THE FUTURE OF THE PUBLIC HEALTH SERVICES

ESPITE the concentration of public thought and energy

upon the war, certain problems, passed on from times of peace, continually thrust themselves forward, and demand solution of difficulties often augmented by the conditions which have prevailed during the last three years. One of these problems is presented by the Insurance Act. Two years prewar experience of this measure had already shown that it was seriously defective; the medical service was unsatisfactory, and was bringing a section of the medical profession into disrepute; the administration was costly and cumbersome, and the financial position of many Approved Societies was unsound. These defects have been increased by the withdrawal of a large number of medical practitioners for service with the army, and the growth of claims for sickness benefit is causing grave anxiety to many Societies. The Government has already come to the rescue, and has partly relieved Societies of the cost of soldiers and sailors disabled in battle. But this can only be regarded as a stop-gap measure, and it is generally recognised that a sweeping reform of the entire Act cannot be long delayed.

When, however, we begin to consider what changes should be effected, we find it impossible to confine our attention to the Insurance Act alone. There is scarcely a branch of the public health services which is not connected in some way with the Insurance Act, and any effective scheme of reform which touches one branch must extend to all. The question of a national medical service must be considered, and the establishment of co-ordination among the central authorities engaged in public health administration, and still more among the local authorities, is an essential condition for the success of any scheme. The object of this article is to outline a scheme. for the complete reorganisation of the public health services, and to consider what functions should be discharged by a central public health office or Ministry of Health, and what are best left to be administered by local authorities., As a

preliminary step it is necessary to examine the present system, with a view to noting the main obstacles which militate against sound public health legislation and administration.

A critical study of the steps which have been taken to improve public health during the last twenty or thirty years shows that many of them have failed to achieve their object, owing to lack of knowledge, or inadequate investigation of the problem to be dealt with, or of the suitability of the measures it was proposed to apply. The science of hygiene is complex: new discoveries are constantly widening its boundaries; research continually shows us that views which yesterday seemed established for all time must to-day be abandoned for better-founded theories, to be themselves replaced in their turn as knowledge steadily advances. But the average legislator does not realise this; he is always a stage behind the scientists, clinging to views which they have discarded. He measures the health of a people by their death-rate, with happy unconcern for the principles of standardisation,' and he would learn with surprise that France and Ireland, although their crude deathrates are several points above the English rate, are actually healthier countries than England.

The layman regards all reductions in disease as the result of sanitary and medical science: small-pox was killed by vaccination, typhus has disappeared because we have swept away dirt and overcrowding in our large cities (!), tuberculosis is being robbed of its terrors by better housing, schemes of notification, prevention of infection and sanatoria. That these diseases have disappeared or declined in areas and countries where none of these wise steps have been taken is conveniently ignored, and our debt to Nature for a process of immunisation, so ably described by Archdall Reid, Metchnikoff, and others, is never acknowledged. Prevention of infection is regarded as the great weapon in the attack on infectious disease, hence the disinfection of patients and houses, and the demand for notification and isolation of those affected, regardless of the fact that the isolation of patients in fever hospitals has had little appreciable effect in reducing the prevalence of scarlet fever or diphtheria.

Much of our public health legislation is the outcome of fashionable fads. Thus at the present time it is highly popular to ascribe infant mortality to maternal ignorance and neglect,

a theory very comforting to the wealthy owner of slum property where the majority of deaths occur. The drawing-rooms of Mayfair discuss this theme alternately with that of venereal disease. Hence the demand for more and more health visitors, schools for mothers, ante-natal clinics, notification of births Acts, and maternity benefits. Lord Rhondda promises to save a thousand babies a week by the establishment of a Ministry of Health, and if the drawing-rooms had their way we should enforce notification of pregnancy. But the truth is that excessive infant mortality is the result of a vicious environment. Scientific investigations show that on the average the children of all classes are born equally healthy, and it is the foul air, dirt, and overcrowding in all our large cities which causes so many of the infants of the working classes to die. The babies of the agricultural labourer thrive better than those born in the wealthiest parts of Kensington, Westminster, and Chelsea, and the badly-housed poverty-stricken peasants of the West of Ireland show a lower rate of infant mortality than is to be found in any other part of the British Isles. We can save a thousand babies a week, but we shall not do it by maternity centres, even if we make them as numerous as public-houses: we shall only do it by a policy of wholesale clearing of slums and formation of open spaces in towns, which will take many years to complete.

