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PUBLIC HEALTH AND INSURANCE:
AMERICAN ADDRESSES
BY
SIR ARTHUR NEWSHOLME, K.C.B., M.D., F.R.C.P.
LECTURER ON PUBLIC HEALTH ADMINISTRATION AT THE SCHOOL OF HYGIENE AND
PUBLIC HEALTH, JOHNS HOPKINS UNIVERSITY, BALTIMORE, MARYLAND; LATE
PRINCIPAL MEDICAL OFFICER OF THE LOCAL GOVERNMENT BOARD, ENGLAND;
PRESIDENT OF THE SOCIETY OF MEDICAL OFFICERS OF HEALTH
AND OF THE EPIDEMIOLOGICAL SOCIETY; EXAMINER IN PUBLIC HEALTH
TO THE UNIVERSITY OF CAMBRIDGE, IN PREVENTIVE MEDICINE TO
THE UNIVERSITY OF OXFORD, AND IN STATE MEDICINE TO THE
UNIVERSITY OF LONDON, MEMBER OF THE GENERAL MEDICAL
COUNCIL, OF THE COUNCIL OF THE IMPERIAL CANCER
RESEARCH FUND, ETC.
BALTIMORE
THE JOHNS HOPKINS PRESS
1920
Copyright, 1920
By THE JOHNS HOPKINS PRESS
PRESS OF
THE NEW ERA PRINTING COMPANY
LANCASTER PA.
DEDICATED BY THE AUTHOR
(WITHOUT PERMISSION)
TO THE
RIGHT HONOURABLE JOHN BURNS
A LEADER IN PUBLIC HEALTH;
WHO IN PARTICULAR MADE THE PUBLIC REALISE THE
IMPORTANCE OF CONCENTRATING ON THE
MOTHER AND HER CHILD
PREFACE
After more than three decades of work in preventive medicine and
public health, the opportunity has arisen in connection with a
year’s visit to America, to take a panoramic view of public health
in England, of the progress which has been secured, of the factors
which have impeded progress, and of the pressing desiderata for more
efficient future action.
During my stay in America I have had the privilege of addressing
public audiences in every part, from New Orleans to Toronto, and
from New York and Boston to San Francisco and Seattle; as well as
more special audiences at Johns Hopkins University, at Saranac
and at Harvard, California, Washington, and Yale Universities;
and at the request of many friends some of the addresses given to
these audiences are now published in volume form. These addresses
briefly outline some of the lessons of long experience, and although
the conditions under which they were delivered rendered complete
exposition impracticable, there are, I think, advantages in not
overloading the presentation for public consideration of a many-sided
subject.
It will be noted that the same problem may be mentioned in several
addresses, though usually from a different angle. The entire
avoidance of repetition would have necessitated the abandonment of
the lecture form, and would, I believe, have diminished the utility
of the volume. The table of contents and index render cross-reference
easy.
Those wishing to ascertain fuller details on most of the problems
discussed in the present volume may refer, I think with advantage,
to my annual reports as Medical Officer of the Local Government
Board, England, and to my four special reports on Maternal and Child
Mortality, which also were issued as English Government publications.
British experience is only partially applicable in the United
States, the almost complete Home Rule in each State creating a
new and interesting problem in efficient national public health
administration. Nevertheless a review of events in Great Britain
cannot fail to be useful in America, which is faced with similar
problems. The main lines of public health administration in Great
Britain have proved their value by their success. There has been
local independence with a minimum of central control, and the
people’s representatives in every area have been made to realize
their commercial responsibility. The mistakes made in permitting the
multiplication of small and inefficient public health authorities,
in allowing official medical work to be divided respectively
between different local and central authorities, in sanctioning the
creation of _ad hoc_ authorities for special work, in associating
state medicine with monetary insurance against sickness, and in
not securing that insurance shall directly assist the prevention
of sickness, have been largely the mistakes of politicians and of
central authorities. These mistakes involve the retracing of steps
and the undoing of the mischief resulting from ill-advised action. In
view of these conflicting events, the marvellous achievements secured
by public health authorities are the more noteworthy.
In every American city visited by me I have been struck with the
earnest desire of voluntary and official public health and social
workers to profit by English experience, to adopt what is good, to
secure the abolition of the short tenure of office of competent
officers under the present political system, and to introduce civil
service conditions for them. There is in many respects a close
parallelism between the course of public health on both sides of the
Atlantic; in some cities the English hygienist has much to learn
in respect of advanced and original work; and in other American
cities in which “political pull” continues, there is evidence of the
development of a wider interest and a more general sense of communal
responsibility; a deeper trend of thought which will make for
steadily increasing efficiency in public health work. As this volume
discusses public health problems especially from a social viewpoint,
it is my earnest hope that it may be useful in this direction.
ARTHUR NEWSHOLME
SCHOOL OF HYGIENE AND
PUBLIC HEALTH,
JOHNS HOPKINS UNIVERSITY,
BALTIMORE,
AND
ATHENAEUM CLUB,
LONDON,
May, 1920
CONTENTS
LECTURE I
PUBLIC HEALTH PROGRESS IN ENGLAND DURING
THE LAST FIFTY YEARS 1-41
Parallelism of Events in Old and New England.
The Utilization of Lay Workers in Public Health Work.
The Influence of Urbanization and Industrialism.
_Laissez faire_ Economic Teaching.
Man and his Environment.
Dirt and Disease.
Cholera, Typhoid Fever, Typhus Fever.
Summary of Results in Life-Saving.
Specific Causation of Disease.
Importance and Present Limitations of Epidemiology.
The Importance of Vital Statistics.
Conditions of Medical Practice Bearing on Public Health.
Poor-law _versus_ Public Health.
Insurance _versus_ Public Health.
A National Medical Service.
Hospitals Important Housing Auxiliaries.
The Need to Avoid Complacency.
LECTURE II
HISTORICAL DEVELOPMENT OF PUBLIC HEALTH
POLICY IN ENGLAND 42-70
Town-Dwelling and Health Problems.
The Scope of Public Health Work.
Reform in the Control of Poverty.
Reform in Industry.
Public Health Reform.
Education Authorities and Health.
The _Ad Hoc_ Vice.
Principles of Local Government.
The Training and Tenure of Office of Medical Officers of Health.
The National Insurance Act and Public Health.
Provision for Sickness.
General Summary.
LECTURE III
THE INCREASING SOCIALIZATION OF MEDICINE 71-102
An Altruistic Profession.
The Past Achievements of Medicine.
The Ever-increasing Importance of Hospitals.
Hospitals and Housing.
The Continuing Mass of Preventible Disease.
The Present Extent of Socialization of Medicine.
Destitution and Sickness.
Insurance and Sickness.
The Needs of the Future.
