THE INCREASING SOCIALIZATION OF MEDICINE[9]
Medicine has always been the most altruistic of learned professions;
and can proudly claim that its practitioners have ever been ready
to give gratuitous assistance to all in need of it. Even more than
when Burton wrote his Anatomy of Melancholy—for then medicine was an
art with but limited foundation in science—physicians can be defined
as “God’s intermediate ministers”; and can rightly assume the proud
position which Burton gives them:
Next, therefore, to God, in all our extremities (_for of the Most
High cometh healing_, Eccles. XXXVIII, 2) we must seek to, and rely
upon, the Physician, who is the _Manus Dei_ (the Hand of God), said
Hierophilus, and to whom He hath given knowledge, that he might be
glorified in his wondrous works.
Each medical practitioner in his own circle, and to the extent of
his medical competence, is a medical officer of health, having more
influence in directing and controlling the habits, occupation, the
housing, the social customs, the dietary and general mode of life
of the families to which he has access, than any other person. It
must be added that in most instances he has even more influence
than the minister of religion in regulating the ethical conduct of
his patients, especially as regards alcoholism and sexual vices. In
the United States the federal government has relieved the medical
profession from their duty of restricting individual alcoholic
consumption, and an experiment has been begun which if continued—and
I trust nothing will prevent this—must forthwith reduce the income of
practising physicians throughout the American continent, and at the
same time do more to diminish crime, accidents and sickness and to
increase national efficiency than any other single step that could
be taken, with one exception. This would consist in the universal
raising of the standard of sexual conduct of men to that which they
expect from their future wives, thus securing a rapid reduction and
early disappearance of gonorrhoea and syphilis, diseases which rank
with pneumonia, tuberculosis and cancer as chief among the captains
of death and disablement in our midst.
The growing possibilities of improvement in personal and social
welfare depend very largely on the extent to which, as I have put it
elsewhere, “each practitioner becomes a medical officer of health in
the range of his own practice.” Even on their present record, if—at
least on one side—the Kingdom of God consists in “the union of all
who love in the service of all who suffer,” medical men can proudly
and yet humbly take their place as essential agents in the daily
fulfilment of the daily prayer, “Thy Kingdom come.”
It is perhaps desirable to attempt at this stage a definition of
the sense in which I employ the term socialization of medicine. In
it I would include the rendering available for every member of the
community, irrespective of any necessary relation to the ordinary
conditions of individual payment, of all the potentialities of
preventive and curative medicine. Within the scope of medicine
are included the basic sciences of physiology and pathology; and
the instruction and training of every child and young person in
elementary hygiene, including dietetics, necessarily come also within
the range of our subject.
There are still agnostics, usually of exclusively classical and
mathematical education, even among men holding official sanitary
administrative positions, who doubt the value of the application of
medical knowledge to the extent indicated; and it becomes desirable,
therefore, briefly to refer to some results already obtained by the
application of preventive and curative medicine.
_The Past Achievements of Medicine_
The increasing span of life is scarcely realized as it should be.
Addison’s description of the bridge of human life, in his Vision
of Mirza, is familiar. Its seventy to a hundred arches support a
bridge which is interrupted by broken arches and hidden pitfalls,
set very thick at the entrance of the bridge, thinner towards its
middle, but multiplied and laid close together towards its further
end. Preventive medicine is gradually repairing the broken arches of
earlier life; with the prospect of rapid reduction of tuberculosis,
of syphilis and gonorrhoea, the removal of pitfalls and the repair
of both earlier and middle arches are ensured, if the knowledge we
already possess is applied; and although pneumonia and cancer still
erode and render unsafe the arches of middle and later adult life, we
have already advanced far towards the ideal of euthanasia in old age.
I may be excused from quoting English figures, as our vital
statistics are more accurate and complete than those hitherto
available for the United States. Parenthetically, may I say that it
is a continual source of astonishment to me that in some American
states death statistics, and in many more states birth statistics
should still be so dubious in their quality as to cause hesitation
in utilizing them. And this in a country which in other respects
combines the highest business qualities with an underlying idealism
which emerges in important crises!
Between 1871-80 and 1910-12 in England the average expectation of
life at birth for males increased from 41.4 to 51.5, for females from
44.6 to 55.4,—an increase within three or four decades of 10 or 11
years in average duration of life. The annual saving of life shown by
these figures means that the persons whose lives _each year_ are thus
saved in England from premature death, have the prospect of living in
the aggregate nearly ten million additional years of life, of which
the greater part will be lived during the working period of life.
