SOME ASPECTS OF POVERTY[16]
I use the word Poverty, for the purpose of this discussion, as
meaning Destitution, in the sense of lack of means to provide some
specific requirement, indispensable for the health of the family, or
the individual.
Such poverty is evidently undesirable and mischievous, from the point
of view of both rich and poor; and I think we shall agree that, given
the adoption of the requisite measures, its continuance in most
instances is unnecessary. Hence the real subject for discussion is,
how poverty may be diminished and prevented.
I do not propose to touch on the important subjects of unemployment,
of under-employment, or of the relation between the size of family
and poverty, though the last named of these opens up an interesting
subject of discussion. (On this see page 164.) I shall confine my
remarks to the very obvious relation between poverty and sickness,
and to the neglect to act on our present knowledge, which if acted
on would in a short time lead to a great reduction of poverty in our
midst.
There is much truth in each of the statements that poverty is
responsible for much disease, that disease is responsible for the
greater part of the total poverty in our midst, and that poverty
begets poverty.
Poverty and disease are allied by the closest bonds, and nothing can
be simpler or more certain than the statement that the removal of
poverty would effect an enormous reduction of disease. The removal of
poverty must, therefore, be in itself an object always fascinating
to those whose study is the public health. The diseases which would
be reduced by this means, include not merely those which physicians
treat, but many moral diseases which persist because they are only
to be avoided by the poor through the exercise of discipline and
self-restraint far beyond what is practised by the average person
in classes not subject to poverty. The happiness of a community
being in itself a desirable object, a national asset, it is also not
irrelevant to consider that the removal of poverty involves enlarged
opportunities for enjoyment which, rightly directed, would be only
of less value than the removal of disease. It is not surprising,
therefore, that the first impulse of a student of the public
well-being, in which the public health is the most important factor,
is to attack disease by demanding the reduction of poverty, with its
more or less inevitable accompaniments of over-fatigue, privation,
overcrowding, and dirt. And it must be freely admitted that when
the most active public health administration, including adequate
medical aid for the sick, has attained its utmost efficiency, and has
in every respect done all that it can to reduce disease, there will
still remain a cruel residuum which can be attacked in no other way
than by the removal of poverty, or by the removal from poverty of the
elements of personal privation which affect the public health.
The importance attached to poverty as a cause of illness and
mortality is illustrated in reports on local investigations,
displaying an inverse relationship in different communities between
family income and the rate of infant mortality, the reader being left
to infer, that increase of the lower incomes is the one method for
obviating excessive loss of infantile life. In suggesting this crude
generalization it is evident that poverty is being regarded as an
element, instead of as a highly complex phenomenon, which needs to be
further analysed into its constituent parts. The crude generalised
statement as to the relation between excessive mortality and poverty,
furthermore, fails to bring out three essential points, viz., that
infant mortality may be very low in communities in which poverty is
the rule; that it may be high in the absence of poverty; and that
where infant mortality is high, it can be greatly reduced without
change of economic conditions.
There should be an adequate family income for every family; and the
social conscience cannot be satisfied until this is realised. But,
in seeking for practical reform we must appreciate that a large
share of the disease and of the inefficiency of the individual and
family associated with poverty can be remedied otherwise than by
an increase of the family income. This is shown by national and
international experience. The death-toll on infant life is very much
lower in Norway and in Ireland—both relatively poor countries—than
in England. Poverty in these instances evidently has less weight
than the favorable factors of rural life and natural feeding. A like
discrepancy in experience of infant mortality is seen between the
experience of towns, and of wards in the same town, with approximate
equality as regards poverty. Similarly in England the infants of
miners with relatively high wages suffer a higher mortality (160
per 1,000 births in 1911) than the infants of textile operatives
(148) with relatively low wages; while the latter suffer more than
the infants of agricultural labourers (97). These instances at once
suggest that some conditions in town life play an important part
in causing excessive infant mortality; that in towns insanitary
conditions and habits of life are even more injurious than the
absence from home of the industrially employed mother; and that
the causation of infant mortality is complex, and its prevention
necessitates a multifarious attack on social and industrial evils,
the character of this attack necessarily varying in different
localities, in accordance with the incidence of these evils. That
the influence of urban life in causing excessive mortality can be
counteracted is shown by the varying mortality in different urban
communities, and in different parts of the same town.