LECTURE IV
THE MEDICAL ASPECTS OF INSURANCE AGAINST
SICKNESS 103-119
Criteria of Value of Insurance.
British System of Insurance.
Limitations and Evils of the “Medical Benefit.”
Need for further State Treatment of Disease.
Prevention of Poverty by the Application of Medical Science.
State Medicine must be Preventive throughout.
Conditions of an Efficient Medical Service.
LECTURE V
SOME PROBLEMS OF PREVENTIVE MEDICINE OF
THE IMMEDIATE FUTURE 120-143
The Incidental Gains from War.
Its Sacrificial Work.
The Comradeship of All Idealists.
Women’s Work.
The Restriction of Alcoholism.
The Change from Empirical to Scientific Methods.
The Still Uncontrollable Diseases.
Influenza and Measles as Types.
The Possibility of Modified Training of Nurses.
The Need for a More Complete Program in Tuberculosis.
The Possibilities of Control of Venereal Diseases.
The More Complete Protection of Maternity and Childhood.
The Abolition of Poverty Tests in Medical Assistance.
Lack of Equality of Service, not Ignorance, the Chief Evil.
The Continuing Value of Voluntary Workers.
LECTURE VI
THE INTER-RELATION OF VARIOUS SOCIAL EFFORTS 144-156
The Possibilities of Good Work under Present Economic Conditions.
The Importance of Social Work to the Physician.
The Constant Need for a Causal Outlook.
Poverty and Disease.
Causes of Intemperance.
The Causation and Prevention of Venereal Diseases.
Lop-sided Views as to Ignorance in Causation of Disease.
LECTURE VII
THE OBSTACLES TO AND IDEALS OF HEALTH PROGRESS 157-182
Degree of Progress Realized.
Obstacle of Urban Life.
Obstacle of Industrialism.
Obstacle of Poverty.
The Influence of the Malthusian Hypothesis.
Obstacle of Ignorance.
Obstacle of Defects of Character.
IDEALS.
Communal Action.
Spread of Altruism.
Supreme Importance of Mother and Child.
LECTURE VIII
SOME ASPECTS OF POVERTY 183-190
Disease a Chief Cause of Poverty.
Diminution of Poverty apart from Increased Family Income.
Poverty a Complex.
Action Needed against Each Constituent Element of Poverty.
LECTURE IX
THE CAUSATION OF TUBERCULOSIS AND THE
MEASURES FOR ITS CONTROL IN ENGLAND 191-239
_A._ Basic Facts as to Tuberculosis.
Explanations of the Decreasing Death-rate from Tuberculosis.
Diminished Virulence of the Tubercle Bacillus.
Increased Human Resistance by Natural Selection.
Immunization by Small Doses of the Contagium.
Diminished Tuberculosis with Increased Aggregation of
Population.
Hospital Treatment of Consumptives.
Koch’s Views as to Hospital Segregation.
Improved Housing in Reduction of Tuberculosis.
_B._ Measures of Control.
Notification of Cases.
Causes of Failure in Notification.
Public Health Action following Notification.
Examination of Contacts.
Scope of Tuberculosis Schemes.
Tuberculosis Dispensaries.
Should be Part of General Dispensaries.
The Home Visitation of Patients.
Sanatorium Benefit.
Residential Institutions.
General Observations on Treatment in Sanatoria.
Hospital Treatment.
Industrial Colonies.
Special Dwellings and Help in Support.
Summary.
LECTURE X
CHILD WELFARE WORK IN ENGLAND 240-267
The Earlier Work of Medical Officers of Health.
The Notification of Births.
Chief Causes and Course of Infant Mortality.
The Influence of School Medical Inspection.
The Influence of Statistical Studies.
The Midwives Acts.
Health Visiting.
Voluntary Work.
Child Welfare Centers.
Training and Provision of Midwives.
Ante-natal Work.
Dental Assistance.
Creches.
Observation Beds at Child Welfare Centers.
Grant’s to Local Authorities.
Course of Mortality in Childbearing.
CHAPTER I
PUBLIC HEALTH PROGRESS IN ENGLAND DURING THE LAST FIFTY YEARS[1]
After thirty-five years in active public health work in
England—during eleven of those years having been the principal
officer of its central public health department on its medical
side—I may be assumed to possess some qualification for the task
of reviewing the past half century’s progress in public health in
England.
_Parallelism of Events in New and Old England_
I find it, however, beyond my power to compass in a short address
a resumé of my subject which shall be complete, or completely
in perspective, or which shall not omit features on which,
had time permitted, one would have wished to comment; and I
must ask you to remember that only a portion—and that chiefly
non-administrative[2]—of the history of this wonderful half century
can be embraced within the present address. The survey should, I
think, take a panoramic view of the story as it has developed, should
note the changes as they have occurred, the obstacles which impeded
reforms as well as the reforms secured; and should also, at least
incidentally, state—in the light of unfailing historical guidance,
as well as of increasing knowledge—the pressing desiderata for more
efficient and more rapid future progress. I cannot hope to accomplish
this task except to a fragmentary extent, but I am happy to remember
that sanitary history in Old and in New England has proceeded largely
on parallel lines. The curves of annual death-rates from all causes,
from typhoid fever, from tuberculosis, and of the mortality of
infants show the closeness of the parallelism of the public health
history of England and Massachusetts.
The work of the last fifty years was built on preceding pioneer work
of men in Old and in New England; and for a complete understanding of
this work, a momentary glance is required at the men of this earlier
generation and their work.
In the old country we speak with reverence of the names of Southwood
Smith, Kay, Chadwick, Farr and Simon; and you remember with gratitude
the names of Lemuel Shattuck, of Bowditch, of Walcott, S. W. Abbott,
and Theobald Smith; and it is gratifying to remember that the
epoch-making report of the Massachusetts Sanitary Commission of
1850—to which were attached the ever memorable names of Shattuck,
N. P. Banks, and Jehiel Abbott—among its many statesmanlike and
far-seeing proposals, recommended a sanitary survey of the State, and
referred to the recent English sanitary surveys, with which British
sanitation may be said to have begun.
_The Utilisation of Lay Workers_
Let me in passing comment on the fact that neither Lemuel Shattuck in
Boston nor Edwin Chadwick in London was a physician; but a perusal of
their writings shows that they were men of sound judgment, of earnest
zeal for their fellow men, with a wide and statesmanlike outlook,
ready to search out, to accept and to apply the medical knowledge on
which necessarily the prevention of disease is based. They illustrate
once for all the need for partnership between all well-wishers of
humanity in this work, and the importance of combined effort by the
sociologist and the physician, as well as of experts in each branch
of sanitation, if all attainable success is to be attained.
