Public health and insurance: American addresses

by Sir Arthur Newsholme

It is desirable to supplement the above statement by some remarks on

Improved Housing as a Means of Reducing Tuberculosis

Not infrequently the thoughtless remark is made that given improved housing sanatoria and hospitals for consumptives would be unnecessary. The frequent occurrence of tuberculosis in well-to-do families shows the absurdity of this statement. It is true that tuberculosis is more prevalent among the poor living in small tenements that among the well-to-do; but there is no consistent proportion between the degree of overcrowding in different districts or towns and the death-rate from tuberculosis. Improved housing and institutional treatment for tuberculosis cannot properly be regarded as alternatives. They are necessary complements to each other, and there must be increased expenditure in both directions, if tuberculosis is to be more rapidly reduced in amount. There are in fact two housing problems—for the healthy, and for the sick. The most rapid method of improving housing for the healthy is to remove the sick, and especially the tuberculous sick to a hospital. This is being done year by year to an increasing extent. In England and Wales in 1870, 8.3 per cent., and in 1912 21.6 per cent. of all deaths from all causes occurred in public institutions. It is difficult to exaggerate the practical relief implied in these figures in respect of satisfactory housing, especially in its functional aspect. Apart altogether from the tuberculosis problem much of the decline in the general death-rate must be attributed to the skilled treatment which a large proportion of the total population have received in our hospitals of various types.

I may, I think, claim to have answered in part the question asked at an earlier stage of this address, as to the causes of the steady decline in the death-rate from tuberculosis in recent decades. I do not claim that any one factor has brought about this result. I do not claim that it has been caused entirely by diminution of opportunities of infection; but I deprecate the view that improved nutrition and other conditions diminishing susceptibility have played a predominant part. The facts of international hygienic history rebut this view. Although segregation of patients in institutions has played a great part in bringing about the result, diminution of domestic infection as the result of more cleanly habits has doubtless had an important influence; as has also the reduction of industrial dust.

It is significant that general hygiene and improved care of the sick—quite apart from any intention to segregate—were associated with a large reduction in the death-rate from tuberculosis before the importance of reducing infection was fully appreciated; and that since the necessity for direct measures against tuberculosis was realised, since such measures have been begun, however imperfectly, in many countries, and since anti-tuberculosis educational propaganda has been somewhat active, there has been no increase in the rapidity of decline of the death-toll of tuberculosis. Of course, it cannot be seriously—though it is foolishly—argued from this fact that such direct measures are futile. Every year there has been increasing migration of masses of people into towns, with a corresponding increase of undesirable domestic overcrowding and of indoor occupations. If, therefore, such anti-tuberculosis measures as have been adopted,—whether direct measures or general sanitary measures,—had been associated with an absence of decline or with actual increase in the death-rate from tuberculosis it might still be that these measures have achieved much. Many conflicting agencies are at work, and it might well be that the apparent lack of success of the measures taken is due to the increased operation of countervailing influences. The importance of direct action for the control of tuberculosis must be judged not solely by necessarily imperfect statistical measurement on the basis of a few years’ observation, but by ascertaining that the proposed measures are in accord with our knowledge of the natural history of the disease. As we have seen, both comparative and human pathology assure us that tuberculosis is a communicable and therefore a preventible disease, and point the way to the means for securing this end.

Before describing the direct measures which have been adopted for the control of tuberculosis, it should be added that in no country have these been in operation sufficiently long, and in no country have they been so adequately applied, as to render it practicable to apply statistical measurement of their value; meanwhile these measures must be judged in the light of our knowledge of the pathology of tuberculosis.

Notification of Tuberculosis

If every tuberculous patient were intelligent, and willing and able to follow the advice given by his doctor, if he consulted his doctor for the first symptoms of illness, if his disease were recognized by the doctor at its earliest recognizable stage, and if the doctor in every instance gave the right advice and made the necessary examinations of all “contacts,” no occasion would arise for the intervention or assistance of Public Health Authorities, except in providing bacteriological facilities and institutional accommodation. In actual fact these conditions are not secured for the majority of patients; and the private practitioner, however willing, is seldom in a position to remedy the domestic and industrial insanitary conditions which favour infection and lower resistance to infection.

Hence notification of cases of tuberculosis was advocated for many years by pioneer medical officers of health who secured voluntary notification by doctors of a considerable proportion of the total cases in their districts, and in a few instances secured compulsory notification by local enactment, before any general regulations on the subject were made. It is noteworthy that in this early period a town like Brighton, which had voluntary notification with sanatorium provision for patients willing thus to be treated, secured the notification of a larger proportion of total cases than another town in which notification was compulsory, but no sanatorium accommodation had been provided. The point is mentioned as emphasizing the general principle that compulsory measures in public health, if they are to be successful, require to be associated with full provision for the action which should follow the compulsory enactment; which provision, as in this case, may be a direct inducement to compliance with the enactment. In view of the change of central policy involved and of the unpreparedness of most local authorities to give the assistance needed for notified cases, the general enforcement of notification of tuberculosis was brought about in stages; in 1909 poor-law cases of consumption were made notifiable throughout England and Wales, hospital cases in 1911, consumption in the general community in 1912, and all forms of tuberculosis in 1913.

It was not anticipated that complete notification of cases would be obtained for some years, but a review of English national experience of notification of tuberculosis up to the present time necessitates the confession that there has been failure to secure the coöperation of an unexpectedly large proportion of the medical profession in this public-health duty. Many cases have never been notified and in a large number of other cases notification has been belated; Dr. Barwise, County Medical Officer of Health of Derbyshire, obtained information as to 417 deaths certified during 1917 to be due to tuberculosis, and found that of this number 39 per cent. had never been notified, and that over 70 per cent. had either not been notified or died within twelve weeks of notification. This may be an exceptionally bad experience; but the duty of notification in many areas is only imperfectly performed, and no adequate steps are being taken to diminish this default.