Public health and insurance: American addresses

by Sir Arthur Newsholme

These being the objects of public health, how far have we travelled toward securing the end in view? I do not propose to myself the pleasant task of showing to what extent the general death-rate has been lowered, infant and child mortality greatly reduced, the duration of life extended, how typhus and smallpox have been almost eradicated, typhoid fever made a disappearing disease, and tuberculosis has become the cause of only half its former death rate. When inclined to indulge in such pleasant considerations, I recall the statement I have made elsewhere that one-half of the mortality and disablement still occurring at ages below seventy can be obviated by the application of medical knowledge already within our possession.

Let me attempt the more difficult task of outlining the history of forms of administrative control of disease since 1834.

Reform in the Control of Poverty

Poverty and disease work in a vicious circle in which cause and effect often change places; but it is certain that disease is one of the most fertile causes of poverty, using the word poverty in the sense of privation of one or other essential of physical well being.

For this reason, and because the half starved form a constant social danger, poor-law administration long antedated public health administration. There is not time to follow the course of earlier poor-law administration, with its many and grievous abuses. The Poor-Law Amendment Act of 1834, gave the Central Government control over the systems of local relief, secured the combination of parishes into unions for poor-law relief,[6] and forbade outdoor relief to able-bodied men. The creation of an organ of central control has led to the subsequent course of aid to paupers being determined in the main in London, action of poor-law guardians being subject to supervision by government inspectors, and to endorsement by the Central Authority. At first, medical assistance under the reformed Poor Law was made as deterrent as non-medical relief; and although there has been much improvement, chiefly on the institutional side, medical treatment under the Poor Law has to some extent retained this deterrent element, and it has, except in the poor-law infirmaries of large cities, remained generally disliked by the people concerned.

The first Central Poor-Law Authority was a Commission having no representative in Parliament. In 1847 it was replaced by a Board, the president of which was a member of Parliament and of the Government. Here once for all Parliament declared its intention to maintain direct control of central official government, and in this and in all other departments has done so. If democracy is to be real,—and we have no sound, practicable alternative to it,—evidently the representatives of the people must be masters of the administration; and English policy has never wavered on this point. After many years’ experience of public life in England, I have no hesitation in saying that this principle is sound; that it insures progress which, although slow, is less liable to relapse than administration under autonomous expert commissions, whether centrally or locally; and that any lack of progress that has been experienced in central government has been as much the result of inactivity and of lack of sympathy with social reform on the part of the permanent officials of government departments who have had access to their parliamentary chief, as of the inertia of politicians or their obstruction to reform.

Dissatisfaction with Poor-Law administration has steadily increased in the years since 1834, as the problem of the able-bodied pauper has diminished and the Poor Law has been concerned more and more with the sick and infirm, the aged, and children. These at the present time form some 98 per cent. of the total population relieved. The fundamental principles of the Poor Law were rightly attacked. It did not comprise elements tending to build up disabled families, or to prevent families from falling hopelessly and permanently into destitution. The law was administered almost entirely with a view to relief; practically not at all as a curative agency. In medical language, symptomatic and not rational causal treatment was the rule.

In medical relief, poor-law administration has been a constant struggle between increasingly humane treatment and the conception that the pauper’s position must remain inferior to that of the non-pauper; an important principle when applied to the able-bodied adult who has drifted into willing dependence; mischievous when applied to sick persons, and to dependent women and children.

The general dissatisfaction with poor-law administration led to the appointment of a Royal Commission on the Poor-Laws which, after several years’ deliberation, published in 1909 a majority and a minority report. Both these reports recommended the abolition of boards of guardians, and the transfer of their duties to the 144 largest public health authorities in the country (County Councils, 44; and the Councils of county boroughs, 82), and the abolition of the general workhouse. The majority report would have continued the Poor-Law Guardians as a Committee of the new Authority; the minority report proposed to distribute the duties of the guardians to different committees of the Public Health Authority; thus medical treatment to the Public Health Committee; the care of lunacy and the feeble-minded to the Asylum Committee; care of children to the Education Committee; vagrants, etc., to the Police Committee; a special committee concerning itself with all questions of monetary assistance.

A compromise between these two schemes has recently been arranged, and when the new Ministry of Health, which will combine public health, poor-law, insurance, and educational medical work in one department, has found time to do urgently needed work, the above indicated reform may be hoped for, along with the even more urgently needed reform of local public health administration, and the abolition of a large number of the smaller and less efficient sanitary authorities. With these reforms will come much needed de-centralization of poor-law work. Good work in all respects cannot be secured if the Central Authority concerns itself, as at present, in minutiae of local administration, and has no time to devote itself to the larger problems, and to the task of bringing indifferent, chiefly smaller authorities, up to the standard of efficient local authorities. A large portion of the expense of local poor-law administration is borne by the central exchequer, and this money if properly applied will give the necessary leverage for reform, while leaving progressive Authorities, and especially the Authorities of large towns, free to experiment and advance.