Public health and insurance: American addresses

by Sir Arthur Newsholme

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.