SOME PROBLEMS OF PREVENTIVE MEDICINE OF THE IMMEDIATE FUTURE[13]
The Great War has changed our outlook on social, including medical,
problems; and has made all of us consider anxiously in the midst of
the terrible wreckage from war, what useful lessons may be garnered
for our future guidance. In speaking of losses, I am not referring
to financial burdens, though these are fabulously high—the bare
statement that the British national debt has increased from 645 to
near 8,000 millions sterling, brings this home—and we shall, most of
us, go relatively poor for the rest of our lives and our children
likewise. Nothing but the most effective and scientific use of our
energies on the part of workers of every class can save us from
protracted poverty.
I am thinking rather, however, of the losses of life and limb, of
hearing and eyesight, and of reason, which have been experienced—one
or other—in nearly every other family in the British Empire, and
which show once more the wantonness of war: how cheaply life is held
by it, how careless it is of the individual; and how disregardful it
is of human promise and performance.
The destruction of over 700,000 lives of sharers in our common
Empire, killed in battle or dead from wounds, represents an imperial
loss, a terrible destruction of the real capital of the Empire—its
manhood—and of the flower of that manhood; and generations will come
and go before the Empire recovers completely.
_Gains from War_
But we can set out some great gains from war.
1. Not the least of these is the fact that the fears entertained
by the more pessimistic that we had become enervated and decadent
have been falsified on many a stricken field; and not less in
the strenuous work of those who have worked remote from the
battlefield. Our men and many women also have shown themselves
willing to give their lives for great impersonal ends. Their lives
have been sacrificed—for our children, for liberty, for peace, for
security against military barbarism, and for high ideals of life.
The emergence of such a high proportion of our total population
from selfishness and self-centred life to a sacrificial position,
raises hope that rightly directed appeal to the collective self
of the community during peace time for aid against the horrors of
peace—especially those caused by disease—will also succeed in
enlisting the assistance of the majority of the population and thus
removing the vast mass of removable disease and disablement which now
prevails.
2. The war has knitted together in active comradeship the Old Country
and its younger and more energetic children in the Dominion of
Canada and in other parts of the British Empire, in bonds of mutual
indebtedness and gratitude and in admiration of great deeds, in a
manner and to an extent which must forever preclude misunderstanding
or separation.
In these two respects especially—and in others which I shall dwell on
more fully—we can, as Wordsworth put it, when commenting on the wars
of the French Revolutionary period:
Though doomed to go in company with Pain,
And Fear and Bloodshed, miserable train!
Turn our necessity to glorious gain.
_The Work of Women_
3. The war has revealed to us the great extent to which women in
emergencies can replace men. I need not repeat the story of how women
in a few months mastered mechanical intricacies in munition works,
for which previously a long training was thought necessary; nor how
educated women after a few months’ intensive training were able,
under war conditions, to undertake the work of fully trained nurses.
We cannot ignore these facts; and in regard to nursing, they should
lead us to consider whether, under modern conditions of life, it is
necessary that the great body of nurses, like the great majority of
medical practitioners, need to be experts in major operations, and
whether they should not be trained chiefly from the standpoint of the
ordinary illnesses of the household. Particularly, it is important to
recognize that the training of the health visitor or public health
nurse must diverge at an early period of training from that of the
clinical nurse.
In another direction women are about to influence vitally the
problems of public health in the near future. The municipal and
parliamentary vote has been given to women in England, and is not
likely long to be withheld here. How will they use it? When they
use it will “politics” be a name for a contemptible thing as it
has become in some towns and states, or will women insist on clean
administration and efficient work to secure the health and welfare of
the community?
_Prohibition of Alcoholic Drinks_
4. The prohibition law against alcoholic drinks in the U. S. A. is
largely the work of American women. Whatever view be taken of this
law—and I regard it as one of the most significant social events
of the age—let there be no doubt as to the essential facts of the
problem.
