How Necessary Is Illness?

I

FREQUENTLY the statement is made that the science of medicine is progressing in this country by rapid strides. In a sense this statement is true. Research is adding every year to our fund of accurate knowledge and the standard of medical training has been raised to a high level. Yet to anyone interested in genuine public health service the question presents itself on every hand: Why is the American medical profession making so little progress in raising the level of health among our people? Especially does that question clamor for an answer when one observes the strides that are being made in certain European countries, where, in spite of straitened economic conditions, good health is being maintained to a remarkable degree.

What are our own most pressing health problems? No one who has had experience with doctors and hospitals can fail to be conscious of some of them. The man with the moderate income is now educated to the value of hospital care, of X-ray and other laboratory tests, but he finds their cost exorbitant. Specialization — necessary though it is in this day — too often degenerates into a system of handing patients around the group so that each may get his fee. ‘Preventive medicine’ is a term much used; yet very few physicians are giving active preventive service to their patients. Medical departments of industries are often so preoccupied with operations and the treatment of ‘interesting cases’ that they fail in the simple but most important everyday health service which, by making advice and first-aid treatment easily accessible and satisfactory, can ward off innumerable serious ailments.

These are some of the defects of our system of which we are all conscious. Other defects exist in fields related directly or indirectly to medicine. In the care of dependent children, for instance, and especially in the care of problem children and defectives, there is no coherent policy, and usually no effort is made to do more than clothe, house, and feed the children and give them a conventional education.

Before we turn to the solution of some of these problems which is to be found in the new public health systems of Europe, let us consider for a moment the general status of health in the United States.

About two million people in this country are sick at all times with diseases largely preventable. We have 700,000 cases of malaria and tuberculosis annually, and there are among us about one million diabetics. Syphilis and gonorrhea remain fairly general, particularly in the rural districts, when they might be almost entirely banished by educational prophylaxis carried on among the younger generation by the family physician. Practitioners do not generally vaccinate families under their care against smallpox until urged to do so by health departments, and in every epidemic the health department must come forward and urge on the average practitioner in preventive work. In defense of the practitioner, it must be said that some of his lack of aggressiveness in this situation and the resulting 40,000 cases of smallpox in the United States every year must be blamed on the anti-vaccinationists and the public’s disposition to listen to them. However, much responsibility lies with the medical profession.

For every ten thousand five children born in the United States, sixty-five women lose their lives from causes connected with childbirth. This rate placed us in 1927 twenty-first on the roster of nations collecting data on the subject. Since Chile improved her conditions, the United States is left at the bottom of the list. Further, even with the advantage of the Schick test and toxin-antitoxin, our statistics on the incidence of diphtheria place us low on the list of civilized nations in the prevention of this malady. Constitutional diseases, such as cancer, kidney trouble, and organic heart disease, are on the increase, the latter two being responsible for one third of all deaths. At a time, also, when ‘nervousness’ and incipient mental disease are on the increase, authorities agree that the average practitioner knows less on this subject than a well-informed social worker. Fifty to sixty per cent of our population have decayed teeth which could be repaired; 30 per cent have adenoids or diseased tonsils; 25 per cent have uncorrected defects of vision; there are 3,000,000 partially or wholly deaf children among us and 350,000 crippled with rickets, bone tuberculosis, and infantile paralysis. We have 100,000 drug addicts and 900,000 feeble-minded, imbeciles, and idiots.

The committee on the cost of medical care has recently reported that people are, on the average, disabled by illness at least once annually — men about once a year, women once or twice, and children twice every school year (180 days). According to this rate, there would be about 130 million cases of disabling illness in the United States each year. This committee concludes that 36 million wage-earners in the United States lose at least 250 million work days a year and 24 million school children lose 170 million days each school year. These figures take into account only half of the total population.

