Public health and insurance: American addresses

by Sir Arthur Newsholme

4. The organization of arrangements for “following up” and “after-care.”

During 1912 and 1913 advance was made in these directions. In 1911 there were 25-30 tuberculosis dispensaries: in 1917 their number had increased to 371. In 1914 the onset of the Great War prevented further development of tuberculosis work and seriously crippled and reduced the efficiency of work already initiated; and this increased as the military demand for medical officers and institutions became greater. It may be stated generally that in only a relatively small number of areas have fairly complete arrangements for the institutional treatment of tuberculosis come into operation; and that even in these areas the arrangements have been at work for only a limited period. It is evident, therefore, as already pointed out, that no argument as to the utility of these arrangements can be based on the facts that the death-rate from tuberculosis has not declined with increased rapidity in recent years, and that women during the war, especially at the working years of life have experienced an increased death-rate from this disease.

Tuberculosis Dispensaries

The tuberculosis officer is the essential element in the dispensary; and in rural districts he may be said to carry the dispensary under his hat. The dispensary if properly organized should serve as the centre of official anti-tuberculosis measures. The medical officer of health receives the notifications of recognised cases whether they are attending the dispensary or not; and it simplifies administration if the home supervision of all tuberculous patients notified to the medical officer of health, and not only of dispensary patients, is placed under the supervision of the tuberculosis officer. At the dispensary itself the tuberculosis officer examines patients, makes records of their condition, and of all facts bearing on their welfare, and recommends the special form of continued treatment adapted to their condition. This may be domiciliary, or given at the dispensary, or in a sanatorium, or in a hospital. A dispensary which does not supervise and treat a large proportion of the total notified cases, including especially patients before and after they have received treatment in a residential institution, is not fulfilling its possibilities of utility.

At the dispensary is organized also the examination by the tuberculosis officer of “contacts,” and of school children suspected to be tuberculous; though it is often necessary to arrange for this officer to make similar examinations at patients’ homes. At the dispensary consultations with private practitioners are conveniently held; though in this instance also the tuberculosis officer should arrange when this is desired for the consultations to be held at the patient’s home.

The dispensary alone cannot ensure the welfare of the tuberculous patient. It is necessary that the tuberculosis officer should have consultations concerning difficult cases with the medical staff of general and special hospitals. To segregate the treatment of tuberculosis from that of other diseases means reduced efficiency of the tuberculosis officers and lowered quality of treatment.

Tuberculosis Dispensaries should become Parts of General Dispensaries

Public Health and School Authorities have already established many centres at which hygienic instructions and medical treatment are given for mothers and their young children when ailing, or with a view to the prevention of future illness; for tuberculosis; for venereal diseases; and for various ailments of school children.

In England in addition there is poor-law provision (sometimes at dispensaries) for patients dependent on official charity. Evidently the multiplicity of authorities, local and central, concerned in this medical work, is not conducive to efficiency; and it will, we hope, soon disappear. Similarly it will be in the interest of efficiency, as well as of economy, to provide for the treatment of the above-named groups of cases in a common Medical Institute for each defined area, at which also it will be advantageous to arrange for much of the treatment of insured persons. By this means it will become practicable to arrange for consultations between experts in different departments of medicine, to the advantage of all concerned.

It will be contrary to the communal interest if the resources of voluntary hospitals in large towns are not also utilised in official medical work. Many of these hospitals have specialised departments (e.g., X-ray, eye, ear, throat, skin, and other special clinics), the use of which ought to be obtainable, even though for many years it may not be practicable to arrange for all hospitals to be financed in part at least out of rates and taxes.