The tradition then established has never been lost. In England, more
perhaps than in America, the control of public health work has been
shared by intelligent laymen on local and central authorities, and
the fact that medical officers of health have found it necessary
to convince these lay representatives of the general public of the
need for the reforms recommended, has led to steady progress, seldom
interrupted by relapses. And this is true, although delays and
disappointments have beset the path of the earnest reformer, who
might well wish that his lay colleagues had been trained in schools
in which natural science formed a more open avenue to distinction
than classics; or that the representatives on local authorities might
more fully and more quickly appreciate in Simon’s words, what they are
sometimes a little apt to forget that, for sanitary purposes, they
are also the appointed guardians of human beings whose lives are at
stake in the business.
What were the ideals with which the Fathers of Sanitation in New and
in Old England began their work?
They cannot be better expressed than in their own words. In the
1850 Report of the Massachusetts Sanitary Commission they are thus
expressed:
We believe that the conditions of perfect health, either public or
personal, are seldom or never attained, though attainable; that the
average length of human life may be very much extended, and its
physical power greatly augmented; that in every year, within this
Commonwealth, thousands of lives are lost which might have been
saved; that tens of thousands of cases of sickness occur, which
might have been prevented; that a vast amount of unnecessarily
impaired health, and physical debility, exists among those not
actually confined by sickness; that these preventible evils require
an enormous expenditure and loss of money, and impose upon the
people unnumbered and immeasurable calamities, pecuniary, social,
physical, mental, and moral, which might be avoided; that means
exist, within our reach, for their mitigation or removal; and that
measures for prevention will effect infinitely more than remedies
for the cure of disease.
In a succeeding paragraph the Commissioners proceed to quote with
approval, the following remarks made by Mr. (afterwards Sir John)
Simon in the preceding year, when he was medical officer of health
to the City of London, and before he became the principal medical
officer and adviser of the British Government in health matters, and
in that capacity laid the foundation and built much of the edifice of
our present health organization.
Ignorant men may sneer at the pretensions of sanitary science;
weak and timorous men may hesitate to commit themselves to its
principles, so large is their application; selfish men may shrink
from the labour of change, which its recognition must entail;
and wicked men may turn indifferently from considering that
which concerns the health and happiness of millions of their
fellow-creatures; but in the great objects which it proposes to
itself, in the immense amelioration which it proffers to the
physical, social, and, indirectly, to the moral conditions of
an immense majority of our fellow creatures, it transcends the
importance of all other sciences; and, in its beneficent operation,
seems to embody the spirit, and to fulfil the intentions, of
practical Christianity.
With such noble ideals, what measure of success crowned their efforts
and those of their successors?
The earlier history I can only briefly mention, as we are chiefly
concerned today with events since 1869. To understand these events,
however, one must understand the forces which had been accumulating
and increasing in power in earlier years, and which rendered possible
the rapid public health progress experienced in the fourth quarter
of the nineteenth and the first quarter—so far as it has passed—of
the twentieth century.
_Laissez Faire Economic Teaching_
Historians in future generations will refer to the second half of the
eighteenth and the first half of the nineteenth century as the period
of unmitigated industrialism, of associated rapid increase of urban
at the expense of rural life, and of the most extreme manifestation
of _laissez faire_ economic science. The older semi-paternal system
of interference with the economic life of the people by King and
Parliament, was replaced, under the influence of Adam Smith,
Malthus, James Mill, and other teachers, by inaction based on the
view that in old countries poverty is the natural and inevitable
result of pressure of population on means of subsistence, and that
any interference with freedom of competition in obtaining work or
employing workers is useless or mischievous. A similar view found
expression in President Jefferson’s dictum: that government is best
which governs least; and until the middle of the nineteenth century
these views were generally accepted and their influence was dominant.
It was assumed that given free competition, enlightened self-interest
would incite effort and improvement, encourage self-reliance, and
guarantee production and economy.
Under the conditions considered inevitable with such teaching,
although great wealth accompanied the rapid industrial development
after the Napoleonic wars, it was associated with unrelieved misery;
for homeworkers and rural workers crowded into mean hovels in towns,
paying exorbitant rents out of a miserable pittance of wages, and
were exposed to the evils resulting from overcrowding, and from
absence of adequate and satisfactory water supply, scavenging or
drainage. By the year 1851 about half the population of England
and Wales had become aggregated in towns; and it may be added that
in 1911, less than one fourth of the population was left in rural
districts. Urbanization in the earlier years meant dense overcrowding
and insanitation; and that it is still an influence adverse to health
may be gathered from the information given by the census of 1911,
that over eight times as large a proportion of the urban as of the
rural population live in one-roomed tenements, and nearly twice as
large a proportion live in two-roomed tenements, while the proportion
of one-roomed tenements in towns which are overcrowded (in the sense
of having more than two persons to a room) in towns is seven times as
great, and of two-roomed tenements is twice as great as in country
districts.
Domestic misery was associated with commensurate industrial misery;
overwork, in insanitary factories and workshops, regardless of the
health of the “hands,” was the rule.
The displacement between 1760 and 1800 of domestic by factory
manufacture represented a new phenomenon in the world’s history,
a true industrial revolution. It was the parting of the ages;
destined not only to change the life of the people of England from
preponderantly outdoor to preponderantly indoor; and to bring for
them for many years all the disadvantages of unregulated town life;
but also, owing to the rapid development of better roads, of canals,
and then of railroads and steamships to end forever the practical
segregation in which countries, and even neighbouring communities,
had previously lived.
It cannot be wondered at that under these circumstances the general
death-rate was excessive, and epidemic disease spread with a rapidity
and to an extent previously unknown.
The reaction against the _laissez faire_ economic teaching began
early, and it is in accordance with the fitness of things that the
national conscience first rebelled. The earliest evidence of reform
was legislation in 1802 on behalf of pauper children indentured to
the overseers in textile factories; and there followed subsequent
Factory and other Acts in 1819, in 1833, in 1844 and in 1847, which
prohibited the factory employment of children under nine, limited
the hours of labour of young persons and of women, and insisted on
elementary sanitation in factories. Subsequent Factory and Mining
Acts, followed by Shop Hours Acts and the Shop Seats’ Act, have
completed a most valuable code of regulations prohibiting overwork,
and securing a measure of protection against dangers to health and
limb or eyesight during industrial employment. It is noteworthy that
the first steps at improved sanitation, and to safeguard health by
preventing overwork, were on the industrial plane. Factory inspectors
preceded medical officers of health and sanitary inspectors appointed
by local authorities.
Philanthropy was the motive power in initiating factory reform; in
securing general sanitary reform, driving power was furnished by the
double motive of economy and fear, caused by the inordinate expense
of poor-law administration, the frequently recurring epidemics of
“fever,” and the alarming occasional invasions of Asiatic cholera.
The sacrifices of life from cholera were truly vicarious; for we owe
it largely to these that our national system of vital statistics was
initiated in 1837 and that serious efforts at sanitary reform were
begun.
