PUBLIC HEALTH AND INSURANCE:
AMERICAN ADDRESSES

BY

SIR ARTHUR NEWSHOLME, K.C.B., M.D., F.R.C.P.

LECTURER ON PUBLIC HEALTH ADMINISTRATION AT THE SCHOOL OF HYGIENE AND
PUBLIC HEALTH, JOHNS HOPKINS UNIVERSITY, BALTIMORE, MARYLAND; LATE
PRINCIPAL MEDICAL OFFICER OF THE LOCAL GOVERNMENT BOARD, ENGLAND;
PRESIDENT OF THE SOCIETY OF MEDICAL OFFICERS OF HEALTH
AND OF THE EPIDEMIOLOGICAL SOCIETY; EXAMINER IN PUBLIC HEALTH
TO THE UNIVERSITY OF CAMBRIDGE, IN PREVENTIVE MEDICINE TO
THE UNIVERSITY OF OXFORD, AND IN STATE MEDICINE TO THE
UNIVERSITY OF LONDON, MEMBER OF THE GENERAL MEDICAL
COUNCIL, OF THE COUNCIL OF THE IMPERIAL CANCER
RESEARCH FUND, ETC.

BALTIMORE

The Johns Hopkins Press
1920

Copyright, 1920
By The Johns Hopkins Press

PRESS OF
THE NEW ERA PRINTING COMPANY
LANCASTER PA.

DEDICATED BY THE AUTHOR

(WITHOUT PERMISSION)

TO THE

RIGHT HONOURABLE JOHN BURNS

A LEADER IN PUBLIC HEALTH;
WHO IN PARTICULAR MADE THE PUBLIC REALISE THE
IMPORTANCE OF CONCENTRATING ON THE
Mother and Her Child

PREFACE

After more than three decades of work in preventive medicine and public health, the opportunity has arisen in connection with a year’s visit to America, to take a panoramic view of public health in England, of the progress which has been secured, of the factors which have impeded progress, and of the pressing desiderata for more efficient future action.

During my stay in America I have had the privilege of addressing public audiences in every part, from New Orleans to Toronto, and from New York and Boston to San Francisco and Seattle; as well as more special audiences at Johns Hopkins University, at Saranac and at Harvard, California, Washington, and Yale Universities; and at the request of many friends some of the addresses given to these audiences are now published in volume form. These addresses briefly outline some of the lessons of long experience, and although the conditions under which they were delivered rendered complete exposition impracticable, there are, I think, advantages in not overloading the presentation for public consideration of a many-sided subject.

It will be noted that the same problem may be mentioned in several addresses, though usually from a different angle. The entire avoidance of repetition would have necessitated the abandonment of the lecture form, and would, I believe, have diminished the utility of the volume. The table of contents and index render cross-reference easy.

Those wishing to ascertain fuller details on most of the problems discussed in the present volume may refer, I think with advantage, to my annual reports as Medical Officer of the Local Government Board, England, and to my four special reports on Maternal and Child Mortality, which also were issued as English Government publications.

British experience is only partially applicable in the United States, the almost complete Home Rule in each State creating a new and interesting problem in efficient national public health administration. Nevertheless a review of events in Great Britain cannot fail to be useful in America, which is faced with similar problems. The main lines of public health administration in Great Britain have proved their value by their success. There has been local independence with a minimum of central control, and the people’s representatives in every area have been made to realize their commercial responsibility. The mistakes made in permitting the multiplication of small and inefficient public health authorities, in allowing official medical work to be divided respectively between different local and central authorities, in sanctioning the creation of ad hoc authorities for special work, in associating state medicine with monetary insurance against sickness, and in not securing that insurance shall directly assist the prevention of sickness, have been largely the mistakes of politicians and of central authorities. These mistakes involve the retracing of steps and the undoing of the mischief resulting from ill-advised action. In view of these conflicting events, the marvellous achievements secured by public health authorities are the more noteworthy.

In every American city visited by me I have been struck with the earnest desire of voluntary and official public health and social workers to profit by English experience, to adopt what is good, to secure the abolition of the short tenure of office of competent officers under the present political system, and to introduce civil service conditions for them. There is in many respects a close parallelism between the course of public health on both sides of the Atlantic; in some cities the English hygienist has much to learn in respect of advanced and original work; and in other American cities in which “political pull” continues, there is evidence of the development of a wider interest and a more general sense of communal responsibility; a deeper trend of thought which will make for steadily increasing efficiency in public health work. As this volume discusses public health problems especially from a social viewpoint, it is my earnest hope that it may be useful in this direction.

Arthur Newsholme

CONTENTS

LECTURE I

Public Health Progress in England during
the Last Fifty Years [1-41]

Parallelism of Events in Old and New England.
The Utilization of Lay Workers in Public Health Work.
The Influence of Urbanization and Industrialism.
Laissez faire Economic Teaching.
Man and his Environment.
Dirt and Disease.
Cholera, Typhoid Fever, Typhus Fever.
Summary of Results in Life-Saving.
Specific Causation of Disease.
Importance and Present Limitations of Epidemiology.
The Importance of Vital Statistics.
Conditions of Medical Practice Bearing on Public Health.
Poor-law versus Public Health.
Insurance versus Public Health.
A National Medical Service.
Hospitals Important Housing Auxiliaries.
The Need to Avoid Complacency.

LECTURE II

Historical Development of Public Health
Policy in England [42-70]

Town-Dwelling and Health Problems.
The Scope of Public Health Work.
Reform in the Control of Poverty.
Reform in Industry.
Public Health Reform.
Education Authorities and Health.
The Ad Hoc Vice.
Principles of Local Government.
The Training and Tenure of Office of Medical Officers of Health.
The National Insurance Act and Public Health.
Provision for Sickness.
General Summary.

LECTURE III

The Increasing Socialization of Medicine [71-102]

An Altruistic Profession.
The Past Achievements of Medicine.
The Ever-increasing Importance of Hospitals.
Hospitals and Housing.
The Continuing Mass of Preventible Disease.
The Present Extent of Socialization of Medicine.
Destitution and Sickness.
Insurance and Sickness.
The Needs of the Future.

LECTURE IV

The Medical Aspects of Insurance against
Sickness [103-119]

Criteria of Value of Insurance.
British System of Insurance.
Limitations and Evils of the “Medical Benefit.”
Need for further State Treatment of Disease.
Prevention of Poverty by the Application of Medical Science.
State Medicine must be Preventive throughout.
Conditions of an Efficient Medical Service.

LECTURE V

Some Problems of Preventive Medicine of
the Immediate Future [120-143]

The Incidental Gains from War.
Its Sacrificial Work.
The Comradeship of All Idealists.
Women’s Work.
The Restriction of Alcoholism.
The Change from Empirical to Scientific Methods.
The Still Uncontrollable Diseases.
Influenza and Measles as Types.
The Possibility of Modified Training of Nurses.
The Need for a More Complete Program in Tuberculosis.
The Possibilities of Control of Venereal Diseases.
The More Complete Protection of Maternity and Childhood.
The Abolition of Poverty Tests in Medical Assistance.
Lack of Equality of Service, not Ignorance, the Chief Evil.
The Continuing Value of Voluntary Workers.

LECTURE VI

The Inter-relation of Various Social Efforts [144-156]

The Possibilities of Good Work under Present Economic Conditions.
The Importance of Social Work to the Physician.
The Constant Need for a Causal Outlook.
Poverty and Disease.
Causes of Intemperance.
The Causation and Prevention of Venereal Diseases.
Lop-sided Views as to Ignorance in Causation of Disease.

LECTURE VII

The Obstacles to and Ideals of Health Progress [157-182]

Degree of Progress Realized.
Obstacle of Urban Life.
Obstacle of Industrialism.
Obstacle of Poverty.
The Influence of the Malthusian Hypothesis.
Obstacle of Ignorance.
Obstacle of Defects of Character.
Ideals.
Communal Action.
Spread of Altruism.
Supreme Importance of Mother and Child.

LECTURE VIII

Some Aspects of Poverty [183-190]

Disease a Chief Cause of Poverty.
Diminution of Poverty apart from Increased Family Income.
Poverty a Complex.
Action Needed against Each Constituent Element of Poverty.

LECTURE IX

The Causation of Tuberculosis and the
Measures for its Control in England [191-239]

A. Basic Facts as to Tuberculosis.
Explanations of the Decreasing Death-rate from Tuberculosis.
Diminished Virulence of the Tubercle Bacillus.
Increased Human Resistance by Natural Selection.
Immunization by Small Doses of the Contagium.
Diminished Tuberculosis with Increased Aggregation of Population.
Hospital Treatment of Consumptives.
Koch’s Views as to Hospital Segregation.
Improved Housing in Reduction of Tuberculosis.
B. Measures of Control.
Notification of Cases.
Causes of Failure in Notification.
Public Health Action following Notification.
Examination of Contacts.
Scope of Tuberculosis Schemes.
Tuberculosis Dispensaries.
Should be Part of General Dispensaries.
The Home Visitation of Patients.
Sanatorium Benefit.
Residential Institutions.
General Observations on Treatment in Sanatoria.
Hospital Treatment.
Industrial Colonies.
Special Dwellings and Help in Support.
Summary.

LECTURE X

Child Welfare Work in England [240-267]

The Earlier Work of Medical Officers of Health.
The Notification of Births.
Chief Causes and Course of Infant Mortality.
The Influence of School Medical Inspection.
The Influence of Statistical Studies.
The Midwives Acts.
Health Visiting.
Voluntary Work.
Child Welfare Centers.
Training and Provision of Midwives.
Ante-natal Work.
Dental Assistance.
Creches.
Observation Beds at Child Welfare Centers.
Grant’s to Local Authorities.
Course of Mortality in Childbearing.