I dare say there are colleagues of mine in this country who could very convincingly place the blame for this admittedly shameful and disorganized state of affairs on other shoulders than those of the doctor. But the public looks upon these problems as medical, and looks to the doctor for their solution. The average man sees the mounting cost to him of illness and the occurrence year after year of preventable disease; he sees no reason why such conditions should be permitted in the most prosperous country on earth, which has more physicians per capita population (one to 800) than any other country in the world. He wonders how Austria, a country that was in a state of starvation and revolution in 1920, could so successfully reorganize its health programme that the infant mortality rate was reduced from 30 per cent in 1920 to 8 per cent in 1929. He investigates further and finds that Vienna has expressed its dissatisfaction with the medical profession’s former lack of attention to preventive medicine by adopting a system of socialized medicine and has undertaken to carry active, not passive, public health to every man, woman, and child in the city. Vienna spends every year seven dollars per person on public health measures that directly concern the health of every person in the municipality. Compare this with the ninety cents per person that we spend in this country on preventive and educational health measures. The state health insurance system of Vienna brings 70 per cent of the population to the clinics and health centres, where frequent physical examinations and active health education are already making marked progress in the reduction of tuberculosis, venereal disease, and other common ailments.

II

What is Vienna’s system, and what has it accomplished?

Vienna adopted in 1920 a Social Democratic form of government, having as its principal aim the betterment and reclamation of her laboring and dependent classes. The first step was the establishment of a municipal welfare office under the direction of Professor Julius Tandler, professor of anatomy in the University of Vienna. The policy of this office is to give aid to all those in need with as little red tape as possible. Anyone obviously requiring assistance can obtain that assistance promptly. Another policy is that of thoroughness. In every case in which aid is rendered, the cause for the need is, if possible, discovered, and when individual need discloses poor conditions in the whole family a corresponding extension of assistance is made available.

Each of Vienna’s twenty-one districts has its own child welfare office, supervised by the central welfare office, which directs the work also of the relief institutes and the bureau of public health. The district child welfare offices deal with children from the pre-natal stage to the age of fourteen. In exceptional cases the supervision is extended to the age of eighteen. Under state health insurance, every mother is entitled to a maintenance allowance which gives her care for six weeks before and six weeks after the birth of her child. Active health propaganda is influencing increasingly large numbers to come to the health centres in the early months of pregnancy for complete examination and for treatment in case of syphilis. In t he fourth month of pregnancy, mothers are advised to consult the mothers’ advice bureau, where blood tests are made. When the blood is found to be positive for syphilis, the patient is placed under treatment at once to prevent the child from being affected. If the mother applies before the fourth month, and the blood test shows she is free from syphilis, she receives a statement to that effect; if affected, she is given a document entitling her to free treatment. If after the child is born the mother applies at the welfare centre with the document she received when examined, she receives a sum of seven dollars, and the child is kept under observation. Thus the occurrence of congenital syphilis is being noticeably reduced.

The city of Vienna has knowledge of the birth of every child within the municipality and ascertains that each is well cared for. The welfare worker, a civil servant, is responsible for seeing that every child in his district is properly housed, clothed, and fed. In spite of the low wages and poverty, the Viennese children show an excellent average of health. Infant mortality, as has been stated, has been reduced to 8 per cent, a rate noticeably lower than our own. Every child is vaccinated against smallpox and is given toxinantitoxin for prevention of diphtheria. The city provides 20,000 dinners daily for school children, and 35,000 underweight children are sent away each summer for a five or six weeks’ vacation. The municipality also cares for 8000 children of pre-school age in its day nurseries and kindergartens.

