‘Born of the devil and filled with the devil’s blood’ was Alexander Solzhenitsyn’s typically over the top dismissal of the Gulag medical system, which he had encountered at first hand in his years as a prisoner. In his view, the doctors, however good their intentions, were powerless in a system whose raison d’être was to maximise labour extraction without regard for human life or suffering. ‘Born of the devil’ – aka the Soviet secret police and Soviet state terror – it certainly was, but there are usually two parents involved in a conception. Like much else in the Soviet system, Gulag medicine was a site of contradiction: after all, the devil’s directives had to be carried out by humans who tended to develop their own agendas. But the fundamental contradiction was that the Soviet Union, while practising terror against its citizens, also had principled commitments to provide them with welfare. One bureaucratic hand might be carrying out the first task while the other, apparently oblivious, pursued the second. Such was the black comedy of Soviet life, with Gulag medicine a prime example.

The point of the Soviet labour camp system was to extract the maximum labour from prisoners, particularly in the distant and climatically inhospitable but resource-rich areas to which free labour was hard to attract. Many of the camps were in the far north, sometimes above the Arctic circle, or the underdeveloped Far East. In the Ukhta camps in the northern Komi Republic, the main economic activity was oil-drilling; in Norilsk, in the Arctic, there was mining for cobalt, copper and platinum. For both free specialists and prisoners in the giant Far East road-building and gold-mining enterprise known as Dal’stroi, based in Magadan, the rest of the Soviet Union was ‘the mainland’.

Like the military, Gulag was required to have its own functioning medical system. This wasn’t only to keep prisoners fit for hard physical work but also because all Soviet citizens, free or not, had the right, enshrined in the Constitution, to medical care. Forget the fact that a substantial proportion of Gulag prisoners in the 1930s and 1940s had had their rights as citizens violated by being arrested for no good reason – condemned simply as ‘kulaks’ or ‘enemies of the people’, or as belonging to a ‘traitor nation’ like the Chechens (who were collectively viewed as collaborators during the German wartime occupation). If the mandated norms of medical care weren’t met and appropriately documented, some bureaucrat would be in trouble. Incredibly, Gulag was better supplied with hospital beds per capita than the population at large. As of 1939, its 1.6 million inhabitants were served by 2459 qualified doctors – double the ratio for the civilian population at the time – along with 7290 nurses, paramedics (feldshers) and pharmacists. Whether this was intentional, or even clearly recognised in Moscow, is unclear. It could have been an unintended product of oversupply, thanks to the arrest of medical specialists and their dispatch as convicts to Gulag: there was little sense in wasting them on hard labour. Whatever the reasons, about 40 per cent of Gulag medical personnel were prisoners, the rest being freely hired professionals. Gulag convicts suffered the same range of ailments like cancer, stroke and heart disease as the free population, and treatment of TB and venereal diseases were important concerns of camp medicine. Healey’s emphasis, however, is on illness related to exhaustion, malnutrition and harsh work conditions – pellagra, scurvy, dysentery, frostbite and limbs broken in industrial accidents.

In Illness and Inhumanity in Stalin’s Gulag (2017), which was based on an extensive study of Gulag archives, Golfo Alexopoulos argued that the degree of exploitation involved, and the callous release of weak prisoners no longer capable of hard labour to die outside Gulag (and thus not be counted in its institutional mortality statistics), meant that the camps should be seen not just as an enterprise careless of human life but rather, following Solzhenitsyn, as a system ‘designed for destruction’ of the inmates. Alexopoulos cites statistical data showing that at any given time a substantial proportion of the convict population – about 40 per cent in 1940 – were classified as invalids or unfit for hard physical work. This puts the economic rationale for the whole system in question – and, of course, makes the political conundrum of its survival for three decades the more puzzling.

