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                    PUBLIC HEALTH AND INSURANCE:

                         AMERICAN ADDRESSES

                                 BY

            SIR ARTHUR NEWSHOLME, K.C.B., M.D., F.R.C.P.

LECTURER ON PUBLIC HEALTH ADMINISTRATION AT THE SCHOOL OF HYGIENE AND
 PUBLIC HEALTH, JOHNS HOPKINS UNIVERSITY, BALTIMORE, MARYLAND; LATE
  PRINCIPAL MEDICAL OFFICER OF THE LOCAL GOVERNMENT BOARD, ENGLAND;
       PRESIDENT OF THE SOCIETY OF MEDICAL OFFICERS OF HEALTH
    AND OF THE EPIDEMIOLOGICAL SOCIETY; EXAMINER IN PUBLIC HEALTH
      TO THE UNIVERSITY OF CAMBRIDGE, IN PREVENTIVE MEDICINE TO
       THE UNIVERSITY OF OXFORD, AND IN STATE MEDICINE TO THE
         UNIVERSITY OF LONDON, MEMBER OF THE GENERAL MEDICAL
           COUNCIL, OF THE COUNCIL OF THE IMPERIAL CANCER
                         RESEARCH FUND, ETC.

                              BALTIMORE
                       THE JOHNS HOPKINS PRESS
                                1920




                           Copyright, 1920
                     By THE JOHNS HOPKINS PRESS

                              PRESS OF
                    THE NEW ERA PRINTING COMPANY
                            LANCASTER PA.




                       DEDICATED BY THE AUTHOR

                        (WITHOUT PERMISSION)

                               TO THE

                     RIGHT HONOURABLE JOHN BURNS

                     A LEADER IN PUBLIC HEALTH;

            WHO IN PARTICULAR MADE THE PUBLIC REALISE THE
                 IMPORTANCE OF CONCENTRATING ON THE

                        MOTHER AND HER CHILD




                               PREFACE


After more than three decades of work in preventive medicine and
public health, the opportunity has arisen in connection with a
year’s visit to America, to take a panoramic view of public health
in England, of the progress which has been secured, of the factors
which have impeded progress, and of the pressing desiderata for more
efficient future action.

During my stay in America I have had the privilege of addressing
public audiences in every part, from New Orleans to Toronto, and
from New York and Boston to San Francisco and Seattle; as well as
more special audiences at Johns Hopkins University, at Saranac
and at Harvard, California, Washington, and Yale Universities;
and at the request of many friends some of the addresses given to
these audiences are now published in volume form. These addresses
briefly outline some of the lessons of long experience, and although
the conditions under which they were delivered rendered complete
exposition impracticable, there are, I think, advantages in not
overloading the presentation for public consideration of a many-sided
subject.

It will be noted that the same problem may be mentioned in several
addresses, though usually from a different angle. The entire
avoidance of repetition would have necessitated the abandonment of
the lecture form, and would, I believe, have diminished the utility
of the volume. The table of contents and index render cross-reference
easy.

Those wishing to ascertain fuller details on most of the problems
discussed in the present volume may refer, I think with advantage,
to my annual reports as Medical Officer of the Local Government
Board, England, and to my four special reports on Maternal and Child
Mortality, which also were issued as English Government publications.

British experience is only partially applicable in the United
States, the almost complete Home Rule in each State creating a
new and interesting problem in efficient national public health
administration. Nevertheless a review of events in Great Britain
cannot fail to be useful in America, which is faced with similar
problems. The main lines of public health administration in Great
Britain have proved their value by their success. There has been
local independence with a minimum of central control, and the
people’s representatives in every area have been made to realize
their commercial responsibility. The mistakes made in permitting the
multiplication of small and inefficient public health authorities,
in allowing official medical work to be divided respectively
between different local and central authorities, in sanctioning the
creation of _ad hoc_ authorities for special work, in associating
state medicine with monetary insurance against sickness, and in
not securing that insurance shall directly assist the prevention
of sickness, have been largely the mistakes of politicians and of
central authorities. These mistakes involve the retracing of steps
and the undoing of the mischief resulting from ill-advised action. In
view of these conflicting events, the marvellous achievements secured
by public health authorities are the more noteworthy.

In every American city visited by me I have been struck with the
earnest desire of voluntary and official public health and social
workers to profit by English experience, to adopt what is good, to
secure the abolition of the short tenure of office of competent
officers under the present political system, and to introduce civil
service conditions for them. There is in many respects a close
parallelism between the course of public health on both sides of the
Atlantic; in some cities the English hygienist has much to learn
in respect of advanced and original work; and in other American
cities in which “political pull” continues, there is evidence of the
development of a wider interest and a more general sense of communal
responsibility; a deeper trend of thought which will make for
steadily increasing efficiency in public health work. As this volume
discusses public health problems especially from a social viewpoint,
it is my earnest hope that it may be useful in this direction.

                                                  ARTHUR NEWSHOLME

  SCHOOL OF HYGIENE AND
  PUBLIC HEALTH,
  JOHNS HOPKINS UNIVERSITY,
  BALTIMORE,
  AND
  ATHENAEUM CLUB,
  LONDON,
  May, 1920




                              CONTENTS


                              LECTURE I

  PUBLIC HEALTH PROGRESS IN ENGLAND DURING
    THE LAST FIFTY YEARS                                          1-41

  Parallelism of Events in Old and New England.
  The Utilization of Lay Workers in Public Health Work.
  The Influence of Urbanization and Industrialism.
  _Laissez faire_ Economic Teaching.
  Man and his Environment.
  Dirt and Disease.
      Cholera, Typhoid Fever, Typhus Fever.
  Summary of Results in Life-Saving.
  Specific Causation of Disease.
  Importance and Present Limitations of Epidemiology.
  The Importance of Vital Statistics.
  Conditions of Medical Practice Bearing on Public Health.
  Poor-law _versus_ Public Health.
  Insurance _versus_ Public Health.
  A National Medical Service.
  Hospitals Important Housing Auxiliaries.
  The Need to Avoid Complacency.


                             LECTURE II

  HISTORICAL DEVELOPMENT OF PUBLIC HEALTH
    POLICY IN ENGLAND                                            42-70

  Town-Dwelling and Health Problems.
  The Scope of Public Health Work.
  Reform in the Control of Poverty.
  Reform in Industry.
  Public Health Reform.
  Education Authorities and Health.
  The _Ad Hoc_ Vice.
  Principles of Local Government.
  The Training and Tenure of Office of Medical Officers of Health.
  The National Insurance Act and Public Health.
  Provision for Sickness.
  General Summary.


                             LECTURE III

  THE INCREASING SOCIALIZATION OF MEDICINE                      71-102

  An Altruistic Profession.
  The Past Achievements of Medicine.
  The Ever-increasing Importance of Hospitals.
      Hospitals and Housing.
  The Continuing Mass of Preventible Disease.
  The Present Extent of Socialization of Medicine.
  Destitution and Sickness.
  Insurance and Sickness.
  The Needs of the Future.


                             LECTURE IV

  THE MEDICAL ASPECTS OF INSURANCE AGAINST
    SICKNESS                                                   103-119

  Criteria of Value of Insurance.
  British System of Insurance.
  Limitations and Evils of the “Medical Benefit.”
  Need for further State Treatment of Disease.
  Prevention of Poverty by the Application of Medical Science.
  State Medicine must be Preventive throughout.
  Conditions of an Efficient Medical Service.


                              LECTURE V

  SOME PROBLEMS OF PREVENTIVE MEDICINE OF
    THE IMMEDIATE FUTURE                                       120-143

  The Incidental Gains from War.
      Its Sacrificial Work.
      The Comradeship of All Idealists.
      Women’s Work.
      The Restriction of Alcoholism.
      The Change from Empirical to Scientific Methods.
  The Still Uncontrollable Diseases.
      Influenza and Measles as Types.
  The Possibility of Modified Training of Nurses.
  The Need for a More Complete Program in Tuberculosis.
  The Possibilities of Control of Venereal Diseases.
  The More Complete Protection of Maternity and Childhood.
  The Abolition of Poverty Tests in Medical Assistance.
  Lack of Equality of Service, not Ignorance, the Chief Evil.
  The Continuing Value of Voluntary Workers.


                             LECTURE VI

  THE INTER-RELATION OF VARIOUS SOCIAL EFFORTS                 144-156

  The Possibilities of Good Work under Present Economic Conditions.
  The Importance of Social Work to the Physician.
  The Constant Need for a Causal Outlook.
      Poverty and Disease.
      Causes of Intemperance.
      The Causation and Prevention of Venereal Diseases.
  Lop-sided Views as to Ignorance in Causation of Disease.


                             LECTURE VII

  THE OBSTACLES TO AND IDEALS OF HEALTH PROGRESS               157-182

  Degree of Progress Realized.
  Obstacle of Urban Life.
  Obstacle of Industrialism.
  Obstacle of Poverty.
  The Influence of the Malthusian Hypothesis.
  Obstacle of Ignorance.
  Obstacle of Defects of Character.
  IDEALS.
  Communal Action.
  Spread of Altruism.
      Supreme Importance of Mother and Child.


                            LECTURE VIII

  SOME ASPECTS OF POVERTY                                      183-190

  Disease a Chief Cause of Poverty.
  Diminution of Poverty apart from Increased Family Income.
  Poverty a Complex.
  Action Needed against Each Constituent Element of Poverty.


                             LECTURE IX

  THE CAUSATION OF TUBERCULOSIS AND THE
    MEASURES FOR ITS CONTROL IN ENGLAND                        191-239

  _A._ Basic Facts as to Tuberculosis.
       Explanations of the Decreasing Death-rate from Tuberculosis.

           Diminished Virulence of the Tubercle Bacillus.
           Increased Human Resistance by Natural Selection.
           Immunization by Small Doses of the Contagium.
       Diminished Tuberculosis with Increased Aggregation of
            Population.
          Hospital Treatment of Consumptives.
       Koch’s Views as to Hospital Segregation.
       Improved Housing in Reduction of Tuberculosis.

  _B._ Measures of Control.
       Notification of Cases.
           Causes of Failure in Notification.
       Public Health Action following Notification.
       Examination of Contacts.
       Scope of Tuberculosis Schemes.
       Tuberculosis Dispensaries.
           Should be Part of General Dispensaries.
       The Home Visitation of Patients.
       Sanatorium Benefit.
       Residential Institutions.
       General Observations on Treatment in Sanatoria.
       Hospital Treatment.
       Industrial Colonies.
       Special Dwellings and Help in Support.
       Summary.


                              LECTURE X

  CHILD WELFARE WORK IN ENGLAND                                240-267

  The Earlier Work of Medical Officers of Health.
  The Notification of Births.
  Chief Causes and Course of Infant Mortality.
  The Influence of School Medical Inspection.
  The Influence of Statistical Studies.
  The Midwives Acts.
  Health Visiting.
  Voluntary Work.
  Child Welfare Centers.
  Training and Provision of Midwives.
  Ante-natal Work.
  Dental Assistance.
  Creches.
  Observation Beds at Child Welfare Centers.
  Grant’s to Local Authorities.
  Course of Mortality in Childbearing.




                              CHAPTER I

  PUBLIC HEALTH PROGRESS IN ENGLAND DURING THE LAST FIFTY YEARS[1]


After thirty-five years in active public health work in
England—during eleven of those years having been the principal
officer of its central public health department on its medical
side—I may be assumed to possess some qualification for the task
of reviewing the past half century’s progress in public health in
England.


           _Parallelism of Events in New and Old England_

I find it, however, beyond my power to compass in a short address
a resumé of my subject which shall be complete, or completely
in perspective, or which shall not omit features on which,
had time permitted, one would have wished to comment; and I
must ask you to remember that only a portion—and that chiefly
non-administrative[2]—of the history of this wonderful half century
can be embraced within the present address. The survey should, I
think, take a panoramic view of the story as it has developed, should
note the changes as they have occurred, the obstacles which impeded
reforms as well as the reforms secured; and should also, at least
incidentally, state—in the light of unfailing historical guidance,
as well as of increasing knowledge—the pressing desiderata for more
efficient and more rapid future progress. I cannot hope to accomplish
this task except to a fragmentary extent, but I am happy to remember
that sanitary history in Old and in New England has proceeded largely
on parallel lines. The curves of annual death-rates from all causes,
from typhoid fever, from tuberculosis, and of the mortality of
infants show the closeness of the parallelism of the public health
history of England and Massachusetts.

The work of the last fifty years was built on preceding pioneer work
of men in Old and in New England; and for a complete understanding of
this work, a momentary glance is required at the men of this earlier
generation and their work.

In the old country we speak with reverence of the names of Southwood
Smith, Kay, Chadwick, Farr and Simon; and you remember with gratitude
the names of Lemuel Shattuck, of Bowditch, of Walcott, S. W. Abbott,
and Theobald Smith; and it is gratifying to remember that the
epoch-making report of the Massachusetts Sanitary Commission of
1850—to which were attached the ever memorable names of Shattuck,
N. P. Banks, and Jehiel Abbott—among its many statesmanlike and
far-seeing proposals, recommended a sanitary survey of the State, and
referred to the recent English sanitary surveys, with which British
sanitation may be said to have begun.


                  _The Utilisation of Lay Workers_

Let me in passing comment on the fact that neither Lemuel Shattuck in
Boston nor Edwin Chadwick in London was a physician; but a perusal of
their writings shows that they were men of sound judgment, of earnest
zeal for their fellow men, with a wide and statesmanlike outlook,
ready to search out, to accept and to apply the medical knowledge on
which necessarily the prevention of disease is based. They illustrate
once for all the need for partnership between all well-wishers of
humanity in this work, and the importance of combined effort by the
sociologist and the physician, as well as of experts in each branch
of sanitation, if all attainable success is to be attained.

The tradition then established has never been lost. In England, more
perhaps than in America, the control of public health work has been
shared by intelligent laymen on local and central authorities, and
the fact that medical officers of health have found it necessary
to convince these lay representatives of the general public of the
need for the reforms recommended, has led to steady progress, seldom
interrupted by relapses. And this is true, although delays and
disappointments have beset the path of the earnest reformer, who
might well wish that his lay colleagues had been trained in schools
in which natural science formed a more open avenue to distinction
than classics; or that the representatives on local authorities might
more fully and more quickly appreciate in Simon’s words, what they are

 sometimes a little apt to forget that, for sanitary purposes, they
 are also the appointed guardians of human beings whose lives are at
 stake in the business.

What were the ideals with which the Fathers of Sanitation in New and
in Old England began their work?

They cannot be better expressed than in their own words. In the
1850 Report of the Massachusetts Sanitary Commission they are thus
expressed:

 We believe that the conditions of perfect health, either public or
 personal, are seldom or never attained, though attainable; that the
 average length of human life may be very much extended, and its
 physical power greatly augmented; that in every year, within this
 Commonwealth, thousands of lives are lost which might have been
 saved; that tens of thousands of cases of sickness occur, which
 might have been prevented; that a vast amount of unnecessarily
 impaired health, and physical debility, exists among those not
 actually confined by sickness; that these preventible evils require
 an enormous expenditure and loss of money, and impose upon the
 people unnumbered and immeasurable calamities, pecuniary, social,
 physical, mental, and moral, which might be avoided; that means
 exist, within our reach, for their mitigation or removal; and that
 measures for prevention will effect infinitely more than remedies
 for the cure of disease.

In a succeeding paragraph the Commissioners proceed to quote with
approval, the following remarks made by Mr. (afterwards Sir John)
Simon in the preceding year, when he was medical officer of health
to the City of London, and before he became the principal medical
officer and adviser of the British Government in health matters, and
in that capacity laid the foundation and built much of the edifice of
our present health organization.

 Ignorant men may sneer at the pretensions of sanitary science;
 weak and timorous men may hesitate to commit themselves to its
 principles, so large is their application; selfish men may shrink
 from the labour of change, which its recognition must entail;
 and wicked men may turn indifferently from considering that
 which concerns the health and happiness of millions of their
 fellow-creatures; but in the great objects which it proposes to
 itself, in the immense amelioration which it proffers to the
 physical, social, and, indirectly, to the moral conditions of
 an immense majority of our fellow creatures, it transcends the
 importance of all other sciences; and, in its beneficent operation,
 seems to embody the spirit, and to fulfil the intentions, of
 practical Christianity.

With such noble ideals, what measure of success crowned their efforts
and those of their successors?

The earlier history I can only briefly mention, as we are chiefly
concerned today with events since 1869. To understand these events,
however, one must understand the forces which had been accumulating
and increasing in power in earlier years, and which rendered possible
the rapid public health progress experienced in the fourth quarter
of the nineteenth and the first quarter—so far as it has passed—of
the twentieth century.


                  _Laissez Faire Economic Teaching_

Historians in future generations will refer to the second half of the
eighteenth and the first half of the nineteenth century as the period
of unmitigated industrialism, of associated rapid increase of urban
at the expense of rural life, and of the most extreme manifestation
of _laissez faire_ economic science. The older semi-paternal system
of interference with the economic life of the people by King and
Parliament, was replaced, under the influence of Adam Smith,
Malthus, James Mill, and other teachers, by inaction based on the
view that in old countries poverty is the natural and inevitable
result of pressure of population on means of subsistence, and that
any interference with freedom of competition in obtaining work or
employing workers is useless or mischievous. A similar view found
expression in President Jefferson’s dictum: that government is best
which governs least; and until the middle of the nineteenth century
these views were generally accepted and their influence was dominant.

It was assumed that given free competition, enlightened self-interest
would incite effort and improvement, encourage self-reliance, and
guarantee production and economy.

Under the conditions considered inevitable with such teaching,
although great wealth accompanied the rapid industrial development
after the Napoleonic wars, it was associated with unrelieved misery;
for homeworkers and rural workers crowded into mean hovels in towns,
paying exorbitant rents out of a miserable pittance of wages, and
were exposed to the evils resulting from overcrowding, and from
absence of adequate and satisfactory water supply, scavenging or
drainage. By the year 1851 about half the population of England
and Wales had become aggregated in towns; and it may be added that
in 1911, less than one fourth of the population was left in rural
districts. Urbanization in the earlier years meant dense overcrowding
and insanitation; and that it is still an influence adverse to health
may be gathered from the information given by the census of 1911,
that over eight times as large a proportion of the urban as of the
rural population live in one-roomed tenements, and nearly twice as
large a proportion live in two-roomed tenements, while the proportion
of one-roomed tenements in towns which are overcrowded (in the sense
of having more than two persons to a room) in towns is seven times as
great, and of two-roomed tenements is twice as great as in country
districts.

Domestic misery was associated with commensurate industrial misery;
overwork, in insanitary factories and workshops, regardless of the
health of the “hands,” was the rule.

The displacement between 1760 and 1800 of domestic by factory
manufacture represented a new phenomenon in the world’s history,
a true industrial revolution. It was the parting of the ages;
destined not only to change the life of the people of England from
preponderantly outdoor to preponderantly indoor; and to bring for
them for many years all the disadvantages of unregulated town life;
but also, owing to the rapid development of better roads, of canals,
and then of railroads and steamships to end forever the practical
segregation in which countries, and even neighbouring communities,
had previously lived.

It cannot be wondered at that under these circumstances the general
death-rate was excessive, and epidemic disease spread with a rapidity
and to an extent previously unknown.

The reaction against the _laissez faire_ economic teaching began
early, and it is in accordance with the fitness of things that the
national conscience first rebelled. The earliest evidence of reform
was legislation in 1802 on behalf of pauper children indentured to
the overseers in textile factories; and there followed subsequent
Factory and other Acts in 1819, in 1833, in 1844 and in 1847, which
prohibited the factory employment of children under nine, limited
the hours of labour of young persons and of women, and insisted on
elementary sanitation in factories. Subsequent Factory and Mining
Acts, followed by Shop Hours Acts and the Shop Seats’ Act, have
completed a most valuable code of regulations prohibiting overwork,
and securing a measure of protection against dangers to health and
limb or eyesight during industrial employment. It is noteworthy that
the first steps at improved sanitation, and to safeguard health by
preventing overwork, were on the industrial plane. Factory inspectors
preceded medical officers of health and sanitary inspectors appointed
by local authorities.

Philanthropy was the motive power in initiating factory reform; in
securing general sanitary reform, driving power was furnished by the
double motive of economy and fear, caused by the inordinate expense
of poor-law administration, the frequently recurring epidemics of
“fever,” and the alarming occasional invasions of Asiatic cholera.
The sacrifices of life from cholera were truly vicarious; for we owe
it largely to these that our national system of vital statistics was
initiated in 1837 and that serious efforts at sanitary reform were
begun.


                      _Man and His Environment_

The history of these earlier steps is full of interest; but I
cannot outline it today. There can be no doubt that as Simon[3]
put it, referring to Dr. Southwood Smith’s report to the Poor-Law
Commissioners in 1838 (“on Some of the Physical Causes of Sickness
and Mortality to which the Poor are particularly exposed, and which
are capable of removal by Sanitary Regulations”)

 the commencement of State interference on behalf of the health of
 the labouring classes may be said to date from its publication and
 to have been in a very important degree determined by its facts and
 arguments.

That the first principles of causation were beginning to be
appreciated is shown in the following extract from Queen Victoria’s
speech in opening Parliament in 1849. In this speech she referred to
the ravages of cholera which it had pleased Almighty God to arrest,
and added:

 Her Majesty is persuaded that we shall best evince our gratitude by
 vigilant precautions against the more obvious causes of sickness,
 and an enlightened consideration for those who are most exposed to
 its attacks.

Note that these words and the early attempts at public health
legislation, culminating in our great sanitary code, the Public
Health Act, 1875, incorporated the tripod on which enlightened public
health administration must always be supported, viz.,

  (1) attack on the causes of sickness,
  (2) satisfactory treatment of the sick, and
  (3) satisfactory care for the poor.

I might properly add

  (4) attack on the causes of poverty,

for it is perhaps the chief merit of the great work of Edwin Chadwick
that, in the light of reports on local surveys made by Kay, Southwood
Smith, and others, he was convinced and was able to convince
Parliament that a very large share of the total destitution then
existing was due to the conditions under which the people lived, and
the disease generated in these conditions.

It is commonly stated that, in the past, public health administration
has concerned itself solely with mankind’s environment, failing to
recognise the predominant importance of man himself as a transmitter
of disease, and of his personal well-being and protection as the
point to which energy should be directed. This cannot be said to have
been the intention of the legislature or of the earlier reformers;
though unhappily this limited view received official acceptance,
in large measure owing to the increasing incompatibility between
poor-law and public health administration and the spreading over from
poor-law to public health administration of the general influence of
“deterrence” as a motive of administration. As time went on, this
principle came to be realised as contrary to the general interest in
anything which concerns the health of the community.


                         _Dirt and Disease_

The crude generalization emerging from the earlier surveys was the
close relation between filth conditions and excessive sickness; and
the motive behind these inquiries was the desire to remove one of
the chief causes of destitution.

So late as 1874 Simon said “filth is the deadliest of our present
removable causes of disease”; and throughout the whole series of
his vividly worded and influential reports, the same fundamentally
important teaching was urged.

Chadwick’s earlier reports were similarly influenced by the teaching
of Dr. Southwood Smith and his collaborators, to the effect that
epidemic diseases as a whole are the direct consequence of local
insanitary conditions. This generalization, as we now know, needs
a modified and more accurate statement, specialized for each
individual disease. In its original form, however, it embodied a
realisation of the immense importance of the environment to make or
to mar individual and national life; it secured the beginning of our
national sanitary improvements, and it laid the foundations of the
house of health which as nations we are still building.

The three diseases which were especially regarded as due to filth
were cholera, typhus, and enteric fever; and the history of public
health in England is largely concerned with these three diseases.


                              _Cholera_

The general view then held in New as in Old England is well stated in
the following extract from the Report of the Massachusetts Sanitary
Commission, 1850:

 Atmospheric contagion is generally harmless unless attracted
 by local causes ... that terrible disease, Asiatic Cholera,
 derives its terrific power chiefly or entirely from the accessory
 or accompanying circumstances which attend it. It bounds over
 habitation after habitation where cleanliness abides; ... while it
 alights near some congenial abode of filth or impurity.... Wherever
 there is a dirty street, court, or dwelling-house, the elements of
 pestilence are at work in that neighbourhood.

And the important moral is drawn that

 the person who permits his neighbour’s atmosphere to be contaminated
 by any filth ... is worse than a highway robber. The latter robs us
 of property, the former of life.

Similarly, Simon in England was teaching that “in order to
the prevention of Filth Diseases, the prevention of filth is
indispensable”; and that there was need for local authorities “to
introduce for the first time, as into savage life, the rudiments of
sanitary civilization.”

The crude generalization that filth causes disease perhaps persisted
too long, and the value of Snow’s investigation in 1855 of the
outbreak of Cholera in the area of supply of the Broad Street
pump was perhaps too slowly appreciated. The influence of Von
Pettenkofer’s theories on the relation between subsoil conditions and
Cholera was largely responsible for this delay; but already in 1856
Simon had accepted the importance of water infection, giving as his
general conclusion that

 under the specific influence which determines an epidemic period,
 fecalised drinking water and fecalised air equally may breed and
 convey the poison (of Cholera).

Still it will be noted there persisted the notion of aerial
convection of the contagia of cholera and enteric fever, in
addition to their convection by dirt, by flies, or the more common
contamination of hands or feet or food by faecal matter; but the
importance of water supplies was beginning to be appreciated. Already
in 1883 local authorities in England and Wales had outstanding loans
for waterworks amounting to twenty-nine million and for sewerage
amounting to fifteen million pounds sterling, while between 1883 and
1912 they expended out of rates and by means of loans one hundred and
thirty-one millions for waterworks and eighty-nine millions sterling
for sewerage.

Although we realise now the greater importance of control of excreta
from persons specifically infected, we must agree with Simon that
communally

 Nowhere out of Laputa could there be serious thought of
 differentiating excremental performances into groups of diarrhœal
 and healthy.... It is excrement, indiscriminately, that must be kept
 from fouling us with its decay.... It is to be hoped that ... for a
 population to be thus poisoned by its own excrement, will some day
 be deemed ignominious and intolerable.

And it is still opportune to draw attention to the terrible
responsibility incurred by local authorities when they distribute
a general supply of water to the inhabitants of their area
without taking every possible precaution against contamination.
The conveniences and advantages of public water supplies “are
countervailed by dangers to life on a scale of gigantic magnitude”;
and sanitary history, in the calamitous experience of Lincoln,
Maidstone, and Worthing and of Lowell and other towns and districts,
has given remarkable illustrations of the need for eternal vigilance.


                           _Typhoid Fever_

With the differentiation of typhoid fever from typhus fever by
Gerhard in Philadelphia in 1837, and by Stewart and W. Jenner
in Great Britain in 1849, it became possible to associate the
former with excremental, the latter with respiratory filth, “the
non-removal of the volatile refuse of the human body.” The question
still remained whether typhoid fever was producible by “emanations
from decomposing organic matter,” whether it was “often generated
spontaneously by faecal fermentation,” as contended by Murchison, who
in 1858 proposed the name “pythogenic fever” for typhoid fever; or
whether as indicated by the remarkable observations of William Budd
of Bristol, the introduction of specific infection from a typhoid
patient was needed to start a local outbreak. Gradually it became
clear that specific contamination was necessary to start an outbreak
or even to cause a single case of this disease, and between 1870 and
1880 a number of water-borne outbreaks were traced. It also gradually
became evident that, however objectionable or even noxious might be
the gaseous emanations from leaky drains or sewers, they did not
cause typhoid fever or diphtheria. Hence the statement, for instance,
of Oliver Wendell Holmes in 1862 (quoted for its historical interest
by Dr. Sedgwick) that “the bills of mortality are more obviously
affected by drainage than by this or that method of practice,” which
expressed universal opinion when it was written, is now known to be
accurate only when specific matter from drains contaminates milk or
water supplies, or causes infection by actual contact.

With the general recognition of the causal relation between impure
water supplies and typhoid fever came the rapid provision of public
supplies, on which, as already seen, large public expenditure was
incurred; and to this fact is owing, in the main, the rapid reduction
in typhoid mortality shown in the following statement:

                          Population of           No. of Deaths
                        England and Wales         from Typhoid
  Year                     in Millions                Fever

  1871                        22⅘                    12,709
  1881                        26                      6,688
  1891                        29                      5,200
  1901                        32⅗                     5,172
  1911                        36⅕                     2,430
  1917                        33⅗ (civilian)            977

The number of cases notified in England and Wales

  in 1911 was 13,852
  in 1917 was 4,601

There was, it will be noted, a period of apparent cessation of
decline in the typhoid mortality between 1891 and 1901, followed by a
striking decline between 1901 and the present time. The late decline
was due in large measure to the discovery of the relation between
contaminated shell-fish and enteric fever, and, probably to a less
extent, to the realisation of the importance of the small minority of
cases of this disease, who continue after their recovery to spread
infection. At the present time typhoid fever promises to become as
rare in England as typhus fever or malaria; and with increased care
in the protection of food, as well as of water supplies, and with the
universal hospital treatment of the sick and observation of their
bacterial condition on discharge, this anticipation bids fair to be
realised.


                           _Typhus Fever_

The history of typhus is similar to that of typhoid fever; and
when Murchison in 1858 asserted its spontaneous generation under
conditions of overcrowding and bad ventilation—

 Its great predisposing cause is destitution; while the exciting
 cause or specific poison is generated by overcrowding of human
 beings with deficient ventilation—

he was expressing the considered conclusion of his period.

Typhus Fever was not differentiated from enteric fever in the
Registrar-General’s returns prior to 1869, but the course of events
in later periods can be seen in the following statement:

                                                Typhus Fever, No.
                                              of Deaths in England
  Years                                            and Wales

  Ten years, 1871-80                                 13,975
  Eight years, 1903-10                                  210
  Seven years, 1911-17                                   42

The cases in recent years were nearly all traceable to imported
infection.

The main factors in the reduction of typhus fever have been
the immobilisation of infectious cases in fever hospitals, the
rigid cleansing and disinfection of invaded households, and the
surveillance of persons who have been exposed to infection. The
clearing of insanitary courts, housing improvements, and the
associated increased cleanliness of the general population have
doubtless aided; and it is a suggestive fact that although the virus
of typhus is not yet determined, and although it has only recently
been shown that typhus is a louse-spread disease, the point of
extinction of the disease under peace conditions has almost been
reached in countries having an efficient sanitary organization and a
cleanly people.

With the demonstration that typhoid fever was commonly water-borne,
that the spread of typhus fever could be controlled by sanitary
surveillance and immobilisation of infectious cases in hospital, and
that diarrhœal mortality could be reduced by increased municipal and
domestic cleanliness, much more rapid improvement in national health
occurred in the decennium 1871-1880 and in subsequent years.

The course of events for typhoid and typhus fever has already been
noted. Before describing further the action taken by central and
local public health authorities and the other influences conducing to
reform, it is convenient to summarise at this point the


               _General Results in the Saving of Life_

Although I do not dwell further on the influence of increase of
wages, of better and cheaper food, of sanitary education of the
people, of a steadily increasing standard of cleanliness,—in person
and in spitting habits,—and of improving home conditions, it will not
be assumed they must be omitted in any considered judgment as to the
means by which the saving of life shown by the following figures has
been secured.

The expectation of life at birth (or mean after-lifetime) in England
and Wales in 1871-80 for males was 41.4 years, for females 41.9
years. It steadily improved decade by decade; based on the experience
of 1910-12 the male expectation of life had been prolonged by 10.1
years, and the female by 10.8 years. A very large proportion
of the lives saved were lived in the years of greatest value to
the community. Comparing 1910-12 with 1871-80, the reduction of
the death-rate meant that _each year_ 116,401 male and 118,554
female lives were saved, and the future lifetime of these persons
whose lives were prolonged,—assuming a continuance of current
experience,—would give an annual gain of nearly ten millions of
additional years of life, of which over seventy per cent. would be
lived at ages 15 to 65.

Of the annual saving of 234,955 lives, 64 per cent. was ascribable to
reduced mortality from acute and chronic infectious diseases; and of
the mortality under these headings nearly one-third was referable to
respiratory diseases, the same amount to tuberculosis, one-seventh to
scarlet fever, one-thirteenth to measles and whooping cough, the same
amount to typhus and enteric fever, and one-sixteenth to diarrhœal
diseases.

The gain of life may be further illustrated by the following
figures. During the 32 years, 1881 to 1912, over seventeen millions
deaths occurred in England and Wales. Had the experience of 1871-80
continued throughout the subsequent years, the number of deaths would
have been increased by close on four millions.


                   _Specific Causation of Disease_

The preceding review will have made it clear that in the period
of earlier slow sanitary reform, although much invaluable work
was being done, it was in some measure a groping in the dark,
a continuous search for further light while pursuing (or at
least advocating in season and out of season) such cleansing and
purification of man’s surroundings as were evidently needed, and
such segregation of the infectious sick as could be secured in the
absence of complete information of the cases of sickness. Happily in
the case of Small Pox there was an additional effective protection in
vaccination.

With Pasteur’s discoveries was inaugurated a new era in sanitation;
the general microbial origin of infectious diseases, inferred from
his discoveries, leading to the conclusion that the chief source
of disease to others is man himself, and that his surroundings in
the main cause disease insofar only as they become a vehicle for
conveying disease by direct inhalation of infected dirt (Sax. _drit_
= excrement), or by swallowing specifically infected foods.

The importance of the sanitary engineer in securing pure water
supplies and satisfactory sewerage continues. The sanitary
inspector’s work in removing nuisances and accumulations, any one
of which might be specifically contaminated,[4] and in controlling
overcrowding and uncleanliness as well as in other respects, remains
indispensable. But the brunt of guidance in the exact prevention of
disease, especially of communicable diseases, must necessarily now
fall on

  the epidemiologist,
  the vital statistician, and
  the laboratory worker.


                _Present Limitations of Epidemiology_

The epidemiologist must always remain the chief of these three,
suggesting and arranging the details appropriate to each
investigation, putting together the facts supplied by the two other
workers and drawing legitimate conclusions. In conducting his
inquiries and in searching for further light on obscure points, he
will need to remember Simon’s remarks (Eighth Report of the Privy
Council):

 In the category of time, far out of human reach, there are
 circumstances which greatly influence contagion.... These almost
 cosmic arisings are spreadings of disease or facts of cosmo-chemical
 disturbance which no mere contagionism can explain.

These words had special reference to cholera, and although we still
know little or nothing of the mysterious influences which permit
cholera when unimpeded to undertake transmundane travels at irregular
intervals of time, we can claim with certainty that in any country
in which sanitary surveillance is well organised, and the internal
sanitation of the country is good, the spread of cholera need
not be feared. Thanks to the great discovery of Jenner and to the
complete organization of measures for isolation of the sick, and for
vaccination and surveillance of contacts, we can make the same claim
for smallpox, whenever this mysterious disease begins its occasional
world travels.

But we have to confess our continuing relative helplessness in
preventing the spread of measles, and of acute catarrhs, among our
endemic infections, and still more of influenza when—as recently—it
makes its devastating swoop on the entire world, and secures a larger
number of victims than the World War itself.

We can recommend isolation of the sick, and personal precautions in
speaking and in coughing and sneezing, and occasionally may score
an isolated success; but we are practically helpless against this
enemy. Nor are we better acquainted with the means for preventing the
spread of poliomyelitis; and we cannot claim that any measure against
the spread of cerebro-spinal fever has had undoubted success, except
only rapid amelioration of the conditions of overcrowding under which
it especially occurs. These instances suffice to show that in the
region of respiratory infections,—with the one notable exception of
tuberculosis, which we can control, whenever we are ready to take
the necessary complete measures—we have much to learn. In respect of
most diseases due to respiratory infection we are groping in darkness
nearly as dense as that which beset Chadwick, Farr and Simon in
their earlier work, and with little hope of any campaign comparable
with that against dirt _en masse_, which was largely effective in
reducing the specific infections of cholera, dysentery, and enteric
fever, of typhus fever and even of tuberculosis.

The great public health requirements for the future are the conquest
over acute respiratory infections, including not only affections
of the lungs, but probably also measles and whooping cough,
cerebro-spinal fever and poliomyelitis and their allies; and the
prevention of cancer. So while thankful for the discoveries already
made, and for the beneficent work already accomplished, we must hope
that the rapid increase of Medical Research in England and here
will in due time enable us to extend the application of preventive
medicine to diseases so far uncontrollable.


                _The Importance of Vital Statistics_

In England public health progress has been largely actuated by
records of mortality, which have served to make the public realise
the need for expenditure of money on sanitary reform. Experience has
shown, as Dr. J. S. Fulton has expressed it, that

 every wheel that turns in the service of public health must be
 belted to the shaft of vital statistics.

Accurate and complete returns of deaths and their causes are
essential in investigating the local and occupational incidence of
disease, and in comparing the experience of different communities:
and the various weekly, quarterly, annual, and decennial reports
issued from the Registrar-General’s Department have rendered
invaluable service to the cause of public health. “Ye shall know the
truth, and the truth shall make you free.”

