Public health and insurance: American addresses

by Sir Arthur Newsholme

FOOTNOTES:

[14] An address to the Alpha-Kappa-Kappa Club, Johns Hopkins University, Wednesday, December 10, 1919.

CHAPTER VII
The Obstacles to and Ideals of Health Progress [15]

There are two ways in which Health Problems can be approached: what may be called the microscopic method, which examines in minute detail each individual problem; and the conspective method, in which an attempt is made to obtain an unbiased and comparative view of the chief problems concerned, in order that their relative importance may be assessed, and the possibilities of improvement may be gauged. In proposing to myself the latter and more difficult task, I appreciate the impossibility of discussing all the items which emerge.

I would not have us forget what has already been achieved. Taking the national figures for England and Wales as an illustration, it is noteworthy that the death-rate from all causes fell from 22.4 per 1,000 of population in 1846-50 to 13.8 in 1911-15, a reduction of nearly 40 per cent. Comparing the decennium 1871-80 with the quinquennium 1911-15, the incidence of reduction of death-rate at different ages was as follows:

Percentage reduction in death-rate

Age		Age
0-5	42	35-45	42
5-10	48	45-55	25
10-15	43	55-65	15
15-20	46	65-75	10
20-25	51	75-85	7
25-35	50	85 and upwards	15

The survey is saddened by the terrible losses of War, and the even more devastating ravages of influenza; and we realize our inadequacy to prevent catarrhal infections, until further research into preventive possibilities proves successful, and until the standard of universal conduct for catarrhal affections becomes much higher than at present. We realize furthermore that probably at least half the deaths from all causes which occur could be postponed until old age. But the standard of health of the general population has greatly improved; typhus has practically disappeared under peace conditions; yellow fever approaches its demise; malaria and typhoid are controllable; tuberculosis and venereal diseases are only waiting for systematic, complete, and continuous measures to secure their rapid decline or actual disappearance; the mortality from childbearing and of young children has greatly declined; and this is an incomplete statement of what has already been done.

Obstacles

This improvement is all the more remarkable in view of the additional obstacles imposed to health improvement by modern conditions of urban and industrial life.

Urbanization

The population during the last century has steadily flocked to the towns from country districts. Streets have taken the place of green fields; rows of unsatisfactory dwellings have replaced country cottages; we have dust and belching smoke and noise instead of sunshine and country air and quiet; bustle and turmoil instead of life in close touch with mother-earth: and this change has been associated with an almost unlimited inter-communication of human beings, and a corresponding increase in opportunities for the convection of germs of disease.

Until the time of the industrial revolution in England modes of locomotion were little if any more advanced than among the ancient Egyptians; and disease, when it travelled at all, travelled by slow and deliberate stages. Now the infections of the entire world may be sampled in any one district in the course of a few weeks. Man has, in fact, reverted from the land-tied condition involved in agriculture to the migratory habits of an earlier period of man’s life on the earth. As Wells has put it: “in every locality ... countless people are delocalised,” and it is not the least evil of urbanization that, in consequence of this, the administration of local affairs falls too often “into the hands of that dwindling moiety which sits tight in one place from the cradle to the grave,” or of persons who have a financial axe to grind.

The difficulties of water supply, of scavenging, and of drainage, until they were overcome, have made towns the inevitable destroyers of mankind. The conditions of housing are worse in towns than in country districts, higher rents and less ground space implying that each family on an average lives in fewer and more crowded rooms than in rural districts.

Furthermore, in towns there is greater difficulty in securing satisfactory arrangements for the storage of food, especially milk, and in obtaining fresh milk and vegetables; and there is the serious disadvantage, especially for children, that their playgrounds are in streets instead of the fields, and that the possibilities of deriving infection from dried expectoration and from fæcal or other organic contamination in yards and backstreets as well as directly from other children or adults are multiplied manifold.

Even more important, town life for the father of a family generally means an indoor and often a dusty indoor occupation; the mother not infrequently is also industrially employed; and these adverse circumstances, so far as they are allowed to continue, now affect three-fourths of the population of England and Wales and probably one-half of that of the United States.

And yet the death-rate from all causes, and especially from communicable diseases is steadily declining, to an even greater extent in urban than in rural communities.