Dan Healey takes a different approach in The Gulag Doctors. Rather than concentrating on government policy as set out in central state archives, his focus is on the lived experience that shaped things on the ground, and the complex ways in which that experience is remembered. He explores the remarkable phenomenon of Gulag medicine by looking at the doctors and nurses who staffed the system. Jews, women and members of ethnic minorities were all well represented in the Soviet medical profession as a whole, thanks in part to affirmative action programmes in the 1920s, and the numbers in the Gulag contingent may proportionally have been even higher. Many of them wrote memoirs, mainly between the late 1980s and early 2000s, in which they generally told their stories in terms of a heroic struggle to care for patients, as their medical vocation required, despite the constraints under which they worked. Another kind of story emerges from local histories and museums in Gulag-heavy regions like Magadan and Ukhta, which in the late Soviet era celebrated the exploration, settlement and development (osvoenie) of new territories. In Western terms, this would be a colonisation story (before colonisation became a dirty word), valorising bravery and ingenuity in the struggle to survive in a hostile environment. Gulag camps were an integral part of this history – as convicts were in the early years of settler colonies such as Australia. Late Soviet regional histories of the 1970s and 1980s described the establishment of a health system – often without mentioning that the system was initially run by Gulag – in terms appropriate for brave pioneers who had the resourcefulness and imagination to build medical facilities from scratch, ‘regardless of the circumstances (in a tent, a corner of a barrack on permafrost, the yurt of a native inhabitant)’.

Healey’s account is structured around the biographies of both free professionals and prisoners. The free professionals reached Gulag by various paths. Some volunteered as young Komsomol members, inspired by the mixture of adventure and patriotism that in the 1930s drew many young Soviet men and women to do their part in the conquest of the north. Sofia Guzikova had just graduated in Moscow when in 1940 she got the assignment to a Gulag camp on the lower Amur: unlike others in her cohort, who begged for assignments close to home, she had an outburst of ‘romanticism’ about a doctor’s vocation to serve the people and asked the commission to ‘send me as far away as possible’. Nina Savoeva, a young woman from Ossetian Komsomol who had been sent to Moscow for her medical education, selected Magadan for her job assignment, saying, ‘I think I’m needed there more than anywhere else’ (she entitled her 1996 memoir I Chose Kolyma). Others were drafted, or at least found that work in the Gulag system under the security police was an offer they couldn’t refuse.

Yan Pullerits had made his career in the OGPU (later NKVD) medical system in the 1920s, working under Eduard Berzin, a senior figure in the secret police who in the early 1930s was the founding director of Dal’stroi. As Dal’stroi’s medical director, Pullerits built a huge network of medical stations, clinics and infirmaries in Kolyma, while conducting research on scurvy – he developed an infusion based on a local variety of pine needles as a source of vitamin C, much disliked by prisoners. For his service, he was rewarded with an Order of the Red Banner by the Kremlin. Like many of the communists of Gulag’s first generation of administrators, Pullerits was shot during the Great Purges following the fall of his patron. Nikolai Glazov had also made his career as a doctor in the NKVD system, though less enthusiastically than Pullerits. Enjoying the privileged lifestyle that went with his job in Moscow, he resisted appointment in the borderlands on grounds of health – until, after his arrest as a Trotskyist in 1936, he was sent to a camp in the Komi Republic. Identified as a doctor during the long and arduous journey, he was appointed on arrival to a job in the camp hospital.

Some of the prisoner-medic contingent, then, had been doctors or feldshers on the outside. Vadim Aleksandrovsky was pulled from his final examinations at the prestigious Leningrad Military Medical Academy in 1949, arrested, and sent to Gulag, where he had the good fortune to arrive at a northern camp along with ‘a group of intellectuals from Leningrad; there were no criminals among them to steal their clothing and make life miserable.’ The welcome party included an Austrian communist, by profession a dental technician, who was head of the camp’s medical division. He took Aleksandrovsky on. It wasn’t untypical for a prisoner with medical qualifications or potential to be quickly identified, though Aleksandrovsky may have set a record in working only a single day as a labourer.

Other prisoners – often educated people who caught the eye of a fellow member of the intelligentsia working in the medical service – acquired their skills inside the camps, not just by learning on the job, but by diligently studying for exams, using textbooks that passed from hand to hand almost as sacred objects. In 1936, Moscow directed all camps to set up six-month courses to train prisoners as nurses and paramedics. In Gulag, as in society as a whole, education was held in high regard, particularly as an agent of upward mobility. Back on the ‘mainland’, Viktor Samsonov, of lower-class provincial origin, had been on the upward path, sent after seven years of primary education to study surveying at Petrozavodsk Industrial Technical School, when in 1937 he was arrested as an 18-year-old student along with other Komsomol activists. He arrived at the Ukhta camp exhausted and suffering from night blindness, a result of vitamin A deficiency. Hospitalised with an eye infection after working in the mines, he made friends with a medical assistant who found him work as a hospital orderly, and with help from other medics managed to pass the exam qualifying him as a midwifery nurse. Subsequent moves around the departments of Ukhta’s Vetlosian Central Camp Hospital, including something like an unofficial internship with the head of surgery (a Ukrainian prisoner, formerly a professor of obstetrics and gynaecology), honed his skills.

