Chapter I: 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

SCHOOL OF HYGIENE AND
PUBLIC HEALTH,
JOHNS HOPKINS UNIVERSITY,
BALTIMORE,
AND
ATHENAEUM CLUB,
LONDON,
May, 1920

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.