CHAPTER I
Public Health Progress in England During the Last Fifty Years[1]

After thirty-five years in active public health work in England—during eleven of those years having been the principal officer of its central public health department on its medical side—I may be assumed to possess some qualification for the task of reviewing the past half century’s progress in public health in England.

Parallelism of Events in New and Old England

I find it, however, beyond my power to compass in a short address a resumé of my subject which shall be complete, or completely in perspective, or which shall not omit features on which, had time permitted, one would have wished to comment; and I must ask you to remember that only a portion—and that chiefly non-administrative[2]—of the history of this wonderful half century can be embraced within the present address. The survey should, I think, take a panoramic view of the story as it has developed, should note the changes as they have occurred, the obstacles which impeded reforms as well as the reforms secured; and should also, at least incidentally, state—in the light of unfailing historical guidance, as well as of increasing knowledge—the pressing desiderata for more efficient and more rapid future progress. I cannot hope to accomplish this task except to a fragmentary extent, but I am happy to remember that sanitary history in Old and in New England has proceeded largely on parallel lines. The curves of annual death-rates from all causes, from typhoid fever, from tuberculosis, and of the mortality of infants show the closeness of the parallelism of the public health history of England and Massachusetts.

The work of the last fifty years was built on preceding pioneer work of men in Old and in New England; and for a complete understanding of this work, a momentary glance is required at the men of this earlier generation and their work.

In the old country we speak with reverence of the names of Southwood Smith, Kay, Chadwick, Farr and Simon; and you remember with gratitude the names of Lemuel Shattuck, of Bowditch, of Walcott, S. W. Abbott, and Theobald Smith; and it is gratifying to remember that the epoch-making report of the Massachusetts Sanitary Commission of 1850—to which were attached the ever memorable names of Shattuck, N. P. Banks, and Jehiel Abbott—among its many statesmanlike and far-seeing proposals, recommended a sanitary survey of the State, and referred to the recent English sanitary surveys, with which British sanitation may be said to have begun.

The Utilisation of Lay Workers

Let me in passing comment on the fact that neither Lemuel Shattuck in Boston nor Edwin Chadwick in London was a physician; but a perusal of their writings shows that they were men of sound judgment, of earnest zeal for their fellow men, with a wide and statesmanlike outlook, ready to search out, to accept and to apply the medical knowledge on which necessarily the prevention of disease is based. They illustrate once for all the need for partnership between all well-wishers of humanity in this work, and the importance of combined effort by the sociologist and the physician, as well as of experts in each branch of sanitation, if all attainable success is to be attained.

The tradition then established has never been lost. In England, more perhaps than in America, the control of public health work has been shared by intelligent laymen on local and central authorities, and the fact that medical officers of health have found it necessary to convince these lay representatives of the general public of the need for the reforms recommended, has led to steady progress, seldom interrupted by relapses. And this is true, although delays and disappointments have beset the path of the earnest reformer, who might well wish that his lay colleagues had been trained in schools in which natural science formed a more open avenue to distinction than classics; or that the representatives on local authorities might more fully and more quickly appreciate in Simon’s words, what they are

sometimes a little apt to forget that, for sanitary purposes, they are also the appointed guardians of human beings whose lives are at stake in the business.

What were the ideals with which the Fathers of Sanitation in New and in Old England began their work?

They cannot be better expressed than in their own words. In the 1850 Report of the Massachusetts Sanitary Commission they are thus expressed:

We believe that the conditions of perfect health, either public or personal, are seldom or never attained, though attainable; that the average length of human life may be very much extended, and its physical power greatly augmented; that in every year, within this Commonwealth, thousands of lives are lost which might have been saved; that tens of thousands of cases of sickness occur, which might have been prevented; that a vast amount of unnecessarily impaired health, and physical debility, exists among those not actually confined by sickness; that these preventible evils require an enormous expenditure and loss of money, and impose upon the people unnumbered and immeasurable calamities, pecuniary, social, physical, mental, and moral, which might be avoided; that means exist, within our reach, for their mitigation or removal; and that measures for prevention will effect infinitely more than remedies for the cure of disease.

In a succeeding paragraph the Commissioners proceed to quote with approval, the following remarks made by Mr. (afterwards Sir John) Simon in the preceding year, when he was medical officer of health to the City of London, and before he became the principal medical officer and adviser of the British Government in health matters, and in that capacity laid the foundation and built much of the edifice of our present health organization.

Ignorant men may sneer at the pretensions of sanitary science; weak and timorous men may hesitate to commit themselves to its principles, so large is their application; selfish men may shrink from the labour of change, which its recognition must entail; and wicked men may turn indifferently from considering that which concerns the health and happiness of millions of their fellow-creatures; but in the great objects which it proposes to itself, in the immense amelioration which it proffers to the physical, social, and, indirectly, to the moral conditions of an immense majority of our fellow creatures, it transcends the importance of all other sciences; and, in its beneficent operation, seems to embody the spirit, and to fulfil the intentions, of practical Christianity.

With such noble ideals, what measure of success crowned their efforts and those of their successors?

The earlier history I can only briefly mention, as we are chiefly concerned today with events since 1869. To understand these events, however, one must understand the forces which had been accumulating and increasing in power in earlier years, and which rendered possible the rapid public health progress experienced in the fourth quarter of the nineteenth and the first quarter—so far as it has passed—of the twentieth century.

Laissez Faire Economic Teaching

Historians in future generations will refer to the second half of the eighteenth and the first half of the nineteenth century as the period of unmitigated industrialism, of associated rapid increase of urban at the expense of rural life, and of the most extreme manifestation of laissez faire economic science. The older semi-paternal system of interference with the economic life of the people by King and Parliament, was replaced, under the influence of Adam Smith, Malthus, James Mill, and other teachers, by inaction based on the view that in old countries poverty is the natural and inevitable result of pressure of population on means of subsistence, and that any interference with freedom of competition in obtaining work or employing workers is useless or mischievous. A similar view found expression in President Jefferson’s dictum: that government is best which governs least; and until the middle of the nineteenth century these views were generally accepted and their influence was dominant.

It was assumed that given free competition, enlightened self-interest would incite effort and improvement, encourage self-reliance, and guarantee production and economy.

Under the conditions considered inevitable with such teaching, although great wealth accompanied the rapid industrial development after the Napoleonic wars, it was associated with unrelieved misery; for homeworkers and rural workers crowded into mean hovels in towns, paying exorbitant rents out of a miserable pittance of wages, and were exposed to the evils resulting from overcrowding, and from absence of adequate and satisfactory water supply, scavenging or drainage. By the year 1851 about half the population of England and Wales had become aggregated in towns; and it may be added that in 1911, less than one fourth of the population was left in rural districts. Urbanization in the earlier years meant dense overcrowding and insanitation; and that it is still an influence adverse to health may be gathered from the information given by the census of 1911, that over eight times as large a proportion of the urban as of the rural population live in one-roomed tenements, and nearly twice as large a proportion live in two-roomed tenements, while the proportion of one-roomed tenements in towns which are overcrowded (in the sense of having more than two persons to a room) in towns is seven times as great, and of two-roomed tenements is twice as great as in country districts.

Domestic misery was associated with commensurate industrial misery; overwork, in insanitary factories and workshops, regardless of the health of the “hands,” was the rule.

The displacement between 1760 and 1800 of domestic by factory manufacture represented a new phenomenon in the world’s history, a true industrial revolution. It was the parting of the ages; destined not only to change the life of the people of England from preponderantly outdoor to preponderantly indoor; and to bring for them for many years all the disadvantages of unregulated town life; but also, owing to the rapid development of better roads, of canals, and then of railroads and steamships to end forever the practical segregation in which countries, and even neighbouring communities, had previously lived.

It cannot be wondered at that under these circumstances the general death-rate was excessive, and epidemic disease spread with a rapidity and to an extent previously unknown.

The reaction against the laissez faire economic teaching began early, and it is in accordance with the fitness of things that the national conscience first rebelled. The earliest evidence of reform was legislation in 1802 on behalf of pauper children indentured to the overseers in textile factories; and there followed subsequent Factory and other Acts in 1819, in 1833, in 1844 and in 1847, which prohibited the factory employment of children under nine, limited the hours of labour of young persons and of women, and insisted on elementary sanitation in factories. Subsequent Factory and Mining Acts, followed by Shop Hours Acts and the Shop Seats’ Act, have completed a most valuable code of regulations prohibiting overwork, and securing a measure of protection against dangers to health and limb or eyesight during industrial employment. It is noteworthy that the first steps at improved sanitation, and to safeguard health by preventing overwork, were on the industrial plane. Factory inspectors preceded medical officers of health and sanitary inspectors appointed by local authorities.

Philanthropy was the motive power in initiating factory reform; in securing general sanitary reform, driving power was furnished by the double motive of economy and fear, caused by the inordinate expense of poor-law administration, the frequently recurring epidemics of “fever,” and the alarming occasional invasions of Asiatic cholera. The sacrifices of life from cholera were truly vicarious; for we owe it largely to these that our national system of vital statistics was initiated in 1837 and that serious efforts at sanitary reform were begun.

Man and His Environment

The history of these earlier steps is full of interest; but I cannot outline it today. There can be no doubt that as Simon[3] put it, referring to Dr. Southwood Smith’s report to the Poor-Law Commissioners in 1838 (“on Some of the Physical Causes of Sickness and Mortality to which the Poor are particularly exposed, and which are capable of removal by Sanitary Regulations”)

the commencement of State interference on behalf of the health of the labouring classes may be said to date from its publication and to have been in a very important degree determined by its facts and arguments.

That the first principles of causation were beginning to be appreciated is shown in the following extract from Queen Victoria’s speech in opening Parliament in 1849. In this speech she referred to the ravages of cholera which it had pleased Almighty God to arrest, and added:

Her Majesty is persuaded that we shall best evince our gratitude by vigilant precautions against the more obvious causes of sickness, and an enlightened consideration for those who are most exposed to its attacks.

