Tamar Matiashvili: Does Diversity Matter? Evidence from the First Female Physicians

In this project, I study the opening of the world's first-ever formal women's medical school and the subsequent entry of the first female physicians into rural medicine in the late Russian Empire. I digitized novel data on health outcomes and healthcare provision over 35 years in almost 350 districts of the Russian Empire to evaluate how these changed when the first female physicians entered. I find that the first female physician entry substantially reduced infant mortality, increased hospital births and smallpox vaccinations, and decreased hospital death rates. I find that the female physicians likely increased overall healthcare provision quality and also brought more female patients into formal medical care.

I am grateful to the Europe Center for providing the financial support necessary to pursue my research on the first female physicians and how they changed healthcare as we know it. The funding enabled me to digitize historical records on healthcare provision in the late 19th-century Russian Empire.

In 1872, the Russian Empire opened the world’s first-ever formal medical school for women. By 1878, the first female physicians graduated and joined the medical workforce, including the local districts’ government programs of free rural healthcare provision. In these programs, usually, one doctor was assigned to treat patients in a catchment area. Before 1878, all the doctors were men. Now, women would join the physicians’ ranks for the first time. 

I ask, then, how did these women change the healthcare and health of the people they treated? In economics, talent misallocation theory would predict that if female and male physicians are equally talented, the overall quality of healthcare would go up as women entered, while less gifted men would choose a different profession. At the same time, female physicians may have had added benefits for female patients, who, out of shame or mistrust, would not have seen a male patient. This would expand the patient pool, providing access to those in need. At this time, laboring women often went to local, less educated midwives for help. The medical profession frequently spoke of the woes associated with these midwives, who often seemed to do more harm than good. Female physicians would provide qualified help to these women who preferred to be overseen by women during childbirth.

To answer the question of how female physicians altered medicine, I required large amounts of novel data. Previously, I had traveled to the National Library of Finland to find original sources and collected scanned books from online libraries to assemble a collection of original documents I would need to enable this research. The various original documents included data from 339 districts of the Russian Empire on births and deaths by age groups, the numbers of doctors, nurses, and midwives, hospital beds, smallpox vaccinations, etc. It also included an annual list of all licensed physicians in the Russian Empire. 

Using funding from The Europe Center and other sources, I hired data entry specialists who have been helping me digitize this vast amount of data. In Figure 1, you can see an example of the medical lists data. For example, we see a female physician, Alexandra Arkhangelskaya, who was born in 1851 and graduated from medical school in 1882. For decades, she worked in the Vereiskij district of the Moscow Province in the free rural healthcare program.

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Figure 1. A scan of the original medical list issued by the Ministry of Internal Affairs of the Russian Empire of 1890, an alphabetical list of female doctors, followed by a translated version. Blue borders highlight female doctors who served in the rural healthcare program.

Alexandra was a genuinely outstanding woman. At 21, she decided to become a doctor, but she did not have the qualifications to enter medical school. So, she decided to join the first grade of elementary school but quickly realized that she could educate herself better. In several years, she had passed all the qualifications to apply to medical school. In her career, she inspired numerous young female physicians and was one of the pioneers of rural surgery. She performed over 1,100 cataract surgeries. As for Alexandra’s case, in addition to collecting data, I sought out and found memoirs and biographies of as many of these pioneering women as I could, enriching the story told by the numbers. 

Based on these novel data enabled by The Europe Center funding, Figure 3 illustrates the “diffusion” of female physicians in the districts of the Russian Empire where the rural healthcare program existed. 

 Figure 3. The entry of the first female physicians into the Russian Empire's districts with the free rural healthcare program.

What do I find in the data? Using a staggered difference-in-differences design often used in Economics for causal identification, I find that the entry of first female physicians reduced infant mortality by almost 5%. They improved both neonatal mortality (<1 month) and later infant mortality, likely through educating mothers on hygiene and proper feeding practices. I also find that they substituted uneducated midwives and increased the share of childbirths taking place in hospitals, where it was cleaner and safer. They also increased smallpox vaccination rates and decreased hospital death rates. Finally, in areas with female doctors, maternal sepsis and venereal disease diagnosis rates were higher.

How can we be sure that we are observing the effect of a first female physician rather than some other contemporaneous change? Or simply the effect of another physician rather than a female one? Using Europe Center funding combined with other funding sources, I was able to move forward on digitizing the data to rule out these competing explanations. First, I digitized the numbers of male physicians each year – a particularly arduous task, as there were ~20,000 male physicians each year, within which I first had to identify the 2-3,000 who worked within the rural healthcare provision programs and then digitize their information. I also digitized data on hospital beds, smallpox vaccinators, nurse-midwives, and midwives.

With the male physician data at hand, I show that the observed effect is uniquely due to female physicians and that the entry of another male physician does not affect infant mortality, for instance. In addition, I show that in the year when the local governments decided to hire the first female physician, they did not also hire more smallpox vaccinators, nurse-midwives, or midwives or install more hospital beds, suggesting that hiring women was not part of a “menu” of changes.

The project's findings, which are still preliminary, suggest that women improved the average quality of medical services for all patients, but especially for women who were underserved before. Thus, allowing women to obtain medical education not only increased gender equity in the labor force but also equity in healthcare. As I continue to work on this project, I plan to incorporate all these results into a former structural framework and quantify the contributions of different channels through which female physician entry changed medicine.