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 England | No. of Deaths | |||
| 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.”