THE HISTORICAL DEVELOPMENT OF PUBLIC HEALTH POLICY IN ENGLAND[5]
The subject is too large to be treated adequately in the course of an
evening’s address; and to bring it within manageable compass it is
necessary for me to select my material rigidly and, as far as I can,
to present this material in such a manner as will bring into relief
its salient and most instructive features.
The evolution of public health in England proceeded by experimental
steps, some mistaken and then retraced, others mistaken and not
retraced, but steps oftenest in the direction of a complete service,
which is the goal of our work.
The evolution has been a gradual growth arising out of realized
needs, rather than a logical development based on general principles;
and as politicians and legislators seldom take a wide outlook, or
consider a specific proposal in relation to what is already being
done, and to what is the desired goal, the English experience is
especially instructive.
_Town-living and Health Problems_
Public health work became an urgent necessity when men began to
huddle in towns; and with the industrial revolution of the eighteenth
and early nineteenth centuries the need for remedial action became
acute. It is hard to realize that in the days of our grandfathers,
the home was in most instances the unit of industry; and that in
the eighteenth century communications between districts and towns
were not more advanced than those of the ancient Egyptians. When,
however, vast urban aggregations of population multiplied, travelling
facilities rapidly increased, and the results of crowding, of
contaminated water supplies, of intensive and widespread infection,
were seen in devastating endemic and epidemic diseases. Poverty,
squalor, dirt, and their consequences, were rampant in the towns,
where underpaid work-people were exploited by masters, whose
self-centred outlook had some share of justification in the political
economy doctrines of the time, which regarded any interference with
“freedom of contract” as useless or even pernicious.
What is public health work? It is best defined by stating its object,
which is to secure the maximum attainable health of every member of
the community, so far as this can be secured by the authorities,
local, state, or federal, concerned in any part of government, acting
in coöperation with all voluntary agencies whose work conduces to
the same end. The connotation of public health becomes wider year
by year. It embraces physiological as well as pathological life;
being as much concerned with improving the standard of health of
each person as with the prevention and cure of disease. Hence the
importance of the “concentration on the mother and her child” (John
Burns), to secure for them by all practicable means the conditions
of complete health, which during the last twelve years has been
a vital part of our public health work, and which is now being
made to include not only all hygienic and medical help that may be
needed, but also such domestic aid as may enable the mother to bring
her children into the world and to rear them under advantageous
conditions.
_Scope of Constructive Health Work_
Public health embraces some eugenic elements, and may comprise more
when eugenists have accumulated adequate non-fallacious evidence on
which to base valid conclusions. Already partial steps are being
taken to secure the segregation and prevent the propagation of the
feeble-minded and the insane; and in sorting out congenital infection
from true heredity action is being taken to avoid congenital syphilis
and to prevent the large number of still-births due to this race
poison.
Public health in the main is concerned primarily with the
environmental measures calculated to prevent the attack of man by
disease, whether pre-natal or post-natal. These measures may be
industrial, as in the prevention of accidents, of dust, of noxious
vapours; or sanitary, as in the control of water supplies, food, or
milk, and in the removal of organic filth; or may be the application
of preventive medicine against infectious and non-infectious
diseases; or therapeutic, consisting of the prompt and adequate
treatment of all illnesses and the curtailment of the incompetence
due to them; or educational, consisting, first in importance, in
the training of medical practitioners, of public health officials,
and nurses; and, next, in the education of the general public and
especially of the children in our schools, in the science and
practice of public health.
Advances in public health in many directions can only be secured
by continued and extended medical research, and public health,
therefore, has a direct and immediate interest in promoting and
subsidizing such research.
These being the objects of public health, how far have we travelled
toward securing the end in view? I do not propose to myself the
pleasant task of showing to what extent the general death-rate
has been lowered, infant and child mortality greatly reduced,
the duration of life extended, how typhus and smallpox have been
almost eradicated, typhoid fever made a disappearing disease, and
tuberculosis has become the cause of only half its former death rate.
When inclined to indulge in such pleasant considerations, I recall
the statement I have made elsewhere that one-half of the mortality
and disablement still occurring at ages below seventy can be obviated
by the application of medical knowledge already within our possession.
Let me attempt the more difficult task of outlining the history of
forms of administrative control of disease since 1834.
