisions on the signing of contracts. The Supervisory Board executes general control over the activities of the Governing Board, the NHIF Director and the RHIF Directors.

The Director of the NHIF represents the Fund within the powers vested in him by the Governing board and organizes and directs the activities of the Fund in accordance with the law. The organizational structure of the NHIF includes five main streams of activities: finance, medical and information activities, human resources, public relations and international cooperation, and general administration. The main task of the NHIF and its structures is ensuring equal use of medical services and their payment to the provider.

The functions of the central management of NHIF include overall management of the system and redistribution of revenues in accordance with the regional characteristics; evaluation of the health insurance costs; analysis and proposals for the prices of medical services; preparation of the National Framework Contract; development of models for the influence of the price policy on the health and health insurance systems; preparation of the essential pharmaceuticals list; training of staff, legal and public relations activities; international activities and cooperation, and development of policy, strategy and methodology of NHIF.

The functions of the RHIF include the preparation of the regional health insurance scheme, incl. the regional health structures of the outpatient and hospital care; the number and the structure of the covered population; the distribution of the revenues and costs; the evaluation of the financial result of the health insurance, etc. In addition to that, the RHIF defines the specific duties and obligations of the local health insurance services, controls the implementation of the individual contracts with the health service providers on the territory of the region, make evaluation of the health status of the population and of the volume of activities in the health institutions, as well as, analysis of the health necessities of their region.

The functions of the local health insurance services are connected with the preparation of registers of the insured persons and the health service providers, the preparation of the individual contracts with the outpatient and hospital care providers within the municipality, and control on the availability of medical care and its quality.

THE NATIONAL HEALTH INSURANCE FUND - 2

From: Almanac Bulgaria 2001

In 1998 the Bulgarian Parliament adopted the Health Insurance Act, which set the basis for restructuring of the outdated and inefficient in present conditions public health care system in Bulgaria. Health care reforms are meant to improve the quality of health care services, and address the state’s inability to finance the entire health care system. The Health Insurance Act was a result of detailed analysis of the previous system, and builds upon the recent developments in other countries facing similar problems. It is the basis for the introduction of both compulsory and voluntary health insurance in Bulgaria.

Under the Health Insurance Act the Bulgarian National Health Insurance Fund (NHIF) was established and principles defining the relationship between the NHIF and the health care providers were set. The NHIF is responsible for the development, operation and management of the compulsory health insurance scheme in Bulgaria.

The compulsory health insurance is a system for health protection of the population, which guarantees a basic package of health services, and is administered by the National Health Insurance Fund. The Health Insurance Act regulates the signing of the National Framework Contract between the NHIF and the professional associations of the health care providers.

The National Framework Contract sets the parameters and procedures related to the functioning of the whole health insurance system. It defines the order, the contents and the payment of the health care activities and services to be provided to the insured population. The National Framework Contract is signed for a period of one year between the NHIF and the professional associations of doctors and dentists, in favor of the insured persons. The first National Framework Contract was signed on 27 April 2000 and was published in the State Gazette on 23 May, 2000. Its term expires at the end of this calendar year.

The NHIF has a Central Office in Sofia and 28 regional structures (regional health insurance funds (RHIFs). An additional number of 100 local offices are now to be established. To this moment, the NHIF has 1800 employees, 250 of them employed at the NHIF Central Office and the rest of them — at its regional structures. Additional 300 employees will be employed at the municipal offices of the NHIF.

The managing bodies of the NHIF are the Assembly of Representatives, the Governing Board, the Supervisory Board and the Director.

The Assembly of Representatives includes elected for a period of 4 years on quota principle representatives of the employers, the insured persons and the state. The Assembly adopts, adds and amends the Regulations on the structure and activities of the NHIF and the RHIF. Furthermore, it appoints and releases members of the Governing

Board and the Supervisory Board, approves the draft annual budget of the NHIF and its annual report.

The Governing Board together with the Director of the NHIF represents the Fund in all negotiations concerning the preparation of the National Framework contract and signs it. The Board prepares the annual budget and the annual report of the Fund, and takes decisions for signing of the contracts.

The Supervisory Board executes general control over the activities of the Governing Board, the NHIF Director and the RHIF Directors.

The Director of the NHIF represents the Fund within the powers vested in him by the Governing board and organizes and directs the activities of the Fund in accordance with the law.

