Health in the Polish People's Republic

Abstract

Before World War II (WWII) Poland was one of the countries with the poorest health in Europe. In the 1930s life expectancy in Poland was around 46 years in both sexes; in the same period in Germany it was over 61 years. Infant mortality was estimated at the level of 150 deaths per 1000 live births. The situation was exacerbated by WWII; between 1939 and 1945 life expectancy in Poland fell by 20-25 years.

The health transformation that took place in Poland after WWII proceeded very rapidly. Control of infectious diseases and infant mortality became a state priority in the post-war Polish People’s Republic. The epidemiological transition that in the United Kingdom or Germany took almost a century, in Poland, and many other Central and East European (CEE) countries, occurred in the two decades following WWII. This process led the CEE region to almost closing the health gap dividing it from Western Europe in the 1960s. Life expectancy in Poland increased to 70 years and infant mortality decreased to 30 deaths per 1000 live births.

However, simultaneously, after WWII the seeds of the epidemic of man-made diseases were sown in CEE. In Poland the consumption of vodka and smoking prevalence reached some of the highest levels in Europe. This dramatic increase in exposure to lifestyle risk factors (an increase in cigarette sale from 20 billion cigarettes per annum after WWII to around 100 billion in the 1980s, and an increase of alcohol consumption from 3 litres per annum to nearly 9 litres in the same period), led Poland and the CEE region to a health catastrophe caused by the rise of chronic diseases. Diseases such as lung cancer, laryngeal and oral cavity cancers, cardiovascular diseases (e.g. ischaemic heart disease and stroke), sudden deaths from external causes (e.g. accidents, injuries, poisonings etc.), and liver cirrhosis, all reached in Poland some of the highest levels observed globally. In contrast to most Western democracies, authorities in communist states of CEE were unable to cope with these new health challenges, which demanded comprehensive, also non-medical solutions. Health literacy was low, also among the better educated segments of population, including the political class.

Full text

7
JOURNAL OF HEALTH INEQUALITIES 2016 / Volume 2 / Issue 1, June
REVIEW PAPER J Health Inequal 2016; 2 (1): 7–16
Submitted: 23.11.2015, accepted: 14.03.2016
Health in the Polish People’s Republic1
Witold A. Zatoński1,2, Mateusz Zatoński1,3
1Health Promotion Foundation, Nadarzyn, Poland
2Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
3London School of Hygiene and Tropical Medicine, London, UK
ABSTRACT
Before World War II (WWII) Poland was one of the countries with the poorest health in Europe. In the
1930s life expectancy in Poland was around 46 years in both sexes; in the same period in Germany it was
over 61 years. Infant mortality was estimated at the level of 150 deaths per 1000 live births. e situation
was exacerbated by WWII; between 1939 and 1945 life expectancy in Poland fell by 20-25 years.
e health transformation that took place in Poland aer WWII proceeded very rapidly. Control of infec-
tious diseases and infant mortality became a state priority in the post-war Polish People’s Republic. e epi-
demiological transition that in the United Kingdom or Germany took almost a century, in Poland, and many
other Central and East European (CEE) countries, occurred in the two decades following WWII. is pro-
cess led the CEE region to almost closing the health gap dividing it from Western Europe in the 1960s. Life
expectancy in Poland increased to 70 years and infant mortality decreased to 30 deaths per 1000 live births.
However, simultaneously, aer WWII the seeds of the epidemic of man-made diseases were sown in
CEE. In Poland the consumption of vodka and smoking prevalence reached some of the highest levels
in Europe. is dramatic increase in exposure to lifestyle risk factors (an increase in cigarette sale from
20 billion cigarettes per annum aer WWII to around 100 billion in the 1980s, and an increase of alcohol
consumption from 3 litres per annum to nearly 9 litres in the same period), led Poland and the CEE region
to a health catastrophe caused by the rise of chronic diseases. Diseases such as lung cancer, laryngeal and
oral cavity cancers, cardiovascular diseases (e.g. ischaemic heart disease and stroke), sudden deaths from
external causes (e.g. accidents, injuries, poisonings etc.), and liver cirrhosis, all reached in Poland some of
the highest levels observed globally. In contrast to most Western democracies, authorities in communist
states of CEE were unable to cope with these new health challenges, which demanded comprehensive, also
non-medical solutions. Health literacy was low, also among the better educated segments of population,
including the political class.
KEY WORDS: epidemiological transition, Semashko model, Poland, infectious diseases, infant mortality,
premature mortality, chronic diseases.
