Public Health and Insurance: American Addresses

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]

PUBLIC HEALTH PROGRESS IN ENGLAND DURING THE LAST FIFTY YEARS

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—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.

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