_Reform in the Control of Poverty_
Poverty and disease work in a vicious circle in which cause and
effect often change places; but it is certain that disease is one of
the most fertile causes of poverty, using the word poverty in the
sense of privation of one or other essential of physical well being.
For this reason, and because the half starved form a constant
social danger, poor-law administration long antedated public health
administration. There is not time to follow the course of earlier
poor-law administration, with its many and grievous abuses. The
Poor-Law Amendment Act of 1834, gave the Central Government control
over the systems of local relief, secured the combination of parishes
into unions for poor-law relief,[6] and forbade outdoor relief to
able-bodied men. The creation of an organ of central control has
led to the subsequent course of aid to paupers being determined in
the main in London, action of poor-law guardians being subject to
supervision by government inspectors, and to endorsement by the
Central Authority. At first, medical assistance under the reformed
Poor Law was made as deterrent as non-medical relief; and although
there has been much improvement, chiefly on the institutional side,
medical treatment under the Poor Law has to some extent retained this
deterrent element, and it has, except in the poor-law infirmaries of
large cities, remained generally disliked by the people concerned.
The first Central Poor-Law Authority was a Commission having no
representative in Parliament. In 1847 it was replaced by a Board, the
president of which was a member of Parliament and of the Government.
Here once for all Parliament declared its intention to maintain
direct control of central official government, and in this and in
all other departments has done so. If democracy is to be real,—and
we have no sound, practicable alternative to it,—evidently the
representatives of the people must be masters of the administration;
and English policy has never wavered on this point. After many
years’ experience of public life in England, I have no hesitation
in saying that this principle is sound; that it insures progress
which, although slow, is less liable to relapse than administration
under autonomous expert commissions, whether centrally or locally;
and that any lack of progress that has been experienced in central
government has been as much the result of inactivity and of lack of
sympathy with social reform on the part of the permanent officials
of government departments who have had access to their parliamentary
chief, as of the inertia of politicians or their obstruction to
reform.
Dissatisfaction with Poor-Law administration has steadily increased
in the years since 1834, as the problem of the able-bodied pauper has
diminished and the Poor Law has been concerned more and more with
the sick and infirm, the aged, and children. These at the present
time form some 98 per cent. of the total population relieved. The
fundamental principles of the Poor Law were rightly attacked. It
did not comprise elements tending to build up disabled families, or
to prevent families from falling hopelessly and permanently into
destitution. The law was administered almost entirely with a view to
_relief_; practically not at all as a _curative_ agency. In medical
language, symptomatic and not rational causal treatment was the rule.
In medical relief, poor-law administration has been a constant
struggle between increasingly humane treatment and the conception
that the pauper’s position must remain inferior to that of the
non-pauper; an important principle when applied to the able-bodied
adult who has drifted into willing dependence; mischievous when
applied to sick persons, and to dependent women and children.
The general dissatisfaction with poor-law administration led to the
appointment of a Royal Commission on the Poor-Laws which, after
several years’ deliberation, published in 1909 a majority and a
minority report. Both these reports recommended the abolition of
boards of guardians, and the transfer of their duties to the 144
largest public health authorities in the country (County Councils,
44; and the Councils of county boroughs, 82), and the abolition of
the general workhouse. The majority report would have continued
the Poor-Law Guardians as a Committee of the new Authority; the
minority report proposed to distribute the duties of the guardians
to different committees of the Public Health Authority; thus medical
treatment to the Public Health Committee; the care of lunacy and
the feeble-minded to the Asylum Committee; care of children to the
Education Committee; vagrants, etc., to the Police Committee; a
special committee concerning itself with all questions of monetary
assistance.
A compromise between these two schemes has recently been arranged,
and when the new Ministry of Health, which will combine public
health, poor-law, insurance, and educational medical work in one
department, has found time to do urgently needed work, the above
indicated reform may be hoped for, along with the even more
urgently needed reform of local public health administration, and
the abolition of a large number of the smaller and less efficient
sanitary authorities. With these reforms will come much needed
de-centralization of poor-law work. Good work in all respects cannot
be secured if the Central Authority concerns itself, as at present,
in minutiae of local administration, and has no time to devote itself
to the larger problems, and to the task of bringing indifferent,
chiefly smaller authorities, up to the standard of efficient local
authorities. A large portion of the expense of local poor-law
administration is borne by the central exchequer, and this money if
properly applied will give the necessary leverage for reform, while
leaving progressive Authorities, and especially the Authorities of
large towns, free to experiment and advance.