Alcoholism is a potent enemy of the race. It is a great creator of
avoidable poverty. It makes the bed ready for tuberculosis. It is a
frequent excitant of exposure to the infection of venereal diseases;
it swells the ranks of fatherless children, and of neglected
infants; it helps to fill our prisons and our hospitals. Let it be
admitted, if you like, that light wines and beers are pleasant, and
in strict moderation with meals are beverages to which little or no
harm can be traced; but heavier drinks and all non-medicinal spirit
drinking are to be condemned; and the country which distinguishes
itself by abolishing these drinks will, other things being equal,
in my opinion, inevitably attain quickly an industrial and economic
superiority over all countries which continue to follow the older
ways.
5. A great gain during the war is constituted by the fact that
science has come into its own. The war has been described as a war
of engineers. Its chief successes have been won largely by applied
science; and it is gratifying to record that the Anglo-Saxon
intellectuals, when their services have been engaged, have proved
themselves more than equal to the German scientist, whether in
physics or chemistry or medicine.
The facts as to the wonderful extent to which disease has been
prevented during this war need not be detailed. Intestinal
diseases have been kept strictly under control. In no previous
war has smallpox or typhoid fever claimed so small a toll on the
belligerents.
Malaria, it is true, has claimed many victims, owing to our soldiers
having to operate in countries in which the needed precautions could
not be completely carried out. Typhus has scarcely claimed a victim
among the British forces, and although trench fever was common,
medical discovery, by showing its relationship to the bite of the
louse, has placed within reach an immediately practicable means for
avoiding this serious cause of military disablement.
Three sets of diseases have not been successfully combatted during
the war—the group of respiratory affections, tuberculosis, and
venereal diseases, and on each of these it is desirable to make a few
remarks.
_Respiratory Diseases_
6. In the group of respiratory diseases I think we should include
a number of diseases not commonly regarded as such, but in which,
so far as can be judged, infection is received by inhalation; and
I would, therefore, group together such miscellaneous diseases as
poliomyelitis, cerebro-spinal fever, measles, bronchitis, pneumonia,
and influenza. All agree in one particular, that attempted preventive
measures against their spread are dubious in effect. These diseases
naturally divide themselves into two groups: the first comprising
measles and influenza, both of which spread—when, as in influenza,
the almost unknown conditions determining spread are present—to an
extent only limited by the failure of susceptible persons; and the
second comprising the other diseases already enumerated, of the
conditions determining attack from which we are profoundly ignorant.
We do know, however, concerning cerebro-spinal fever and measles,
that they spread more easily and become more severe under conditions
of massive overcrowding; and their unusual severity in war is thus
partially explained. Beyond this obvious indication for prevention we
can do but little.
It may, however, be mentioned, that in England during the last
few years, we have determined that our lack of ability to prevent
outbreaks of measles shall not prevent us from attempts to _diminish
their fatality_, and the notification of this disease has therefore
been enforced, as a necessary preliminary to prompt and fairly
complete action, and local authorities have been urged to provide
nurses to assist in the domiciliary nursing of cases of measles.
Grants of half the expenditure expended in nursing this and some
other children’s diseases are paid by the Central Government. If the
spread of infection cannot be stayed, it is our duty to diminish
the loss of life by providing nursing assistance whenever required.
This provision of nursing assistance in a number of children’s and
maternal illnesses, half the expenditure being paid from Central and
half from local funds, will, I trust, soon be followed by a general
provision of nursing assistance from public funds.
The recent epidemic of influenza has taught us several important
lessons—First, we have been painfully reminded that we are completely
ignorant of the causes of the pandemic waves of this terrible
disease, which, at irregular intervals of years, traverse the
world. We may surmise that the crowding and the mental and physical
depression of war caused increased rapidity of spread and a greater
fatality in the present outbreak; but influenza has spread and been
only less fatal than in the present outbreak when there was no war,
and we must admit our ignorance of the cause of this.
Numerous investigators in many lands have been striving to illumine
our ignorance; but until success crowns their efforts, it is well to
admit that on the large scale all attempts to prevent the spread of
influenza have failed.
But, in this disease, as in measles, this failure in prevention is no
reason for refraining from every possible effort to restrain death.
In every country and in nearly every invaded district, many sick were
unable to obtain adequate nursing and other domestic care. Here and
there organized mobile team work partially overcame the difficulty;
but the one lesson which emerges from this great pandemic is the
necessity for having in every area a large nursing reserve. Here is
one of many spheres of utility, which should, I think, be occupied by
Red Cross workers, who have done such admirable work during the Great
War.