_Man and His Environment_
The history of these earlier steps is full of interest; but I
cannot outline it today. There can be no doubt that as Simon[3]
put it, referring to Dr. Southwood Smith’s report to the Poor-Law
Commissioners in 1838 (“on Some of the Physical Causes of Sickness
and Mortality to which the Poor are particularly exposed, and which
are capable of removal by Sanitary Regulations”)
the commencement of State interference on behalf of the health of
the labouring classes may be said to date from its publication and
to have been in a very important degree determined by its facts and
arguments.
That the first principles of causation were beginning to be
appreciated is shown in the following extract from Queen Victoria’s
speech in opening Parliament in 1849. In this speech she referred to
the ravages of cholera which it had pleased Almighty God to arrest,
and added:
Her Majesty is persuaded that we shall best evince our gratitude by
vigilant precautions against the more obvious causes of sickness,
and an enlightened consideration for those who are most exposed to
its attacks.
Note that these words and the early attempts at public health
legislation, culminating in our great sanitary code, the Public
Health Act, 1875, incorporated the tripod on which enlightened public
health administration must always be supported, viz.,
(1) attack on the causes of sickness,
(2) satisfactory treatment of the sick, and
(3) satisfactory care for the poor.
I might properly add
(4) attack on the causes of poverty,
for it is perhaps the chief merit of the great work of Edwin Chadwick
that, in the light of reports on local surveys made by Kay, Southwood
Smith, and others, he was convinced and was able to convince
Parliament that a very large share of the total destitution then
existing was due to the conditions under which the people lived, and
the disease generated in these conditions.
It is commonly stated that, in the past, public health administration
has concerned itself solely with mankind’s environment, failing to
recognise the predominant importance of man himself as a transmitter
of disease, and of his personal well-being and protection as the
point to which energy should be directed. This cannot be said to have
been the intention of the legislature or of the earlier reformers;
though unhappily this limited view received official acceptance,
in large measure owing to the increasing incompatibility between
poor-law and public health administration and the spreading over from
poor-law to public health administration of the general influence of
“deterrence” as a motive of administration. As time went on, this
principle came to be realised as contrary to the general interest in
anything which concerns the health of the community.
_Dirt and Disease_
The crude generalization emerging from the earlier surveys was the
close relation between filth conditions and excessive sickness; and
the motive behind these inquiries was the desire to remove one of
the chief causes of destitution.
So late as 1874 Simon said “filth is the deadliest of our present
removable causes of disease”; and throughout the whole series of
his vividly worded and influential reports, the same fundamentally
important teaching was urged.
Chadwick’s earlier reports were similarly influenced by the teaching
of Dr. Southwood Smith and his collaborators, to the effect that
epidemic diseases as a whole are the direct consequence of local
insanitary conditions. This generalization, as we now know, needs
a modified and more accurate statement, specialized for each
individual disease. In its original form, however, it embodied a
realisation of the immense importance of the environment to make or
to mar individual and national life; it secured the beginning of our
national sanitary improvements, and it laid the foundations of the
house of health which as nations we are still building.
The three diseases which were especially regarded as due to filth
were cholera, typhus, and enteric fever; and the history of public
health in England is largely concerned with these three diseases.
_Cholera_
The general view then held in New as in Old England is well stated in
the following extract from the Report of the Massachusetts Sanitary
Commission, 1850:
Atmospheric contagion is generally harmless unless attracted
by local causes ... that terrible disease, Asiatic Cholera,
derives its terrific power chiefly or entirely from the accessory
or accompanying circumstances which attend it. It bounds over
habitation after habitation where cleanliness abides; ... while it
alights near some congenial abode of filth or impurity.... Wherever
there is a dirty street, court, or dwelling-house, the elements of
pestilence are at work in that neighbourhood.
And the important moral is drawn that
the person who permits his neighbour’s atmosphere to be contaminated
by any filth ... is worse than a highway robber. The latter robs us
of property, the former of life.
Similarly, Simon in England was teaching that “in order to
the prevention of Filth Diseases, the prevention of filth is
indispensable”; and that there was need for local authorities “to
introduce for the first time, as into savage life, the rudiments of
sanitary civilization.”
The crude generalization that filth causes disease perhaps persisted
too long, and the value of Snow’s investigation in 1855 of the
outbreak of Cholera in the area of supply of the Broad Street
pump was perhaps too slowly appreciated. The influence of Von
Pettenkofer’s theories on the relation between subsoil conditions and
Cholera was largely responsible for this delay; but already in 1856
Simon had accepted the importance of water infection, giving as his
general conclusion that
under the specific influence which determines an epidemic period,
fecalised drinking water and fecalised air equally may breed and
convey the poison (of Cholera).
Still it will be noted there persisted the notion of aerial
convection of the contagia of cholera and enteric fever, in
addition to their convection by dirt, by flies, or the more common
contamination of hands or feet or food by faecal matter; but the
importance of water supplies was beginning to be appreciated. Already
in 1883 local authorities in England and Wales had outstanding loans
for waterworks amounting to twenty-nine million and for sewerage
amounting to fifteen million pounds sterling, while between 1883 and
1912 they expended out of rates and by means of loans one hundred and
thirty-one millions for waterworks and eighty-nine millions sterling
for sewerage.
Although we realise now the greater importance of control of excreta
from persons specifically infected, we must agree with Simon that
communally
Nowhere out of Laputa could there be serious thought of
differentiating excremental performances into groups of diarrhœal
and healthy.... It is excrement, indiscriminately, that must be kept
from fouling us with its decay.... It is to be hoped that ... for a
population to be thus poisoned by its own excrement, will some day
be deemed ignominious and intolerable.
And it is still opportune to draw attention to the terrible
responsibility incurred by local authorities when they distribute
a general supply of water to the inhabitants of their area
without taking every possible precaution against contamination.
The conveniences and advantages of public water supplies “are
countervailed by dangers to life on a scale of gigantic magnitude”;
and sanitary history, in the calamitous experience of Lincoln,
Maidstone, and Worthing and of Lowell and other towns and districts,
has given remarkable illustrations of the need for eternal vigilance.
