Public health and insurance: American addresses

by Sir Arthur Newsholme

FOOTNOTES:

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

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

CHAPTER V
Some Problems of Preventive Medicine of the Immediate Future[13]

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

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

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

Gains from War

But we can set out some great gains from war.

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

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

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

Though doomed to go in company with Pain,

And Fear and Bloodshed, miserable train!

Turn our necessity to glorious gain.

The Work of Women

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

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

Prohibition of Alcoholic Drinks

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

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

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

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

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

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

Respiratory Diseases

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

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

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

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

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

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

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

Tuberculosis

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

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

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

Venereal Diseases

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

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

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

The Mother and the Child

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Work of Voluntary Agencies

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

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

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