_Reform in Industry_
The industrial revolution meant the subjection of large masses of
working class families to evil conditions of housing and work in
crowded and insanitary dwellings and factories. The public conscience
first rebelled in regard to boarded out and apprentised pauper
children; and the first Factory Act in 1802 concerned itself with
them; and with this Act emerged the germ of machinery for securing
compliance with the law, magistrates and clergymen being appointed as
inspectors under the Act.
The Act was largely futile; but it meant the beginning of the gradual
breaking down of _laissez faire_ doctrines; and there followed a
more widely operative Factory Act in 1833, restricting hours of
labor of children, and initiating professional inspectors controlled
and paid by the Government. In 1842 the underground employment of
women in mines was forbidden; and at intervals since then numerous
factory and allied acts have been passed, restricting the duration
and conditions of work of women and children, improving rules as to
sanitation, insuring systematic inspection by government inspectors,
and constituting a far reaching system of supervision and control.
The inspectors, on whom falls the burden of ensuring compliance with
the Factory Laws and regulations made under them, are controlled by
the department of the central government known as the Home Office;
their work on the whole has been well done, and the conditions of
factory and workshop life have greatly improved. Some portion of
the sanitary supervision of these work-places falls on the local
Sanitary Authority; but in the main the system is one of absolutely
centralized government control. This secures almost complete absence
of improper influence of interested local persons, whether masters or
workmen; but it is arguable that this system should be replaced by a
localized system, the inspectors being officers of the 144 larger
authorities. These local officers could be placed in direct touch
with the Home Office or the Ministry of Health and with the central
staff of inspectors having expert knowledge in the different branches
of industrial work.
_Public Health Reform_
Public health reform was a direct consequence of the Poor-Law
Amendment Act, 1834. Anxious to diminish the enormous expense of
the existing Poor Law, and realizing that a large share of this
sickness was due to fever and other illnesses, surveys and inquiries
were set on foot by the commissioners administering this Act, and
the reports which followed revealed a state of things urgently
calling for sanitary reform, in the interest of national economy
as well as of health. “An Act for Promoting the Public Health” was
passed in August, 1848, which created a General Board of Health
consisting of four members and a secretary. These Commissioners,
among whom was Edwin Chadwick, former Secretary of the Poor Law
Board, initiated a system of procedure which was largely on the lines
of poor-law action, and which involved constant pin-pricking by the
Central Authority of the grossly indifferent local authorities. The
commissioners were more zealous than discreet; and after six years
they were no longer tolerated. At that time centralization was as
much a bogie as socialism has become in more recent years. Parliament
and the localities represented by its members doubtless feared
the reforming activity of Chadwick and his colleagues, though they
sheltered themselves behind their exaggerated fears of bureaucracy
and centralization.
A new board replaced the old, parliamentary in character, its
president being a member of the Government. This repeated, so far as
concerns Parliamentary headship, the story of the Poor-Law Board,
and established once more the theory of the administrative control
of the representatives of the people. Nor, although the change meant
for the time serious slackening in sanitary reform, can objection be
taken to it. In a democratic government the elected representatives
of the people must take first place; and it is the rôle of officials
to educate them in the direction of needed reforms. Reforms which do
not carry public opinion with them are not likely to be permanently
successful; and, whether in administration or in legislation,
attempts to sidetrack or ignore this fact are not likely to be
permanently effective.
_Public Health Reforms_
When the Local Government Board was formed in 1870, a second
opportunity was lost of developing Public Health Administration on
lines which we now know to be the best adapted for a complete service
of preventive medicine. The first lost opportunity was when sanitary
authorities, completely separate from poor-law authorities, were
created for administering the sanitary laws. Probably this arose
from Chadwick’s despair of getting effective sanitary reform from
poor-law guardians; but the creation of separate authorities was
scarcely consistent with the fact recognized by him that pauperism
is largely, if not predominantly a question of sickness; or with the
less recognized fact that its treatment forms an essential part of
prevention. It was recognized that the care of the sick was largely
idle until the unnecessary causes of disease had been cut off, but
not that the adequate treatment of sickness is an important means
of preventing it or of curtailing it. Rumsey,[7] in 1856, stated
the unrealized possibilities of the poor-law medical officer’s
domiciliary attendance on paupers in the following words:
There are much higher functions of a preventive nature than those of
a mere “public informer” which the district medical officer ought to
perform. He should become the sanitary adviser of the poor in their
dwellings ... he (should) be in a peculiar sense, the missionary
of health in his own parish or district,—instructing the working
classes in personal and domestic hygiene,—and practically proving to
the helpless and debased, the disheartened and disaffected, that the
State cares for them, a fact of which, until of late, they have seen
but little evidence.