It was not the least of Chadwick’s services to the State that he
discovered William Farr, who was intrusted with the compilation of,
and comment on, our early statistics from 1837 onwards. His reports,
with those of Simon, embody the history of sanitary progress in
England and the motives and arguments which actuated it.

The registration of births similarly enabled comparison of
birth-rates to be made; also of maternal mortality in child-bearing
and of infant mortality in different areas, and at different parts of
the first year of life; and these studies made by medical officers
of health and more exhaustively in the Medical Department of the
Local Government Board have had great influence in determining the
intensive work for improving the conditions of childbearing and of
infant rearing, which in recent years has been accomplished.

As time went on it became clear that registration of deaths gave a
very imperfect view of the prevalence of disease, and that so far
as infectious diseases were concerned, valuable time was lost when
preventive action could only be taken after the patient’s death.
Death registration told of the total wrecks which had occurred during
the storm; it gave no information as to early mishaps, enabling
others to trim their vessels and thus weather through. It gave a list
of killed in battle, not of the wounded also.

And so began gradually, in characteristic British fashion, the
notification of infectious cases, the list of notifiable diseases
being extended from time to time.

From 1911 onwards the Local Government Board prepared a weekly
statement of infectious cases notified in each sanitary area
which was distributed to every medical officer of health. Similar
returns of exotic diseases of interest to port medical officers
were distributed; and the successive annual summaries prepared in
the Medical Department of the Local Government Board showing the
incidence of the chief epidemic diseases in every area now constitute
one of the most valuable epidemiological records extant.

Collaterally with the notification of infectious diseases, including
tuberculosis, to the medical officer of health, occurred the
enforcement of notification of various industrial diseases occurring
in factories, such as anthrax, lead and arsenic poisoning, to the
Chief Inspector of Factories, Home Office.


      _Conditions of Medical Practice Bearing on Public Health_

It cannot be claimed that notification of acute infectious diseases,
still less of tuberculosis, has been complete. It is impossible to
discuss the reasons for this in the present address (see Lecture
IX); but the present conditions of medical practice are largely
responsible for the partial lack of success. Hasty conditions of
work, failure to employ laboratory means of diagnosis, or to utilise
available consultation facilities (especially in tuberculosis), and
lack of training of medical practitioners in preventive medicine, are
among the obstacles to further control of disease.

There will not be complete success until means are discovered for
training and enlisting every medical practitioner as a medical
officer of health in the circle of his private or public practice,
and of securing his services not only in the early and prompt
detection of disease, but also in the systematic supervision during
health of the families under his care, and in advising them as to
habits or methods of life which are inimical to health.


                     _Poor Law v. Public Health_

An approximation to this ideal was in the minds of the early sanitary
reformers; and it was one of the misfortunes associated with the
deterrent policy of poor-law administration in medical relief, that
separation between Poor Law and Public Health appeared to offer the
best prospect of sanitary progress.

Had Simon’s advice been followed, when the Local Government Board was
about to take over the public health duties of the Privy Council, the
poor-law organization might, and probably would gradually, have been
permeated by public health activities, and thus the sanitary welfare
of the poorest class of the community would have been more completely
safeguarded on its personal as well as on its environmental side.

In his Eleventh Report to the Privy Council (1868) Simon recommended
adherence to the intention of Mr. Lowe’s Nuisance Bill of 1860, which
would have identified the health and destitution authorities. He
deprecated the institution of “a differently planned organization for
objects exclusively of health”; subject to the conditions that public
health should not be subordinate to poor-law work and that there
should be power to combine districts for certain purposes, and action
through committees in sub-areas.

Had this course been pursued, and had the central public health
policy not been preponderantly non-medical and poor-law in sentiment
and tradition, more rapid progress in public health would have been
experienced. The central evil was intensified, as is shown in Simon’s
_Public Health Institutions_, by regarding the medical officer of
the Local Government Board as merely advisory, and by the retention
and extension on a large scale of local inspection by lay officers
of the Central Board, for conditions which needed systematic medical
control.

The problem of the proper relation between destitution and public
health and between the authorities dealing with these, runs right
through our past history of social progress, and it is not even yet
satisfactorily adjusted.

The gradually increasing dissatisfaction with Poor Law administration
led to the appointment of a Royal Commission which after several
years deliberation, in 1909 presented a Majority and a Minority
Report.

The dissatisfaction, which these reports justified, may be said to
have been inherent in the situation; for the Poor Law organization
was constantly attempting,—more or less under the influence of
the principle of “deterrence,”—two incompatible tasks: to prevent
undue dependence upon parochial assistance and to give to those
needing them the medical and nursing assistance which the principles
of preventive medicine require should be given unstintingly, and
completely freed from any deterrent element. Although in many
parochial areas admirable medical work was done, this was the
exception, not the rule; and public sentiment rebelled against the
giving or the receiving of medical assistance to which was attached
the “poor-law stigma.” Both reports recommended the scrapping of the
poor-law machinery by abolishing the present Boards of Guardians and
the general mixed workhouse; and the Minority Report went further,
proposing to complete the supersession of the poor-law by various
preventive authorities, which were already partially in operation.
Thus everything connected with the treatment of the sick would be
transferred to the Public Health Authorities, the care of school
children to Education Authorities, of lunacy and the feeble-minded to
already existing Asylum Committees, and so on.

Behind these proposals lay the principle that _the treatment and the
prevention of disease cannot administratively be separated without
injuring the possibilities of success of both_; and this is a
principle which happily is becoming more generally accepted.

Before the report of the Poor Law Commission was issued, examples of
the application of this axiom existed in the isolation and treatment
of patients with acute infectious diseases; in the increasing
provision for the treatment of tuberculosis; in the extension of
provision for care of parturient women and for their infants; and in
the system of school medical inspection followed to some extent by
treatment.

It is convenient to add here, that under each of these headings,
great extensions have been made since 1911; and an even more
spectacular public provision of treatment, as the best method of
preventing further extension of disease, is exemplified in the
gratuitous and confidential diagnosis by laboratory assistance and
the treatment of venereal diseases now given in every large town in
the country, the Central Government paying three fourths and the
Local Authority one fourth of its cost. In order further to secure
the success of this treatment,—which is provided for all comers with
no residential or financial conditions,—the legislature has passed an
enactment forbidding the advertisement or offering for sale of any
remedy for these diseases, and forbidding their treatment except by
qualified medical practitioners.

It is one of the great misfortunes of more recent Public Health
administration that the Report of the Royal Commission on the Poor
Laws has not hitherto been made the subject of legislation. It
would not have been an insuperable task to find a common measure of
agreement between the Majority and the Minority Reports. Indeed an
adjustment has recently been made between these two reports, as the
result of the deliberations of a House of Commons Committee, over
which Sir Donald Maclean presided; and it may be hoped that ere long
this will mean the realisation of a much belated reform of local
administration.

This forms an indispensable step in the needed further struggle
against the problems of Destitution. So much of destitution is due to
sickness that the separation of the two problems is inconsistent with
success. “One-third of all the paupers are sick, one-third children,
and one-quarter either widows encumbered by young families or
certified lunatics.” There are economic causes of poverty, apart from
sickness, but it is essential to remember that every disease which is
controlled frees the community not only from a measurable amount of
sickness, but from the amount of poverty implied by this sickness.

Had the policy of transfer of the duties of Poor Law authorities to
the Councils of Counties and County Boroughs recommended in 1909 by
the Poor Law Commission been adopted, these last named authorities
would already possess a medical service for the poor employing some
4,000 doctors; they would be in possession of the large infirmaries
and other medical institutions of the poor law, and given reforms and
readjustments of these which are urgently required, and combination
of the hospital arrangements of poor-law and public health, would
have a greatly improved medical service freed from poor-law shackles
and capable of gradual extension as needs and policy indicate. The
fusion of these two services with the school medical service would
have been an easy further step; and England would by this time have
built up a National Medical Service, for the very poor, for all
purposes of public health—including poor-law—administration, and for
children and their mothers in special circumstances.


                    _Insurance v. Public Health_

Political circumstances, into which it is unnecessary to enter, led
to the adoption of a course, which medically ran directly athwart
the course of needed reform. The National (Health) Insurance Act,
1911, was passed, giving sickness and invalidity benefits to those
employed persons below a certain income who could contribute a weekly
sum, which was considerably less than half the estimated cost of the
benefits to be received; and an additional medical service, further
complicating the already existing medical services of the poor law,
public health, and educational authorities, was set up.

The establishment of national insurance against sickness and
disablement in the United Kingdom exemplifies the contagiousness,
under modern conditions of life, of a new course adopted in
any country; and Bismarck’s attempt to counteract socialism by
insurance has been responsible for international, state and official
experimentation in insurance which has not generally been well
advised, and which is associated in England with extravagant cost of
administration.

Insurance against sickness is a praiseworthy and valuable provision
against future contingencies; and on its non-medical side free from
drawbacks. Neither on its medical nor on its non-medical side,
however, is it an alternative to prevention of disease; and the
National Insurance Act in England must be held in the main to have
delayed the public health reform which would have been secured had
equal effort been devoted to it, and the money lavished on insurance
given in the form of central public health grants conditional on the
active coöperation of local authorities. True, the English public
have been educated to think in regard to sickness in millions when
previous provisions for the treatment and prevention of sickness
had been thought of in thousands of pounds; and there has been
an extension of provision for the institutional treatment of
tuberculosis, which probably has been more rapid than would otherwise
have been made, in the absence of the alternative grants named above.
It should be added that, owing to the natural insistence of insured
tuberculous patients on treatment in a sanatorium, and to the desire
of Local Insurance Committees and their officers to satisfy insured
persons, sanatoria have often been filled with unsuitable patients,
sent there regardless of relative social and public health needs. The
Maternity Benefit (of a sum of money on the birth of an infant to
the wife of an insured person or to an employed woman) similarly is
given unconditionally, and should be replaced or supplemented by the
provision of service needed at this time (doctor or midwife, nurse,
domestic assistance), which would ensure the welfare of both mother
and infant.

Apart from other reforms the transfer of medical provision, of
provision for tuberculous patients, and for parturient women to
public health authorities is urgently needed; and the service should
be given according to need irrespective of insurance. The valuable
fund for medical research has already been placed under the Privy
Council.

The absurdity of regarding insurance as anything beyond a possibly
useful handmaiden and auxiliary to Public Health, when strict
administrative arrangements are made for this purpose, may be
illustrated by the question as to what would have been the result in
sanitary progress if Chadwick or Simon had persuaded the government
of their day to insure a favoured section of the public against the
risk of typhus or smallpox or tuberculosis or even of non-infectious
illness?

Under the National Insurance Act medical domiciliary assistance,—but
only to the extent which is within the competence of a medical
practitioner of average ability,—is provided under contract for
one-third of the total population; and evidently this implies an
immense abstraction from ordinary private medical practice. There is
no provision, hitherto, for consultant and expert facilities when
required (except for tuberculosis), for the nursing of patients, or
for institutional treatment of any disease, except tuberculosis; and
no funds are generally available for these purposes except such as
belong to the community at large.

In view of the preceding facts and of other considerations which I
have not mentioned, reconstruction of the English Insurance scheme
is obviously required. The scheme cannot persist in its present
form. The already accomplished amalgamation of the Local Government
Board and National Insurance Commission, should make radical changes
easier; an equally important step would be the transfer of the
medical functions of the Local Insurance Committees to Public Health
Authorities. The creation of these independent committees was one
of the greatest blunders of the National Insurance Act, which was
conceived ill-advisedly, had too short a gestation, and suffered a
premature and forced delivery; and we may hope that ere long, it may
be replaced entirely, on its medical and hygienic side, by a rapid
extension of the medical activities of the public health service
which will conduce to the welfare of the whole nation.

It is impossible to justify the continuance of state subsidisation
of benefits for a favoured portion of the wage-earning classes,
when poorer persons who do not come within the category of employed
persons or who fall out of employment, and when clerks and others on
limited salaries who are unable to provide adequately for sickness,
are left unprovided for.


                    _A National Medical Service_

What is most urgently needed is a national medical service which
will give for all who cannot afford them hospital treatment and
the services of consultants and of scientific aids to diagnosis and
treatment whenever required; and which will provide nurses during
illness treated at home, when this is asked for by the doctor in
attendance.

Outside the operation of the National Insurance Act, these
services have been provided to a steadily increasing extent, but
in a characteristically British fashion. They have grown largely
under voluntary management, and as exemplifications of Christian
philanthropy; though official has rapidly overtaken the voluntary
provision of hospitals and nursing, the two working side by side,
each in their respective spheres, and on the whole with cordial
coöperation. The extent to which institutional treatment with its
more satisfactory arrangements is replacing the domiciliary treatment
of disease may be gathered from the following striking facts:

  In England and Wales

  Of deaths from all causes, in 1881 = 1 in every 9
  Of deaths from all causes, in 1910 = 1 in every 5

  In London

  Of deaths from all causes, in 1881 = 1 in every 5
  Of deaths from all causes, in 1910 = 2 in every 5
  occurred in public institutions.

The facts as to Pulmonary Tuberculosis are even more significant:

  In the year 1911

  in England and Wales 34% of male 22% of female
  and in London 59% of male and 48% of female

deaths from pulmonary tuberculosis occurred in public institutions;
and as each of these patients spent on an average several months in
hospital, at the most infectious stage of their illness, a material
annual reduction in the possibility of massive infection of relatives
and others has been secured.


              _Hospitals Important Housing Auxiliaries_

This institutional treatment of the sick has been one of the chief
influences counteracting the pernicious effects of industrialism and
urbanization. It has relieved housing difficulties at a time when
insufficient bedroom accommodation is most injurious; and it has
secured year by year for a steadily increasing proportion of the
total population the improvements of modern surgery and medicine as
practised in institutions, which permit of the poor thus treated
receiving more satisfactory and more hopeful treatment than is
obtainable for a large proportion of other classes of society.

My address is already too long. Other opportunities will be taken
of explaining the rapidly increasing part which the State and
Public Health Authorities are taking in the hygiene and care of
motherhood and childhood and of school children; in the provision
of additional nursing services for the sick, in the rapid growth
in numbers of public health nurses, health visitors, school nurses,
etc.; in special schemes for the treatment of tuberculosis and of
venereal diseases; and the circumstances under which the Central
Government are to a rapidly increasing extent paying half (or in
certain instances three-fourths) of approved local expenditure on the
provision of hygienic, nursing and medical services; and I do not
therefore dwell on these points further.

Nor need I comment here on the remarkable fact that the British
Government under present circumstances have departed from the
economic position that houses built by local authorities must be able
to be let at a rental covering all outgoings.

In Lecture II I shall deal with problems of local and central
government, and with the training and appointment of medical officers
of health; but the present review, if it omitted from consideration
on the one hand the value of specially trained whole-time health
officers, and on the other hand the health significance of the
general advance in the standard of medical treatment, as factors of
prime importance in securing the already achieved improvement in
human life and health, would give a most imperfect picture of the
actual facts.


                   _The need to avoid Complacency_

Such figures as I have given, showing saving and prolongation of life
during the last fifty years, are apt, if left uncorrected, to create
a complacent warmth tending to public health inertia. It may conduce
further to this folding of the hands when I state that Simon in his
first report to the Local Government Board expressed the opinion that
the half million deaths a year approximately which occurred in 1871
in England and Wales were a third (125,000) more numerous than they
would be if existing knowledge of the chief causes of disease were
reasonably well applied throughout the country; and further that
had the mortality experience during 1911-15 held good for 1871, the
deaths in that year would have been reduced by 200,000 instead of by
125,000, the ideal then aimed at by Simon.

But with increased knowledge we know that a larger proportion of
diseases are preventable than was formerly supposed. It will be easy
within the next ten years to reduce the death-rate by one-third of
its present amount, given systematic and adequate action on the
part of Public Health Authorities and an effective educational
propaganda among the general public. More important still, an even
larger proportion of mankind’s total illness can be avoided, and life
on a higher plane of health secured, as well as life prolonged to
its normal limit. The work carried out during the last ten years,
sanitary, medical and hygienic, in improving the prospects of healthy
child-bearing and of normal infancy and childhood constitute the most
important advance toward national physiological life on a higher
plane which has hitherto been made.

Preventive medicine can never be satisfied until it has approached
Isaiah’s ideal (Isaiah, LXV, 20), “There shall be no more thence an
infant of days, nor an old man that hath not filled his days; for the
child shall die a hundred years old.”


FOOTNOTES:

[1] An address prepared for the celebration of the fiftieth
anniversary of the Massachusetts Board of Health, September, 1919.

[2] The administrative side of the subject is sketched in the next
chapter.

[3] Reprint of Reports, Vol. I, p. 448.

[4] There is still no evidence to show that in the production of the
excessive diarrhœa which prevails in insanitary districts, specific
contamination of the filth accumulations is necessary.




                             CHAPTER II

  THE HISTORICAL DEVELOPMENT OF PUBLIC HEALTH POLICY IN ENGLAND[5]


The subject is too large to be treated adequately in the course of an
evening’s address; and to bring it within manageable compass it is
necessary for me to select my material rigidly and, as far as I can,
to present this material in such a manner as will bring into relief
its salient and most instructive features.

The evolution of public health in England proceeded by experimental
steps, some mistaken and then retraced, others mistaken and not
retraced, but steps oftenest in the direction of a complete service,
which is the goal of our work.

The evolution has been a gradual growth arising out of realized
needs, rather than a logical development based on general principles;
and as politicians and legislators seldom take a wide outlook, or
consider a specific proposal in relation to what is already being
done, and to what is the desired goal, the English experience is
especially instructive.


                  _Town-living and Health Problems_

Public health work became an urgent necessity when men began to
huddle in towns; and with the industrial revolution of the eighteenth
and early nineteenth centuries the need for remedial action became
acute. It is hard to realize that in the days of our grandfathers,
the home was in most instances the unit of industry; and that in
the eighteenth century communications between districts and towns
were not more advanced than those of the ancient Egyptians. When,
however, vast urban aggregations of population multiplied, travelling
facilities rapidly increased, and the results of crowding, of
contaminated water supplies, of intensive and widespread infection,
were seen in devastating endemic and epidemic diseases. Poverty,
squalor, dirt, and their consequences, were rampant in the towns,
where underpaid work-people were exploited by masters, whose
self-centred outlook had some share of justification in the political
economy doctrines of the time, which regarded any interference with
“freedom of contract” as useless or even pernicious.

What is public health work? It is best defined by stating its object,
which is to secure the maximum attainable health of every member of
the community, so far as this can be secured by the authorities,
local, state, or federal, concerned in any part of government, acting
in coöperation with all voluntary agencies whose work conduces to
the same end. The connotation of public health becomes wider year
by year. It embraces physiological as well as pathological life;
being as much concerned with improving the standard of health of
each person as with the prevention and cure of disease. Hence the
importance of the “concentration on the mother and her child” (John
Burns), to secure for them by all practicable means the conditions
of complete health, which during the last twelve years has been
a vital part of our public health work, and which is now being
made to include not only all hygienic and medical help that may be
needed, but also such domestic aid as may enable the mother to bring
her children into the world and to rear them under advantageous
conditions.


                 _Scope of Constructive Health Work_

Public health embraces some eugenic elements, and may comprise more
when eugenists have accumulated adequate non-fallacious evidence on
which to base valid conclusions. Already partial steps are being
taken to secure the segregation and prevent the propagation of the
feeble-minded and the insane; and in sorting out congenital infection
from true heredity action is being taken to avoid congenital syphilis
and to prevent the large number of still-births due to this race
poison.

Public health in the main is concerned primarily with the
environmental measures calculated to prevent the attack of man by
disease, whether pre-natal or post-natal. These measures may be
industrial, as in the prevention of accidents, of dust, of noxious
vapours; or sanitary, as in the control of water supplies, food, or
milk, and in the removal of organic filth; or may be the application
of preventive medicine against infectious and non-infectious
diseases; or therapeutic, consisting of the prompt and adequate
treatment of all illnesses and the curtailment of the incompetence
due to them; or educational, consisting, first in importance, in
the training of medical practitioners, of public health officials,
and nurses; and, next, in the education of the general public and
especially of the children in our schools, in the science and
practice of public health.

Advances in public health in many directions can only be secured
by continued and extended medical research, and public health,
therefore, has a direct and immediate interest in promoting and
subsidizing such research.

These being the objects of public health, how far have we travelled
toward securing the end in view? I do not propose to myself the
pleasant task of showing to what extent the general death-rate
has been lowered, infant and child mortality greatly reduced,
the duration of life extended, how typhus and smallpox have been
almost eradicated, typhoid fever made a disappearing disease, and
tuberculosis has become the cause of only half its former death rate.
When inclined to indulge in such pleasant considerations, I recall
the statement I have made elsewhere that one-half of the mortality
and disablement still occurring at ages below seventy can be obviated
by the application of medical knowledge already within our possession.

Let me attempt the more difficult task of outlining the history of
forms of administrative control of disease since 1834.


                 _Reform in the Control of Poverty_

Poverty and disease work in a vicious circle in which cause and
effect often change places; but it is certain that disease is one of
the most fertile causes of poverty, using the word poverty in the
sense of privation of one or other essential of physical well being.

For this reason, and because the half starved form a constant
social danger, poor-law administration long antedated public health
administration. There is not time to follow the course of earlier
poor-law administration, with its many and grievous abuses. The
Poor-Law Amendment Act of 1834, gave the Central Government control
over the systems of local relief, secured the combination of parishes
into unions for poor-law relief,[6] and forbade outdoor relief to
able-bodied men. The creation of an organ of central control has
led to the subsequent course of aid to paupers being determined in
the main in London, action of poor-law guardians being subject to
supervision by government inspectors, and to endorsement by the
Central Authority. At first, medical assistance under the reformed
Poor Law was made as deterrent as non-medical relief; and although
there has been much improvement, chiefly on the institutional side,
medical treatment under the Poor Law has to some extent retained this
deterrent element, and it has, except in the poor-law infirmaries of
large cities, remained generally disliked by the people concerned.

The first Central Poor-Law Authority was a Commission having no
representative in Parliament. In 1847 it was replaced by a Board, the
president of which was a member of Parliament and of the Government.
Here once for all Parliament declared its intention to maintain
direct control of central official government, and in this and in
all other departments has done so. If democracy is to be real,—and
we have no sound, practicable alternative to it,—evidently the
representatives of the people must be masters of the administration;
and English policy has never wavered on this point. After many
years’ experience of public life in England, I have no hesitation
in saying that this principle is sound; that it insures progress
which, although slow, is less liable to relapse than administration
under autonomous expert commissions, whether centrally or locally;
and that any lack of progress that has been experienced in central
government has been as much the result of inactivity and of lack of
sympathy with social reform on the part of the permanent officials
of government departments who have had access to their parliamentary
chief, as of the inertia of politicians or their obstruction to
reform.

Dissatisfaction with Poor-Law administration has steadily increased
in the years since 1834, as the problem of the able-bodied pauper has
diminished and the Poor Law has been concerned more and more with
the sick and infirm, the aged, and children. These at the present
time form some 98 per cent. of the total population relieved. The
fundamental principles of the Poor Law were rightly attacked. It
did not comprise elements tending to build up disabled families, or
to prevent families from falling hopelessly and permanently into
destitution. The law was administered almost entirely with a view to
_relief_; practically not at all as a _curative_ agency. In medical
language, symptomatic and not rational causal treatment was the rule.

In medical relief, poor-law administration has been a constant
struggle between increasingly humane treatment and the conception
that the pauper’s position must remain inferior to that of the
non-pauper; an important principle when applied to the able-bodied
adult who has drifted into willing dependence; mischievous when
applied to sick persons, and to dependent women and children.

The general dissatisfaction with poor-law administration led to the
appointment of a Royal Commission on the Poor-Laws which, after
several years’ deliberation, published in 1909 a majority and a
minority report. Both these reports recommended the abolition of
boards of guardians, and the transfer of their duties to the 144
largest public health authorities in the country (County Councils,
44; and the Councils of county boroughs, 82), and the abolition of
the general workhouse. The majority report would have continued
the Poor-Law Guardians as a Committee of the new Authority; the
minority report proposed to distribute the duties of the guardians
to different committees of the Public Health Authority; thus medical
treatment to the Public Health Committee; the care of lunacy and
the feeble-minded to the Asylum Committee; care of children to the
Education Committee; vagrants, etc., to the Police Committee; a
special committee concerning itself with all questions of monetary
assistance.

A compromise between these two schemes has recently been arranged,
and when the new Ministry of Health, which will combine public
health, poor-law, insurance, and educational medical work in one
department, has found time to do urgently needed work, the above
indicated reform may be hoped for, along with the even more
urgently needed reform of local public health administration, and
the abolition of a large number of the smaller and less efficient
sanitary authorities. With these reforms will come much needed
de-centralization of poor-law work. Good work in all respects cannot
be secured if the Central Authority concerns itself, as at present,
in minutiae of local administration, and has no time to devote itself
to the larger problems, and to the task of bringing indifferent,
chiefly smaller authorities, up to the standard of efficient local
authorities. A large portion of the expense of local poor-law
administration is borne by the central exchequer, and this money if
properly applied will give the necessary leverage for reform, while
leaving progressive Authorities, and especially the Authorities of
large towns, free to experiment and advance.


                        _Reform in Industry_

The industrial revolution meant the subjection of large masses of
working class families to evil conditions of housing and work in
crowded and insanitary dwellings and factories. The public conscience
first rebelled in regard to boarded out and apprentised pauper
children; and the first Factory Act in 1802 concerned itself with
them; and with this Act emerged the germ of machinery for securing
compliance with the law, magistrates and clergymen being appointed as
inspectors under the Act.

The Act was largely futile; but it meant the beginning of the gradual
breaking down of _laissez faire_ doctrines; and there followed a
more widely operative Factory Act in 1833, restricting hours of
labor of children, and initiating professional inspectors controlled
and paid by the Government. In 1842 the underground employment of
women in mines was forbidden; and at intervals since then numerous
factory and allied acts have been passed, restricting the duration
and conditions of work of women and children, improving rules as to
sanitation, insuring systematic inspection by government inspectors,
and constituting a far reaching system of supervision and control.

The inspectors, on whom falls the burden of ensuring compliance with
the Factory Laws and regulations made under them, are controlled by
the department of the central government known as the Home Office;
their work on the whole has been well done, and the conditions of
factory and workshop life have greatly improved. Some portion of
the sanitary supervision of these work-places falls on the local
Sanitary Authority; but in the main the system is one of absolutely
centralized government control. This secures almost complete absence
of improper influence of interested local persons, whether masters or
workmen; but it is arguable that this system should be replaced by a
localized system, the inspectors being officers of the 144 larger
authorities. These local officers could be placed in direct touch
with the Home Office or the Ministry of Health and with the central
staff of inspectors having expert knowledge in the different branches
of industrial work.


                       _Public Health Reform_

Public health reform was a direct consequence of the Poor-Law
Amendment Act, 1834. Anxious to diminish the enormous expense of
the existing Poor Law, and realizing that a large share of this
sickness was due to fever and other illnesses, surveys and inquiries
were set on foot by the commissioners administering this Act, and
the reports which followed revealed a state of things urgently
calling for sanitary reform, in the interest of national economy
as well as of health. “An Act for Promoting the Public Health” was
passed in August, 1848, which created a General Board of Health
consisting of four members and a secretary. These Commissioners,
among whom was Edwin Chadwick, former Secretary of the Poor Law
Board, initiated a system of procedure which was largely on the lines
of poor-law action, and which involved constant pin-pricking by the
Central Authority of the grossly indifferent local authorities. The
commissioners were more zealous than discreet; and after six years
they were no longer tolerated. At that time centralization was as
much a bogie as socialism has become in more recent years. Parliament
and the localities represented by its members doubtless feared
the reforming activity of Chadwick and his colleagues, though they
sheltered themselves behind their exaggerated fears of bureaucracy
and centralization.

A new board replaced the old, parliamentary in character, its
president being a member of the Government. This repeated, so far as
concerns Parliamentary headship, the story of the Poor-Law Board,
and established once more the theory of the administrative control
of the representatives of the people. Nor, although the change meant
for the time serious slackening in sanitary reform, can objection be
taken to it. In a democratic government the elected representatives
of the people must take first place; and it is the rôle of officials
to educate them in the direction of needed reforms. Reforms which do
not carry public opinion with them are not likely to be permanently
successful; and, whether in administration or in legislation,
attempts to sidetrack or ignore this fact are not likely to be
permanently effective.


                       _Public Health Reforms_

When the Local Government Board was formed in 1870, a second
opportunity was lost of developing Public Health Administration on
lines which we now know to be the best adapted for a complete service
of preventive medicine. The first lost opportunity was when sanitary
authorities, completely separate from poor-law authorities, were
created for administering the sanitary laws. Probably this arose
from Chadwick’s despair of getting effective sanitary reform from
poor-law guardians; but the creation of separate authorities was
scarcely consistent with the fact recognized by him that pauperism
is largely, if not predominantly a question of sickness; or with the
less recognized fact that its treatment forms an essential part of
prevention. It was recognized that the care of the sick was largely
idle until the unnecessary causes of disease had been cut off, but
not that the adequate treatment of sickness is an important means
of preventing it or of curtailing it. Rumsey,[7] in 1856, stated
the unrealized possibilities of the poor-law medical officer’s
domiciliary attendance on paupers in the following words:

 There are much higher functions of a preventive nature than those of
 a mere “public informer” which the district medical officer ought to
 perform. He should become the sanitary adviser of the poor in their
 dwellings ... he (should) be in a peculiar sense, the missionary
 of health in his own parish or district,—instructing the working
 classes in personal and domestic hygiene,—and practically proving to
 the helpless and debased, the disheartened and disaffected, that the
 State cares for them, a fact of which, until of late, they have seen
 but little evidence.

In the result the _ad hoc_ poor-law authority did not absorb into
it the newly created municipal and urban and rural sanitary
administration, but continued on its separate path.

Simon, in 1868, had urged the inadvisability of continuing _ad hoc_
authorities, and had urged that, at least, sanitary should be made
coterminous in area of administration with poor-law districts. His
advice was not adopted, and there followed years in which sanitary
authorities were allowed to subdivide areas, until the total number
became 1,807 instead of 635, the number of poor-law authorities;
and in which they concerned themselves chiefly with nuisances and
water supplies and with inadequate provision for the prevention
and treatment of infectious diseases. With the creation of county
councils and the more complete autonomy of the councils of county
boroughs, the large centres of population developed and improved
their sanitary administration more rapidly; and it became practicable
to undertake every division of sanitary work on an efficient scale.
Although much remains to be done, it can be claimed that in our
larger towns, containing more than half of the total population
of the country, the public health work in nearly all its branches
is of a high order. It would have been still more efficient had
the poor-law guardians been merged in the Town Council, and had
the relationship between the school medical service and the other
branches of the public health service been closer than has been the
case.

What is now needed is that the defects just named should be
made good; that more complete autonomy should be given to the
authorities which come up to a required standard, and that
especially they should have greater freedom in developing local
possibilities of improved administration. Central grants in aid of
local sanitary administration are steadily increasing. Already the
Government pays one-half of local expenditure on a large program
of maternity and child welfare work, one-half of the expense of
local tuberculosis work, and three-fourths of the expense of local
work for the diagnosis and treatment of venereal diseases, and for
propaganda work concerning these. These grants should be the means
of greatly increasing good local administration; but if,—this is
improbable,—they curtail local experimentation and extension, and
bring local public health administration into anything approaching
the subservience of local poor-law administration, the value of these
subventions will be doubtful.


                 _Education Authorities and Health_

The national system of compulsory elementary education inaugurated
in 1870 has had valuable indirect influence in promoting the public
health. Apart from the beneficent effect of education, the steadily
increasing pressure on children to come to school in a cleanly
condition and the stimulus of emulation in tidiness and cleanliness,
have done much to improve the home conditions of the people.
After the South African war much attention was drawn to the large
number of recruits rejected owing to physical disabilities; and an
inter-departmental committee reported _inter alia_ in favour of a
system of medical inspection of pupils in elementary schools, which
had often been urged by hygienists. Observations made in Glasgow
and Edinburgh by Leslie Mackenzie did much to draw attention to the
physical defects in Scottish school children. In 1907 the Board
of Education acquired power to make provision through the local
education authorities for the medical inspection and treatment of
school children. At first little more than inspection of pupils
was undertaken, a large number of defects of sight, hearing,
parasitic conditions, as well as malnutrition and actual disease
being discovered. Gradually some items of treatment were undertaken
at school clinics, or at hospitals or centres subsidized by the
education authorities; though the amount of treatment is still small
compared to the defects discovered and not otherwise treated.

But there now existed in every locality three authorities concerned
in the treatment of disease:

1. Poor-law guardians, treating all forms of illness in paupers, at
home and in institutions.

2. Public health authorities, undertaking preventive measures against
disease, and treating fevers, tuberculosis, and occasionally other
diseases in institutions; and more recently providing nurses at home
for certain conditions.

3. Local education authorities, concerned in treating certain
ailments in school children.

Centrally two government departments were supervising this work, and
subsidizing it to some extent from government funds; and poor-law
medical work and public health medical work were supervised by two
divisions of the Local Government Board acting in almost complete
isolation. More recently Parliament has permitted the Board of
Education to give grants in aid of schools for mothers, and allied
institutions for the care of children under school age; for which
institutions, substantially, the Local Government Board in other
instances was giving grants.

The separation of the medical work of Education Authorities from
public health medical work was contrary to the first principles
of sound administration; although it is possible that, owing to
the inertia in some public health circles, this separation at
first favored rapid advance in school hygiene; just as the early
development of public health apart from poor-law administration was
probably more rapid than could have been expected from centrally
ridden local authorities, concerned chiefly in keeping down the poor
rates.


                          _The Ad Hoc Vice_

But in both instances there was an offence against the first
principles of good administration, which require that when a special
function is to be undertaken it shall be undertaken by one governing
body for the whole community needing the service, and not for
different sections of the community by several governing bodies.
Medical treatment is needed for school children and for the poor
generally. Why separate this into two administrations? Hospitals are
required for paupers with tuberculosis, and for non-paupers with
tuberculosis. Why have two authorities for this work? The separate
existence of Education and Poor-Law Authorities _qûa_ medical
attendance on those children needing it erred, not only in this
fundamental respect, but also because neither of these authorities
had the preventive facilities and powers possessed by Public Health
Authorities, who were also partially engaged in the treatment of
disease.

The inveterate tendency in the past has been to create a new
authority when any new work was inaugurated, this authority then
fulfilling all purposes for a special portion of the community
and thus necessarily duplicating the staffs of other departments
of local or central government. The crowning instance of this
recurring instance of legislative myopia is seen in the case of the
National Insurance Act, under which has been provided an imperfect
and unsatisfactory domiciliary medical service for one-third of
the entire population of Great Britain, when by combining and
extending the medical forces of existing departments of the state, a
satisfactory service for all needing it would have been secured. The
axiom that “the object of community service is to do away with group
competitions and bring in its place group coöperation or team work”
(Goodnow), is especially applicable to all public health and medical
work; and the spirit of this axiom is infringed by the existence of
separate, sometimes competing, occasionally conflicting, services
under separate local and central control.


                  _Principles of Local Government_

The preceding considerations bear on the perennial problem of
efficient government, local and central. There are three functions
to be performed in government, legislation, determination of
administrative policy and extent of work, and the actual executive
work. In England, legislation is in the hands of Parliament and is
usually national in scope. Large cities, however, not infrequently
obtain special legislative power to meet local needs; and by this
means have succeeded in advancing local efficiency above the average
standard. Local authorities, furthermore, have the power to make
regulations and by-laws for special purposes, subject to the approval
of the Central Authority.

In settling the details of local administration, the elected
representatives of the public are supreme. They meet in Council, and
action is taken on a majority vote. The councils of counties and
cities, and even of smaller municipal boroughs divide themselves into
committees, each consisting of about a dozen members, elected by vote
of the whole Council. The chairman or mayor of the Council has no
special power, except that he may give a casting vote.

The chief defect in local sanitary administration in England is
the continued existence of a large number of small and relatively
inefficient local authorities. The larger authorities, as a rule,
do their work well, and politics enter but little into elections.
Official posts are not vacated with changing councils. These councils
are approximating to the ideal of a complete local Parliament dealing
with all governmental concerns, and to the further ideal that each
unit of government should be large enough to minimize the influence
of local interested motives, and to undertake each department of
municipal work on a considerable scale. The local Parliament has
committees concerned with police, finance, public health, education;
and when the urgently needed poor-law reforms are made, and when the
Education Committee hands over its medical work to the Public Health
Committee, the ideal will become a fact.

Power is already given to coopt on to some of these committees a few
persons who are not members of the Council, from among men or women
having special knowledge of the Committee’s work; and the exercise of
this power has been found to be useful.