But perhaps more striking than collective statistics are the
illustrations of unnecessary premature mortality with which history
and literature in the Georgian and Victorian period supply us. Many
such instances will occur to you. William Pitt died at the age of 47,
Charles James Fox at 57. The history of the Brontë family, given the
clue that tuberculosis was at work, can be seen on the tablet which I
have often read in Haworth Church. Each sister and the brother died
in steady succession at intervals of two and three years; the only
exception being Charlotte, who had lived much away from home, and who
died at the age of 39 of unrestrained vomiting, a condition which
probably would not have been allowed to kill the expectant mother
today. Robert Burns died at the age of 37, Keats at the age of 26.
Lord Byron on his thirty-third birthday, only three years before his
death, wrote as a man already “in the sere and yellow leaf”
Along life’s road, so dim and dirty,
I’ve travelled till I’m three and thirty;
And what has this life left for me:
Nothing but my thirty-three.
Did time permit, the claims of preventive medicine might be
illustrated in the facts as to the almost complete annihilation
of typhus fever in this country and in Great Britain, under the
influence of hospital segregation of each case, of supervision
of contacts, and of increased national cleanliness; in the rapid
reduction of enteric fever brought about by pure water and milk
supplies, the avoidance of sewage-contaminated shell-fish,
the control of carriers among food handlers, and the hospital
immobilization of cases; and in the almost complete abolition of
smallpox, secured by prompt recognition, notification and isolation
of each case, the searching out and vaccination of all contacts,
and their continued surveillance. The list of medical triumphs,
especially in tropical diseases, might easily be extended. I do
not fail to remember that respiratory infections have hitherto
proved refractory to preventive measures; and that common catarrh,
pneumonia, and still more influenza—as also cerebro-spinal fever
and poliomyelitis—constitute territories on which the flag of
public health has not yet been firmly placed. Tuberculosis must not
be thought of in the same category. It is a controllable disease,
so soon as physicians, public health authorities and the patients
themselves will combine on an adequate scale to adopt measures
already within reach. These measures will be less costly than the
present position of partial inertia; health is always less costly
than disease, and, as Dr. Herman Biggs has often reminded us, can
be purchased within natural limits, to the extent which we really
desire. This is preëminently true for tuberculosis.
Medical triumphs have not been restricted to preventive medicine.
Time would fail me to speak of the introduction of general
anaesthetics by Morton and Simpson, which has rendered possible
the reaping of the full harvest of the work of Pasteur and Lister.
Conversely modern surgery has itself abolished more pain than
anaesthetics themselves.
The chief triumphs of modern curative medicine and surgery have been
rendered practicable by the more accurate study of disease and the
more skilled attention for the masses of the population obtainable in
hospitals. The steady advance in the provision of skilled nursing has
kept pace with medical advance.
_Increasing Importance of Hospitals_
From a return prepared by the Local Government Board in 1915 it
appears that the number of hospital beds in England and Wales (not
including lunatic asylums, tuberculosis institutions, or convalescent
or nursing homes) was 4.9 per 1,000 of the population. In the United
States, according to the Modern Hospital Year Book for 1919, the
number of hospital beds amounts to 6 per 1,000 of the population,
or 3.4 per 1,000, excluding beds for mental and nervous cases. It is
not certain that the two sets of figures are comparable; but in both
instances the distribution of hospital provision is very unequal,
and large tracts of each country are left unprovided with available
hospital accommodation.
Hospital services have grown in a manner which is characteristic
of the Anglo-Saxon: first largely under voluntary management, and
as examples of Christian charity; afterwards continued in the same
way, but followed by official provision of hospitals on an even
larger scale, the two systems working side by side. The extent to
which the more satisfactory institutional treatment is replacing the
domiciliary treatment of disease may be gathered from the striking
facts that in England and Wales one in every nine of the deaths from
all causes in 1881 occurred in public institutions, and in 1910, one
in every five; while in London the proportion increased from one in
five in 1881 to two in five in 1910.
The facts as to pulmonary tuberculosis are even more significant.
In the year 1911 in England and Wales 34 per cent. of male and 22
per cent. of female and in London 59 per cent. of male and 48 per
cent. of female deaths from pulmonary tuberculosis occurred in public
institutions. As each of the patients, who thus had the solace of
good nursing and treatment when they were needed most, spent on an
average several months in hospitals, at the most infectious stage of
their illness, an important annual reduction in the possibility of
massive infection of relatives and others has also been secured.
