THE INTER-RELATION OF VARIOUS SOCIAL EFFORTS[14]
On examining the local city directory, one cannot but be impressed
by the multiplicity of voluntary organizations having for their
object the immediate relief of destitution or the social or economic
“uplift” of sections of the population. The multiplicity of these
agencies becomes more striking when one remembers that probably
every one of the hundreds of churches and chapels in the city has
its periodical sacramental and other collections for the poor, and
may have also a system of parochial district visiting, with such
auxiliary assistance as is provided through mothers’ meetings, etc.
Nor does this exhaust the possibilities of social help available
for the poorer members of society in cities in which there is a
satisfactory distribution of rich and poor, that is, in which the
segregation of different social strata in separate areas has happily
not befallen. There is the further help provided by individual
charity, the amount of which in the aggregate probably exceeds
beneficence through churches and social agencies.
If these different agencies could pool their resources, while
retaining the enthusiasm and driving power of separate organization,
what an economy of effort and what increase of efficiency would
result, especially if these agencies were also satisfactorily related
to the official organizations of local and central governing bodies
having the same object!
But I am not concerned this evening to discuss the machinery of
social help or the attempts already made in different centres for
securing their satisfactory coöperation. Nor am I disposed to discuss
the economic problems underlying the need for social assistance of
the poor. Ideally we must agree with St. Augustine’s statement:
“Thou givest bread to the hungry; but better were it, that none
hungered, and that thou had’st none to give him.” My present object,
however, is to set out some elementary—and when stated fairly
obvious—considerations bearing on social evils and their remedies
under present conditions of society, the recollection of which
if followed by practical action, would secure greatly increased
efficiency in social work.
For the following reasons I do not hesitate to bring this subject
before a gathering of graduate medical students:
First.—Every physician as soon as he engages in medical practice
almost immediately comes into touch with organized and unorganized
social workers, and his success—personal as well as communal—can
almost be measured in terms of his outlook towards their work;
Second.—The physician, with his scientific training in the tracing of
effects back to their causes, is in a specially favourable position
to promote rational as contradistinguished from empirical social
help; and
Third.—The physician is now learning to appreciate that he can
only treat his patients satisfactorily in the light of knowledge
of their social, including housing conditions, of their industrial
relationships, and of their personal history and habits of life.
This is the age of anxiety to give social help.
I hold strongly the view that ere many of you are advanced in years
the fundamentally important social help which is constituted by
adequate medical attendance will be provided, for all who wish to
have it thus, at the expense of the state, i.e., coöperatively by
means of common charges on every member of the community according to
his means, exactly as elementary education is now provided. This will
involve radical reconstruction of the relationship between hospital
and private medical practice, and will, I trust, include also the
introduction of preventive medicine into the practice of every
physician. But this is in the future. How can medical practice under
present conditions, and how can non-medical social agencies, be made
subservient to the fullest extent to the welfare of the community?
A few elementary illustrations will show the many unexploited or only
partially exploited or misused opportunities for efficient social
help.
The greatest science is to know the causes of things; and there is no
branch of work in which this is more important than in medicine. But
causation is complex. A given result commonly follows from a chain,
or it may be a bundle of events: and as we shall shortly see the end
links of the chain are oftimes joined, thus forming a circle.
If a man shoots a companion with whom he has quarrelled, it may be
urged that a more rigid system of license for the use of firearms
would have prevented the calamity; that the companion was also
quarrelsome; that the homicide had been the spoiled child of his
mother and had not had a satisfactory up-bringing; and that he
inherited from his father a violent temper; but none of these
circumstances,—all of which may have contributed to the murder,—is
likely to succeed in preventing the murderer from being hanged after
due trial.
It would be difficult to find a more striking instance of the linking
of elements in causation than in the origin of a case of malaria.
For the transmission of this disease two human beings, one already
infected with the specific contagium, and a mosquito are required,
and the chain of causation can be broken at the infecting person,
by strict screening from mosquitos, and by the use of quinine; at
the mosquito by preventing its emergence from the larval stage, and
later by preventing its access to the patient; or at the prospective
patient, possibly by prophylactic medication, more certainly by
strict screening from mosquitos. Hence one might claim lack of
segregation of infected persons, lack of screening of the healthy,
failure to drain marshes, to apply oil to the surface of stagnant
pools, or to adopt allied measures destroying the larvae of mosquitos
as each of them the cause of malarial disease.