But in each committee it is the direct representatives of the
public who decide points of policy and settle the main outlines of
administration. There is growing up a tendency to appoint local
advisory committees, consisting of special groups representing
professional or trade interests. Thus a medical committee may
be consulted on medical proposals, and so on. This is still
in the experimental stage. It will probably prove permanently
useful, as voicing the occupational aspect of any proposed work
of the municipality; but it will need to be kept to its strictly
consultative limitations, and the responsibility of the Council as
representing the combined wisdom or unwisdom of the entire community
must be maintained.

All substitutes for government of the people by the representatives
of the whole population are open to objection. They do not contain
within them the elements of permanence. If there is a corrupt
council, the remedy is not its supersession by an independent
executive. Such an executive is the abrogation of popular government.
“Good and efficient government is possible under almost any form
of organization. More depends upon men than devices.... But ... if
we believe that the functions of deliberation or determination of
municipal policy and of administration or the execution or carrying
out of that policy should be kept distinct, we cannot avoid the
conclusion that a city council is a necessary part of the municipal
organization.”[8]

Each committee of the local Council is advised by the County Clerk
or Town Clerk on legal and administrative matters; and the medical
officer of health and other expert officers, like the legal adviser,
in nearly every instance, hold office during good behaviour. Under
the above arrangements the elected members and the officials are
kept in touch with each other. The latter’s recommendations and
actual work must be approved by the former; and this works well under
the system of determination of policy by committees, subject to
confirmation and control by the entire Council. The motive power is
public opinion. Good work cannot for any prolonged period go beyond
what the public demand, and the work of officials is one of constant
education of their masters and of the public.


       _The Training and Tenure of Office of Health Officers_

Every sanitary district is required to appoint a medical officer of
health and since 1888 every medical officer of health for a district
with a population exceeding 50,000 must have a special diploma in
public health. The enforcement of this requirement has done much
to raise the standard of work of these officers. It is significant,
furthermore, that while in 1873 the percentage of the total
population of England and Wales having whole-time medical officers
of health was only 20.6, it had increased to 61.4 per cent. in 1911.
In the metropolis, in the whole of Scotland, in every English county
(forty-four) and in many other districts these officers possess
security of tenure, in the sense that they cannot be removed from
office without the consent of the Central Government, which usually
pays half their salaries. Even without this safeguard, removal from
office by the local authority is rare; but there has been long delay
in securing the further reform that in all areas the medical officer
of health should be able to perform his difficult and sometimes
obnoxious duties without fear of removal from office, or of reduction
in his emolument, except as the result of deliberate action on appeal
to a central authority.

When pensions can be earned by medical officers of health and by all
medical men on the public health staff, their position will become
more attractive for men of good standing; and this reform has become
more important in view of the steadily increasing complexity of the
medical work now undertaken in a large public health department. It
will include _inter alia_ the following officers and activities:
superintendent medical officers of health; district medical officers
of health; tuberculosis officers; medical officers of maternity and
child welfare centres, of venereal disease centres; fever hospitals,
and tuberculosis sanatoriums and hospitals.

The development of a graduated public health medical service in which
each physician employed will be able to develop his own special
abilities, will be easier when to the above list is added the work
of district (late Poor-Law) medical officers; medical practitioners
attending insured persons and such other persons as are treated at
the expense of the State; treatment centres for special conditions of
the ear, eye, throat; gynecological and other special departments;
hospital treatment for general diseases.

That there will be development in these directions when the tangle
caused by the National Insurance Act of 1911 has been unravelled,
there can be no doubt.

I have in Lecture IV expressed my opinion as to the additional tangle
introduced into the central and local government of the United
Kingdom by the National Insurance Act of 1911.

The failure of the British Government to act on the recommendations
of the Poor-Law Commission of 1909 was a serious misfortune to public
health. Sickness is the cause of a predominant part of our total
destitution, and to allow the continued separation of administrative
action respecting these two problems is inconsistent with a full
measure of success. Political circumstances, however, led to the
adoption of a course which, medically, ran directly athwart the
course of needed reform.


           _The National Insurance Act and Public Health_

The National Insurance Act was passed, placing one-third of the
total population (all employed manual workers and other employed
workers with an income below £160, since increased to £250) under an
obligation to pay 4d weekly (women 3d), 3d being contributed for each
person by the employer and 2d by the State. In return each worker
receives a money payment weekly during disability from illness,
attendance by a doctor, sanatorium treatment for tuberculosis, and a
maternity benefit on the birth of a child to his wife (30 shillings),
or, if the wife also is industrially employed, an additional 30
shillings. The medical benefit is limited to such domiciliary
attendance as a medical practitioner of average ability can furnish.
It continues the old popular conception of private medical practice,
and allows the public to remain obsessed with the notion that
satisfactory medical care consists in a “visit and a bottle.” No
provision is made for pathological aids to diagnosis, beyond what
is already provided by public health authorities. No nurses are
available for serious cases; the insured person is not entitled to
surgical operations, when needed, except of the simplest character.
With few exceptions, no appliances are provided; the treatment
of special diseases of the eye, ear, nose and teeth is commonly
excluded. No hospital provision whatever, except for tuberculosis, is
made.

The contract system of medical practice has been accompanied by a
serious amount of lax certification of sickness. The sanatorium
benefit is unnecessary, as soon as the duty of public authorities
to provide treatment for tuberculosis is declared obligatory. It is
already very largely provided. The maternity benefit is entirely
unconditional; there is no guarantee that it is devoted to the
welfare of the mother and infant. It needs to be supplemented or
replaced by the arrangements for providing nurses, doctors, midwives,
and domestic assistance which are in process of development by
public health authorities. In short, there is no justification for
providing medical services, preponderantly at the expense of the
state (contributions by employers are a form of taxation), which are
limited to a favored portion of the total population, and which do
not benefit all in need of these services.


                      _Provision for Sickness_

The principle of monetary insurance against sickness and disability
is thoroughly sound. It forms a praiseworthy and valuable provision
against future contingencies. Insurance, however, is not synonymous
with prevention as is too often suggested. In England insurance
has been an actual impediment to public health work, though it
might have gradually become a useful auxiliary to it if otherwise
organized, and especially if the creation of independent insurance
committees representing interests to a preponderant extent had been
avoided. But any medical service needed for purposes of insurance
should not form part of the insurance system. Medical aid is needed
for a large section of the population who are unable to afford
deductions from their wages, or who have no wages. It is needed for
wives and children as much as for the industrially employed head of
the household; and it is needed for many others who are excluded
from the scope of the National Insurance Act. Only when the medical
is separated from the insurance service, and when the medical
practitioner, as far as practicable, is made independent of the
patient who desires too facile a sick-certificate, will good medical
work and sound sickness insurance be secured.


                          _General Summary_

The preceding review of the history of public health in England
is necessarily fragmentary. It does not include, for instance, a
discussion of the relationship of the medical profession to public
health authorities. On this I content myself with repeating my oft
stated opinion that until every medical practitioner is trained
to investigate each case of illness from a preventive as well as
from what is often rather a pharmaceutical than a really curative
standpoint, until a communal system of consultant and hospital
services independent of any insurance system is made available for
all needing it, and until every medical practitioner is related by
financial and official ties to this communal system, full control
over disease,—to the extent of our present available medical
knowledge,—will not be secured.

The communal system will include not only the provision of
domiciliary nurses for all needing them, but also a greatly increased
staff of public health nurses engaged in educational supervision
in connection with the work of the communal services and of each
individual practitioner. Such a system will repay the community
manifold in improved health and in a higher standard of happiness and
well being.

If objection is taken to such wide sweeping proposals, let me remind
you that free communal services of sanitation and education are
already provided; and that the care of personal health is of equal
importance with these. All will agree that a large proportion of the
population cannot afford to pay individually for medical attendance
and nursing under present conditions, still less for the consultant
and hospital services which advances in medical service have rendered
indispensable. There is always present in our midst a large mass of
illness which might have been avoided or curtailed, had there been
an organized system of state medicine.

Lest there should be alarm as to the possible consequences of the
coöperative provision on such a scale of this primary need of
humanity, let me also remind you that coöperative medical aid differs
from financial aid in an essential particular. It does not create a
demand for further aid, but is always engaged in diminishing this
demand. Dependency on financial assistance is liable to continue
indefinitely; much wants more. This result of medical aid is almost
inconceivable. The Reverend Doctor Chalmers, of Glasgow, said early
in the last century: “Ostensible provision for the relief of poverty
creates more poverty. An ostensible provision for the relief of
disease does not create more disease.”

Doctor Chalmers was opposed to the giving of any domiciliary
assistance from rates or taxes, and he organized his parish so that
every needy person was adequately helped out of charitable funds. But
he advocated extended hospital and other medical assistance for the
poor; and until this is done, apart altogether from any system of
insurance, and as a complete measure on the lines of our educational
system, we cannot say that all that is practicable has been done to
secure the physical well being of our fellow citizens.


FOOTNOTES:

[5] An Address at the Forty-seventh Annual Meeting of the American
Public Health Association, New Orleans, October 27, 1919.

[6] The importance of this is seen in the fact that there are in
England and Wales 14,614 parishes, and only 646 unions for the relief
of the poor.

[7] Rumsey: Essays in State Medicine, 1856, pp. 190, 277, 282.

[8] Goodnow: Municipal Problems, p. 226.




                             CHAPTER III

             THE INCREASING SOCIALIZATION OF MEDICINE[9]


Medicine has always been the most altruistic of learned professions;
and can proudly claim that its practitioners have ever been ready
to give gratuitous assistance to all in need of it. Even more than
when Burton wrote his Anatomy of Melancholy—for then medicine was an
art with but limited foundation in science—physicians can be defined
as “God’s intermediate ministers”; and can rightly assume the proud
position which Burton gives them:

 Next, therefore, to God, in all our extremities (_for of the Most
 High cometh healing_, Eccles. XXXVIII, 2) we must seek to, and rely
 upon, the Physician, who is the _Manus Dei_ (the Hand of God), said
 Hierophilus, and to whom He hath given knowledge, that he might be
 glorified in his wondrous works.

Each medical practitioner in his own circle, and to the extent of
his medical competence, is a medical officer of health, having more
influence in directing and controlling the habits, occupation, the
housing, the social customs, the dietary and general mode of life
of the families to which he has access, than any other person. It
must be added that in most instances he has even more influence
than the minister of religion in regulating the ethical conduct of
his patients, especially as regards alcoholism and sexual vices. In
the United States the federal government has relieved the medical
profession from their duty of restricting individual alcoholic
consumption, and an experiment has been begun which if continued—and
I trust nothing will prevent this—must forthwith reduce the income of
practising physicians throughout the American continent, and at the
same time do more to diminish crime, accidents and sickness and to
increase national efficiency than any other single step that could
be taken, with one exception. This would consist in the universal
raising of the standard of sexual conduct of men to that which they
expect from their future wives, thus securing a rapid reduction and
early disappearance of gonorrhoea and syphilis, diseases which rank
with pneumonia, tuberculosis and cancer as chief among the captains
of death and disablement in our midst.

The growing possibilities of improvement in personal and social
welfare depend very largely on the extent to which, as I have put it
elsewhere, “each practitioner becomes a medical officer of health in
the range of his own practice.” Even on their present record, if—at
least on one side—the Kingdom of God consists in “the union of all
who love in the service of all who suffer,” medical men can proudly
and yet humbly take their place as essential agents in the daily
fulfilment of the daily prayer, “Thy Kingdom come.”

It is perhaps desirable to attempt at this stage a definition of
the sense in which I employ the term socialization of medicine. In
it I would include the rendering available for every member of the
community, irrespective of any necessary relation to the ordinary
conditions of individual payment, of all the potentialities of
preventive and curative medicine. Within the scope of medicine
are included the basic sciences of physiology and pathology; and
the instruction and training of every child and young person in
elementary hygiene, including dietetics, necessarily come also within
the range of our subject.

There are still agnostics, usually of exclusively classical and
mathematical education, even among men holding official sanitary
administrative positions, who doubt the value of the application of
medical knowledge to the extent indicated; and it becomes desirable,
therefore, briefly to refer to some results already obtained by the
application of preventive and curative medicine.


                 _The Past Achievements of Medicine_

The increasing span of life is scarcely realized as it should be.
Addison’s description of the bridge of human life, in his Vision
of Mirza, is familiar. Its seventy to a hundred arches support a
bridge which is interrupted by broken arches and hidden pitfalls,
set very thick at the entrance of the bridge, thinner towards its
middle, but multiplied and laid close together towards its further
end. Preventive medicine is gradually repairing the broken arches of
earlier life; with the prospect of rapid reduction of tuberculosis,
of syphilis and gonorrhoea, the removal of pitfalls and the repair
of both earlier and middle arches are ensured, if the knowledge we
already possess is applied; and although pneumonia and cancer still
erode and render unsafe the arches of middle and later adult life, we
have already advanced far towards the ideal of euthanasia in old age.

I may be excused from quoting English figures, as our vital
statistics are more accurate and complete than those hitherto
available for the United States. Parenthetically, may I say that it
is a continual source of astonishment to me that in some American
states death statistics, and in many more states birth statistics
should still be so dubious in their quality as to cause hesitation
in utilizing them. And this in a country which in other respects
combines the highest business qualities with an underlying idealism
which emerges in important crises!

Between 1871-80 and 1910-12 in England the average expectation of
life at birth for males increased from 41.4 to 51.5, for females from
44.6 to 55.4,—an increase within three or four decades of 10 or 11
years in average duration of life. The annual saving of life shown by
these figures means that the persons whose lives _each year_ are thus
saved in England from premature death, have the prospect of living in
the aggregate nearly ten million additional years of life, of which
the greater part will be lived during the working period of life.

But perhaps more striking than collective statistics are the
illustrations of unnecessary premature mortality with which history
and literature in the Georgian and Victorian period supply us. Many
such instances will occur to you. William Pitt died at the age of 47,
Charles James Fox at 57. The history of the Brontë family, given the
clue that tuberculosis was at work, can be seen on the tablet which I
have often read in Haworth Church. Each sister and the brother died
in steady succession at intervals of two and three years; the only
exception being Charlotte, who had lived much away from home, and who
died at the age of 39 of unrestrained vomiting, a condition which
probably would not have been allowed to kill the expectant mother
today. Robert Burns died at the age of 37, Keats at the age of 26.
Lord Byron on his thirty-third birthday, only three years before his
death, wrote as a man already “in the sere and yellow leaf”

  Along life’s road, so dim and dirty,
  I’ve travelled till I’m three and thirty;

  And what has this life left for me:
  Nothing but my thirty-three.

Did time permit, the claims of preventive medicine might be
illustrated in the facts as to the almost complete annihilation
of typhus fever in this country and in Great Britain, under the
influence of hospital segregation of each case, of supervision
of contacts, and of increased national cleanliness; in the rapid
reduction of enteric fever brought about by pure water and milk
supplies, the avoidance of sewage-contaminated shell-fish,
the control of carriers among food handlers, and the hospital
immobilization of cases; and in the almost complete abolition of
smallpox, secured by prompt recognition, notification and isolation
of each case, the searching out and vaccination of all contacts,
and their continued surveillance. The list of medical triumphs,
especially in tropical diseases, might easily be extended. I do
not fail to remember that respiratory infections have hitherto
proved refractory to preventive measures; and that common catarrh,
pneumonia, and still more influenza—as also cerebro-spinal fever
and poliomyelitis—constitute territories on which the flag of
public health has not yet been firmly placed. Tuberculosis must not
be thought of in the same category. It is a controllable disease,
so soon as physicians, public health authorities and the patients
themselves will combine on an adequate scale to adopt measures
already within reach. These measures will be less costly than the
present position of partial inertia; health is always less costly
than disease, and, as Dr. Herman Biggs has often reminded us, can
be purchased within natural limits, to the extent which we really
desire. This is preëminently true for tuberculosis.

Medical triumphs have not been restricted to preventive medicine.
Time would fail me to speak of the introduction of general
anaesthetics by Morton and Simpson, which has rendered possible
the reaping of the full harvest of the work of Pasteur and Lister.
Conversely modern surgery has itself abolished more pain than
anaesthetics themselves.

The chief triumphs of modern curative medicine and surgery have been
rendered practicable by the more accurate study of disease and the
more skilled attention for the masses of the population obtainable in
hospitals. The steady advance in the provision of skilled nursing has
kept pace with medical advance.


                _Increasing Importance of Hospitals_

From a return prepared by the Local Government Board in 1915 it
appears that the number of hospital beds in England and Wales (not
including lunatic asylums, tuberculosis institutions, or convalescent
or nursing homes) was 4.9 per 1,000 of the population. In the United
States, according to the Modern Hospital Year Book for 1919, the
number of hospital beds amounts to 6 per 1,000 of the population,
or 3.4 per 1,000, excluding beds for mental and nervous cases. It is
not certain that the two sets of figures are comparable; but in both
instances the distribution of hospital provision is very unequal,
and large tracts of each country are left unprovided with available
hospital accommodation.

Hospital services have grown in a manner which is characteristic
of the Anglo-Saxon: first largely under voluntary management, and
as examples of Christian charity; afterwards continued in the same
way, but followed by official provision of hospitals on an even
larger scale, the two systems working side by side. The extent to
which the more satisfactory institutional treatment is replacing the
domiciliary treatment of disease may be gathered from the striking
facts that in England and Wales one in every nine of the deaths from
all causes in 1881 occurred in public institutions, and in 1910, one
in every five; while in London the proportion increased from one in
five in 1881 to two in five in 1910.

The facts as to pulmonary tuberculosis are even more significant.
In the year 1911 in England and Wales 34 per cent. of male and 22
per cent. of female and in London 59 per cent. of male and 48 per
cent. of female deaths from pulmonary tuberculosis occurred in public
institutions. As each of the patients, who thus had the solace of
good nursing and treatment when they were needed most, spent on an
average several months in hospitals, at the most infectious stage of
their illness, an important annual reduction in the possibility of
massive infection of relatives and others has also been secured.


      _Hospitals as a Partial Solution of Housing Difficulties_

We may fairly claim that general and special hospitals have been
important agents, not only in reducing the fatality of disease,
and in restoring to efficiency more rapidly than in the past a
large proportion of the total population; but also in reducing the
incidence of tuberculosis, of syphilis, and of other diseases.

The public indebtedness to hospitals has another aspect, too
often overlooked. The aggregation during the last hundred years
of a steadily increasing proportion of our population in crowded
towns has meant the introduction on a gigantic scale of elements
inimical to health. Smoke and obscuration of sunlight, dust and
noise, the substitution of indoor for outdoor occupations, the
difficulties of milk supply for children, and above all inferior
housing with associated increased facilities for infection, have
combined to render healthy life in towns difficult of attainment.
Nor must we omit from the adverse side of the balance sheet the
greater loneliness of family life in towns, the diminution in
neighbourliness, and the failure of public social opinion to produce
the wholesome effect on conduct which it exercises in village
life. And yet, notwithstanding these factors, urban death-rates and
especially tuberculosis death-rates have declined more than rural
death-rates, and in parts of some countries urban is even lower than
rural mortality.

Why is this? Our hospitals provide the key to the mystery.
Parturition is freer from risk in town than in remote country
districts; the means for the prevention of infection are better
organized, and accident and disease are more promptly and more
efficiently treated. The poor in towns receive as a matter of course
in hospitals better treatment gratuitously than king or president
could command thirty years ago. The relief to housing deficiency
given by hospitals comes when most needed, in the emergencies of
child-bearing and of sickness; and the net result of this and of
better sanitary supervision is that although room-accommodation for
families is much more restricted in towns than in country districts,
the town-dwellers have a large share of their urban handicap removed
by their superiority over country people in medical treatment.


            _The Continuing Mass of Preventible Disease_

The medical record of the past on the side of preventive medicine
is one of increasing control over infectious diseases. In securing
this result epidemiologists, pathologists, and vital statisticians
can rightly claim first place, aided by the sanitary and industrial
inspector and the sanitary engineer; the epidemiologist being
dependent largely on the work of the pathologist and of the
statistician for guidance in his field investigations, which have
led to the discovery and removal of numerous sources and channels of
infection.

The record in curative medicine, especially on its surgical side,
is one of increasing triumph over serious disease and injury, in
which the discovery of anaesthetics and of Listerism have borne an
essential part.

None of us can, however, be satisfied with the success already
obtained, and I have elsewhere given reasons for concluding that at
least one-half of the mortality and disablement still occurring at
ages below 70 can be obviated by the application of medical knowledge
already in our possession.

The Great War has shown both in Great Britain and in America the
extent to which defects and disease exist in would-be recruits to
our armies. In the United Kingdom only two-fifths of a large section
of recruits could be placed in the first grade; and among American
recruits out of two and one-quarter million men measured and examined
physically at local boards 29.1 per cent. were rejected on physical
grounds; though in the introduction to the Official Bulletin (No.
11, March, 1919) it is pointed out that many of the disabilities
have little importance in civil life, and that these considerations
possibly “reduce to 15 per cent. the proportion of males 20 to 30
years old who carry a serious handicap against normal activity in
civil occupations.”

These figures, whatever doubt may attach to their exact arithmetical
value, signify the existence in the community of a large amount of
physical disability which must greatly reduce the sum of national
efficiency and happiness. The records of our medical examinations
of school children bring out the same fact, and emphasize the
necessity not only for school clinics on an immensely larger scale
than at present, but also for additional medical and nursing care in
connection with child-bearing and during the pre-school period, which
would discover defects and disease at an earlier stage, and would
secure the provision not only of early preventive treatment, but
also of more systematic improvement of the sanitary environment of
maternity and childhood.


            _Present Extent of Socialization of Medicine_

A mental effort is needed to realize the distance traveled in the
public provision of medical assistance in the United Kingdom by
the state and by voluntary organizations, including the committees
of hospitals, convalescent homes, dispensaries, etc., prior to the
passing of the National Insurance Act of 1911. I have already given
some illustrative figures regarding hospitals. The _Lancet_ some
years ago gave a statement of the number of attendances of patients
at voluntary hospitals in London during the year 1908. Assuming that
each out-patient made five attendances, that all in-patients had
previously been out-patients and that no patient received a hospital
or dispensary letter more than once in the year, it could be inferred
that a number equivalent to one in four of the total population of
London had received free medical aid in these voluntary institutions
during that year. And this did not include the large mass of
treatment given gratuitously in poor-law infirmaries, public-health
fever and tuberculosis hospitals, and lunatic asylums.

The majority of the medical profession in Great Britain is engaged
in either whole-time or part-time service for the state or for
local authorities. Of the 24,000 medical practitioners in England
and Wales, some 5,000 are engaged as poor-law doctors, some 4,000
or 5,000 in the public-health service, possibly 500 in the lunacy
service, some 1,300 in the school medical service, and smaller
numbers in various other forms of medical service for the state. This
is exclusive of the general practitioners who undertake contract work
under the National Insurance Act, and who cannot fall far short of
three-fourths of the total membership of the profession. It should be
noted that many doctors hold several appointments.

The state has, quite apart from National Insurance, given a rapidly
increasing amount of medical assistance to the public.

1. Under the Poor Law, every destitute person is entitled to
gratuitous medical attendance, at home or in an institution, and
after a fashion has received this during the last century.

2. The institutional treatment of lunacy has grown to an extent which
permits the treatment in an asylum of every certified lunatic.

3. The treatment at the expense of the state of feeble-minded persons
is rapidly increasing.

4. Public health authorities provide institutional, and to a limited
extent domiciliary, treatment of infectious diseases, this treatment
being given, as in the preceding cases, in nearly every instance
gratuitously.

5. To some extent prior to, and to an increased extent since, the
passing of the National Insurance Act, sanatoriums and hospitals
for the treatment of tuberculosis are provided by the public health
authorities, the central government contributing to the local
authority undertaking this duty one-half of all approved expenditure
on these institutions, on tuberculosis clinics, and of the expenses
incurred in the domiciliary nursing and supervision of tuberculosis
patients.

6. Similarly the central government pays one-half of the approved
expenditure incurred by local authorities or in certain cases by
voluntary agencies in assistance given in aid of maternity and child
welfare, e.g., in the provision of midwives, of consultant doctors,
of lying-in homes and hospitals, of beds for præpartum treatment,
of convalescent homes for mothers or their children, of infant
consultations and clinics, etc.

7. In regard to venereal diseases the central government has gone
still further. It has made it obligatory on the larger local
authorities to provide facilities for pathological diagnosis, and for
the treatment of patients suffering from these diseases irrespective
of any residential or financial limitations. Arseno-benzol
preparations are given gratuitously to medical practitioners, as
also laboratory assistance in diagnosis. To ensure the success of
the local arrangements the central government pays three-fourths
of their total cost; and have passed an act which prohibits the
treatment of venereal diseases by any unqualified person, as also the
advertisement or sale of any remedies for these diseases.

8. Many public health authorities provide gratuitous assistance
to medical practitioners in the bacteriological diagnosis of
tuberculosis, enteric fever, diphtheria, etc. Recently Wasserman
tests and searches for gonococci and spirochaetes have been added.
In 1914 plans for further development, including the provision
of complete clinical laboratories for the gratuitous use of
practitioners had been planned, and the necessary grant had been
obtained from Parliament; but the war led to the plans remaining in
abeyance. At the same time government grants in aid of nursing, and
of the provision of consultants and referees for insured patients
were passed, but were similarly held in abeyance.

9. The local education authorities provide for the medical inspection
of each scholar in elementary day schools several times during the
nine years of his compulsory attendance at school. Parents are
advised as to treatment needed, in suitable cases are referred to
hospitals (payment being made by the education authorities), and for
an increasing number of conditions actual treatment is provided at
school clinics (teeth, eyes, ringworm, etc.).

The above enumeration, which does not include the recently
necessitated activities of the Pensions Department for sailors
and soldiers, and those under the National Insurance Act, is not
otherwise complete; but it serves to indicate that the state is
already committed very deeply to provide for the medical needs of the
community. That the work done on behalf of the community, _plus_ the
work accomplished by private medical practitioners, is not equal to
national needs is obvious to any one considering the vast amount of
avoidable disease in our midst. Why is this and what is the remedy? A
partial answer is given by English experience. The medical provision
made in a large proportion of cases is belated and inadequate; and
in perhaps a still larger proportion of cases medical advice is not
obtained, or being obtained, is not followed. This applies even more
to hygienic than to clinical medical advice.


                     _Destitution and Sickness_

It was one of the greatest misfortunes in the history of medicine
in England that poor law medicine and public health medicine were
not administratively combined when the Local Government Board was
formed in 1870, and that the preventive ideals of public health
were not allowed to operate in the treatment and supervision of the
destitute. Although there has been a fairly steady improvement in the
conditions of medical treatment under the poor law, its association
with the deterrent general policy of that department of state, as
well as its actual defects, culminated in the appointment of a royal
commission of inquiry, which in 1909 presented reports recommending
the abolition of the local boards of guardians and transference of
their duties to the larger public health authorities.

Behind these proposals of the royal commission lay the absolutely
sound principle—which many years previously had been recognized by
the pioneers of public health—that the treatment and the prevention
of disease cannot administratively be separated without injuring
the possibilities of success of both. The public health activities
preceding the report of the royal commission illustrate this axiom,
such as the isolation and treatment of infectious cases, the
treatment of tuberculosis, the provision for the care of parturient
women and of their infants, and the medical inspection and treatment
of school children.

It was an even greater misfortune to the satisfactory progress of
public medicine that the report of the royal commission on the
poor laws was not followed by legislation on the lines of its
recommendations. So much of destitution is associated with sickness,
and sickness is the cause of such a preponderant share of the
total destitution in our midst, that the continued administrative
separation of the two problems of poverty and sickness is
inconsistent with a full measure of success.

Had the transfer of the duties of the poor law authorities to the
councils of counties and county boroughs been adopted, and ancillary
legislation enacted, the public health organization would have at
once possessed a medical service for the poor of some 4,000 doctors,
in addition to the doctors already engaged in the public health
service; it would have had large infirmaries and the other medical
institutions of both services; would have been able to make liaison
working arrangements with the committees of voluntary hospitals; and
there would have been secured a greatly improved medical service,
freed from poor-law shackles, which could gradually be extended as
needs and policy indicated.


                  _Insurance versus Public Health_

Political circumstances led to the adoption of a course which
medically ran directly athwart the course of needed reform. The
National Insurance Act of 1911 was passed, giving sickness and
invalidity benefits to all employed manual workers and to others
below an income limit of £160 (recently increased to £250), who
could contribute a weekly sum which was considerably less than half
of the estimated cost of the benefits to be received; and a new
medical service was created, further complicating administratively
the already existing medical services of the poor law, public health,
and educational authorities, and converting the majority of general
practitioners into part-time civil servants.

The case is an illustration of the moral contagiousness under
modern conditions of life, of a new course adopted in any country.
Bismarck’s attempt to counteract socialism by insurance has been
responsible for state and official experimentation in insurance
in many countries, which at least in England was not actuarially,
financially, or medically sound, and which has involved expenditure
in administration entirely incommensurate with the benefits received.

Insurance against sickness and disability is a praiseworthy and
valuable provision against future contingencies. I am not concerned
here to point out inequalities to the insured in the English
Insurance Act inherent in the apportionment of a flat rate for all
ages, districts and occupations, and for both sexes, irrespective
of known or suspected incidence of sickness, nor the difficulties
created by continuing the nonlocalized work of friendly societies
and other private organizations, and at the same time creating local
insurance committees, who furthermore were not organically related
to local health authorities, and had no opportunity, therefore, to
develop the conceivable potentialities of insurance experience as
an aid to public health work. The act in its present form is now
generally condemned; and it is significant that the need for its
radical reorganization appears to be universally accepted.[10]

Two medical benefits (medical and sanatorium) and a maternity benefit
were conferred under the act; but, as they have been administered, it
cannot be affirmed that any marked public benefit has accrued; and it
is certain that if the same amount of money had been placed in the
hands of public health authorities to provide adequate medical aid to
those needing it, of the kind most lacking and which they could least
afford to obtain, great benefit to the public health would have been
secured.

What was given? (1) There was the medical benefit, each insured
person being entitled to the services of a medical practitioner of
his own choice (a “panel” doctor). The services given were limited by
regulation to mean such medical attendance as is “within the ordinary
professional competence and skill” of a medical practitioner; and so
the treatment given has often been more limited than what is given
by the more advanced poor law authorities. The latter can supply
hospital treatment and expert assistance when required; under the
insurance system no such provision is made. The insured patient
is not entitled to surgical operations when needed, except of the
simplest character; treatment of eye, ear, nose and teeth conditions
is commonly excluded; no appliances are given except a few bandages
and simple splints; and there are no facilities for modern scientific
laboratory investigation, except those provided gratuitously by
public health authorities. Furthermore, by the rules of most friendly
societies sickness (monetary) benefit during treatment of illness due
to the patient’s misconduct is excluded.

The title of the act—National (Health) Insurance Act—has hitherto
proved a misnomer. The panel or contract system of medical treatment
of insured persons has done much to continue the obsession of the
public with the conception of medical care as consisting of a “visit
and a bottle”; and so long as the doctor’s medical work is on the
present basis, and he is under the constant temptation, not only to
accept more patients on his panel than he can satisfactorily treat
and to give each patient on application the mental satisfaction of a
“bottle,” but also to be more than lenient in the giving of sickness
certificates, it will remain questionable whether on the balance
state insurance against sickness does more good than harm. If medical
consultants and referees, treatment centres, and hospitals are in the
future provided for insured patients, this will mitigate the evils
of the panel system; but the present contributions of patients will
not purchase this additional provision. All the new money needed,
and most of the money needed under present conditions, must continue
to be provided by the state and employers of the insured (a form of
taxation); and provisions thus made, like the present contributions
of the state for insured persons, are in direct contravention of the
general principle that government grants being derived from the whole
community, should enure to the benefit of the whole community in need
of them, and not only to the benefit of a section of it.

About one-third of the total population of Great Britain is
included within the terms of the National Insurance Act. If the
wives and children of insured men were also included, as has been
proposed, over two-thirds of the total population would be embraced
in the scheme; but as persons manually employed, but working for
themselves—e.g., cotters and hawkers, are encluded, and as persons
not manually employed cannot be insured unless their income is below
£160 (recently raised to £250), large classes of the population who
can ill-afford to pay for their own medical attendance are excluded
from the operation of the act, and taxed to pay the benefits of
insured persons.

(2) The sanatorium benefit was intended to secure for the insured
person special treatment for tuberculosis, while capital sums were
provided for the erection of sanatoria and hospitals for consumptives
for insured and non-insured alike. Fortunately during the passage of
the bill, the provision of these institutions for insured persons was
delegated to public health authorities; and as it was already within
the power of these authorities to provide such institutions and
tuberculosis clinics for the entire population, and as the infection
of tuberculosis is no respecter of parliamentary distinctions
between insured and non-insured, there was little difficulty in
persuading the government to promise half the total approved local
expenditure on the treatment of tuberculosis in institutions,
whether this was given to insured or non-insured persons. Indeed
when local authorities were willing to undertake their share in
a complete scheme for the treatment of tuberculosis an insured
consumptive person might be regarded even as paying fractionally for
his treatment while a non-insured person received such treatment
gratuitously.

(3) The maternity benefit, conferring thirty shillings on the wife
of an insured person, and an additional thirty shillings if she also
is an employed person within the meaning of the act, on the birth of
her infant, was perhaps the most popular benefit under the act. The
money was given unconditionally, and thus an opportunity was lost
of insuring that the benefit should improve maternal and infantile
prospects.

Collaterally public health authorities, central and local, were
beginning to organize medical and nursing assistance during
pregnancy, in confinement and afterwards for the mother, and similar
assistance on a large scale for infants and children under five
years of age. And there will, I think, be no hesitation in agreeing
that the _supply of service_ at this critical period of the mother’s
and infant’s life, so as to insure the most satisfactory recovery
of parent and the best start in infantile life, is infinitely more
important than a money grant.

I cannot pretend to have more than touched on the fringe of the
complicated subject of insurance in relation to public health. The
inauguration of the act meant an enormous increase in the direct
relationship of the medical profession to the state. A great
stride in the socialization of medicine was taken. But it was done
ill-advisedly; it continued a false and low ideal of isolated
general medical practice; it has even been described as a fraud on
the insured, in view of the incompleteness of the medical service
provided; and it diverted into an unsatisfactory channel the energy
and money which were urgently needed for the immense good obtainable
by reform of poor law and public health administration, and extension
of their medical services. Had the lines indicated by history and
experience and by the report of a strong royal commission on the poor
law—there was a majority and a minority report, but both agreed in
the chief essential points—been followed, England would now possess a
nearly completely unified state medical service, instead of standing
at the point whence false steps need to be retraced, with a view to a
coördinated and simplified medical and public health policy. With the
principle of contributory insurance to secure monetary support during
illness there can be no quarrel; but in the interest of national
efficiency complete medical provision, preventive and curative,
must be made by the state, irrespective of insurance, for all in
need of it; and the medical practitioners employed in the necessary
certification of such insurance work as is continued must, if the
insurance is to be satisfactory, be employed under conditions which
will render them independent of the favor of the insured, and will
enable them to utilize their knowledge of each patient’s case for
the needed preventive measures, whether these be concerned with the
sanitation of home or factory or workplace, or with personal habits.


                      _The Need of the Future_

It is, I think, clear that the state will year by year take an
increasing hand in medical matters. It is useless, even if it were
desired, to attempt to oppose the inevitable and the eminently
desirable trend towards vastly increased utilization by the state of
medical science in the interests of humanity. It is for physicians
to guide the course of events, and to insure that no plant is sown
which will afterwards need to be uprooted; that no development is
permitted which will hinder the fulfillment of our ideal. Personal
hygiene forms a rapidly increasing part of public health work; hence
it is indispensable that all forms of public medical service shall
be linked up with the public health service and controlled locally
and centrally in accordance with this. This may imply—and in England
it does imply—the urgent need for reform and reconstruction of local
as well of central public health administration; but to attempt
to separate medical from public health provision is to repeat the
blunders which, despite skilled advice to the contrary, have been
made on two great historic occasions.

A complete service, adequate to the needs of the community, cannot
be secured by a session’s legislation. It must grow as the result
of steady advance. The motto in growth might well be, “First things
first.” What are the medical services which are provided too sparsely
at the present time and for which the masses of the population
cannot afford individually to pay, except possibly to a fractional
extent? There can be no doubt as to the answer. What is most urgently
needed is the provision of skilled hospital attendance for every
patient who can be more satisfactorily treated in hospital than
at home. Next to this comes the provision of gratuitous medical
services—(e.g., maternity and infant consultations, eye, throat,
ear, skin and venereal diseases, tuberculosis, X-ray departments)
preferably linked around a hospital, where patients can be sent by
private practitioners for an expert opinion, or in certain cases may
present themselves independently. And as important as either of the
preceding desiderata, is the provision of a complete nursing service,
on which each private practitioner can call for assistance as
required, payment, if any is exacted, being on the easiest possible
conditions, and not made compulsory.