_Typhoid Fever_
With the differentiation of typhoid fever from typhus fever by
Gerhard in Philadelphia in 1837, and by Stewart and W. Jenner
in Great Britain in 1849, it became possible to associate the
former with excremental, the latter with respiratory filth, “the
non-removal of the volatile refuse of the human body.” The question
still remained whether typhoid fever was producible by “emanations
from decomposing organic matter,” whether it was “often generated
spontaneously by faecal fermentation,” as contended by Murchison, who
in 1858 proposed the name “pythogenic fever” for typhoid fever; or
whether as indicated by the remarkable observations of William Budd
of Bristol, the introduction of specific infection from a typhoid
patient was needed to start a local outbreak. Gradually it became
clear that specific contamination was necessary to start an outbreak
or even to cause a single case of this disease, and between 1870 and
1880 a number of water-borne outbreaks were traced. It also gradually
became evident that, however objectionable or even noxious might be
the gaseous emanations from leaky drains or sewers, they did not
cause typhoid fever or diphtheria. Hence the statement, for instance,
of Oliver Wendell Holmes in 1862 (quoted for its historical interest
by Dr. Sedgwick) that “the bills of mortality are more obviously
affected by drainage than by this or that method of practice,” which
expressed universal opinion when it was written, is now known to be
accurate only when specific matter from drains contaminates milk or
water supplies, or causes infection by actual contact.
With the general recognition of the causal relation between impure
water supplies and typhoid fever came the rapid provision of public
supplies, on which, as already seen, large public expenditure was
incurred; and to this fact is owing, in the main, the rapid reduction
in typhoid mortality shown in the following statement:
Population of No. of Deaths
England and Wales from Typhoid
Year in Millions Fever
1871 22⅘ 12,709
1881 26 6,688
1891 29 5,200
1901 32⅗ 5,172
1911 36⅕ 2,430
1917 33⅗ (civilian) 977
The number of cases notified in England and Wales
in 1911 was 13,852
in 1917 was 4,601
There was, it will be noted, a period of apparent cessation of
decline in the typhoid mortality between 1891 and 1901, followed by a
striking decline between 1901 and the present time. The late decline
was due in large measure to the discovery of the relation between
contaminated shell-fish and enteric fever, and, probably to a less
extent, to the realisation of the importance of the small minority of
cases of this disease, who continue after their recovery to spread
infection. At the present time typhoid fever promises to become as
rare in England as typhus fever or malaria; and with increased care
in the protection of food, as well as of water supplies, and with the
universal hospital treatment of the sick and observation of their
bacterial condition on discharge, this anticipation bids fair to be
realised.
_Typhus Fever_
The history of typhus is similar to that of typhoid fever; and
when Murchison in 1858 asserted its spontaneous generation under
conditions of overcrowding and bad ventilation—
Its great predisposing cause is destitution; while the exciting
cause or specific poison is generated by overcrowding of human
beings with deficient ventilation—
he was expressing the considered conclusion of his period.
Typhus Fever was not differentiated from enteric fever in the
Registrar-General’s returns prior to 1869, but the course of events
in later periods can be seen in the following statement:
Typhus Fever, No.
of Deaths in England
Years and Wales
Ten years, 1871-80 13,975
Eight years, 1903-10 210
Seven years, 1911-17 42
The cases in recent years were nearly all traceable to imported
infection.
The main factors in the reduction of typhus fever have been
the immobilisation of infectious cases in fever hospitals, the
rigid cleansing and disinfection of invaded households, and the
surveillance of persons who have been exposed to infection. The
clearing of insanitary courts, housing improvements, and the
associated increased cleanliness of the general population have
doubtless aided; and it is a suggestive fact that although the virus
of typhus is not yet determined, and although it has only recently
been shown that typhus is a louse-spread disease, the point of
extinction of the disease under peace conditions has almost been
reached in countries having an efficient sanitary organization and a
cleanly people.
With the demonstration that typhoid fever was commonly water-borne,
that the spread of typhus fever could be controlled by sanitary
surveillance and immobilisation of infectious cases in hospital, and
that diarrhœal mortality could be reduced by increased municipal and
domestic cleanliness, much more rapid improvement in national health
occurred in the decennium 1871-1880 and in subsequent years.
The course of events for typhoid and typhus fever has already been
noted. Before describing further the action taken by central and
local public health authorities and the other influences conducing to
reform, it is convenient to summarise at this point the
_General Results in the Saving of Life_
Although I do not dwell further on the influence of increase of
wages, of better and cheaper food, of sanitary education of the
people, of a steadily increasing standard of cleanliness,—in person
and in spitting habits,—and of improving home conditions, it will not
be assumed they must be omitted in any considered judgment as to the
means by which the saving of life shown by the following figures has
been secured.
The expectation of life at birth (or mean after-lifetime) in England
and Wales in 1871-80 for males was 41.4 years, for females 41.9
years. It steadily improved decade by decade; based on the experience
of 1910-12 the male expectation of life had been prolonged by 10.1
years, and the female by 10.8 years. A very large proportion
of the lives saved were lived in the years of greatest value to
the community. Comparing 1910-12 with 1871-80, the reduction of
the death-rate meant that _each year_ 116,401 male and 118,554
female lives were saved, and the future lifetime of these persons
whose lives were prolonged,—assuming a continuance of current
experience,—would give an annual gain of nearly ten millions of
additional years of life, of which over seventy per cent. would be
lived at ages 15 to 65.
Of the annual saving of 234,955 lives, 64 per cent. was ascribable to
reduced mortality from acute and chronic infectious diseases; and of
the mortality under these headings nearly one-third was referable to
respiratory diseases, the same amount to tuberculosis, one-seventh to
scarlet fever, one-thirteenth to measles and whooping cough, the same
amount to typhus and enteric fever, and one-sixteenth to diarrhœal
diseases.
The gain of life may be further illustrated by the following
figures. During the 32 years, 1881 to 1912, over seventeen millions
deaths occurred in England and Wales. Had the experience of 1871-80
continued throughout the subsequent years, the number of deaths would
have been increased by close on four millions.
_Specific Causation of Disease_
The preceding review will have made it clear that in the period
of earlier slow sanitary reform, although much invaluable work
was being done, it was in some measure a groping in the dark,
a continuous search for further light while pursuing (or at
least advocating in season and out of season) such cleansing and
purification of man’s surroundings as were evidently needed, and
such segregation of the infectious sick as could be secured in the
absence of complete information of the cases of sickness. Happily in
the case of Small Pox there was an additional effective protection in
vaccination.
With Pasteur’s discoveries was inaugurated a new era in sanitation;
the general microbial origin of infectious diseases, inferred from
his discoveries, leading to the conclusion that the chief source
of disease to others is man himself, and that his surroundings in
the main cause disease insofar only as they become a vehicle for
conveying disease by direct inhalation of infected dirt (Sax. _drit_
= excrement), or by swallowing specifically infected foods.
The importance of the sanitary engineer in securing pure water
supplies and satisfactory sewerage continues. The sanitary
inspector’s work in removing nuisances and accumulations, any one
of which might be specifically contaminated,[4] and in controlling
overcrowding and uncleanliness as well as in other respects, remains
indispensable. But the brunt of guidance in the exact prevention of
disease, especially of communicable diseases, must necessarily now
fall on
the epidemiologist,
the vital statistician, and
the laboratory worker.