The organizational structure of the NHIF covers five main areas of activities: finances, medical and information activities, human resources, public relations and international cooperation, and general administration.

The main task of the NHIF and its regional structures is to ensure equal access to medical services for all insured persons and payment of the services provided by the health care providers.

The functions of the central management of NHIF include: overall management of the system and redistribution of revenues in accordance with the regional characteristics; evaluation of the health insurance costs; analysis and proposals for the prices of medical activities; preparation of the National Framework Contract; development of models for the impact of the price policy on the health and health insurance systems; preparation of the essential pharmaceuticals list; staff training, activities concerning legal issues and public relations; international activities and cooperation, as well as development of the policy, the strategy and the methodology of NHIF.

The functions of the RHIFs include: the development of the regional health insurance scheme, incl. the regional health structures of outpatient and hospital care; the number and the structure of the covered population; the distribution of revenues and costs; the evaluation of the financial results of health insurance. In addition to that, the RHIFs define the specific duties and responsibilities of the local health insurance offices, control the implementation of individual contracts with the health service providers on the territory of the region, make evaluation of the health status of the population and of the volume of activities in the health institutions, as well as, analysis of the health needs of the respective region.

The functions of the local health insurance offices are connected with the preparation of registers of the insured persons and the health service providers, the preparation of the individual contracts with the outpatient and hospital care providers on the territory of the municipality, the control on the availability of medical care and its quality.

According to the Health Insurance Act the new health care system for the outpatient cases is operational as of 1st July 2000, and for the inpatient (hospital) cases — as of 1st January 2001. The NHIF enters into contractual relations with some 5000 general practitioners, medical professionals providing outpatient services, as well as, a number of hospitals in Bulgaria.

THE NATIONAL HEALTH INSURANCE FUND - 3

From: Almanac Bulgaria 2002

In 1998 the Bulgarian Parliament adopted the Health Insurance Act which set the basis for restructuring of the outdated and inefficient in present conditions public health care system in Bulgaria. Health care reforms are meant to improve the quality of health care services, and address the state’s inability to finance the entire health care system. The Health Insurance Act was a result of detailed analysis of the previous system, and builds upon the recent developments in other countries facing similar problems. It is the basis for the introduction of both compulsory and voluntary health insurance in Bulgaria.

Under the Health Insurance Act the Bulgarian National Health Insurance Fund (NHIF) was established and principles defining the relationship between the NHIF and the health care providers were set. NHIF is responsible for the development, operation and management of the compulsory health insurance scheme in Bulgaria. The compulsory health insurance is a system for health protection of the population, which guarantees a basic package of health services, and is administered by the National Health Insurance Fund. The Health Insurance Act regulates the signing of the National Framework Contract between NHIF and the professional associations of the health care providers.

The National Framework Contract sets the parameters and procedures related to the functioning of the whole health insurance system. It defines the order, the contents and the payment of the health care activities and services to be provided to the insured population. The National Framework Contract is signed for a period of one year between NHIF and the professional associations of doctors and dentists, in favor of the insured persons. The first National Framework Contract was signed on 27 April 2000 and its term expired at the end of the year 2000. The second one, concerning outpatient care, was signed on 22 December 2000 and is effective until the end of the year 2001. In May 2001 an addition to the National Framework Contract 2001 was signed, which concerns hospital care.

NHIF has a Central Office in Sofia and 28 regional structures (regional health insurance funds (RHIFs). An additional number of 121 municipal offices have also been established. At present NHIF has 1800 employees, 250 of them employed at the NHIF Central Office and the rest of them — at its regional structures. Additional 300 employees are employed at the municipal offices of NHIF.

The managing bodies of NHIF are the Assembly of Representatives, the Board of Directors, the Supervisory Board and the Director.

The Assembly of Representatives includes elected for a term of 4 years on quota principle representatives of the employers, the insured persons and the state. The Assembly adopts, supplements and amends the Regulations on the structure and the activities of NHIF and RHIFs. Furthermore it appoints and releases members of the Board of Directors and the Supervisory Board, approves the draft annual budget of the NHIF and its annual report.

The Board of Directors, together with the Director of NHIF, represents the Fund in all negotiations concerning the preparation of the National Framework contract and signs it. The Board prepares the annual budget and the annual report of the Fund, and takes decisions for signing of the contracts.