The hospital under such circumstances would become a centre from
which community work of the highest value would radiate; and
patients, private practitioners, and the staffs of hospitals would
alike live in a new world in which the interest and efficiency of
medical work would be greatly increased. The present irregular
localization of hospitals makes the realization of such a scheme
difficult; but local partially successful schemes are already
in operation; difficulties can be overcome with good-will; and
eventually we may hope to have for each unit of subdivided public
health administration and as an organic part of this, a hospital,
with out-patient or dispensary clinics, and radiating from these the
various forms of medical attendance, domiciliary nursing, public
health nursing, and sanitary supervision which are needed.

In securing such a result there will be needed medical practitioners
who are imbued with the ideals of preventive medicine in its widest
sense. Let me, in this connection quote the following extract from a
recent official report of my own:

 There is needed a reconstruction of the training of each medical
 student, which will make preventive medicine in its widest sense
 an integral part of his training, and will insure that before he
 begins practice he has definite instruction in the application
 of the whole of his knowledge to preventive purposes. The past
 conception by the public of the relation of medical men to the
 community—apart from the special case of medical officers of
 health—has been mistaken. The doctor has been regarded as a help
 when serious or acute incapacitating illness occurs, and he has but
 seldom had the opportunity of giving advice in the earlier and more
 controllable stages of illness. His training has been conducted on
 the assumption that his chief rôle should be on present lines, with
 the result that most medical practitioners enter into practice with
 a too scanty knowledge of hygiene and preventive medicine, and have
 to learn slowly in belated experience the influence of environment
 on the health of their patients. The teaching of medicine should
 be much more largely physiological and hygienic than at present,
 and such subjects as food values, the hygiene of infancy and
 childbirth, the physiology of breast feeding, and the influence
 of environment on the health of their future patients should be
 the subject of careful training—especially in regard to housing,
 feeding, clothing, and conditions of work. Were this done, the ideal
 condition, in which each medical practitioner becomes a medical
 officer of health in the range of his own practice, would approach
 realization.—[Annual Report to the Local Government Board, 1917-18.]

Many medical practitioners already fulfill this ideal. It would
oftener be realized were it not for the excessive work which many
are obliged to undertake. In the early history of public health in
England poor law medical officers, attending the impoverished in
their dwellings and familiar with their home conditions, became
part-time medical officers of health. But the attempt to combine
prevention and treatment proved unsuccessful, because these officers
visited only a small proportion of the dwellings of the poor, because
they were not trained in preventive work, and because the good seed
of preventive work was choked by the increasing demands of lucrative
private practice. In connection with the future general medical
service, curative as well as preventive, it is not beyond the range
of human ingenuity to provide schemes for district medical officers
(health and clinical) adequately trained in public health work, and
linked up closely with the hospital and dispensary unit for their
area.

This will cost money. But sound health is our greatest personal and
national asset, and disease is always more expensive than health.
“Who winds up days with toil, and nights with sleep” has “the
forehand and vantage of the king,” if the latter suffers in body or
mind. The real wealth of a nation does not consist in its money, in
the volume of its trade, or in the extent of its dominion. These are
only valuable insofar as they help to maintain a population—and not
only a portion of it—of the right quality; men, women and children
possessing bodily vigor, alert mind, firm character, courage and
self-control. This ideal can never be realized unless and until the
medical men of the future train themselves for and devote themselves
to their essential share in its fulfillment, and while keeping this
ideal in view see to it that every step taken is one which will be
consistent with the complete scheme of the future.

We are all concerned in the efficiency of every member of the
community, from an economic as well as from a humanitarian
standpoint. Can we be satisfied while a large proportion of the
population do not obtain medical and ancillary assistance to the
extent of their needs? Does such a state of things conduce to
the settlement of social unrest? Is it consistent with Christian
principles?

If communal provision has been recognized as a duty for police
protection, for sanitation, for elementary education, should it not
likewise be admitted for the more subtle and maleficent enemies of
health which have been recognized, but which in no community have
hitherto been completely combatted?

We scarcely realize how far we have gone in the socialization of
medicine. It is impossible to go back, or to stand still. The
services of the medical profession are needed, not only to provide
the necessary service, but in helping to determine its conditions.
One essential item will be the substitution for fees during sickness
of an annual payment to private practitioners by each family for
supervising its members in health, for inquiry into their industrial
and domestic life, so far as it contains elements inimical to health,
and for giving preventive more than curative advice. The second and
most urgent element consists in the organization of hospital and
consultative expert services for all, which, while greatly increasing
each patient’s prospect of prompt recovery, will enable the general
practitioner to escape from the soul-destroying inefficiency of
unaided medical practice.

Of course, any service provided, whether partial or complete, will
need to be kept free from “political pull.” This spells inefficiency;
and inefficiency means disease and death. “Political pull,” although
not in the official list of Causes of Death, is among the potent
causes of excessive mortality; and for this, every one of us must
bear his individual share of responsibility, insofar as we have
abstained from active support of sound and clean government, when we
were unable to take an actual share in government.


FOOTNOTES:

[9] The Wesley M. Carpenter lecture delivered October 2, 1919, before
the New York Academy of Medicine.

[10] Thus Mr. Bishop Harman, an ophthalmic surgeon, and a member of
the Council of the British Medical Association, says:

“In my out-patient clinic 60% of the patients are insured persons
who attend for treatment that is essential to their industrial
efficiency.... A scheme of medical benefit which does not provide for
specialist service and for institutional treatment is no scheme, it
is poorer in status than the Poor Law provision which does all these
things.” (_British Medical Journal_, Mar. 15, 19).

Dr. R. Sanderson, of Brighton, writing on behalf of medical
practitioners, says:

“We are the victims of a half-fledged, inadequate piece of
legislation which is founded apparently on the supposition that
disease can be dealt with effectually by giving bottles of medicine
or liniment to the sick, or that if this fails and the sick get
worse, they can be sent to one of the overcrowded voluntary hospitals
with which the legislature has nothing whatever to do. Anything more
unsatisfactory to the sick, or demoralizing to us as a profession, it
is hard to imagine.”

He then proceeds to advocate an urgent need of the profession, viz:
the establishment of an adequate number of auxiliary hospitals
throughout the country, staffed by teams of general practitioners, to
which all practitioners can have access, and to which they can send
cases requiring clinical observation of any kind, rest or treatment
that cannot be carried out in the sick person’s home. (_British
Medical Journal_, July 19, 19.)

Dr. Howarth, Medical Officer of Health of the City of London,
and Dr. B. A. Richmond, Secretary of the London Panel Committee,
affirm “the limitation of medical benefit to insured persons
alone cannot continue. Another service has been added to the many
competing classes of state treatment”; and they bring out the fact
that personal contributions of insured persons are swallowed up
in supplying the sickness and disablement benefit, and contribute
nothing to the cost of the sanatorium benefit, maternity benefit, or
medical benefit.

Dr. H. S. Beadles, Secretary of the Stratford & West Ham Panel
Committee, says: “The British Medical Association should fearlessly
acknowledge that the attendance under the National Insurance Act,
which is itself a part-time State service, is an absolute failure
and amounts to little more than first aid, carried on at an enormous
cost.”




                             CHAPTER IV

                      INSURANCE AND HEALTH[11]


So far as a majority of the population are concerned, it is necessary
to realize that they are never far removed from the line dividing
destitution from adequacy, using the word destitution to mean
insufficiency or lack of some provision essential for health and
continued welfare.

It may be urged that this is owing in large measure to the
improvidence or thriftlessness of the wage-earners who are chiefly
concerned; but such a statement fails to appreciate the higher
standard of conduct and the greater self-denial which is demanded
from weekly wage-earners than from ourselves, if out of their
wages provision is to be made for a “rainy day,” without affecting
unfavourably the present health of the worker or his family.

The general appreciation of the above considerations has led to the
provision of non-contributory old-age pensions in the United Kingdom;
and similar sentiments have led in many countries to compensation
for accidents at the expense of employers; and to the various
national systems of insurance against sickness. With the principle of
sickness insurance there can be no quarrel. It is the substitution of
coöperative for individual provision, thereby distributing some of
the loss and eliminating some of the risk of suffering from illness.

The value of any system of sickness insurance, however, must
necessarily be judged by several criteria.


                  _Criteria of Value of Insurance_

Is the adopted system one which is equitable in its incidence and
economical in its administration; and does it supply maintenance
during sickness adequate for the needs of the patient and his family,
while at the same time offering no temptation to the patient to
continue on the sick funds, when his condition no longer necessitates
this?

In the case of the English National Insurance Act, these questions
unfortunately cannot be answered completely in the affirmative.

The finance of the Act arranges for the uniform contributions
(differing for each sex) from some thirteen million persons, living
under most diverse conditions, to furnish equal benefits (differing
for each sex) to all insured persons, irrespective of age, locality,
or occupations; while at the same time some 23,000 independent
insurance societies continue to administer the distribution of money
benefits, each with its own segregated experience, some prosperous,
others owing to excessive sickness almost bankrupt. There is the
remote possibility for each society to pay additional benefits if
justified on the quinquennial valuation.

Substantially men and women have been placed on a similar financial
basis. The sickness of pregnancy apparently was overlooked; and for
this and other reasons the insurance funds for women are financially
inadequate for the benefits promised.

On the point of equity, it must be admitted that any system of
so-called insurance which, like that of the English Act, excludes
a large proportion of the population who, while paying in taxes in
aid of the insured, require but do not receive their benefits, is
contrary to the principle that any expenditure of Government funds
should enure to the whole community in need of the provision in
question.

The provision of 10 shillings a week for incapacity lasting 26 weeks
(7s. 6d for women), followed by 5s. a week disablement benefit,
although inadequate provision for family maintenance during sickness
undoubtedly is helpful. It is mischievous when in consequence of
this provision, the patient is tempted to remain at home under
unsatisfactory domiciliary treatment, instead of receiving the
shorter and more successful institutional treatment, which should
have been given.

As to economy of administration, I can speak only with reserve; but
it requires little imagination to appreciate that the numerous
migrations of wage-earners imply great difficulties in book-keeping
as well as in securing insurance medical attendance, and that a very
high percentage of the total insurance funds is swallowed up in
elaborate and meticulous account keeping.

The point as to malingering can best be considered in connection with
a discussion of the


                          _Medical Benefit_

This consists of such medical treatment, at home or at the office of
the panel doctor,[12] as “can consistently with the best interests
of the patient be properly undertaken by a practitioner of ordinary
professional competence and skill.”

The Act itself promised “adequate medical attendance and treatment,”
but under regulations this has been limited, so that in practice it
means chiefly the treatment only of minor ailments. Thus (_a_) there
is no provision for hospital treatment of patients needing this,
except the Sanatorium provision for tuberculosis; (_b_) with the
same exception, there is no provision for expert services. A patient
requiring operative treatment for fractures, for an amputation, or an
operation for appendicitis, or needing treatment for some affection
of the eyes, or nose, or throat, or ears, or the intravenous
treatment of syphilis is excluded from medical benefit. So likewise
are dental requirements. (_c_) There is no provision for pathological
diagnosis, except such as is common to the entire population, and no
X-ray diagnosis, except possibly for tuberculosis. (_d_) There is no
provision for nursing assistance.

In view of the unequal distribution and insufficient provision of
hospitals for the general population, of their inaccessibility to
large masses of patients, and of the insufficiency of the present
provision for the scientific aid to treatment which modern medicine
demands for insured and non-insured alike, it is evident that the
provision for medical treatment under the Act is unsatisfactory
and inadequate, and that it conduces to prolonged illness, which
treatment provided on more satisfactory lines would avoid.

To state adequately the defects of the medical provisions of the
Insurance Act a long address would be required. They are, however,
generally well known, and their existence and seriousness is admitted
by all. (See also page 90.)

It is necessary, however, to say more on the


                  _General Practitioner Treatment_

provided under the Act. Every insured person is allowed to choose his
own doctor within a given distance. In practice very few patients
change their doctor at a fixed time each year as they are allowed
to do; and a considerable proportion of insured persons do not
trouble to choose a doctor at all. The free choice of doctors is
rather a sentimental than a real demand. The panel doctor is paid
an annual capitation fee, and hitherto no limit has been placed on
the number who may place themselves on his roll. The domiciliary
treatment given by some doctors is entirely satisfactory within the
limits stated above. Commonly, however, it is as unsatisfactory as
the “club practice” which preceded it, and against which the British
Medical Association inveighed. It involves a continuance of the
mischievous ideal of medical practice of the past, a conception still
held by a large portion of the public to its own detriment, that a
hasty inquiry, a perfunctory examination, and a bottle of medicine,
represent the best that scientific medicine can offer a patient. Had
there been organized a chain of medical services for all needing it,
including consultations and expert assistance when needed, every
patient having the right to call for these when dissatisfied with
his panel doctor, including also hospital provision and nursing as
required, what a different story could now be told!

It is probable that some at least of these additional services will
be added gradually; but it must be noted that the present payments of
the insured will not suffice to pay for them; and that if they are to
be provided,—as they will probably need to be,—out of public funds,
the general public are in equity entitled to these services even
though they are not insured.

If these complete services were provided, the medical treatment now
provided largely at the expense of the community could be made a
means for advancing the public health. This it can not at present
claim to be. For nothing is more certain than that the prompt and
adequate treatment of disease curtails its duration, diminishes its
severity, and prevents its spread to others.

But even such a service would not fulfil its complete possibilities
for good unless it were joined to a system of hygienic supervision of
each insured person and of each insured person’s family, this system
being organically linked up with the wider public health work of the
larger Public Health Authorities.

The chief justification of a national system of insurance against
sickness is that it shall be an active auxiliary in the prevention
of disease. At present it is doubtful whether any national system of
sickness insurance has been so. It has only been so, to the extent to
which the medical treatment of the masses of the population has been
improved by it; and no such improvement can be claimed for British
insurance. The wider possibilities of prevention of illness and
elevation of the general standard of health, by making each medical
practitioner a family adviser on health more than a practitioner in
medicine, have not been realised or even brought within sight.


               _Evils of the Present Medical Benefit_

The inadequacy and unscientific character of the medical treatment
given to insured persons are associated with a large amount of lax
certification of illness, which is injurious to the character of
doctor and patient, besides being unfair to the insurance funds.
Those interested in this point should read paragraphs 118, 119, 120,
121, 123, 125 of the Report of the Departmental Committee on Sickness
Benefit Claims (Official Report Cd 7687).

 There is almost universal testimony of the belief (of
 representatives of friendly societies) that medical certificates are
 granted recklessly (par. 119).

 Doctors ... feel a difficulty in refusing certificates owing to the
 possible effect upon their practice.... If a doctor falls out with
 his patient he loses the entire family (par. 120).

 These statements ... are representative of an enormous volume of
 dissatisfaction with the action of the medical profession.

The Committee state:

 We are of opinion that in many cases doctors have given certificates
 for sickness benefit in circumstances in which these certificates
 were not justified.

From the standpoint of the conscientious practitioner the present
position is profoundly unsatisfactory. He has no official access to
arrangements for consultative and expert advice, he has no hospital
beds, no skilled nurses. For the patient the position is anomalous
and leaves him with but a fragment of what he could reasonably expect
under the terms of the Act.

Of the other medical benefit, i.e., the Sanatorium benefit and of
the Maternity benefit, I can say only a few words here. The former
gives the insured patient little more than in the more enlightened
sanitary districts is being provided, independently of insurance, by
Public Health Authorities. It would have been practicable to make
it obligatory on all Public Health Authorities to provide adequate
treatment for all consumptive patients. They are already authorized
to do this under Public Health Acts, and the duty could have been,
and can still be made, obligatory by regulation. And in that case
the connection of the Sanatorium Benefit with the National (Health)
Insurance Act would happily cease, and one great obstacle to a really
national organization against tuberculosis would disappear.

The Maternity Benefit provides a money payment for each insured
woman and for the wife of each insured man on the birth of a
child. The money payment is made through the Insurance Societies
unconditionally, instead of being made a means of securing that
the birth takes place under circumstances favourable to mother and
infant. During recent years public health authorities (aided by
grants from the Government of one half of the total approved local
expenditure) have been making medical and nursing provision for the
care of women in pregnancy, in parturition, and during the nursing
period, on a rapidly increasing scale, the grants including not only
skilled assistance but also domestic aid (home helps) in suitable
cases. There can be no question that increased provision in these
directions will have a more generally beneficial influence than money
payments, and should at least supplement the latter.

To sum up, if the national English system of insurance is to
continue, it ought in my view to be shorn of its medical functions
and to be limited to money payments during sickness, in return for
the weekly contribution made by employees and employers. If it be
thought inadvisable to limit the State’s contribution, as in Germany,
to what is spent in administration, then in equity the present system
of insurance cannot continue to be limited to those now participating
in it.

I hold strongly that the State should embark on a much larger scale
than at present on


                  _The State Treatment of Disease_

The great and fundamental mistake made in the initiation of the
English Insurance Act was that in effect it ignored the entire
history of the relation of preventive and curative medicine to
the State. This history cannot be detailed now: but, briefly, for
long years the destitute had been entitled to domiciliary and
institutional treatment at the public expense. This medical aid was
given by Poor Law Authorities, and their method of doing this work
had rendered the benefaction commonly unacceptable. Then Public
Health Authorities on a steadily increasing scale found it necessary
to treat disease in order the more effectively to prevent it. And so
fevers and smallpox, and chronic infective diseases like tuberculosis
and syphilis came under treatment, practically for all comers, at
the public expense. As already mentioned the fundamental importance
of maternity and childhood has also been realised, and the State is
now taking an increasing share in ensuring health at these periods
of life. And while Public Health Authorities were increasing their
activities, Education Authorities began to subject school children
to medical inspection, and to treat them for the detected defects,
the treatment of which they could not otherwise secure. And so, not
to make this sketch too complex, three great central government
departments or sub-departments and three sets of local authorities
were engaged in medically treating the people at the public expense.
This sketch does not include the smaller (nevertheless enormous)
amount of treatment of disease by voluntary hospitals. It is safe to
state that at any one time one-half of the total treatment of disease
is being carried out at the public expense. If the domiciliary
treatment of insured persons is worthy to come into the same category
as the skilled services mentioned above, the proportion of disease
already treated at the public expense greatly exceeds 50 per cent.
(Note.—Less than four-ninths of the cost of medical treatment of
insured persons comes from the contributions of the insured.)

The complexity of local authorities concerned in the treatment of
disease was wilfully increased under the National (Health) Insurance
Act; and, contrary to the advice of public health workers and of the
Royal Commission on the Poor Laws a golden opportunity for securing
the merging of poor law into public health work and for initiating a
unified system of State Medicine for all who need it was lost.

Poverty to a preponderant extent is due to sickness. Two statements
have recently been made by the Medical Society of the State of New
York, viz., that “evidence is against the fact that any considerable
amount of impoverishment is caused by illness,” and that they can
find no “available evidence that ... in the main, medical attendance
in this State is grossly deficient in quantity or grossly defective
in quality.” (_Monthly Labor Review_, January, 1920, p. 256.)

One can admire the optimism, while denying the accuracy of the first
statement: of the second statement, as it refers to the State of
New York, I can say nothing, except that a statement identical with
the one denied above would be literally true for England. In 1907
I wrote, “the coexistent but uncoördinated systems of treatment
of disease have failed lamentably to provide what the health of
the community requires—means for ensuring effectively the early
recognition and proper treatment of all disease” (_British Medical
Journal_, Sept. 14, ’07). That remains broadly true, and no remedy
will suffice which does not ensure for every member of the community
in essential particulars as good treatment as the most favored now
possess.

The socialization of medicine has gone too far, its beneficent
effects are becoming too well appreciated, to render it possible,
even were it not undesirable and mischievous, to hinder its further
extension. We have travelled more than half the road towards the goal
of general provision of skilled medical assistance by coöperative
means, i.e., out of the communal purse. If this is desirable for
elementary general education, it is even more important when the aim
is the restoration and the maintenance of the highest attainable
level of health for each member of the community, who is willing
to share in the offered benefits. If we include the third of the
total population who now receive in Great Britain the unsatisfactory
medical benefit under the National (Health) Insurance Act, and
remember the rapidly increasing scope of voluntary and official
institutional treatment of disease, hesitation in accepting the
inevitable should be replaced by a determination to guide future
developments and to render them efficient and economical. What is
good for the public is good also for the members of the medical
profession.

If asked to advise on the steps which it is advisable to take in
regard to Sickness Insurance in a community which has not adopted
a scheme, I should emphasise the prior necessity for the State to
secure a completely satisfactory system of public medical care before
engaging in the more difficult task of providing monetary payments
in sickness. It is well to bear in mind that medical attendance is
a form of communal assistance the demand for which does not tend
to increase with the supply; whereas monetary benefits have always
shown this trend, as demonstrated by the experience of both Friendly
Societies and charitable agencies. As satisfactory administration
of monetary benefits during sickness depends on securing medical
certification which is above suspicion, it is fundamentally important
that under any method of public medical attendance the certification
(for incapacity to work) should be completely independent of any
coexistent system of sickness insurance.

A completely efficient public medical service, if preventive as well
as curative, will diminish greatly the monetary calls on sickness
insurance and lower its expense. Let me briefly enumerate the
conditions which such a medical service must fulfil:

1. It must possess facilities for consultations with physicians and
surgeons having special knowledge, equalling in efficiency those
possessed by the well-to-do.

2. All modern pathological and physical aids to diagnosis and
treatment must be available.

3. Hospital treatment must be secured for all whose illness cannot be
satisfactorily treated at home.

4. In the ordinary treatment of patients by medical practitioners
there must be provision for team work, as for instance at local
dispensaries, so that a patient may, where this is desirable be
conveniently examined by several doctors. (Group medicine.)

5. Skilled nursing must be obtainable for patients needing to be
treated at home, though the extent to which this is required will be
greatly reduced by increased use of hospital beds.

6. In every district the patient might have the choice between
several doctors; but unnecessary change of doctors should be
discouraged. Subject to general regulations, however, he should
be entitled to demand a consultation when not satisfied as to his
treatment.

7. The doctor chosen by the head of the family should be held
responsible for supervising the health of the whole family; and
should be required at least once in three months to arrange to
see each member of it, to ascertain any existing disease, or any
habits, manner of life or work tending to cause disease, and to make
a concise statement to the medical officer of health or health
commissioner embodying his recommendations as to any public health
action which may be needed.

8. The scheme at first might be limited to one section of the
population, but there is no reason why ultimately it should not
embrace all willing to join it.

9. The remuneration of doctors engaging in this public work should
be adequate at once to attract junior members of the profession. The
remuneration should not be on a capitation basis, but by salary,
modified according to the success achieved. The scheme would enable
doctors to have ample leisure and holidays and to take part in
post-graduate courses. Every inducement should be given to physicians
to undertake along with their family work special work in connection
with one of the following activities:

      Pathological laboratories,
      Hospitals,
      Health centres for infants and mothers,
      Prenatal and post-natal clinics,
      Consultant obstetric work,
      Pre-school clinics,
      School medical inspection and clinics,
      Industrial inspections and clinics, etc.

10. Medical schemes on the above general lines can only be completely
satisfactory to the extent to which every physician taking part in
them becomes imbued with an appreciation of the _almost unlimited
preventive possibilities opened up by the opportunity to treat
disease_, and by the realization likewise that an essential part
of his family work should consist in detecting the _beginnings of
disease_ and in detecting and securing the removal of domestic,
dietetic, housing, industrial or other factors liable to cause
disease.

If these ideals can be even partially realised, we shall have
approached the time when every practising physician will become a
hygienist, and when any sickness insurance still demanded or required
will be on a scale much lower than is necessary at the present time.
In short, compulsory sickness insurance under present conditions is
a measure of relief. It has almost as little prevention involved in
it, as has insurance against the risk of fire. Relief must be given,
by insurance or otherwise. How much preferable, however, it would be
to precede it by a far-reaching scheme of effective preventive and
curative work, or at the least to place it in a strictly subsidiary
position to such a scheme in actual operation!


FOOTNOTES:

[11] An address given to the Quiz Medical Society, New York, Feb. 14,
1920.

[12] _I. e._, any doctor in a given area who is willing to treat
patients under the conditions of the Insurance Act.




                              CHAPTER V

  SOME PROBLEMS OF PREVENTIVE MEDICINE OF THE IMMEDIATE FUTURE[13]


The Great War has changed our outlook on social, including medical,
problems; and has made all of us consider anxiously in the midst of
the terrible wreckage from war, what useful lessons may be garnered
for our future guidance. In speaking of losses, I am not referring
to financial burdens, though these are fabulously high—the bare
statement that the British national debt has increased from 645 to
near 8,000 millions sterling, brings this home—and we shall, most of
us, go relatively poor for the rest of our lives and our children
likewise. Nothing but the most effective and scientific use of our
energies on the part of workers of every class can save us from
protracted poverty.

I am thinking rather, however, of the losses of life and limb, of
hearing and eyesight, and of reason, which have been experienced—one
or other—in nearly every other family in the British Empire, and
which show once more the wantonness of war: how cheaply life is held
by it, how careless it is of the individual; and how disregardful it
is of human promise and performance.

The destruction of over 700,000 lives of sharers in our common
Empire, killed in battle or dead from wounds, represents an imperial
loss, a terrible destruction of the real capital of the Empire—its
manhood—and of the flower of that manhood; and generations will come
and go before the Empire recovers completely.


                          _Gains from War_

But we can set out some great gains from war.

1. Not the least of these is the fact that the fears entertained
by the more pessimistic that we had become enervated and decadent
have been falsified on many a stricken field; and not less in
the strenuous work of those who have worked remote from the
battlefield. Our men and many women also have shown themselves
willing to give their lives for great impersonal ends. Their lives
have been sacrificed—for our children, for liberty, for peace, for
security against military barbarism, and for high ideals of life.
The emergence of such a high proportion of our total population
from selfishness and self-centred life to a sacrificial position,
raises hope that rightly directed appeal to the collective self
of the community during peace time for aid against the horrors of
peace—especially those caused by disease—will also succeed in
enlisting the assistance of the majority of the population and thus
removing the vast mass of removable disease and disablement which now
prevails.

2. The war has knitted together in active comradeship the Old Country
and its younger and more energetic children in the Dominion of
Canada and in other parts of the British Empire, in bonds of mutual
indebtedness and gratitude and in admiration of great deeds, in a
manner and to an extent which must forever preclude misunderstanding
or separation.

In these two respects especially—and in others which I shall dwell on
more fully—we can, as Wordsworth put it, when commenting on the wars
of the French Revolutionary period:

      Though doomed to go in company with Pain,
      And Fear and Bloodshed, miserable train!
      Turn our necessity to glorious gain.


                         _The Work of Women_

3. The war has revealed to us the great extent to which women in
emergencies can replace men. I need not repeat the story of how women
in a few months mastered mechanical intricacies in munition works,
for which previously a long training was thought necessary; nor how
educated women after a few months’ intensive training were able,
under war conditions, to undertake the work of fully trained nurses.
We cannot ignore these facts; and in regard to nursing, they should
lead us to consider whether, under modern conditions of life, it is
necessary that the great body of nurses, like the great majority of
medical practitioners, need to be experts in major operations, and
whether they should not be trained chiefly from the standpoint of the
ordinary illnesses of the household. Particularly, it is important to
recognize that the training of the health visitor or public health
nurse must diverge at an early period of training from that of the
clinical nurse.

In another direction women are about to influence vitally the
problems of public health in the near future. The municipal and
parliamentary vote has been given to women in England, and is not
likely long to be withheld here. How will they use it? When they
use it will “politics” be a name for a contemptible thing as it
has become in some towns and states, or will women insist on clean
administration and efficient work to secure the health and welfare of
the community?


                  _Prohibition of Alcoholic Drinks_

4. The prohibition law against alcoholic drinks in the U. S. A. is
largely the work of American women. Whatever view be taken of this
law—and I regard it as one of the most significant social events
of the age—let there be no doubt as to the essential facts of the
problem.

Alcoholism is a potent enemy of the race. It is a great creator of
avoidable poverty. It makes the bed ready for tuberculosis. It is a
frequent excitant of exposure to the infection of venereal diseases;
it swells the ranks of fatherless children, and of neglected
infants; it helps to fill our prisons and our hospitals. Let it be
admitted, if you like, that light wines and beers are pleasant, and
in strict moderation with meals are beverages to which little or no
harm can be traced; but heavier drinks and all non-medicinal spirit
drinking are to be condemned; and the country which distinguishes
itself by abolishing these drinks will, other things being equal,
in my opinion, inevitably attain quickly an industrial and economic
superiority over all countries which continue to follow the older
ways.

5. A great gain during the war is constituted by the fact that
science has come into its own. The war has been described as a war
of engineers. Its chief successes have been won largely by applied
science; and it is gratifying to record that the Anglo-Saxon
intellectuals, when their services have been engaged, have proved
themselves more than equal to the German scientist, whether in
physics or chemistry or medicine.

The facts as to the wonderful extent to which disease has been
prevented during this war need not be detailed. Intestinal
diseases have been kept strictly under control. In no previous
war has smallpox or typhoid fever claimed so small a toll on the
belligerents.

Malaria, it is true, has claimed many victims, owing to our soldiers
having to operate in countries in which the needed precautions could
not be completely carried out. Typhus has scarcely claimed a victim
among the British forces, and although trench fever was common,
medical discovery, by showing its relationship to the bite of the
louse, has placed within reach an immediately practicable means for
avoiding this serious cause of military disablement.

Three sets of diseases have not been successfully combatted during
the war—the group of respiratory affections, tuberculosis, and
venereal diseases, and on each of these it is desirable to make a few
remarks.


                       _Respiratory Diseases_

6. In the group of respiratory diseases I think we should include
a number of diseases not commonly regarded as such, but in which,
so far as can be judged, infection is received by inhalation; and
I would, therefore, group together such miscellaneous diseases as
poliomyelitis, cerebro-spinal fever, measles, bronchitis, pneumonia,
and influenza. All agree in one particular, that attempted preventive
measures against their spread are dubious in effect. These diseases
naturally divide themselves into two groups: the first comprising
measles and influenza, both of which spread—when, as in influenza,
the almost unknown conditions determining spread are present—to an
extent only limited by the failure of susceptible persons; and the
second comprising the other diseases already enumerated, of the
conditions determining attack from which we are profoundly ignorant.
We do know, however, concerning cerebro-spinal fever and measles,
that they spread more easily and become more severe under conditions
of massive overcrowding; and their unusual severity in war is thus
partially explained. Beyond this obvious indication for prevention we
can do but little.

It may, however, be mentioned, that in England during the last
few years, we have determined that our lack of ability to prevent
outbreaks of measles shall not prevent us from attempts to _diminish
their fatality_, and the notification of this disease has therefore
been enforced, as a necessary preliminary to prompt and fairly
complete action, and local authorities have been urged to provide
nurses to assist in the domiciliary nursing of cases of measles.
Grants of half the expenditure expended in nursing this and some
other children’s diseases are paid by the Central Government. If the
spread of infection cannot be stayed, it is our duty to diminish
the loss of life by providing nursing assistance whenever required.
This provision of nursing assistance in a number of children’s and
maternal illnesses, half the expenditure being paid from Central and
half from local funds, will, I trust, soon be followed by a general
provision of nursing assistance from public funds.

The recent epidemic of influenza has taught us several important
lessons—First, we have been painfully reminded that we are completely
ignorant of the causes of the pandemic waves of this terrible
disease, which, at irregular intervals of years, traverse the
world. We may surmise that the crowding and the mental and physical
depression of war caused increased rapidity of spread and a greater
fatality in the present outbreak; but influenza has spread and been
only less fatal than in the present outbreak when there was no war,
and we must admit our ignorance of the cause of this.

Numerous investigators in many lands have been striving to illumine
our ignorance; but until success crowns their efforts, it is well to
admit that on the large scale all attempts to prevent the spread of
influenza have failed.

But, in this disease, as in measles, this failure in prevention is no
reason for refraining from every possible effort to restrain death.
In every country and in nearly every invaded district, many sick were
unable to obtain adequate nursing and other domestic care. Here and
there organized mobile team work partially overcame the difficulty;
but the one lesson which emerges from this great pandemic is the
necessity for having in every area a large nursing reserve. Here is
one of many spheres of utility, which should, I think, be occupied by
Red Cross workers, who have done such admirable work during the Great
War.

Many of these Red Cross workers were not fully trained before the
war, but intelligent workers under stress of circumstances showed
themselves competent in many instances to undertake highly skilled
work; while a much larger number under the supervision of more fully
trained nurses and doctors were able to carry out satisfactorily the
routine but still extremely important work, of ordinary nursing.
During the influenza outbreak many such “Nursing Aids” did admirable
work, and the epidemic has demonstrated once for all the absolute
necessity of having available a large number of such nursing aids.
Cannot these be employed on a large scale when no epidemic is raging?
Is it necessary for every case of sickness that a fully-trained nurse
should be engaged? Would not the physician be equally satisfied in a
large proportion of his cases, if he had available a less elaborately
trained assistant, who understood personal hygiene thoroughly, who
could give an enema, could take temperatures, and would follow
instructions implicitly and intelligently?

Incidentally I consider that some such modified and simplified
training in actual nursing would form an adequate background for
the special training required to obtain a competent school nurse,
tuberculosis nurse, or public health nurse (health visitor); and that
under present conditions a three years’ training as a nurse is not
the best foundation on which to build the special training required
for these public health nurses.


                           _Tuberculosis_

7. A serious penalty of war conditions has been the increase of
tuberculosis. It is not surprising that the crowding in barracks,
the overwork and overstrain, the dirtier habits, and risks from
expectoration in massed communities, should have increased
tuberculosis among soldiers; both by activating latent tuberculosis
and by introducing new infection. Nor is it surprising that under
analogous conditions tuberculosis has increased among women,
especially at the ages in which the enormous increase in their
industrial employment has taken place.

The national anti-tuberculosis arrangements which were made in
connection with the National Insurance Act had scarcely been fully
organized when the war began. At an early stage it had become plain
that in essentials non-insured must be provided for as well as
insured, and Government grants of half the approved expenditure on
the treatment of tuberculosis in the general population endorsed this
principle. There was no reason, therefore, for the continued separate
existence of the “Sanatorium Benefit”; and had it not been for
political considerations the treatment of tuberculosis would probably
already have been handed over to public health authorities, while
leaving intact the general provisions of the National Insurance Act
as to monetary payments and benefits. The same transference should
apply also to the treatment of any disease undertaken at the public
expense. The treatment of disease, especially in its more difficult
specialist and institutional branches, should become a matter of
communal provision, to which every person would be entitled as he is
to the common provision under our system of elementary education, or
to the common use of free libraries and of drinking water.

There is needed a widely extended propaganda against tuberculosis.
The public as well as the medical profession need to be educated,
the latter in the carrying out of complete and prompt notification
of cases of the disease, and in the use of all facilities provided
for aiding diagnosis; the former in the risks of industrial
and other dust infections, of indiscriminate expectoration, of
alcoholism, of imperfect nutrition, of bad housing, and so on.
We all need to learn the folly of imperfect measures against
tuberculosis. Complete success can only be attained if we assume
responsibility for the whole course of the life of the consumptive.
Not only must educational sanatoria be provided—and, still more
important—hospital treatment for all the emergencies of the disease
and in advanced disease; but in the quiescent intervals assistance
must be forthcoming to cover the margin between a living wage and the
earning capacity of the ex-patient, and economic assistance must be
provided for protecting the patient, and still more his family, from
defective nutrition and from infection. To stop short of this is to
be extravagantly parsimonious; to do this is to economize in sickness
and to secure increased efficiency in future generations. What better
work can be thought of for Red Cross volunteers than in supplementing
the work already carried out by anti-tuberculosis organizations and
in extending and systematizing these agencies. Is not such peace work
equal in importance with the war work which Red Cross workers have
already accomplished?


                         _Venereal Diseases_

8. Venus and Mars are always closely associated, and it is a
lamentable fact that one heritage of the war will be a great
increase of venereal diseases in our midst. In England we had become
thoroughly aroused to the magnitude of this evil even in peace
time. The report of the Royal Commission on Venereal Diseases and
the propaganda since actively carried out, have led to the taking
of measures which I can only briefly enumerate. The duty has been
imposed on every county and county borough council of providing aids
to pathological diagnosis, and of providing clinics for the treatment
of these diseases for all comers, irrespective of residential or
monetary conditions. These clinics have been generally started
throughout the country, and their use has been widely advertised and
encouraged by propaganda in the form of lectures and addresses in
factories and to various social groups, and by public advertisement.
In addition an enactment has been secured absolutely prohibiting
the treatment of venereal diseases except by qualified medical
practitioners, and prohibiting the advertising or offering for sale
of any remedy for venereal diseases. In addition, arsenobenzol
preparations are supplied to medical practitioners who have
experience in their use for their own patients.

These measures do not cover the entire ground. The enforcement of
police regulations against vice, the detention of infectious persons
who cannot be trusted to refrain from spreading disease, the raising
of the general standard of sexual morality—until public opinion
demands that it shall be as high for men as for women—are among the
reforms which are called for.