In the result the _ad hoc_ poor-law authority did not absorb into
it the newly created municipal and urban and rural sanitary
administration, but continued on its separate path.
Simon, in 1868, had urged the inadvisability of continuing _ad hoc_
authorities, and had urged that, at least, sanitary should be made
coterminous in area of administration with poor-law districts. His
advice was not adopted, and there followed years in which sanitary
authorities were allowed to subdivide areas, until the total number
became 1,807 instead of 635, the number of poor-law authorities;
and in which they concerned themselves chiefly with nuisances and
water supplies and with inadequate provision for the prevention
and treatment of infectious diseases. With the creation of county
councils and the more complete autonomy of the councils of county
boroughs, the large centres of population developed and improved
their sanitary administration more rapidly; and it became practicable
to undertake every division of sanitary work on an efficient scale.
Although much remains to be done, it can be claimed that in our
larger towns, containing more than half of the total population
of the country, the public health work in nearly all its branches
is of a high order. It would have been still more efficient had
the poor-law guardians been merged in the Town Council, and had
the relationship between the school medical service and the other
branches of the public health service been closer than has been the
case.
What is now needed is that the defects just named should be
made good; that more complete autonomy should be given to the
authorities which come up to a required standard, and that
especially they should have greater freedom in developing local
possibilities of improved administration. Central grants in aid of
local sanitary administration are steadily increasing. Already the
Government pays one-half of local expenditure on a large program
of maternity and child welfare work, one-half of the expense of
local tuberculosis work, and three-fourths of the expense of local
work for the diagnosis and treatment of venereal diseases, and for
propaganda work concerning these. These grants should be the means
of greatly increasing good local administration; but if,—this is
improbable,—they curtail local experimentation and extension, and
bring local public health administration into anything approaching
the subservience of local poor-law administration, the value of these
subventions will be doubtful.
_Education Authorities and Health_
The national system of compulsory elementary education inaugurated
in 1870 has had valuable indirect influence in promoting the public
health. Apart from the beneficent effect of education, the steadily
increasing pressure on children to come to school in a cleanly
condition and the stimulus of emulation in tidiness and cleanliness,
have done much to improve the home conditions of the people.
After the South African war much attention was drawn to the large
number of recruits rejected owing to physical disabilities; and an
inter-departmental committee reported _inter alia_ in favour of a
system of medical inspection of pupils in elementary schools, which
had often been urged by hygienists. Observations made in Glasgow
and Edinburgh by Leslie Mackenzie did much to draw attention to the
physical defects in Scottish school children. In 1907 the Board
of Education acquired power to make provision through the local
education authorities for the medical inspection and treatment of
school children. At first little more than inspection of pupils
was undertaken, a large number of defects of sight, hearing,
parasitic conditions, as well as malnutrition and actual disease
being discovered. Gradually some items of treatment were undertaken
at school clinics, or at hospitals or centres subsidized by the
education authorities; though the amount of treatment is still small
compared to the defects discovered and not otherwise treated.
But there now existed in every locality three authorities concerned
in the treatment of disease:
1. Poor-law guardians, treating all forms of illness in paupers, at
home and in institutions.
2. Public health authorities, undertaking preventive measures against
disease, and treating fevers, tuberculosis, and occasionally other
diseases in institutions; and more recently providing nurses at home
for certain conditions.
3. Local education authorities, concerned in treating certain
ailments in school children.
Centrally two government departments were supervising this work, and
subsidizing it to some extent from government funds; and poor-law
medical work and public health medical work were supervised by two
divisions of the Local Government Board acting in almost complete
isolation. More recently Parliament has permitted the Board of
Education to give grants in aid of schools for mothers, and allied
institutions for the care of children under school age; for which
institutions, substantially, the Local Government Board in other
instances was giving grants.