Note that these words and the early attempts at public health legislation, culminating in our great sanitary code, the Public Health Act, 1875, incorporated the tripod on which enlightened public health administration must always be supported, viz.,

(1) attack on the causes of sickness,
(2) satisfactory treatment of the sick, and
(3) satisfactory care for the poor.

I might properly add

(4) attack on the causes of poverty,

for it is perhaps the chief merit of the great work of Edwin Chadwick that, in the light of reports on local surveys made by Kay, Southwood Smith, and others, he was convinced and was able to convince Parliament that a very large share of the total destitution then existing was due to the conditions under which the people lived, and the disease generated in these conditions.

It is commonly stated that, in the past, public health administration has concerned itself solely with mankind’s environment, failing to recognise the predominant importance of man himself as a transmitter of disease, and of his personal well-being and protection as the point to which energy should be directed. This cannot be said to have been the intention of the legislature or of the earlier reformers; though unhappily this limited view received official acceptance, in large measure owing to the increasing incompatibility between poor-law and public health administration and the spreading over from poor-law to public health administration of the general influence of “deterrence” as a motive of administration. As time went on, this principle came to be realised as contrary to the general interest in anything which concerns the health of the community.

Dirt and Disease

The crude generalization emerging from the earlier surveys was the close relation between filth conditions and excessive sickness; and the motive behind these inquiries was the desire to remove one of the chief causes of destitution.

So late as 1874 Simon said “filth is the deadliest of our present removable causes of disease”; and throughout the whole series of his vividly worded and influential reports, the same fundamentally important teaching was urged.

Chadwick’s earlier reports were similarly influenced by the teaching of Dr. Southwood Smith and his collaborators, to the effect that epidemic diseases as a whole are the direct consequence of local insanitary conditions. This generalization, as we now know, needs a modified and more accurate statement, specialized for each individual disease. In its original form, however, it embodied a realisation of the immense importance of the environment to make or to mar individual and national life; it secured the beginning of our national sanitary improvements, and it laid the foundations of the house of health which as nations we are still building.

The three diseases which were especially regarded as due to filth were cholera, typhus, and enteric fever; and the history of public health in England is largely concerned with these three diseases.

Cholera

The general view then held in New as in Old England is well stated in the following extract from the Report of the Massachusetts Sanitary Commission, 1850:

Atmospheric contagion is generally harmless unless attracted by local causes ... that terrible disease, Asiatic Cholera, derives its terrific power chiefly or entirely from the accessory or accompanying circumstances which attend it. It bounds over habitation after habitation where cleanliness abides; ... while it alights near some congenial abode of filth or impurity.... Wherever there is a dirty street, court, or dwelling-house, the elements of pestilence are at work in that neighbourhood.

And the important moral is drawn that

the person who permits his neighbour’s atmosphere to be contaminated by any filth ... is worse than a highway robber. The latter robs us of property, the former of life.

Similarly, Simon in England was teaching that “in order to the prevention of Filth Diseases, the prevention of filth is indispensable”; and that there was need for local authorities “to introduce for the first time, as into savage life, the rudiments of sanitary civilization.”

The crude generalization that filth causes disease perhaps persisted too long, and the value of Snow’s investigation in 1855 of the outbreak of Cholera in the area of supply of the Broad Street pump was perhaps too slowly appreciated. The influence of Von Pettenkofer’s theories on the relation between subsoil conditions and Cholera was largely responsible for this delay; but already in 1856 Simon had accepted the importance of water infection, giving as his general conclusion that

under the specific influence which determines an epidemic period, fecalised drinking water and fecalised air equally may breed and convey the poison (of Cholera).

Still it will be noted there persisted the notion of aerial convection of the contagia of cholera and enteric fever, in addition to their convection by dirt, by flies, or the more common contamination of hands or feet or food by faecal matter; but the importance of water supplies was beginning to be appreciated. Already in 1883 local authorities in England and Wales had outstanding loans for waterworks amounting to twenty-nine million and for sewerage amounting to fifteen million pounds sterling, while between 1883 and 1912 they expended out of rates and by means of loans one hundred and thirty-one millions for waterworks and eighty-nine millions sterling for sewerage.

Although we realise now the greater importance of control of excreta from persons specifically infected, we must agree with Simon that communally

Nowhere out of Laputa could there be serious thought of differentiating excremental performances into groups of diarrhœal and healthy.... It is excrement, indiscriminately, that must be kept from fouling us with its decay.... It is to be hoped that ... for a population to be thus poisoned by its own excrement, will some day be deemed ignominious and intolerable.

And it is still opportune to draw attention to the terrible responsibility incurred by local authorities when they distribute a general supply of water to the inhabitants of their area without taking every possible precaution against contamination. The conveniences and advantages of public water supplies “are countervailed by dangers to life on a scale of gigantic magnitude”; and sanitary history, in the calamitous experience of Lincoln, Maidstone, and Worthing and of Lowell and other towns and districts, has given remarkable illustrations of the need for eternal vigilance.

Typhoid Fever

With the differentiation of typhoid fever from typhus fever by Gerhard in Philadelphia in 1837, and by Stewart and W. Jenner in Great Britain in 1849, it became possible to associate the former with excremental, the latter with respiratory filth, “the non-removal of the volatile refuse of the human body.” The question still remained whether typhoid fever was producible by “emanations from decomposing organic matter,” whether it was “often generated spontaneously by faecal fermentation,” as contended by Murchison, who in 1858 proposed the name “pythogenic fever” for typhoid fever; or whether as indicated by the remarkable observations of William Budd of Bristol, the introduction of specific infection from a typhoid patient was needed to start a local outbreak. Gradually it became clear that specific contamination was necessary to start an outbreak or even to cause a single case of this disease, and between 1870 and 1880 a number of water-borne outbreaks were traced. It also gradually became evident that, however objectionable or even noxious might be the gaseous emanations from leaky drains or sewers, they did not cause typhoid fever or diphtheria. Hence the statement, for instance, of Oliver Wendell Holmes in 1862 (quoted for its historical interest by Dr. Sedgwick) that “the bills of mortality are more obviously affected by drainage than by this or that method of practice,” which expressed universal opinion when it was written, is now known to be accurate only when specific matter from drains contaminates milk or water supplies, or causes infection by actual contact.

With the general recognition of the causal relation between impure water supplies and typhoid fever came the rapid provision of public supplies, on which, as already seen, large public expenditure was incurred; and to this fact is owing, in the main, the rapid reduction in typhoid mortality shown in the following statement:

The number of cases notified in England and Wales

in 1911 was 13,852
in 1917 was 4,601

There was, it will be noted, a period of apparent cessation of decline in the typhoid mortality between 1891 and 1901, followed by a striking decline between 1901 and the present time. The late decline was due in large measure to the discovery of the relation between contaminated shell-fish and enteric fever, and, probably to a less extent, to the realisation of the importance of the small minority of cases of this disease, who continue after their recovery to spread infection. At the present time typhoid fever promises to become as rare in England as typhus fever or malaria; and with increased care in the protection of food, as well as of water supplies, and with the universal hospital treatment of the sick and observation of their bacterial condition on discharge, this anticipation bids fair to be realised.

Typhus Fever

The history of typhus is similar to that of typhoid fever; and when Murchison in 1858 asserted its spontaneous generation under conditions of overcrowding and bad ventilation—

Its great predisposing cause is destitution; while the exciting cause or specific poison is generated by overcrowding of human beings with deficient ventilation—

he was expressing the considered conclusion of his period.

Typhus Fever was not differentiated from enteric fever in the Registrar-General’s returns prior to 1869, but the course of events in later periods can be seen in the following statement:

The cases in recent years were nearly all traceable to imported infection.

The main factors in the reduction of typhus fever have been the immobilisation of infectious cases in fever hospitals, the rigid cleansing and disinfection of invaded households, and the surveillance of persons who have been exposed to infection. The clearing of insanitary courts, housing improvements, and the associated increased cleanliness of the general population have doubtless aided; and it is a suggestive fact that although the virus of typhus is not yet determined, and although it has only recently been shown that typhus is a louse-spread disease, the point of extinction of the disease under peace conditions has almost been reached in countries having an efficient sanitary organization and a cleanly people.

With the demonstration that typhoid fever was commonly water-borne, that the spread of typhus fever could be controlled by sanitary surveillance and immobilisation of infectious cases in hospital, and that diarrhœal mortality could be reduced by increased municipal and domestic cleanliness, much more rapid improvement in national health occurred in the decennium 1871-1880 and in subsequent years.

The course of events for typhoid and typhus fever has already been noted. Before describing further the action taken by central and local public health authorities and the other influences conducing to reform, it is convenient to summarise at this point the

General Results in the Saving of Life

Although I do not dwell further on the influence of increase of wages, of better and cheaper food, of sanitary education of the people, of a steadily increasing standard of cleanliness,—in person and in spitting habits,—and of improving home conditions, it will not be assumed they must be omitted in any considered judgment as to the means by which the saving of life shown by the following figures has been secured.

The expectation of life at birth (or mean after-lifetime) in England and Wales in 1871-80 for males was 41.4 years, for females 41.9 years. It steadily improved decade by decade; based on the experience of 1910-12 the male expectation of life had been prolonged by 10.1 years, and the female by 10.8 years. A very large proportion of the lives saved were lived in the years of greatest value to the community. Comparing 1910-12 with 1871-80, the reduction of the death-rate meant that each year 116,401 male and 118,554 female lives were saved, and the future lifetime of these persons whose lives were prolonged,—assuming a continuance of current experience,—would give an annual gain of nearly ten millions of additional years of life, of which over seventy per cent. would be lived at ages 15 to 65.

