Until the 1920s, peasants relied on traditional medicine and went to a doctor or hospital only as a last resort. Traditional healers believed that many illnesses were caused by evil spirits (baiane) and could therefore be treated with magic, with chants against the spirits, with prayers, or by using medicinal herbs. The knowledge of healing herbs was highly valued in village society. For healing one could also drink, wash, or bathe in water from mineral springs, some of which were considered holy. Even in postcommunist Bulgaria, some resorted to herbal medicine or to persons with reputed extrasensory healing powers. Herbalists and "extrasenses" resurged in popularity in Bulgaria after the overthrow of Zhivkov. Because of the skepticism of conventional doctors, little research was done on the validity of traditional herbal medicine, but in 1991 doctors began to consider rating skilled herbalists as qualified specialists.

Beginning in 1944, Bulgaria made significant progress in increasing life expectancy and decreasing infant mortality rates. In 1986 Bulgaria's life expectancy was 68.1 years for men and 74.4 years for women. In 1939 the mortality rate for children under one year had been 138.9 per 1,000 by 1986 it was 18.2 per 1,000, and in 1990 it was 14 per 1,000, the lowest rate in Eastern Europe. The proportion of long-lived people in Bulgaria was quite large a 1988 study cited a figure of 52 centenarians per 1 million inhabitants, most of whom lived in the Smolyan, Kurdzhali, and Blagoevgrad regions.

The steady demographic aging of the Bulgarian population was a concern, however. In the 1980s, the number of children in the population decreased by over 100,000. The prenatal mortality rate for 1989 was 11 per 1,000, twice that in West European countries. In 1989 the mortality rate for children of ages one to fourteen was twice as great as in Western Europe. The mortality rate for village children was more than twice the rate for city children. However, in 1990 some Bulgarian cities had mortality rates as low as 8.9 per 1,000, which compared favorably with the rates in Western Europe.

Poor conditions in maternity wards and shortages of baby needs worried new and prospective mothers. Hospital staff shortages meant that doctors and nurses were overworked and babies received scant attention. Expensive neonatal equipment was not available in every hospital, and transferral to better-equipped facilities was rare. In 1990 the standard minimum weight to ensure survival at birth was 1,000 grams, compared with the World Health Organization standard of 500 grams.

The number of medical doctors, nurses, and dentists in Bulgaria increased during the 1980s. Bulgaria had 27,750 doctors in 1988, almost 6,000 more than in 1980. This meant one doctor for every 323 Bulgarians. Some 257 hospitals were operating in 1990, with 105 beds per 1,000 people.

Like other aspects of society, health services underwent significant reform after 1989. In 1990 health officials declared that the socialist system of polyclinics in sectors serving 3,000 to 4,000 people did not satisfy the public 1000 c's need for more complex diagnostic services. They cÍÍÍÍÍÍÍÍlaimed the system was too centralized and bureaucratic, provided too few incentives for health personnel, and lacked sufficient modern equipment and supplies. Thereafter, new emphasis was placed on allowing free choice of a family doctor and providing more general practitioners to treat families on an ongoing basis. Beginning in 1990, Bulgaria began accepting donations of money and medicine from Western countries. During the reform period, even common medicines such as aspirin were sometimes in short supply. Prices for medicines skyrocketed. Shortages of antibiotics, analgesics, dressings, sutures, and disinfectants were chronic.

In November 1989, the Council of Ministers decreed that doctors could be self-employed during their time off from their assigned clinics. Doctors could work for pay either in health facilities or in patients' homes, but with significant restrictions: when acting privately, they could not certify a patient's health or disability, issue prescriptions for free medicine, perform outpatient surgery or abortions, conduct intensive diagnostic tests, use anesthetics, or serve patients with infectious or venereal diseases. In 1990 the National Assembly extended the right of private practice to all qualified medical specialists, and private health establishments and pharmacies were legalized. Church-sponsored facilities were included in this provision. The 1990 law did not provide for a health insurance system, however, and establishment of such a system was not a high legislative priority for the early 1990s.