If a child is left an orphan, or if his parents are unable to provide him a home, or if for any reason his home is judged unfit for him to live in, he is placed under the supervision of a bureau referred to as the central reception office. In this group of children one finds, besides the true orphans, deserted and illegitimate children, perverted children, and problem children of many kinds, but none obviously feeble-minded, insane, or with an obvious bodily ailment. These latter types are taken over directly by suitable institutions. For six weeks every child entering such an institution is kept there under observation, the first three weeks in isolation, so as to detect and prevent the spread of any possible contagious disease. He lives in pleasant, sunny quarters with special opportunity for play. During the six weeks’ period the following routine measures are taken: vaccination against smallpox, diphtheria toxinantitoxin injections, Pirquet skin test for tuberculosis, tonsillectomy, circumcision in the case of boys, treatment of vaginitis in girls when indicated, and a thorough general physical and mental examination for all. This general examination includes careful investigation of the state of the child’s endocrine glands, since disturbances in the functioning of these glands is so often related to instability.

By the end of the six weeks’ period, the child has been classified both physically and mentally. He has been surrounded by a variety of opportunities in work and play and has been under constant observation, so that his mental reactions and natural tendencies and aptitudes have been carefully recorded. Whatever intermediate stages he may go through in case physical ailments need to be treated, his personal and mental classification is never lost sight of, the aim being to place him as soon as possible in a home or institution best suited to his type. In general, the children who show poor aptitude for abstract mental work and who are classified as ‘dull normals’ are placed in vocational schools and are taught trades such as carpentry, plumbing, and machine-shop work. These children show special aptitude for work that they can perform wdth their hands.

In addition to these special institutions Vienna has a welfare department for small children not in need of direct pecuniary assistance. These are children of parents who must both work during the day, and who consequently cannot care personally for their children. To meet this need the municipality has day nurseries where the children may remain from 7 A.M. to 6 P.M. The children are not only cared for, but are given kindergarten work, are fed, bathed, and given rest and sleep periods. They are examined carefully to determine any mental or physical defects, which, if found, are corrected.

These day nurseries are, for the most part, situated in Vienna’s new workers’ apartment houses. The city of Vienna has approximately 50,000 families in these model homes. One building is now under construction which will house 2000 families. Every apartment has hot and cold running water, gas, and electricity, and either faces the street — and frequently parks and playgrounds beyond — or faces a large court which usually contains a garden. Each apartment house has a system of daily collection of garbage and a community laundry in the basement. Workers’ stores, libraries, lecture halls, moving-picture rooms, and schools are included in the larger houses. Generally these buildings are erected in the vicinity of the industry where the workers are employed, in order to reduce the time required in going to and coming from work. It is the policy of the city to build them outright with money derived from taxation, while the worker is expected to pay only enough rent to maintain cost of upkeep and depreciation. This, as a rule, amounts to about one American dollar per room per month. By thus housing her labor population in clean, sunny, and hygienic surroundings Vienna is preventing many diseases that invariably accompany overcrowding, filth, impure air, and lack of sunshine.

III

These, briefly, are a few of the ways in which Vienna is solving her physical and mental health problems. The American public, learning of this comprehensive programme that is highly developed and successful in Vienna, a city economically depressed, wonders why our own prosperous communities should lag so far behind.

Compare, for instance, Vienna’s system with ours in the care of dependent children. Our public has given and does give generously to care for its homeless and needy. The United States has more than 10,000 institutions devoted to this work under the various welfare and charitable organizations. Actual space and routine care for homeless children are not lacking, but where is there any intelligently formulated system like that in Vienna? With certain exceptions, children in this country are received into institutions with very little thought as to their classification, segregation, and special training. In every institution one can find all degrees of mentality and many problem types. Hardly any of these children are given vocational training. There is very little effort made to segregate certain types into institutions specially suited to them, where they could be fitted for life and where psychiatrists might study them. Medical attention consists mainly of treatment in case of actual illness, and the medical attendants are contributing little to the development of a comprehensive and progressive system in the care of such children. I mention this because it is a field, I believe, closely bound up with the work of public health and preventive medicine, and is one in which our doctors should be taking a more active part.