ADDRESS FOR CORRESPONDENCE: Prof. Witold A. Zatoński, Health Promotion Foundation, 51 Mszczonowska St.,
05-830 Nadarzyn, Poland, phone: +48 22739 76 40, e-mail: wazatonski@promocjazdrowia.pl
DOI: 10.5114/jhi.2016.61413
INTRODUCTION
Both the scale and the pace of improvement of
human health in the 20th century are without historical
precedent. Within a century life expectancy has dou-
bled in many countries, increasing from 40 to 80 years.
However, while in most countries of Western Europe
this improvement has occurred in a harmonious and
balanced fashion, population health in countries of East-
ern Europe, including Poland, has been characterised by
rapid uctuations.
1 In the present study the authors have used mortality statistics from the World Health Organization Mortality Database [1].

8
Witold A. Zatoński, Mateusz Zatoński
JOURNAL OF HEALTH INEQUALITIES 2016 / Volume 2 / Issue 1, June
From the end of the 19th century, steep rises in life
expectancy have been observed in the developed coun-
tries of Western Europe. Between 1870 and 1880 life
expectancy in Germany amounted to 37 years, in France
to 42 years, in England and Wales to 43 years, and in Swe-
den to 47 years. By the end of the 1920s it has increased
to over 61 years in Germany, 57 years in France, 61 years
in England and Wales, and over 64 years in Sweden. In
Poland, however, life expectancy in this period remained
low, with 1927 estimates being 46 years for both sexes.
is backwardness had also been conrmed by high
infant mortality rates, which during the interwar peri-
od were estimated to be over 150 deaths per 1,000 live
births. Similarly, 40% of infants died before 5 years of age
[2]. In comparison, in Sweden the infant mortality rates
before 5 years of age were around 15% in 1920 [3, 4].
World War II (WWII) further exacerbated this prob-
lem. e war le Poland’s infrastructure in ruins, and the
poor pre-war levels of sanitation and hygiene became
even worse. With famine raging in Poland, there were
severe shortages of medicines and basic medical sup-
plies, and epidemics of infectious diseases were breaking
out. It is estimated that in the catastrophic years 1939-
1945 life expectancy in Poland fell by 20-25 years2 [5].
In 1950, life expectancy in Poland was estimated at
56 years for men and 61 years for women. At the same
time, life expectancy for both sexes amounted to 71 years
in Sweden, 69 years in Great Britain, and 66 years in France.
Infant mortality in Poland was estimated at around 110
deaths per 1,000 live births, and 33% of children died
before the age of 5. In Sweden and England infant mor-
tality was at a level of about 20 per 1,000 live births, and
about 5% of babies died before the age of 5. e mortality
of perinatal mothers in Poland was also high at 100 deaths
per 100,000 births [3, 6].
One of the principal causes of mortality in Poland in
the 1950s were infectious diseases. In 1959 mortality due
to infectious and parasitic disease was nine times high-
er among Polish men (89/100,000) than among Swedish
men (10/100,000) [2]. In contrast, chronic non-infec-
tious conditions, such as cardiac failure and lung can-
cer (particularly pronounced in the UK and Finland) or
liver cirrhosis, oesophageal and laryngeal cancer (pro-
nounced in the Mediterranean countries), which became
the predominant causes of death in Western countries
aer WWII, were much less prevalent in Poland3 [7-9].
One of the most interesting accounts of the public
health situation in Poland aer WWII comes from ajour-
nalist, Aleksander Janta-Połczyński, who in 1948 report-
ed from Poland for the Parisian émigré monthly Kultura.
Poland emerges from his articles as acountry character-
ised by widespread alcoholism and venereal disease, dif-
cult conditions for medical treatment, tuberculosis, low
resistance to infections, shortages of medical sta and
medicines. He wrote that “If it weren’t for the sulfa drugs
and the dynamic activity of the Supreme Commission for
Fighting Epidemics, Poland would face the threat of wide-
spread infectious disease akin to the Middle Ages” [10].
HEALTH IMPROVEMENT IN THE 1950s AND 60s
In Poland, the epidemiological transition began in
earnest only in the 1950s, almost acentury later than in
Sweden or the United Kingdom. At this starting point,
health conditions in Poland were very poor and resem-
bled those in 19th century Western Europe. e health
improvement in Poland in the rst decades aer WWII
proceeded at an impressive pace (Fig. 1) [4, 11].
