Public health and insurance: American addresses

by Sir Arthur Newsholme

FOOTNOTES:

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

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

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

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

CHAPTER III
The Increasing Socialization of Medicine[9]

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

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

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

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

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

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

The Past Achievements of Medicine

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

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

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

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

Along life’s road, so dim and dirty,

I’ve travelled till I’m three and thirty;

And what has this life left for me:

Nothing but my thirty-three.

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

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

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

Increasing Importance of Hospitals

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

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

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

Hospitals as a Partial Solution of Housing Difficulties

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

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

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

The Continuing Mass of Preventible Disease

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

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

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

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

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

Present Extent of Socialization of Medicine

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

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

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

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

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

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

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

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

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

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

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

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

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

Destitution and Sickness

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

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

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

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

Insurance versus Public Health

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

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

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

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

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

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

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

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

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

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

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

The Need of the Future

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

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

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

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

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

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

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

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

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

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

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