It is but fair to add that the differences between urban and rural populations tend to decrease; at least this is so in England; probably the same is true to a less extent in America. The nominally rural population is becoming more and more urban in character, and composed not solely of rustics,—who live in and by the soil and are altogether more natural in their habits,—but largely of town-dwellers who only sleep in country dormitories. But this makes it all the more remarkable that notwithstanding the multitudinous circumstances which have tended to increase disease, the death-rate has been lowered to an amount already indicated, and life has been prolonged to an extent which has secured an increase in its average expectation of 10 or 11 years within the last thirty years.

Industrialism

Considerations of time render it impracticable to discuss in this address the mischievous influence of modern industrialism on national health. This influence runs collaterally with that of urbanization; and in it in the past can be seen the evil results of overwork, of dust inhalation, of chemical poisoning, of industrial infections including tuberculosis, and of the general depressing effect of protracted monotonous work. The evils of industrialism like those of urbanization are happily being in a large measure counteracted.

Poverty

The problems of industrialism in relation to health cannot be adequately discussed apart from a consideration of the remuneration for work, which necessarily depends on the power of the worker to strike a satisfactory bargain with his employer, and the extent to which he can ensure regular employment. If these conditions cannot be fulfilled, or if the breadwinner is dead or disabled, poverty results, using this word here in the sense of inability to provide for the personal and family essentials of health. And here we are at once faced with the problem of relation of population to means of subsistence. Malthus in 1798 advanced the pessimistic hypothesis that poverty is the inevitable result of increase of population, which entitles him to be characterised as the Schopenhauer of Political Economy, as Schopenhauer was the Malthus of Philosophy. Without attempting detailed discussion of Malthus’s hypothesis, it is clear that the wealth of the population depends upon

1. The amount of food produced,
2. The amount of materials produced,
3. The efficiency in preparation of these materials, and
4. Convenience of transport.

In all these particulars means of subsistence, considered internationally, have during the last century grown more rapidly than population; and now, whether we like it or not, a new element has entered into the problem in this and several other countries,—voluntary control of births,—necessitating the estimation of future growth of population on a radically different basis from that of the past, and banishing the fear of poverty as the result of too large a population.

It may even become necessary to adopt some method of national remission of taxation or subsidisation of wages in accordance with size of the family, not only in France, but hereafter in England, if in England, as already in France, the voluntary control of births is practised to an extent resulting in a stationary or even a decreasing population. In America the possible need for such action will not arise for several generations, during which, however, unless the present trend of events is changed, Roman Catholics appear likely largely to replace Protestants, and the Slavonic and Irish to preponderate over the Anglo-Saxon elements of the population. It is possible, of course, that in another generation the Roman Catholic Church may not be able to continue its ban on birth-control, and that the more “backward” (?) races will adopt similar devices, including even the Japanese and the Chinese.

The Malthusian Hypothesis

(a) The Malthusian hypothesis has been held to justify the laissez faire, laissez aller policy which held the industrial world in its malignant grip during the latter part of the eighteenth and the earlier part of the nineteenth century, and from which we are not yet completely freed. Workers were exploited and reduced to a position of modified slavery; and this was assumed by clergy and political economists alike to be part of the ordered course of life. This doctrine was made to support the belief that God had ordained the poor man’s lot, with its attendant misery and hopelessness.

On page 438 of the sixth edition of his book Malthus says:

that the principal and most permanent cause of poverty has little or no direct relation to forms of government, or the unequal division of property; and that, as the rich do not in reality possess the power of finding employment and maintenance for the poor, the poor cannot in the nature of things, possess the right to demand them, are important truths flowing from the principle of population.

In the first edition of his book a more extreme, plainer statement of the position, as assumed by Malthus, was given, but was omitted from later editions (the extract is translated by Beale from a French edition):

A man born into the world already occupied, if his family can no longer keep him, or if society cannot utilise his work, has not the least right whatever to claim any share of food, and he is already one too many upon the earth. At the great banquet of Nature there is no cover laid for him. Nature commands him to go and she is not long in putting this order herself into execution.

Malthus supplied the clue which helped to start Darwin on his epoch-making investigations; and to the present day there are men who do not appreciate that the mutual aid which is fundamental in human society is an enemy to the continued operation of natural selection, and that we cannot revert to natural selection without destroying the characteristic work of civilization. To think otherwise is the secret behind German aggression; to act otherwise is to revert to barbarism. Man has definitely replaced natural by rational selection, and will, I have no doubt, to a steadily increasing extent replace competition by coöperation.