_Present Limitations of Epidemiology_
The epidemiologist must always remain the chief of these three,
suggesting and arranging the details appropriate to each
investigation, putting together the facts supplied by the two other
workers and drawing legitimate conclusions. In conducting his
inquiries and in searching for further light on obscure points, he
will need to remember Simon’s remarks (Eighth Report of the Privy
Council):
In the category of time, far out of human reach, there are
circumstances which greatly influence contagion.... These almost
cosmic arisings are spreadings of disease or facts of cosmo-chemical
disturbance which no mere contagionism can explain.
These words had special reference to cholera, and although we still
know little or nothing of the mysterious influences which permit
cholera when unimpeded to undertake transmundane travels at irregular
intervals of time, we can claim with certainty that in any country
in which sanitary surveillance is well organised, and the internal
sanitation of the country is good, the spread of cholera need
not be feared. Thanks to the great discovery of Jenner and to the
complete organization of measures for isolation of the sick, and for
vaccination and surveillance of contacts, we can make the same claim
for smallpox, whenever this mysterious disease begins its occasional
world travels.
But we have to confess our continuing relative helplessness in
preventing the spread of measles, and of acute catarrhs, among our
endemic infections, and still more of influenza when—as recently—it
makes its devastating swoop on the entire world, and secures a larger
number of victims than the World War itself.
We can recommend isolation of the sick, and personal precautions in
speaking and in coughing and sneezing, and occasionally may score
an isolated success; but we are practically helpless against this
enemy. Nor are we better acquainted with the means for preventing the
spread of poliomyelitis; and we cannot claim that any measure against
the spread of cerebro-spinal fever has had undoubted success, except
only rapid amelioration of the conditions of overcrowding under which
it especially occurs. These instances suffice to show that in the
region of respiratory infections,—with the one notable exception of
tuberculosis, which we can control, whenever we are ready to take
the necessary complete measures—we have much to learn. In respect of
most diseases due to respiratory infection we are groping in darkness
nearly as dense as that which beset Chadwick, Farr and Simon in
their earlier work, and with little hope of any campaign comparable
with that against dirt _en masse_, which was largely effective in
reducing the specific infections of cholera, dysentery, and enteric
fever, of typhus fever and even of tuberculosis.
The great public health requirements for the future are the conquest
over acute respiratory infections, including not only affections
of the lungs, but probably also measles and whooping cough,
cerebro-spinal fever and poliomyelitis and their allies; and the
prevention of cancer. So while thankful for the discoveries already
made, and for the beneficent work already accomplished, we must hope
that the rapid increase of Medical Research in England and here
will in due time enable us to extend the application of preventive
medicine to diseases so far uncontrollable.
_The Importance of Vital Statistics_
In England public health progress has been largely actuated by
records of mortality, which have served to make the public realise
the need for expenditure of money on sanitary reform. Experience has
shown, as Dr. J. S. Fulton has expressed it, that
every wheel that turns in the service of public health must be
belted to the shaft of vital statistics.
Accurate and complete returns of deaths and their causes are
essential in investigating the local and occupational incidence of
disease, and in comparing the experience of different communities:
and the various weekly, quarterly, annual, and decennial reports
issued from the Registrar-General’s Department have rendered
invaluable service to the cause of public health. “Ye shall know the
truth, and the truth shall make you free.”
It was not the least of Chadwick’s services to the State that he
discovered William Farr, who was intrusted with the compilation of,
and comment on, our early statistics from 1837 onwards. His reports,
with those of Simon, embody the history of sanitary progress in
England and the motives and arguments which actuated it.
The registration of births similarly enabled comparison of
birth-rates to be made; also of maternal mortality in child-bearing
and of infant mortality in different areas, and at different parts of
the first year of life; and these studies made by medical officers
of health and more exhaustively in the Medical Department of the
Local Government Board have had great influence in determining the
intensive work for improving the conditions of childbearing and of
infant rearing, which in recent years has been accomplished.
As time went on it became clear that registration of deaths gave a
very imperfect view of the prevalence of disease, and that so far
as infectious diseases were concerned, valuable time was lost when
preventive action could only be taken after the patient’s death.
Death registration told of the total wrecks which had occurred during
the storm; it gave no information as to early mishaps, enabling
others to trim their vessels and thus weather through. It gave a list
of killed in battle, not of the wounded also.
And so began gradually, in characteristic British fashion, the
notification of infectious cases, the list of notifiable diseases
being extended from time to time.
From 1911 onwards the Local Government Board prepared a weekly
statement of infectious cases notified in each sanitary area
which was distributed to every medical officer of health. Similar
returns of exotic diseases of interest to port medical officers
were distributed; and the successive annual summaries prepared in
the Medical Department of the Local Government Board showing the
incidence of the chief epidemic diseases in every area now constitute
one of the most valuable epidemiological records extant.
Collaterally with the notification of infectious diseases, including
tuberculosis, to the medical officer of health, occurred the
enforcement of notification of various industrial diseases occurring
in factories, such as anthrax, lead and arsenic poisoning, to the
Chief Inspector of Factories, Home Office.
_Conditions of Medical Practice Bearing on Public Health_
It cannot be claimed that notification of acute infectious diseases,
still less of tuberculosis, has been complete. It is impossible to
discuss the reasons for this in the present address (see Lecture
IX); but the present conditions of medical practice are largely
responsible for the partial lack of success. Hasty conditions of
work, failure to employ laboratory means of diagnosis, or to utilise
available consultation facilities (especially in tuberculosis), and
lack of training of medical practitioners in preventive medicine, are
among the obstacles to further control of disease.
There will not be complete success until means are discovered for
training and enlisting every medical practitioner as a medical
officer of health in the circle of his private or public practice,
and of securing his services not only in the early and prompt
detection of disease, but also in the systematic supervision during
health of the families under his care, and in advising them as to
habits or methods of life which are inimical to health.
_Poor Law v. Public Health_
An approximation to this ideal was in the minds of the early sanitary
reformers; and it was one of the misfortunes associated with the
deterrent policy of poor-law administration in medical relief, that
separation between Poor Law and Public Health appeared to offer the
best prospect of sanitary progress.
Had Simon’s advice been followed, when the Local Government Board was
about to take over the public health duties of the Privy Council, the
poor-law organization might, and probably would gradually, have been
permeated by public health activities, and thus the sanitary welfare
of the poorest class of the community would have been more completely
safeguarded on its personal as well as on its environmental side.
In his Eleventh Report to the Privy Council (1868) Simon recommended
adherence to the intention of Mr. Lowe’s Nuisance Bill of 1860, which
would have identified the health and destitution authorities. He
deprecated the institution of “a differently planned organization for
objects exclusively of health”; subject to the conditions that public
health should not be subordinate to poor-law work and that there
should be power to combine districts for certain purposes, and action
through committees in sub-areas.