_Hospitals as a Partial Solution of Housing Difficulties_
We may fairly claim that general and special hospitals have been
important agents, not only in reducing the fatality of disease,
and in restoring to efficiency more rapidly than in the past a
large proportion of the total population; but also in reducing the
incidence of tuberculosis, of syphilis, and of other diseases.
The public indebtedness to hospitals has another aspect, too
often overlooked. The aggregation during the last hundred years
of a steadily increasing proportion of our population in crowded
towns has meant the introduction on a gigantic scale of elements
inimical to health. Smoke and obscuration of sunlight, dust and
noise, the substitution of indoor for outdoor occupations, the
difficulties of milk supply for children, and above all inferior
housing with associated increased facilities for infection, have
combined to render healthy life in towns difficult of attainment.
Nor must we omit from the adverse side of the balance sheet the
greater loneliness of family life in towns, the diminution in
neighbourliness, and the failure of public social opinion to produce
the wholesome effect on conduct which it exercises in village
life. And yet, notwithstanding these factors, urban death-rates and
especially tuberculosis death-rates have declined more than rural
death-rates, and in parts of some countries urban is even lower than
rural mortality.
Why is this? Our hospitals provide the key to the mystery.
Parturition is freer from risk in town than in remote country
districts; the means for the prevention of infection are better
organized, and accident and disease are more promptly and more
efficiently treated. The poor in towns receive as a matter of course
in hospitals better treatment gratuitously than king or president
could command thirty years ago. The relief to housing deficiency
given by hospitals comes when most needed, in the emergencies of
child-bearing and of sickness; and the net result of this and of
better sanitary supervision is that although room-accommodation for
families is much more restricted in towns than in country districts,
the town-dwellers have a large share of their urban handicap removed
by their superiority over country people in medical treatment.
_The Continuing Mass of Preventible Disease_
The medical record of the past on the side of preventive medicine
is one of increasing control over infectious diseases. In securing
this result epidemiologists, pathologists, and vital statisticians
can rightly claim first place, aided by the sanitary and industrial
inspector and the sanitary engineer; the epidemiologist being
dependent largely on the work of the pathologist and of the
statistician for guidance in his field investigations, which have
led to the discovery and removal of numerous sources and channels of
infection.
The record in curative medicine, especially on its surgical side,
is one of increasing triumph over serious disease and injury, in
which the discovery of anaesthetics and of Listerism have borne an
essential part.
None of us can, however, be satisfied with the success already
obtained, and I have elsewhere given reasons for concluding that at
least one-half of the mortality and disablement still occurring at
ages below 70 can be obviated by the application of medical knowledge
already in our possession.
The Great War has shown both in Great Britain and in America the
extent to which defects and disease exist in would-be recruits to
our armies. In the United Kingdom only two-fifths of a large section
of recruits could be placed in the first grade; and among American
recruits out of two and one-quarter million men measured and examined
physically at local boards 29.1 per cent. were rejected on physical
grounds; though in the introduction to the Official Bulletin (No.
11, March, 1919) it is pointed out that many of the disabilities
have little importance in civil life, and that these considerations
possibly “reduce to 15 per cent. the proportion of males 20 to 30
years old who carry a serious handicap against normal activity in
civil occupations.”
These figures, whatever doubt may attach to their exact arithmetical
value, signify the existence in the community of a large amount of
physical disability which must greatly reduce the sum of national
efficiency and happiness. The records of our medical examinations
of school children bring out the same fact, and emphasize the
necessity not only for school clinics on an immensely larger scale
than at present, but also for additional medical and nursing care in
connection with child-bearing and during the pre-school period, which
would discover defects and disease at an earlier stage, and would
secure the provision not only of early preventive treatment, but
also of more systematic improvement of the sanitary environment of
maternity and childhood.
_Present Extent of Socialization of Medicine_
A mental effort is needed to realize the distance traveled in the
public provision of medical assistance in the United Kingdom by
the state and by voluntary organizations, including the committees
of hospitals, convalescent homes, dispensaries, etc., prior to the
passing of the National Insurance Act of 1911. I have already given
some illustrative figures regarding hospitals. The _Lancet_ some
years ago gave a statement of the number of attendances of patients
at voluntary hospitals in London during the year 1908. Assuming that
each out-patient made five attendances, that all in-patients had
previously been out-patients and that no patient received a hospital
or dispensary letter more than once in the year, it could be inferred
that a number equivalent to one in four of the total population of
London had received free medical aid in these voluntary institutions
during that year. And this did not include the large mass of
treatment given gratuitously in poor-law infirmaries, public-health
fever and tuberculosis hospitals, and lunatic asylums.