In encouraging social reform in these directions Red Cross workers
have a most fruitful field of work, and they can render invaluable
assistance in removing a canker which at present eats into the vitals
of the community, and is responsible for untold suffering in women
and children, for premature old age and paralysis in men, and for a
large share of the total inmates of our lunatic asylums.


                     _The Mother and the Child_

9. I have left myself but scant time to speak of what is at once
a chief lesson of the war and the most pressing problem in the
preventive medicine of the immediate future. I refer to the need
for more complete protection of motherhood and childhood against the
dangers besetting them.

It would be a mistake to assume that only since war began have
efforts both by sanitary authorities and by voluntary agencies been
made on a large scale to diminish infantile and maternal mortality.
But during the war, and since it terminated, these efforts have been
redoubled and are becoming universal; and there is opening out a
prospect of safe maternity for mothers and of protected infancy for
all newcomers on the stage of life. If only we are prepared to do
what is almost immediately practicable for this end, death or injury
associated with child-bearing will become rare, the loss of infant
and child life will be halved, and what is still more important,
mothers and infants will cease to be damaged by neglect or ignorance
at critical periods of their life, and will not become burdens to
themselves and to the community.

This is no visionary dream. Past experience shows that it is within
reach. What other interpretations can be placed on the facts revealed
in official reports?

I am unable to quote Canadian figures; but I am justified in assuming
that differences similar to these I am about to quote from my own
reports exist also here. The average number of deaths of mothers
from complications arising during pregnancy, and at or after
confinement, are one maternal death for every 250 infants born
alive. In some parts of England instead of four mothers, six or even
eight or nine mothers die for every thousand infants born. There
are marked differences in maternal mortality in neighbouring towns
and districts; and the only conclusion which fits in with the facts
is that, in many parts of the country, the arrangements for medical
attendance on mothers at and before their confinement are inadequate
or deficient in quality or both.

The Maternity Benefit under the National Insurance Act, though a
valuable evidence of the interest of the State in maternity, has
not provided a sufficient remedy. It was an unconditional benefit
limited to insured women or the wives of insured men, and there
was no guarantee that the money allotted would be utilized in
supplying the medical, midwifery, or nursing assistance needed by
the patient, or in relieving her from domestic duties which she is
unfit to perform. It was furthermore, inadequate for these purposes.
We should not think of handing over to each individual householder
an annual sum of money, advising him to expend it on a supply of
books or in the education of his children. It is more economical
and more effective to provide free libraries and public elementary
schools without payment of fees. Is not similar action important in
connection with child-bearing, on which the continuity of family life
and civilization depends? That this is so is recognized in the steps
towards the desired end taken in recent years by the Local Government
Board jointly with local authorities. Let me enumerate some of these.
The Central Authority have undertaken to pay one-half of approved
expenditure incurred locally on the following agencies:

(_a_) The salaries and expenses of inspectors of midwives;

(_b_) The salaries and expenses of health visitors and nurses engaged
in maternity and child welfare work;

(_c_) The provision of a midwife for necessitous women in confinement
and for areas which are insufficiently supplied with this service;

(_d_) The provision, for necessitous women, of a doctor for illness
connected with pregnancy and for aid during the period of confinement
for mother and child;

(_e_) The expenses of a Centre, i.e., an institution providing any or
all of the following activities: Medical supervision and service for
expectant and nursing mothers, and for children under five years of
age, and medical treatment at the Centre for cases needing it;

(_f_) Arrangements for instruction in the general hygiene of
maternity and childhood;

(_g_) Hospital treatment provided or contracted for by local
authorities for complicated cases of confinement or complications
arising after parturition, or for cases in which a woman to be
confined suffers from illness or deformity, or for cases of women
who, in the opinion of the Medical Officer of Health cannot with
safety be confined in their homes or such other provision for
securing proper conditions for the confinement of necessitous women
as may be approved by the Medical Officer of Health;

(_h_) Hospital treatment provided or contracted for by local
authorities for children under five years of age found to need
in-patient treatment;

(_i_) The cost of food provided for expectant mothers and nursing
mothers and for children under five years of age, where such
provision is certified by the Medical Officer of the Centre or by
the Medical Officer of Health to be necessary and where the case is
necessitous;

(_j_) Expenses of creches and day nurseries and of other arrangements
for attending to the health of children under five years of age,
whose mothers go out to work;

(_k_) The provision of accommodation in convalescent homes for
nursing mothers and for children under five years of age;

(_l_) The provision of homes and other arrangements for attending to
the health of children of widowed, deserted and unmarried mothers,
under five years of age;

(_m_) Experimental work for the health of expectant and nursing
mothers and of infants and children under five years of age, carried
out by local authorities or voluntary agencies with the approval of
the Board;

(_n_) Contributions by the local authority to voluntary institutions
and agencies approved under the scheme.

Grants will be paid to voluntary agencies aided by the Board on
condition:

1. That the work of the agency is approved by the Board and
coördinated as far as practicable with the public health work of the
local authority and the school medical service of the local education
authority.

2. That the premises and work of the institution are subject to
inspection by any of the Board officer’s or inspectors.

3. That records of the work done by the agency are kept to the
satisfaction of the Board.

Possibly much of the past failure to protect maternity and to
reduce the still-births and mortality among infants under a month
old has been due to the erroneous assumption that damage to health
and life at these times is in the main inevitable. That this is
not so for maternal mortality is proved by the great difference in
experience of sickness and death for mothers in different social
strata and according to the availability of skilled midwives and
doctors. There are similar differences locally and socially in the
proportion of still-births. Wassermann tests, followed by appropriate
medical action, in all instances in which there have been previous
miscarriages or in which for other reasons syphilis comes under
suspicion, and subsequent action based on the diagnosis thus secured,
would at once greatly reduce maternal and infantile mortality. So
also would systematic examination of urine during pregnancy and the
ascertainment that in other respects the physical conditions of
normal parturition are present. These are adequate reasons for the
establishment of ante-natal consultations, which happily are rapidly
increasing in England under the stimulus of the Government grants
already mentioned.

The further fact that about one-third of the total deaths in the
first year after live-birth occur in the first four weeks of life,
adds force to my plea for the establishment of these ante-natal
consultations in connection with all lying-in institutions and at
child welfare centres, where infants and children up to school age
will be submitted to periodical medical examination and supervision.

It has been erroneously asserted that the greater part of this early
infant mortality is unavoidable; but careful examination of national
and local statistics shows that in some places it is twice as high as
in others, and examination of the causes of death in the districts
with more favourable mortality shows that their experience can be
improved. All experienced obstetricians and pædiatricians will agree
that, given adequate care of the mother during pregnancy, skilled
care by a competent obstetrician during labor, and satisfactory
medical and nursing care in the following month, there can be secured
large reductions in the early infant mortality of the first month
after birth, as well as in the number of still-births and in the
present toll on maternal life.

In early infancy, as in advanced old age, the hold on life is
slight, normal and abnormal are soon interchanged, and there is
needed not only more knowledge on the part of mothers and nurses,
and even of physicians, of the hygienic side of medicine as applied
to the physiological life of the mother and her infant, but also
personal care and assistance to enable the mother to apply the
useful information and advice given by the public health nurse. I
lay special stress on this association of counsel and assistance.
It is important also that nursing and medical assistance should
be so given as not to create a feeling of dependence. In view of
the wide provision of medical assistance from public funds which
already obtains, I submit that poverty tests in the giving of such
assistance should be abolished, or that, at least, the availability
of such assistance should be greatly extended. Given the fulfilment
of this condition, it will be practicable to enlist the remunerated
coöperation of the medical profession in a general provision of
medical and nursing facilities, which will secure the early detection
of disease of every kind and its prompt and adequate treatment. Not
only so, but the same service can be utilized for the preservation of
health by securing the change of habits and customs and conditions of
housing or work which are likely to prove detrimental.

I have laid stress on the ideal after which we must, in my opinion,
strive. Meanwhile, it is essential that we should not regard the
mere removal of ignorance as the _summum bonum_. This is plain when
we come into close contact with the facts of life as lived by the
greater part of the wage-earning classes.

Has the wife of the wage-earner domestic help such as her well-to-do
sister possesses? Is there a nurse to help her even when the children
are sick, much less while they remain fairly healthy? How often has
every kettle-full of water to be heated separately on a stove? Under
such circumstances is it reasonable to expect the cleanliness which
is an indispensable condition of health? Is there a clean supply of
milk for every working-man’s family and are there arrangements for
sanitary and cool storage of food in his dwelling?

And so we might go on multiplying questions, knowing that, if
the answers are well-informed and candid, they will confess that
the mothers of the wage-earning classes, especially in our large
cities—in England, if not also here—have not a fair chance to keep
themselves well, or to rear a healthy and robust family.

I do not wish to stress this view of the case; but I have said enough
to justify the action of the British Government in deciding during
the war—and announcing the fact in more than one official circular
issued to all Local Authorities by the Local Government Board—that,
next to the active pursuance of war, measures for promoting maternal
and child welfare ranked next in importance, and that no efforts must
be spared to continue and extend such measures. And the history of
the last four years shows that this has been done. The central grants
for special maternal and child welfare work undertaken by local
authorities and voluntary agencies have increased twelve-fold, the
number of health visitors has been more than doubled, and the number
of maternity and child welfare centres has increased five-fold; and
coincident with these facts, infant mortality, which was falling
before the war, has continued to decline steadily during the war,—the
corrected figures for the years 1912-17 respectively were 104, 117,
113, 111, 98, and 94—although the number of mothers employed away
from home has greatly increased during the same period.


                  _The Work of Voluntary Agencies_

I have several times in this address mentioned the valuable work of
voluntary health agencies. No official can fail to recognize that
pioneer work is commonly started by them; and it has often happened
that only when the evidence of its value has become obtrusive has
it been taken over by local authorities. This is the true function
of voluntary agencies, and will remain so, until local authorities
(which after all are manned by voluntary workers) become saturated
with the ideals of voluntary workers and of the new women-voters.
Local authorities always have one great advantage over voluntary
societies, that their action can be supported by legal powers.

The proper attitude of voluntary workers is to initiate and
demonstrate the value of reforms, to persuade local authorities to
adopt them, themselves to become members of these local authorities
to ensure this end, and thus eventually render the voluntary
organization for the object in question superfluous. There need be
no fear; openings for further desirable voluntary work will always
appear, as official work increases. In the main, however, the care
of the health of the people is a governmental function, whether it
has to do with the prevention of sickness or the satisfactory medical
treatment and nursing of the sick.

There is no early prospect of voluntary workers becoming unnecessary;
for average human nature, as represented on governmental bodies, is
shortsighted and needs much education, morally and intellectually,
before it will undertake the whole sphere of work called for in the
interest of the welfare of the mother and her child. Hence my plea
that the magnificent potentialities of the Red Cross organization
should not be allowed to fall into abeyance; that they should replace
their relief work by preventive work; that, to use a well-known
simile, they should erect a parapet at the top of a dangerous cliff
as well as provide ambulances at its foot. In so doing they will, I
am confident, not encroach on present successful work of existing
bodies concerned with promoting child welfare, or with the prevention
of tuberculosis or of venereal diseases, or with existing agencies
for providing nurses for the poor. But they can supplement the
efforts of these organizations; they can bring monetary as well as
personal assistance; and they can, above all, bring a mass of public
opinion to bear on local and central governing bodies which will
lead to the only real economy, which consists in expenditure on an
adequate scale, bringing to the aid of the families of the people the
preventive, the medical, and the nursing facilities of which they
remain in need.


FOOTNOTES:

[13] An address to the Academy of Medicine, Toronto, June 20, 1919.




                             CHAPTER VI

          THE INTER-RELATION OF VARIOUS SOCIAL EFFORTS[14]


On examining the local city directory, one cannot but be impressed
by the multiplicity of voluntary organizations having for their
object the immediate relief of destitution or the social or economic
“uplift” of sections of the population. The multiplicity of these
agencies becomes more striking when one remembers that probably
every one of the hundreds of churches and chapels in the city has
its periodical sacramental and other collections for the poor, and
may have also a system of parochial district visiting, with such
auxiliary assistance as is provided through mothers’ meetings, etc.
Nor does this exhaust the possibilities of social help available
for the poorer members of society in cities in which there is a
satisfactory distribution of rich and poor, that is, in which the
segregation of different social strata in separate areas has happily
not befallen. There is the further help provided by individual
charity, the amount of which in the aggregate probably exceeds
beneficence through churches and social agencies.

If these different agencies could pool their resources, while
retaining the enthusiasm and driving power of separate organization,
what an economy of effort and what increase of efficiency would
result, especially if these agencies were also satisfactorily related
to the official organizations of local and central governing bodies
having the same object!

But I am not concerned this evening to discuss the machinery of
social help or the attempts already made in different centres for
securing their satisfactory coöperation. Nor am I disposed to discuss
the economic problems underlying the need for social assistance of
the poor. Ideally we must agree with St. Augustine’s statement:
“Thou givest bread to the hungry; but better were it, that none
hungered, and that thou had’st none to give him.” My present object,
however, is to set out some elementary—and when stated fairly
obvious—considerations bearing on social evils and their remedies
under present conditions of society, the recollection of which
if followed by practical action, would secure greatly increased
efficiency in social work.

For the following reasons I do not hesitate to bring this subject
before a gathering of graduate medical students:

First.—Every physician as soon as he engages in medical practice
almost immediately comes into touch with organized and unorganized
social workers, and his success—personal as well as communal—can
almost be measured in terms of his outlook towards their work;

Second.—The physician, with his scientific training in the tracing of
effects back to their causes, is in a specially favourable position
to promote rational as contradistinguished from empirical social
help; and

Third.—The physician is now learning to appreciate that he can
only treat his patients satisfactorily in the light of knowledge
of their social, including housing conditions, of their industrial
relationships, and of their personal history and habits of life.

This is the age of anxiety to give social help.

I hold strongly the view that ere many of you are advanced in years
the fundamentally important social help which is constituted by
adequate medical attendance will be provided, for all who wish to
have it thus, at the expense of the state, i.e., coöperatively by
means of common charges on every member of the community according to
his means, exactly as elementary education is now provided. This will
involve radical reconstruction of the relationship between hospital
and private medical practice, and will, I trust, include also the
introduction of preventive medicine into the practice of every
physician. But this is in the future. How can medical practice under
present conditions, and how can non-medical social agencies, be made
subservient to the fullest extent to the welfare of the community?

A few elementary illustrations will show the many unexploited or only
partially exploited or misused opportunities for efficient social
help.

The greatest science is to know the causes of things; and there is no
branch of work in which this is more important than in medicine. But
causation is complex. A given result commonly follows from a chain,
or it may be a bundle of events: and as we shall shortly see the end
links of the chain are oftimes joined, thus forming a circle.

If a man shoots a companion with whom he has quarrelled, it may be
urged that a more rigid system of license for the use of firearms
would have prevented the calamity; that the companion was also
quarrelsome; that the homicide had been the spoiled child of his
mother and had not had a satisfactory up-bringing; and that he
inherited from his father a violent temper; but none of these
circumstances,—all of which may have contributed to the murder,—is
likely to succeed in preventing the murderer from being hanged after
due trial.

It would be difficult to find a more striking instance of the linking
of elements in causation than in the origin of a case of malaria.
For the transmission of this disease two human beings, one already
infected with the specific contagium, and a mosquito are required,
and the chain of causation can be broken at the infecting person,
by strict screening from mosquitos, and by the use of quinine; at
the mosquito by preventing its emergence from the larval stage, and
later by preventing its access to the patient; or at the prospective
patient, possibly by prophylactic medication, more certainly by
strict screening from mosquitos. Hence one might claim lack of
segregation of infected persons, lack of screening of the healthy,
failure to drain marshes, to apply oil to the surface of stagnant
pools, or to adopt allied measures destroying the larvae of mosquitos
as each of them the cause of malarial disease.

There is a constant excess of sickness among the poor as compared
with the well-to-do. Measures for the relief of poverty, therefore,
may be regarded as within the scope of the physician’s prescription.
This may be accomplished for the moment by monetary or material help;
but unless the causes of poverty are sought out and counteracted, the
assistance given is merely palliative. For nothing is more certain
than that poverty tends to become a self-perpetuating condition.

Thus poverty leads to premature employment of children, with
detriment to their normal growth, followed by diminished efficiency
in adult life. This implies low wages throughout life, and so poverty
is passed on to a second generation.

Evidently timely assistance to induce the parent to delay employing
the boy, until he has been prepared for work, and to ensure his
being put to work which will not be a “blind-alley” occupation, might
have obviated the evil chain of events.

Poverty again when carried to the point of destitution may tempt
to larceny; this may be followed by loss of employment, and so the
temporary unrelieved poverty is liable to become permanent.

Intemperance has been almost wiped out as a cause of disease in
the United States; and we have in the fact that the whole country
has “gone dry” a remarkable example of a “short-cut” towards
social salvation from alcoholism which will be most instructive.
Apart from such universal prohibition of alcoholic beverages, the
physician has to think of an alcoholic patient under his care as
the possible victim of one or more or all of several coöperating
influences conducing to intemperance. The alcoholic habit may have
been gradually acquired as the result of protracted social indulgence
in moderation acting on a person of unstable mental constitution;
it may, especially in wage-earners, have been hastened by the evil
custom of treating. It not infrequently follows overwork, with
the associated feeling of need for stimulants; it accompanies bad
housing, with unsatisfactory sleeping accommodation; and it is aided
by poor and badly cooked food, due to shiftlessness, overwork, or
lack of domestic training of the man’s wife. If there is to be
successful control of alcoholism, action in all the directions
briefly indicated above, and in other directions which will suggest
themselves, is necessary; and although the physician cannot himself
do all this, his efforts should run parallel with social efforts in
these directions.

Even when the “short-cut” of compulsory abstinence has been taken,
the efforts indicated above are still needed; for alcoholism is
not the only resultant of bad social habits, of overwork, of
unsatisfactory feeding, of deficient sleep, and so on.

Perhaps even more far reaching in their evil effects than
intemperance are the Venereal Diseases. As you know, special efforts
during and since the war have been made to limit the spread of these
diseases. I do not propose to trouble you with statistics to prove
the mischief caused by these diseases. Has not Osler said that the
whole of clinical medicine can be taught around syphilis, and that
it is the third in importance of the killing diseases? And as a
further illustration, let me add that no less than one-tenth of the
total accommodation in our lunatic asylums might be dispensed with if
syphilis were eliminated.

Among the measures being taken to combat these diseases are
educational propaganda, and the provision of clinics, free for
all, at which patients may be treated promptly and adequately. It
is evident, however, that if the medical and educational efforts
now being made are to succeed they must include recognition of
all the factors causing sexual vice, and appropriate action in
respect of each of these—they must indeed go further than this; for
self-restraint is a wider problem than in relation to exposure to
these diseases. It embraces the whole subject of formation of the
habit of self-control. One of the most striking facts in the great
war has been the extent to which young girls of previously decent
behaviour have fallen victims to what has sometimes appeared to be
passion combined with a perverted form of patriotism; and one of the
measures most called for is better mothering and maternal training
of both girls and boys. The problem is one of special difficulty as
regards the economically independent girl; and to shield her the
combined efforts of home influence, of girls’ clubs, and of various
social and religious organizations are all required.

Judicious and restrained teaching of the physiology and hygiene of
sex would do much to counteract the evil influence of bad teaching
by companions; and in emphasizing this duty on parents the physician
may do untold good. So also, especially when the daughters of his
patients are about to marry “men of the world,” he should urge
the need for asking a satisfactory certificate from the intended
bridegroom of freedom from infection.

The influence of unaccustomed alcoholic indulgence in leading to the
first “slip,” often with the production of life-long disease, is well
known.

Nor must we leave out of account the tolerance of vice in
conversation between young men, as a frequent excuse of and even
excitant to vice. The happiest young man is he who can go to the
marriage ceremony with the same sexual purity as is even now
expected from the bride. Is it too much to expect that our social
conscience will grow up to this standard? I think not; and when this
point has been reached, venereal diseases will have almost entirely
disappeared, and the sum total of human happiness and efficiency will
be enormously enhanced.

Meanwhile partial remedies must be pushed for all they are worth—and
this is much. Fear of consequences may deter some from vice; fear
of consequences to future wife and child form a much more potent
argument. Treatment of venereal diseases, especially of syphilis,
is a most valuable means of preventing their spread. This treatment
may be urged even at the stage after exposure to infection before
any symptoms of illness appear; and the more promptly this is done
the more successful is it. There has been much heated debate as to
whether persons known to intend to expose themselves to possible
infection should be provided with disinfectant or other arrangements
for obviating infection. This cannot be done without some loss of
moral position; it almost makes the provider a co-partner with the
sensualist. It may be urged, however, but with dubious cogency,
that if the man is told beforehand that immediately afterwards he
can have access to disinfectant provisions, the same objection holds
good. I do not regard the provision of “outfits” as wise. Evidence
tends to the conclusion that they are commonly not used efficiently;
and there is a distinct loss in the moral position by their use. The
whole subject is one of great difficulty. The prevention of venereal
diseases is clearly, however, not merely a medical problem; and the
physician who realises this and throws the weight of his influence,
in warning and in counsel, on the side of moral restraint, is adding
greatly to the value of his social service to the community.

Other instances will occur to you, illustrating the importance
of a broad outlook in the causation of disease or other forms of
social misery. I will adduce one more. It is well known that infant
mortality is much heavier among the poor than among the well-to-do.
The rule does not hold universally in rural areas, but in towns it
applies almost without exception. And it is assumed by a large school
of social workers that enlightenment of the ignorance of the poor
mother will effectively correct this evil. Such a lop-sided view
ignores many of the elements of the problem of infant mortality.
Think for a moment of the contrast between the working-class mother
of five children living in a small city tenement, and the mother
of an equal number of children in easy circumstances, living in
a residential suburb, and having domestic servants, a nurse, and
a physician always available. The two mothers probably differ but
little in their knowledge of the hygiene of infancy; but the one has
helpers to ensure scrupulous cleanliness, to prevent over-fatigue of
the nursing mother, to detect the first sign of infantile illness and
provide the needed action; while the other mother has to struggle
alone in respect of her infant, without either domestic or nursing
assistance, the struggle being complicated by the fact that the
care of four older children and of her husband is on her shoulders.
Even when there is no actual direct poverty in the working-class
home, the differences thus indicated—supplemented by the inability
of the mother to obtain medical advice for apparently minor
ailments—outweigh enormously the factor of ignorance as a cause of
excessive infant mortality. By all means let instruction be given by
public health nurses or other agencies, and this is most valuable;
but it does not fully meet the needs of the case. There is required
also actual domestic, as well as nursing, assistance in the home of
the overworked working-class mother, especially after the birth of
her infant and when illness attacks any of her children; and unless
the physician realises these elements in the problem, his efforts in
securing the welfare of his patient and in reducing infant mortality
can have but partial success.

The main lessons arising from the foregoing illustrations of medical
and social problems are two: Each evil should be attacked in its
causal relationships; and causation is multiple.

Hence—apart from total prohibition—in attacking alcoholism, the
physician may bless the efforts of tee-total advocates, of those
engaged in reducing the number of saloons, of those securing better
dietetics and cooking, less industrial fatigue, or more satisfactory
domestic sleeping accommodation, and of parents and teachers engaged
in promoting self-control in the young as a habit of life; and he
will call them all in aid of his curative and preventive life work.

So, also in the control of venereal diseases, early and prompt
diagnosis and treatment must go hand in hand with police measures for
the suppression of prostitution, with educational work respecting
these diseases, and with the inculcation of a higher standard of
morality, considered as part of the general cultivation of moral
self-restraint.

And in the prevention of infant mortality and of the even more
serious handicapping of the up-growing child produced by the factors
of infant mortality, we need to bring to bear all our medical and
hygienic knowledge, and to realise that until every mother in the
land is furnished with the elementary requirements, domestic,
sanitary, social, and medical, for rearing a healthy family, we have
no right to mental comfort while enjoying these elementary needs of
family life ourselves.

Coöperation and solidarity of effort are needed on the part
of the multitude of workers engaged in social work for the
community—official and non-official; and in bringing this about the
physician of the early future will, I am confident, take a leading
part.


FOOTNOTES:

[14] An address to the Alpha-Kappa-Kappa Club, Johns Hopkins
University, Wednesday, December 10, 1919.




                             CHAPTER VII

         THE OBSTACLES TO AND IDEALS OF HEALTH PROGRESS[15]


There are two ways in which Health Problems can be approached: what
may be called the microscopic method, which examines in minute detail
each individual problem; and the conspective method, in which an
attempt is made to obtain an unbiased and comparative view of the
chief problems concerned, in order that their relative importance may
be assessed, and the possibilities of improvement may be gauged. In
proposing to myself the latter and more difficult task, I appreciate
the impossibility of discussing all the items which emerge.

I would not have us forget what has already been achieved. Taking
the national figures for England and Wales as an illustration, it
is noteworthy that the death-rate from all causes fell from 22.4
per 1,000 of population in 1846-50 to 13.8 in 1911-15, a reduction
of nearly 40 per cent. Comparing the decennium 1871-80 with the
quinquennium 1911-15, the incidence of reduction of death-rate at
different ages was as follows:

                _Percentage reduction in death-rate_

     Age

     0-5                42
     5-10               48
    10-15               43
    15-20               46
    20-25               51
    25-35               50
    35-45               42
    45-55               25
    55-65               15
    65-75               10
    75-85                7
    85 and upwards      15

The survey is saddened by the terrible losses of War, and the even
more devastating ravages of influenza; and we realize our inadequacy
to prevent catarrhal infections, until further research into
preventive possibilities proves successful, and until the standard
of universal conduct for catarrhal affections becomes much higher
than at present. We realize furthermore that probably at least half
the deaths from all causes which occur could be postponed until old
age. But the standard of health of the general population has greatly
improved; typhus has practically disappeared under peace conditions;
yellow fever approaches its demise; malaria and typhoid are
controllable; tuberculosis and venereal diseases are only waiting for
systematic, complete, and continuous measures to secure their rapid
decline or actual disappearance; the mortality from childbearing and
of young children has greatly declined; and this is an incomplete
statement of what has already been done.


                             _Obstacles_

This improvement is all the more remarkable in view of the additional
obstacles imposed to health improvement by modern conditions of urban
and industrial life.


                           _Urbanization_

The population during the last century has steadily flocked to the
towns from country districts. Streets have taken the place of green
fields; rows of unsatisfactory dwellings have replaced country
cottages; we have dust and belching smoke and noise instead of
sunshine and country air and quiet; bustle and turmoil instead of
life in close touch with mother-earth: and this change has been
associated with an almost unlimited inter-communication of human
beings, and a corresponding increase in opportunities for the
convection of germs of disease.

Until the time of the industrial revolution in England modes of
locomotion were little if any more advanced than among the ancient
Egyptians; and disease, when it travelled at all, travelled by slow
and deliberate stages. Now the infections of the entire world may be
sampled in any one district in the course of a few weeks. Man has, in
fact, reverted from the land-tied condition involved in agriculture
to the migratory habits of an earlier period of man’s life on the
earth. As Wells has put it: “in every locality ... countless people
are delocalised,” and it is not the least evil of urbanization that,
in consequence of this, the administration of local affairs falls
too often “into the hands of that dwindling moiety which sits tight
in one place from the cradle to the grave,” or of persons who have a
financial axe to grind.

The difficulties of water supply, of scavenging, and of drainage,
until they were overcome, have made towns the inevitable destroyers
of mankind. The conditions of housing are worse in towns than in
country districts, higher rents and less ground space implying that
each family on an average lives in fewer and more crowded rooms than
in rural districts.

Furthermore, in towns there is greater difficulty in securing
satisfactory arrangements for the storage of food, especially milk,
and in obtaining fresh milk and vegetables; and there is the serious
disadvantage, especially for children, that their playgrounds are in
streets instead of the fields, and that the possibilities of deriving
infection from dried expectoration and from fæcal or other organic
contamination in yards and backstreets as well as directly from other
children or adults are multiplied manifold.

Even more important, town life for the father of a family generally
means an indoor and often a dusty indoor occupation; the mother
not infrequently is also industrially employed; and these adverse
circumstances, so far as they are allowed to continue, now affect
three-fourths of the population of England and Wales and probably
one-half of that of the United States.

And yet the death-rate from all causes, and especially from
communicable diseases is steadily declining, to an even greater
extent in urban than in rural communities.

It is but fair to add that the differences between urban and rural
populations tend to decrease; at least this is so in England;
probably the same is true to a less extent in America. The nominally
rural population is becoming more and more urban in character, and
composed not solely of rustics,—who live in and by the soil and are
altogether more natural in their habits,—but largely of town-dwellers
who only sleep in country dormitories. But this makes it all the more
remarkable that notwithstanding the multitudinous circumstances which
have tended to increase disease, the death-rate has been lowered to
an amount already indicated, and life has been prolonged to an extent
which has secured an increase in its average expectation of 10 or 11
years within the last thirty years.


                           _Industrialism_

Considerations of time render it impracticable to discuss in this
address the mischievous influence of modern industrialism on national
health. This influence runs collaterally with that of urbanization;
and in it in the past can be seen the evil results of overwork, of
dust inhalation, of chemical poisoning, of industrial infections
including tuberculosis, and of the general depressing effect of
protracted monotonous work. The evils of industrialism like those of
urbanization are happily being in a large measure counteracted.


                              _Poverty_

The problems of industrialism in relation to health cannot be
adequately discussed apart from a consideration of the remuneration
for work, which necessarily depends on the power of the worker to
strike a satisfactory bargain with his employer, and the extent to
which he can ensure regular employment. If these conditions cannot
be fulfilled, or if the breadwinner is dead or disabled, poverty
results, using this word here in the sense of inability to provide
for the personal and family essentials of health. And here we are at
once faced with the problem of relation of population to means of
subsistence. Malthus in 1798 advanced the pessimistic hypothesis that
poverty is the inevitable result of increase of population, which
entitles him to be characterised as the Schopenhauer of Political
Economy, as Schopenhauer was the Malthus of Philosophy. Without
attempting detailed discussion of Malthus’s hypothesis, it is clear
that the wealth of the population depends upon

  1. The amount of food produced,
  2. The amount of materials produced,
  3. The efficiency in preparation of these materials, and
  4. Convenience of transport.

In all these particulars means of subsistence, considered
internationally, have during the last century grown more rapidly
than population; and now, whether we like it or not, a new
element has entered into the problem in this and several other
countries,—voluntary control of births,—necessitating the estimation
of future growth of population on a radically different basis from
that of the past, and banishing the fear of poverty as the result of
too large a population.

It may even become necessary to adopt some method of national
remission of taxation or subsidisation of wages in accordance with
size of the family, not only in France, but hereafter in England, if
in England, as already in France, the voluntary control of births is
practised to an extent resulting in a stationary or even a decreasing
population. In America the possible need for such action will not
arise for several generations, during which, however, unless the
present trend of events is changed, Roman Catholics appear likely
largely to replace Protestants, and the Slavonic and Irish to
preponderate over the Anglo-Saxon elements of the population. It is
possible, of course, that in another generation the Roman Catholic
Church may not be able to continue its ban on birth-control, and that
the more “backward” (?) races will adopt similar devices, including
even the Japanese and the Chinese.


                     _The Malthusian Hypothesis_

(_a_) The Malthusian hypothesis has been held to justify _the laissez
faire, laissez aller_ policy which held the industrial world in its
malignant grip during the latter part of the eighteenth and the
earlier part of the nineteenth century, and from which we are not yet
completely freed. Workers were exploited and reduced to a position
of modified slavery; and this was assumed by clergy and political
economists alike to be part of the ordered course of life. This
doctrine was made to support the belief that God had ordained the
poor man’s lot, with its attendant misery and hopelessness.

On page 438 of the sixth edition of his book Malthus says:

 that the principal and most permanent cause of poverty has little or
 no direct relation to forms of government, or the unequal division
 of property; and that, as the rich do not in reality possess the
 power of finding employment and maintenance for the poor, the poor
 cannot in the nature of things, possess the right to demand them,
 are important truths flowing from the principle of population.

In the first edition of his book a more extreme, plainer statement
of the position, as assumed by Malthus, was given, but was omitted
from later editions (the extract is translated by Beale from a French
edition):

 A man born into the world already occupied, if his family can no
 longer keep him, or if society cannot utilise his work, has not the
 least right whatever to claim any share of food, and he is already
 one too many upon the earth. At the great banquet of Nature there is
 no cover laid for him. Nature commands him to go and she is not long
 in putting this order herself into execution.

Malthus supplied the clue which helped to start Darwin on his
epoch-making investigations; and to the present day there are men who
do not appreciate that the mutual aid which is fundamental in human
society is an enemy to the continued operation of natural selection,
and that we cannot revert to natural selection without destroying the
characteristic work of civilization. To think otherwise is the secret
behind German aggression; to act otherwise is to revert to barbarism.
Man has definitely replaced natural by rational selection, and will,
I have no doubt, to a steadily increasing extent replace competition
by coöperation.

(_b_) The Malthusian hypothesis and the policy based on it ignored
the human element in industry. Happily revolt against the strict
application of the _laissez faire_ policy set in soon after
urbanization and industrialism (under the then conditions) began
their maleficient work, first in regard to children, then for women,
and latterly more general in character.

Nothing is more conspicuous in recent years than the growth of
sensibility on the subject of economic evils, especially as to the
conditions of industry. Economic efficiency, as a sole object,
appeared to preclude regard to morality of method, and the result
has been poverty for the masses of mankind. If this is to cease,
satisfactory minimum standards of comfort and welfare for the entire
population must be accepted, which will form a first charge on
industry. This can only be hoped for when there is complete practical
acceptance of the fact that “we are members one of another,” and
servitude is completely replaced by the ideal of mutual service.

(_c_) The Malthusian hypothesis ignores the great though paradoxical
truth, that although under circumstances permitting malnutrition and
defective training, large families spell poverty, especially when
population is not distributed where it is needed, the real wealth of
the world after all depends on man himself. Nature gives him little
that he can use in the form in which he finds it. It is by him and by
him alone that “wealth” is created by converting useless into useful
matter.

It appears to me clear that over-population need not excite
apprehension; that population in itself is the only means by which
national wealth can materialise; and that our chief aim in securing
national efficiency must be to train each unit of the population
adequately for work, and to prevent the terrible loss of efficiency
due to avoidable sickness.

And this brings me to the direct statement of the truism that health
progress can only be secured by preventing preventible illness.

Poverty and disease are allied in the closest relationship; and
while it is true that the removal of poverty would effect a great
improvement in national health, it is even truer that the prevention
of illness forms the most important means for the avoidance of
poverty.

In various reports it has recently been shown that in a number of
districts an inverse correlation exists between infant mortality and
the amount of the family income; the implication appearing to be that
increase of the lower income is the best and perhaps the only method
for obviating excessive loss of infantile life.

In such an argument poverty evidently is considered as an element,
instead of as a highly complex phenomenon needing to be further
analyzed into its constituent parts. In the instance quoted, the
fact that the correlation between poverty and high infant mortality
is not essential can be shown by examples of low infant mortality
in communities in which poverty is the rule; by examples of high
infant mortality in which wages are high; and by other examples of
communities in which high infant mortality has been lowered without
any change in economic conditions.

The social conscience cannot be satisfied until every family has
an income sufficing for all its essential needs; but there are
possibilities of successful attack on infant mortality which can
be pursued when economic change is not within reach, and when such
economic change would not obviate the need for further measures.
Among such measures may be mentioned the abolition of alcoholism, the
provision of a pure and adequate milk-supply, increased attention to
domestic and municipal sanitation, health teaching by public health
nurses, and prompt and adequate medical and nursing assistance when
required.


                             _Ignorance_

It may have surprised you that I have not placed ignorance in the
forefront, before industrialism, urbanization, and poverty, as the
chief enemy of personal and public health. I have no hesitation in
making the statement that although there is need for large additions
to present educational work in hygiene, the utilisation of existing
knowledge by those holding responsible positions is even more
important. Is it not true that it is easier to promote educational
“drives” for any single branch of health education, than to obtain
money for the actual execution of health work?

Let us look more critically at educational work in hygiene. Whose
ignorance is it proposed to enlighten? Ignorance is common to
all classes, and it is fundamentally important that systematic
instruction in physiology and hygiene should be given in all our
schools; and that especially every teacher should have adequate
training in these subjects, and in the recognition of the common
mental and physical defects of children. If a course of instruction
were given for all, approaching that which is given for public
health nurses at Yale University, how much more hopeful would be the
prospect of public health progress, both in New and Old England.
But this does not cover the entire needs of the case. Consider, for
instance, the relation of maternal ignorance to excessive child
mortality.

Maternal ignorance is sometimes regarded as a chief factor in the
causation of excessive child mortality. It is a comfortable doctrine
for the well-to-do person to adopt; and it goes far to relieve his
conscience in the contemplation of excessive suffering and mortality
among the poor.

This doctrine has found favour in occasional official reports and
in miscellaneous addresses. It embodies an aspect of truth, but it
is mischievous when it implies, as it sometimes does, that what is
chiefly required is the distribution of leaflets of advice, or the
giving of theoretical instruction as to matters of personal hygiene.