Soviet domination over Eastern Europe aer WWII
inuenced the development of new health policies
throughout this region. e so-called “Universal Health
System”, or the Semashko model (named aer the Min-
ister of Health in Lenin’s government), which had its
origins in military medicine, was introduced in many
socialist countries and led to fundamental changes in
health policy, also in the newly formed Polish People’s
Republic (PRL)4. Its basic tenets were that every citizen
2 ere are no mortality statistics in Poland for the period between 1939 and 1945. Estimates can be based on the health situation in the Soviet Union, Czecho-
slovakia and Western European countries such as the United Kingdom and Luxembourg.
3 In the early 1950s lung cancer was a major killer of middle-aged men in the UK.
4 e Semashko model was adopted from the Soviet Union by all satellite countries of the so-called “Soviet bloc” aer WWII.
FIG. 1. Life expectancy at birth in selected countries, both
sexes
85
80
75
70
65
60
55
50
45
40
1940 1950
Sweden
Russia
Poland
Portugal
Rep. of
South
Africa
Tunisia
South
Korea
1960 1970 1980 1990 2000

9
JOURNAL OF HEALTH INEQUALITIES 2016 / Volume 2 / Issue 1, June
Health in the Polish People’s Republic
should have access to free medical care, and the so-called
“medicalisation of health”5.
Avital ingredient of the Semashko model was the
creation of an eective system for mother and child
healthcare. A new scheme for the training of nurses,
midwives, and paediatricians was established, and spe-
cialised paediatric departments were funded at medical
schools6. is rapid post-war development of paediat-
rics was undoubtedly one of the most important reasons
driving the improvements to child health in Poland
[12]. Already in 1953, aDepartment of the Mother and
Child was established at the Ministry of Health and
Social Welfare. It coordinated the creation of a regis-
try of maternal deaths, supported the development of
perinatal medicine and amore eective communication
system which would allow for the better use of existing
human resources and infrastructure. e socialist sys-
tem brought with it some undisputable social gains, like
universal access to healthcare or free hospitalisation and
paediatric care, all of which helped to improve maternal
and infant health.
Dealing with infectious diseases was an even greater
strategic priority of the Semashko model than paediatric
care. e rst post-war decades were characterized by
the development of sanitary-epidemiological services in
Poland. In order to control infectious diseases the State
Sanitary Inspectorate was set up in 1954. Local sanitary-
epidemiological stations were created and vaccination
campaigns were rolled out, alongside educational cam-
paigns raising awareness of the importance of vaccina-
tion and personal hygiene. Disinfectants and pest control
chemicals also became widely available in this period [13].
ese favourable developments were aptly summa-
rised in a World Bank publication from 1996, which
stated that “rates of infant mortality in the former social-
ist countries are lower than one would predict based on
their income levels. is positive health development is
mainly attributed to the higher education levels among
women, the wide scope of prophylactic vaccinations
among children (> 90%), and environmental hygiene in
the former socialist countries” [14].
A good example of state involvement in public
health under PRL was the struggle against tuberculosis
[15]. Aer the war, the state took over all actions direct-
ed against this disease7. Already in 1945, aTuberculosis
Section of the State Health Board was established. In
March 1948, the director of the Polish Anti-Tuberculosis
Institute was appointed, and the Institute was allocated
signicant state funding. In 1951, by decree of the Pres-
ident of the Council of Ministers, an Institute of Tuber-
culosis was established as an independent research cen-
tre overseen to the Minister of Health. One of the aims
of the Institute, as described in its statute, was to best
utilise “the scientic achievements of pioneering Sovi-
et science”. In April 1955, by decree of the Minister of
Health, compulsory and free of charge BCG vaccinations
were introduced, and on 22 April 1959 the Polish Parlia-
ment passed the Anti-Tuberculosis Law. e conference
abstract titles of the 10th Polish Anti-Tuberculosis Con-
gress, held in September 1951, betray how politicised
the subject of tuberculosis had become in Poland. ey
included, “e struggle against tuberculosis in the 6-year
plan”, or “Principles of dialectical materialism applied to
the ght against tuberculosis”.
Another spectacular symbol of PRL’s authorities’
commitment to ghting infectious diseases was Poland’s
pioneering role in the ght against polio (also known
as Heine-Medin disease). In the 1950s every year thou-
sands of children in Poland got the disease. Towards the
end of the 1950s Hilary Koprowski, a Polish virologist
working in the USA, and the creator of the rst polio vac-
cine, secured 9 million doses of the vaccine for Poland.