The majority of the medical profession in Great Britain is engaged
in either whole-time or part-time service for the state or for
local authorities. Of the 24,000 medical practitioners in England
and Wales, some 5,000 are engaged as poor-law doctors, some 4,000
or 5,000 in the public-health service, possibly 500 in the lunacy
service, some 1,300 in the school medical service, and smaller
numbers in various other forms of medical service for the state. This
is exclusive of the general practitioners who undertake contract work
under the National Insurance Act, and who cannot fall far short of
three-fourths of the total membership of the profession. It should be
noted that many doctors hold several appointments.
The state has, quite apart from National Insurance, given a rapidly
increasing amount of medical assistance to the public.
1. Under the Poor Law, every destitute person is entitled to
gratuitous medical attendance, at home or in an institution, and
after a fashion has received this during the last century.
2. The institutional treatment of lunacy has grown to an extent which
permits the treatment in an asylum of every certified lunatic.
3. The treatment at the expense of the state of feeble-minded persons
is rapidly increasing.
4. Public health authorities provide institutional, and to a limited
extent domiciliary, treatment of infectious diseases, this treatment
being given, as in the preceding cases, in nearly every instance
gratuitously.
5. To some extent prior to, and to an increased extent since, the
passing of the National Insurance Act, sanatoriums and hospitals
for the treatment of tuberculosis are provided by the public health
authorities, the central government contributing to the local
authority undertaking this duty one-half of all approved expenditure
on these institutions, on tuberculosis clinics, and of the expenses
incurred in the domiciliary nursing and supervision of tuberculosis
patients.
6. Similarly the central government pays one-half of the approved
expenditure incurred by local authorities or in certain cases by
voluntary agencies in assistance given in aid of maternity and child
welfare, e.g., in the provision of midwives, of consultant doctors,
of lying-in homes and hospitals, of beds for præpartum treatment,
of convalescent homes for mothers or their children, of infant
consultations and clinics, etc.
7. In regard to venereal diseases the central government has gone
still further. It has made it obligatory on the larger local
authorities to provide facilities for pathological diagnosis, and for
the treatment of patients suffering from these diseases irrespective
of any residential or financial limitations. Arseno-benzol
preparations are given gratuitously to medical practitioners, as
also laboratory assistance in diagnosis. To ensure the success of
the local arrangements the central government pays three-fourths
of their total cost; and have passed an act which prohibits the
treatment of venereal diseases by any unqualified person, as also the
advertisement or sale of any remedies for these diseases.
8. Many public health authorities provide gratuitous assistance
to medical practitioners in the bacteriological diagnosis of
tuberculosis, enteric fever, diphtheria, etc. Recently Wasserman
tests and searches for gonococci and spirochaetes have been added.
In 1914 plans for further development, including the provision
of complete clinical laboratories for the gratuitous use of
practitioners had been planned, and the necessary grant had been
obtained from Parliament; but the war led to the plans remaining in
abeyance. At the same time government grants in aid of nursing, and
of the provision of consultants and referees for insured patients
were passed, but were similarly held in abeyance.
9. The local education authorities provide for the medical inspection
of each scholar in elementary day schools several times during the
nine years of his compulsory attendance at school. Parents are
advised as to treatment needed, in suitable cases are referred to
hospitals (payment being made by the education authorities), and for
an increasing number of conditions actual treatment is provided at
school clinics (teeth, eyes, ringworm, etc.).
The above enumeration, which does not include the recently
necessitated activities of the Pensions Department for sailors
and soldiers, and those under the National Insurance Act, is not
otherwise complete; but it serves to indicate that the state is
already committed very deeply to provide for the medical needs of the
community. That the work done on behalf of the community, _plus_ the
work accomplished by private medical practitioners, is not equal to
national needs is obvious to any one considering the vast amount of
avoidable disease in our midst. Why is this and what is the remedy? A
partial answer is given by English experience. The medical provision
made in a large proportion of cases is belated and inadequate; and
in perhaps a still larger proportion of cases medical advice is not
obtained, or being obtained, is not followed. This applies even more
to hygienic than to clinical medical advice.