Released at the end of his sentence in 1942, but still with the status of ‘exile’ and so forbidden to leave the area, he continued to work in the camp medical department until the end of the war. Eager to receive a formal qualification as a feldsher, Samsonov applied to the nearest feldsher school, three hundred kilometres away, and was accepted, but still had to plead with the Ukhta camp governor to get dispensation ‘to make the journey with his notes, meagre rations and books to the Komi capital for his examinations’. Over three days he took fourteen oral vivas – in obstetrics, pharmacy, pathological anatomy, children’s diseases and the history of the USSR, and more. If it weren’t for the Gulag setting, his memoir would read as a classic ‘I came from nothing but became a respected professional’ story. After his release from exile status in 1946, Samsonov continued in similar vein in the free world, obtaining his medical degree in Ivanovo (one of only two medical schools in the Soviet Union that accepted applicants with a criminal record), then going on to two higher degrees, and ending up as a professor at Petrozavodsk State University. But it was the Vetlosian camp hospital that ‘became, in Samsonov’s retrospective gaze, his alma mater’.

An illustrious medical career like Samsonov’s, which ultimately earned him the title of Honoured Scientist of the Russian Federation, something like a Soviet knighthood, was an almost unthinkable outcome of a prisoner’s transfer from outdoor physical labour to work in the camp medical service. The short-term advantage of staying alive was surely uppermost in the minds of most who managed to scramble in. Working in an infirmary or hospital meant release from backbreaking physical work, more to eat, and more rest. It was undoubtedly the best available path to long-term survival, which surely explains why it frames so many Gulag survivors’ memoirs. One well-known example is the memoirist Evgenia Ginzburg (Journey into the Whirlwind and Within the Whirlwind), who was saved from near death by a chance encounter with a prisoner-doctor, a former Leningrad surgeon; she was taken on as a nurse. Thanks to her training by the surgeon, and by another prisoner-doctor, whom she married after release from the camp, she became ‘a proper ward nurse. I had learned all the secrets of the art.’ Another is Varlam Shalamov, whose fourteen years in Gulag were the basis of his ‘Kolyma Tales’, the publication of which in magazines in the West was a sensation in the mid-1960s. On the verge of death in 1946, he was brought back to life in a camp hospital, after which he was able to enrol in a training course for feldshers, courtesy of a friendly prisoner-doctor, which made possible his longer-term survival – though after his release he was enraged to discover that an in-house Gulag qualification as a feldsher was not acceptable on the mainland. It is Shalamov’s relatively positive view of the Gulag medical system that Solzhenitsyn, the other great literary chronicler of Gulag, was contesting. (They were in a sense competitors, with Solzhenitsyn’s One Day in the Life of Ivan Denisovich coming out four years before the first of the ‘Kolyma Tales’, and Gulag Archipelago seven years after.)

Co-operation between free and prisoner specialists seems to have been the norm, at any rate in memoirists’ recollections, many of which noted the ‘strength of professional solidarity across the prisoner-free employee divide’. They were written primarily by prisoner-doctors, who found it easier than freely hired specialists did to distance themselves from the institution in which they had worked. To judge by these accounts, the line between the two statuses could be porous. Nikolai Viktorov was arrested in the late 1920s on espionage charges after serving as a military doctor in the Caucasus. Sent to Solovki, he not only worked as a prisoner-doctor but was part of the OGPU’s first expedition to Ukhta; he was appointed to a senior medical position when the new camp was set up. Released in the mid-1930s but without the right to leave the region, he became director of the Ukhta medical system and later (when he was formally outside the Gulag medical system, but only just) worked in the hospitals of Syktyvkar, which in 1961 awarded him the title of Honoured Physician.