Of the annual saving of 234,955 lives, 64 per cent. was ascribable to reduced mortality from acute and chronic infectious diseases; and of the mortality under these headings nearly one-third was referable to respiratory diseases, the same amount to tuberculosis, one-seventh to scarlet fever, one-thirteenth to measles and whooping cough, the same amount to typhus and enteric fever, and one-sixteenth to diarrhœal diseases.

The gain of life may be further illustrated by the following figures. During the 32 years, 1881 to 1912, over seventeen millions deaths occurred in England and Wales. Had the experience of 1871-80 continued throughout the subsequent years, the number of deaths would have been increased by close on four millions.

Specific Causation of Disease

The preceding review will have made it clear that in the period of earlier slow sanitary reform, although much invaluable work was being done, it was in some measure a groping in the dark, a continuous search for further light while pursuing (or at least advocating in season and out of season) such cleansing and purification of man’s surroundings as were evidently needed, and such segregation of the infectious sick as could be secured in the absence of complete information of the cases of sickness. Happily in the case of Small Pox there was an additional effective protection in vaccination.

With Pasteur’s discoveries was inaugurated a new era in sanitation; the general microbial origin of infectious diseases, inferred from his discoveries, leading to the conclusion that the chief source of disease to others is man himself, and that his surroundings in the main cause disease insofar only as they become a vehicle for conveying disease by direct inhalation of infected dirt (Sax. drit = excrement), or by swallowing specifically infected foods.

The importance of the sanitary engineer in securing pure water supplies and satisfactory sewerage continues. The sanitary inspector’s work in removing nuisances and accumulations, any one of which might be specifically contaminated,[4] and in controlling overcrowding and uncleanliness as well as in other respects, remains indispensable. But the brunt of guidance in the exact prevention of disease, especially of communicable diseases, must necessarily now fall on

the epidemiologist,

the vital statistician, and

the laboratory worker.

Present Limitations of Epidemiology

The epidemiologist must always remain the chief of these three, suggesting and arranging the details appropriate to each investigation, putting together the facts supplied by the two other workers and drawing legitimate conclusions. In conducting his inquiries and in searching for further light on obscure points, he will need to remember Simon’s remarks (Eighth Report of the Privy Council):

In the category of time, far out of human reach, there are circumstances which greatly influence contagion.... These almost cosmic arisings are spreadings of disease or facts of cosmo-chemical disturbance which no mere contagionism can explain.

These words had special reference to cholera, and although we still know little or nothing of the mysterious influences which permit cholera when unimpeded to undertake transmundane travels at irregular intervals of time, we can claim with certainty that in any country in which sanitary surveillance is well organised, and the internal sanitation of the country is good, the spread of cholera need not be feared. Thanks to the great discovery of Jenner and to the complete organization of measures for isolation of the sick, and for vaccination and surveillance of contacts, we can make the same claim for smallpox, whenever this mysterious disease begins its occasional world travels.

But we have to confess our continuing relative helplessness in preventing the spread of measles, and of acute catarrhs, among our endemic infections, and still more of influenza when—as recently—it makes its devastating swoop on the entire world, and secures a larger number of victims than the World War itself.

We can recommend isolation of the sick, and personal precautions in speaking and in coughing and sneezing, and occasionally may score an isolated success; but we are practically helpless against this enemy. Nor are we better acquainted with the means for preventing the spread of poliomyelitis; and we cannot claim that any measure against the spread of cerebro-spinal fever has had undoubted success, except only rapid amelioration of the conditions of overcrowding under which it especially occurs. These instances suffice to show that in the region of respiratory infections,—with the one notable exception of tuberculosis, which we can control, whenever we are ready to take the necessary complete measures—we have much to learn. In respect of most diseases due to respiratory infection we are groping in darkness nearly as dense as that which beset Chadwick, Farr and Simon in their earlier work, and with little hope of any campaign comparable with that against dirt en masse, which was largely effective in reducing the specific infections of cholera, dysentery, and enteric fever, of typhus fever and even of tuberculosis.

The great public health requirements for the future are the conquest over acute respiratory infections, including not only affections of the lungs, but probably also measles and whooping cough, cerebro-spinal fever and poliomyelitis and their allies; and the prevention of cancer. So while thankful for the discoveries already made, and for the beneficent work already accomplished, we must hope that the rapid increase of Medical Research in England and here will in due time enable us to extend the application of preventive medicine to diseases so far uncontrollable.

The Importance of Vital Statistics

In England public health progress has been largely actuated by records of mortality, which have served to make the public realise the need for expenditure of money on sanitary reform. Experience has shown, as Dr. J. S. Fulton has expressed it, that

every wheel that turns in the service of public health must be belted to the shaft of vital statistics.

Accurate and complete returns of deaths and their causes are essential in investigating the local and occupational incidence of disease, and in comparing the experience of different communities: and the various weekly, quarterly, annual, and decennial reports issued from the Registrar-General’s Department have rendered invaluable service to the cause of public health. “Ye shall know the truth, and the truth shall make you free.”

It was not the least of Chadwick’s services to the State that he discovered William Farr, who was intrusted with the compilation of, and comment on, our early statistics from 1837 onwards. His reports, with those of Simon, embody the history of sanitary progress in England and the motives and arguments which actuated it.

The registration of births similarly enabled comparison of birth-rates to be made; also of maternal mortality in child-bearing and of infant mortality in different areas, and at different parts of the first year of life; and these studies made by medical officers of health and more exhaustively in the Medical Department of the Local Government Board have had great influence in determining the intensive work for improving the conditions of childbearing and of infant rearing, which in recent years has been accomplished.

As time went on it became clear that registration of deaths gave a very imperfect view of the prevalence of disease, and that so far as infectious diseases were concerned, valuable time was lost when preventive action could only be taken after the patient’s death. Death registration told of the total wrecks which had occurred during the storm; it gave no information as to early mishaps, enabling others to trim their vessels and thus weather through. It gave a list of killed in battle, not of the wounded also.

And so began gradually, in characteristic British fashion, the notification of infectious cases, the list of notifiable diseases being extended from time to time.

From 1911 onwards the Local Government Board prepared a weekly statement of infectious cases notified in each sanitary area which was distributed to every medical officer of health. Similar returns of exotic diseases of interest to port medical officers were distributed; and the successive annual summaries prepared in the Medical Department of the Local Government Board showing the incidence of the chief epidemic diseases in every area now constitute one of the most valuable epidemiological records extant.

Collaterally with the notification of infectious diseases, including tuberculosis, to the medical officer of health, occurred the enforcement of notification of various industrial diseases occurring in factories, such as anthrax, lead and arsenic poisoning, to the Chief Inspector of Factories, Home Office.

Conditions of Medical Practice Bearing on Public Health

It cannot be claimed that notification of acute infectious diseases, still less of tuberculosis, has been complete. It is impossible to discuss the reasons for this in the present address (see Lecture IX); but the present conditions of medical practice are largely responsible for the partial lack of success. Hasty conditions of work, failure to employ laboratory means of diagnosis, or to utilise available consultation facilities (especially in tuberculosis), and lack of training of medical practitioners in preventive medicine, are among the obstacles to further control of disease.

There will not be complete success until means are discovered for training and enlisting every medical practitioner as a medical officer of health in the circle of his private or public practice, and of securing his services not only in the early and prompt detection of disease, but also in the systematic supervision during health of the families under his care, and in advising them as to habits or methods of life which are inimical to health.

Poor Law v. Public Health

An approximation to this ideal was in the minds of the early sanitary reformers; and it was one of the misfortunes associated with the deterrent policy of poor-law administration in medical relief, that separation between Poor Law and Public Health appeared to offer the best prospect of sanitary progress.

Had Simon’s advice been followed, when the Local Government Board was about to take over the public health duties of the Privy Council, the poor-law organization might, and probably would gradually, have been permeated by public health activities, and thus the sanitary welfare of the poorest class of the community would have been more completely safeguarded on its personal as well as on its environmental side.

In his Eleventh Report to the Privy Council (1868) Simon recommended adherence to the intention of Mr. Lowe’s Nuisance Bill of 1860, which would have identified the health and destitution authorities. He deprecated the institution of “a differently planned organization for objects exclusively of health”; subject to the conditions that public health should not be subordinate to poor-law work and that there should be power to combine districts for certain purposes, and action through committees in sub-areas.

Had this course been pursued, and had the central public health policy not been preponderantly non-medical and poor-law in sentiment and tradition, more rapid progress in public health would have been experienced. The central evil was intensified, as is shown in Simon’s Public Health Institutions, by regarding the medical officer of the Local Government Board as merely advisory, and by the retention and extension on a large scale of local inspection by lay officers of the Central Board, for conditions which needed systematic medical control.

The problem of the proper relation between destitution and public health and between the authorities dealing with these, runs right through our past history of social progress, and it is not even yet satisfactorily adjusted.

The gradually increasing dissatisfaction with Poor Law administration led to the appointment of a Royal Commission which after several years deliberation, in 1909 presented a Majority and a Minority Report.

The dissatisfaction, which these reports justified, may be said to have been inherent in the situation; for the Poor Law organization was constantly attempting,—more or less under the influence of the principle of “deterrence,”—two incompatible tasks: to prevent undue dependence upon parochial assistance and to give to those needing them the medical and nursing assistance which the principles of preventive medicine require should be given unstintingly, and completely freed from any deterrent element. Although in many parochial areas admirable medical work was done, this was the exception, not the rule; and public sentiment rebelled against the giving or the receiving of medical assistance to which was attached the “poor-law stigma.” Both reports recommended the scrapping of the poor-law machinery by abolishing the present Boards of Guardians and the general mixed workhouse; and the Minority Report went further, proposing to complete the supersession of the poor-law by various preventive authorities, which were already partially in operation. Thus everything connected with the treatment of the sick would be transferred to the Public Health Authorities, the care of school children to Education Authorities, of lunacy and the feeble-minded to already existing Asylum Committees, and so on.