The Supervisory Board executes general control over the activities of the Governing Board, the NHIF Director and the RHIF Directors.

The Director of NHIF represents the Fund within the powers vested in him by the Board of Directors and organizes and manages the activities of the Fund in accordance with the law.

The organizational structure of the NHIF covers five main areas of activities: finance, medical and information activities, human resources, public relations and international cooperation, and general administration.

The main task of the NHIF and its regional structures is to ensure equal access to medical services for all insured persons and payment of the services provided by the health care providers.

The functions of the central management of NHIF include: overall management of the system and redistribution of revenues in accordance with the regional characteristics; evaluation of the health insurance costs; analysis and proposals for the prices of medical activities; preparation of the National Framework Contract; development of models for the impact of the price policy on the health and health insurance systems; preparation of the essential pharmaceuticals list; staff training, activities concerning legal issues and public relations; international activities and cooperation, as well as, development of the policy, the strategy and the methodology of NHIF.

The functions of the RHIFs include: the development of the regional health insurance scheme, incl. the regional health structures of outpatient and hospital care; the number and the structure of the covered population, the distribution of revenues and costs; the evaluation of the financial results of health insurance. In addition to that, the RHIFs define the specific duties and responsibilities of the municipal health insurance offices, control the implementation of individual contracts with the health service providers on the territory of the region, make evaluation of the health status of the population and of

the volume of activities in the health institutions, as well as, analysis of the health needs of the respective region.

The functions of the municipal health insurance offices are connected with the preparation of registers of the insured persons and the health service providers, the preparation of the individual contracts with the outpatient and hospital care providers on the territory of the municipality, the control on the availability of medical care and its quality.

According to the Health Insurance Act the new health care system for outpatient cases is operational as of 1st July 2000. Nowadays, NHIF enters into contractual relations with 12 096 general practitioners, medical professionals providing outpatient services, dentists and laboratories. In addition, NHIF pays completely or partially for 1054 medicines and medical supplies for the outpatient health care service. On July 1, 2001 NHIF started financing the hospital care and currently pays the medication of patients for 30 clinical pathways, which cover 159 diagnoses. Since July 1, 2001 NHIF has concluded contracts with 140 hospitals in Bulgaria.

ADDENDUM:

First Update

It is a timely matter to update our history on the health care in Bulgaria. The world has lived through tremendous changes at the end of the XXth century. Such changes are subject of commentary from the viewpoint of the most astute political annalists. However, our job is unrelated to such commentaries right now. Here is an overview in a very detached manner:

• Cold War has ended, thus, leaving a hegemony in world politics - namely, in the

face of the United States of America;

• It was a precursory to a series of local political conflicts in different parts of the

world - namely, the First and Second Gulf Wars; the Wars in former Yugoslavia;

accident Wars in Cuba, Libya, Korea, Indonesia etc;

• Major political institutions failed to prove their /assumed?/ leadership role -

namely, the United Nations; the North Atlantic Treaty Organization etc;

• Many countries became oriented, towards, a status of independent sovereign

states and lacking interest in international collaboration - namely, Russia as a

global world contester; Western Europe as keeper of a tradition in Anglo-Saxon

partnership etc;

• Small and middle-to-low income countries /Bulgaria, also, being on-line!/ have

broadly speaking two alternatives - namely, firstly to stick to alliances on a

regional and interregional level, like European Union, etc; secondly to stay aloof,

like super-populated countries China, India, etc;

• Preventive diplomacy failed to prove its purpose aim - namely, international

terrorism has won the upper hand, which, is evident from the September 11

attack, and, the train bombing in Spain etc;

Without further debating on contemporary political turmoil, let us present to our historical column some important links - here. They speak for themselves about the Transition Period in Bulgaria.

The Editor hopes, that, by year 2007 a succession mechanism to the European Union will be complete. Then, a more comprehensive chapter could be written in view of the changes having taken place.