There is a constant excess of sickness among the poor as compared
with the well-to-do. Measures for the relief of poverty, therefore,
may be regarded as within the scope of the physician’s prescription.
This may be accomplished for the moment by monetary or material help;
but unless the causes of poverty are sought out and counteracted, the
assistance given is merely palliative. For nothing is more certain
than that poverty tends to become a self-perpetuating condition.
Thus poverty leads to premature employment of children, with
detriment to their normal growth, followed by diminished efficiency
in adult life. This implies low wages throughout life, and so poverty
is passed on to a second generation.
Evidently timely assistance to induce the parent to delay employing
the boy, until he has been prepared for work, and to ensure his
being put to work which will not be a “blind-alley” occupation, might
have obviated the evil chain of events.
Poverty again when carried to the point of destitution may tempt
to larceny; this may be followed by loss of employment, and so the
temporary unrelieved poverty is liable to become permanent.
Intemperance has been almost wiped out as a cause of disease in
the United States; and we have in the fact that the whole country
has “gone dry” a remarkable example of a “short-cut” towards
social salvation from alcoholism which will be most instructive.
Apart from such universal prohibition of alcoholic beverages, the
physician has to think of an alcoholic patient under his care as
the possible victim of one or more or all of several coöperating
influences conducing to intemperance. The alcoholic habit may have
been gradually acquired as the result of protracted social indulgence
in moderation acting on a person of unstable mental constitution;
it may, especially in wage-earners, have been hastened by the evil
custom of treating. It not infrequently follows overwork, with
the associated feeling of need for stimulants; it accompanies bad
housing, with unsatisfactory sleeping accommodation; and it is aided
by poor and badly cooked food, due to shiftlessness, overwork, or
lack of domestic training of the man’s wife. If there is to be
successful control of alcoholism, action in all the directions
briefly indicated above, and in other directions which will suggest
themselves, is necessary; and although the physician cannot himself
do all this, his efforts should run parallel with social efforts in
these directions.
Even when the “short-cut” of compulsory abstinence has been taken,
the efforts indicated above are still needed; for alcoholism is
not the only resultant of bad social habits, of overwork, of
unsatisfactory feeding, of deficient sleep, and so on.
Perhaps even more far reaching in their evil effects than
intemperance are the Venereal Diseases. As you know, special efforts
during and since the war have been made to limit the spread of these
diseases. I do not propose to trouble you with statistics to prove
the mischief caused by these diseases. Has not Osler said that the
whole of clinical medicine can be taught around syphilis, and that
it is the third in importance of the killing diseases? And as a
further illustration, let me add that no less than one-tenth of the
total accommodation in our lunatic asylums might be dispensed with if
syphilis were eliminated.
Among the measures being taken to combat these diseases are
educational propaganda, and the provision of clinics, free for
all, at which patients may be treated promptly and adequately. It
is evident, however, that if the medical and educational efforts
now being made are to succeed they must include recognition of
all the factors causing sexual vice, and appropriate action in
respect of each of these—they must indeed go further than this; for
self-restraint is a wider problem than in relation to exposure to
these diseases. It embraces the whole subject of formation of the
habit of self-control. One of the most striking facts in the great
war has been the extent to which young girls of previously decent
behaviour have fallen victims to what has sometimes appeared to be
passion combined with a perverted form of patriotism; and one of the
measures most called for is better mothering and maternal training
of both girls and boys. The problem is one of special difficulty as
regards the economically independent girl; and to shield her the
combined efforts of home influence, of girls’ clubs, and of various
social and religious organizations are all required.
Judicious and restrained teaching of the physiology and hygiene of
sex would do much to counteract the evil influence of bad teaching
by companions; and in emphasizing this duty on parents the physician
may do untold good. So also, especially when the daughters of his
patients are about to marry “men of the world,” he should urge
the need for asking a satisfactory certificate from the intended
bridegroom of freedom from infection.
The influence of unaccustomed alcoholic indulgence in leading to the
first “slip,” often with the production of life-long disease, is well
known.
Nor must we leave out of account the tolerance of vice in
conversation between young men, as a frequent excuse of and even
excitant to vice. The happiest young man is he who can go to the
marriage ceremony with the same sexual purity as is even now
expected from the bride. Is it too much to expect that our social
conscience will grow up to this standard? I think not; and when this
point has been reached, venereal diseases will have almost entirely
disappeared, and the sum total of human happiness and efficiency will
be enormously enhanced.
