Public health and insurance: American addresses

by Sir Arthur Newsholme

1. That the work of the agency is approved by the Board and coördinated as far as practicable with the public health work of the local authority and the school medical service of the local education authority.

2. That the premises and work of the institution are subject to inspection by any of the Board officer’s or inspectors.

3. That records of the work done by the agency are kept to the satisfaction of the Board.

Possibly much of the past failure to protect maternity and to reduce the still-births and mortality among infants under a month old has been due to the erroneous assumption that damage to health and life at these times is in the main inevitable. That this is not so for maternal mortality is proved by the great difference in experience of sickness and death for mothers in different social strata and according to the availability of skilled midwives and doctors. There are similar differences locally and socially in the proportion of still-births. Wassermann tests, followed by appropriate medical action, in all instances in which there have been previous miscarriages or in which for other reasons syphilis comes under suspicion, and subsequent action based on the diagnosis thus secured, would at once greatly reduce maternal and infantile mortality. So also would systematic examination of urine during pregnancy and the ascertainment that in other respects the physical conditions of normal parturition are present. These are adequate reasons for the establishment of ante-natal consultations, which happily are rapidly increasing in England under the stimulus of the Government grants already mentioned.

The further fact that about one-third of the total deaths in the first year after live-birth occur in the first four weeks of life, adds force to my plea for the establishment of these ante-natal consultations in connection with all lying-in institutions and at child welfare centres, where infants and children up to school age will be submitted to periodical medical examination and supervision.

It has been erroneously asserted that the greater part of this early infant mortality is unavoidable; but careful examination of national and local statistics shows that in some places it is twice as high as in others, and examination of the causes of death in the districts with more favourable mortality shows that their experience can be improved. All experienced obstetricians and pædiatricians will agree that, given adequate care of the mother during pregnancy, skilled care by a competent obstetrician during labor, and satisfactory medical and nursing care in the following month, there can be secured large reductions in the early infant mortality of the first month after birth, as well as in the number of still-births and in the present toll on maternal life.

In early infancy, as in advanced old age, the hold on life is slight, normal and abnormal are soon interchanged, and there is needed not only more knowledge on the part of mothers and nurses, and even of physicians, of the hygienic side of medicine as applied to the physiological life of the mother and her infant, but also personal care and assistance to enable the mother to apply the useful information and advice given by the public health nurse. I lay special stress on this association of counsel and assistance. It is important also that nursing and medical assistance should be so given as not to create a feeling of dependence. In view of the wide provision of medical assistance from public funds which already obtains, I submit that poverty tests in the giving of such assistance should be abolished, or that, at least, the availability of such assistance should be greatly extended. Given the fulfilment of this condition, it will be practicable to enlist the remunerated coöperation of the medical profession in a general provision of medical and nursing facilities, which will secure the early detection of disease of every kind and its prompt and adequate treatment. Not only so, but the same service can be utilized for the preservation of health by securing the change of habits and customs and conditions of housing or work which are likely to prove detrimental.

I have laid stress on the ideal after which we must, in my opinion, strive. Meanwhile, it is essential that we should not regard the mere removal of ignorance as the summum bonum. This is plain when we come into close contact with the facts of life as lived by the greater part of the wage-earning classes.

Has the wife of the wage-earner domestic help such as her well-to-do sister possesses? Is there a nurse to help her even when the children are sick, much less while they remain fairly healthy? How often has every kettle-full of water to be heated separately on a stove? Under such circumstances is it reasonable to expect the cleanliness which is an indispensable condition of health? Is there a clean supply of milk for every working-man’s family and are there arrangements for sanitary and cool storage of food in his dwelling?

And so we might go on multiplying questions, knowing that, if the answers are well-informed and candid, they will confess that the mothers of the wage-earning classes, especially in our large cities—in England, if not also here—have not a fair chance to keep themselves well, or to rear a healthy and robust family.