Public health and insurance: American addresses

by Sir Arthur Newsholme

The facts as to the wonderful extent to which disease has been prevented during this war need not be detailed. Intestinal diseases have been kept strictly under control. In no previous war has smallpox or typhoid fever claimed so small a toll on the belligerents.

Malaria, it is true, has claimed many victims, owing to our soldiers having to operate in countries in which the needed precautions could not be completely carried out. Typhus has scarcely claimed a victim among the British forces, and although trench fever was common, medical discovery, by showing its relationship to the bite of the louse, has placed within reach an immediately practicable means for avoiding this serious cause of military disablement.

Three sets of diseases have not been successfully combatted during the war—the group of respiratory affections, tuberculosis, and venereal diseases, and on each of these it is desirable to make a few remarks.

Respiratory Diseases

6. In the group of respiratory diseases I think we should include a number of diseases not commonly regarded as such, but in which, so far as can be judged, infection is received by inhalation; and I would, therefore, group together such miscellaneous diseases as poliomyelitis, cerebro-spinal fever, measles, bronchitis, pneumonia, and influenza. All agree in one particular, that attempted preventive measures against their spread are dubious in effect. These diseases naturally divide themselves into two groups: the first comprising measles and influenza, both of which spread—when, as in influenza, the almost unknown conditions determining spread are present—to an extent only limited by the failure of susceptible persons; and the second comprising the other diseases already enumerated, of the conditions determining attack from which we are profoundly ignorant. We do know, however, concerning cerebro-spinal fever and measles, that they spread more easily and become more severe under conditions of massive overcrowding; and their unusual severity in war is thus partially explained. Beyond this obvious indication for prevention we can do but little.

It may, however, be mentioned, that in England during the last few years, we have determined that our lack of ability to prevent outbreaks of measles shall not prevent us from attempts to diminish their fatality, and the notification of this disease has therefore been enforced, as a necessary preliminary to prompt and fairly complete action, and local authorities have been urged to provide nurses to assist in the domiciliary nursing of cases of measles. Grants of half the expenditure expended in nursing this and some other children’s diseases are paid by the Central Government. If the spread of infection cannot be stayed, it is our duty to diminish the loss of life by providing nursing assistance whenever required. This provision of nursing assistance in a number of children’s and maternal illnesses, half the expenditure being paid from Central and half from local funds, will, I trust, soon be followed by a general provision of nursing assistance from public funds.

The recent epidemic of influenza has taught us several important lessons—First, we have been painfully reminded that we are completely ignorant of the causes of the pandemic waves of this terrible disease, which, at irregular intervals of years, traverse the world. We may surmise that the crowding and the mental and physical depression of war caused increased rapidity of spread and a greater fatality in the present outbreak; but influenza has spread and been only less fatal than in the present outbreak when there was no war, and we must admit our ignorance of the cause of this.

Numerous investigators in many lands have been striving to illumine our ignorance; but until success crowns their efforts, it is well to admit that on the large scale all attempts to prevent the spread of influenza have failed.

But, in this disease, as in measles, this failure in prevention is no reason for refraining from every possible effort to restrain death. In every country and in nearly every invaded district, many sick were unable to obtain adequate nursing and other domestic care. Here and there organized mobile team work partially overcame the difficulty; but the one lesson which emerges from this great pandemic is the necessity for having in every area a large nursing reserve. Here is one of many spheres of utility, which should, I think, be occupied by Red Cross workers, who have done such admirable work during the Great War.

Many of these Red Cross workers were not fully trained before the war, but intelligent workers under stress of circumstances showed themselves competent in many instances to undertake highly skilled work; while a much larger number under the supervision of more fully trained nurses and doctors were able to carry out satisfactorily the routine but still extremely important work, of ordinary nursing. During the influenza outbreak many such “Nursing Aids” did admirable work, and the epidemic has demonstrated once for all the absolute necessity of having available a large number of such nursing aids. Cannot these be employed on a large scale when no epidemic is raging? Is it necessary for every case of sickness that a fully-trained nurse should be engaged? Would not the physician be equally satisfied in a large proportion of his cases, if he had available a less elaborately trained assistant, who understood personal hygiene thoroughly, who could give an enema, could take temperatures, and would follow instructions implicitly and intelligently?