FOOTNOTES:
[13] An address to the Academy of Medicine, Toronto, June 20, 1919.
CHAPTER VI
The Inter-relation of Various Social Efforts[14]
On examining the local city directory, one cannot but be impressed by the multiplicity of voluntary organizations having for their object the immediate relief of destitution or the social or economic “uplift” of sections of the population. The multiplicity of these agencies becomes more striking when one remembers that probably every one of the hundreds of churches and chapels in the city has its periodical sacramental and other collections for the poor, and may have also a system of parochial district visiting, with such auxiliary assistance as is provided through mothers’ meetings, etc. Nor does this exhaust the possibilities of social help available for the poorer members of society in cities in which there is a satisfactory distribution of rich and poor, that is, in which the segregation of different social strata in separate areas has happily not befallen. There is the further help provided by individual charity, the amount of which in the aggregate probably exceeds beneficence through churches and social agencies.
If these different agencies could pool their resources, while retaining the enthusiasm and driving power of separate organization, what an economy of effort and what increase of efficiency would result, especially if these agencies were also satisfactorily related to the official organizations of local and central governing bodies having the same object!
But I am not concerned this evening to discuss the machinery of social help or the attempts already made in different centres for securing their satisfactory coöperation. Nor am I disposed to discuss the economic problems underlying the need for social assistance of the poor. Ideally we must agree with St. Augustine’s statement: “Thou givest bread to the hungry; but better were it, that none hungered, and that thou had’st none to give him.” My present object, however, is to set out some elementary—and when stated fairly obvious—considerations bearing on social evils and their remedies under present conditions of society, the recollection of which if followed by practical action, would secure greatly increased efficiency in social work.
For the following reasons I do not hesitate to bring this subject before a gathering of graduate medical students:
First.—Every physician as soon as he engages in medical practice almost immediately comes into touch with organized and unorganized social workers, and his success—personal as well as communal—can almost be measured in terms of his outlook towards their work;
Second.—The physician, with his scientific training in the tracing of effects back to their causes, is in a specially favourable position to promote rational as contradistinguished from empirical social help; and
Third.—The physician is now learning to appreciate that he can only treat his patients satisfactorily in the light of knowledge of their social, including housing conditions, of their industrial relationships, and of their personal history and habits of life.
This is the age of anxiety to give social help.
I hold strongly the view that ere many of you are advanced in years the fundamentally important social help which is constituted by adequate medical attendance will be provided, for all who wish to have it thus, at the expense of the state, i.e., coöperatively by means of common charges on every member of the community according to his means, exactly as elementary education is now provided. This will involve radical reconstruction of the relationship between hospital and private medical practice, and will, I trust, include also the introduction of preventive medicine into the practice of every physician. But this is in the future. How can medical practice under present conditions, and how can non-medical social agencies, be made subservient to the fullest extent to the welfare of the community?
A few elementary illustrations will show the many unexploited or only partially exploited or misused opportunities for efficient social help.
The greatest science is to know the causes of things; and there is no branch of work in which this is more important than in medicine. But causation is complex. A given result commonly follows from a chain, or it may be a bundle of events: and as we shall shortly see the end links of the chain are oftimes joined, thus forming a circle.
If a man shoots a companion with whom he has quarrelled, it may be urged that a more rigid system of license for the use of firearms would have prevented the calamity; that the companion was also quarrelsome; that the homicide had been the spoiled child of his mother and had not had a satisfactory up-bringing; and that he inherited from his father a violent temper; but none of these circumstances,—all of which may have contributed to the murder,—is likely to succeed in preventing the murderer from being hanged after due trial.
It would be difficult to find a more striking instance of the linking of elements in causation than in the origin of a case of malaria. For the transmission of this disease two human beings, one already infected with the specific contagium, and a mosquito are required, and the chain of causation can be broken at the infecting person, by strict screening from mosquitos, and by the use of quinine; at the mosquito by preventing its emergence from the larval stage, and later by preventing its access to the patient; or at the prospective patient, possibly by prophylactic medication, more certainly by strict screening from mosquitos. Hence one might claim lack of segregation of infected persons, lack of screening of the healthy, failure to drain marshes, to apply oil to the surface of stagnant pools, or to adopt allied measures destroying the larvae of mosquitos as each of them the cause of malarial disease.