There is little reason to believe that the average ignorance in
matters of health of the working-class mother is much greater than
that of mothers in other classes of society. Furthermore, it would
appear that working-class mothers give their infants the supremely
important initial start of breast feeding in a larger proportion of
cases than do the mothers in other stations of life.

The mothers in both classes may be ignorant; in both there is
deficient training in habits of observation, especially in regard
to the beginnings of illness; but the mother in comfortable
circumstances is able to ensure for her infant certain advantages
which the infant of the poorer mother often cannot obtain. What are
these?

1. The well-to-do mother is commonly able to devote herself to her
infant and have assistance in this duty; the working class mother is
single-handed, and has also to perform, unaided, all the duties of
her household, including the washing and cooking for her husband and
herself and possibly for several children.

2. The well-to-do mother is commonly able to ensure that the milk
for her infant is purchased under the best circumstances, is stored
in a satisfactory pantry, and is prepared under cleanly conditions.
The working-class mother often is supplied with stale, impoverished
milk, may have no pantry, and, except when suckling her infant, is
handicapped at every stage in the cleanly preparation of her infant’s
food.

3. If the well-to-do mother is ill, adequate medical and nursing
assistance is at once available, and the child’s welfare can be
safeguarded; if the working-class mother is ill, the child usually
must suffer with its mother.

4. If the child of the well-to-do mother falls ill, everything
that good nursing and medical attendance can furnish is commonly
at once available; for the child of the working-class mother the
state of matters is remote from the ideal. Facilities for obtaining
medical attendance and nursing vary greatly in different districts;
but in none are they satisfactory for the poor, and especially for
the classes who have limited incomes, but do not as a rule receive
skilled hospital treatment, or avail themselves of help from nursing
associations. Prompt medical assistance at home commonly cannot be
afforded for children of wage-earners, and particularly not for the
children of unskilled workers.

5. Infants and nursing mothers are very rapidly influenced by their
environment. This environment is complex. The mother is the main
element in the environment of the infant. If she is overworked and
suffers from chronic fatigue her infant must suffer; directly,
because the mother’s milk under these circumstances is liable to be
scanty or impoverished or otherwise unwholesome; or indirectly, owing
to her being unable to give sufficient attention to her infant. The
infant of the well-to-do mother is less likely to suffer in either of
these ways.

6. Not only are the milk supply, and the storage and preparation
of artificial food, important parts of the environment of the
infant, but so also are the housing conditions of the family, and
the sanitary conditions of the back-yard and of the street in which
the house is situate. The superiority of the circumstances of the
one mother and infant over those of the other in these respects is
obvious.

There is no reason to assume that the one mother is more ignorant
than the other. But the ignorance of the working-class mother
is dangerous, because it is associated with relative social
helplessness. To remedy this what is needed is that the environment
of the infant of the poor shall be levelled up towards that of
the infant of the well-to-do, and that medical advice and nursing
assistance shall be made available for the poor as promptly as it is
for persons of higher social status.

The assistance given will include advice, but it will be the advice
which a medical practitioner gives to his patient; which a health
visitor or public health nurse gives as to personal hygiene; and
which a sanitary inspector gives to a householder. It should include
also the advice given by a trained midwife or midwifery nurse, who is
in a favourable position to secure the adoption of her advice by the
mother. Such advice is becoming available to a steadily increasing
extent, but in some industrial towns a majority of midwives and
midwifery nurses are still untrained women, who are not competent to
give the best advice.

I would not have it assumed that I do not attach high values to the
teaching which the physician gives to his patient and the public
health nurse to the healthy mother and infant; but unless this is
combined with assistance to provide the necessary means to health,
whether this be hospital treatment, home nursing, pure milk, improved
domestic conditions, or help to the over-tired mother, the advice
falls far short of its potentialities for good.

There is need for further instruction of the public in all branches
of hygiene; and we need, if we are to be efficient in social work,
to follow the advice of Oliver Wendell Holmes, to remove the
intellectual _membrana nictitans_ from our eyes, and to consider the
physical and moral as well as the intellectual obstacles to health.

In the cultivation of communal health


                       _Defects of Character_

are even more pernicious than lack of knowledge. No member of any
of our local authorities can fail to have been warned that typhoid
fever is still being spread in many communities by impure water, and
as the result of inadequate hospital isolation of cases. The means
of prevention of tuberculosis are well known; but how few local
authorities will face the problem of supplying adequate funds for
clinics, for examination of contacts, for hospitals for bed-ridden
cases, and for convalescent homes; and how few are willing to give
help to ensure that the consumptive patient has a separate bedroom?
In how few instances are the regulations against indiscriminate
expectoration enforced, and how seldom are physicians called to
account for not obeying the law as to prompt notification of cases of
tuberculosis? Will all the “drives” against tuberculosis effectually
remedy this condition of things? Would not public opinion amply
support _the one “drive” which, above all others, is necessary_: a
systematized effort on the part of all social workers to exact a
definite promise from every candidate for local or state office that
he will give earnest support to all well-considered anti-tuberculosis
measures, for the diminution of venereal diseases, for improving the
welfare of mothers and their children, for promoting school hygiene,
and for improving the housing of the poor. Democratic Government,
alas! hitherto, has meant government by active minorities. The great
danger of democracy is that the minority may and often does consist
largely of persons having a mercenary interest in the machinery of
local government. Why should not it become an active and preponderant
minority of health gospellers? This will involve the taking of
infinite trouble to overcome the multiform activities associated
with “political pull”; it will involve the watching of the record
of each elected person, merciless exposure of those who do not
whole-heartedly support reforms, and systematic effort to prevent
the reëlection of all whose record proves unsatisfactory. Are we
equal to this task? Is our national and local patriotism equal to
this heroic test, involving most prosaic work, the surveillance and
the “besting” of the politician? If not, our indirect attack on the
enemy by means of special educational drives can have relatively
little effect. Where the enemy is, there our fight should be; and
the chief enemies of health are local authorities possessing powers
to secure health for the community, who corruptly or parsimoniously
refrain from their duty. Nor can we avoid responsibility, or the
need for strenuous effort after efficiency by not taking part in
official or voluntary administrative work. We may have sufficiently
good reasons for this abstinence; and onlookers have their rôle in
life. If all were authors, where would be the readers? There are many
indifferent writers who would be appreciative readers, and the same
remark applies in local administration. Appreciation is necessary as
well as a subject to be appreciated; and the onlooker at social work
may be most helpful. If he is to be helpful he must be kindly and
charitable, as well as watchful. Rancorous and ill-informed criticism
must be avoided, and the onlooker must be ready to do justice to good
work, or attempted good work. Nothing has made it so difficult to
secure good men to undertake the burden of local government as the
undiscriminating and uncharitable criticism aimed at those engaged
in it. Criticism of representatives has often been deserved; but
critics are too often those who will not aid to the slightest extent
in the work which, often without sufficient knowledge of the facts,
they vilify. When we read of administrative scandals, it is desirable
to have a sense of proportion, and to remember, as the reader of old
records or even of Pepys’ diary will scarcely need to be reminded,
that corruption was rampant in the past, and especially to remember
that the best way to remove that most subtle and mischievous form of
corruption which consists in giving and accepting appointments as
political rewards, is by ourselves taking a part in local government,
or by steadily upholding those who are doing so with integrity.

The onlooker, then, has his duty to perform as well as the
administrator. He cannot do his duty unless he intelligently studies
local administration, even though he takes no part in it. A chief
need is this interested study of the phases of local administration
by the general inhabitants of each district. Happily there are
indications of the increasing local patriotism which such study
implies. The exact knowledge thus acquired is the best means
of neutralising much of the ill-natured, because ill-informed,
criticism with which the founts of local administration are too often
fouled. A high moral ideal on the part of onlookers as well as of
administrators is needed if we are to secure that high standard of
social efficiency which is an indispensable condition of the further
triumphs of preventive medicine now waiting to be secured.


                              _Ideals_

In my discussion of the difficulties of health progress, I have
evidently encroached here and there on the second division of my lay
sermon. Let me now attempt to state more systematically some ideals
of health and means for their realisation.

Intelligent human society, permeated more than we realise by the
essentials of Christianity, has already gone far in securing
remedies, notwithstanding the too frequent other-worldliness or
lack of vision of those who should have been foremost in rebuilding
Jerusalem in this green and pleasant land. Industrialism no sooner
huddled together labourers and their families in the courts and
alleys of insanitary towns and overworked them for scanty wages, than
the voices of such philanthropists as Percival, Oastler, Shaftesbury,
Owen, and of many others were heard in favour of interference with
that freedom (!) of contract between workers and employers, which the
professors of the dismal science regarded as a fundamental principle
in political economy. And so gradually, too slowly, regulated
industry, improved sanitation, better housing, the isolation and
hospitalisation of infectious cases, the readier access than in rural
districts of all sick to skilled treatment, higher wages, better
food began to counteract the evils of industrialism and urbanization.
Communal action was taken in the regulation of industry, in the
promotion of sanitation, in providing elementary education; and the
result is seen in the remarkable fact that, notwithstanding its
enormous handicap, urban life has become almost as safe as rural
life, so far as life itself is concerned, though not in standard of
health.

The first lesson, then, which has already been partially learnt, is
that _no member of a community can live to himself_. We now believe
in the solidarity of society; that the sores of one section of it
means peril for all. And we are gradually learning to appreciate
that this is true not only in respect of the acute infectious
diseases, and of chronic infectious diseases, such as tuberculosis
and syphilis, but of every disease and of every other factor in life
which causes individual inefficiency, and which consequently inflicts
additional burdens on the competent section of the community. I do
not wish to underestimate the basic self-centredness, if not actual
selfishness, which, to a varying extent, is part of the nature of all
of us; but in industrial, as in other social problems, whatever may
be the intermediate turmoil and misunderstandings and disturbance
which appear to loom so threateningly, it is plain that the mere
cash nexus of relationship is becoming more and more entangled in
a moral nexus; and that a prophet’s vision is scarcely needed to
forecast a future of consolidation and conformity of efforts of
employers and employed such as has never yet been generally realised.
In such a consolidation the idea of servitude will disappear, and
mutual service will take its place. This will happen by the growth
of an idealistic standpoint; even more, perhaps through motives of
community self-defence.

Secondly, the Great War, though the most terrible calamity to
humanity of the ages, has brought out a most comforting and elevating
thought. _Our brothers and our sons_,—and our daughters also in a
multitude of munition and other works,—have proved that, under the
overwhelming moral compulsion of national need, they _are willing
and ready to lay down their lives for great impersonal things_, and
in their hundreds of thousands they have done so. Coincidently with
this, a great impetus has been given to work for the health and
welfare of the civilian population, and especially of mothers and
their children. The removable horrors and losses of peace, in the
aggregate, are greater than those of war. Cannot an equal spirit
of sacrifice be induced against these? Is it not possible to evoke
a like devotion to secure the triumph of good over evil, of clean
administration over political pull, of fair dealing over industrial
exploitation, of adequate output over “slacking,” of determination to
spend and be spent to secure the welfare of all, in peace as in war?

Thirdly, prior to the war, for years, many among us had been
realising to an increasing extent the supreme importance of the
Mother and the Child, in safeguarding family life, and in securing
the beginnings of personal and national health. In past years
medical officers of health have been busily occupied in struggling
to overcome epidemic diseases, and in attacking the circumstances
favouring their prevalence. But for twenty years, at least, the
outlook has widened; the physiological as well as the pathological
aspects of hygiene have received attention; and it has been realised,
more and more, that in the conservation and upbuilding of the health
of the infant and the pre-school child rests the chief hope of the
future; and somewhat more recently, public health policy has directed
itself to the protection of motherhood, on which depends essentially
the welfare of the child.

This can only be done by ensuring, chiefly through its mother, _for
every newcomer on the stage of life, in all essential points, a
footing of equality of opportunity, physical, mental, and moral, with
all others_.

The ideal that every child should have equality of opportunity is
really part of a general upward movement in our national ethical life.

 The thoughts of men are widened with the process of the suns.

We begin to appreciate the full significance of the older words,
“it is not the will of your Father that one of these little ones
should perish”; and this ideal happily is now certain to replace the
materialistic doctrine of the German type which drives the weaker to
the wall.

Progress has been slow; but when we recall how true it was in St.
Paul’s day that “the whole creation groaneth and travaileth in pain
together until now”; and how gradually through the ages the mass of
human suffering has been abated, we can, while regretting the slow
rate of progress, gain encouragement for more rapid future advance.
The abolition of slavery, the higher position of women, the steadily
increasing force leading towards one standard of sexual morality
for both sexes, the improved conditions of housing and sanitation
notwithstanding the impediments of urban life, and the increasingly
humanitarian conditions of modern industrialism, all give us reason
to lift up our hearts.

There have been three stages in the attitude of mankind to altruistic
work. The first of these is illustrated by the attitude of the
father who said to his son: “Learn, my son, to bear tranquilly
the calamities of others.” Is not the second stage, illustrated
by the sleeping disciples in the Garden of Gethsemane, ignorant
or regardless of the impending tragedy; while the third stage
is manifest in the thousands of earnest social workers,—and the
supremely important conscientious members of our governing bodies
come in this group,—who are endeavouring to secure the realisation
in communal practice of every measure for uplifting mankind.

It is well for mankind that the Mother and the Child have become the
foundation on which, more and more, we expect health progress to be
built.

    A child more than all other gifts
    That earth can offer to declining man
    Brings hope with it and forward looking thoughts.
                                                        (Wordsworth.)

The history of the Mother and Child summarises the history of the
uplifting of mankind: and although there are not lacking sinister
elements in the present position, it is a great gain that both
in regard to the Mother and Child and to the saving of life and
improvement of national health generally, we are beginning to realise
that this is not merely a question of self-interest, personal or
national; but that we are concerned also with duty, and honour, and
chivalry.


FOOTNOTES:

[15] A lecture given to the Alumni Association of the University of
Yale, January 22, 1920.




                            CHAPTER VIII

                     SOME ASPECTS OF POVERTY[16]


I use the word Poverty, for the purpose of this discussion, as
meaning Destitution, in the sense of lack of means to provide some
specific requirement, indispensable for the health of the family, or
the individual.

Such poverty is evidently undesirable and mischievous, from the point
of view of both rich and poor; and I think we shall agree that, given
the adoption of the requisite measures, its continuance in most
instances is unnecessary. Hence the real subject for discussion is,
how poverty may be diminished and prevented.

I do not propose to touch on the important subjects of unemployment,
of under-employment, or of the relation between the size of family
and poverty, though the last named of these opens up an interesting
subject of discussion. (On this see page 164.) I shall confine my
remarks to the very obvious relation between poverty and sickness,
and to the neglect to act on our present knowledge, which if acted
on would in a short time lead to a great reduction of poverty in our
midst.

There is much truth in each of the statements that poverty is
responsible for much disease, that disease is responsible for the
greater part of the total poverty in our midst, and that poverty
begets poverty.

Poverty and disease are allied by the closest bonds, and nothing can
be simpler or more certain than the statement that the removal of
poverty would effect an enormous reduction of disease. The removal of
poverty must, therefore, be in itself an object always fascinating
to those whose study is the public health. The diseases which would
be reduced by this means, include not merely those which physicians
treat, but many moral diseases which persist because they are only
to be avoided by the poor through the exercise of discipline and
self-restraint far beyond what is practised by the average person
in classes not subject to poverty. The happiness of a community
being in itself a desirable object, a national asset, it is also not
irrelevant to consider that the removal of poverty involves enlarged
opportunities for enjoyment which, rightly directed, would be only
of less value than the removal of disease. It is not surprising,
therefore, that the first impulse of a student of the public
well-being, in which the public health is the most important factor,
is to attack disease by demanding the reduction of poverty, with its
more or less inevitable accompaniments of over-fatigue, privation,
overcrowding, and dirt. And it must be freely admitted that when
the most active public health administration, including adequate
medical aid for the sick, has attained its utmost efficiency, and has
in every respect done all that it can to reduce disease, there will
still remain a cruel residuum which can be attacked in no other way
than by the removal of poverty, or by the removal from poverty of the
elements of personal privation which affect the public health.

The importance attached to poverty as a cause of illness and
mortality is illustrated in reports on local investigations,
displaying an inverse relationship in different communities between
family income and the rate of infant mortality, the reader being left
to infer, that increase of the lower incomes is the one method for
obviating excessive loss of infantile life. In suggesting this crude
generalization it is evident that poverty is being regarded as an
element, instead of as a highly complex phenomenon, which needs to be
further analysed into its constituent parts. The crude generalised
statement as to the relation between excessive mortality and poverty,
furthermore, fails to bring out three essential points, viz., that
infant mortality may be very low in communities in which poverty is
the rule; that it may be high in the absence of poverty; and that
where infant mortality is high, it can be greatly reduced without
change of economic conditions.

There should be an adequate family income for every family; and the
social conscience cannot be satisfied until this is realised. But,
in seeking for practical reform we must appreciate that a large
share of the disease and of the inefficiency of the individual and
family associated with poverty can be remedied otherwise than by
an increase of the family income. This is shown by national and
international experience. The death-toll on infant life is very much
lower in Norway and in Ireland—both relatively poor countries—than
in England. Poverty in these instances evidently has less weight
than the favorable factors of rural life and natural feeding. A like
discrepancy in experience of infant mortality is seen between the
experience of towns, and of wards in the same town, with approximate
equality as regards poverty. Similarly in England the infants of
miners with relatively high wages suffer a higher mortality (160
per 1,000 births in 1911) than the infants of textile operatives
(148) with relatively low wages; while the latter suffer more than
the infants of agricultural labourers (97). These instances at once
suggest that some conditions in town life play an important part
in causing excessive infant mortality; that in towns insanitary
conditions and habits of life are even more injurious than the
absence from home of the industrially employed mother; and that
the causation of infant mortality is complex, and its prevention
necessitates a multifarious attack on social and industrial evils,
the character of this attack necessarily varying in different
localities, in accordance with the incidence of these evils. That
the influence of urban life in causing excessive mortality can be
counteracted is shown by the varying mortality in different urban
communities, and in different parts of the same town.

We may in a given instance be totally unable to increase the
family income; but the family’s present expenditure may be more
satisfactorily distributed; and some, at least, of the constituent
elements of poverty producing excessive child mortality can be
obviated. We know, indeed, that this can be done. The fact that
in the United States no part of the family income can be spent on
alcoholic drinks, implies the removal from multitudes of families of
the demoralising influences associated with alcoholism, which are
unfavourable to the health of adults and children alike.

Similarly, increased attention to domestic and municipal sanitation
and to the provision of a pure and adequate milk supply, the health
teaching given by public health nurses, and the prompt medical and
hygienic guidance at Child Welfare Centres are having an important
influence in the same direction. Work on these medical and sanitary
lines, for both adults and children, comes legitimately within the
sphere of the work of Public Health Authorities, provided out of
rates and taxes.

It may be urged that such provision, after all, means supplementation
of the family income at the public expense. It is more properly to
be regarded as a measure of insurance against contingencies by which
every member of the community is benefited; for we are each and all
concerned in the efficiency of every other member of the community.
We are members one of another. The objection stated above has no
greater validity than an argument similarly advanced against the
provision of police protection or of sanitary measures out of public
funds.

Elementary, and to some extent secondary and university, education
are regarded as not only the legitimate subjects of communal
provision, but also as incapable of being provided satisfactorily
by each individual family; and this view applies with even greater
force to the provision of hospitals and expert medical assistance,
of nursing assistance, and of such additional occasional domestic
service as is required to maintain the functional integrity of the
family.

I have given the above as a special instance of the contention that
poverty is a complex, including a number of elements, and that it is
our duty to ascertain in each area by careful local inquiry what are
these constituent elements, and if practicable their relative weight;
and then to apply the most urgently needed remedies, not contenting
ourselves with the relatively useless generalisation that the evils
we see are ascribable to poverty.

I lay special stress on the provision of skilled medical advice and
treatment, and of nursing assistance at the public expense, which at
present are sorely deficient for the vast majority of the population,
and perhaps for none more so than for the less well-to-do people who
receive salaries and not weekly wages. This assistance possesses the
special advantage previously pointed out, that it does not tend to
create a demand for further assistance, when such assistance is not
required.

The greatest bulk of poverty is due directly to sickness. A vast
mass of sickness still occurs, which is not owing to lack of family
or communal means, but is due to ignorance or neglect on the part of
the individual, of the responsible owners of houses, of the employers
of work-people, and still more of the members of local authorities
or state legislatures. Typhoid fever still commonly prevails as
the result of neglected sanitation; hookworm disease still causes
incapacity of hundreds of thousands for the same reason; malaria,
still one of the greatest scourges of humanity, might be reduced to
a fraction of its present amount if each community and each person
would carry out available simple preventive measures; tuberculosis
is still spread throughout every civilized community chiefly because
indiscriminate expectoration is unregulated, and satisfactory and
acceptable hospital treatment is not provided for all those who need
it. And so we continue to allow avoidable poverty to be perpetuated,
and to impose not only on the sick poor themselves, but also on
the efficient and solvent part of the community a heavy burden, the
removal of which would, to an almost incredible extent, increase the
general happiness of mankind.

The relief of poverty is at the best an inefficient and expensive
remedy. It is seldom adequate, and it has few preventive elements.
The prevention of poverty by prevention of the illness causing it,
and by early and satisfactory treatment of such illness as fails to
be prevented is the only efficient, as well as in the long run the
only economical plan of campaign. Money insurance against sickness
has its place as a means of alleviating the results of poverty.
But it is not an aid to its prevention; under any existing system
of insurance the money payment is insufficient and definitely
limited in duration. Although such relief is useful, it is totally
unsatisfactory when not linked up with a complete system of hygienic
measures, and when not associated with adequate medical treatment and
nursing. For the linking of treatment provided largely out of public
funds with insurance there is no justification, and it is contrary to
the public interest; and it is unfortunate that monetary insurance
has been provided in England for a section of the population under
these unsatisfactory conditions, thus diverting expenditure from the
public health services in which it was urgently needed, and in which
its use would at once have been fruitful in increased health and
happiness.


FOOTNOTES:

[16] An address to the Political Economy Club, Johns Hopkins
University, Jan. 19, 1920.




                             CHAPTER IX

  THE CAUSATION OF TUBERCULOSIS AND THE MEASURES FOR ITS CONTROL IN
                             ENGLAND[17]


My task is to attempt to give a bird’s-eye view of “The Methods of
Controlling Tuberculosis in England,” and to revaluate, as far as
is practicable, in the light of many years’ study of the disease,
the relative value of the measures which historically have been
followed by the greatly reduced mortality from tuberculosis. The
subject teems with difficulties, and as you are aware there is no
unanimity of opinion when tuberculosis is thus considered. This is
the more surprising in view of our present accurate knowledge of the
pathology of disease caused by bovine and human tubercle bacilli, and
in view of the fairly general unanimity of opinion as to the methods
of control which are needed to secure still more rapid reduction
of the devastations of tuberculosis. This general opinion may, I
think, be summarised in the statement which I have made elsewhere,
that the removal or diminution of infection from each single case of
tuberculosis reduces correspondingly the prospect of further cases,
but that tuberculosis will not be completely controlled until every
tuberculous patient receives such care throughout the whole course of
his life, as will ensure his welfare and will obviate the likelihood
of his infecting others.

It is noteworthy that the English death-rate from pulmonary
tuberculosis—which is responsible for 71 per cent. of the total
mortality from tuberculosis, and which is practically always due to
infection from a human source,—declined in males between 1871-75
and 1876-80 by 7.2 per cent.; in the next quinquennium by 9.8 per
cent.; between 1881-85 and 1886-90 by 8.3 per cent.; in the next
quinquennium by 9.5 per cent.; between 1896-1900 and 1901-05 by 7 per
cent.; and between 1901-06 and 1906-10 by 9.7 per cent. Evidently a
large share of the reduction of the death-rate from phthisis occurred
before it was generally regarded as an infectious disease, and before
sanatoria were in existence for its treatment. It should be added
that since the possibilities of infection have been realised and
the need for treatment of the disease has been appreciated, there
has in no part of the world, so far as I am aware, been an adequate
application of known methods of prevention and treatment.

We must look elsewhere, therefore, than to intentional measures
directed against tuberculosis for an explanation of its decline
during the period before Koch discovered the tubercle bacilli
and before the significance of this discovery was appreciated;
and attempt to appreciate the relative value of the factors of
decline operating before and since our outlook on the disease was
fundamentally changed.

Certain facts stand out beyond controversy, and on these
administrative control must necessarily be based.


                  _Basic Facts as to Tuberculosis_

1. Tuberculosis is a chronic infectious disease with a low degree of
infectivity. Circumstances favouring infection have a high degree of
importance; but tuberculosis does not develop in the absence of the
tubercle bacillus. No infection, no disease.

2. Tuberculosis may remain latent in the system for many years, and
there is strong reason for thinking that the infection of a large
proportion of early adult tuberculosis was acquired in childhood.

3. The two types of tubercle bacilli, bovine and human, are
stable both in character and in degree of virulence, and are not
interchangeable so far as can be shown by protracted experimentation.
The human type of bacillus is the chief source of infection of
mankind, though bovine infection is not negligible.

Out of 98 children between the age of 2 and 10 years who had died in
various hospitals from all causes unselected, 18 or 18.4 per cent.
were found to have been infected by tubercle bacilli of the bovine
type, and 81 or 81.6 per cent. by tubercle bacilli of the human
type. (Report on Investigations made in the Laboratory of the Local
Government Board, Annual Report of the Medical Officer of the Local
Government Board, 1913-14, p. lix.)

4. Animal experimentation shows that in animals of the same
species the extent of tuberculosis produced depends to a large and
probably to a dominant extent on the number of tubercle bacilli
introduced into the system. Although doubtless there are variations
in susceptibility in families, and in each individual at different
periods, there is little doubt that in the main the same rule holds
good for mankind.

5. Experience shows that dusty occupations, indoor occupations,
alcoholism, over-fatigue, an attack of acute illness, especially of
influenza, measles, or enteric fever, increase the danger of minimal
doses of tubercle bacilli, and serve to bring latent foci of disease
into activity.


    _Explanations of the Decreasing Death-rate from Tuberculosis_

In the light of the above facts, how is the steady and continuous
decline in the death-rate from tuberculosis during the last fifty
years to be explained?

(_a_) No support is given by animal experiment to the assumption
that the types of human bacillus infecting mankind have declined in
virulence; and changes in the severity of consumption historically
or currently in different races of mankind are equally explicable on
the ground of differences in social misery, in sanitary conditions
and associated heavier dosage of infection and neglect of treatment.

(_b_) The facts do not appear to me to be reconcilable with the
assumption that natural selection has increased human resistance
to infection by tuberculosis; though, were this so, it would
not justify refraining from every possible effort to control
infection and to treat every tuberculous patient by the best known
methods. Tuberculosis is an ancient disease, there being evidence
of it in Egyptian mummies 1000 years B.C.; and any selective
agency has, therefore, had ages for its operation. If the steady
decline—approximating 2 per cent. per annum in the death-rate from
pulmonary tuberculosis in England during the last thirty or forty
years—has resulted from the acquirement of racial immunity, it is
remarkable that a somewhat similar decline has occurred almost
simultaneously during the last forty years in Great Britain, Germany,
and America; while in France, Norway, and Ireland there has been
little if any decline, or it has occurred only in very recent years.

To assume that susceptibility to the tubercle bacillus in the course
of its natural history has diminished in England, and that Ireland
has not shared in this privilege would be to add one more to Irish
grievances! This assumption does not fit in with international
facts; which point rather to the conclusion that, during the period
in question, unsatisfactory sanitary and social circumstances,
including opportunities for massive and protracted infection, have
continued to a greater extent and for a longer time in Ireland and
France than in Great Britain, America and Germany.

(_c_) If the assumption of increasing racial immunity does not
consist well with all the facts, more perhaps can be said in favour
of the unproved hypothesis that a high proportion of the population
are from time to time temporarily immunized by small doses of
tubercle bacilli; and their resistance to larger doses of infection
thereby increased. Experimentally calves inoculated with small doses
of tubercle bacilli remain during the next year or two unaffected by
much larger doses of tubercle bacilli, unlike calves not submitted
to this treatment. Tubercle bacilli are somewhat widely distributed,
though they occur chiefly in the immediate environment of careless
consumptive patients; and it is conceivable that minimal doses of
bacilli may arouse the resistance of the cells and fluids of the body
and prepare them to resist successfully larger doses of infection.
This is consistent with the fact that while one in about ten deaths
from all causes is caused by tuberculosis, a majority of the total
population are shown by pathological evidence to have been at one
time or another infected by tuberculosis, and yet have either
never been ill, or have recovered, usually without the existence of
tuberculosis being detected or even suspected. Obviously this is
satisfactory evidence that mankind is relatively resistant to the
infection of tuberculosis.

The fact just mentioned naturally leads to the question: what
determines the result when tubercle bacilli invade the human subject?
Assuming fairly uniform virulence of tubercle bacilli, the result for
an infected person depends on two factors: the dosage of infection,
and the resistance of the cells and fluids of the invaded person;
and evidently increase in the dosage of infection and lowering of
personal resistance may have identical effect in determining serious
disease. Of the importance of the already mentioned factors which
lower personal resistance to disease,—often also at the same time
increasing infection,—there can be no doubt.

It is impossible in most instances to set out separately
circumstances increasing infection from circumstances lowering
resistance. During the last three or four decades there has been
improvement in respect of the factors lowering resistance to attack,
but there has been simultaneously a great decline in opportunities
for infection on a massive scale, as a result of habits of greater
cleanliness, especially in regard to spitting, of diminished
overcrowding of population, and of increased treatment and the
incidental segregation of advanced cases of disease in hospital beds.


                _Hospital Treatment of Consumptives_

I have seen no reason for revoking the conclusion expressed in 1908
in a lecture to the Washington International Congress on Tuberculosis
that historically the hospital treatment and coincident segregation
of patients suffering from pulmonary tuberculosis has been an
important and probably a dominant factor in producing the national
decline in the death-rate from tuberculosis in the countries in which
a decline has been experienced. This explanation fits in with our
knowledge of the disease, and with the analogous history of leprosy;
and it is supported by the fact that by complete segregation of
infected from non-infected cattle tuberculosis can be eliminated at
will from a herd of cattle. It is remarkable, as I have elsewhere
set out in much detail, that improved general health, increased
well-being, and sanitary education have operated in Great Britain,
Germany, Belgium, Denmark, and Massachusetts side by side with great
decrease in the death-rate from pulmonary tuberculosis; while up to
very recent years the same influences in France, Norway, and Ireland
have produced little or no decrease in the national death-rate from
tuberculosis. And similarly no constant relation can be shown between
the degree of sanitary and social well-being in different countries
and cities, and the amount of mortality imposed by tuberculosis. How
is it that in some countries a high degree of domestic overcrowding
is associated with a low and declining phthisis death-rate and
conversely that a persistently high phthisis death-rate may occur
with a less but still diminishing degree of overcrowding? The
explanation is contained, I maintain, in the following statement:

_A given amount of domestic overcrowding with a large amount of
institutional segregation of consumptives is associated with less
tuberculosis than when overcrowding is less but accompanied by only a
small amount of institutional segregation of consumptives._ The data
as to institutional segregation are difficult to obtain; but there is
sufficient evidence to show that in countries which have experienced
a large reduction in the death-rate from tuberculosis a large
proportion of hospital treatment for many years has been provided
for consumptives, while in countries which have not experienced
this decline such provision has been absent or imperfect. In London
about 56 per cent., in county boroughs 35 per cent., in other urban
districts 21 per cent., and even in rural districts of England near
16 per cent. of all deaths from pulmonary tuberculosis occur in
hospitals (poor-law institutions, general and special hospitals, and
asylums). Prior to the patient’s death he has had on an average at
least three months, and probably in the aggregate more nearly five or
six months, residential treatment, and this at the stages of disease
in which there is the greatest discharge of infective material, in
which owing to feebleness the patient is least able to control its
hygienic disposal, and in which—had the patient been treated at
home—the relatives would be especially liable to receive massive
infection, and would be enfeebled by overwork and anxiety, or by the
malnutrition associated with poverty.

Some writers have failed to visualize the fact that the segregation
of a minority of the total cases of pulmonary tuberculosis for a
portion of their illness can have had a marked influence on the
prevalence of this disease. They appear to be judging tuberculosis
by the same measure as they would apply to smallpox, which in an
unprotected community spreads rapidly if a few cases are overlooked.
The case of tuberculosis, like that of leprosy, is governed by the
considerations that both these diseases as a rule require intimate
and protracted contact for their spread, and that in both diseases
there may be prolonged latency before active disease develops.
A hypothetical illustration may serve to elucidate the order of
magnitude of the influence exercised by institutional segregation.
Let us assume—as is probably the case in England—that one-fifth of
the cases of pulmonary tuberculosis are treated during one-third of
a year institutionally under conditions in which they will not be
liable to spread infection. Let us assume further that each of these
cases has an infectious lifetime of three years. Thus one-fifth of
the cases are deprived of their power to spread infection during
one-ninth of their period of “open” disease. It being assumed that
personal infection causes pulmonary tuberculosis and that segregation
is efficient, segregation to the extent indicated above should secure
a reduction in the death-rate from pulmonary tuberculosis of 100/(5 ×
9) approximately 2 per cent.

In actual fact the decline in the English death-rate from pulmonary
tuberculosis since 1871 has been at a rate slightly under 2 per cent.
per annum.


              _Koch’s Endorsement of Segregation View_

An extract from an article written by Robert Koch shortly before his
death may be permitted (Epidemiologie der Tuberkulose Zeitschr. für
Hyg. und Infektious Krankheiten. 4. XVII, 1910).

 I am entirely in agreement with Newsholme that the allocation of
 consumptives to institutions for the sick, as freely as possible
 and for as long as possible, is the most active means of avoiding
 infection and the consequent spread of phthisis.

 In my experience, too, phthisis has shown the most marked decline
 in those places where comprehensive measures have been taken for
 bringing consumptives into hospitals, and the converse has been the
 case where the converse conditions prevail. It is indeed obvious
 that in no other way can the danger of infection, which a phthisical
 patient constitutes, be so effectively removed as by isolation in
 hospital. Strong support of this method is afforded by leprosy,
 where good results in attacking the disease have been obtained by
 following the same principle.

 In addition to this factor there is a second, which also plays a
 very important part, viz., housing.

A hypothesis explanatory of a given phenomenon should be consistent
with all the associated facts. We have seen that the hypothesis
that segregation of consumptives is an important factor in the
reduction of the death-rate from pulmonary tuberculosis agrees (1)
with our knowledge of the tubercle bacillus, and (2) with veterinary
and agricultural experience; also (3) that,—although exact data
are unobtainable,—the degree of segregation when ascertainable
is consistent with the degree of decline in the death-rate; (4)
it is important to note also that this hypothesis is consistent
with the otherwise anomalous facts that although the proportion of
the population subjected to urban conditions of life has steadily
increased, and the number of persons per inhabited room remains much
greater in towns than in country districts, the death-rate from
pulmonary tuberculosis in England has declined as much in them as in
country districts; and that notwithstanding the greater overcrowding
in towns, the urban is rapidly falling to the level of the rural
death-rate from this disease. The town dweller’s better and more
frequent treatment in hospitals is an important factor in overcoming
the handicap of urban conditions of life, including overcrowding and
preponderance of indoor and dusty occupations.

It is desirable to supplement the above statement by some remarks on


       _Improved Housing as a Means of Reducing Tuberculosis_

Not infrequently the thoughtless remark is made that given
improved housing sanatoria and hospitals for consumptives would be
unnecessary. The frequent occurrence of tuberculosis in well-to-do
families shows the absurdity of this statement. It is true that
tuberculosis is more prevalent among the poor living in small
tenements that among the well-to-do; but there is no consistent
proportion between the degree of overcrowding in different districts
or towns and the death-rate from tuberculosis. Improved housing
and institutional treatment for tuberculosis cannot properly be
regarded as alternatives. They are necessary complements to each
other, and there must be increased expenditure in both directions,
if tuberculosis is to be more rapidly reduced in amount. There are
in fact two housing problems—for the healthy, and for the sick. The
most rapid method of improving housing for the healthy is to remove
the sick, and especially the tuberculous sick to a hospital. This is
being done year by year to an increasing extent. In England and Wales
in 1870, 8.3 per cent., and in 1912 21.6 per cent. of all deaths
from all causes occurred in public institutions. It is difficult to
exaggerate the practical relief implied in these figures in respect
of satisfactory housing, especially in its functional aspect. Apart
altogether from the tuberculosis problem much of the decline in
the general death-rate must be attributed to the skilled treatment
which a large proportion of the total population have received in our
hospitals of various types.