Many of these Red Cross workers were not fully trained before the
war, but intelligent workers under stress of circumstances showed
themselves competent in many instances to undertake highly skilled
work; while a much larger number under the supervision of more fully
trained nurses and doctors were able to carry out satisfactorily the
routine but still extremely important work, of ordinary nursing.
During the influenza outbreak many such “Nursing Aids” did admirable
work, and the epidemic has demonstrated once for all the absolute
necessity of having available a large number of such nursing aids.
Cannot these be employed on a large scale when no epidemic is raging?
Is it necessary for every case of sickness that a fully-trained nurse
should be engaged? Would not the physician be equally satisfied in a
large proportion of his cases, if he had available a less elaborately
trained assistant, who understood personal hygiene thoroughly, who
could give an enema, could take temperatures, and would follow
instructions implicitly and intelligently?
Incidentally I consider that some such modified and simplified
training in actual nursing would form an adequate background for
the special training required to obtain a competent school nurse,
tuberculosis nurse, or public health nurse (health visitor); and that
under present conditions a three years’ training as a nurse is not
the best foundation on which to build the special training required
for these public health nurses.
_Tuberculosis_
7. A serious penalty of war conditions has been the increase of
tuberculosis. It is not surprising that the crowding in barracks,
the overwork and overstrain, the dirtier habits, and risks from
expectoration in massed communities, should have increased
tuberculosis among soldiers; both by activating latent tuberculosis
and by introducing new infection. Nor is it surprising that under
analogous conditions tuberculosis has increased among women,
especially at the ages in which the enormous increase in their
industrial employment has taken place.
The national anti-tuberculosis arrangements which were made in
connection with the National Insurance Act had scarcely been fully
organized when the war began. At an early stage it had become plain
that in essentials non-insured must be provided for as well as
insured, and Government grants of half the approved expenditure on
the treatment of tuberculosis in the general population endorsed this
principle. There was no reason, therefore, for the continued separate
existence of the “Sanatorium Benefit”; and had it not been for
political considerations the treatment of tuberculosis would probably
already have been handed over to public health authorities, while
leaving intact the general provisions of the National Insurance Act
as to monetary payments and benefits. The same transference should
apply also to the treatment of any disease undertaken at the public
expense. The treatment of disease, especially in its more difficult
specialist and institutional branches, should become a matter of
communal provision, to which every person would be entitled as he is
to the common provision under our system of elementary education, or
to the common use of free libraries and of drinking water.
There is needed a widely extended propaganda against tuberculosis.
The public as well as the medical profession need to be educated,
the latter in the carrying out of complete and prompt notification
of cases of the disease, and in the use of all facilities provided
for aiding diagnosis; the former in the risks of industrial
and other dust infections, of indiscriminate expectoration, of
alcoholism, of imperfect nutrition, of bad housing, and so on.
We all need to learn the folly of imperfect measures against
tuberculosis. Complete success can only be attained if we assume
responsibility for the whole course of the life of the consumptive.
Not only must educational sanatoria be provided—and, still more
important—hospital treatment for all the emergencies of the disease
and in advanced disease; but in the quiescent intervals assistance
must be forthcoming to cover the margin between a living wage and the
earning capacity of the ex-patient, and economic assistance must be
provided for protecting the patient, and still more his family, from
defective nutrition and from infection. To stop short of this is to
be extravagantly parsimonious; to do this is to economize in sickness
and to secure increased efficiency in future generations. What better
work can be thought of for Red Cross volunteers than in supplementing
the work already carried out by anti-tuberculosis organizations and
in extending and systematizing these agencies. Is not such peace work
equal in importance with the war work which Red Cross workers have
already accomplished?
_Venereal Diseases_
8. Venus and Mars are always closely associated, and it is a
lamentable fact that one heritage of the war will be a great
increase of venereal diseases in our midst. In England we had become
thoroughly aroused to the magnitude of this evil even in peace
time. The report of the Royal Commission on Venereal Diseases and
the propaganda since actively carried out, have led to the taking
of measures which I can only briefly enumerate. The duty has been
imposed on every county and county borough council of providing aids
to pathological diagnosis, and of providing clinics for the treatment
of these diseases for all comers, irrespective of residential or
monetary conditions. These clinics have been generally started
throughout the country, and their use has been widely advertised and
encouraged by propaganda in the form of lectures and addresses in
factories and to various social groups, and by public advertisement.