Behind these proposals lay the principle that the treatment and the prevention of disease cannot administratively be separated without injuring the possibilities of success of both; and this is a principle which happily is becoming more generally accepted.

Before the report of the Poor Law Commission was issued, examples of the application of this axiom existed in the isolation and treatment of patients with acute infectious diseases; in the increasing provision for the treatment of tuberculosis; in the extension of provision for care of parturient women and for their infants; and in the system of school medical inspection followed to some extent by treatment.

It is convenient to add here, that under each of these headings, great extensions have been made since 1911; and an even more spectacular public provision of treatment, as the best method of preventing further extension of disease, is exemplified in the gratuitous and confidential diagnosis by laboratory assistance and the treatment of venereal diseases now given in every large town in the country, the Central Government paying three fourths and the Local Authority one fourth of its cost. In order further to secure the success of this treatment,—which is provided for all comers with no residential or financial conditions,—the legislature has passed an enactment forbidding the advertisement or offering for sale of any remedy for these diseases, and forbidding their treatment except by qualified medical practitioners.

It is one of the great misfortunes of more recent Public Health administration that the Report of the Royal Commission on the Poor Laws has not hitherto been made the subject of legislation. It would not have been an insuperable task to find a common measure of agreement between the Majority and the Minority Reports. Indeed an adjustment has recently been made between these two reports, as the result of the deliberations of a House of Commons Committee, over which Sir Donald Maclean presided; and it may be hoped that ere long this will mean the realisation of a much belated reform of local administration.

This forms an indispensable step in the needed further struggle against the problems of Destitution. So much of destitution is due to sickness that the separation of the two problems is inconsistent with success. “One-third of all the paupers are sick, one-third children, and one-quarter either widows encumbered by young families or certified lunatics.” There are economic causes of poverty, apart from sickness, but it is essential to remember that every disease which is controlled frees the community not only from a measurable amount of sickness, but from the amount of poverty implied by this sickness.

Had the policy of transfer of the duties of Poor Law authorities to the Councils of Counties and County Boroughs recommended in 1909 by the Poor Law Commission been adopted, these last named authorities would already possess a medical service for the poor employing some 4,000 doctors; they would be in possession of the large infirmaries and other medical institutions of the poor law, and given reforms and readjustments of these which are urgently required, and combination of the hospital arrangements of poor-law and public health, would have a greatly improved medical service freed from poor-law shackles and capable of gradual extension as needs and policy indicate. The fusion of these two services with the school medical service would have been an easy further step; and England would by this time have built up a National Medical Service, for the very poor, for all purposes of public health—including poor-law—administration, and for children and their mothers in special circumstances.

Insurance v. Public Health

Political circumstances, into which it is unnecessary to enter, led to the adoption of a course, which medically ran directly athwart the course of needed reform. The National (Health) Insurance Act, 1911, was passed, giving sickness and invalidity benefits to those employed persons below a certain income who could contribute a weekly sum, which was considerably less than half the estimated cost of the benefits to be received; and an additional medical service, further complicating the already existing medical services of the poor law, public health, and educational authorities, was set up.

The establishment of national insurance against sickness and disablement in the United Kingdom exemplifies the contagiousness, under modern conditions of life, of a new course adopted in any country; and Bismarck’s attempt to counteract socialism by insurance has been responsible for international, state and official experimentation in insurance which has not generally been well advised, and which is associated in England with extravagant cost of administration.

Insurance against sickness is a praiseworthy and valuable provision against future contingencies; and on its non-medical side free from drawbacks. Neither on its medical nor on its non-medical side, however, is it an alternative to prevention of disease; and the National Insurance Act in England must be held in the main to have delayed the public health reform which would have been secured had equal effort been devoted to it, and the money lavished on insurance given in the form of central public health grants conditional on the active coöperation of local authorities. True, the English public have been educated to think in regard to sickness in millions when previous provisions for the treatment and prevention of sickness had been thought of in thousands of pounds; and there has been an extension of provision for the institutional treatment of tuberculosis, which probably has been more rapid than would otherwise have been made, in the absence of the alternative grants named above. It should be added that, owing to the natural insistence of insured tuberculous patients on treatment in a sanatorium, and to the desire of Local Insurance Committees and their officers to satisfy insured persons, sanatoria have often been filled with unsuitable patients, sent there regardless of relative social and public health needs. The Maternity Benefit (of a sum of money on the birth of an infant to the wife of an insured person or to an employed woman) similarly is given unconditionally, and should be replaced or supplemented by the provision of service needed at this time (doctor or midwife, nurse, domestic assistance), which would ensure the welfare of both mother and infant.

Apart from other reforms the transfer of medical provision, of provision for tuberculous patients, and for parturient women to public health authorities is urgently needed; and the service should be given according to need irrespective of insurance. The valuable fund for medical research has already been placed under the Privy Council.

The absurdity of regarding insurance as anything beyond a possibly useful handmaiden and auxiliary to Public Health, when strict administrative arrangements are made for this purpose, may be illustrated by the question as to what would have been the result in sanitary progress if Chadwick or Simon had persuaded the government of their day to insure a favoured section of the public against the risk of typhus or smallpox or tuberculosis or even of non-infectious illness?

Under the National Insurance Act medical domiciliary assistance,—but only to the extent which is within the competence of a medical practitioner of average ability,—is provided under contract for one-third of the total population; and evidently this implies an immense abstraction from ordinary private medical practice. There is no provision, hitherto, for consultant and expert facilities when required (except for tuberculosis), for the nursing of patients, or for institutional treatment of any disease, except tuberculosis; and no funds are generally available for these purposes except such as belong to the community at large.

In view of the preceding facts and of other considerations which I have not mentioned, reconstruction of the English Insurance scheme is obviously required. The scheme cannot persist in its present form. The already accomplished amalgamation of the Local Government Board and National Insurance Commission, should make radical changes easier; an equally important step would be the transfer of the medical functions of the Local Insurance Committees to Public Health Authorities. The creation of these independent committees was one of the greatest blunders of the National Insurance Act, which was conceived ill-advisedly, had too short a gestation, and suffered a premature and forced delivery; and we may hope that ere long, it may be replaced entirely, on its medical and hygienic side, by a rapid extension of the medical activities of the public health service which will conduce to the welfare of the whole nation.

It is impossible to justify the continuance of state subsidisation of benefits for a favoured portion of the wage-earning classes, when poorer persons who do not come within the category of employed persons or who fall out of employment, and when clerks and others on limited salaries who are unable to provide adequately for sickness, are left unprovided for.

A National Medical Service

What is most urgently needed is a national medical service which will give for all who cannot afford them hospital treatment and the services of consultants and of scientific aids to diagnosis and treatment whenever required; and which will provide nurses during illness treated at home, when this is asked for by the doctor in attendance.

Outside the operation of the National Insurance Act, these services have been provided to a steadily increasing extent, but in a characteristically British fashion. They have grown largely under voluntary management, and as exemplifications of Christian philanthropy; though official has rapidly overtaken the voluntary provision of hospitals and nursing, the two working side by side, each in their respective spheres, and on the whole with cordial coöperation. The extent to which institutional treatment with its more satisfactory arrangements is replacing the domiciliary treatment of disease may be gathered from the following striking facts:

In England and Wales

Of deaths from all causes, in 1881 = 1 in every 9

Of deaths from all causes, in 1910 = 1 in every 5

In London

Of deaths from all causes, in 1881 = 1 in every 5

Of deaths from all causes, in 1910 = 2 in every 5

occurred in public institutions.

The facts as to Pulmonary Tuberculosis are even more significant:

In the year 1911

in England and Wales 34% of male 22% of female

and in London 59% of male and 48% of female

deaths from pulmonary tuberculosis occurred in public institutions; and as each of these patients spent on an average several months in hospital, at the most infectious stage of their illness, a material annual reduction in the possibility of massive infection of relatives and others has been secured.

Hospitals Important Housing Auxiliaries

This institutional treatment of the sick has been one of the chief influences counteracting the pernicious effects of industrialism and urbanization. It has relieved housing difficulties at a time when insufficient bedroom accommodation is most injurious; and it has secured year by year for a steadily increasing proportion of the total population the improvements of modern surgery and medicine as practised in institutions, which permit of the poor thus treated receiving more satisfactory and more hopeful treatment than is obtainable for a large proportion of other classes of society.

My address is already too long. Other opportunities will be taken of explaining the rapidly increasing part which the State and Public Health Authorities are taking in the hygiene and care of motherhood and childhood and of school children; in the provision of additional nursing services for the sick, in the rapid growth in numbers of public health nurses, health visitors, school nurses, etc.; in special schemes for the treatment of tuberculosis and of venereal diseases; and the circumstances under which the Central Government are to a rapidly increasing extent paying half (or in certain instances three-fourths) of approved local expenditure on the provision of hygienic, nursing and medical services; and I do not therefore dwell on these points further.

Nor need I comment here on the remarkable fact that the British Government under present circumstances have departed from the economic position that houses built by local authorities must be able to be let at a rental covering all outgoings.

In Lecture II I shall deal with problems of local and central government, and with the training and appointment of medical officers of health; but the present review, if it omitted from consideration on the one hand the value of specially trained whole-time health officers, and on the other hand the health significance of the general advance in the standard of medical treatment, as factors of prime importance in securing the already achieved improvement in human life and health, would give a most imperfect picture of the actual facts.

The need to avoid Complacency

Such figures as I have given, showing saving and prolongation of life during the last fifty years, are apt, if left uncorrected, to create a complacent warmth tending to public health inertia. It may conduce further to this folding of the hands when I state that Simon in his first report to the Local Government Board expressed the opinion that the half million deaths a year approximately which occurred in 1871 in England and Wales were a third (125,000) more numerous than they would be if existing knowledge of the chief causes of disease were reasonably well applied throughout the country; and further that had the mortality experience during 1911-15 held good for 1871, the deaths in that year would have been reduced by 200,000 instead of by 125,000, the ideal then aimed at by Simon.