Despite coming from Wyeth, an American company,
the gi was accepted by the communist authorities. In
autumn 1959, under the leadership of Feliks Przesmycki,
the director of the National Institute of Hygiene (PZH)
in Warsaw, Poland became one of the rst countries in
the world to launch amass vaccination campaign against
polio. As aresult polio morbidity fell to just afew dozen
cases per annum at beginning of the 1960s [16].
As aresult of those changes infant and child mortality
rates in Poland rapidly declined (Fig. 2). Newborn mor-
tality rates were halved within adecade, from 109/1000
live births in 1950 to 55/1000 in 1960. By 1970 the new-
born mortality rates amounted to around 30/1000 live
births. At this time, the corresponding newborn mortal-
ity rates for the Federal Republic of Germany (West Ger-
many) were 23/1000 live births, Austria – 26, Italy – 29,
and Portugal – 53. Furthermore, the likelihood of child
mortality before the age of 5 in Poland decreased to 7%
from 33% in 1950. us, 25 years aer the end of WWII
the survival of infants and young children in Poland
had achieved asatisfactory European level. At the same
time, maternal mortality had dropped to 30/100,000 live
births in 1970. Mortality from infectious diseases was
also decreasing at an extraordinary rate e.g. for men it
declined from 99/100,000 in 1963, to 65/100,000 in 1970,
and to about 20/100,000 in 1985 [4].
5 In Poland the term medicalisation is oen positively perceived as providing easier access to medical care, hospitals and medicines. In some Western countries,
however, adebate over the negative inuence of over-medicalisation on society has been going on since the 1960s.
6 e importance of health within the political doctrine of the Polish state was underlined by the establishment of separate and autonomous higher education
institutions dealing with health.
7 Until 1948, medical treatment of tuberculosis had been of no avail. Only by introducing streptomycin was it possible to eectively treat this disease for which
incidence rates had signicantly increased during WWII and aerwards, as aresult of harsh living conditions and overcrowded housing. Aer the war,
the large scale battle against tuberculosis was organised and undertaken by the Institute of Tuberculosis, and in the following years has helped to signicantly
reduce tuberculosis morbidity rates.

10
Witold A. Zatoński, Mateusz Zatoński
JOURNAL OF HEALTH INEQUALITIES 2016 / Volume 2 / Issue 1, June
All these favourable health developments led to
arapid increase of life expectancy rates in Poland in both
sexes. In the 1950s, life expectancy in Poland increased
75
70
65
60
55
50
45
1930 1940 1950 1960 1970
12 years
9 years
Men
A
Germany Poland
FIG. 3. Life expectancy at birth in Poland and Germany, 1930-1970
B75
70
65
60
55
50
45
1930 1940 1950 1960 1970
Women
12 years
7 years
Germany Poland
FIG. 2. Percentage of deaths before the age of 5, Poland and
England and Wales
45
40
35
30
25
20
15
10
5
0
1820
1840
1860
1880
1900
1920
1940
1960
1980
2000
2020
[%]
England and Wales Poland
by almost 9 years, whereas it only increased by 2.5 years
in West Germany over the same period (Fig. 3). Indeed
at the end of the 1960s, there was only 1 to 2 years dif-
ference in life expectancy at birth for both sexes between
Poland and developed market economy countries of
Western Europe (in Poland life expectancy was 70 years
whilst in England and Wales 72 years, and in West Ger-
many 71 years). e health gap between Poland and
Western Europe was almost closed [17].
THE HEALTH COLLAPSE SINCE THE LATE 1960s
Regrettably, this period of health improvement was
accompanied by many developments, which in the next
decades were to reverse this positive pattern. While in
western countries population health continued to improve,
Poland between the end of the 1960s and the end of the
1980s experienced an extremely rare occurrence in aperi-
od of peacetime – adecrease in the life expectancy of adult
males, and astagnation in the health of adult women.
At the heart of this health collapse lay the same
philosophy that had previously helped reduce infant
mortality and infectious disease in Poland, namely the
complete medicalisation of health resulting from the
Semashko model. e state, and not the citizen, was per-
ceived as being responsible for one’s health – as aresult
the Poles did not develop crucial health competencies
and remained in astate of health illiteracy. Every disease
or disease group had its own respective institute. Health
governance was dominated by doctors, who held all the
directorial positions at the Ministry of Health. In con-
trast to Western Europe, the concept of preventive med-

11
JOURNAL OF HEALTH INEQUALITIES 2016 / Volume 2 / Issue 1, June
Health in the Polish People’s Republic
icine was not based on amultidisciplinary approach to
health in all policy, but only on strictly medical solutions.
Preventive medicine had been fully integrated with cura-
tive medicine, to which it was completely subordinated.