_Destitution and Sickness_
It was one of the greatest misfortunes in the history of medicine
in England that poor law medicine and public health medicine were
not administratively combined when the Local Government Board was
formed in 1870, and that the preventive ideals of public health
were not allowed to operate in the treatment and supervision of the
destitute. Although there has been a fairly steady improvement in the
conditions of medical treatment under the poor law, its association
with the deterrent general policy of that department of state, as
well as its actual defects, culminated in the appointment of a royal
commission of inquiry, which in 1909 presented reports recommending
the abolition of the local boards of guardians and transference of
their duties to the larger public health authorities.
Behind these proposals of the royal commission lay the absolutely
sound principle—which many years previously had been recognized by
the pioneers of public health—that the treatment and the prevention
of disease cannot administratively be separated without injuring
the possibilities of success of both. The public health activities
preceding the report of the royal commission illustrate this axiom,
such as the isolation and treatment of infectious cases, the
treatment of tuberculosis, the provision for the care of parturient
women and of their infants, and the medical inspection and treatment
of school children.
It was an even greater misfortune to the satisfactory progress of
public medicine that the report of the royal commission on the
poor laws was not followed by legislation on the lines of its
recommendations. So much of destitution is associated with sickness,
and sickness is the cause of such a preponderant share of the
total destitution in our midst, that the continued administrative
separation of the two problems of poverty and sickness is
inconsistent with a full measure of success.
Had the transfer of the duties of the poor law authorities to the
councils of counties and county boroughs been adopted, and ancillary
legislation enacted, the public health organization would have at
once possessed a medical service for the poor of some 4,000 doctors,
in addition to the doctors already engaged in the public health
service; it would have had large infirmaries and the other medical
institutions of both services; would have been able to make liaison
working arrangements with the committees of voluntary hospitals; and
there would have been secured a greatly improved medical service,
freed from poor-law shackles, which could gradually be extended as
needs and policy indicated.
_Insurance versus Public Health_
Political circumstances led to the adoption of a course which
medically ran directly athwart the course of needed reform. The
National Insurance Act of 1911 was passed, giving sickness and
invalidity benefits to all employed manual workers and to others
below an income limit of £160 (recently increased to £250), who
could contribute a weekly sum which was considerably less than half
of the estimated cost of the benefits to be received; and a new
medical service was created, further complicating administratively
the already existing medical services of the poor law, public health,
and educational authorities, and converting the majority of general
practitioners into part-time civil servants.
The case is an illustration of the moral contagiousness under
modern conditions of life, of a new course adopted in any country.
Bismarck’s attempt to counteract socialism by insurance has been
responsible for state and official experimentation in insurance
in many countries, which at least in England was not actuarially,
financially, or medically sound, and which has involved expenditure
in administration entirely incommensurate with the benefits received.
Insurance against sickness and disability is a praiseworthy and
valuable provision against future contingencies. I am not concerned
here to point out inequalities to the insured in the English
Insurance Act inherent in the apportionment of a flat rate for all
ages, districts and occupations, and for both sexes, irrespective
of known or suspected incidence of sickness, nor the difficulties
created by continuing the nonlocalized work of friendly societies
and other private organizations, and at the same time creating local
insurance committees, who furthermore were not organically related
to local health authorities, and had no opportunity, therefore, to
develop the conceivable potentialities of insurance experience as
an aid to public health work. The act in its present form is now
generally condemned; and it is significant that the need for its
radical reorganization appears to be universally accepted.[10]
Two medical benefits (medical and sanatorium) and a maternity benefit
were conferred under the act; but, as they have been administered, it
cannot be affirmed that any marked public benefit has accrued; and it
is certain that if the same amount of money had been placed in the
hands of public health authorities to provide adequate medical aid to
those needing it, of the kind most lacking and which they could least
afford to obtain, great benefit to the public health would have been
secured.
What was given? (1) There was the medical benefit, each insured
person being entitled to the services of a medical practitioner of
his own choice (a “panel” doctor). The services given were limited by
regulation to mean such medical attendance as is “within the ordinary
professional competence and skill” of a medical practitioner; and so
the treatment given has often been more limited than what is given
by the more advanced poor law authorities. The latter can supply
hospital treatment and expert assistance when required; under the
insurance system no such provision is made. The insured patient
is not entitled to surgical operations when needed, except of the
simplest character; treatment of eye, ear, nose and teeth conditions
is commonly excluded; no appliances are given except a few bandages
and simple splints; and there are no facilities for modern scientific
laboratory investigation, except those provided gratuitously by
public health authorities. Furthermore, by the rules of most friendly
societies sickness (monetary) benefit during treatment of illness due
to the patient’s misconduct is excluded.