But with increased knowledge we know that a larger proportion of diseases are preventable than was formerly supposed. It will be easy within the next ten years to reduce the death-rate by one-third of its present amount, given systematic and adequate action on the part of Public Health Authorities and an effective educational propaganda among the general public. More important still, an even larger proportion of mankind’s total illness can be avoided, and life on a higher plane of health secured, as well as life prolonged to its normal limit. The work carried out during the last ten years, sanitary, medical and hygienic, in improving the prospects of healthy child-bearing and of normal infancy and childhood constitute the most important advance toward national physiological life on a higher plane which has hitherto been made.

Preventive medicine can never be satisfied until it has approached Isaiah’s ideal (Isaiah, LXV, 20), “There shall be no more thence an infant of days, nor an old man that hath not filled his days; for the child shall die a hundred years old.”

FOOTNOTES:

[1] An address prepared for the celebration of the fiftieth anniversary of the Massachusetts Board of Health, September, 1919.

[2] The administrative side of the subject is sketched in the next chapter.

[3] Reprint of Reports, Vol. I, p. 448.

[4] There is still no evidence to show that in the production of the excessive diarrhœa which prevails in insanitary districts, specific contamination of the filth accumulations is necessary.

CHAPTER II
The Historical Development of Public Health Policy in England[5]

The subject is too large to be treated adequately in the course of an evening’s address; and to bring it within manageable compass it is necessary for me to select my material rigidly and, as far as I can, to present this material in such a manner as will bring into relief its salient and most instructive features.

The evolution of public health in England proceeded by experimental steps, some mistaken and then retraced, others mistaken and not retraced, but steps oftenest in the direction of a complete service, which is the goal of our work.

The evolution has been a gradual growth arising out of realized needs, rather than a logical development based on general principles; and as politicians and legislators seldom take a wide outlook, or consider a specific proposal in relation to what is already being done, and to what is the desired goal, the English experience is especially instructive.

Town-living and Health Problems

Public health work became an urgent necessity when men began to huddle in towns; and with the industrial revolution of the eighteenth and early nineteenth centuries the need for remedial action became acute. It is hard to realize that in the days of our grandfathers, the home was in most instances the unit of industry; and that in the eighteenth century communications between districts and towns were not more advanced than those of the ancient Egyptians. When, however, vast urban aggregations of population multiplied, travelling facilities rapidly increased, and the results of crowding, of contaminated water supplies, of intensive and widespread infection, were seen in devastating endemic and epidemic diseases. Poverty, squalor, dirt, and their consequences, were rampant in the towns, where underpaid work-people were exploited by masters, whose self-centred outlook had some share of justification in the political economy doctrines of the time, which regarded any interference with “freedom of contract” as useless or even pernicious.

What is public health work? It is best defined by stating its object, which is to secure the maximum attainable health of every member of the community, so far as this can be secured by the authorities, local, state, or federal, concerned in any part of government, acting in coöperation with all voluntary agencies whose work conduces to the same end. The connotation of public health becomes wider year by year. It embraces physiological as well as pathological life; being as much concerned with improving the standard of health of each person as with the prevention and cure of disease. Hence the importance of the “concentration on the mother and her child” (John Burns), to secure for them by all practicable means the conditions of complete health, which during the last twelve years has been a vital part of our public health work, and which is now being made to include not only all hygienic and medical help that may be needed, but also such domestic aid as may enable the mother to bring her children into the world and to rear them under advantageous conditions.

Scope of Constructive Health Work

Public health embraces some eugenic elements, and may comprise more when eugenists have accumulated adequate non-fallacious evidence on which to base valid conclusions. Already partial steps are being taken to secure the segregation and prevent the propagation of the feeble-minded and the insane; and in sorting out congenital infection from true heredity action is being taken to avoid congenital syphilis and to prevent the large number of still-births due to this race poison.

Public health in the main is concerned primarily with the environmental measures calculated to prevent the attack of man by disease, whether pre-natal or post-natal. These measures may be industrial, as in the prevention of accidents, of dust, of noxious vapours; or sanitary, as in the control of water supplies, food, or milk, and in the removal of organic filth; or may be the application of preventive medicine against infectious and non-infectious diseases; or therapeutic, consisting of the prompt and adequate treatment of all illnesses and the curtailment of the incompetence due to them; or educational, consisting, first in importance, in the training of medical practitioners, of public health officials, and nurses; and, next, in the education of the general public and especially of the children in our schools, in the science and practice of public health.

Advances in public health in many directions can only be secured by continued and extended medical research, and public health, therefore, has a direct and immediate interest in promoting and subsidizing such research.

These being the objects of public health, how far have we travelled toward securing the end in view? I do not propose to myself the pleasant task of showing to what extent the general death-rate has been lowered, infant and child mortality greatly reduced, the duration of life extended, how typhus and smallpox have been almost eradicated, typhoid fever made a disappearing disease, and tuberculosis has become the cause of only half its former death rate. When inclined to indulge in such pleasant considerations, I recall the statement I have made elsewhere that one-half of the mortality and disablement still occurring at ages below seventy can be obviated by the application of medical knowledge already within our possession.

Let me attempt the more difficult task of outlining the history of forms of administrative control of disease since 1834.

Reform in the Control of Poverty

Poverty and disease work in a vicious circle in which cause and effect often change places; but it is certain that disease is one of the most fertile causes of poverty, using the word poverty in the sense of privation of one or other essential of physical well being.

For this reason, and because the half starved form a constant social danger, poor-law administration long antedated public health administration. There is not time to follow the course of earlier poor-law administration, with its many and grievous abuses. The Poor-Law Amendment Act of 1834, gave the Central Government control over the systems of local relief, secured the combination of parishes into unions for poor-law relief,[6] and forbade outdoor relief to able-bodied men. The creation of an organ of central control has led to the subsequent course of aid to paupers being determined in the main in London, action of poor-law guardians being subject to supervision by government inspectors, and to endorsement by the Central Authority. At first, medical assistance under the reformed Poor Law was made as deterrent as non-medical relief; and although there has been much improvement, chiefly on the institutional side, medical treatment under the Poor Law has to some extent retained this deterrent element, and it has, except in the poor-law infirmaries of large cities, remained generally disliked by the people concerned.

The first Central Poor-Law Authority was a Commission having no representative in Parliament. In 1847 it was replaced by a Board, the president of which was a member of Parliament and of the Government. Here once for all Parliament declared its intention to maintain direct control of central official government, and in this and in all other departments has done so. If democracy is to be real,—and we have no sound, practicable alternative to it,—evidently the representatives of the people must be masters of the administration; and English policy has never wavered on this point. After many years’ experience of public life in England, I have no hesitation in saying that this principle is sound; that it insures progress which, although slow, is less liable to relapse than administration under autonomous expert commissions, whether centrally or locally; and that any lack of progress that has been experienced in central government has been as much the result of inactivity and of lack of sympathy with social reform on the part of the permanent officials of government departments who have had access to their parliamentary chief, as of the inertia of politicians or their obstruction to reform.

Dissatisfaction with Poor-Law administration has steadily increased in the years since 1834, as the problem of the able-bodied pauper has diminished and the Poor Law has been concerned more and more with the sick and infirm, the aged, and children. These at the present time form some 98 per cent. of the total population relieved. The fundamental principles of the Poor Law were rightly attacked. It did not comprise elements tending to build up disabled families, or to prevent families from falling hopelessly and permanently into destitution. The law was administered almost entirely with a view to relief; practically not at all as a curative agency. In medical language, symptomatic and not rational causal treatment was the rule.

In medical relief, poor-law administration has been a constant struggle between increasingly humane treatment and the conception that the pauper’s position must remain inferior to that of the non-pauper; an important principle when applied to the able-bodied adult who has drifted into willing dependence; mischievous when applied to sick persons, and to dependent women and children.

The general dissatisfaction with poor-law administration led to the appointment of a Royal Commission on the Poor-Laws which, after several years’ deliberation, published in 1909 a majority and a minority report. Both these reports recommended the abolition of boards of guardians, and the transfer of their duties to the 144 largest public health authorities in the country (County Councils, 44; and the Councils of county boroughs, 82), and the abolition of the general workhouse. The majority report would have continued the Poor-Law Guardians as a Committee of the new Authority; the minority report proposed to distribute the duties of the guardians to different committees of the Public Health Authority; thus medical treatment to the Public Health Committee; the care of lunacy and the feeble-minded to the Asylum Committee; care of children to the Education Committee; vagrants, etc., to the Police Committee; a special committee concerning itself with all questions of monetary assistance.

A compromise between these two schemes has recently been arranged, and when the new Ministry of Health, which will combine public health, poor-law, insurance, and educational medical work in one department, has found time to do urgently needed work, the above indicated reform may be hoped for, along with the even more urgently needed reform of local public health administration, and the abolition of a large number of the smaller and less efficient sanitary authorities. With these reforms will come much needed de-centralization of poor-law work. Good work in all respects cannot be secured if the Central Authority concerns itself, as at present, in minutiae of local administration, and has no time to devote itself to the larger problems, and to the task of bringing indifferent, chiefly smaller authorities, up to the standard of efficient local authorities. A large portion of the expense of local poor-law administration is borne by the central exchequer, and this money if properly applied will give the necessary leverage for reform, while leaving progressive Authorities, and especially the Authorities of large towns, free to experiment and advance.

Reform in Industry

The industrial revolution meant the subjection of large masses of working class families to evil conditions of housing and work in crowded and insanitary dwellings and factories. The public conscience first rebelled in regard to boarded out and apprentised pauper children; and the first Factory Act in 1802 concerned itself with them; and with this Act emerged the germ of machinery for securing compliance with the law, magistrates and clergymen being appointed as inspectors under the Act.