The separation of the medical work of Education Authorities from
public health medical work was contrary to the first principles
of sound administration; although it is possible that, owing to
the inertia in some public health circles, this separation at
first favored rapid advance in school hygiene; just as the early
development of public health apart from poor-law administration was
probably more rapid than could have been expected from centrally
ridden local authorities, concerned chiefly in keeping down the poor
rates.
_The Ad Hoc Vice_
But in both instances there was an offence against the first
principles of good administration, which require that when a special
function is to be undertaken it shall be undertaken by one governing
body for the whole community needing the service, and not for
different sections of the community by several governing bodies.
Medical treatment is needed for school children and for the poor
generally. Why separate this into two administrations? Hospitals are
required for paupers with tuberculosis, and for non-paupers with
tuberculosis. Why have two authorities for this work? The separate
existence of Education and Poor-Law Authorities _qûa_ medical
attendance on those children needing it erred, not only in this
fundamental respect, but also because neither of these authorities
had the preventive facilities and powers possessed by Public Health
Authorities, who were also partially engaged in the treatment of
disease.
The inveterate tendency in the past has been to create a new
authority when any new work was inaugurated, this authority then
fulfilling all purposes for a special portion of the community
and thus necessarily duplicating the staffs of other departments
of local or central government. The crowning instance of this
recurring instance of legislative myopia is seen in the case of the
National Insurance Act, under which has been provided an imperfect
and unsatisfactory domiciliary medical service for one-third of
the entire population of Great Britain, when by combining and
extending the medical forces of existing departments of the state, a
satisfactory service for all needing it would have been secured. The
axiom that “the object of community service is to do away with group
competitions and bring in its place group coöperation or team work”
(Goodnow), is especially applicable to all public health and medical
work; and the spirit of this axiom is infringed by the existence of
separate, sometimes competing, occasionally conflicting, services
under separate local and central control.
_Principles of Local Government_
The preceding considerations bear on the perennial problem of
efficient government, local and central. There are three functions
to be performed in government, legislation, determination of
administrative policy and extent of work, and the actual executive
work. In England, legislation is in the hands of Parliament and is
usually national in scope. Large cities, however, not infrequently
obtain special legislative power to meet local needs; and by this
means have succeeded in advancing local efficiency above the average
standard. Local authorities, furthermore, have the power to make
regulations and by-laws for special purposes, subject to the approval
of the Central Authority.
In settling the details of local administration, the elected
representatives of the public are supreme. They meet in Council, and
action is taken on a majority vote. The councils of counties and
cities, and even of smaller municipal boroughs divide themselves into
committees, each consisting of about a dozen members, elected by vote
of the whole Council. The chairman or mayor of the Council has no
special power, except that he may give a casting vote.
The chief defect in local sanitary administration in England is
the continued existence of a large number of small and relatively
inefficient local authorities. The larger authorities, as a rule,
do their work well, and politics enter but little into elections.
Official posts are not vacated with changing councils. These councils
are approximating to the ideal of a complete local Parliament dealing
with all governmental concerns, and to the further ideal that each
unit of government should be large enough to minimize the influence
of local interested motives, and to undertake each department of
municipal work on a considerable scale. The local Parliament has
committees concerned with police, finance, public health, education;
and when the urgently needed poor-law reforms are made, and when the
Education Committee hands over its medical work to the Public Health
Committee, the ideal will become a fact.
Power is already given to coopt on to some of these committees a few
persons who are not members of the Council, from among men or women
having special knowledge of the Committee’s work; and the exercise of
this power has been found to be useful.
But in each committee it is the direct representatives of the
public who decide points of policy and settle the main outlines of
administration. There is growing up a tendency to appoint local
advisory committees, consisting of special groups representing
professional or trade interests. Thus a medical committee may
be consulted on medical proposals, and so on. This is still
in the experimental stage. It will probably prove permanently
useful, as voicing the occupational aspect of any proposed work
of the municipality; but it will need to be kept to its strictly
consultative limitations, and the responsibility of the Council as
representing the combined wisdom or unwisdom of the entire community
must be maintained.
All substitutes for government of the people by the representatives
of the whole population are open to objection. They do not contain
within them the elements of permanence. If there is a corrupt
council, the remedy is not its supersession by an independent
executive. Such an executive is the abrogation of popular government.