The title of the act—National (Health) Insurance Act—has hitherto
proved a misnomer. The panel or contract system of medical treatment
of insured persons has done much to continue the obsession of the
public with the conception of medical care as consisting of a “visit
and a bottle”; and so long as the doctor’s medical work is on the
present basis, and he is under the constant temptation, not only to
accept more patients on his panel than he can satisfactorily treat
and to give each patient on application the mental satisfaction of a
“bottle,” but also to be more than lenient in the giving of sickness
certificates, it will remain questionable whether on the balance
state insurance against sickness does more good than harm. If medical
consultants and referees, treatment centres, and hospitals are in the
future provided for insured patients, this will mitigate the evils
of the panel system; but the present contributions of patients will
not purchase this additional provision. All the new money needed,
and most of the money needed under present conditions, must continue
to be provided by the state and employers of the insured (a form of
taxation); and provisions thus made, like the present contributions
of the state for insured persons, are in direct contravention of the
general principle that government grants being derived from the whole
community, should enure to the benefit of the whole community in need
of them, and not only to the benefit of a section of it.
About one-third of the total population of Great Britain is
included within the terms of the National Insurance Act. If the
wives and children of insured men were also included, as has been
proposed, over two-thirds of the total population would be embraced
in the scheme; but as persons manually employed, but working for
themselves—e.g., cotters and hawkers, are encluded, and as persons
not manually employed cannot be insured unless their income is below
£160 (recently raised to £250), large classes of the population who
can ill-afford to pay for their own medical attendance are excluded
from the operation of the act, and taxed to pay the benefits of
insured persons.
(2) The sanatorium benefit was intended to secure for the insured
person special treatment for tuberculosis, while capital sums were
provided for the erection of sanatoria and hospitals for consumptives
for insured and non-insured alike. Fortunately during the passage of
the bill, the provision of these institutions for insured persons was
delegated to public health authorities; and as it was already within
the power of these authorities to provide such institutions and
tuberculosis clinics for the entire population, and as the infection
of tuberculosis is no respecter of parliamentary distinctions
between insured and non-insured, there was little difficulty in
persuading the government to promise half the total approved local
expenditure on the treatment of tuberculosis in institutions,
whether this was given to insured or non-insured persons. Indeed
when local authorities were willing to undertake their share in
a complete scheme for the treatment of tuberculosis an insured
consumptive person might be regarded even as paying fractionally for
his treatment while a non-insured person received such treatment
gratuitously.
(3) The maternity benefit, conferring thirty shillings on the wife
of an insured person, and an additional thirty shillings if she also
is an employed person within the meaning of the act, on the birth of
her infant, was perhaps the most popular benefit under the act. The
money was given unconditionally, and thus an opportunity was lost
of insuring that the benefit should improve maternal and infantile
prospects.
Collaterally public health authorities, central and local, were
beginning to organize medical and nursing assistance during
pregnancy, in confinement and afterwards for the mother, and similar
assistance on a large scale for infants and children under five
years of age. And there will, I think, be no hesitation in agreeing
that the _supply of service_ at this critical period of the mother’s
and infant’s life, so as to insure the most satisfactory recovery
of parent and the best start in infantile life, is infinitely more
important than a money grant.
I cannot pretend to have more than touched on the fringe of the
complicated subject of insurance in relation to public health. The
inauguration of the act meant an enormous increase in the direct
relationship of the medical profession to the state. A great
stride in the socialization of medicine was taken. But it was done
ill-advisedly; it continued a false and low ideal of isolated
general medical practice; it has even been described as a fraud on
the insured, in view of the incompleteness of the medical service
provided; and it diverted into an unsatisfactory channel the energy
and money which were urgently needed for the immense good obtainable
by reform of poor law and public health administration, and extension
of their medical services. Had the lines indicated by history and
experience and by the report of a strong royal commission on the poor
law—there was a majority and a minority report, but both agreed in
the chief essential points—been followed, England would now possess a
nearly completely unified state medical service, instead of standing
at the point whence false steps need to be retraced, with a view to a
coördinated and simplified medical and public health policy. With the
principle of contributory insurance to secure monetary support during
illness there can be no quarrel; but in the interest of national
efficiency complete medical provision, preventive and curative,
must be made by the state, irrespective of insurance, for all in
need of it; and the medical practitioners employed in the necessary
certification of such insurance work as is continued must, if the
insurance is to be satisfactory, be employed under conditions which
will render them independent of the favor of the insured, and will
enable them to utilize their knowledge of each patient’s case for
the needed preventive measures, whether these be concerned with the
sanitation of home or factory or workplace, or with personal habits.