Meanwhile partial remedies must be pushed for all they are worth—and
this is much. Fear of consequences may deter some from vice; fear
of consequences to future wife and child form a much more potent
argument. Treatment of venereal diseases, especially of syphilis,
is a most valuable means of preventing their spread. This treatment
may be urged even at the stage after exposure to infection before
any symptoms of illness appear; and the more promptly this is done
the more successful is it. There has been much heated debate as to
whether persons known to intend to expose themselves to possible
infection should be provided with disinfectant or other arrangements
for obviating infection. This cannot be done without some loss of
moral position; it almost makes the provider a co-partner with the
sensualist. It may be urged, however, but with dubious cogency,
that if the man is told beforehand that immediately afterwards he
can have access to disinfectant provisions, the same objection holds
good. I do not regard the provision of “outfits” as wise. Evidence
tends to the conclusion that they are commonly not used efficiently;
and there is a distinct loss in the moral position by their use. The
whole subject is one of great difficulty. The prevention of venereal
diseases is clearly, however, not merely a medical problem; and the
physician who realises this and throws the weight of his influence,
in warning and in counsel, on the side of moral restraint, is adding
greatly to the value of his social service to the community.
Other instances will occur to you, illustrating the importance
of a broad outlook in the causation of disease or other forms of
social misery. I will adduce one more. It is well known that infant
mortality is much heavier among the poor than among the well-to-do.
The rule does not hold universally in rural areas, but in towns it
applies almost without exception. And it is assumed by a large school
of social workers that enlightenment of the ignorance of the poor
mother will effectively correct this evil. Such a lop-sided view
ignores many of the elements of the problem of infant mortality.
Think for a moment of the contrast between the working-class mother
of five children living in a small city tenement, and the mother
of an equal number of children in easy circumstances, living in
a residential suburb, and having domestic servants, a nurse, and
a physician always available. The two mothers probably differ but
little in their knowledge of the hygiene of infancy; but the one has
helpers to ensure scrupulous cleanliness, to prevent over-fatigue of
the nursing mother, to detect the first sign of infantile illness and
provide the needed action; while the other mother has to struggle
alone in respect of her infant, without either domestic or nursing
assistance, the struggle being complicated by the fact that the
care of four older children and of her husband is on her shoulders.
Even when there is no actual direct poverty in the working-class
home, the differences thus indicated—supplemented by the inability
of the mother to obtain medical advice for apparently minor
ailments—outweigh enormously the factor of ignorance as a cause of
excessive infant mortality. By all means let instruction be given by
public health nurses or other agencies, and this is most valuable;
but it does not fully meet the needs of the case. There is required
also actual domestic, as well as nursing, assistance in the home of
the overworked working-class mother, especially after the birth of
her infant and when illness attacks any of her children; and unless
the physician realises these elements in the problem, his efforts in
securing the welfare of his patient and in reducing infant mortality
can have but partial success.
The main lessons arising from the foregoing illustrations of medical
and social problems are two: Each evil should be attacked in its
causal relationships; and causation is multiple.
Hence—apart from total prohibition—in attacking alcoholism, the
physician may bless the efforts of tee-total advocates, of those
engaged in reducing the number of saloons, of those securing better
dietetics and cooking, less industrial fatigue, or more satisfactory
domestic sleeping accommodation, and of parents and teachers engaged
in promoting self-control in the young as a habit of life; and he
will call them all in aid of his curative and preventive life work.
So, also in the control of venereal diseases, early and prompt
diagnosis and treatment must go hand in hand with police measures for
the suppression of prostitution, with educational work respecting
these diseases, and with the inculcation of a higher standard of
morality, considered as part of the general cultivation of moral
self-restraint.
And in the prevention of infant mortality and of the even more
serious handicapping of the up-growing child produced by the factors
of infant mortality, we need to bring to bear all our medical and
hygienic knowledge, and to realise that until every mother in the
land is furnished with the elementary requirements, domestic,
sanitary, social, and medical, for rearing a healthy family, we have
no right to mental comfort while enjoying these elementary needs of
family life ourselves.
Coöperation and solidarity of effort are needed on the part
of the multitude of workers engaged in social work for the
community—official and non-official; and in bringing this about the
physician of the early future will, I am confident, take a leading
part.
FOOTNOTES:
[14] An address to the Alpha-Kappa-Kappa Club, Johns Hopkins
University, Wednesday, December 10, 1919.