Public health and insurance: American addresses

by Sir Arthur Newsholme

It would be difficult to find a more striking instance of the linking of elements in causation than in the origin of a case of malaria. For the transmission of this disease two human beings, one already infected with the specific contagium, and a mosquito are required, and the chain of causation can be broken at the infecting person, by strict screening from mosquitos, and by the use of quinine; at the mosquito by preventing its emergence from the larval stage, and later by preventing its access to the patient; or at the prospective patient, possibly by prophylactic medication, more certainly by strict screening from mosquitos. Hence one might claim lack of segregation of infected persons, lack of screening of the healthy, failure to drain marshes, to apply oil to the surface of stagnant pools, or to adopt allied measures destroying the larvae of mosquitos as each of them the cause of malarial disease.

There is a constant excess of sickness among the poor as compared with the well-to-do. Measures for the relief of poverty, therefore, may be regarded as within the scope of the physician’s prescription. This may be accomplished for the moment by monetary or material help; but unless the causes of poverty are sought out and counteracted, the assistance given is merely palliative. For nothing is more certain than that poverty tends to become a self-perpetuating condition.

Thus poverty leads to premature employment of children, with detriment to their normal growth, followed by diminished efficiency in adult life. This implies low wages throughout life, and so poverty is passed on to a second generation.

Evidently timely assistance to induce the parent to delay employing the boy, until he has been prepared for work, and to ensure his being put to work which will not be a “blind-alley” occupation, might have obviated the evil chain of events.

Poverty again when carried to the point of destitution may tempt to larceny; this may be followed by loss of employment, and so the temporary unrelieved poverty is liable to become permanent.

Intemperance has been almost wiped out as a cause of disease in the United States; and we have in the fact that the whole country has “gone dry” a remarkable example of a “short-cut” towards social salvation from alcoholism which will be most instructive. Apart from such universal prohibition of alcoholic beverages, the physician has to think of an alcoholic patient under his care as the possible victim of one or more or all of several coöperating influences conducing to intemperance. The alcoholic habit may have been gradually acquired as the result of protracted social indulgence in moderation acting on a person of unstable mental constitution; it may, especially in wage-earners, have been hastened by the evil custom of treating. It not infrequently follows overwork, with the associated feeling of need for stimulants; it accompanies bad housing, with unsatisfactory sleeping accommodation; and it is aided by poor and badly cooked food, due to shiftlessness, overwork, or lack of domestic training of the man’s wife. If there is to be successful control of alcoholism, action in all the directions briefly indicated above, and in other directions which will suggest themselves, is necessary; and although the physician cannot himself do all this, his efforts should run parallel with social efforts in these directions.

Even when the “short-cut” of compulsory abstinence has been taken, the efforts indicated above are still needed; for alcoholism is not the only resultant of bad social habits, of overwork, of unsatisfactory feeding, of deficient sleep, and so on.

Perhaps even more far reaching in their evil effects than intemperance are the Venereal Diseases. As you know, special efforts during and since the war have been made to limit the spread of these diseases. I do not propose to trouble you with statistics to prove the mischief caused by these diseases. Has not Osler said that the whole of clinical medicine can be taught around syphilis, and that it is the third in importance of the killing diseases? And as a further illustration, let me add that no less than one-tenth of the total accommodation in our lunatic asylums might be dispensed with if syphilis were eliminated.

Among the measures being taken to combat these diseases are educational propaganda, and the provision of clinics, free for all, at which patients may be treated promptly and adequately. It is evident, however, that if the medical and educational efforts now being made are to succeed they must include recognition of all the factors causing sexual vice, and appropriate action in respect of each of these—they must indeed go further than this; for self-restraint is a wider problem than in relation to exposure to these diseases. It embraces the whole subject of formation of the habit of self-control. One of the most striking facts in the great war has been the extent to which young girls of previously decent behaviour have fallen victims to what has sometimes appeared to be passion combined with a perverted form of patriotism; and one of the measures most called for is better mothering and maternal training of both girls and boys. The problem is one of special difficulty as regards the economically independent girl; and to shield her the combined efforts of home influence, of girls’ clubs, and of various social and religious organizations are all required.

Judicious and restrained teaching of the physiology and hygiene of sex would do much to counteract the evil influence of bad teaching by companions; and in emphasizing this duty on parents the physician may do untold good. So also, especially when the daughters of his patients are about to marry “men of the world,” he should urge the need for asking a satisfactory certificate from the intended bridegroom of freedom from infection.