_The Need of the Future_
It is, I think, clear that the state will year by year take an
increasing hand in medical matters. It is useless, even if it were
desired, to attempt to oppose the inevitable and the eminently
desirable trend towards vastly increased utilization by the state of
medical science in the interests of humanity. It is for physicians
to guide the course of events, and to insure that no plant is sown
which will afterwards need to be uprooted; that no development is
permitted which will hinder the fulfillment of our ideal. Personal
hygiene forms a rapidly increasing part of public health work; hence
it is indispensable that all forms of public medical service shall
be linked up with the public health service and controlled locally
and centrally in accordance with this. This may imply—and in England
it does imply—the urgent need for reform and reconstruction of local
as well of central public health administration; but to attempt
to separate medical from public health provision is to repeat the
blunders which, despite skilled advice to the contrary, have been
made on two great historic occasions.
A complete service, adequate to the needs of the community, cannot
be secured by a session’s legislation. It must grow as the result
of steady advance. The motto in growth might well be, “First things
first.” What are the medical services which are provided too sparsely
at the present time and for which the masses of the population
cannot afford individually to pay, except possibly to a fractional
extent? There can be no doubt as to the answer. What is most urgently
needed is the provision of skilled hospital attendance for every
patient who can be more satisfactorily treated in hospital than
at home. Next to this comes the provision of gratuitous medical
services—(e.g., maternity and infant consultations, eye, throat,
ear, skin and venereal diseases, tuberculosis, X-ray departments)
preferably linked around a hospital, where patients can be sent by
private practitioners for an expert opinion, or in certain cases may
present themselves independently. And as important as either of the
preceding desiderata, is the provision of a complete nursing service,
on which each private practitioner can call for assistance as
required, payment, if any is exacted, being on the easiest possible
conditions, and not made compulsory.
The hospital under such circumstances would become a centre from
which community work of the highest value would radiate; and
patients, private practitioners, and the staffs of hospitals would
alike live in a new world in which the interest and efficiency of
medical work would be greatly increased. The present irregular
localization of hospitals makes the realization of such a scheme
difficult; but local partially successful schemes are already
in operation; difficulties can be overcome with good-will; and
eventually we may hope to have for each unit of subdivided public
health administration and as an organic part of this, a hospital,
with out-patient or dispensary clinics, and radiating from these the
various forms of medical attendance, domiciliary nursing, public
health nursing, and sanitary supervision which are needed.
In securing such a result there will be needed medical practitioners
who are imbued with the ideals of preventive medicine in its widest
sense. Let me, in this connection quote the following extract from a
recent official report of my own:
There is needed a reconstruction of the training of each medical
student, which will make preventive medicine in its widest sense
an integral part of his training, and will insure that before he
begins practice he has definite instruction in the application
of the whole of his knowledge to preventive purposes. The past
conception by the public of the relation of medical men to the
community—apart from the special case of medical officers of
health—has been mistaken. The doctor has been regarded as a help
when serious or acute incapacitating illness occurs, and he has but
seldom had the opportunity of giving advice in the earlier and more
controllable stages of illness. His training has been conducted on
the assumption that his chief rôle should be on present lines, with
the result that most medical practitioners enter into practice with
a too scanty knowledge of hygiene and preventive medicine, and have
to learn slowly in belated experience the influence of environment
on the health of their patients. The teaching of medicine should
be much more largely physiological and hygienic than at present,
and such subjects as food values, the hygiene of infancy and
childbirth, the physiology of breast feeding, and the influence
of environment on the health of their future patients should be
the subject of careful training—especially in regard to housing,
feeding, clothing, and conditions of work. Were this done, the ideal
condition, in which each medical practitioner becomes a medical
officer of health in the range of his own practice, would approach
realization.—[Annual Report to the Local Government Board, 1917-18.]
Many medical practitioners already fulfill this ideal. It would
oftener be realized were it not for the excessive work which many
are obliged to undertake. In the early history of public health in
England poor law medical officers, attending the impoverished in
their dwellings and familiar with their home conditions, became
part-time medical officers of health. But the attempt to combine
prevention and treatment proved unsuccessful, because these officers
visited only a small proportion of the dwellings of the poor, because
they were not trained in preventive work, and because the good seed
of preventive work was choked by the increasing demands of lucrative
private practice. In connection with the future general medical
service, curative as well as preventive, it is not beyond the range
of human ingenuity to provide schemes for district medical officers
(health and clinical) adequately trained in public health work, and
linked up closely with the hospital and dispensary unit for their
area.