Public health was dened as social medicine, and was
seen as the remit of medical doctors [4, 18].
Epidemiology, the fundamental science of public
health, focused almost exclusively on infectious diseases.
Unlike the USA or the UK, the epidemiology of chronic
non-communicable diseases was poorly developed; lag-
ging 15-20 years behind English-speaking countries and
Scandinavia. In the absence of epidemiological informa-
tion and perspective, Poland, similarly to other countries
of Eastern Europe, did not take on board new develop-
ments in public health, such as identifying risk factors
impacting particular sections of the population, in which
mortality rates had risen. is situation was thus not con-
ducive to the dissemination of relevant health informa-
tion and expertise, nor to the mobilisation of adequate
means for the appropriate public health response. Medi-
cal doctors developed the tendency to focus on individ-
ual patient care, based on their experience with the suc-
cessful campaign to contain infectious diseases. Primary
prevention was considered from a medical standpoint,
and was focused principally on routine patient check-
ups. Health policy prioritised actions which aimed to
continue increasing the number of doctors, polyclinics
and hospital beds. An inordinately large clinical sector,
combined with passive curative medicine strategies and
long hospital stays, was unable to keep up with techno-
logical progress and devoured alarge part of the already
limited funds earmarked for healthcare [4].
e rapid development of evidence-based medicine
(EBM) which took place in the West in the 1960s and
1970s, was accompanied by research into the causes of
chronic non-communicable diseases, such as studies on
the causal relationship between smoking and lung can-
cer [19], the relationship between diet and cardiovas-
cular disease [20], or, as in the case of alcohol, between
the consumption of alcohol and liver cirrhosis or injury.
However, this went by unnoticed in Poland. ere were
no open public debates nor, except in the case of afew
infectious diseases, any large-scale public health inter-
ventions involving the state or society.
In contrast to many western countries, medicine in
Poland was more commonly dened as an art, the suc-
cess of which depends on the doctor’s skill, rather than
a science, whose methods should be based upon evi-
dence. Meanwhile, in countries such as the UK, large-
scale clinical studies had become astandard method for
dening the ecacy of drugs and medical technologies.
e growing importance of EBM manifested itself in the
use of experimental and observational studies as abasis
for clinical practice. is ensured that medical doctors
had access to knowledge derived from systematic sci-
entic studies8 [21]. ese advances had been largely
ignored in Poland and had little eect on broadly dened
clinical practice.
e development of health cultures and perceptions
also took dierent paths. In the West, the advent of large-
scale health campaigns, and health interventions based
on the results of scientic studies, allowed to build the
popular awareness that people themselves can inuence
and improve their own health (e.g. through physical
exercise or following the recommendations of so-called
“preventive medicine”). is stood in stark contrast with
the Soviet bloc, where health was dened primarily as
the business of the state and government.
e concept of “health elds”, developed by Lalonde
in Canada in the 1970s, and subsequently modied and
dened in several documents9 was dicult to nd in
Polish health policy, where it was not the whole govern-
ment, but only the Health Minister who was responsi-
ble for health. is stood in contrast to, for instance, the
Scandinavian countries [22]. ere were no multi-disci-
plinary schools of public health (i.e. epidemiology, bio-
statistics, disease prevention, healthcare organisation,
environmental health, health education and health pro-
motion). e public health eld lacked representatives
of any professions other than medical doctors: hospital
administrators, health science lecturers, nutritionists,
biostatisticians, social scientists, epidemiologists, law-
yers, etc.
As aresult, the health awareness of Poles, as in the
other countries of the Soviet bloc, remained very low.
Aer WWII, tobacco and alcohol consumption in East-
ern Europe grew steadily (Fig. 4). Both these products
were readily available and their prices were maintained
8 Aer WWII, Austin B. Hill, aprofessor of applied medical statistics at the London School of Hygiene and Tropical Medicine, developed methodologies for
assessing and evaluating new treatments and medical interventions. He pointed out the need for making appropriate comparisons in modern epidemiology,
which would allow to avoid bias and to understand the role of probability (i.e. role of chance). He designed and conducted some of the rst randomised,
double-blind clinical trials, which were designed in a way which would minimise investigator bias. is method was rst used to test the eectiveness of
treating tuberculosis with streptomycin. Hill divided his tuberculosis patients into two groups; neither the physician (researcher), nor the patient (subject)
knew whether they are receiving placebo or streptomycin (hence the term “double-blind study”). In this way anew methodology arose for measuring ecacy
of treatment and the eectiveness of other medical interventions. Elements of this reasoning were then used to study the relationship between smoking and
lung cancer. Research designs such as the case control study, and the prospective and retrospective cohort studies, were created, and were used in research on
the role of smoking in causing lung cancer. e key moment when EBM became established in Western medical thinking was the 1972 publication by Archie
Cochrane entitled “Eectiveness and Eciency: Random Reections on Health Services”, which criticized the dearth of clinical experiments as the basis for
medical practice.