There is a constant excess of sickness among the poor as compared with the well-to-do. Measures for the relief of poverty, therefore, may be regarded as within the scope of the physician’s prescription. This may be accomplished for the moment by monetary or material help; but unless the causes of poverty are sought out and counteracted, the assistance given is merely palliative. For nothing is more certain than that poverty tends to become a self-perpetuating condition.
Thus poverty leads to premature employment of children, with detriment to their normal growth, followed by diminished efficiency in adult life. This implies low wages throughout life, and so poverty is passed on to a second generation.
Evidently timely assistance to induce the parent to delay employing the boy, until he has been prepared for work, and to ensure his being put to work which will not be a “blind-alley” occupation, might have obviated the evil chain of events.
Poverty again when carried to the point of destitution may tempt to larceny; this may be followed by loss of employment, and so the temporary unrelieved poverty is liable to become permanent.
Intemperance has been almost wiped out as a cause of disease in the United States; and we have in the fact that the whole country has “gone dry” a remarkable example of a “short-cut” towards social salvation from alcoholism which will be most instructive. Apart from such universal prohibition of alcoholic beverages, the physician has to think of an alcoholic patient under his care as the possible victim of one or more or all of several coöperating influences conducing to intemperance. The alcoholic habit may have been gradually acquired as the result of protracted social indulgence in moderation acting on a person of unstable mental constitution; it may, especially in wage-earners, have been hastened by the evil custom of treating. It not infrequently follows overwork, with the associated feeling of need for stimulants; it accompanies bad housing, with unsatisfactory sleeping accommodation; and it is aided by poor and badly cooked food, due to shiftlessness, overwork, or lack of domestic training of the man’s wife. If there is to be successful control of alcoholism, action in all the directions briefly indicated above, and in other directions which will suggest themselves, is necessary; and although the physician cannot himself do all this, his efforts should run parallel with social efforts in these directions.
Even when the “short-cut” of compulsory abstinence has been taken, the efforts indicated above are still needed; for alcoholism is not the only resultant of bad social habits, of overwork, of unsatisfactory feeding, of deficient sleep, and so on.
Perhaps even more far reaching in their evil effects than intemperance are the Venereal Diseases. As you know, special efforts during and since the war have been made to limit the spread of these diseases. I do not propose to trouble you with statistics to prove the mischief caused by these diseases. Has not Osler said that the whole of clinical medicine can be taught around syphilis, and that it is the third in importance of the killing diseases? And as a further illustration, let me add that no less than one-tenth of the total accommodation in our lunatic asylums might be dispensed with if syphilis were eliminated.
Among the measures being taken to combat these diseases are educational propaganda, and the provision of clinics, free for all, at which patients may be treated promptly and adequately. It is evident, however, that if the medical and educational efforts now being made are to succeed they must include recognition of all the factors causing sexual vice, and appropriate action in respect of each of these—they must indeed go further than this; for self-restraint is a wider problem than in relation to exposure to these diseases. It embraces the whole subject of formation of the habit of self-control. One of the most striking facts in the great war has been the extent to which young girls of previously decent behaviour have fallen victims to what has sometimes appeared to be passion combined with a perverted form of patriotism; and one of the measures most called for is better mothering and maternal training of both girls and boys. The problem is one of special difficulty as regards the economically independent girl; and to shield her the combined efforts of home influence, of girls’ clubs, and of various social and religious organizations are all required.
Judicious and restrained teaching of the physiology and hygiene of sex would do much to counteract the evil influence of bad teaching by companions; and in emphasizing this duty on parents the physician may do untold good. So also, especially when the daughters of his patients are about to marry “men of the world,” he should urge the need for asking a satisfactory certificate from the intended bridegroom of freedom from infection.
The influence of unaccustomed alcoholic indulgence in leading to the first “slip,” often with the production of life-long disease, is well known.
Nor must we leave out of account the tolerance of vice in conversation between young men, as a frequent excuse of and even excitant to vice. The happiest young man is he who can go to the marriage ceremony with the same sexual purity as is even now expected from the bride. Is it too much to expect that our social conscience will grow up to this standard? I think not; and when this point has been reached, venereal diseases will have almost entirely disappeared, and the sum total of human happiness and efficiency will be enormously enhanced.