(b) The Malthusian hypothesis and the policy based on it ignored the human element in industry. Happily revolt against the strict application of the laissez faire policy set in soon after urbanization and industrialism (under the then conditions) began their maleficient work, first in regard to children, then for women, and latterly more general in character.

Nothing is more conspicuous in recent years than the growth of sensibility on the subject of economic evils, especially as to the conditions of industry. Economic efficiency, as a sole object, appeared to preclude regard to morality of method, and the result has been poverty for the masses of mankind. If this is to cease, satisfactory minimum standards of comfort and welfare for the entire population must be accepted, which will form a first charge on industry. This can only be hoped for when there is complete practical acceptance of the fact that “we are members one of another,” and servitude is completely replaced by the ideal of mutual service.

(c) The Malthusian hypothesis ignores the great though paradoxical truth, that although under circumstances permitting malnutrition and defective training, large families spell poverty, especially when population is not distributed where it is needed, the real wealth of the world after all depends on man himself. Nature gives him little that he can use in the form in which he finds it. It is by him and by him alone that “wealth” is created by converting useless into useful matter.

It appears to me clear that over-population need not excite apprehension; that population in itself is the only means by which national wealth can materialise; and that our chief aim in securing national efficiency must be to train each unit of the population adequately for work, and to prevent the terrible loss of efficiency due to avoidable sickness.

And this brings me to the direct statement of the truism that health progress can only be secured by preventing preventible illness.

Poverty and disease are allied in the closest relationship; and while it is true that the removal of poverty would effect a great improvement in national health, it is even truer that the prevention of illness forms the most important means for the avoidance of poverty.

In various reports it has recently been shown that in a number of districts an inverse correlation exists between infant mortality and the amount of the family income; the implication appearing to be that increase of the lower income is the best and perhaps the only method for obviating excessive loss of infantile life.

In such an argument poverty evidently is considered as an element, instead of as a highly complex phenomenon needing to be further analyzed into its constituent parts. In the instance quoted, the fact that the correlation between poverty and high infant mortality is not essential can be shown by examples of low infant mortality in communities in which poverty is the rule; by examples of high infant mortality in which wages are high; and by other examples of communities in which high infant mortality has been lowered without any change in economic conditions.

The social conscience cannot be satisfied until every family has an income sufficing for all its essential needs; but there are possibilities of successful attack on infant mortality which can be pursued when economic change is not within reach, and when such economic change would not obviate the need for further measures. Among such measures may be mentioned the abolition of alcoholism, the provision of a pure and adequate milk-supply, increased attention to domestic and municipal sanitation, health teaching by public health nurses, and prompt and adequate medical and nursing assistance when required.

Ignorance

It may have surprised you that I have not placed ignorance in the forefront, before industrialism, urbanization, and poverty, as the chief enemy of personal and public health. I have no hesitation in making the statement that although there is need for large additions to present educational work in hygiene, the utilisation of existing knowledge by those holding responsible positions is even more important. Is it not true that it is easier to promote educational “drives” for any single branch of health education, than to obtain money for the actual execution of health work?

Let us look more critically at educational work in hygiene. Whose ignorance is it proposed to enlighten? Ignorance is common to all classes, and it is fundamentally important that systematic instruction in physiology and hygiene should be given in all our schools; and that especially every teacher should have adequate training in these subjects, and in the recognition of the common mental and physical defects of children. If a course of instruction were given for all, approaching that which is given for public health nurses at Yale University, how much more hopeful would be the prospect of public health progress, both in New and Old England. But this does not cover the entire needs of the case. Consider, for instance, the relation of maternal ignorance to excessive child mortality.

Maternal ignorance is sometimes regarded as a chief factor in the causation of excessive child mortality. It is a comfortable doctrine for the well-to-do person to adopt; and it goes far to relieve his conscience in the contemplation of excessive suffering and mortality among the poor.

This doctrine has found favour in occasional official reports and in miscellaneous addresses. It embodies an aspect of truth, but it is mischievous when it implies, as it sometimes does, that what is chiefly required is the distribution of leaflets of advice, or the giving of theoretical instruction as to matters of personal hygiene.

There is little reason to believe that the average ignorance in matters of health of the working-class mother is much greater than that of mothers in other classes of society. Furthermore, it would appear that working-class mothers give their infants the supremely important initial start of breast feeding in a larger proportion of cases than do the mothers in other stations of life.