16 May 2004

Sofia

Second Update, which, a reader would have omitted as well as the first

We are at the brink of year 2005. Thanks God, the War in Iraq is over and with success for United States and the coalition. Peaceful parliamentary elections are held and it seems the Iraqi problem is solved for the time. However, the world is more than ever divided around an old paradigm - namely, the affluent Occident in the west and the havocked Orient in the east. This being the problem and we are going to briefly outline a summary of events from the past year:

• United States won that last war, even though - and we must state that beyond

mere symbolism - viz., the country is in a badly need for more cash and more

soldiers regarding a next conflict;

• Western European partnership seems to linger with France and Germany

constantly on some "not so well planned" crusades around the world and being

lured by more investment projects in the Far East and the South Americas;

• Russia remains alone and isolated, while, to some political analyzers and the

country looks too distant and too slow to be a real competitor in world affairs;

• Countries from the former Eastern block are being sequentially included and in a

row to a rather inert working succession mechanism, while, separate members are

under constant stress that they should be misunderstood and by the pattern of

reactions from their Western counterparts;

• "Third World" countries - so generously endowed with space and resource -

appear to be important as an actors of a global scale and only where it succeeded

in playing out two rivals /i.e., understand here countries from the West/ against

each other or confronting them with its own demands, while, even Japan finds

difficulty flexing their economic muscles beyond terms of political clout;

The Editor is encouraging and for the time being every volatile reader to consult the list of links - here. We have not forgotten and to bring our history project to an end. Just some more time and resources would be necessary.

25 February 2005

Sofia

Third Update, with timeliness and calmness as to the future of a nation

We, Bulgarians, are going to be happy members of the European Union. By this time next year and we are joining the Eurozone, with all benefits and negatives. I wish to mention, however, that this transition has not been a happy one and with respect to the physical and social wellbeing of the nation. Bulgaria – namely, as poor as before on terms with a GDP and indebtedness to world financial institutions; as well as, a country depressed by it’s own misfortunes or because of them.

I don’t see easy solutions for a long term perspective. These are reflections on a worldwide scale and are not supposed to influence anyone except a personal ego of the

author. With such resolutions in mind and we are going to proceed to some two themes, which, have lately imbued as important in national and international politics /and history?/:

• Firstly, let us think on the collective attitude of the Great European Powers

towards a new member state. It is by far unequivocal and unsolicited. I am not

very definite on the fact, whether, Old Europeans have been nourishing the

New Europeans – although, this has been a leading theme in many an official

visitors from EU. Bulgaria – as a newcomer – has been a bad child and a problem

one; it has received a lot of scolding and petting, moreover. This has left a

definite impression on the character of the Bulgarians – which, sooner or later are

going to accept their new role. And let me remind everyone for a lesson from the

not so far gone past – viz., at the end of the World War II and at a time when a

fate of the nation was decided by the world powers; unfortunately, this was a

time when a tradeoff has postulated that Bulgaria should join the East rather than

West as a geo-strategically unit. This seems to be far from the case right now –

when, world powers are rather unwilling to loose a utility again.

• Secondly, look at what is going on a worldwide scale. I am far from making a

prognosis on debates within the circles of world capital. It seems that country like

United States is going to make an easy prey on anyone, whatsoever. This has

been given successful check by two of the main contenders – namely, France and

Germany /which, by the way, have not been so united since the early Middle

Ages/. But let me pond on another poignant question – namely, the War in Iraq

and its repercussions on the future of nations. It has not been an easy war -

however, before making conclusions on the winner and the looser, we wish to

remind to the public that it has been a racial war. Someone will say that this is a

surprising statement, but it is not. It came to reestablish a role for the Middle

East and not less important than that of the Scandinavian Peninsula, for

instance. If one compares two countries – likely, Norway and Iraq – it becomes

evident that both are totally dependant on their crude oil resources. Obviously, it

is not so much the human factor /i.e., belonging to a Nordic or Mediterranean

races/, rather then a strategically directed effort to contribute for an improvement

/or deterioration?/ of the wellbeing of a nation. The rest is interplay of time and

chance schedules.

This update, which has been third in a row for the past several years, has been augmented with an important list of links - here. Expressly, we have been approaching our ultimate target to present a picture of Bulgarian healthcare with a view on international politics. Timeliness and calmness have been our leading principle.

22 January 2006

Sofia

Fourth Update, which stand more like a personal reflection

I heard these day someone, saying that the United States will not be able to exploit it’s hard-won victory in the Middle East. Now, let me answer to a “friend” like this and to other skeptical political eyes in the neighborhood. By the way, political divide has become wider than ever and nowadays you can find within a perimeter of 50 km2 – namely, we are speaking of cultural differences which could have accumulated for thousand years. If we contend, that, genetic drift is minimal in the civilized world and the role of society has become boosted to a tremendous dimensions.