In 1991 the government created a National Health Council to be financed by 2.5 billion leva from the state budget plus funds from donors and payments for medical services. The goal of the new council was to create a more autonomous health system. Also in 1991, the Ministry of Health set up a Supreme Medical Council and a Pharmaceutics Council to advise on proposed private health centers, pharmacies, and laboratories and to regulate the supply and distribution of medicine.

In 1988 the top three causes of death in Bulgaria were cardiovascular illnesses, cancer, and respiratory illnesses. An expert estimated that 88 percent of all deaths were caused by "socially significant diseases" that resulted from an unhealthy lifestyle and were thus preventable. Strokes, the most prevalent cause of death, killed a higher percentage of the population in Bulgaria than anywhere else in the world. In 1985 nearly 58,000 Bulgarians suffered strokes, and nearly 24,000 of them died. The mortality rate for strokes was especially high in northern Bulgaria, where it sometimes exceeded 300 fatalities per 100,000 persons. In villages the rate was three times as high as in the cities. Doctors cited unhealthy eating habits, smoking, alcohol abuse, and stress as lifestyle causes of the high stroke rate.

In 1990 about 35 percent of Bulgarian women and 25 percent of men were overweight. Sugar provided an average of 22 percent of the calories in Bulgarian diets, twice as much as the standard for balanced nutrition. Another 35 percent of average calories came from animal fat, also twice as much as the recommended amount. That percentage was likely much higher in the villages, where many animal products were made at home. Modernization of the food supply generally led to increased consumption of carbohydrates and fats. In contrast, the traditional Bulgarian diet emphasized dairy products, beans, vegetables, and fruits. Large quantities of bread were always a key element of the Bulgarian diet. Average salt consumption was also very high. In 1990 the average Bulgarian consumed 14.5 kilograms of bread, 4.4 kilograms of meat, 12.6 kilograms of milk and milk products, 15 eggs, and 15 kilograms of fruits and vegetables per month.

In the 1980s, Bulgaria ranked tenth in the world in per capita tobacco consumption. Tobacco consumption was growing, especially among young people. Each Bulgarian consumed 7.34 liters of alcohol per month, not including huge amounts of h cf4 omemade alcoholic beverages. Between 1962 and 1982, recorded alcohol consumption increased 1.6 times.

In 1990 an estimated 35 percent of the population risked serious health problems because of environmental pollution (see Environment , this ch.). In the most polluted areas, the sickness rate increased by as much as twenty times in the 1980s. By 1990, pollution was rated the fastest-growing cause of "socially significant diseases," particularly for respiratory and digestive disorders. Doctors in the smelting center of Srednogorie found that the incidence of cancer, high blood pressure, and dental disorders had increased significantly in the 1980s.

Pollution had an especially adverse effect on the immune systems of children. In the first few years of the Giurgiu plant's operation, the number of deformed children born across the Danube in Ruse increased 144 percent. From 1985 to 1990, this number increased from 27.5 to 39.7 per 1,000. Miscarriages, stillbirths, and premature, low-weight births doubled during that period. The infant mortality rate in Srednogorie was three times the national average in 1990. Excessive lead in the soil and water at Kurdzhali had caused a great increase in skin and infectious diseases in children there. In 1990 environmental authorities named the village of Dolno Ezerovo, near Burgas, the "sickest village in Bulgaria" because over 60 percent of its children suffered from severe respiratory illnesses and allergies.

In 1987 Bulgarian health authorities instituted limited mandatory testing for human immunodeficiency virus (HIV), which causes acquired immune deficiency syndrome (AIDS). All prospective marriage partners, all pregnant women, and all transportation workers arriving from outside Bulgaria were required to be tested. Hemophiliacs, Bulgarian navy sailors who had traveled abroad after 1982, and students and workers visiting vacation resorts also fell under this rule. As of October 1989, some 2.5 million people in Bulgaria, including about 66,000 foreigners, had been tested for HIV, and 81 Bulgarians were diagnosed as HIV positive. According to government figures, six of that number had contracted AIDS. Foreigners diagnosed as HIV positive were ordered to leave the country. Bulgaria estimated it would spend over US$4 million to treat AIDS and HIV-positive patients in 1991.

Data as of June 1992