The mothers in both classes may be ignorant; in both there is deficient training in habits of observation, especially in regard to the beginnings of illness; but the mother in comfortable circumstances is able to ensure for her infant certain advantages which the infant of the poorer mother often cannot obtain. What are these?

1. The well-to-do mother is commonly able to devote herself to her infant and have assistance in this duty; the working class mother is single-handed, and has also to perform, unaided, all the duties of her household, including the washing and cooking for her husband and herself and possibly for several children.

2. The well-to-do mother is commonly able to ensure that the milk for her infant is purchased under the best circumstances, is stored in a satisfactory pantry, and is prepared under cleanly conditions. The working-class mother often is supplied with stale, impoverished milk, may have no pantry, and, except when suckling her infant, is handicapped at every stage in the cleanly preparation of her infant’s food.

3. If the well-to-do mother is ill, adequate medical and nursing assistance is at once available, and the child’s welfare can be safeguarded; if the working-class mother is ill, the child usually must suffer with its mother.

4. If the child of the well-to-do mother falls ill, everything that good nursing and medical attendance can furnish is commonly at once available; for the child of the working-class mother the state of matters is remote from the ideal. Facilities for obtaining medical attendance and nursing vary greatly in different districts; but in none are they satisfactory for the poor, and especially for the classes who have limited incomes, but do not as a rule receive skilled hospital treatment, or avail themselves of help from nursing associations. Prompt medical assistance at home commonly cannot be afforded for children of wage-earners, and particularly not for the children of unskilled workers.

5. Infants and nursing mothers are very rapidly influenced by their environment. This environment is complex. The mother is the main element in the environment of the infant. If she is overworked and suffers from chronic fatigue her infant must suffer; directly, because the mother’s milk under these circumstances is liable to be scanty or impoverished or otherwise unwholesome; or indirectly, owing to her being unable to give sufficient attention to her infant. The infant of the well-to-do mother is less likely to suffer in either of these ways.

6. Not only are the milk supply, and the storage and preparation of artificial food, important parts of the environment of the infant, but so also are the housing conditions of the family, and the sanitary conditions of the back-yard and of the street in which the house is situate. The superiority of the circumstances of the one mother and infant over those of the other in these respects is obvious.

There is no reason to assume that the one mother is more ignorant than the other. But the ignorance of the working-class mother is dangerous, because it is associated with relative social helplessness. To remedy this what is needed is that the environment of the infant of the poor shall be levelled up towards that of the infant of the well-to-do, and that medical advice and nursing assistance shall be made available for the poor as promptly as it is for persons of higher social status.

The assistance given will include advice, but it will be the advice which a medical practitioner gives to his patient; which a health visitor or public health nurse gives as to personal hygiene; and which a sanitary inspector gives to a householder. It should include also the advice given by a trained midwife or midwifery nurse, who is in a favourable position to secure the adoption of her advice by the mother. Such advice is becoming available to a steadily increasing extent, but in some industrial towns a majority of midwives and midwifery nurses are still untrained women, who are not competent to give the best advice.

I would not have it assumed that I do not attach high values to the teaching which the physician gives to his patient and the public health nurse to the healthy mother and infant; but unless this is combined with assistance to provide the necessary means to health, whether this be hospital treatment, home nursing, pure milk, improved domestic conditions, or help to the over-tired mother, the advice falls far short of its potentialities for good.

There is need for further instruction of the public in all branches of hygiene; and we need, if we are to be efficient in social work, to follow the advice of Oliver Wendell Holmes, to remove the intellectual membrana nictitans from our eyes, and to consider the physical and moral as well as the intellectual obstacles to health.