The Act was largely futile; but it meant the beginning of the gradual breaking down of laissez faire doctrines; and there followed a more widely operative Factory Act in 1833, restricting hours of labor of children, and initiating professional inspectors controlled and paid by the Government. In 1842 the underground employment of women in mines was forbidden; and at intervals since then numerous factory and allied acts have been passed, restricting the duration and conditions of work of women and children, improving rules as to sanitation, insuring systematic inspection by government inspectors, and constituting a far reaching system of supervision and control.

The inspectors, on whom falls the burden of ensuring compliance with the Factory Laws and regulations made under them, are controlled by the department of the central government known as the Home Office; their work on the whole has been well done, and the conditions of factory and workshop life have greatly improved. Some portion of the sanitary supervision of these work-places falls on the local Sanitary Authority; but in the main the system is one of absolutely centralized government control. This secures almost complete absence of improper influence of interested local persons, whether masters or workmen; but it is arguable that this system should be replaced by a localized system, the inspectors being officers of the 144 larger authorities. These local officers could be placed in direct touch with the Home Office or the Ministry of Health and with the central staff of inspectors having expert knowledge in the different branches of industrial work.

Public Health Reform

Public health reform was a direct consequence of the Poor-Law Amendment Act, 1834. Anxious to diminish the enormous expense of the existing Poor Law, and realizing that a large share of this sickness was due to fever and other illnesses, surveys and inquiries were set on foot by the commissioners administering this Act, and the reports which followed revealed a state of things urgently calling for sanitary reform, in the interest of national economy as well as of health. “An Act for Promoting the Public Health” was passed in August, 1848, which created a General Board of Health consisting of four members and a secretary. These Commissioners, among whom was Edwin Chadwick, former Secretary of the Poor Law Board, initiated a system of procedure which was largely on the lines of poor-law action, and which involved constant pin-pricking by the Central Authority of the grossly indifferent local authorities. The commissioners were more zealous than discreet; and after six years they were no longer tolerated. At that time centralization was as much a bogie as socialism has become in more recent years. Parliament and the localities represented by its members doubtless feared the reforming activity of Chadwick and his colleagues, though they sheltered themselves behind their exaggerated fears of bureaucracy and centralization.

A new board replaced the old, parliamentary in character, its president being a member of the Government. This repeated, so far as concerns Parliamentary headship, the story of the Poor-Law Board, and established once more the theory of the administrative control of the representatives of the people. Nor, although the change meant for the time serious slackening in sanitary reform, can objection be taken to it. In a democratic government the elected representatives of the people must take first place; and it is the rôle of officials to educate them in the direction of needed reforms. Reforms which do not carry public opinion with them are not likely to be permanently successful; and, whether in administration or in legislation, attempts to sidetrack or ignore this fact are not likely to be permanently effective.

Public Health Reforms

When the Local Government Board was formed in 1870, a second opportunity was lost of developing Public Health Administration on lines which we now know to be the best adapted for a complete service of preventive medicine. The first lost opportunity was when sanitary authorities, completely separate from poor-law authorities, were created for administering the sanitary laws. Probably this arose from Chadwick’s despair of getting effective sanitary reform from poor-law guardians; but the creation of separate authorities was scarcely consistent with the fact recognized by him that pauperism is largely, if not predominantly a question of sickness; or with the less recognized fact that its treatment forms an essential part of prevention. It was recognized that the care of the sick was largely idle until the unnecessary causes of disease had been cut off, but not that the adequate treatment of sickness is an important means of preventing it or of curtailing it. Rumsey,[7] in 1856, stated the unrealized possibilities of the poor-law medical officer’s domiciliary attendance on paupers in the following words:

There are much higher functions of a preventive nature than those of a mere “public informer” which the district medical officer ought to perform. He should become the sanitary adviser of the poor in their dwellings ... he (should) be in a peculiar sense, the missionary of health in his own parish or district,—instructing the working classes in personal and domestic hygiene,—and practically proving to the helpless and debased, the disheartened and disaffected, that the State cares for them, a fact of which, until of late, they have seen but little evidence.

In the result the ad hoc poor-law authority did not absorb into it the newly created municipal and urban and rural sanitary administration, but continued on its separate path.

Simon, in 1868, had urged the inadvisability of continuing ad hoc authorities, and had urged that, at least, sanitary should be made coterminous in area of administration with poor-law districts. His advice was not adopted, and there followed years in which sanitary authorities were allowed to subdivide areas, until the total number became 1,807 instead of 635, the number of poor-law authorities; and in which they concerned themselves chiefly with nuisances and water supplies and with inadequate provision for the prevention and treatment of infectious diseases. With the creation of county councils and the more complete autonomy of the councils of county boroughs, the large centres of population developed and improved their sanitary administration more rapidly; and it became practicable to undertake every division of sanitary work on an efficient scale. Although much remains to be done, it can be claimed that in our larger towns, containing more than half of the total population of the country, the public health work in nearly all its branches is of a high order. It would have been still more efficient had the poor-law guardians been merged in the Town Council, and had the relationship between the school medical service and the other branches of the public health service been closer than has been the case.

What is now needed is that the defects just named should be made good; that more complete autonomy should be given to the authorities which come up to a required standard, and that especially they should have greater freedom in developing local possibilities of improved administration. Central grants in aid of local sanitary administration are steadily increasing. Already the Government pays one-half of local expenditure on a large program of maternity and child welfare work, one-half of the expense of local tuberculosis work, and three-fourths of the expense of local work for the diagnosis and treatment of venereal diseases, and for propaganda work concerning these. These grants should be the means of greatly increasing good local administration; but if,—this is improbable,—they curtail local experimentation and extension, and bring local public health administration into anything approaching the subservience of local poor-law administration, the value of these subventions will be doubtful.

Education Authorities and Health

The national system of compulsory elementary education inaugurated in 1870 has had valuable indirect influence in promoting the public health. Apart from the beneficent effect of education, the steadily increasing pressure on children to come to school in a cleanly condition and the stimulus of emulation in tidiness and cleanliness, have done much to improve the home conditions of the people. After the South African war much attention was drawn to the large number of recruits rejected owing to physical disabilities; and an inter-departmental committee reported inter alia in favour of a system of medical inspection of pupils in elementary schools, which had often been urged by hygienists. Observations made in Glasgow and Edinburgh by Leslie Mackenzie did much to draw attention to the physical defects in Scottish school children. In 1907 the Board of Education acquired power to make provision through the local education authorities for the medical inspection and treatment of school children. At first little more than inspection of pupils was undertaken, a large number of defects of sight, hearing, parasitic conditions, as well as malnutrition and actual disease being discovered. Gradually some items of treatment were undertaken at school clinics, or at hospitals or centres subsidized by the education authorities; though the amount of treatment is still small compared to the defects discovered and not otherwise treated.

But there now existed in every locality three authorities concerned in the treatment of disease:

1. Poor-law guardians, treating all forms of illness in paupers, at home and in institutions.

2. Public health authorities, undertaking preventive measures against disease, and treating fevers, tuberculosis, and occasionally other diseases in institutions; and more recently providing nurses at home for certain conditions.

3. Local education authorities, concerned in treating certain ailments in school children.

Centrally two government departments were supervising this work, and subsidizing it to some extent from government funds; and poor-law medical work and public health medical work were supervised by two divisions of the Local Government Board acting in almost complete isolation. More recently Parliament has permitted the Board of Education to give grants in aid of schools for mothers, and allied institutions for the care of children under school age; for which institutions, substantially, the Local Government Board in other instances was giving grants.

The separation of the medical work of Education Authorities from public health medical work was contrary to the first principles of sound administration; although it is possible that, owing to the inertia in some public health circles, this separation at first favored rapid advance in school hygiene; just as the early development of public health apart from poor-law administration was probably more rapid than could have been expected from centrally ridden local authorities, concerned chiefly in keeping down the poor rates.

The Ad Hoc Vice

But in both instances there was an offence against the first principles of good administration, which require that when a special function is to be undertaken it shall be undertaken by one governing body for the whole community needing the service, and not for different sections of the community by several governing bodies. Medical treatment is needed for school children and for the poor generally. Why separate this into two administrations? Hospitals are required for paupers with tuberculosis, and for non-paupers with tuberculosis. Why have two authorities for this work? The separate existence of Education and Poor-Law Authorities qûa medical attendance on those children needing it erred, not only in this fundamental respect, but also because neither of these authorities had the preventive facilities and powers possessed by Public Health Authorities, who were also partially engaged in the treatment of disease.

The inveterate tendency in the past has been to create a new authority when any new work was inaugurated, this authority then fulfilling all purposes for a special portion of the community and thus necessarily duplicating the staffs of other departments of local or central government. The crowning instance of this recurring instance of legislative myopia is seen in the case of the National Insurance Act, under which has been provided an imperfect and unsatisfactory domiciliary medical service for one-third of the entire population of Great Britain, when by combining and extending the medical forces of existing departments of the state, a satisfactory service for all needing it would have been secured. The axiom that “the object of community service is to do away with group competitions and bring in its place group coöperation or team work” (Goodnow), is especially applicable to all public health and medical work; and the spirit of this axiom is infringed by the existence of separate, sometimes competing, occasionally conflicting, services under separate local and central control.

Principles of Local Government

The preceding considerations bear on the perennial problem of efficient government, local and central. There are three functions to be performed in government, legislation, determination of administrative policy and extent of work, and the actual executive work. In England, legislation is in the hands of Parliament and is usually national in scope. Large cities, however, not infrequently obtain special legislative power to meet local needs; and by this means have succeeded in advancing local efficiency above the average standard. Local authorities, furthermore, have the power to make regulations and by-laws for special purposes, subject to the approval of the Central Authority.