This will cost money. But sound health is our greatest personal and
national asset, and disease is always more expensive than health.
“Who winds up days with toil, and nights with sleep” has “the
forehand and vantage of the king,” if the latter suffers in body or
mind. The real wealth of a nation does not consist in its money, in
the volume of its trade, or in the extent of its dominion. These are
only valuable insofar as they help to maintain a population—and not
only a portion of it—of the right quality; men, women and children
possessing bodily vigor, alert mind, firm character, courage and
self-control. This ideal can never be realized unless and until the
medical men of the future train themselves for and devote themselves
to their essential share in its fulfillment, and while keeping this
ideal in view see to it that every step taken is one which will be
consistent with the complete scheme of the future.
We are all concerned in the efficiency of every member of the
community, from an economic as well as from a humanitarian
standpoint. Can we be satisfied while a large proportion of the
population do not obtain medical and ancillary assistance to the
extent of their needs? Does such a state of things conduce to
the settlement of social unrest? Is it consistent with Christian
principles?
If communal provision has been recognized as a duty for police
protection, for sanitation, for elementary education, should it not
likewise be admitted for the more subtle and maleficent enemies of
health which have been recognized, but which in no community have
hitherto been completely combatted?
We scarcely realize how far we have gone in the socialization of
medicine. It is impossible to go back, or to stand still. The
services of the medical profession are needed, not only to provide
the necessary service, but in helping to determine its conditions.
One essential item will be the substitution for fees during sickness
of an annual payment to private practitioners by each family for
supervising its members in health, for inquiry into their industrial
and domestic life, so far as it contains elements inimical to health,
and for giving preventive more than curative advice. The second and
most urgent element consists in the organization of hospital and
consultative expert services for all, which, while greatly increasing
each patient’s prospect of prompt recovery, will enable the general
practitioner to escape from the soul-destroying inefficiency of
unaided medical practice.
Of course, any service provided, whether partial or complete, will
need to be kept free from “political pull.” This spells inefficiency;
and inefficiency means disease and death. “Political pull,” although
not in the official list of Causes of Death, is among the potent
causes of excessive mortality; and for this, every one of us must
bear his individual share of responsibility, insofar as we have
abstained from active support of sound and clean government, when we
were unable to take an actual share in government.
FOOTNOTES:
[9] The Wesley M. Carpenter lecture delivered October 2, 1919, before
the New York Academy of Medicine.
[10] Thus Mr. Bishop Harman, an ophthalmic surgeon, and a member of
the Council of the British Medical Association, says:
“In my out-patient clinic 60% of the patients are insured persons
who attend for treatment that is essential to their industrial
efficiency.... A scheme of medical benefit which does not provide for
specialist service and for institutional treatment is no scheme, it
is poorer in status than the Poor Law provision which does all these
things.” (_British Medical Journal_, Mar. 15, 19).
Dr. R. Sanderson, of Brighton, writing on behalf of medical
practitioners, says:
“We are the victims of a half-fledged, inadequate piece of
legislation which is founded apparently on the supposition that
disease can be dealt with effectually by giving bottles of medicine
or liniment to the sick, or that if this fails and the sick get
worse, they can be sent to one of the overcrowded voluntary hospitals
with which the legislature has nothing whatever to do. Anything more
unsatisfactory to the sick, or demoralizing to us as a profession, it
is hard to imagine.”
He then proceeds to advocate an urgent need of the profession, viz:
the establishment of an adequate number of auxiliary hospitals
throughout the country, staffed by teams of general practitioners, to
which all practitioners can have access, and to which they can send
cases requiring clinical observation of any kind, rest or treatment
that cannot be carried out in the sick person’s home. (_British
Medical Journal_, July 19, 19.)
Dr. Howarth, Medical Officer of Health of the City of London,
and Dr. B. A. Richmond, Secretary of the London Panel Committee,
affirm “the limitation of medical benefit to insured persons
alone cannot continue. Another service has been added to the many
competing classes of state treatment”; and they bring out the fact
that personal contributions of insured persons are swallowed up
in supplying the sickness and disablement benefit, and contribute
nothing to the cost of the sanatorium benefit, maternity benefit, or
medical benefit.
Dr. H. S. Beadles, Secretary of the Stratford & West Ham Panel
Committee, says: “The British Medical Association should fearlessly
acknowledge that the attendance under the National Insurance Act,
which is itself a part-time State service, is an absolute failure
and amounts to little more than first aid, carried on at an enormous
cost.”