We may in a given instance be totally unable to increase the
family income; but the family’s present expenditure may be more
satisfactorily distributed; and some, at least, of the constituent
elements of poverty producing excessive child mortality can be
obviated. We know, indeed, that this can be done. The fact that
in the United States no part of the family income can be spent on
alcoholic drinks, implies the removal from multitudes of families of
the demoralising influences associated with alcoholism, which are
unfavourable to the health of adults and children alike.
Similarly, increased attention to domestic and municipal sanitation
and to the provision of a pure and adequate milk supply, the health
teaching given by public health nurses, and the prompt medical and
hygienic guidance at Child Welfare Centres are having an important
influence in the same direction. Work on these medical and sanitary
lines, for both adults and children, comes legitimately within the
sphere of the work of Public Health Authorities, provided out of
rates and taxes.
It may be urged that such provision, after all, means supplementation
of the family income at the public expense. It is more properly to
be regarded as a measure of insurance against contingencies by which
every member of the community is benefited; for we are each and all
concerned in the efficiency of every other member of the community.
We are members one of another. The objection stated above has no
greater validity than an argument similarly advanced against the
provision of police protection or of sanitary measures out of public
funds.
Elementary, and to some extent secondary and university, education
are regarded as not only the legitimate subjects of communal
provision, but also as incapable of being provided satisfactorily
by each individual family; and this view applies with even greater
force to the provision of hospitals and expert medical assistance,
of nursing assistance, and of such additional occasional domestic
service as is required to maintain the functional integrity of the
family.
I have given the above as a special instance of the contention that
poverty is a complex, including a number of elements, and that it is
our duty to ascertain in each area by careful local inquiry what are
these constituent elements, and if practicable their relative weight;
and then to apply the most urgently needed remedies, not contenting
ourselves with the relatively useless generalisation that the evils
we see are ascribable to poverty.
I lay special stress on the provision of skilled medical advice and
treatment, and of nursing assistance at the public expense, which at
present are sorely deficient for the vast majority of the population,
and perhaps for none more so than for the less well-to-do people who
receive salaries and not weekly wages. This assistance possesses the
special advantage previously pointed out, that it does not tend to
create a demand for further assistance, when such assistance is not
required.
The greatest bulk of poverty is due directly to sickness. A vast
mass of sickness still occurs, which is not owing to lack of family
or communal means, but is due to ignorance or neglect on the part of
the individual, of the responsible owners of houses, of the employers
of work-people, and still more of the members of local authorities
or state legislatures. Typhoid fever still commonly prevails as
the result of neglected sanitation; hookworm disease still causes
incapacity of hundreds of thousands for the same reason; malaria,
still one of the greatest scourges of humanity, might be reduced to
a fraction of its present amount if each community and each person
would carry out available simple preventive measures; tuberculosis
is still spread throughout every civilized community chiefly because
indiscriminate expectoration is unregulated, and satisfactory and
acceptable hospital treatment is not provided for all those who need
it. And so we continue to allow avoidable poverty to be perpetuated,
and to impose not only on the sick poor themselves, but also on
the efficient and solvent part of the community a heavy burden, the
removal of which would, to an almost incredible extent, increase the
general happiness of mankind.
The relief of poverty is at the best an inefficient and expensive
remedy. It is seldom adequate, and it has few preventive elements.
The prevention of poverty by prevention of the illness causing it,
and by early and satisfactory treatment of such illness as fails to
be prevented is the only efficient, as well as in the long run the
only economical plan of campaign. Money insurance against sickness
has its place as a means of alleviating the results of poverty.
But it is not an aid to its prevention; under any existing system
of insurance the money payment is insufficient and definitely
limited in duration. Although such relief is useful, it is totally
unsatisfactory when not linked up with a complete system of hygienic
measures, and when not associated with adequate medical treatment and
nursing. For the linking of treatment provided largely out of public
funds with insurance there is no justification, and it is contrary to
the public interest; and it is unfortunate that monetary insurance
has been provided in England for a section of the population under
these unsatisfactory conditions, thus diverting expenditure from the
public health services in which it was urgently needed, and in which
its use would at once have been fruitful in increased health and
happiness.
FOOTNOTES:
[16] An address to the Political Economy Club, Johns Hopkins
University, Jan. 19, 1920.