Meanwhile partial remedies must be pushed for all they are worth—and this is much. Fear of consequences may deter some from vice; fear of consequences to future wife and child form a much more potent argument. Treatment of venereal diseases, especially of syphilis, is a most valuable means of preventing their spread. This treatment may be urged even at the stage after exposure to infection before any symptoms of illness appear; and the more promptly this is done the more successful is it. There has been much heated debate as to whether persons known to intend to expose themselves to possible infection should be provided with disinfectant or other arrangements for obviating infection. This cannot be done without some loss of moral position; it almost makes the provider a co-partner with the sensualist. It may be urged, however, but with dubious cogency, that if the man is told beforehand that immediately afterwards he can have access to disinfectant provisions, the same objection holds good. I do not regard the provision of “outfits” as wise. Evidence tends to the conclusion that they are commonly not used efficiently; and there is a distinct loss in the moral position by their use. The whole subject is one of great difficulty. The prevention of venereal diseases is clearly, however, not merely a medical problem; and the physician who realises this and throws the weight of his influence, in warning and in counsel, on the side of moral restraint, is adding greatly to the value of his social service to the community.
Other instances will occur to you, illustrating the importance of a broad outlook in the causation of disease or other forms of social misery. I will adduce one more. It is well known that infant mortality is much heavier among the poor than among the well-to-do. The rule does not hold universally in rural areas, but in towns it applies almost without exception. And it is assumed by a large school of social workers that enlightenment of the ignorance of the poor mother will effectively correct this evil. Such a lop-sided view ignores many of the elements of the problem of infant mortality. Think for a moment of the contrast between the working-class mother of five children living in a small city tenement, and the mother of an equal number of children in easy circumstances, living in a residential suburb, and having domestic servants, a nurse, and a physician always available. The two mothers probably differ but little in their knowledge of the hygiene of infancy; but the one has helpers to ensure scrupulous cleanliness, to prevent over-fatigue of the nursing mother, to detect the first sign of infantile illness and provide the needed action; while the other mother has to struggle alone in respect of her infant, without either domestic or nursing assistance, the struggle being complicated by the fact that the care of four older children and of her husband is on her shoulders. Even when there is no actual direct poverty in the working-class home, the differences thus indicated—supplemented by the inability of the mother to obtain medical advice for apparently minor ailments—outweigh enormously the factor of ignorance as a cause of excessive infant mortality. By all means let instruction be given by public health nurses or other agencies, and this is most valuable; but it does not fully meet the needs of the case. There is required also actual domestic, as well as nursing, assistance in the home of the overworked working-class mother, especially after the birth of her infant and when illness attacks any of her children; and unless the physician realises these elements in the problem, his efforts in securing the welfare of his patient and in reducing infant mortality can have but partial success.
The main lessons arising from the foregoing illustrations of medical and social problems are two: Each evil should be attacked in its causal relationships; and causation is multiple.
Hence—apart from total prohibition—in attacking alcoholism, the physician may bless the efforts of tee-total advocates, of those engaged in reducing the number of saloons, of those securing better dietetics and cooking, less industrial fatigue, or more satisfactory domestic sleeping accommodation, and of parents and teachers engaged in promoting self-control in the young as a habit of life; and he will call them all in aid of his curative and preventive life work.
So, also in the control of venereal diseases, early and prompt diagnosis and treatment must go hand in hand with police measures for the suppression of prostitution, with educational work respecting these diseases, and with the inculcation of a higher standard of morality, considered as part of the general cultivation of moral self-restraint.
And in the prevention of infant mortality and of the even more serious handicapping of the up-growing child produced by the factors of infant mortality, we need to bring to bear all our medical and hygienic knowledge, and to realise that until every mother in the land is furnished with the elementary requirements, domestic, sanitary, social, and medical, for rearing a healthy family, we have no right to mental comfort while enjoying these elementary needs of family life ourselves.
Coöperation and solidarity of effort are needed on the part of the multitude of workers engaged in social work for the community—official and non-official; and in bringing this about the physician of the early future will, I am confident, take a leading part.