“Good and efficient government is possible under almost any form
of organization. More depends upon men than devices.... But ... if
we believe that the functions of deliberation or determination of
municipal policy and of administration or the execution or carrying
out of that policy should be kept distinct, we cannot avoid the
conclusion that a city council is a necessary part of the municipal
organization.”[8]
Each committee of the local Council is advised by the County Clerk
or Town Clerk on legal and administrative matters; and the medical
officer of health and other expert officers, like the legal adviser,
in nearly every instance, hold office during good behaviour. Under
the above arrangements the elected members and the officials are
kept in touch with each other. The latter’s recommendations and
actual work must be approved by the former; and this works well under
the system of determination of policy by committees, subject to
confirmation and control by the entire Council. The motive power is
public opinion. Good work cannot for any prolonged period go beyond
what the public demand, and the work of officials is one of constant
education of their masters and of the public.
_The Training and Tenure of Office of Health Officers_
Every sanitary district is required to appoint a medical officer of
health and since 1888 every medical officer of health for a district
with a population exceeding 50,000 must have a special diploma in
public health. The enforcement of this requirement has done much
to raise the standard of work of these officers. It is significant,
furthermore, that while in 1873 the percentage of the total
population of England and Wales having whole-time medical officers
of health was only 20.6, it had increased to 61.4 per cent. in 1911.
In the metropolis, in the whole of Scotland, in every English county
(forty-four) and in many other districts these officers possess
security of tenure, in the sense that they cannot be removed from
office without the consent of the Central Government, which usually
pays half their salaries. Even without this safeguard, removal from
office by the local authority is rare; but there has been long delay
in securing the further reform that in all areas the medical officer
of health should be able to perform his difficult and sometimes
obnoxious duties without fear of removal from office, or of reduction
in his emolument, except as the result of deliberate action on appeal
to a central authority.
When pensions can be earned by medical officers of health and by all
medical men on the public health staff, their position will become
more attractive for men of good standing; and this reform has become
more important in view of the steadily increasing complexity of the
medical work now undertaken in a large public health department. It
will include _inter alia_ the following officers and activities:
superintendent medical officers of health; district medical officers
of health; tuberculosis officers; medical officers of maternity and
child welfare centres, of venereal disease centres; fever hospitals,
and tuberculosis sanatoriums and hospitals.
The development of a graduated public health medical service in which
each physician employed will be able to develop his own special
abilities, will be easier when to the above list is added the work
of district (late Poor-Law) medical officers; medical practitioners
attending insured persons and such other persons as are treated at
the expense of the State; treatment centres for special conditions of
the ear, eye, throat; gynecological and other special departments;
hospital treatment for general diseases.
That there will be development in these directions when the tangle
caused by the National Insurance Act of 1911 has been unravelled,
there can be no doubt.
I have in Lecture IV expressed my opinion as to the additional tangle
introduced into the central and local government of the United
Kingdom by the National Insurance Act of 1911.
The failure of the British Government to act on the recommendations
of the Poor-Law Commission of 1909 was a serious misfortune to public
health. Sickness is the cause of a predominant part of our total
destitution, and to allow the continued separation of administrative
action respecting these two problems is inconsistent with a full
measure of success. Political circumstances, however, led to the
adoption of a course which, medically, ran directly athwart the
course of needed reform.
_The National Insurance Act and Public Health_
The National Insurance Act was passed, placing one-third of the
total population (all employed manual workers and other employed
workers with an income below £160, since increased to £250) under an
obligation to pay 4d weekly (women 3d), 3d being contributed for each
person by the employer and 2d by the State. In return each worker
receives a money payment weekly during disability from illness,
attendance by a doctor, sanatorium treatment for tuberculosis, and a
maternity benefit on the birth of a child to his wife (30 shillings),
or, if the wife also is industrially employed, an additional 30
shillings. The medical benefit is limited to such domiciliary
attendance as a medical practitioner of average ability can furnish.
It continues the old popular conception of private medical practice,
and allows the public to remain obsessed with the notion that
satisfactory medical care consists in a “visit and a bottle.” No
provision is made for pathological aids to diagnosis, beyond what
is already provided by public health authorities. No nurses are
available for serious cases; the insured person is not entitled to
surgical operations, when needed, except of the simplest character.
With few exceptions, no appliances are provided; the treatment
of special diseases of the eye, ear, nose and teeth is commonly
excluded. No hospital provision whatever, except for tuberculosis, is
made.