In the cultivation of communal health

Defects of Character

are even more pernicious than lack of knowledge. No member of any of our local authorities can fail to have been warned that typhoid fever is still being spread in many communities by impure water, and as the result of inadequate hospital isolation of cases. The means of prevention of tuberculosis are well known; but how few local authorities will face the problem of supplying adequate funds for clinics, for examination of contacts, for hospitals for bed-ridden cases, and for convalescent homes; and how few are willing to give help to ensure that the consumptive patient has a separate bedroom? In how few instances are the regulations against indiscriminate expectoration enforced, and how seldom are physicians called to account for not obeying the law as to prompt notification of cases of tuberculosis? Will all the “drives” against tuberculosis effectually remedy this condition of things? Would not public opinion amply support the one “drive” which, above all others, is necessary: a systematized effort on the part of all social workers to exact a definite promise from every candidate for local or state office that he will give earnest support to all well-considered anti-tuberculosis measures, for the diminution of venereal diseases, for improving the welfare of mothers and their children, for promoting school hygiene, and for improving the housing of the poor. Democratic Government, alas! hitherto, has meant government by active minorities. The great danger of democracy is that the minority may and often does consist largely of persons having a mercenary interest in the machinery of local government. Why should not it become an active and preponderant minority of health gospellers? This will involve the taking of infinite trouble to overcome the multiform activities associated with “political pull”; it will involve the watching of the record of each elected person, merciless exposure of those who do not whole-heartedly support reforms, and systematic effort to prevent the reëlection of all whose record proves unsatisfactory. Are we equal to this task? Is our national and local patriotism equal to this heroic test, involving most prosaic work, the surveillance and the “besting” of the politician? If not, our indirect attack on the enemy by means of special educational drives can have relatively little effect. Where the enemy is, there our fight should be; and the chief enemies of health are local authorities possessing powers to secure health for the community, who corruptly or parsimoniously refrain from their duty. Nor can we avoid responsibility, or the need for strenuous effort after efficiency by not taking part in official or voluntary administrative work. We may have sufficiently good reasons for this abstinence; and onlookers have their rôle in life. If all were authors, where would be the readers? There are many indifferent writers who would be appreciative readers, and the same remark applies in local administration. Appreciation is necessary as well as a subject to be appreciated; and the onlooker at social work may be most helpful. If he is to be helpful he must be kindly and charitable, as well as watchful. Rancorous and ill-informed criticism must be avoided, and the onlooker must be ready to do justice to good work, or attempted good work. Nothing has made it so difficult to secure good men to undertake the burden of local government as the undiscriminating and uncharitable criticism aimed at those engaged in it. Criticism of representatives has often been deserved; but critics are too often those who will not aid to the slightest extent in the work which, often without sufficient knowledge of the facts, they vilify. When we read of administrative scandals, it is desirable to have a sense of proportion, and to remember, as the reader of old records or even of Pepys’ diary will scarcely need to be reminded, that corruption was rampant in the past, and especially to remember that the best way to remove that most subtle and mischievous form of corruption which consists in giving and accepting appointments as political rewards, is by ourselves taking a part in local government, or by steadily upholding those who are doing so with integrity.

The onlooker, then, has his duty to perform as well as the administrator. He cannot do his duty unless he intelligently studies local administration, even though he takes no part in it. A chief need is this interested study of the phases of local administration by the general inhabitants of each district. Happily there are indications of the increasing local patriotism which such study implies. The exact knowledge thus acquired is the best means of neutralising much of the ill-natured, because ill-informed, criticism with which the founts of local administration are too often fouled. A high moral ideal on the part of onlookers as well as of administrators is needed if we are to secure that high standard of social efficiency which is an indispensable condition of the further triumphs of preventive medicine now waiting to be secured.

Ideals

In my discussion of the difficulties of health progress, I have evidently encroached here and there on the second division of my lay sermon. Let me now attempt to state more systematically some ideals of health and means for their realisation.

Intelligent human society, permeated more than we realise by the essentials of Christianity, has already gone far in securing remedies, notwithstanding the too frequent other-worldliness or lack of vision of those who should have been foremost in rebuilding Jerusalem in this green and pleasant land. Industrialism no sooner huddled together labourers and their families in the courts and alleys of insanitary towns and overworked them for scanty wages, than the voices of such philanthropists as Percival, Oastler, Shaftesbury, Owen, and of many others were heard in favour of interference with that freedom (!) of contract between workers and employers, which the professors of the dismal science regarded as a fundamental principle in political economy. And so gradually, too slowly, regulated industry, improved sanitation, better housing, the isolation and hospitalisation of infectious cases, the readier access than in rural districts of all sick to skilled treatment, higher wages, better food began to counteract the evils of industrialism and urbanization. Communal action was taken in the regulation of industry, in the promotion of sanitation, in providing elementary education; and the result is seen in the remarkable fact that, notwithstanding its enormous handicap, urban life has become almost as safe as rural life, so far as life itself is concerned, though not in standard of health.