In addition an enactment has been secured absolutely prohibiting
the treatment of venereal diseases except by qualified medical
practitioners, and prohibiting the advertising or offering for sale
of any remedy for venereal diseases. In addition, arsenobenzol
preparations are supplied to medical practitioners who have
experience in their use for their own patients.
These measures do not cover the entire ground. The enforcement of
police regulations against vice, the detention of infectious persons
who cannot be trusted to refrain from spreading disease, the raising
of the general standard of sexual morality—until public opinion
demands that it shall be as high for men as for women—are among the
reforms which are called for.
In encouraging social reform in these directions Red Cross workers
have a most fruitful field of work, and they can render invaluable
assistance in removing a canker which at present eats into the vitals
of the community, and is responsible for untold suffering in women
and children, for premature old age and paralysis in men, and for a
large share of the total inmates of our lunatic asylums.
_The Mother and the Child_
9. I have left myself but scant time to speak of what is at once
a chief lesson of the war and the most pressing problem in the
preventive medicine of the immediate future. I refer to the need
for more complete protection of motherhood and childhood against the
dangers besetting them.
It would be a mistake to assume that only since war began have
efforts both by sanitary authorities and by voluntary agencies been
made on a large scale to diminish infantile and maternal mortality.
But during the war, and since it terminated, these efforts have been
redoubled and are becoming universal; and there is opening out a
prospect of safe maternity for mothers and of protected infancy for
all newcomers on the stage of life. If only we are prepared to do
what is almost immediately practicable for this end, death or injury
associated with child-bearing will become rare, the loss of infant
and child life will be halved, and what is still more important,
mothers and infants will cease to be damaged by neglect or ignorance
at critical periods of their life, and will not become burdens to
themselves and to the community.
This is no visionary dream. Past experience shows that it is within
reach. What other interpretations can be placed on the facts revealed
in official reports?
I am unable to quote Canadian figures; but I am justified in assuming
that differences similar to these I am about to quote from my own
reports exist also here. The average number of deaths of mothers
from complications arising during pregnancy, and at or after
confinement, are one maternal death for every 250 infants born
alive. In some parts of England instead of four mothers, six or even
eight or nine mothers die for every thousand infants born. There
are marked differences in maternal mortality in neighbouring towns
and districts; and the only conclusion which fits in with the facts
is that, in many parts of the country, the arrangements for medical
attendance on mothers at and before their confinement are inadequate
or deficient in quality or both.
The Maternity Benefit under the National Insurance Act, though a
valuable evidence of the interest of the State in maternity, has
not provided a sufficient remedy. It was an unconditional benefit
limited to insured women or the wives of insured men, and there
was no guarantee that the money allotted would be utilized in
supplying the medical, midwifery, or nursing assistance needed by
the patient, or in relieving her from domestic duties which she is
unfit to perform. It was furthermore, inadequate for these purposes.
We should not think of handing over to each individual householder
an annual sum of money, advising him to expend it on a supply of
books or in the education of his children. It is more economical
and more effective to provide free libraries and public elementary
schools without payment of fees. Is not similar action important in
connection with child-bearing, on which the continuity of family life
and civilization depends? That this is so is recognized in the steps
towards the desired end taken in recent years by the Local Government
Board jointly with local authorities. Let me enumerate some of these.