9 Published in 1974 by the Canadian Government, the Lalonde report was an inuential symbol of the Western countries’ departure from the medicalisation
of health model. It proposed aholistic approach to building population health, through focusing of four key “health elds” – people’s lifestyle, their living envi-
ronment, biology and genetics, and healthcare organisation (M. Lalonde, A new perspective on the health of Canadians; a working document, Ottawa, 1974).

12
Witold A. Zatoński, Mateusz Zatoński
JOURNAL OF HEALTH INEQUALITIES 2016 / Volume 2 / Issue 1, June
at very low levels. In Poland, alcohol consumption per
capita increased from about 3 litres in 1950 to 8.4 litres
in 1980, and the dominant fashion of drinking became
the “Russian” model of binge drinking. Another good
example of alack of strong health policy was the state’s
dismissive attitude towards tobacco. Within the milita-
rised societies of Eastern Europe, cigarette production
and sale became a national priority. Everyone in the
army received acigarette allocation regardless of wheth-
er they smoked or not, and non-smoking among sol-
diers was frowned upon. Cigarette prices were low, and
cigarettes were widely available. Indeed, smoking was
allowed practically everywhere and at all times, except in
places where re safety could be compromised. Cigarette
sale increased from 20 billion cigarettes per annum to
around 100 billion in 1980. is state of aairs changed
very little until the end of the 1980s (Fig. 4).
Poland, and the other closed societies of the Soviet
bloc, were deprived of information about the harmful
eects of smoking. Paradoxically, the heaviest smokers
were the better educated (including physicians) and the
better-o. Such approaches to smoking, observed in the
countries of communist Eastern Europe, meant that
Poland became one of the global leaders in tobacco con-
sumption between the late 1970s and the end of the 20th
century [4, 23, 24].
Another important factor that can help account for
Poland’s health disaster was diet. e state heavily subsi-
dised certain basic foodstus. is meant that the prices
of meat and dairy products remained relatively low com-
pared to people’s incomes. is, combined with alack of
awareness about the adverse eects of certain diets on
the cardiovascular system, led to ahigh consumption of
saturated animal fats. Up until 1980, caloric intakes were
higher in Eastern Europe than in Western Europe (Fig. 4).
is was likely the reason that the onset of obesity
became aproblem rst in Eastern European countries.
Alack of diversity and innovation in eating habits meant
that in the northern part of Eastern Europe vegetable oil
consumption remained at very low levels, probably con-
tributing to the deciency of certain essential unsaturat-
ed fatty acids [4, 25].
Although high seasonal consumption of fruits and
vegetables from local markets was noted in many Soviet
bloc countries, such produce was practically unavailable
out of season; in contrast to Western Europe (including its
northern region). e low consumption of fresh fruits and
vegetables out of season was coupled with a reliance on
traditional methods of preparing food. is was connect-
ed with ahigh salt intake (15-20 g day) [26], which in itself
carried the risk of cardiovascular disease. Many vegetables
were consumed in marinated form, and meats were usual-
ly processed with large amounts of salt, potassium nitrate
(saltpetre), or were smoked (mainly sausages).
Meanwhile, in Western Europe in the 1960s and
1970s anew public health philosophy was being devel-
oped. Health policy was to be carried out by the entire
state apparatus – and with asignicant role of the Min-
istry of Finance – and not just by the Ministry of Health.
e so-called “Health in All Policies” approach was suc-
cessfully carried out by countries such as Finland, which
underwent the transformation from acountry with poor
health indicators in the 1960s, to aEuropean leader in
health [22]. Another example was the UK, aworld power
in the trade, sale and consumption of tobacco (in the late
1940s 80% of adult males in Britain smoked, and lung
cancer became the number 1 killer of middle-aged men).
