Three Centuries of Fighting Epidemics and the Current Victory
For nearly three centuries already, the government of Estonia has been fighting against epidemics.
During this time, the understanding of the nature of infection, as well as the political system and the relations between the citizens and the state have undergone a total change. The paternalistic, so-called “medicine police” approach that developed in the 18th century on the basis of empirical observations was replaced by methods based on bacteriological theory in the 19th century. Both during the tsarist times and in independent Estonia, local governments had the main role in fighting against the outbreaks of infections. The national healthcare structure, especially in the tsarist times, was intended mainly for mediating of information. Only in the case of larger outbreaks and the diseases that were considered a serious risk (in 1933, there were12 diseases in the list), the state took commitments in regard to covering the costs of treatment or vaccination. Vaccination against smallpox became mandatory only in 1914; compulsory hospitalisation of patients diagnosed with dangerous communicable diseases was possible, but due to the opposition of population, it was implemented cautiously. (Compulsory hospitalisation was the most consistently applied in regard to lepers, however, leprosy has never been a real threat to public health.)
There is a paradox in the history of medicine that totalitarian systems tend to be ambitious and at the same time capable in the sphere of healthcare. Incorporation of Estonia into the Soviet Union and the German occupation that followed also brought along notable changes in the attitude of the state towards its citizens, as well as restrictions of autonomy for healthcare purposes. Mandatory vaccination against several diseases was introduced in Soviet Estonia by regulations of the executive power. The German occupation powers, who under certain conditions recognised the legislation in force in Estonia before the Soviet annexation, did not follow that principle in fight against communicable diseases, and the Reichskommissar issued their own regulations. Both the Soviet Union and Germany imposed harsh punishments on those who violated the healthcare laws.
In 1944, the soviet power returned to Estonia. Development of medicine and healthcare was from then on carried out extensively, based on the healthcare system established in the Soviet Union already before the war and focused mainly on prevention of communicable diseases. The work was effective, besides the opportunities to control the health behaviour of citizens provided by totalitarianism, the new instruments taken into use after the war, like the antibiotics, were also of help. It may be said that by the middle of the 1960s, an epidemiological transition had been achieved in Estonia by those means, and communicable diseases no longer had a significant role among the causes of death. This is one way to interpret the situation where the increase of average life expectancy, which had been taking place until then, stopped for several decades. It started to grow again when Estonia regained independence and the state started to value the subjectivity of its citizens. This in turn created conditions for more substantive work in combating non-communicable diseases, including the so-called life-style diseases.