I may, I think, claim to have answered in part the question asked
at an earlier stage of this address, as to the causes of the steady
decline in the death-rate from tuberculosis in recent decades. I do
not claim that any one factor has brought about this result. I do not
claim that it has been caused entirely by diminution of opportunities
of infection; but I deprecate the view that improved nutrition and
other conditions diminishing susceptibility have played a predominant
part. The facts of international hygienic history rebut this view.
Although segregation of patients in institutions has played a great
part in bringing about the result, diminution of domestic infection
as the result of more cleanly habits has doubtless had an important
influence; as has also the reduction of industrial dust.

It is significant that general hygiene and improved care of the
sick—quite apart from any intention to segregate—were associated
with a large reduction in the death-rate from tuberculosis before
the importance of reducing infection was fully appreciated; and that
since the necessity for direct measures against tuberculosis was
realised, since such measures have been begun, however imperfectly,
in many countries, and since anti-tuberculosis educational
propaganda has been somewhat active, there has been no increase
in the rapidity of decline of the death-toll of tuberculosis. Of
course, it cannot be seriously—though it is foolishly—argued from
this fact that such direct measures are futile. Every year there
has been increasing migration of masses of people into towns, with
a corresponding increase of undesirable domestic overcrowding
and of indoor occupations. If, therefore, such anti-tuberculosis
measures as have been adopted,—whether direct measures or general
sanitary measures,—had been associated with an absence of decline or
with actual increase in the death-rate from tuberculosis it might
still be that these measures have achieved much. Many conflicting
agencies are at work, and it might well be that the apparent lack
of success of the measures taken is due to the increased operation
of countervailing influences. The importance of direct action for
the control of tuberculosis must be judged not solely by necessarily
imperfect statistical measurement on the basis of a few years’
observation, but _by ascertaining that the proposed measures are in
accord with our knowledge of the natural history of the disease_. As
we have seen, both comparative and human pathology assure us that
tuberculosis is a communicable and therefore a preventible disease,
and point the way to the means for securing this end.

Before describing the direct measures which have been adopted for the
control of tuberculosis, it should be added that in no country have
these been in operation sufficiently long, and in no country have
they been so adequately applied, as to render it practicable to apply
statistical measurement of their value; meanwhile these measures
must be judged in the light of our knowledge of the pathology of
tuberculosis.


                   _Notification of Tuberculosis_

If every tuberculous patient were intelligent, and willing and able
to follow the advice given by his doctor, if he consulted his doctor
for the first symptoms of illness, if his disease were recognized
by the doctor at its earliest recognizable stage, and if the doctor
in every instance gave the right advice and made the necessary
examinations of all “contacts,” no occasion would arise for the
intervention or assistance of Public Health Authorities, except in
providing bacteriological facilities and institutional accommodation.
In actual fact these conditions are not secured for the majority of
patients; and the private practitioner, however willing, is seldom
in a position to remedy the domestic and industrial insanitary
conditions which favour infection and lower resistance to infection.

Hence notification of cases of tuberculosis was advocated for many
years by pioneer medical officers of health who secured voluntary
notification by doctors of a considerable proportion of the total
cases in their districts, and in a few instances secured compulsory
notification by local enactment, before any general regulations on
the subject were made. It is noteworthy that in this early period a
town like Brighton, which had voluntary notification with sanatorium
provision for patients willing thus to be treated, secured the
notification of a larger proportion of total cases than another town
in which notification was compulsory, but no sanatorium accommodation
had been provided. The point is mentioned as emphasizing the general
principle that compulsory measures in public health, if they are to
be successful, require to be associated with full provision for the
action which should follow the compulsory enactment; which provision,
as in this case, may be a direct inducement to compliance with the
enactment. In view of the change of central policy involved and of
the unpreparedness of most local authorities to give the assistance
needed for notified cases, the general enforcement of notification
of tuberculosis was brought about in stages; in 1909 poor-law cases
of consumption were made notifiable throughout England and Wales,
hospital cases in 1911, consumption in the general community in 1912,
and all forms of tuberculosis in 1913.

It was not anticipated that complete notification of cases would
be obtained for some years, but a review of English national
experience of notification of tuberculosis up to the present time
necessitates the confession that there has been failure to secure
the coöperation of an unexpectedly large proportion of the medical
profession in this public-health duty. Many cases have never been
notified and in a large number of other cases notification has been
belated; Dr. Barwise, County Medical Officer of Health of Derbyshire,
obtained information as to 417 deaths certified during 1917 to be
due to tuberculosis, and found that of this number 39 per cent. had
never been notified, and that over 70 per cent. had either not been
notified or died within twelve weeks of notification. This may be an
exceptionally bad experience; but the duty of notification in many
areas is only imperfectly performed, and no adequate steps are being
taken to diminish this default.

As notification is the first step towards coördinated measures for
the patient and in the interest of the public health, the causes
of delay in notification and of failure to notify deserve further
examination.


                 _Causes of Failure in Notification_

1. The patient himself commonly is responsible for much delay in
the recognition of his disease. A large proportion of consumptive
patients refrain from applying for treatment until disease is
fully established, and until they are incapacitated for work.
Not infrequently this means that the patient does not consult a
doctor until a few months or even weeks before his death. Until the
conditions of general medical practice are altered, and every person
has the right to state-paid medical consultations, belated recourse
to medical advice will continue.

With this there is badly needed further education of the public as to
seeking advice for protracted colds and coughs, or for other symptoms
suggestive of tuberculosis; and a wider hygienic propaganda as to
housing, overcrowding, dusty indoor occupations, expectoration, etc.,
is also called for.

2. Under present conditions of medical practice, early diagnosis
of tuberculosis often fails to be secured, even when the patient
places himself under medical care. It is to the private practitioner
that most patients resort, and the early recognition and treatment
of disease depends primarily (_a_) on his skill, (_b_) on his not
being so overworked as to be unable to devote adequate time to the
examination of each patient coming under his care, and (_c_) on
his willingness to refer doubtful cases for consultation with the
official tuberculosis officer of each area. These officials have
only existed during the last few years; their work was partially in
abeyance during the four and a half years of war; and apart from
this, they have not always succeeded in persuading the private
practitioner that their coöperation is to be welcomed and that they
are not agents for depriving him of his private patients. This
assumed antagonism between private and public medical practice is one
of the most serious difficulties in securing more rapid progress in
anti-tuberculosis work.

3. For nearly every sanitary area gratuitous facilities are now
provided for the examination of sputum for tubercle bacilli, and yet
in many areas there is grave neglect to utilize this provision, and
patients with chronic phthisis may be treated during long months
or even years for “winter cough,” “bronchitis,” etc., without
adequate physical examination of sputum. The diagnosis of pulmonary
tuberculosis ought, it is true, to be made before tubercle bacilli
are found in the sputum, and failure to recognize the disease prior
to this implies that the disease has already become serious; but
in fact a very large proportion of consumptive patients for many
months have tubercle bacilli in their sputum, before the diagnosis of
tuberculosis is made.

4. When, as in some areas, the medical officer of health or the
tuberculosis officer takes little, if any, useful action after
notifications have been received, the practitioner has an excuse
for not notifying subsequent cases. He can argue with some cogency
that notification has no value _per se_; its utility depends on the
action which follows on notification. Unless useful action follows
on notification, default in notification has little practical
importance.


            _Public Health Action Following Notification_

Under the English Tuberculosis Regulations the medical officer
of health or an officer of the local authority acting under his
instructions is required to make such inquiries and take such steps
as may be necessary or desirable for investigating the source of
infection, for preventing the spread of infection, and for removing
conditions favourable to infection. The action required includes
_inter alia_

1. Attention to the personal hygiene of the patient, including
instruction in the necessary precautions as to coughing and
expectoration.

2. Any assistance needed to ensure for the patient

(_a_) Skilled medical attendance and nursing as required while he is
treated at home;

(_b_) Institutional treatment when required;

(_c_) Supplementation of the convalescent patient’s funds, when
needed, to obviate the necessity for him at once to embark in
full-time work; to provide additional bedroom accommodation when
needed; and to ensure that the patient and his family are not
undernourished or overworked.

3. Remedial action for any insanitary conditions of the home, such as
uncleanliness, dampness, overcrowding; or of the patient’s workplace,
especially for dusty occupations.

4. Examination of home contacts with the patient.

The last named item may conveniently be considered further at this
point.


                      _Examination of Contacts_

This branch of tuberculosis work is most important. Often the first
notified case is not the first clinical case of tuberculosis in a
given family; and from the standpoint of prevention the detection of
such cases of longer standing is important. Examination of contacts
also frequently discovers patients in an earlier and more curable
stage of disease than the notified patient.

It is important that all home contacts of each notified case of
tuberculosis should be examined; and one of the most important
functions of the tuberculosis officer is to arrange for this. The
examination may be carried out by arrangement at the tuberculosis
dispensary; but otherwise, at the home of the invaded family. When
there is a medical practitioner in attendance his coöperation and
presence should as a rule be invited.

Such systematic examination of the household not only is more
efficient in discovering sources of continuing infection than the
desultory examination of a few contacts,—which often still represents
the extent of this important work,—but it has in addition a greater
educational effect on the public; and general recourse to such
systematic observations would rapidly improve the prospect of
satisfactory control of tuberculosis.

Even when examination of contacts is practised after notification
of a case of pulmonary tuberculosis, it is too often neglected
after notification of non-pulmonary cases. This represents a
great public-health loss; the majority of cases of non-pulmonary
tuberculosis are caused by infection of human source, and this source
often is an unrecognized case of pulmonary tuberculosis in the
patient’s family.


                   _Scope of Tuberculosis Schemes_

Prior to the general enforcement of notification of tuberculosis
in England excellent local work had been done in a relatively
small number of areas in direct efforts to control the spread of
tuberculosis, in addition to the previous general measures, such as
improved sanitation, better housing, more satisfactory nutrition, and
especially the hospital treatment of a large proportion of advanced
and acute cases of tuberculosis. The Report of the last Royal
Commission on Tuberculosis appeared in 1911; and although precautions
against human infection by tuberculous cows’ milk are still very
incomplete, the pasteurisation or boiling of milk is more generally
practised than in the past.

Local Authorities prior to 1911 had power to build sanatoria or
otherwise provide institutional accommodations for the treatment
of tuberculous patients; relatively little had been done in most
areas. In 1911 the Finance Act provided a sum of £1,116,000 for the
erection of sanatoria in England and Wales, and this, with money
provided by local rates, has led to rapid increase in accommodation
for the residential institutional treatment of tuberculosis. In
England in 1911 local authorities, other than poor-law authorities,
had about 1300 beds for the institutional treatment of tuberculosis,
while there were 4,200 beds in private sanatoria and voluntary
institutions. In 1917 the total available beds numbered 12,441, of
which about one-half had been provided by local authorities.

In 1911 the National Insurance Act was passed and came into operation
in July, 1912. This provided a special “Sanatorium Benefit.”

The Departmental Committee appointed to make recommendations as to
detailed direct measures against tuberculosis, reported in April,
1912, that any scheme which is to form the basis of an attempt to
deal with the problem of tuberculosis should be available for the
whole community, and that its organization should be undertaken by
the large local authorities (the councils of counties and county
boroughs). These recommendations were at once adopted by the
Government, which undertook to provide out of the national exchequer
one-half of the net cost of approved local schemes for the general
treatment of tuberculosis. Local authorities were invited at once
to prepare schemes for institutional treatment, residential and
non-residential, domiciliary treatment remaining in the hands of
private practitioners, of poor-law doctors, and of doctors engaged in
the contract work under the National Insurance Act (“panel doctors”).
The last named are in medical charge of the large mass of the
wage-earners of the community, comprising roughly one-third of the
total population, in so far as their treatment at home is within the
power of a practitioner of average competence. The schemes proposed
for each area comprised,

1. The appointment of a tuberculosis officer, usually a whole-time
official, who was required to have had special experience in the
diagnosis and treatment of tuberculosis, and who as a rule was an
officer in the public-health department under the administrative
supervision of the medical officer of health, but independent in his
clinical work;

2. The establishment of tuberculosis dispensaries, at which patients
were treated, consultations as to doubtful cases held, and contacts
examined;

3. The provision of beds in residential institutions for curable and
for acute and advanced cases;

4. The organization of arrangements for “following up” and
“after-care.”

During 1912 and 1913 advance was made in these directions. In 1911
there were 25-30 tuberculosis dispensaries: in 1917 their number
had increased to 371. In 1914 the onset of the Great War prevented
further development of tuberculosis work and seriously crippled and
reduced the efficiency of work already initiated; and this increased
as the military demand for medical officers and institutions became
greater. It may be stated generally that in only a relatively
small number of areas have fairly complete arrangements for the
institutional treatment of tuberculosis come into operation; and
that even in these areas the arrangements have been at work for only
a limited period. It is evident, therefore, as already pointed out,
that no argument as to the utility of these arrangements can be based
on the facts that the death-rate from tuberculosis has not declined
with increased rapidity in recent years, and that women during the
war, especially at the working years of life have experienced an
increased death-rate from this disease.


                     _Tuberculosis Dispensaries_

The tuberculosis officer is the essential element in the dispensary;
and in rural districts he may be said to carry the dispensary under
his hat. The dispensary if properly organized should serve as the
centre of official anti-tuberculosis measures. The medical officer of
health receives the notifications of recognised cases whether they
are attending the dispensary or not; and it simplifies administration
if the home supervision of all tuberculous patients notified to
the medical officer of health, and not only of dispensary patients,
is placed under the supervision of the tuberculosis officer. At
the dispensary itself the tuberculosis officer examines patients,
makes records of their condition, and of all facts bearing on their
welfare, and recommends the special form of continued treatment
adapted to their condition. This may be domiciliary, or given at the
dispensary, or in a sanatorium, or in a hospital. A dispensary which
does not supervise and treat a large proportion of the total notified
cases, including especially patients before and after they have
received treatment in a residential institution, is not fulfilling
its possibilities of utility.

At the dispensary is organized also the examination by the
tuberculosis officer of “contacts,” and of school children suspected
to be tuberculous; though it is often necessary to arrange for this
officer to make similar examinations at patients’ homes. At the
dispensary consultations with private practitioners are conveniently
held; though in this instance also the tuberculosis officer should
arrange when this is desired for the consultations to be held at the
patient’s home.

The dispensary alone cannot ensure the welfare of the tuberculous
patient. It is necessary that the tuberculosis officer should have
consultations concerning difficult cases with the medical staff
of general and special hospitals. To segregate the treatment of
tuberculosis from that of other diseases means reduced efficiency of
the tuberculosis officers and lowered quality of treatment.


      _Tuberculosis Dispensaries should become Parts of General
                            Dispensaries_

Public Health and School Authorities have already established many
centres at which hygienic instructions and medical treatment are
given for mothers and their young children when ailing, or with a
view to the prevention of future illness; for tuberculosis; for
venereal diseases; and for various ailments of school children.

In England in addition there is poor-law provision (sometimes at
dispensaries) for patients dependent on official charity. Evidently
the multiplicity of authorities, local and central, concerned in
this medical work, is not conducive to efficiency; and it will,
we hope, soon disappear. Similarly it will be in the interest of
efficiency, as well as of economy, to provide for the treatment of
the above-named groups of cases in a common Medical Institute for
each defined area, at which also it will be advantageous to arrange
for much of the treatment of insured persons. By this means it will
become practicable to arrange for consultations between experts in
different departments of medicine, to the advantage of all concerned.

It will be contrary to the communal interest if the resources of
voluntary hospitals in large towns are not also utilised in official
medical work. Many of these hospitals have specialised departments
(e.g., X-ray, eye, ear, throat, skin, and other special clinics), the
use of which ought to be obtainable, even though for many years it
may not be practicable to arrange for all hospitals to be financed in
part at least out of rates and taxes.

The tuberculosis officer in order to be able to treat his dispensary
patients with adequate knowledge, and in order to advise as to the
form of treatment—in a residential institution or not,—most fitted to
the patient’s case, must know the sanitary and social circumstances
of the patient’s industrial and domiciliary life. He must, therefore,
have reports on these circumstances respecting each patient. This
raises the general question of the relation of the tuberculosis
officer to the medical officer of health. The medical officer of
health is officially responsible for controlling the tuberculous
patient and his environment from a public health standpoint. As the
tuberculosis officer also needs the information acquired in the
inquiries which it is the duty of the medical officer of health to
make personally or by an authorized agent, coördination of the work
of the two officers is evidently required; and this need cause no
difficulty when the tuberculosis officer is an officer in the Public
Health Department of which the medical officer of health is the chief
administrator.


                  _The Home Visitation of Patients_

This is important, (_a_) to inquire into the social circumstances
of each patient; (_b_) to instruct him in detail as to the carrying
out of instructions for treatment and in the hygiene of his life;
(_c_) to make a sanitary survey of the dwelling house, and especially
of the patient’s bedroom, and to advise as to any needed reforms;
and (_d_) in certain cases to give actual assistance in nursing the
patient.

The report on these inquiries should be seen by both the medical
officer of health and the tuberculosis officer, and on them in
conjunction with the tuberculosis officer’s knowledge of the medical
condition of the patient, the subsequent course of supervision and
treatment will depend.

Home visitation can be carried out by nurses attached to the
dispensary or by inspectors of the public health department. The
latter will usually be more competent in detecting and remedying
sanitary defects in the home; the former in encouraging the patient
to carry out the needed requirements in personal hygiene and nursing.
Many visitors are equally competent in both directions; and as the
number of women specially trained in tuberculosis work increases this
will more generally be the rule.

The dispensary should be the active working centre from which
home visitation is undertaken; and this is especially important
in “following up” work. Following up is needed for persons who
have been examined once, concerning whom there is doubt as to
their freedom from disease and who fail to present themselves for
later examination. It is needed also for patients who have been
under treatment and neglect to continue it; and for patients who
after having been treated have been discharged and fail to report
themselves at intervals as directed. It is important to have
efficient arrangements for ascertaining these leakages and for making
the necessary inquiries. The method of securing this will vary
according to local circumstances; but the following example given by
Dr. Chapman of an official method may be placed on record:

 When a patient is instructed to attend again at the dispensary his
 name is noted in a diary under the date upon which he is asked
 to attend. In some instances a definite time is fixed for the
 appointment so as to save the patient’s time. The names of all
 patients who attended the dispensary upon the day appointed are
 ticked off as they are seen, and at the end of the day the names of
 patients who have failed to attend remain on the list. Letters are
 then sent reminding these patients of their engagement and making
 another appointment. If they still fail to attend they are visited
 by the dispensary nurse or the health visitor. Failure to attend
 may be due to relapse, and, when this is likely, an early visit of
 inquiry by the nurse is advantageous.

 Examination of a register kept for facilitating work of this kind
 showed that the majority of the patients followed up attended
 subsequently, and that in the cases of the remainder non-attendance
 as a rule was satisfactorily explained.

In areas having, as yet, no adequate system of following up, an
appreciable percentage of patients usually cease to attend during the
course of treatment at a dispensary, and many are lost sight of after
discharge from a sanatorium. The value of the work of a dispensary
and of after-care work is materially impaired in the absence of
a system of “following up.” As schemes develop, more stress will
doubtless be generally laid upon this branch of the dispensary
function.


                       _“Sanatorium Benefit.”_

Under the National Insurance Act the annual sum of 1s 3d (30 cents)
was set apart for each insured person; as the result of subsequent
bargaining with medical practitioners 6d of this was devoted to
the domiciliary treatment of tuberculosis patients (payable on the
number of panel patients on each doctor’s list, not on the number
of his tuberculous patients), the remainder being payable to local
authorities who undertook the provision of institutions for the
treatment of tuberculous insured patients.

Thus the “Sanatorium Benefit” comprises

  _A_. Domiciliary treatment.
  _B_. Institutional treatment.
      (_a_) Non-residential—Dispensaries.
      (_b_) Residential—Sanatoria,
                       Hospitals,
                       Convalescent Homes and
                       “Farm Colonies.”

Soon after the passing of the National Insurance Act in 1911
representations were made that tuberculosis affected non-insured as
well as insured; that treatment of insured could have only partial
success so long as non-insured members of the same household were
neglected; and that this was work for public health authorities which
they were already partially undertaking. It was evident that the
inextricably interlaced measures for the prevention and the treatment
of tuberculosis must accrue to the whole population; and the mistake
of the National Insurance Act was remedied to the extent that
Public Health Authorities were informed that the National Treasury
was prepared to pay one-half of the approved expenditure incurred
by these authorities in establishing schemes for the treatment of
tuberculosis available for the entire population. Such schemes
were proceeded with, as already indicated; but there remained the
fact that insured persons who had paid their weekly quota and were
therefore entitled to “Sanatorium Benefit” usually interpreted this
as a right to three months’ treatment in a Sanatorium. The choice of
persons to receive treatment in a Sanatorium lay with Local Insurance
Committees appointed under the National Insurance Act, who generally
acted on the advice of the tuberculosis officer; but influences
other than medical led to the unsatisfactory use of institutional
treatment. A large number of patients were sent to and retained
in sanatoria for prolonged periods, who might have been adequately
treated at home, or who should have been in hospitals. Satisfactory
results for sanatorium treatment were not secured under these
conditions; and there will probably be no material improvement until
the Sanatorium Benefit is withdrawn as a special benefit under the
National Insurance Act, and the treatment of tuberculosis becomes an
obligatory duty of Public Health Authorities, with a minimum standard
of provision to which all must attain.


                     _Residential Institutions_

The extent to which these have been provided in England since 1911
has already been stated. The number of beds available in 1917 was
12,441, in addition to some 9,000 beds in poor-law institutions,
which in 1911 were occupied by consumptives. From the point of
view of the provision required in residential institutions for the
treatment of tuberculosis the following classification is useful. It
is confined to pulmonary cases:

 Group _A_—Cases in which permanent improvement or recovery can
 usually be anticipated.

 Group _B_—Cases in which only temporary, though possibly prolonged,
 improvement may be anticipated.

 This group will include

 1. Patients who may be expected to recover considerable ability to
 work, as a result of protracted treatment.

 2. Patients admitted for a short term for educational treatment.

 3. Patients with advanced disease, many of whom improve greatly
 under institutional treatment.

 Group _C_—Advanced cases requiring continuous medical care and
 nursing.

 Group _D_—Cases requiring Special Observation.

 1. Patients admitted for the purpose of diagnosis.

 2. Patients needing to be watched, before the best form of continued
 treatment can be determined.

 Emergency cases, e.g., patients with haemoptysis, and patients
 requiring surgical treatment may come within any of the above groups.

Of the 12,441 beds probably 5,000 are in the hands of voluntary
organizations, and are intended for patients in group _A_, though
for the reasons set out on pages 208 and 223 they contain a large
proportion of patients in the other groups. It appears not unlikely,
however, that the total accommodation, official and voluntary,
for patients in group A has reached one bed per 5,000 population,
the accommodation recommended by the Departmental Committee on
Tuberculosis as immediately advisable. This accommodation is unevenly
distributed and much of it is being utilised for patients coming
within groups _B_, _C_, and _D_. All the evidence available shows
a great need for additional beds for patients coming within the
last-named groups. The Departmental Committee recommended that the
total needs of the community might be assumed to amount to one bed
to 2,500 population for all stages of pulmonary tuberculosis, in
addition to poor-law accommodation. This means a provision of some
14,000 beds in addition to the 9,000 poor-law beds, or a total
provision of about one bed to 1,500 population.

If we include cases of non-pulmonary tuberculosis it may be safely
assumed that each community should aim at having available for the
treatment of tuberculosis at least one bed per 1,000 inhabitants.
Fewer beds may suffice for sparsely populated communities, and more
will be needed in some towns.

In England various existing institutions have been utilised in the
treatment of tuberculosis.

1. Emphasis has already been laid on the large number of beds in
_workhouse infirmaries under the Poor-Law Authorities_. Of the
historical, as well as of the present value of this accommodation
for advanced cases of tuberculosis in the poorest section of the
population—which is most seriously exposed domestically to massive
infection,—there can be no doubt.

But there has been prejudice against the use of this accommodation
for insured persons, and such use is legally precluded; and since
the passing of the National Insurance Act additional provision has
been made by Public Health Authorities, and ere long the whole of
the present poor-law accommodation should come under public health
authorities.

2. Detached pavilions of _hospitals for infectious diseases_ have
also been employed for the treatment of tuberculosis, and experience
has demonstrated that in well-conducted institutions consumptives are
not exposed to risk of acquiring acute infectious diseases.

The use of these institutions favours economy of administration. It
possesses the advantage that patients are, as a rule, more accessible
to their relatives than in a sanatorium; and this renders patients
suffering from progressive disease more willing to remain in the
institution than they would otherwise be. Patients can advantageously
be placed in such an institution for observation, before deciding
whether prolonged treatment in a distant curative sanatorium is
indicated.

Occasionally empty _smallpox hospitals_ have also been employed for
the institutional treatment of tuberculosis; but if this plan were to
be generally adopted, tuberculosis work would be seriously crippled
if smallpox became epidemic. The treatment of consumptives in a
smallpox hospital should only be permitted for patients who could be
at once transferred and who can be at once vaccinated.

_General hospitals_ are well fitted to deal with the following
classes of cases of tuberculosis:

 (_a_) Patients admitted for observation, with a view to diagnosis;

 (_b_) Patients admitted to ascertain the form of treatment best
 adapted for the patient’s needs;

 (_c_) Emergency cases, e.g., haemoptysis;

 (_d_) Patients requiring surgical aid for intercurrent diseases;

 (_e_) Patients with advanced disease admitted for special purposes;

 (_f_) Patients with non-pulmonary tuberculosis, requiring special
 surgical treatment.

In approving arrangements for the treatment of pulmonary tuberculosis
in a general hospital, it should be made a condition that they shall
not be received into general wards of the hospital in which there are
persons suffering from other diseases, unless for a sudden emergency,
or for a short period for operative treatment, or unless there is no
expectoration, or if this, on repeated examinations has been found to
be free from tubercle bacilli.


                _Sanatoria and Combined Institutions_

To ensure efficiency in a sanatorium a resident physician is, as
a rule, necessary; and this is desirable also for a tuberculosis
hospital. Smaller authorities may be unable to combine together
or to provide alone an institution with about 100 beds, which is
generally regarded as the unit best adapted to secure a well-placed
and efficiently organized institution, with due regard to economy of
administration. To provide such a unit, and even apart from this,
the desirability of treating patients in all stages of disease in
the same institution should be considered. Experience in England
has shown that this combination presents no medical administrative
difficulties, provided that the type of sleeping accommodation
for patients consists chiefly of rooms for one or two patients
or of small wards. With such an arrangement, if a section of the
institution consisting of one or two bedded rooms or small wards is
devoted to patients needing special nursing, irrespective of the
stage of disease, efficiency is secured, the special needs of each
class of patients can be met, and—this is especially important—the
patient with advanced disease cannot infer the hopeless character
of his illness from his place in the institution. Such a combined
institution affords the medical and administrative advantage that the
tuberculosis officer can, as a rule, watch his patients throughout
the whole course of their treatment, both in the residential
institution and at the dispensary.

In choosing a sanatorium an area of at least twenty acres should be
available; and at least one-fifth of an acre should be allowed per
patient. For a hospital a smaller area is permissible. There should
be a floor-space of at least 64 square feet for each patient; and the
centres of the heads of adjacent beds should not be distant less
than 8 feet measured against the wall. Experience appears to show
that in a large sanatorium one nurse will generally be adequate for
every twelve patients. In a hospital for advanced patients, or in a
combined institution a larger staff may be required.


                         _Observation Beds_

There is but little systematised experience as yet of the employment
of observation beds; a difficulty arising from the fact that the
tuberculosis officer under most local tuberculosis schemes has
not been sufficiently in touch with the medical officers of the
residential institutions to which he sends patients. There are
practical difficulties in the provision of observation beds on the
dispensary premises, including the difficulty of due regard to
economy of administration in the nursing and treatment of three or
four in-patients at a dispensary. Whatever arrangements are made for
such beds, it is desirable that the tuberculosis officer should have
access to the patients treated in them.


          _General Observations on Treatment in Sanatoria_

In 1911 the extent and limitations of the utility of sanatorium
treatment of tuberculosis were already fairly well recognized by
physicians; and it is unfortunate that in connection with the
passage of the National Insurance Act this treatment acquired a
somewhat political aspect, and became the subject of much popular
misapprehension and exaggeration. Disappointment necessarily followed
on the sending of patients to sanatoria for treatment with a view to
cure at a stage of disease when anything beyond ephemeral improvement
was impossible. The patients who, under present conditions, are
admitted to sanatoria come roughly into two groups:

First. Patients with limited disease and little or no systemic
disturbance. Comparatively few patients who now enter sanatoria come
within this group.

Second. Patients with more extensive or acute disease. In a large
proportion of cases within the first group the immediate result
of sanatorium treatment extending over three to six months is the
complete restoration of general health and working capacity with
arrest of disease. In a large further proportion of cases in the same
group there is recovery of working capacity and apparent restoration
of general health without complete arrest of disease.

For patients coming within the second group a similar period of
treatment in a sanatorium results:

(_a_) In restoration of general health and working capacity with
arrest of disease in only a small proportion of cases;

(_b_) In recovery of working capacity and apparent restoration of
general health without arrest of disease in a fair proportion of
cases; and

(_c_) In the remainder, disease progresses steadily with or without
temporary improvement in general health.

The subsequent history of sanatorium patients varies greatly. Some
of them maintain their health indefinitely on return to their
ordinary life. Others who have been discharged with arrested disease
ultimately relapse, even if they live under excellent environmental
conditions; and such relapses are excessive among those who return to
unsatisfactory conditions of life and work.

Among patients discharged from a sanatorium without arrest of the
disease a small proportion ultimately recover completely, but the
majority relapse at a date which is earlier or later in accordance
more or less with the conditions under which they live and work and
the severity of their disease.

The experience of the last few years has been that only a small
proportion of the patients admitted to sanatoria are cases in which
arrest of the disease can be anticipated; and this will continue
until the disease is more generally detected at an earlier stage than
at present, and the sanatorium treatment is prescribed and continued
solely in accord with the medical needs of the patient.

The conditions of local administration of the Sanatorium Benefit
under the National Insurance Act have led to a very high proportion
of consumptives being treated in sanatoria with a view to cure,
who might advantageously have received educational treatment for a
few weeks and then have been treated at home or at a tuberculosis
dispensary. Furthermore, a large number of patients with advanced
disease have been sent to sanatoria for whom treatment in a hospital
was more appropriate.


                   _Educational Work of Sanatoria_

Apart from the question of cure, which with belated treatment can
only be expected in a minority of cases, the sanatorium serves an
important purpose, not only in restoring patients to a considerable
degree of health and working capacity for a longer or shorter
time, but also in educating the patients how to live and conduct
themselves. A stay in a sanatorium for a short period—a month or
six weeks—under doctors and nurses who realise the value of this
work—would there were more of these!—secures the training of the
patient on lines beneficial to his future health and enables him to
obviate all danger for others.

In such a short stay in a sanatorium what may be called tuberculosis
discipline can be and is acquired when the sanatorium is
satisfactorily administered; and the patient thus disciplined is in
a much more favorable position for securing his own welfare and that
of others than the undisciplined patient, just as the soldier who has
had routine drill under a competent instructor is more efficient
than the untrained recruit.

The preceding remarks as to the treatment of tuberculosis in
sanatoria illustrate certain well-known features in the natural
history of this disease. In the majority of instances of disease
recognised under present conditions we are dealing with a slowly
progressing disease. This sometimes become spontaneously arrested;
occasionally it may be arrested or its course delayed under
medical treatment at home associated with manageable changes in
domestic and industrial life. In still further instances it may
be arrested by treatment in a sanatorium; while for other cases
sanatorium treatment, however prolonged, is followed by only
temporary improvement, and the chief benefit thus received is that
of training as to mode of life, which might have been secured by a
much less protracted stay in the institution, followed by measures
supplementing sanatorium treatment. We have further to recognise
the fact that, under present conditions of social life and medical
practice, many tuberculous patients will slowly, by intermittent
stages, but none the less surely, die from tuberculosis in the course
of one, three or five years. Regard must be paid to this fact if our
total measures for the control of tuberculosis are to be successful.


                        _Hospital Treatment_

This fact emphasizes the importance of adequate hospital treatment
for all patients acutely ill or bed-ridden, who cannot be
hygienically treated at home; and the importance becomes evident of
exercising _complete supervision over and provision for the whole
of the sick life of the consumptive, whether he is trending towards
complete recovery or to death_.

Such complete supervision and provision necessitates further
development in three directions in which beginnings have already been
made:


                        _Industrial Colonies_

These are the provision of “Farm or Industrial Colonies,” the
adaptation of domestic dwellings to meet the special needs of
consumptives, and the more complete organization of “Care” and
“After-care” arrangements.

In a large proportion of cases, the patient on leaving the sanatorium
is unable at once to embark on full work without risk of early
relapse, or to refrain from this without endangering his nutrition
and that of his family. His work, furthermore, may be unsuitable for
a consumptive.

This has led to many tentative efforts to train the consumptive
in a suitable occupation while under sanatorium treatment, or in
an industrial colony which should preferably be attached to or in
close communication with a sanatorium, in order that the patient
may continue under skilled medical supervision. The graduated labour
which forms part of the routine method of treatment in many sanatoria
can be made a preparatory stage in this industrial training.
The training may be made to merge into the pursuit of an actual
livelihood; and then the sanatorium becomes an industrial colony.
Market gardening, pig-keeping, forestry, and other occupations
may be thus pursued for protracted periods, if the patients are
suitably selected. The ex-patients continue to live under protected
conditions, earning part at least of their livelihood. Attempts
in this direction are not likely to have wide success unless the
patient is re-instated in his family; and the most promising efforts
are those which install the ex-consumptive with his family in a
cottage near a sanatorium, where he can remain under partial medical
supervision, while engaged in his daily work. It remains to be seen
to what extent such arrangements are practicable on a considerable
scale, and the experiments now being made will be watched with
interest.


               _Special Dwellings and Help in Support_

An alternative to the “colony” proposal, which will probably be found
practicable in a much larger number of cases is to arrange for the
ex-patient to be housed at his home under special conditions and
for his work to be graduated according to his physical condition,
assistance being given by way of payment of rent, or otherwise to
ensure that the patient and his family live under satisfactory
conditions. Proposals have been made by Dr. Chapman in a report
to the English Local Government Board that in connection with new
housing schemes a certain proportion of the houses erected should
have rooms providing free perflation of air reserved for consumptive
patients. If with this is combined the assistance indicated above,
the risk of the ex-patient relapsing will be materially reduced, and
the risk of other members of the family becoming consumptive may be
obviated.

Whatever methods are employed, the principle already enunciated must
be maintained that the patient in his own interest and in that of his
family must be the subject of uninterrupted care and supervision.

In securing this end _Care Committees_ play a valuable part. Owing to
the war their development has been retarded; but a local scheme for
such supervision and assistance as the members or agents of a Care
Committee can give forms an essential part of a complete tuberculosis
scheme.

These Committees are formed of non-official persons, inasmuch as a
large share of their work is at present beyond the scope of official
possibilities, outside the poor-law organization; they can help,

 (_a_) in obtaining appropriate work for the ex-patients;

 (_b_) in supplementing his wages;

 (_c_) in providing separate sleeping accommodation for the patient,
 additional food or clothing, or in loaning out an additional bed or
 bedding;

 (_d_) in aiding the family during the absence of the patient
 in a sanatorium, and thus reducing the temptation to terminate
 institutional treatment prematurely, and

 (_e_) in encouraging each patient to take the necessary precautions
 and to adopt the special treatment recommended for him.

Some of these activities overlap into the activities of the
tuberculosis officer and of the visiting nurse of the local
authority; but there need be no practical difficulty in adjusting
this. It is important that Care Committees should act in coöperation
with local authorities, insurance committees, and charitable
agencies, and should have representatives of these bodies on them.
The medical officer of health and tuberculosis should also be
ex-officio members of their committee.

_Summary_.—The preceding review of the problem of tuberculosis may be
summarised in a few final statements.

1. Our knowledge of tuberculosis, if fully applied by combined attack
on the disease by all known methods, is adequate to secure a great
reduction in its prevalence, if not its absolute abolition.

This is true, although certain problems respecting tuberculosis
still need elucidation, e.g., as to improved methods of treating the
diseases, and of increasing individual immunity during exposure to
protracted infection.

2. Domestic protection is at once practicable against infected cows’
milk; and control of this source of infection at its source is also
practicable.

3. Of the circumstances favouring the development of pulmonary
tuberculosis industrial dust and domestic overcrowding are the most
potent. More detailed and systematic supervision of factories and
workshops is needed, followed by general adoption of remedies, which
would increase industrial efficiency as well as reduce tuberculosis.

4. Tuberculosis is especially a “bedroom infection.” But improvement
in housing is a dual problem, and it is a blunder to assume that
improved housing, so long as the healthy and tuberculous sick
continue to be housed together, will produce a rapid decline in the
prevalence of tuberculosis. Hospital provision for the sick is as
necessary as improved general housing.


FOOTNOTES:

[17] The substance of two lectures at the Summer School on
Tuberculosis, Trudeau Sanatorium, Saranac, N. Y., July, 1919.