In settling the details of local administration, the elected representatives of the public are supreme. They meet in Council, and action is taken on a majority vote. The councils of counties and cities, and even of smaller municipal boroughs divide themselves into committees, each consisting of about a dozen members, elected by vote of the whole Council. The chairman or mayor of the Council has no special power, except that he may give a casting vote.

The chief defect in local sanitary administration in England is the continued existence of a large number of small and relatively inefficient local authorities. The larger authorities, as a rule, do their work well, and politics enter but little into elections. Official posts are not vacated with changing councils. These councils are approximating to the ideal of a complete local Parliament dealing with all governmental concerns, and to the further ideal that each unit of government should be large enough to minimize the influence of local interested motives, and to undertake each department of municipal work on a considerable scale. The local Parliament has committees concerned with police, finance, public health, education; and when the urgently needed poor-law reforms are made, and when the Education Committee hands over its medical work to the Public Health Committee, the ideal will become a fact.

Power is already given to coopt on to some of these committees a few persons who are not members of the Council, from among men or women having special knowledge of the Committee’s work; and the exercise of this power has been found to be useful.

But in each committee it is the direct representatives of the public who decide points of policy and settle the main outlines of administration. There is growing up a tendency to appoint local advisory committees, consisting of special groups representing professional or trade interests. Thus a medical committee may be consulted on medical proposals, and so on. This is still in the experimental stage. It will probably prove permanently useful, as voicing the occupational aspect of any proposed work of the municipality; but it will need to be kept to its strictly consultative limitations, and the responsibility of the Council as representing the combined wisdom or unwisdom of the entire community must be maintained.

All substitutes for government of the people by the representatives of the whole population are open to objection. They do not contain within them the elements of permanence. If there is a corrupt council, the remedy is not its supersession by an independent executive. Such an executive is the abrogation of popular government. “Good and efficient government is possible under almost any form of organization. More depends upon men than devices.... But ... if we believe that the functions of deliberation or determination of municipal policy and of administration or the execution or carrying out of that policy should be kept distinct, we cannot avoid the conclusion that a city council is a necessary part of the municipal organization.”[8]

Each committee of the local Council is advised by the County Clerk or Town Clerk on legal and administrative matters; and the medical officer of health and other expert officers, like the legal adviser, in nearly every instance, hold office during good behaviour. Under the above arrangements the elected members and the officials are kept in touch with each other. The latter’s recommendations and actual work must be approved by the former; and this works well under the system of determination of policy by committees, subject to confirmation and control by the entire Council. The motive power is public opinion. Good work cannot for any prolonged period go beyond what the public demand, and the work of officials is one of constant education of their masters and of the public.

The Training and Tenure of Office of Health Officers

Every sanitary district is required to appoint a medical officer of health and since 1888 every medical officer of health for a district with a population exceeding 50,000 must have a special diploma in public health. The enforcement of this requirement has done much to raise the standard of work of these officers. It is significant, furthermore, that while in 1873 the percentage of the total population of England and Wales having whole-time medical officers of health was only 20.6, it had increased to 61.4 per cent. in 1911. In the metropolis, in the whole of Scotland, in every English county (forty-four) and in many other districts these officers possess security of tenure, in the sense that they cannot be removed from office without the consent of the Central Government, which usually pays half their salaries. Even without this safeguard, removal from office by the local authority is rare; but there has been long delay in securing the further reform that in all areas the medical officer of health should be able to perform his difficult and sometimes obnoxious duties without fear of removal from office, or of reduction in his emolument, except as the result of deliberate action on appeal to a central authority.

When pensions can be earned by medical officers of health and by all medical men on the public health staff, their position will become more attractive for men of good standing; and this reform has become more important in view of the steadily increasing complexity of the medical work now undertaken in a large public health department. It will include inter alia the following officers and activities: superintendent medical officers of health; district medical officers of health; tuberculosis officers; medical officers of maternity and child welfare centres, of venereal disease centres; fever hospitals, and tuberculosis sanatoriums and hospitals.

The development of a graduated public health medical service in which each physician employed will be able to develop his own special abilities, will be easier when to the above list is added the work of district (late Poor-Law) medical officers; medical practitioners attending insured persons and such other persons as are treated at the expense of the State; treatment centres for special conditions of the ear, eye, throat; gynecological and other special departments; hospital treatment for general diseases.

That there will be development in these directions when the tangle caused by the National Insurance Act of 1911 has been unravelled, there can be no doubt.

I have in Lecture IV expressed my opinion as to the additional tangle introduced into the central and local government of the United Kingdom by the National Insurance Act of 1911.

The failure of the British Government to act on the recommendations of the Poor-Law Commission of 1909 was a serious misfortune to public health. Sickness is the cause of a predominant part of our total destitution, and to allow the continued separation of administrative action respecting these two problems is inconsistent with a full measure of success. Political circumstances, however, led to the adoption of a course which, medically, ran directly athwart the course of needed reform.

The National Insurance Act and Public Health

The National Insurance Act was passed, placing one-third of the total population (all employed manual workers and other employed workers with an income below £160, since increased to £250) under an obligation to pay 4d weekly (women 3d), 3d being contributed for each person by the employer and 2d by the State. In return each worker receives a money payment weekly during disability from illness, attendance by a doctor, sanatorium treatment for tuberculosis, and a maternity benefit on the birth of a child to his wife (30 shillings), or, if the wife also is industrially employed, an additional 30 shillings. The medical benefit is limited to such domiciliary attendance as a medical practitioner of average ability can furnish. It continues the old popular conception of private medical practice, and allows the public to remain obsessed with the notion that satisfactory medical care consists in a “visit and a bottle.” No provision is made for pathological aids to diagnosis, beyond what is already provided by public health authorities. No nurses are available for serious cases; the insured person is not entitled to surgical operations, when needed, except of the simplest character. With few exceptions, no appliances are provided; the treatment of special diseases of the eye, ear, nose and teeth is commonly excluded. No hospital provision whatever, except for tuberculosis, is made.

The contract system of medical practice has been accompanied by a serious amount of lax certification of sickness. The sanatorium benefit is unnecessary, as soon as the duty of public authorities to provide treatment for tuberculosis is declared obligatory. It is already very largely provided. The maternity benefit is entirely unconditional; there is no guarantee that it is devoted to the welfare of the mother and infant. It needs to be supplemented or replaced by the arrangements for providing nurses, doctors, midwives, and domestic assistance which are in process of development by public health authorities. In short, there is no justification for providing medical services, preponderantly at the expense of the state (contributions by employers are a form of taxation), which are limited to a favored portion of the total population, and which do not benefit all in need of these services.

Provision for Sickness

The principle of monetary insurance against sickness and disability is thoroughly sound. It forms a praiseworthy and valuable provision against future contingencies. Insurance, however, is not synonymous with prevention as is too often suggested. In England insurance has been an actual impediment to public health work, though it might have gradually become a useful auxiliary to it if otherwise organized, and especially if the creation of independent insurance committees representing interests to a preponderant extent had been avoided. But any medical service needed for purposes of insurance should not form part of the insurance system. Medical aid is needed for a large section of the population who are unable to afford deductions from their wages, or who have no wages. It is needed for wives and children as much as for the industrially employed head of the household; and it is needed for many others who are excluded from the scope of the National Insurance Act. Only when the medical is separated from the insurance service, and when the medical practitioner, as far as practicable, is made independent of the patient who desires too facile a sick-certificate, will good medical work and sound sickness insurance be secured.

General Summary

The preceding review of the history of public health in England is necessarily fragmentary. It does not include, for instance, a discussion of the relationship of the medical profession to public health authorities. On this I content myself with repeating my oft stated opinion that until every medical practitioner is trained to investigate each case of illness from a preventive as well as from what is often rather a pharmaceutical than a really curative standpoint, until a communal system of consultant and hospital services independent of any insurance system is made available for all needing it, and until every medical practitioner is related by financial and official ties to this communal system, full control over disease,—to the extent of our present available medical knowledge,—will not be secured.

The communal system will include not only the provision of domiciliary nurses for all needing them, but also a greatly increased staff of public health nurses engaged in educational supervision in connection with the work of the communal services and of each individual practitioner. Such a system will repay the community manifold in improved health and in a higher standard of happiness and well being.

If objection is taken to such wide sweeping proposals, let me remind you that free communal services of sanitation and education are already provided; and that the care of personal health is of equal importance with these. All will agree that a large proportion of the population cannot afford to pay individually for medical attendance and nursing under present conditions, still less for the consultant and hospital services which advances in medical service have rendered indispensable. There is always present in our midst a large mass of illness which might have been avoided or curtailed, had there been an organized system of state medicine.

Lest there should be alarm as to the possible consequences of the coöperative provision on such a scale of this primary need of humanity, let me also remind you that coöperative medical aid differs from financial aid in an essential particular. It does not create a demand for further aid, but is always engaged in diminishing this demand. Dependency on financial assistance is liable to continue indefinitely; much wants more. This result of medical aid is almost inconceivable. The Reverend Doctor Chalmers, of Glasgow, said early in the last century: “Ostensible provision for the relief of poverty creates more poverty. An ostensible provision for the relief of disease does not create more disease.”

Doctor Chalmers was opposed to the giving of any domiciliary assistance from rates or taxes, and he organized his parish so that every needy person was adequately helped out of charitable funds. But he advocated extended hospital and other medical assistance for the poor; and until this is done, apart altogether from any system of insurance, and as a complete measure on the lines of our educational system, we cannot say that all that is practicable has been done to secure the physical well being of our fellow citizens.

FOOTNOTES:

[5] An Address at the Forty-seventh Annual Meeting of the American Public Health Association, New Orleans, October 27, 1919.

[6] The importance of this is seen in the fact that there are in England and Wales 14,614 parishes, and only 646 unions for the relief of the poor.

[7] Rumsey: Essays in State Medicine, 1856, pp. 190, 277, 282.

[8] Goodnow: Municipal Problems, p. 226.

CHAPTER III
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: