Public health and insurance: American addresses

by Sir Arthur Newsholme

4. If the child of the well-to-do mother falls ill, everything that good nursing and medical attendance can furnish is commonly at once available; for the child of the working-class mother the state of matters is remote from the ideal. Facilities for obtaining medical attendance and nursing vary greatly in different districts; but in none are they satisfactory for the poor, and especially for the classes who have limited incomes, but do not as a rule receive skilled hospital treatment, or avail themselves of help from nursing associations. Prompt medical assistance at home commonly cannot be afforded for children of wage-earners, and particularly not for the children of unskilled workers.

5. Infants and nursing mothers are very rapidly influenced by their environment. This environment is complex. The mother is the main element in the environment of the infant. If she is overworked and suffers from chronic fatigue her infant must suffer; directly, because the mother’s milk under these circumstances is liable to be scanty or impoverished or otherwise unwholesome; or indirectly, owing to her being unable to give sufficient attention to her infant. The infant of the well-to-do mother is less likely to suffer in either of these ways.

6. Not only are the milk supply, and the storage and preparation of artificial food, important parts of the environment of the infant, but so also are the housing conditions of the family, and the sanitary conditions of the back-yard and of the street in which the house is situate. The superiority of the circumstances of the one mother and infant over those of the other in these respects is obvious.

There is no reason to assume that the one mother is more ignorant than the other. But the ignorance of the working-class mother is dangerous, because it is associated with relative social helplessness. To remedy this what is needed is that the environment of the infant of the poor shall be levelled up towards that of the infant of the well-to-do, and that medical advice and nursing assistance shall be made available for the poor as promptly as it is for persons of higher social status.

The assistance given will include advice, but it will be the advice which a medical practitioner gives to his patient; which a health visitor or public health nurse gives as to personal hygiene; and which a sanitary inspector gives to a householder. It should include also the advice given by a trained midwife or midwifery nurse, who is in a favourable position to secure the adoption of her advice by the mother. Such advice is becoming available to a steadily increasing extent, but in some industrial towns a majority of midwives and midwifery nurses are still untrained women, who are not competent to give the best advice.

I would not have it assumed that I do not attach high values to the teaching which the physician gives to his patient and the public health nurse to the healthy mother and infant; but unless this is combined with assistance to provide the necessary means to health, whether this be hospital treatment, home nursing, pure milk, improved domestic conditions, or help to the over-tired mother, the advice falls far short of its potentialities for good.

There is need for further instruction of the public in all branches of hygiene; and we need, if we are to be efficient in social work, to follow the advice of Oliver Wendell Holmes, to remove the intellectual membrana nictitans from our eyes, and to consider the physical and moral as well as the intellectual obstacles to health.

In the cultivation of communal health

Defects of Character

are even more pernicious than lack of knowledge. No member of any of our local authorities can fail to have been warned that typhoid fever is still being spread in many communities by impure water, and as the result of inadequate hospital isolation of cases. The means of prevention of tuberculosis are well known; but how few local authorities will face the problem of supplying adequate funds for clinics, for examination of contacts, for hospitals for bed-ridden cases, and for convalescent homes; and how few are willing to give help to ensure that the consumptive patient has a separate bedroom? In how few instances are the regulations against indiscriminate expectoration enforced, and how seldom are physicians called to account for not obeying the law as to prompt notification of cases of tuberculosis? Will all the “drives” against tuberculosis effectually remedy this condition of things? Would not public opinion amply support the one “drive” which, above all others, is necessary: a systematized effort on the part of all social workers to exact a definite promise from every candidate for local or state office that he will give earnest support to all well-considered anti-tuberculosis measures, for the diminution of venereal diseases, for improving the welfare of mothers and their children, for promoting school hygiene, and for improving the housing of the poor. Democratic Government, alas! hitherto, has meant government by active minorities. The great danger of democracy is that the minority may and often does consist largely of persons having a mercenary interest in the machinery of local government. Why should not it become an active and preponderant minority of health gospellers? This will involve the taking of infinite trouble to overcome the multiform activities associated with “political pull”; it will involve the watching of the record of each elected person, merciless exposure of those who do not whole-heartedly support reforms, and systematic effort to prevent the reëlection of all whose record proves unsatisfactory. Are we equal to this task? Is our national and local patriotism equal to this heroic test, involving most prosaic work, the surveillance and the “besting” of the politician? If not, our indirect attack on the enemy by means of special educational drives can have relatively little effect. Where the enemy is, there our fight should be; and the chief enemies of health are local authorities possessing powers to secure health for the community, who corruptly or parsimoniously refrain from their duty. Nor can we avoid responsibility, or the need for strenuous effort after efficiency by not taking part in official or voluntary administrative work. We may have sufficiently good reasons for this abstinence; and onlookers have their rôle in life. If all were authors, where would be the readers? There are many indifferent writers who would be appreciative readers, and the same remark applies in local administration. Appreciation is necessary as well as a subject to be appreciated; and the onlooker at social work may be most helpful. If he is to be helpful he must be kindly and charitable, as well as watchful. Rancorous and ill-informed criticism must be avoided, and the onlooker must be ready to do justice to good work, or attempted good work. Nothing has made it so difficult to secure good men to undertake the burden of local government as the undiscriminating and uncharitable criticism aimed at those engaged in it. Criticism of representatives has often been deserved; but critics are too often those who will not aid to the slightest extent in the work which, often without sufficient knowledge of the facts, they vilify. When we read of administrative scandals, it is desirable to have a sense of proportion, and to remember, as the reader of old records or even of Pepys’ diary will scarcely need to be reminded, that corruption was rampant in the past, and especially to remember that the best way to remove that most subtle and mischievous form of corruption which consists in giving and accepting appointments as political rewards, is by ourselves taking a part in local government, or by steadily upholding those who are doing so with integrity.