e British initiated an anti-smoking crusade using all
FIG. 4. Cigarette sale, alcohol consumption, and caloric intake in Poland
100
90
80
70
60
50
40
30
20
10
0
Billions of cigarettes
A
1935 1950 1965 19801920
Cigarettes sales in Poland,
1923-1980 10
9
8
7
6
5
4
3
2
1
0
Liters of pure alcohol/per capita/year
B
1955 1960 1965 1970 1975 19801932
Alcohol consumption in Poland,
1950-1980 3600
3500
3400
3300
3200
3100
3000
2900
2800
2700
2600
Kcal/per capita/day
C
1940 1948 1956 1964 1972 19801932
Total energy intake in Poland,
1936-1980

13
JOURNAL OF HEALTH INEQUALITIES 2016 / Volume 2 / Issue 1, June
Health in the Polish People’s Republic
possible means; with economic and educational meas-
ures being paramount. For example, huge taxes were set
on tobacco products, and until now the UK is the country
where cigarette prices are among the highest in Europe
(four times higher than in Poland). is helped to reverse
the trend of lung cancer incidence, which decreased
threefold. British scientists estimate that the declining
smoking prevalence rates are also responsible in 50%
for the decrease in the incidence of cardiovascular dis-
eases in the UK [27]. e unprecedented health growth
in western European democracies (which is continuing
in the 21st century) has been possible thanks to chang-
ing the way their citizens think about health (not just
as amatter of curative medicine), building their health
competencies and reducing health illiteracy, building
healthy lifestyle models, and the active participation of
state and society in public health programs (“health is
too important to be le to doctors”) [28].
Despite the low mortality rates from chronic dis-
ease in post-WWII Poland, followed initially by only
modest increases (keeping in mind the long period of
disease development in the case of many chronic diseas-
es), already around the mid-1960s increases in mortality
began to be observed, particularly in the group of young
and middle-aged men. Among adult women (aged
20-64), mortality rates were stagnant. As aresult, at the
same time as arapid improvement was occurring in the
control of infectious diseases and child health, an equal-
FIG. 5. Life expectancy at age 20, Poland, men
51
50.5
50
49.5
49
48.5
48
47.5
1950 1960 1970 1980 1990 2000
FIG. 6. Mortality of men aged 20-64, selected causes, Poland
1963-1991
350
300
250
200
150
100
50
0
1962 1967 1972 1977 1982 1987 1992
CVD Cancer Injuries Infectious
ly rapid deterioration of adult health could be observed.
Life expectancy at 20 years of age was decreasing (Fig. 5).
Myocardial infarction sharply rose. Lung cancer rates
soared for men, breaking world records, especially in
young and middle-aged adults. Morbidity rates of liver
cirrhosis also rose. Almost one in ve adult men suered
premature death from injury (Fig. 6).
is deterioration in population health in Poland
was not aresult of any shortage of doctors or hospitals.
In fact, this dramatic decrease in health occurred at the
same time as the number of doctors in Eastern Europe
signicantly increased (in 1990 the number of doctors
per 1000 inhabitants in Eastern Europe was 4.7, while
in market economy countries it was just 2.5), and their
level of education was improving. Similarly, the number
of hospital beds increased (in 1990 there were 11 hospi-
tal beds per 1000 inhabitants in Eastern Europe, versus
just 8 beds per 1000 inhabitants in developed countries).
Access to new drugs and medical technologies also con-
tinued to improve in Eastern Europe [17].
While mortality rates in the UK and Finland have
decreased by over 30% between 1965 and 1990, in
Poland they have increased by almost 40%. Life expec-
tancy among males at age 20 decreased by 2.3 years, and
in women it increased by just 1.1 years. During this same
time, life expectancy at age 20 in western countries such
as France and Finland had increased by more than 4 years
in men and more than 5 years for women.
Stand. mortality rates per 100,000 population

14
Witold A. Zatoński, Mateusz Zatoński
JOURNAL OF HEALTH INEQUALITIES 2016 / Volume 2 / Issue 1, June
FIG. 7. Risk of dying by world region, 1990
Males aged 15-60 years Females aged 15-60 years
[%]
[%]
40
35
30
25
20
15
10
5
0
40
35
30
25
20
15
10
5
0
EME EMEFSE FSE
CHN CHNLAC LAC
OAI OAI
MEC MECIND INDSSA SSA
Injuries
Non-communicable diseases
Communicable diseases
Injuries
Non-communicable diseases
Communicable diseases
C D
Males aged 0-15 years
[%]
30
25
20
15
10
5
0EME FSE CHN LAC OAI MEC IND SSA
Injuries
Non-communicable diseases
Communicable diseases
Females aged 0-15 years
[%]
30
25
20
15
10
5
0EME FSE CHN LAC OAI MEC IND SSA
Injuries
Non-communicable diseases
Communicable diseases
A B
Males aged 60-70 years Females aged 60-70 years
[%]
[%]
35
30
25
20
15
10
5
0
35
30
25
20
15
10
5
0
EME EMEFSE FSE
CHN CHNLAC LAC
OAI OAI
MEC MECIND INDSSA SSA
Injuries
Non-communicable diseases
Communicable diseases
Injuries
Non-communicable diseases
Communicable diseases
E F
EME – Established Market Economies; FSE – Former Socialist Economies; CHN – China; LAC – Latin America and the Caribbean; OAI – Other Asia and Islands;
MEC – Middle Eastern Crescent; IND – India; SSA – Sub-Saharan Africa.