One important problem of which our public is bearing the brunt is that of the distribution of physicians. There is a growing tendency among doctors to abandon the rural districts and flock to the cities. The recent graduates do not go to the country. They remain in the city and specialize. As a result, not only are many rural districts lacking in efficient medical service, but some have actually no medical service at all. Statistics for 1023 showed that in Vermont 102 towns contained no physicians; in one county in rural Virginia the proportion of physicians to population was one to 3370; in New Mexico there was one to 2000; one county in Montana offered a bonus of a hundred dollars monthly to a physician who would settle there. From Mississippi death reports frequently come with the notation, ‘No attending physician.’

Our distribution of hospitals is just as inadequate. To be adequately equipped a community should, generally speaking, have one hospital bed to every 150 persons. While we had, in 1927, one bed to every 175 persons in New York State and the District of Columbia, there was in Mississippi one to 1054, in Oklahoma one to 980, and in Georgia one to 897 — again evidence of faulty distribution.

IV

How have other countries solved this problem? Perhaps in no other civilized country has the problem been so staggering as in Russia. Yet Russia seems well on the way to solving it successfully. Let us consider for a moment how the Soviet Government is meeting this and other health problems which still confront us unsolved. In 1913 there were only 12,677 doctors in all of Russia, or one to every 12,500 people. Of these, 8900, or 71 per cent, lived in the cities, leaving an average ratio of one doctor to every 20,300 peasants. The peasants comprised about 80 per cent of the population. The death rate in this year (the last year when the old régime was in full force) was, for all ages throughout Russia, 27.3 per thousand. The infant death rate was 35 per hundred, as against Norway’s 6.5.

Russia in 1913 was a country in which the medical profession was organized on much the same basis as in our own country, particularly as regards irregular distribution and lack of preventive medicine. When the revolution of 1917 ushered in the Communist régime, the new government assumed complete control of medicine and public health. Disease was regarded, not as a person’s private affair to be indulged in as he saw fit, but as harmful, not only to the person suffering from it, but also to the State of which he was an economic and social unit. The shifting of emphasis, therefore, was definitely from curative to preventive medicine. The doctors, feldshers, nurses, and pharmacists became civil servants, and all hospitals, sanatoria, and drug stores became state institutions. One of the first problems was that of equalizing the distribution of medical service. It was done in this way: The Soviet Government now supports 97 per cent of all medical students through medical school, the support extending even to spending money. As soon as medical students graduate, they are sent to the rural districts, each to give three years’ service wherever he is sent. This compulsory three-year period of medical service among the peasants is considered just payment for the support and training that he has received through aid extended by the government. The number of doctors in all of Russia in 1928 was 44,800, nearly four times as many as in 1913. The average ratio in the peasant districts was one to every 14,000, instead of one to 20,300, as in 1913.

Whereas most of our cities have several hospitals, each receiving all types of cases and thereby duplicating equipment and personnel, Russia’s system is to establish specialized institutes, such as tuberculosis, neurological, occupational-disease, and endocrinological institutes. In this manner, not only are great savings effected, but better methods of study for physicians are afforded.

Russia has day nurseries and kindergartens to care for children of parents who are both engaged as wage-earners. Parents leaving children at home uncared for are severely penalized. In the day nurseries, the children are cared for from 7 A.M. to 6 P.M. Fullt ime physicians and nurses are on hand who examine the children from every conceivable standpoint. Heart and lung examinations, Schick tests and toxin-antitoxin for diphtheria are given. Height and weight charts of each child are made, the use of the toothbrush is taught, and defective teeth are repaired. In short, the State welcomes this opportunity to come in contact with the child, for it feels that the time and money thus expended are good investments in the future manhood and womanhood of Russia.

Russia has carried active public health to the worker by means of institutions that, so far as I know, are entirely new and unique. I refer to the laborers’ night sanatoria. The workers who are not sick enough to stop work, but who need special food and good sleeping conditions, are admitted to these sanatoria. When they leave work in the evening they come to the institutions, are given a bath, and lie down from 6 to 7.30 P.M. They then have dinner and go to bed until 9 P.M., when they have tea, followed by light calisthenics, and retire for the night not later than 10 P.M. In the morning they go to work as usual. These sanatoria undoubtedly reclaim most of the incipient cases of stomach ulcer, tuberculosis, and other chronic illnesses that later constitute a large item in the expense of any industrial concern.