The first lesson, then, which has already been partially learnt, is that no member of a community can live to himself. We now believe in the solidarity of society; that the sores of one section of it means peril for all. And we are gradually learning to appreciate that this is true not only in respect of the acute infectious diseases, and of chronic infectious diseases, such as tuberculosis and syphilis, but of every disease and of every other factor in life which causes individual inefficiency, and which consequently inflicts additional burdens on the competent section of the community. I do not wish to underestimate the basic self-centredness, if not actual selfishness, which, to a varying extent, is part of the nature of all of us; but in industrial, as in other social problems, whatever may be the intermediate turmoil and misunderstandings and disturbance which appear to loom so threateningly, it is plain that the mere cash nexus of relationship is becoming more and more entangled in a moral nexus; and that a prophet’s vision is scarcely needed to forecast a future of consolidation and conformity of efforts of employers and employed such as has never yet been generally realised. In such a consolidation the idea of servitude will disappear, and mutual service will take its place. This will happen by the growth of an idealistic standpoint; even more, perhaps through motives of community self-defence.

Secondly, the Great War, though the most terrible calamity to humanity of the ages, has brought out a most comforting and elevating thought. Our brothers and our sons,—and our daughters also in a multitude of munition and other works,—have proved that, under the overwhelming moral compulsion of national need, they are willing and ready to lay down their lives for great impersonal things, and in their hundreds of thousands they have done so. Coincidently with this, a great impetus has been given to work for the health and welfare of the civilian population, and especially of mothers and their children. The removable horrors and losses of peace, in the aggregate, are greater than those of war. Cannot an equal spirit of sacrifice be induced against these? Is it not possible to evoke a like devotion to secure the triumph of good over evil, of clean administration over political pull, of fair dealing over industrial exploitation, of adequate output over “slacking,” of determination to spend and be spent to secure the welfare of all, in peace as in war?

Thirdly, prior to the war, for years, many among us had been realising to an increasing extent the supreme importance of the Mother and the Child, in safeguarding family life, and in securing the beginnings of personal and national health. In past years medical officers of health have been busily occupied in struggling to overcome epidemic diseases, and in attacking the circumstances favouring their prevalence. But for twenty years, at least, the outlook has widened; the physiological as well as the pathological aspects of hygiene have received attention; and it has been realised, more and more, that in the conservation and upbuilding of the health of the infant and the pre-school child rests the chief hope of the future; and somewhat more recently, public health policy has directed itself to the protection of motherhood, on which depends essentially the welfare of the child.

This can only be done by ensuring, chiefly through its mother, for every newcomer on the stage of life, in all essential points, a footing of equality of opportunity, physical, mental, and moral, with all others.

The ideal that every child should have equality of opportunity is really part of a general upward movement in our national ethical life.

The thoughts of men are widened with the process of the suns.

We begin to appreciate the full significance of the older words, “it is not the will of your Father that one of these little ones should perish”; and this ideal happily is now certain to replace the materialistic doctrine of the German type which drives the weaker to the wall.

Progress has been slow; but when we recall how true it was in St. Paul’s day that “the whole creation groaneth and travaileth in pain together until now”; and how gradually through the ages the mass of human suffering has been abated, we can, while regretting the slow rate of progress, gain encouragement for more rapid future advance. The abolition of slavery, the higher position of women, the steadily increasing force leading towards one standard of sexual morality for both sexes, the improved conditions of housing and sanitation notwithstanding the impediments of urban life, and the increasingly humanitarian conditions of modern industrialism, all give us reason to lift up our hearts.

There have been three stages in the attitude of mankind to altruistic work. The first of these is illustrated by the attitude of the father who said to his son: “Learn, my son, to bear tranquilly the calamities of others.” Is not the second stage, illustrated by the sleeping disciples in the Garden of Gethsemane, ignorant or regardless of the impending tragedy; while the third stage is manifest in the thousands of earnest social workers,—and the supremely important conscientious members of our governing bodies come in this group,—who are endeavouring to secure the realisation in communal practice of every measure for uplifting mankind.

It is well for mankind that the Mother and the Child have become the foundation on which, more and more, we expect health progress to be built.

A child more than all other gifts

That earth can offer to declining man

Brings hope with it and forward looking thoughts.

(Wordsworth.)

The history of the Mother and Child summarises the history of the uplifting of mankind: and although there are not lacking sinister elements in the present position, it is a great gain that both in regard to the Mother and Child and to the saving of life and improvement of national health generally, we are beginning to realise that this is not merely a question of self-interest, personal or national; but that we are concerned also with duty, and honour, and chivalry.