Had this course been pursued, and had the central public health
policy not been preponderantly non-medical and poor-law in sentiment
and tradition, more rapid progress in public health would have been
experienced. The central evil was intensified, as is shown in Simon’s
_Public Health Institutions_, by regarding the medical officer of
the Local Government Board as merely advisory, and by the retention
and extension on a large scale of local inspection by lay officers
of the Central Board, for conditions which needed systematic medical
control.
The problem of the proper relation between destitution and public
health and between the authorities dealing with these, runs right
through our past history of social progress, and it is not even yet
satisfactorily adjusted.
The gradually increasing dissatisfaction with Poor Law administration
led to the appointment of a Royal Commission which after several
years deliberation, in 1909 presented a Majority and a Minority
Report.
The dissatisfaction, which these reports justified, may be said to
have been inherent in the situation; for the Poor Law organization
was constantly attempting,—more or less under the influence of
the principle of “deterrence,”—two incompatible tasks: to prevent
undue dependence upon parochial assistance and to give to those
needing them the medical and nursing assistance which the principles
of preventive medicine require should be given unstintingly, and
completely freed from any deterrent element. Although in many
parochial areas admirable medical work was done, this was the
exception, not the rule; and public sentiment rebelled against the
giving or the receiving of medical assistance to which was attached
the “poor-law stigma.” Both reports recommended the scrapping of the
poor-law machinery by abolishing the present Boards of Guardians and
the general mixed workhouse; and the Minority Report went further,
proposing to complete the supersession of the poor-law by various
preventive authorities, which were already partially in operation.
Thus everything connected with the treatment of the sick would be
transferred to the Public Health Authorities, the care of school
children to Education Authorities, of lunacy and the feeble-minded to
already existing Asylum Committees, and so on.
Behind these proposals lay the principle that _the treatment and the
prevention of disease cannot administratively be separated without
injuring the possibilities of success of both_; and this is a
principle which happily is becoming more generally accepted.
Before the report of the Poor Law Commission was issued, examples of
the application of this axiom existed in the isolation and treatment
of patients with acute infectious diseases; in the increasing
provision for the treatment of tuberculosis; in the extension of
provision for care of parturient women and for their infants; and in
the system of school medical inspection followed to some extent by
treatment.
It is convenient to add here, that under each of these headings,
great extensions have been made since 1911; and an even more
spectacular public provision of treatment, as the best method of
preventing further extension of disease, is exemplified in the
gratuitous and confidential diagnosis by laboratory assistance and
the treatment of venereal diseases now given in every large town in
the country, the Central Government paying three fourths and the
Local Authority one fourth of its cost. In order further to secure
the success of this treatment,—which is provided for all comers with
no residential or financial conditions,—the legislature has passed an
enactment forbidding the advertisement or offering for sale of any
remedy for these diseases, and forbidding their treatment except by
qualified medical practitioners.
It is one of the great misfortunes of more recent Public Health
administration that the Report of the Royal Commission on the Poor
Laws has not hitherto been made the subject of legislation. It
would not have been an insuperable task to find a common measure of
agreement between the Majority and the Minority Reports. Indeed an
adjustment has recently been made between these two reports, as the
result of the deliberations of a House of Commons Committee, over
which Sir Donald Maclean presided; and it may be hoped that ere long
this will mean the realisation of a much belated reform of local
administration.
This forms an indispensable step in the needed further struggle
against the problems of Destitution. So much of destitution is due to
sickness that the separation of the two problems is inconsistent with
success. “One-third of all the paupers are sick, one-third children,
and one-quarter either widows encumbered by young families or
certified lunatics.” There are economic causes of poverty, apart from
sickness, but it is essential to remember that every disease which is
controlled frees the community not only from a measurable amount of
sickness, but from the amount of poverty implied by this sickness.
Had the policy of transfer of the duties of Poor Law authorities to
the Councils of Counties and County Boroughs recommended in 1909 by
the Poor Law Commission been adopted, these last named authorities
would already possess a medical service for the poor employing some
4,000 doctors; they would be in possession of the large infirmaries
and other medical institutions of the poor law, and given reforms and
readjustments of these which are urgently required, and combination
of the hospital arrangements of poor-law and public health, would
have a greatly improved medical service freed from poor-law shackles
and capable of gradual extension as needs and policy indicate. The
fusion of these two services with the school medical service would
have been an easy further step; and England would by this time have
built up a National Medical Service, for the very poor, for all
purposes of public health—including poor-law—administration, and for
children and their mothers in special circumstances.
_Insurance v. Public Health_
Political circumstances, into which it is unnecessary to enter, led
to the adoption of a course, which medically ran directly athwart
the course of needed reform. The National (Health) Insurance Act,
1911, was passed, giving sickness and invalidity benefits to those
employed persons below a certain income who could contribute a weekly
sum, which was considerably less than half the estimated cost of the
benefits to be received; and an additional medical service, further
complicating the already existing medical services of the poor law,
public health, and educational authorities, was set up.
The establishment of national insurance against sickness and
disablement in the United Kingdom exemplifies the contagiousness,
under modern conditions of life, of a new course adopted in
any country; and Bismarck’s attempt to counteract socialism by
insurance has been responsible for international, state and official
experimentation in insurance which has not generally been well
advised, and which is associated in England with extravagant cost of
administration.
Insurance against sickness is a praiseworthy and valuable provision
against future contingencies; and on its non-medical side free from
drawbacks. Neither on its medical nor on its non-medical side,
however, is it an alternative to prevention of disease; and the
National Insurance Act in England must be held in the main to have
delayed the public health reform which would have been secured had
equal effort been devoted to it, and the money lavished on insurance
given in the form of central public health grants conditional on the
active coöperation of local authorities. True, the English public
have been educated to think in regard to sickness in millions when
previous provisions for the treatment and prevention of sickness
had been thought of in thousands of pounds; and there has been
an extension of provision for the institutional treatment of
tuberculosis, which probably has been more rapid than would otherwise
have been made, in the absence of the alternative grants named above.
It should be added that, owing to the natural insistence of insured
tuberculous patients on treatment in a sanatorium, and to the desire
of Local Insurance Committees and their officers to satisfy insured
persons, sanatoria have often been filled with unsuitable patients,
sent there regardless of relative social and public health needs. The
Maternity Benefit (of a sum of money on the birth of an infant to
the wife of an insured person or to an employed woman) similarly is
given unconditionally, and should be replaced or supplemented by the
provision of service needed at this time (doctor or midwife, nurse,
domestic assistance), which would ensure the welfare of both mother
and infant.
Apart from other reforms the transfer of medical provision, of
provision for tuberculous patients, and for parturient women to
public health authorities is urgently needed; and the service should
be given according to need irrespective of insurance. The valuable
fund for medical research has already been placed under the Privy
Council.