The Central Authority have undertaken to pay one-half of approved
expenditure incurred locally on the following agencies:
(_a_) The salaries and expenses of inspectors of midwives;
(_b_) The salaries and expenses of health visitors and nurses engaged
in maternity and child welfare work;
(_c_) The provision of a midwife for necessitous women in confinement
and for areas which are insufficiently supplied with this service;
(_d_) The provision, for necessitous women, of a doctor for illness
connected with pregnancy and for aid during the period of confinement
for mother and child;
(_e_) The expenses of a Centre, i.e., an institution providing any or
all of the following activities: Medical supervision and service for
expectant and nursing mothers, and for children under five years of
age, and medical treatment at the Centre for cases needing it;
(_f_) Arrangements for instruction in the general hygiene of
maternity and childhood;
(_g_) Hospital treatment provided or contracted for by local
authorities for complicated cases of confinement or complications
arising after parturition, or for cases in which a woman to be
confined suffers from illness or deformity, or for cases of women
who, in the opinion of the Medical Officer of Health cannot with
safety be confined in their homes or such other provision for
securing proper conditions for the confinement of necessitous women
as may be approved by the Medical Officer of Health;
(_h_) Hospital treatment provided or contracted for by local
authorities for children under five years of age found to need
in-patient treatment;
(_i_) The cost of food provided for expectant mothers and nursing
mothers and for children under five years of age, where such
provision is certified by the Medical Officer of the Centre or by
the Medical Officer of Health to be necessary and where the case is
necessitous;
(_j_) Expenses of creches and day nurseries and of other arrangements
for attending to the health of children under five years of age,
whose mothers go out to work;
(_k_) The provision of accommodation in convalescent homes for
nursing mothers and for children under five years of age;
(_l_) The provision of homes and other arrangements for attending to
the health of children of widowed, deserted and unmarried mothers,
under five years of age;
(_m_) Experimental work for the health of expectant and nursing
mothers and of infants and children under five years of age, carried
out by local authorities or voluntary agencies with the approval of
the Board;
(_n_) Contributions by the local authority to voluntary institutions
and agencies approved under the scheme.
Grants will be paid to voluntary agencies aided by the Board on
condition:
1. That the work of the agency is approved by the Board and
coördinated as far as practicable with the public health work of the
local authority and the school medical service of the local education
authority.
2. That the premises and work of the institution are subject to
inspection by any of the Board officer’s or inspectors.
3. That records of the work done by the agency are kept to the
satisfaction of the Board.
Possibly much of the past failure to protect maternity and to
reduce the still-births and mortality among infants under a month
old has been due to the erroneous assumption that damage to health
and life at these times is in the main inevitable. That this is
not so for maternal mortality is proved by the great difference in
experience of sickness and death for mothers in different social
strata and according to the availability of skilled midwives and
doctors. There are similar differences locally and socially in the
proportion of still-births. Wassermann tests, followed by appropriate
medical action, in all instances in which there have been previous
miscarriages or in which for other reasons syphilis comes under
suspicion, and subsequent action based on the diagnosis thus secured,
would at once greatly reduce maternal and infantile mortality. So
also would systematic examination of urine during pregnancy and the
ascertainment that in other respects the physical conditions of
normal parturition are present. These are adequate reasons for the
establishment of ante-natal consultations, which happily are rapidly
increasing in England under the stimulus of the Government grants
already mentioned.
The further fact that about one-third of the total deaths in the
first year after live-birth occur in the first four weeks of life,
adds force to my plea for the establishment of these ante-natal
consultations in connection with all lying-in institutions and at
child welfare centres, where infants and children up to school age
will be submitted to periodical medical examination and supervision.
It has been erroneously asserted that the greater part of this early
infant mortality is unavoidable; but careful examination of national
and local statistics shows that in some places it is twice as high as
in others, and examination of the causes of death in the districts
with more favourable mortality shows that their experience can be
improved. All experienced obstetricians and pædiatricians will agree
that, given adequate care of the mother during pregnancy, skilled
care by a competent obstetrician during labor, and satisfactory
medical and nursing care in the following month, there can be secured
large reductions in the early infant mortality of the first month
after birth, as well as in the number of still-births and in the
present toll on maternal life.
In early infancy, as in advanced old age, the hold on life is
slight, normal and abnormal are soon interchanged, and there is
needed not only more knowledge on the part of mothers and nurses,
and even of physicians, of the hygienic side of medicine as applied
to the physiological life of the mother and her infant, but also
personal care and assistance to enable the mother to apply the
useful information and advice given by the public health nurse. I
lay special stress on this association of counsel and assistance.
It is important also that nursing and medical assistance should
be so given as not to create a feeling of dependence. In view of
the wide provision of medical assistance from public funds which
already obtains, I submit that poverty tests in the giving of such
assistance should be abolished, or that, at least, the availability
of such assistance should be greatly extended. Given the fulfilment
of this condition, it will be practicable to enlist the remunerated
coöperation of the medical profession in a general provision of
medical and nursing facilities, which will secure the early detection
of disease of every kind and its prompt and adequate treatment. Not
only so, but the same service can be utilized for the preservation of
health by securing the change of habits and customs and conditions of
housing or work which are likely to prove detrimental.
