Public health and insurance: American addresses

by Sir Arthur Newsholme

It is, I think, clear that the state will year by year take an increasing hand in medical matters. It is useless, even if it were desired, to attempt to oppose the inevitable and the eminently desirable trend towards vastly increased utilization by the state of medical science in the interests of humanity. It is for physicians to guide the course of events, and to insure that no plant is sown which will afterwards need to be uprooted; that no development is permitted which will hinder the fulfillment of our ideal. Personal hygiene forms a rapidly increasing part of public health work; hence it is indispensable that all forms of public medical service shall be linked up with the public health service and controlled locally and centrally in accordance with this. This may imply—and in England it does imply—the urgent need for reform and reconstruction of local as well of central public health administration; but to attempt to separate medical from public health provision is to repeat the blunders which, despite skilled advice to the contrary, have been made on two great historic occasions.

A complete service, adequate to the needs of the community, cannot be secured by a session’s legislation. It must grow as the result of steady advance. The motto in growth might well be, “First things first.” What are the medical services which are provided too sparsely at the present time and for which the masses of the population cannot afford individually to pay, except possibly to a fractional extent? There can be no doubt as to the answer. What is most urgently needed is the provision of skilled hospital attendance for every patient who can be more satisfactorily treated in hospital than at home. Next to this comes the provision of gratuitous medical services—(e.g., maternity and infant consultations, eye, throat, ear, skin and venereal diseases, tuberculosis, X-ray departments) preferably linked around a hospital, where patients can be sent by private practitioners for an expert opinion, or in certain cases may present themselves independently. And as important as either of the preceding desiderata, is the provision of a complete nursing service, on which each private practitioner can call for assistance as required, payment, if any is exacted, being on the easiest possible conditions, and not made compulsory.

The hospital under such circumstances would become a centre from which community work of the highest value would radiate; and patients, private practitioners, and the staffs of hospitals would alike live in a new world in which the interest and efficiency of medical work would be greatly increased. The present irregular localization of hospitals makes the realization of such a scheme difficult; but local partially successful schemes are already in operation; difficulties can be overcome with good-will; and eventually we may hope to have for each unit of subdivided public health administration and as an organic part of this, a hospital, with out-patient or dispensary clinics, and radiating from these the various forms of medical attendance, domiciliary nursing, public health nursing, and sanitary supervision which are needed.

In securing such a result there will be needed medical practitioners who are imbued with the ideals of preventive medicine in its widest sense. Let me, in this connection quote the following extract from a recent official report of my own:

There is needed a reconstruction of the training of each medical student, which will make preventive medicine in its widest sense an integral part of his training, and will insure that before he begins practice he has definite instruction in the application of the whole of his knowledge to preventive purposes. The past conception by the public of the relation of medical men to the community—apart from the special case of medical officers of health—has been mistaken. The doctor has been regarded as a help when serious or acute incapacitating illness occurs, and he has but seldom had the opportunity of giving advice in the earlier and more controllable stages of illness. His training has been conducted on the assumption that his chief rôle should be on present lines, with the result that most medical practitioners enter into practice with a too scanty knowledge of hygiene and preventive medicine, and have to learn slowly in belated experience the influence of environment on the health of their patients. The teaching of medicine should be much more largely physiological and hygienic than at present, and such subjects as food values, the hygiene of infancy and childbirth, the physiology of breast feeding, and the influence of environment on the health of their future patients should be the subject of careful training—especially in regard to housing, feeding, clothing, and conditions of work. Were this done, the ideal condition, in which each medical practitioner becomes a medical officer of health in the range of his own practice, would approach realization.—[Annual Report to the Local Government Board, 1917-18.]

Many medical practitioners already fulfill this ideal. It would oftener be realized were it not for the excessive work which many are obliged to undertake. In the early history of public health in England poor law medical officers, attending the impoverished in their dwellings and familiar with their home conditions, became part-time medical officers of health. But the attempt to combine prevention and treatment proved unsuccessful, because these officers visited only a small proportion of the dwellings of the poor, because they were not trained in preventive work, and because the good seed of preventive work was choked by the increasing demands of lucrative private practice. In connection with the future general medical service, curative as well as preventive, it is not beyond the range of human ingenuity to provide schemes for district medical officers (health and clinical) adequately trained in public health work, and linked up closely with the hospital and dispensary unit for their area.

This will cost money. But sound health is our greatest personal and national asset, and disease is always more expensive than health. “Who winds up days with toil, and nights with sleep” has “the forehand and vantage of the king,” if the latter suffers in body or mind. The real wealth of a nation does not consist in its money, in the volume of its trade, or in the extent of its dominion. These are only valuable insofar as they help to maintain a population—and not only a portion of it—of the right quality; men, women and children possessing bodily vigor, alert mind, firm character, courage and self-control. This ideal can never be realized unless and until the medical men of the future train themselves for and devote themselves to their essential share in its fulfillment, and while keeping this ideal in view see to it that every step taken is one which will be consistent with the complete scheme of the future.

We are all concerned in the efficiency of every member of the community, from an economic as well as from a humanitarian standpoint. Can we be satisfied while a large proportion of the population do not obtain medical and ancillary assistance to the extent of their needs? Does such a state of things conduce to the settlement of social unrest? Is it consistent with Christian principles?

If communal provision has been recognized as a duty for police protection, for sanitation, for elementary education, should it not likewise be admitted for the more subtle and maleficent enemies of health which have been recognized, but which in no community have hitherto been completely combatted?

We scarcely realize how far we have gone in the socialization of medicine. It is impossible to go back, or to stand still. The services of the medical profession are needed, not only to provide the necessary service, but in helping to determine its conditions. One essential item will be the substitution for fees during sickness of an annual payment to private practitioners by each family for supervising its members in health, for inquiry into their industrial and domestic life, so far as it contains elements inimical to health, and for giving preventive more than curative advice. The second and most urgent element consists in the organization of hospital and consultative expert services for all, which, while greatly increasing each patient’s prospect of prompt recovery, will enable the general practitioner to escape from the soul-destroying inefficiency of unaided medical practice.