The absurdity of regarding insurance as anything beyond a possibly
useful handmaiden and auxiliary to Public Health, when strict
administrative arrangements are made for this purpose, may be
illustrated by the question as to what would have been the result in
sanitary progress if Chadwick or Simon had persuaded the government
of their day to insure a favoured section of the public against the
risk of typhus or smallpox or tuberculosis or even of non-infectious
illness?
Under the National Insurance Act medical domiciliary assistance,—but
only to the extent which is within the competence of a medical
practitioner of average ability,—is provided under contract for
one-third of the total population; and evidently this implies an
immense abstraction from ordinary private medical practice. There is
no provision, hitherto, for consultant and expert facilities when
required (except for tuberculosis), for the nursing of patients, or
for institutional treatment of any disease, except tuberculosis; and
no funds are generally available for these purposes except such as
belong to the community at large.
In view of the preceding facts and of other considerations which I
have not mentioned, reconstruction of the English Insurance scheme
is obviously required. The scheme cannot persist in its present
form. The already accomplished amalgamation of the Local Government
Board and National Insurance Commission, should make radical changes
easier; an equally important step would be the transfer of the
medical functions of the Local Insurance Committees to Public Health
Authorities. The creation of these independent committees was one
of the greatest blunders of the National Insurance Act, which was
conceived ill-advisedly, had too short a gestation, and suffered a
premature and forced delivery; and we may hope that ere long, it may
be replaced entirely, on its medical and hygienic side, by a rapid
extension of the medical activities of the public health service
which will conduce to the welfare of the whole nation.
It is impossible to justify the continuance of state subsidisation
of benefits for a favoured portion of the wage-earning classes,
when poorer persons who do not come within the category of employed
persons or who fall out of employment, and when clerks and others on
limited salaries who are unable to provide adequately for sickness,
are left unprovided for.
_A National Medical Service_
What is most urgently needed is a national medical service which
will give for all who cannot afford them hospital treatment and
the services of consultants and of scientific aids to diagnosis and
treatment whenever required; and which will provide nurses during
illness treated at home, when this is asked for by the doctor in
attendance.
Outside the operation of the National Insurance Act, these
services have been provided to a steadily increasing extent, but
in a characteristically British fashion. They have grown largely
under voluntary management, and as exemplifications of Christian
philanthropy; though official has rapidly overtaken the voluntary
provision of hospitals and nursing, the two working side by side,
each in their respective spheres, and on the whole with cordial
coöperation. The extent to which institutional treatment with its
more satisfactory arrangements is replacing the domiciliary treatment
of disease may be gathered from the following striking facts:
In England and Wales
Of deaths from all causes, in 1881 = 1 in every 9
Of deaths from all causes, in 1910 = 1 in every 5
In London
Of deaths from all causes, in 1881 = 1 in every 5
Of deaths from all causes, in 1910 = 2 in every 5
occurred in public institutions.
The facts as to Pulmonary Tuberculosis are even more significant:
In the year 1911
in England and Wales 34% of male 22% of female
and in London 59% of male and 48% of female
deaths from pulmonary tuberculosis occurred in public institutions;
and as each of these patients spent on an average several months in
hospital, at the most infectious stage of their illness, a material
annual reduction in the possibility of massive infection of relatives
and others has been secured.
_Hospitals Important Housing Auxiliaries_
This institutional treatment of the sick has been one of the chief
influences counteracting the pernicious effects of industrialism and
urbanization. It has relieved housing difficulties at a time when
insufficient bedroom accommodation is most injurious; and it has
secured year by year for a steadily increasing proportion of the
total population the improvements of modern surgery and medicine as
practised in institutions, which permit of the poor thus treated
receiving more satisfactory and more hopeful treatment than is
obtainable for a large proportion of other classes of society.
My address is already too long. Other opportunities will be taken
of explaining the rapidly increasing part which the State and
Public Health Authorities are taking in the hygiene and care of
motherhood and childhood and of school children; in the provision
of additional nursing services for the sick, in the rapid growth
in numbers of public health nurses, health visitors, school nurses,
etc.; in special schemes for the treatment of tuberculosis and of
venereal diseases; and the circumstances under which the Central
Government are to a rapidly increasing extent paying half (or in
certain instances three-fourths) of approved local expenditure on the
provision of hygienic, nursing and medical services; and I do not
therefore dwell on these points further.
Nor need I comment here on the remarkable fact that the British
Government under present circumstances have departed from the
economic position that houses built by local authorities must be able
to be let at a rental covering all outgoings.
In Lecture II I shall deal with problems of local and central
government, and with the training and appointment of medical officers
of health; but the present review, if it omitted from consideration
on the one hand the value of specially trained whole-time health
officers, and on the other hand the health significance of the
general advance in the standard of medical treatment, as factors of
prime importance in securing the already achieved improvement in
human life and health, would give a most imperfect picture of the
actual facts.
_The need to avoid Complacency_
Such figures as I have given, showing saving and prolongation of life
during the last fifty years, are apt, if left uncorrected, to create
a complacent warmth tending to public health inertia. It may conduce
further to this folding of the hands when I state that Simon in his
first report to the Local Government Board expressed the opinion that
the half million deaths a year approximately which occurred in 1871
in England and Wales were a third (125,000) more numerous than they
would be if existing knowledge of the chief causes of disease were
reasonably well applied throughout the country; and further that
had the mortality experience during 1911-15 held good for 1871, the
deaths in that year would have been reduced by 200,000 instead of by
125,000, the ideal then aimed at by Simon.
But with increased knowledge we know that a larger proportion of
diseases are preventable than was formerly supposed. It will be easy
within the next ten years to reduce the death-rate by one-third of
its present amount, given systematic and adequate action on the
part of Public Health Authorities and an effective educational
propaganda among the general public. More important still, an even
larger proportion of mankind’s total illness can be avoided, and life
on a higher plane of health secured, as well as life prolonged to
its normal limit. The work carried out during the last ten years,
sanitary, medical and hygienic, in improving the prospects of healthy
child-bearing and of normal infancy and childhood constitute the most
important advance toward national physiological life on a higher
plane which has hitherto been made.
Preventive medicine can never be satisfied until it has approached
Isaiah’s ideal (Isaiah, LXV, 20), “There shall be no more thence an
infant of days, nor an old man that hath not filled his days; for the
child shall die a hundred years old.”
FOOTNOTES:
[1] An address prepared for the celebration of the fiftieth
anniversary of the Massachusetts Board of Health, September, 1919.
[2] The administrative side of the subject is sketched in the next
chapter.
[3] Reprint of Reports, Vol. I, p. 448.
[4] There is still no evidence to show that in the production of the
excessive diarrhœa which prevails in insanitary districts, specific
contamination of the filth accumulations is necessary.