Popular views on public health unfortunately too often. determine the trend of legislation, and it is in this direction that the absence of expert investigation, such as might be supplied by a Ministry of Health, is most severely felt. A Public Health Bill may be introduced in Parliament by a minister who has no special knowledge of the subject, and has not held any of the offices connected with public health administration. If his department has a medical adviser, he may or may not have consulted that officer, or he may have overruled his opinion. The Bill passes through a House in which there is a mere handful of medical men, most of whom have not been closely associated with public health. When it becomes an Act, its administration is entrusted to a government department in which medical opinion is strictly subordinated to that of lay civil servants and lawyers. From first to last the measure may have received no real expert criticism, and we are bound to recognise that such criticism as may be directed towards it

from outside, even by medical bodies, is more often inspired by fear of threatened vested interests than by genuine concern for the public welfare.

Many instances could be given of the way in which measures intended to improve national health have led to little but fruitless expenditure, owing to the fact that they were attacking the particular problem on the wrong lines. We may take the school medical service as the first example. A good many years ago the report of the Committee on Physical Deterioration and other investigations showed that the physical condition of a large proportion of the school children in this country was deplorable, many thousands being stunted in growth, badly nourished, or suffering from defects of the eyes, nose, throat, or ears. Accordingly in 1907 an Act was passed providing for the medical inspection of school children, the object being to detect' incipient defects,' it apparently being assumed that as soon as a defect was noticed steps would be taken to have it corrected, although no facilities for medical treatment were provided under the Act, and the examining medical officers were debarred from undertaking treatment. The futility of these proposals would readily have been shown by competent scientific investigation. We now know that defectiveness begins in children long before they reach the school age; and when the children come up for their first examination at school, the officers, who were to detect incipient defects, find that at least fifty per cent. of the children are suffering from the effects of rickets in earlier years, malnutrition, adenoids, and other physical defects. Then when a large amount of irreparable harm has been done, a half-hearted attempt is made to correct the condition.

Equally fallacious was the belief that treatment would necessarily follow inspection. Statistics show that only about half the children who are recommended for treatment actually receive it. Here also it is customary to ascribe the failure to the neglect of parents, but, while admitting this as a factor, we learn from the reports of many school medical officers that children are not receiving adequate treatment, simply because the facilities for that treatment do not exist. About one-third of the total school population comes under medical inspection during the course of the year, and of those found defective about onethird are ultimately classed as 'remedied.' Hence it follows

that out of the total mass of defectiveness, the school medical service is only correcting one-ninth in the course of the year. It is admitted that there has been substantial improvement in cleanliness among school children, but how small has been the total effect of the school medical service upon the great mass of serious disease and defects may be judged from Sir George Newman's statement in his report for 1915-16, eight years. after the passing of the Act. He says: He says: Not less than a 'quarter of a million children of school age are seriously crippled, invalided or disabled; not less than a million 'children of school age are so physically or mentally defective 'or diseased as to be unable to derive reasonable benefit from 'the education which the State provides.' Of 1,900,000 children who were examined in 1913-14 in England and Wales, no less than 650,000 were found to be suffering from diseases or defects needing medical treatment.

The cardinal error underlying the whole scheme is the belief that medical treatment can be made to compensate for the effects of a bad environment. The fact now recognised is that a large part of the medical treatment is useless, and always will be useless, so long as the surroundings of the children in pre-school years are defective, their homes insanitary, the playgrounds inadequate, and the schools built in crowded and noisy districts. Sooner or later our legislators must learn the lesson that the sweeping away of insanitary conditions in overcrowded districts is the only way of combating preventable disease effectively.

The National Insurance Act provides us with still more striking instances of errors which need never have been made had its introduction been preceded by efficient investigation. Some of the mistakes could have been pointed out by any doctor with experience of general practice, as, for example, the assumption that sickness rates would be the same for men and women, or that pregnancy could be disregarded as a cause of sickness. But the worst errors could have been avoided by careful study of the experience of Germany where national insurance had been in force for many years. This was not done. It is true that Mr. Lloyd George visited Germany in 1910, and on his return he issued from the Treasury a 'Memorandum of Opinions of various Authorities in Germany,' consisting of a number of statements from German employers,