The Health of the Nation: A Plea for Public Medicine

A Boston physician of leading and liberal opinion, CHANNING FROTHINGHAM was physician to the Peter Bent Brigham Hospital from 1912 to 1933, and has been consultant physician since 1933. He was a member of the faculty of the Harvard Medical School from 1908 to 1933, when he became physician-in-chief of the Faulkner Hospital.

By Channing Frothingham

Many Americans do not receive adequate medical care. The figures presented by the Selective Service Examiners in 1942 and 1943 showed that throughout the United States 39.2 per cent of the registrants examined by the Local Boards and at the Induction Centers were rejected. This high percentage of our boys found unfit to fight was not evenly distributed throughout the country. For instance, in Oregon there were only 24.4 per cent rejected and in Kansas 25.4 per cent. On the other hand, in North Carolina 56.8 per cent were rejected and in Arkansas 55.9 per cent. Between these two extremes, Massachusetts and New York had 37.7 per cent rejected. Usually the poorer the state, the more neglect of health.

Good medical care includes the activities of the public health services—Federal, state, and local—and the preventive medical procedures, diagnosis, and treatment for the sick provided by practicing physicians. Public health services vary not only from state to state, but also in different communities within a state. In recent years the Federal government has been contributing more and more towards the public health programs of the states, the size of the appropriation varying, with a higher percentage of assistance offered to the less wealthy states. In the fiscal year 1946, Massachusetts, for instance, paid $3,930,399 for its Department of Public Health, and to the Commonwealth in the same year the Federal government contributed $3,158,842; in addition, the Department of Mental Health in Massachusetts, which cares for the mentally ill, had a budget of $14,053,672 drawn from state funds.

The activities of the Massachusetts Department of Public Health include diagnosis and treatment of the sick as well as an extensive program for the prevention of disease. The Department runs biological and diagnostic laboratories. It has food and drug laboratories with inspection service. It has a Division of Sanitary Engineering involved in the control of water supply and sewage disposal. It also is closely allied with the Department of Labor and Industries in the study of occupational hygiene. It is active in dental health and in the study and control of communicable diseases. It has responsibility for various hospitals and out-patient clinics for the control and treatment of tuberculosis. It has clinics for the control and treatment of venereal diseases. It also has responsibility for the Emergency Maternal and Infant Care Program. The Department not only deals with general health problems but participates in the care of the sick. This emphasizes a point which is not always appreciated: namely, that you cannot separate the health of the individual from the public health. In addition to what the state does, the individual cities and towns in Massachusetts support their own public health agencies.

In the years to come there will be continued expansion of the activities of the Departments of Public Health in the different states. The diagnosis and care of more and more patients will undoubtedly come under the control of these departments, if one can judge by the steady growth of these services in the past. Even in those communities already well supplied, the demand for the extension of health services exists, as is shown by requests for more legislation and for increased appropriations.

The problem of developing satisfactory public health services in a good medical program is complicated by the lack of well-trained public health officers. It is further complicated by the opposition of some practicing physicians. Such hostility often develops when the state encroaches upon the field of the private practitioner or laboratory expert, even if the patient's advantage is served. To develop satisfactory public health services in a National Health Program, therefore, further education of both laymen and physicians is essential. Physicians must be attracted into the service by satisfactory financial reward. Public health services are expensive, and it is obvious that more Federal aid will be necessary for some states if the advantages of such services is to be evenly distributed. As disease does not recognize state lines, measures to protect us from preventable illness should be uniform throughout the country.

All the studies show that physicians, laboratories, and hospitals are very unevenly distributed through out the United States. For example, in New York City there is one physician to every five hundred inhabitants, while in the United States as a whole there is one physician to every seventeen hundred. Clearly, many areas do not have the hoped-for percentage of one physician for every thousand of the population.

Good medicine cannot be practiced without laboratories, hospitals, and well-trained specialists. The lack of these facilities and specialists leaves many areas unable to attract well-trained practicing physicians. Furthermore, the resulting overcrowding of physicians in our urban centers where these facilities exist produces another problem, because even in these areas there are not enough hospitals to provide all the physicians with hospital privileges. Many communities are unable to raise the funds necessary to supply suitable hospitals and laboratories and to guarantee proper financial return to the physicians. Therefore, some plan must be developed to aid the poorer communities in the states.

The most serious obstacle in making good medical care available to the people is its cost. The following table shows the usual charges for certain operations in a hospital in which different types of accommodations exist for the comfort of the patients. These are actual figures supplied by reliable and conscientious surgeons.

Removal of thyroid
Moderate-price accommodations: $200
Full-price accommodations: $350-500

Resection of stomach
Moderate-price accommodations: $200
Full-price accommodations: $500-750

Hernia
Moderate-price accommodations: $100
Full-price accommodations: $200

Removal of gall bladder
Moderate-price accommodations: $200
Full-price accommodations: $500-750

Acute appendicitis
Moderate-price accommodations: $150
Full-price accommodations: $250-500

Removal of prostate
Moderate-price accommodations: $200
Full-price accommodations: $500-750

Compound fracture of humerus
Moderate-price accommodations: $200
Full-price accommodations: $300-500

Fracture of hip
Moderate-price accommodations: $200
Full-price accommodations: $300-500

It is estimated that more than half the families in the United States have incomes of less than $2000 a year. How can such families meet these charges? Some distribution of the justifiable costs for specialists' services must be arranged for the majority of our population.

Furthermore, in a well-organized medical program the family physician who gives the preventive inoculations and the periodic examinations, and makes the early diagnosis, and who will take care of all conditions which do not need specialists' services, should receive an adequate income. Many people cannot afford complete care on the present fee-for-service basis and therefore do without these preventive and other important medical procedures. Some program must be devised to provide to a vast number of our people a family physician of their own choice.

Another troublesome factor is that this method of paying for medical care by individual fees tempts many to gamble on avoiding preventable diseases by self medication, drug-clerk diagnosis, and the employment of cultists, all in the hope that they will be less expensive than a good doctor.