The contract system of medical practice has been accompanied by a
serious amount of lax certification of sickness. The sanatorium
benefit is unnecessary, as soon as the duty of public authorities
to provide treatment for tuberculosis is declared obligatory. It is
already very largely provided. The maternity benefit is entirely
unconditional; there is no guarantee that it is devoted to the
welfare of the mother and infant. It needs to be supplemented or
replaced by the arrangements for providing nurses, doctors, midwives,
and domestic assistance which are in process of development by
public health authorities. In short, there is no justification for
providing medical services, preponderantly at the expense of the
state (contributions by employers are a form of taxation), which are
limited to a favored portion of the total population, and which do
not benefit all in need of these services.
_Provision for Sickness_
The principle of monetary insurance against sickness and disability
is thoroughly sound. It forms a praiseworthy and valuable provision
against future contingencies. Insurance, however, is not synonymous
with prevention as is too often suggested. In England insurance
has been an actual impediment to public health work, though it
might have gradually become a useful auxiliary to it if otherwise
organized, and especially if the creation of independent insurance
committees representing interests to a preponderant extent had been
avoided. But any medical service needed for purposes of insurance
should not form part of the insurance system. Medical aid is needed
for a large section of the population who are unable to afford
deductions from their wages, or who have no wages. It is needed for
wives and children as much as for the industrially employed head of
the household; and it is needed for many others who are excluded
from the scope of the National Insurance Act. Only when the medical
is separated from the insurance service, and when the medical
practitioner, as far as practicable, is made independent of the
patient who desires too facile a sick-certificate, will good medical
work and sound sickness insurance be secured.
_General Summary_
The preceding review of the history of public health in England
is necessarily fragmentary. It does not include, for instance, a
discussion of the relationship of the medical profession to public
health authorities. On this I content myself with repeating my oft
stated opinion that until every medical practitioner is trained
to investigate each case of illness from a preventive as well as
from what is often rather a pharmaceutical than a really curative
standpoint, until a communal system of consultant and hospital
services independent of any insurance system is made available for
all needing it, and until every medical practitioner is related by
financial and official ties to this communal system, full control
over disease,—to the extent of our present available medical
knowledge,—will not be secured.
The communal system will include not only the provision of
domiciliary nurses for all needing them, but also a greatly increased
staff of public health nurses engaged in educational supervision
in connection with the work of the communal services and of each
individual practitioner. Such a system will repay the community
manifold in improved health and in a higher standard of happiness and
well being.
If objection is taken to such wide sweeping proposals, let me remind
you that free communal services of sanitation and education are
already provided; and that the care of personal health is of equal
importance with these. All will agree that a large proportion of the
population cannot afford to pay individually for medical attendance
and nursing under present conditions, still less for the consultant
and hospital services which advances in medical service have rendered
indispensable. There is always present in our midst a large mass of
illness which might have been avoided or curtailed, had there been
an organized system of state medicine.
Lest there should be alarm as to the possible consequences of the
coöperative provision on such a scale of this primary need of
humanity, let me also remind you that coöperative medical aid differs
from financial aid in an essential particular. It does not create a
demand for further aid, but is always engaged in diminishing this
demand. Dependency on financial assistance is liable to continue
indefinitely; much wants more. This result of medical aid is almost
inconceivable. The Reverend Doctor Chalmers, of Glasgow, said early
in the last century: “Ostensible provision for the relief of poverty
creates more poverty. An ostensible provision for the relief of
disease does not create more disease.”
Doctor Chalmers was opposed to the giving of any domiciliary
assistance from rates or taxes, and he organized his parish so that
every needy person was adequately helped out of charitable funds. But
he advocated extended hospital and other medical assistance for the
poor; and until this is done, apart altogether from any system of
insurance, and as a complete measure on the lines of our educational
system, we cannot say that all that is practicable has been done to
secure the physical well being of our fellow citizens.
FOOTNOTES:
[5] An Address at the Forty-seventh Annual Meeting of the American
Public Health Association, New Orleans, October 27, 1919.
[6] The importance of this is seen in the fact that there are in
England and Wales 14,614 parishes, and only 646 unions for the relief
of the poor.
[7] Rumsey: Essays in State Medicine, 1856, pp. 190, 277, 282.
[8] Goodnow: Municipal Problems, p. 226.