15
JOURNAL OF HEALTH INEQUALITIES 2016 / Volume 2 / Issue 1, June
Health in the Polish People’s Republic
e main reason for this growing gap in health, espe-
cially for young and middle-aged men, were cardiovascu-
lar disease, especially coronary heart disease. e increase
in cardiovascular disease mortality for men aged 20-64
in the years 1965-1990 in Poland amounted to 83%,
while in the same period in Belgium or Finland adecrease
of around 50% was observed. e second principal rea-
son for the growing East-West gap was an increase in
mortality due to sudden external causes. is rate grew
by 57% among Poles aged 20-64, while it decreased by
25% in Austria, and 37% in the Netherlands [4].
Until the 1980s, cancer mortality in Poland was low-
er than in Western Europe. However, while in the 1980s
Western Europe experienced for the rst time adown-
ward trend in cancer mortality, in Poland this rapidly
grew. is was primarily due to lung cancer incidence, as
well as other tobacco-related cancer locations [4].
Another health development typifying this period
in Poland, as well as other countries of the Soviet bloc,
were the growing dierences in health between men
and women; the so-called “excess male mortality”. is
was particularly pronounced in the 20-64 age group.
e dierence in life expectancy between men and wom-
en increased throughout the period of PRL. In 1960 the
gap was 6 years, at alife expectancy of 71 years for wom-
en and 65 for men. When the communist regime was
collapsing in 1989, life expectancy was almost 9 years
higher for women, at alevel of 75 years, compared to just
66 years for men [29].
Before the economic and political transformations of
the 1990s, the health status of adults in Poland, and in
the rest of the Soviet bloc, diered dramatically from the
western countries [4, 30].
CONCLUDING REMARKS
e untrammelled rise of adult premature mortality
in Poland has demonstrated the inability of communist
countries to eectively respond to the new health challeng-
es. Chronic diseases among adults were becoming an ever
greater burden for the economy. Human capital was wast-
ed and economic development retarded. ese failures in
public health were part of a larger pattern of Poland’s ina-
bility to compete eectively in the globalising economy.
At the end of the 1980s the health of adult Poles was
in a catastrophic state. Premature mortality among mid-
dle-aged Poles, lung cancer mortality, cardiovascular dis-
eases, sudden deaths from external causes (i.e. accidents,
injuries, poisonings, etc.), and liver cirrhosis, had achieved
in Poland (and other CEE countries) levels that were not
observed anywhere else in the world. is epidemic of
“man-made diseases” became one of the main challenges
facing Poland at the end of the PRL period. According to
10 At the end of the PRL years, premature mortality rates of adult Poles, especially men, had attained disastrously high levels. In 1990 almost 30% of the male
population aged 15-59 years were dying; this being higher than levels seen in India and China [30].
11 is paper is based on the authors’ forthcoming chapter in the Polish-language publication by Noszczyk W (ed.). Zarys dziejów medycyny wPolsce – tom III.
[History of medicine in Poland – vol. 3]. PZWL, Warszawa 2016.
WHO estimates in 1990, the chances of a15-year-old boy in
Poland (along with his peers in other former socialist coun-
tries) to survive to 60 years of age was lower than that of
ateenager living in China, Latin America, or India10 (Fig. 7).
As the PRL was collapsing in 1989, the predictions
for the future of the country were dire. e uncertainty
about what the collapse of socialist economy will bring,
the impoverishment of society, the return of unemploy-
ment (inexistent under communism) – all of this augured
very poorly for the health of Poles. Forecasts indicat-
ed that infant and child mortality rates will increase.
e tobacco industry predicted further increases in ciga-
rette sales. Poland’s looming food shortage and malnutri-
tion crisis were widely debated11.
ACKNOWLEDGEMENTS
e authors would like to thank Kinga Janik-Kon-
cewicz, Urszula Sulkowska and Piotr Hołownia for their
help in the preparation of the manuscript.
DISCLOSURE
Authors report no conict of interest.
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