Public health and insurance: American addresses

by Sir Arthur Newsholme

In his Eleventh Report to the Privy Council (1868) Simon recommended adherence to the intention of Mr. Lowe’s Nuisance Bill of 1860, which would have identified the health and destitution authorities. He deprecated the institution of “a differently planned organization for objects exclusively of health”; subject to the conditions that public health should not be subordinate to poor-law work and that there should be power to combine districts for certain purposes, and action through committees in sub-areas.

Had this course been pursued, and had the central public health policy not been preponderantly non-medical and poor-law in sentiment and tradition, more rapid progress in public health would have been experienced. The central evil was intensified, as is shown in Simon’s Public Health Institutions, by regarding the medical officer of the Local Government Board as merely advisory, and by the retention and extension on a large scale of local inspection by lay officers of the Central Board, for conditions which needed systematic medical control.

The problem of the proper relation between destitution and public health and between the authorities dealing with these, runs right through our past history of social progress, and it is not even yet satisfactorily adjusted.

The gradually increasing dissatisfaction with Poor Law administration led to the appointment of a Royal Commission which after several years deliberation, in 1909 presented a Majority and a Minority Report.

The dissatisfaction, which these reports justified, may be said to have been inherent in the situation; for the Poor Law organization was constantly attempting,—more or less under the influence of the principle of “deterrence,”—two incompatible tasks: to prevent undue dependence upon parochial assistance and to give to those needing them the medical and nursing assistance which the principles of preventive medicine require should be given unstintingly, and completely freed from any deterrent element. Although in many parochial areas admirable medical work was done, this was the exception, not the rule; and public sentiment rebelled against the giving or the receiving of medical assistance to which was attached the “poor-law stigma.” Both reports recommended the scrapping of the poor-law machinery by abolishing the present Boards of Guardians and the general mixed workhouse; and the Minority Report went further, proposing to complete the supersession of the poor-law by various preventive authorities, which were already partially in operation. Thus everything connected with the treatment of the sick would be transferred to the Public Health Authorities, the care of school children to Education Authorities, of lunacy and the feeble-minded to already existing Asylum Committees, and so on.

Behind these proposals lay the principle that the treatment and the prevention of disease cannot administratively be separated without injuring the possibilities of success of both; and this is a principle which happily is becoming more generally accepted.

Before the report of the Poor Law Commission was issued, examples of the application of this axiom existed in the isolation and treatment of patients with acute infectious diseases; in the increasing provision for the treatment of tuberculosis; in the extension of provision for care of parturient women and for their infants; and in the system of school medical inspection followed to some extent by treatment.

It is convenient to add here, that under each of these headings, great extensions have been made since 1911; and an even more spectacular public provision of treatment, as the best method of preventing further extension of disease, is exemplified in the gratuitous and confidential diagnosis by laboratory assistance and the treatment of venereal diseases now given in every large town in the country, the Central Government paying three fourths and the Local Authority one fourth of its cost. In order further to secure the success of this treatment,—which is provided for all comers with no residential or financial conditions,—the legislature has passed an enactment forbidding the advertisement or offering for sale of any remedy for these diseases, and forbidding their treatment except by qualified medical practitioners.

It is one of the great misfortunes of more recent Public Health administration that the Report of the Royal Commission on the Poor Laws has not hitherto been made the subject of legislation. It would not have been an insuperable task to find a common measure of agreement between the Majority and the Minority Reports. Indeed an adjustment has recently been made between these two reports, as the result of the deliberations of a House of Commons Committee, over which Sir Donald Maclean presided; and it may be hoped that ere long this will mean the realisation of a much belated reform of local administration.

This forms an indispensable step in the needed further struggle against the problems of Destitution. So much of destitution is due to sickness that the separation of the two problems is inconsistent with success. “One-third of all the paupers are sick, one-third children, and one-quarter either widows encumbered by young families or certified lunatics.” There are economic causes of poverty, apart from sickness, but it is essential to remember that every disease which is controlled frees the community not only from a measurable amount of sickness, but from the amount of poverty implied by this sickness.