I see adherents of two political lines, as of today’s date. One group, is a believer of the values of September 11, 2001 disaster /i.e., as if by an interplay of chance and the same year my best friend died in a car accident/. So these people, are followers of the Two Towers approach – viz., let as name allegorically the WTO twin-skyscrapers on

Manhattan Island in New York. The philosophy of such people is, that, while somebody could smash such an asset in the center of the world civilization and that could be done with the rest of the world, as well. It doesn’t matter, whether, the enemy is within or without the country /i.e., in this case the country of the United States/. In passim, let me mention that the fact you are wearing an American passport doesn’t make you less dangerous for world democracy.

Other group, is the people with the King Kong approach – viz., let as use this allegory for the abysmal brute from the novel of Edgar Wallace and filmed three times with major cinema success. Those people, whom I already mentioned and have been living in close neighborhood with us – namely, I categorize myself and other people from the alternative group mentioned above. Whatever, there are still people with animal instincts and psyche, explicitly, who believe that hatred and physical force could stop the pace of world progress. They have been hampering efforts from United States and allied forces to fulfill a mission of globalization and prosperity for all. As if, in passim, the same people had stopped hundreds of years ago great events and world clashes of civilization.

I want to finish this excise with a statement on the British character and British civilization. England has been a bearer of the spirit of the great Roman Empire. The reasons for this are manifold and we are not going to argue with anyone about the rightfulness of this thesis. The British Empire can be proud with it’s children states – namely, with United States, Australia, South Africa, Canada, New Zealand, etc. The new Eurodollar zone, which, has been created on the old European continent is eager to resist and will pose threat to a new expansion from the side of the British and allied forces. However, I firmly believe in a total defeat for the brutal side in the white race. I think, the future is bright for the whole world and if we could unite ourselves, instead to continue terrible cleansing and defeatist policy.

Albeit, our project is continuing and unfortunately we still can not register our site for general purposes. It is for now on a private perusal and a hand-to-hand basis. You can still use it’s links – namely, here.

27 April 2006

Sofia

Fifth Update, or when words doesn’t make much sense

At the brink of year 2007, and not without much consensusness we resemble it to the Orwellian’ year 1984, finally we arrived at our final destination in the European Union /EU/. It has been a long ride and with much trouble alongside some 17 years of transition,

whatever, we are there and have to look around us. The first thing that catches one’s eye is the problem of “equity”, ditto.

This above mentioned factotum have been curtailing definition for some time, at least for the author of these lines. We define “equity” as a subjective status of relative safety and a state of wellbeingness. Other people may perceive it otherwise. But let me comment on it with an example from the not so long ago past. I go back to the year 1989, when the whole “proclaimed” democratic change started. These were times, which, unequivocally I would recall as orderly and happy, with some bearable degree of affluence that was not so much but enough for the time being. However, obviously this “equity” was objective in its underground and while we were still living in a quasi-state of non-democracy. Unleashing the potentials of a common market space and giving the individual the rights of his own destiny, subsequently upturned the whole stuff upside down. And as we have already said, we are there and we perceive subjectively the need for “equity”, which is regrettably somewhat away from being neither safe nor being well. The solution of the philosophical dilemma is closed ended, but it necessitates some reshaping and more confidence.

Difficult issues are proceeding on the international arena. The War that has been waged in the Near East has become strictly a business war, nothing personal to whomever. The Muslims are more fanatical than ever, preparing their body for the funeral and going for the “Jihad”. The Communists are sneering from aside with their slant eyes, but they don’t waste any time to support the conflict with money and arm force whenever their interest allows them. In the midst of these squeeze of muscle and nerves is the tiny, ordinary citizen of the “Civilized” world – viz., perceive it as you wish and with whatever outlook you find proper for your own tastes. It’s a world apart but for how long?

We finish this short excise with dubious attitude and not any real expectations at all. The appended commentary to our short history – i.e., that has been shaped in a chronological manner – further, provides links for enhancing the story contained within. These can be found here. Meanwhile, it has occurred to the mind of the author of these lines that a second book could be produced, already, from the unsystematically gathered material in our site.