Public health and insurance: American addresses

by Sir Arthur Newsholme

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.