                              CHAPTER X

                  CHILD WELFARE WORK IN ENGLAND[18]


The subject of child welfare, in its chief developments, cannot be
separated from that of Public Health, of which it forms a constituent
part, though I do not ignore the fact that child welfare is largely
dependent also on the extent to which child labor is exploited, and
to which expectant and nursing mothers,—as also other mothers whose
extra-domestic employment or whose employment for gain is within the
home itself,—involves neglect of young children.

Improvement in child welfare has occurred as the sanitary and social
progress of the country has advanced. Whereas in the decade 1871-80,
when money began to be spent more freely on elementary sanitary
reform, the expectation of life or mean after-lifetime at birth of
males was 41.4 years and of females was 44.6 years; in the years
1910-12 these had increased to 51.5 and 55.4 years respectively. The
greater part of the saving of life which this addition of ten years
to the average duration of life was the result of reduced mortality
in children under five years of age.

The first direct steps towards the reduction of infant mortality
were directed against epidemic or summer diarrhœa. Medical officers
of health have always been required in their annual reports to
summarize the vital statistics in their districts; and since 1905
a more detailed statement of infant mortality during each part of
infancy has been required. Annually, therefore, as well as when they
received the weekly returns of deaths from the local registrars,
there was forced upon their attention the fact that deaths of infants
under one year of age formed a high proportion of total deaths at all
ages (12.9 per cent. in 1917), and that of these infantile deaths a
large proportion were caused by diarrhœa, the number varying with
the temperature and the deficiency of rainfall in the summer months.
In 1912, a year of relatively small mortality from diarrhœa, this
disease caused 8.1 per cent. of all deaths under one year of age.

For many years past it has been customary for medical officers of
health to issue warnings as to summer diarrhœa, to arrange for the
distribution of leaflets of advice concerning the disease, and to
urge the necessity of more thorough cleanliness both municipal and
domestic during the summer months. Even before the early notification
of births became obligatory, in many areas the addresses of infants
were obtained from the registrars of births and special visits were
made to the mothers of infants during the months of June and July
and especially to the mothers of those infants who were known to be
artificially fed.

The reports of medical officers of health of many of the large
towns from 1890 onwards show that much valuable work was being
accomplished, and the way was being prepared for more general
measures against infant mortality.

The importance of municipal sanitation in aiding the elimination
of diarrhœal mortality is illustrated in the experience of many
towns, and strikingly by the comparative experience of Leicester
and Nottingham. The chief difference between the sanitary condition
of the two towns was that in Nottingham in 1909 pail closets still
served more than half the houses, while Leicester had abandoned this
system entirely, substituting water-closets. Between 1889-93 and 1909
the diarrhœal mortality in Leicester had declined 52 per cent.; in
Nottingham it had only declined 4 per cent.

Diarrhœa is not the only disease of infancy which can be greatly
diminished by improved public health administration. Tuberculosis
and whooping cough and measles figure largely in the infantile death
returns. Over 21 per cent. of the total deaths in infancy are due
to these three diseases and to diarrhœa. The amount of syphilis
appearing in the death-returns is small; but its actual amount is
much greater than the figures show. If pneumonia and bronchitis,
which account for 19 per cent. of the deaths in infancy, be
regarded—as they should—as infective diseases, then it may be said
that the problem of saving child life and securing the correlative
improvement in the standard of health of children who survive to
higher ages, _consists very largely in the prevention of infections_,
including diarrhœal diseases and acute respiratory diseases.

It follows from this that even if the limited and erroneous view
be taken that Sanitary Authorities are concerned only with the
prevention of infectious diseases, the reduction of infant mortality
is a duty devolving on these authorities, and cannot be effectively
carried out without their coöperation. Voluntary effort must
therefore always, in large measure, be directed towards stimulating
local authorities to perform their duties.

The influence of diarrhœal summer mortality on the progress of child
welfare work is further shown by the fact that among the earliest
efforts were those to provide pure cows’ milk to infants. In England
official Milk Depots for this purpose were never numerous; and
little voluntary effort went in this direction. There now remain
very few such Milk Depots; but many local authorities provide milk,
more particularly dried milk, to infants for whom it is specially
prescribed at Infant Consultations. Early investigations at Brighton
and elsewhere showed that the mortality of infants fed on condensed
milk,—chiefly of the sweetened variety,—was greater than that
of infants fed on fresh cows’ milk, and directed attention to
the supreme importance of domestic cleanliness in the prevention
of summer diarrhœa. The Milk Depots and the concurrent agitation
for purer cows’ milk served a useful purpose; though it cannot
yet be said that the cows’ milk ordinarily supplied in England is
satisfactorily clean.

It became evident ere long that the broadcast distribution of
instructions as to how cows’ milk might safely be stored and prepared
for infants had but a limited utility, and that the directions given
were liable to be misinterpreted by mothers as an encouragement to
abandon breast-feeding; and there is reason to believe that these
directions did sometimes have this effect. Hence the importance
of the work initiated by the late Dr. Sykes at the St. Pancras
School for Mothers, which brought into relief the importance of
encouraging breast-feeding by every possible means. In towns in which
the aided supply of milk was continued, advice as to its use was
also initiated; and thus gradually Infant Consultations, in which
the main element was the giving of individual advice and treatment
as required, superseded Milk Depots, and were established in very
large numbers where Milk Depots had never been started. These had
educational as well as medical and hygienic activities; and there
need be no dispute as to the relative value of these two aspects of
the work of Infant Consultations (also known as Schools for Mothers,
Child Welfare Centres, Baby Weighings, Mothers’ Welcomes, etc.); for
whether advice and instruction are given to the individual mother or
to mothers collectively,—or as is advisable in both ways,—it should
be exactly the advice which a physician skilled in the hygiene of
infancy as well as in the treatment of infantile complaints would
give to his individual patient. In this sense it remains true, as
Professor Budin, the distinguished founder of Infant Consultations
said: “An infant consultation is worth precisely as much as the
presiding physician.” This is true whether it is possible to arrange
for a physician to be present at each meeting of a Child Welfare
Centre; or whether, as has happened during the Great War in England,
nurses or health visitors trained under such a physician have given
hygienic advice in his absence.


                    _The Notification of Births_

For many years before the Notification of Births Act was passed, it
had been customary, especially in towns, to arrange for inquiry by
a sanitary inspector or female visitor into death occurring under
one year of age, and in many instances for the giving of systematic
advice to mothers concerning their infants. More than twenty years
ago the Manchester and Salform Sanitary Association had initiated
a system of home visitation by volunteer ladies and by women
workers paid by the Association who went from house to house, gave
elementary sanitary advice, and reported serious defects to the
Sanitary Authority. The City Council at an early stage showed its
appreciation of the importance of this work by giving grants towards
the expenditure incurred.

In order to enable early visits to be made, the town council of
Salford had begun as early as 1899 a system of voluntary notification
of births by midwives.

Prior to the stage at which early notifications of births was
obtained, the medical officer of health was dependent for his
information on the registration of births, for which an interval of
six weeks after birth was permitted before it became compulsory.
During this interval a large proportion of the total mortality of
infancy had occurred,—approximately one-fifth of the total deaths
in the first year after birth occur in the first week and one-third
in the first month after birth,—and the possibility of successfully
influencing the mother to continue breast-feeding had gone. The
action of the town of Huddersfield in 1906 in obtaining Parliamentary
power to secure the compulsory notification of births within
thirty-six hours of birth represented a rapid growth of opinion
based on experience in that and other towns to the effect that in
the absence of early information of birth the necessary sanitary
precautions and counsel as to personal hygiene could not be given
with the greatest prospect of success. This local pioneer work
doubtless facilitated the passing of the Notification of Births Act
in 1907.

Much important work followed the notification of births. Home visits
to the mother were regarded and continue to be regarded as the most
important part of this work; but there also grew up rapidly the
present system of Infant Consultations and similar organizations.

The Notification of Births (Extension) Act, 1915, not only made
the enforcement of this act universal, but it also empowered each
local authority administering the Act to exercise any powers which a
sanitary authority possesses under the Public Health Acts “for the
purpose of the care of expectant mothers, nursing mothers, and young
children.” In drawing the attention of Local Authorities to the terms
of the Act the Local Government Board, as well as earlier in the war,
deprecated false economy during the war. They said:

 At a time like the present the urgent need for taking all possible
 steps to secure the health of mothers and children and to diminish
 ante-natal and post-natal infant mortality is obvious, and the Board
 are confident that they can rely upon local authorities making the
 fullest use of the powers conferred on them.

The Board in the same circular laid stress on “the importance of
linking up this work with the other medical and sanitary services
provided by local authorities under the Public Health and other Acts.”

The passing of this Act has been followed by an increasingly rapid
development of Maternity and Child Welfare work, and the Maternity
and Child Welfare Act passed in August, 1918, made it obligatory on
each Council exercising powers under the Act to appoint a Maternity
and Child Welfare Committee, which must include at least two women,
and may include persons specially qualified by training or experience
in subjects relating to health and maternity who are not members of
the Council.

In the circular letter sent out to local authorities explaining the
new Act, the Local Government Board reëmphasizes its previously
stated views that child welfare work was second only in importance
to direct war work, and was really a “measure of war emergence,” and
added:

 although we have enjoined as local authorities the necessity of the
 strictest of economy in public expenditure, we have urged increased
 activity in work which has for its object the preservation of
 infant life and health. We are glad to note that the great majority
 of local authorities have realized the value of continuing and
 extending their efforts for child welfare at the present time.


                   _The Causes of Child Mortality_

For detailed consideration of the causes of infant mortality and of
mortality during the next four years of life in England and Wales,
the reader may be referred to official reports by the writer.

No consistent and continuous decline had taken place in infant
mortality prior to 1900, although there had been marked reduction of
the mortality in each of the next four years of life. This difference
corresponds in the main with the facts that greater success had been
achieved in the general measures of sanitation and in the reduction
of prevalence of and mortality from such infectious diseases as
scarlet fever, diphtheria, and enteric fever, than in respect of the
special causes of mortality in infancy. These special causes may be
placed under three headings: First, infections,—acute respiratory
diseases, measles, whooping cough, syphilis, tuberculosis, and
diarrhœa; second, errors of nutrition, due largely to poverty, to
mismanagement, and to imperfect provision of facilities for healthy
family life; and third, developmental conditions present at the birth
of the infants. Under none of these headings had marked success been
achieved prior to 1900, though the steady work devoted to the subject
of diarrhœa had already begun to show fruit.

The statistics of infant mortality may be stated as follows:

                         _England and Wales_

                       Deaths of Infants under
    Period             1 Year per 1,000 Births

    1896-1900                    156
    1901-1905                    138
    1906-1910                    117
         1911                    130
         1912                     95
         1913                    108
         1914                    105
         1915                    110
         1916                     91
         1917                     96
         1918                     97

The above are the crude rates, the infantile death-rate being stated
by the usual method per 1,000 births _during the same year_. Owing to
the great decline of births during the war, this method overstates
the infant mortality in recent years. In a table given in the
Registrar-General’s annual report for 1917, this unusual source of
error is corrected. When this is done, and the infantile deaths are
stated “per 1,000 of population aged 0-1,” the rates for the years
1912-17 inclusive in successive years became respectively

    104, 117, 113, 111, 98, and 94.

In other words, there has been a steady and uninterrupted decline in
the death-rate of infants during the war.

This decline has followed similar declines in preceding years, and
it is to be noted that much of this decline occurred during the
period when the hygienic work effecting child-welfare was confined
to general public health measures. Thus it anticipated the more
direct and active measures adopted by voluntary societies and by
local authorities for the prevention of infant mortality. Comparing
the five year periods 1896-1900 and 1901-05, a decrease in the
death-rate of 12 per cent. is seen; comparing 1901-05 with 1906-10,
a decline of 15 per cent. occurred; comparing 1906-10 with the
average experience of the three years 1911-13 mortality declined 5
per cent.; comparing these three years with the average experience of
the five years 1914-18, during which war conditions prevailed more or
less, a reduction 9 per cent. was experienced. The actual reduction
during war time is greater than is indicated by these percentages,
when allowance is made for the statistical error indicated above.
The exceptional experience of the year 1911 illustrates one of the
chief sources of error in forming conclusions on the experience of a
single year. In this year the summer was excessively hot, and summer
diarrhœa prevailed to an exceptional extent; and the illustration is
important, as serving to remind us of the limitations of the value of
statistical tests and of the fact that increase of good work tending
to improve child life may be associated temporarily with increase of
total infant mortality.


            _The Influence of School Medical Inspection_

In the development of child welfare work in England important place
must be given to the system of medical inspection of school children
initiated in 1907. The numerous physical defects found in school
children have led to the beginning of measures for remedial action,
confined in some areas to measures for securing greater cleanliness
and the treatment of minor skin diseases; but extending in other
areas to such measures as the remedial treatment of adenoids, the
cure of ringworm, the correction of errors of refraction, and the
provision of dental treatment. Perhaps the chief value of the system
of medical inspection of school children has been the fact that it
has demonstrated the extent to which children when they first come
to school are already suffering from physical disease which might
have been prevented or minimized by attention in the pre-school
period. The information thus accumulated has had much influence in
encouraging the institution of Infant Consultations, with a view to
the early discovery of disease or of tendency to disease.


               _The Influence of Statistical Studies_

The intensive study of our national and of local vital statistics
has also had a most important bearing on the further development of
maternity and child welfare work. In successive official reports
it has been shown that infant mortality varies greatly in different
parts of the country, irrespective of climatic conditions; that it
varies greatly in different parts of the same town, in accordance
with variations in respect of industrial and housing conditions, of
local sanitation, of poverty and alcoholism; that the variations
extend to different portions of infant life, the death-rate in
infants under a week, or under a month in age, for instance, being
two or three times as high in some areas as in others; and that the
distribution of special diseases in infancy similarly varies greatly.
Intensive studies of infant mortality on these and other lines have
pointed plainly the directions in which preventive work is especially
called for; and have incidentally demonstrated the fundamental value
of accurate statistics of births and of deaths in the child welfare
campaign. Surveys of local conditions both statistical and based
on actual local observations form an indispensable preliminary to
and concomitant of good child welfare work; and it is to combined
work on these lines that the improvement of recent years is largely
attributable. To _act helpfully_ we must _know thoroughly_ the
summation of conditions which form the evil to be attacked.

One important result of investigations such as those already
mentioned has been to bring more clearly into relief the fact, which
previously had been partially neglected, that _child welfare work
can only succeed in so far as the welfare of the mother is also
maintained_.

This may imply extensions of work involving serious economic
considerations; but apart from such possibilities and apart from
questions of housing, and of provision of additional domestic
facilities for assisting the overworked mother, there is ample
evidence that medical and hygienic measures by themselves can do much
to relieve the excessive strain on the mother which childbearing
under present conditions often involves.


             _The Course of Mortality from Childbearing_

The general course of mortality from childbearing (including deaths
ascribable to pregnancy) in England and Wales is shown by the
following table:

        _Average Annual Death-rates per 100,000 births from_

                          Puerperal    Other Diseases
                          Septic       of Pregnancy
                          Diseases     and Childbirth

    5 years, 1902-06        185             228
    5 years, 1907-11        152             215
    3 years, 1912-14        148             233
    2 years, 1915-16        151             239

It will be noted that although there has been a marked decline of
deaths from puerperal sepsis, the death-rate from other complications
of childbearing has not declined. The decline in puerperal sepsis
is general throughout the country, and evidences the greater care
in midwifery both on the part of doctors and of midwives. The
administration of the Midwives Act, 1902, has doubtless done much
to secure this. The death-rate from conditions other than puerperal
fever continues to differ greatly throughout the country. It is
highest in Welsh counties, Westmoreland, Lancashire and Cheshire
coming next in order of unfavourable portion; in many industrial,
including textile, towns it is also excessive. The general conclusion
reached by the writer in an elaborate official report on the subject
is that “the quality and availability of skilled assistance before,
during, and after childbirth are probably the most important factors
in determining the remarkable and serious differences in respect of
mortality from childbearing shown in the report.”—“The differences
are caused in the main by differences in availability of skilled
assistance when needed in pregnancy, and at and after childbirth.”


                      _The Midwives Act, 1902_

This Act forbade any woman after April 1, 1906, who was not certified
under the Act, from using the title of midwife or any similar
description of herself. It forbade after April 1, 1910, any such
woman from “habitually and for gain attending women in childbirth,
except under the direction of a qualified medical practitioner”; and
it forbade any certified midwife to use an uncertified person as her
substitute. The Act defined the limits of function of the midwife
by stating that the Act did not confer upon her any title to give
certificates of death or of still-birth, or to take charge of any
abnormality or disease in connection with parturition.

The Act set up the Central Midwives Board, giving it special
disciplinary powers over midwives. It also imposed on county councils
and the councils of county boroughs the duty of supervising the work
of midwives. For further details the Act itself and the Rules of the
Central Midwives Board made under the Act should be consulted.

The Midwives Act, 1918, gave further powers to the Central Midwives
Board and to local supervising authorities, and made it the duty of
the latter to pay the fee of a doctor called in by a midwife in any
of the emergencies for which Rules are made by the Central Midwives
Board, the fee paid to be in accordance with a scale prescribed by
the Ministry of Health.

As at least three-fourths of the total births in England and Wales
are attended by midwives with or without the assistance of doctors,
their work has great importance in relation to the reduction of
maternal disablement and mortality and to the prevention of early
infant mortality, and it is of happy augury that they are being
enlisted more and more in official work for safeguarding the health
of the mother and her unborn or recently delivered infant. An
important recent addition has been made to the rules of the Central
Midwives Board, which makes it obligatory on the midwife to notify
to the medical officer of health any instance, while the patient is
under her charge, in which for any reason breast-feeding has been
discontinued.

_Administrative Work._—Largely through the machinery provided by
the Midwives Act and the Notification of Births Act a system of
supervision of maternity and child welfare has been organized in
every county and county borough, and this has been responsible for
a large share of the improvement experienced in recent years. The
character and extent of development of the work varies greatly in
different centres; and as a rule the work is more fully developed
in county boroughs than in counties. In county districts it has
sometimes been found necessary to unite the offices of assistant
inspector of midwives, infant visitor and tuberculosis visitor in one
adequately trained health visitor, thus saving time in travelling
by enabling the visitor to have a smaller district allotted to her
than if she undertook only one branch of work. In some counties the
school nurse’s work is also undertaken by the health visitor. In some
country areas arrangements have been made for infant visiting to be
carried out by district nurses who are also midwives.

_Voluntary Workers._—Much of the success so far achieved in improving
the health conditions of infancy and childhood has been secured by
coöperation between voluntary and official health visitors. Excellent
work has been done by local and other societies, particularly during
the last ten years, in educating public opinion and in direct
assistance to mothers and their infants. It is essential that such
voluntary work should have a nucleus of highly trained and well-paid
workers; but given this condition, a large amount of good work can be
accomplished by voluntary aid.

The main work has been that of the _health visitor_. The details of
this work, the conditions of qualification of workers, the number of
visits which it is desirable to make, the character of the advice
intended to be given at these visits are set out in an official
memorandum of the Medical Officer of the Local Government Board and
it is unnecessary to repeat this information in these pages.

A similar remark applies to the next most important development of
work, the institution of _Maternity and Child Welfare Centres_. The
conditions of work of these institutions are set out in the same
document.


                _Training and Provision of Midwives_

The provision of additional trained midwives is a pressing problem.
The increased cost of living, longer training required, and the
rapid development of less laborious and more lucrative occupations,
have made it difficult to secure women to train as midwives, or to
continue to practise in this capacity after qualification. In many
industrial areas the older _bonâ fide_ midwife is preferred, although
it is the almost universal experience that the trained midwife more
quickly detects conditions endangering the life of the mother or
infant, and sends for medical help. In order to encourage further
the supply of practising midwives, the government gives grants
for increased remuneration to midwives newly appointed by local
authorities, sufficient to recoup them in the course of a few years’
service for the cost of their training.

At a recent date, of some 30,543 trained midwives on the Roll, only
6,754 were returned as being in actual practice as such.

In order to make midwives available for all women needing them, the
Board repays to local authorities and voluntary associations half the
cost of the provision of a midwife for necessitous women. During the
Great War a woman might receive assistance in her confinement from
several central sources; for in addition to the above

 (1) If she was the wife of an insured person, or if she herself is
 insured, she received under the conditions of the National (Health)
 Insurance Act 30s. in cash, or if she is insured and the wife of an
 insured person 60s. in cash.

 (2) If she was the wife of a soldier or sailor and not entitled to
 maternity benefit she received from 10s. per week up to £2 from the
 Local Pensions Committee.

 (3) If she was a munition worker she might be aided under a scheme
 provided under the Ministry of Munitions.

 (4) She also might obtain priority for the supply of milk, or obtain
 free milk or milk at cost price under the Local Committee Board
 Food Control Order, No. 1, 1918, empowering local authorities to
 supply milk and food and an extra ration under the Food Controller’s
 Order. In addition, after confinement she had available the ration
 apportioned to the infant and its allowance of milk under the
 priority scheme.

There was evidently need for simplification and unification of effort
in the above cases.

In many instances maternity nursing is required. The midwife may have
too many patients to be able to give this during the ten days in
which she is in charge of the patient; and even when she carries out
her duty in this respect in accordance with the Rules of the Central
Midwives Board additional help is required in the feeding and care of
the mother and infant, and in the care of the household. Often also
nursing is required for both mother and infant for a considerable
period beyond the ten days. For these persons the government gives
grants for maternity nursing and for “home helps.”

Even when all the above requirements are or can be fulfilled, there
remain a large number of cases of pregnant women, and especially
of unmarried women, who cannot be satisfactorily confined at home,
either because of their social or sanitary circumstances, or
because abnormal or complicated childbirth is expected. For such
cases hospital provision is needed. This is one of the most urgent
requirements of the present time.

Under present conditions, institutional lying-in provision is
chiefly voluntary in character; and the government has advised
local authorities to contract for its use, rather than wait for the
erection of special hospitals. In other instances houses are being
taken and adapted as maternity homes.


                          _Ante-natal Work_

The progress made in the organisation of ante-natal work is slow for
reasons which are fairly obvious. There has been difficulty under war
conditions in securing assistance from doctors and midwives. There
is the well-known difficulty as to notification of pregnancy, which
the government has not encouraged, except when the definite consent
of the mother has been previously obtained. The facilities for
help provided at the Centre have in some areas attracted patients;
and health visitors and midwives have done much in other areas to
persuade mothers of the advisability of safeguarding themselves
against possible complications, as well as of securing adequate
preparation for the lying-in period.

This subject is closely associated with that of abortions,
still-births, and deaths in the first two weeks after birth. One of
the most promising methods for securing the sound development of
ante-natal work consists in the investigation of still-births and
early infant mortality. When these inquiries are made mothers can
be induced to obtain medical advice not only at the time, but also
in the event of a subsequent pregnancy. The investigation at the
patient’s home of all such cases and assistance in prevention of
recurrence of unnecessary ante-natal, natal, and early post-natal
deaths have as great an importance as the building up of a successful
ante-natal clinic. The anti-syphilis work now being carried on will
help greatly in this direction.


                         _Dental Assistance_

There has been a large extension of dental assistance at Centres for
expectant and for nursing mothers, and for children, especially in
the metropolis and its vicinity. The government has lately extended
its grant to cover dentures for mothers who are nursing or pregnant,
if the medical officer of the Centre is satisfied that the woman’s
health will be materially improved by the denture, and that she is
unable to provide it for herself.


                              _Creches_

Creches and day nurseries may be expected to exercise influence in
educating mothers in the care of their children. For this purpose it
is very desirable to have the creche attached to or near an infant
welfare centre.

These creches, unless managed with the most rigid medical and
general cleanliness, are very apt to spread infectious diseases; not
merely such diseases as whooping cough, measles, and chickenpox,
but also catarrhal and diarrhœal diseases. In the prevention of all
of these the enforcement of the strictest cleanliness is essential,
especially during the summer months for the last named diseases. For
the prevention of catarrhal infections, it is essential that the
creche should be conducted, so far as practicable, on strict open-air
lines. Open-air creches give admirable occasional relief to mothers,
even when these do not go out to work. The “toddler’s playground”
is a blessing to all concerned, but the indoor creche may be, and
often is, mischievous. The risks are greatly reduced by insisting on
open-air conditions and by not allowing large groups of children to
come together. Smaller groups mean greatly decreased possibility of
cross-infection.


             _Observation Beds at Child Welfare Centres_

At infant welfare centres infants are not infrequently seen who
fail to make progress while living at home, and who yet are not ill
enough to be sent to a hospital. This especially applies to cases of
defective nutrition. For these cases beds in connection with centres
have been found to be necessary for observation purposes and to
initiate further treatment. In some instances, especially for failure
of breast-feeding, it is advisable to admit the mother with the
infant.

On July 30, 1914, the Local Government Board sent a circular letter
and a covering memorandum by their Medical Officer which may be
claimed to have been the starting point of maternity and child
welfare work on a larger scale, more generally distributed throughout
the country, and more completely covering the whole sphere of
medical and hygienic work for this purpose than had previously been
envisaged. Although the country at that time might be said to be
already under the shadow of war, these documents had been previously
prepared, and their appearance four days before the declaration
of war was a coincidence. The chief burden of the additional work
to which local authorities were urged was that there should be
_continuity in dealing with the whole period from before birth until
the time when the child is entered upon a school register_; and the
memorandum contemplated that “medical advice and, where necessary,
treatment should be continuously and systematically available for
expectant mothers and for children till they are entered on a school
register, and that arrangements should be made for home visitation
throughout this period.” It was added that “the work of home
visitation is one to which the Board attach very great importance and
in promoting schemes laid down in the accompanying memorandum the
first step should be the appointment of an adequate staff of health
visitors.”

The main provisions of this memorandum are printed on page 135.

The increase of work since that date may be gathered from the
following table, which shows the increase each year in the number of
health visitors, of child welfare centres, and of grants given on the
50 per cent. basis by the Local Government Board and the Board of
Education.


_Amounts of Grants (pounds sterling) in Each Financial Year to Local
 Authorities and Voluntary Agencies, on the Basis of 50 Per Cent. of
                  Total Approved Local Expenditure_

  Financial Year          Local Government Board  Board of Education
     1914-15                     11,488                 10,830
     1915-16                     41,466                 15,334
     1916-17                     67,961                 19,023
     1917-18                    122,285                 24,110
     1918-19 (estimated)        209,000                 44,000

These grants do not cover the entire scope of child welfare work
carried out throughout the country, and their amount must not be
taken as a complete indication of the extent of this work.

The increase during the war period has been very great; and this can
be attributed to the desire to do everything practicable for mothers
and children, especially those belonging to soldiers and sailors
who were risking their lives for the country; and to the increased
realisation of the importance of preserving and improving our chief
national asset which consists in a healthy population. During this
period there was a great increase in the industrial employment of
women, including married women, in factories including munition and
other works. This increase it is believed amounted to a million and a
half workers.

Notwithstanding the many adverse influences, to which must be added
great overcrowding in many industrial areas, especially those in
which new industries were hurriedly started, and the increasing cost
of food and especially of milk with a scarcity of supply, it has been
seen that infant mortality remained low and on the whole declined
during the whole period of the war.

To what circumstances can this be ascribed?

It is unnecessary to assume that this result was entirely due to the
active measures favorable to maternity and child welfare which were
taken as an unexampled scale, though these measures can claim an
important share in the result.

A number of contributory factors were at work:

1. In none of the years in question did the summer weather favor an
excess of diarrhœal mortality. With this factor, however, eliminated
the infant mortality each year was lower than in previous years.

2. Although so many husbands were away from home, in a large
proportion of cases the wife, in virtue of her separation allowance,
was financially in a more favorable position than when she was
dependent on her husband’s wages or such portion of it as he allowed
her for the support of the household.

3. In addition, every soldier became an insured person, and his wife
was therefore entitled to the Maternity Benefit of 30 shillings on
the birth of a child, and an additional 30 shillings if she was
herself an employed person.

4. There can be no reasonable doubt that the restrictions on the
consumption of alcoholic drinks and the limitation of hours for
opening public houses were a factor in improving domestic welfare.

But attaching full value to these and other similar factors which
undoubtedly were at work, chief place must, I think, be given to
the awakening of the public conscience on the subject, and to the
concentration on the mother and her child which had been urged in
season and which now became a fact. An indication of the public
mind is given by the advice issued by the Local Government Board in
August, 1918, which is quoted on page 248.


FOOTNOTES:

[18] Extracted from addresses given at Conferences held by the
Children’s Bureau of the Department of Labor, Washington.




                                INDEX


  Abbott, J., 2

  Abbott, S. W., 2

  Alcoholic drinks, 123, 149, 187

  Anaesthetics, 77

  Ante-natal work, 261


  Bacteriological diagnosis, 85

  Banks, N. P., 2

  Biggs, H., 77

  Bowditch, 2

  Budd, Wm., 15

  Burns, John, 44

  Burton, R., 71


  Care Committees, 237

  Causation, 147

  Causation, specific, 20

  Cerebro-spinal fever, 23, 76, 126

  Chadwick, 2, 3, 11, 12, 25, 52, 54

  Chalmers, 70

  Chapman, 221, 237

  Character and health, 173

  Childbearing, care of, 137, 254

  Child mortality, causes of, 248

  Child welfare work, 240

  Cholera, 12

  Colonies for consumptives, 235

  Consumption, see Tuberculosis.

  Contacts in tuberculosis, 212

  Creches, 263


  Decadence, 121

  Democracy and public health, 47

  Dental assistance, 262

  Destitution (see also Poor Law), 31, 65, 87

  Deterrence, principle of, 29

  Diarrhœal diseases, 20, 241

  Dirt and disease, 11

  Dispensaries for tuberculosis, 216

  ” general, 218

  Domiciliary treatment, 35


  Education authorities and public health, 56, 58, 86

  Educational propaganda, 130, 168

  ” work of sanatoria, 233

  Enteric fever, see Typhoid.

  Epidemiology, present limitations of, 22, 81

  Eugenics and public health, 44

  Expectation of life, 20, 74, 192


  Factory hygiene and legislation, 8, 26

  Farr, Wm., 2, 25

  Fulton, J. S., 24


  Gerhard, 15

  Goodnow, 60, 63

  Grants in aid, 56, 135, 265


  Historical development of public health, 42

  Holmes, O. Wendell, 16

  Hospitals, see Institutional treatment.

  ” as housing auxiliaries, 38, 77, 79, 98

  ” and private practice, 146

  Housing, 38, 79

  ” and tuberculosis, 203

  Huddersfield, 246


  Ideals of public work, 4

  Ignorance and sickness, 168

  Immunity to tuberculosis, 196

  Industrial colonies, 235

  Industry and public health, 50, 161

  Infant consultations, 243

  Infant mortality, 144, 250

  Infant mortality and poverty, 153, 185

  Infants, care of, 30

  Influenza, 23, 76, 127

  Inspectors of factories, 51

  Institutional treatment, 37, 79, 98

  Insurance and public health, 33, 59, 66, 88, 92, 95, 103

  Intemperance, 149


  Jefferson, President, 6

  Jenner, Wm., 15


  Kay, 2, 11

  Koch, Robert, 192

  ” and segregation in tuberculosis, 201


  Laissez faire policy, 6

  Lay workers, utilisation of, 3

  Loans for public health work, 14

  Local Government Board, 53, 58, 77

  Lowe, Robert, 28


  Mackenzie, L., 57

  Maclean, D., 31

  Malaria, 147

  Malthus, 6, 162

  Malthusian hypothesis, 164

  Massachusetts, 2, 4

  Maternity benefit, 34, 95, 111, 134

  Measles, 20, 126

  Measurement of results in life saving, 19

  Medical benefit, 34, 106, 110

  Medical practice and public health, 27, 83

  Medical officers of health, 63

  Midwives Act, 255

  Midwifery nursing, 260

  Milk depots, 243

  Mill, James, 6

  Ministry of Health, 49

  Mother and child, 132, 180

  Murchison, Chas., 15, 17


  National Health Insurance Act, 33, 59, 88, 104

  National medical service, 32, 36

  New England, 1

  Notification of tuberculosis, 206

  ” of births, 245

  Nursing, training of, 122

  ” public health work of, 126


  Oastler, 177

  Overcrowding, 7, 199

  Over-population, 166

  Owen, 177


  Panel doctors, 215

  Pasteur, 21

  Percival, 177

  Pettenkofer, Von, 13

  Philanthropy and public health, 9, 37

  Physical defects, 81

  Pneumonia, 76

  Poliomyelitis, 23, 76

  Political pull, 102, 175

  Poor law and public health, 27, 29, 31, 46, 49

  Population problem, 163

  Poverty, causes of, 31, 182

  ” control of, 46, 114

  ” tests, 139

  ” and sickness, 148, 162, 167, 184, 189

  Preventive medicine, 99

  Progress of public health, 1

  Public health nurses, 128, 154


  Racial immunity, 196

  Red Cross workers, 127, 132, 143

  Registrar-General’s returns, 18, 25

  Relief _v._ prevention, 109, 190

  Relief _v._ prevention, 48

  Research, 24, 35

  Resistance _v._ infection, 195

  Respiratory diseases, 23, 125

  Rumsey, 54

  Rural conditions, 161


  Sanatorium benefit, 34, 94, 111, 129, 214, 222

  Sanatorium treatment, 228

  Sanitation and infant mortality, 242

  Scarlet fever, 20

  Schools for mothers, 244

  School medical inspection, 30, 57, 252

  Scope of public health work, 44

  Sedgwick, 16

  Segregation of feeble-minded, 44

  ” in tuberculosis, 200

  Sex teaching, 151

  Shaftesbury, 177

  Shattuck, L., 2, 3

  Shop hygiene, 9

  Sickness and pauperism, 67, 68

  Sickness insurance, 10, 32, 65, 67, 87, 116

  Sickness registration, 26

  Simon, Jno., 2, 4, 5, 9, 12, 13, 22, 25, 28, 55

  Smallpox, 21

  Smith, Adam, 6

  Smith, Southwood, 2, 9, 11, 12

  Smith, Theobald, 2

  Snow, Jno., 13

  Socialization of medicine, 82, 102, 115

  State treatment of disease, 112, 137

  Statistical studies, influence of, 252

  Still-births, 137

  Syphilis, 137

  Sykes, J. F. J., 244


  Town living, influence on health, 43

  Tuberculosis, 20, 23, 34, 76, 78, 129, 192

  Tuberculosis and hospital treatment, 198

  ” and overcrowding, 199

  ” and housing, 203

  ” notification of, 206

  Typhoid fever, 15

  Typhus fever, 17, 20


  Unqualified practice, 31

  Urbanization, 7, 159


  Venereal diseases, 30, 85, 131, 150

  Victoria, Queen, 10

  Vital statistics, importance of, 24

  Voluntary agencies, 141


  Walcott, 2

  War, 81, 120, 158, 179

  Water supplies and health, 16

  Wells, 159

  Whooping cough, 20

  Women, work of, 122

  ” position of, 184




  Transcriber’s Notes

  pg 14 Changed groups of diarrhoeal to: diarrhœal
  pg 19 Changed and that diarrhoeal to: diarrhœal
  pg 20 Changed one-sixteenth to diarrhoeal to: diarrhœal
  pg 34 Changed doctor or mid-wife to: midwife
  pg 34 Changed in a sanatorum to: sanatorium
  pg 42 Changed of the excessive diarrhoea to: diarrhœa
  pg 49 Changed and the feebleminded to: feeble-minded
  pg 89 Changed England was not actuarily to: actuarially
  pg 101 Changed if the latters to: latter
  pg 105 Changed for the benfits to: benefits
  pg 114 Added period after: due to sickness
  pg 115 Changed assistance by cooperative to: coöperative
  pg 118 Changed period to comma after: Pre-school clinics
  pg 145 Changed their satisfactory cooperation to: coöperation
  pg 159 Changed rows of unsatistory to: unsatisfactory
  pg 164 Changed power of finding enployment to: employment
  pg 171 Changed she is over-worked to: overworked
  pg 176 Changed facts, they villify to: vilify
  pg 178 Changed more and more entagled to: entangled
  pg 184 Changed accompaniments of overfatigue to: over-fatigue
  pg 221 Changed Examination of a register kept for faciliating
           to: facilitating
  pg 228 Changed efficiency in a santorium to: sanatorium
  pg 241 Changed caused 8.1 percent to: per cent
  pg 246 Changed total deaths in ths to: the
  pg 259 Added period after: Insurance Act 30s
  pg 262 Changed that of abortions, stillbirths to: still-births
  pg 262 Changed investigation of stillbirths to: still-births
  pg 267 Changed it as he ollowed to: allowed
  pg 268 Changed Antenatal work, 261 to Ante-natal
  pg 268 Added period after: Enteric fever, see Typhoid
  pg 268 Added period after: Hospitals, see Institutional treatment
  pg 270 Sickness and pauperism had no page references added 67, 68
  Table of contents used lectures, but refers to chapters
  Many hyphenated and non-hyphenated word combinations left as written.