I have laid stress on the ideal after which we must, in my opinion,
strive. Meanwhile, it is essential that we should not regard the
mere removal of ignorance as the _summum bonum_. This is plain when
we come into close contact with the facts of life as lived by the
greater part of the wage-earning classes.
Has the wife of the wage-earner domestic help such as her well-to-do
sister possesses? Is there a nurse to help her even when the children
are sick, much less while they remain fairly healthy? How often has
every kettle-full of water to be heated separately on a stove? Under
such circumstances is it reasonable to expect the cleanliness which
is an indispensable condition of health? Is there a clean supply of
milk for every working-man’s family and are there arrangements for
sanitary and cool storage of food in his dwelling?
And so we might go on multiplying questions, knowing that, if
the answers are well-informed and candid, they will confess that
the mothers of the wage-earning classes, especially in our large
cities—in England, if not also here—have not a fair chance to keep
themselves well, or to rear a healthy and robust family.
I do not wish to stress this view of the case; but I have said enough
to justify the action of the British Government in deciding during
the war—and announcing the fact in more than one official circular
issued to all Local Authorities by the Local Government Board—that,
next to the active pursuance of war, measures for promoting maternal
and child welfare ranked next in importance, and that no efforts must
be spared to continue and extend such measures. And the history of
the last four years shows that this has been done. The central grants
for special maternal and child welfare work undertaken by local
authorities and voluntary agencies have increased twelve-fold, the
number of health visitors has been more than doubled, and the number
of maternity and child welfare centres has increased five-fold; and
coincident with these facts, infant mortality, which was falling
before the war, has continued to decline steadily during the war,—the
corrected figures for the years 1912-17 respectively were 104, 117,
113, 111, 98, and 94—although the number of mothers employed away
from home has greatly increased during the same period.
_The Work of Voluntary Agencies_
I have several times in this address mentioned the valuable work of
voluntary health agencies. No official can fail to recognize that
pioneer work is commonly started by them; and it has often happened
that only when the evidence of its value has become obtrusive has
it been taken over by local authorities. This is the true function
of voluntary agencies, and will remain so, until local authorities
(which after all are manned by voluntary workers) become saturated
with the ideals of voluntary workers and of the new women-voters.
Local authorities always have one great advantage over voluntary
societies, that their action can be supported by legal powers.
The proper attitude of voluntary workers is to initiate and
demonstrate the value of reforms, to persuade local authorities to
adopt them, themselves to become members of these local authorities
to ensure this end, and thus eventually render the voluntary
organization for the object in question superfluous. There need be
no fear; openings for further desirable voluntary work will always
appear, as official work increases. In the main, however, the care
of the health of the people is a governmental function, whether it
has to do with the prevention of sickness or the satisfactory medical
treatment and nursing of the sick.
There is no early prospect of voluntary workers becoming unnecessary;
for average human nature, as represented on governmental bodies, is
shortsighted and needs much education, morally and intellectually,
before it will undertake the whole sphere of work called for in the
interest of the welfare of the mother and her child. Hence my plea
that the magnificent potentialities of the Red Cross organization
should not be allowed to fall into abeyance; that they should replace
their relief work by preventive work; that, to use a well-known
simile, they should erect a parapet at the top of a dangerous cliff
as well as provide ambulances at its foot. In so doing they will, I
am confident, not encroach on present successful work of existing
bodies concerned with promoting child welfare, or with the prevention
of tuberculosis or of venereal diseases, or with existing agencies
for providing nurses for the poor. But they can supplement the
efforts of these organizations; they can bring monetary as well as
personal assistance; and they can, above all, bring a mass of public
opinion to bear on local and central governing bodies which will
lead to the only real economy, which consists in expenditure on an
adequate scale, bringing to the aid of the families of the people the
preventive, the medical, and the nursing facilities of which they
remain in need.
FOOTNOTES:
[13] An address to the Academy of Medicine, Toronto, June 20, 1919.