Camp​ commandants and other non-medical officials play only a minor role in the memoirs Healey cites. But it’s obvious that the senior medical personnel needed to have reasonably good working relations with the administrators to get anything done, and one would assume that, since the doctors treated these same administrators in a parallel medical system to that available for prisoners, there were likely to be not only professional but also social interactions. It is understandable that late and post-Soviet memoirs, in which victimhood is a central trope, would avoid this topic. But there is at least one exception (not cited by Healey): Red Tempest, the memoir of the Lvov-born surgeon Isaac Vogelfanger, published in Montreal in the 1990s. Vogelfanger, young and personable when he found himself working as a prisoner-surgeon in the Northern Urals in the 1940s, describes winning the trust and even friendship of the bosses, including NKVD men, through treating their ailments, in effect becoming part of the camp’s social elite. The bosses, in Vogelfanger’s representation, often had their own sense of victimhood, since it wasn’t the first choice of most making a career in the NKVD to be sent to run a camp out in the back of beyond when luckier colleagues got positions in Moscow or Leningrad.

Solzhenitsyn described Gulag as a world invisible to the mainland Soviet world that co-existed in parallel with it, and Gulag developed its own mores and patterns, distinct from those of mainland society. But on its privileged fringes, the Gulag medical service retained strikingly Soviet characteristics. Patron-client relations – of the sort described by Vogelfanger, and hinted at in many of the memoirs Healey quotes – were an integral part of social functioning. Education was valued, science respected. The secret police ran their own scientific research institutes, staffed by qualified prisoners extracted from the regular camps (for a small group, including Solzhenitsyn, this was an alternative route of salvation from hard labour). But in the camps, too, doctors, including prisoner-doctors, were encouraged to do research and present their results at conferences (Gulag conferences – mainland academic conferences weren’t accessible), which they remember as important sites of professional bonding. ‘Research’ wasn’t a sinister matter of experimenting on prisoners who were no longer seen as human, as they were by Nazi doctors in German concentration camps, but rather had the more benign function of improving diagnosis and treatment, especially of the starvation and exhaustion-related diseases that (thanks to state policy on rations and work norms) were most prevalent in the camps. Pullerits and his pine needles for vitamin C deficiency was an early example.

The most striking research case Healey discusses is that of Lev Sokolovsky, a qualified Jewish psychiatrist in Kazan when he was arrested in 1940, who, within a year of his arrival in Ukhta’s central hospital, had organised its first psychiatric department. One might ask why Gulag hospitals needed psychiatrists, especially given that the profession, though not as crushed by the drive against 1920s avant-gardism as the scholarly literature often suggests, still held a lesser place among medical specialties. One answer – though not one to be publicly admitted – may have been the necessity of dealing with the high incidence of psychiatric disorders among the cohort of Great Purges arrivals in 1937-38; the number of psychiatric hospitals in the Gulag system grew from four in 1937 to 76 in 1938. A more officially acceptable rationale was to discover malingerers, those feigning illness in order to get off physical work, and return them to hard labour. Sokolovsky made a study of the ‘simulation’ of psychosis among prisoner patients in the Ukhta hospital in 1944, but the conclusions he came up with were surely not what his bosses wanted to hear. In the case of one patient, he found that her ‘pathological fits’ were indeed simulated, but that she was a genuine psychiatric sufferer whose urge to simulate was itself a pathology – ‘the only means of escape from an intolerable situation’. Sokolovsky appears to have suffered no adverse consequences.

There is black comedy potential in all this – Solzhenitsyn could have made hay with it, had he chosen to turn his satirical eye on the inherent contradictions of Gulag medicine rather than just damning it – but Healey is too fair-minded and serious to play this up. He is careful and scrupulous, respectful of and sympathetic to his protagonists while always alert to the possibility of self-misrepresentation. Yet the liminal terrain of Gulag medicine also complicates the popular binary between ‘perpetrators’ and ‘victims’ in states that use terror against their citizens. Solzhenitsyn would have it that, as collaborators in the system, the doctors were functionally perpetrators. But the doctors – particularly the prisoner-doctors – generally saw themselves as victims. As Healey’s account demonstrates, drawing a firm line between the two categories is almost impossible. It could be argued, of course, that this is simply a fact of life: that we humans are all sometime perpetrators who like to see ourselves as victims. But that makes it all the more interesting when Soviet society, and specifically the world of Gulag medicine, presents us with a familiar paradox, raised to the nth degree.