Russia has attacked the problem of high infant and maternity mortality rate and has made notable progress in its reduction. In order to combat the forces responsible for the mortality of mothers and infants, there was organized in Moscow in 1918 the health protection institute. Under the leadership of Dr. Lebedev, a woman physician, the infant death rate over the whole of Russia has been lowered from 35 per cent before the war to 19 per cent at the present time. This has been accomplished by means of day nurseries for factories, by a system of preand post-natal work (whereby the mother is supported by the State for two months before and two months after the birth of her child), and by the systematic teaching of infant and child hygiene in city and village clinics. In the health protection institute itself are model beds, model rooms for mother and infant, wax specimens illustrating disease processes, posters showing which types of work are dangerous for pregnant women, and charts and pictures teaching proper methods of child feeding and child care. The institute in Moscow is visited by about 20,000 workers annually, of whom 65 per cent are women. Similar institutes are established in most of the large cities and industrial centres throughout Russia.

In conjunction with the health protection institute and its various branches, there are established museums for social insurance and labor protection. Here the laborers can learn in simple graphic form the elements of anatomy and physiology, of hygiene and sanitation. They are also informed regarding the requirements of health in working conditions and the dangers attached to certain forms of occupation. One may see in these museums every day literally hundreds of workers from factories, students from schools, and Red Army soldiers who have come in organized groups to study.

Russia is dealing comprehensively with the problems of venereal disease, of the prostitute, and of abortions. In Russia a trained commission acts as adviser for every woman applying for an abortion. If she is judged physically able to bear her child, she has presented to her every reason for bearing it and is given information in regard to the care and support of mothers before and after childbirth which the government gives free to all women who need it. About 25 per cent of all women so approached decide to have their babies. The other 75 per cent are allowed abortions, performed scientifically under hygienic conditions, without cost. The record of the number of abortions performed in Russia compares not unfavorably with the estimated records in other countries, and, because of the scientific methods used, the unfavorable results are reduced to a minimum and the abortion quack has gone out of existence.

In the large cities are venerealogical institutes where patients may go for scientific treatment and where extensive research work is constantly going on regarding questions of immunity and improved methods of treatment. In the institute in Moscow under the direction of Professor Efron more than 60,000 patients are treated annually, and fifty physicians from the farm provinces are there constantly studying modern methods of treatment so that they may return to their own communities and carry on their work more scientifically. Besides these visiting physicians, more than 150 physicians are there in regular attendance, devoting their full time to work in the institute. In addition to the actual work of treating the patients, these physicians carry on an intensive campaign of education and follow-up work among the patients and their families by means of posters, lectures, and motion-picture films that have a nation-wide distribution.

So many prostitutes came to these institutes for treatment that it soon became apparent that some programme of reclamation of these unfortunate girls was necessary. There were accordingly organized vocational homes for prostitutes. At the present time there are five in Moscow, two in Leningrad, and others are being organized in Odessa, Kiev, Stalingrad, and other cities. The girls received into the homes remain for from six to eighteen months. They are taught vocational work, most often the trades, such as stocking weaving and dressmaking. The illiterate are taught to read and write; the more intelligent are allowed to study art, music, science, and other more abstract work. At the end of their training they are given work, usually in factories, and they go back to society with no stigma attached to them. The statistics after three years of such a policy show that 40 per cent return to prostitution, while 60 per cent remain reclaimed.

V

The question naturally arises whether a system of complete socialization of medicine such as Russia’s, which makes health opportunities equal among all classes, is the most desirable plan. Let us see, specifically, mass medicine at work. The railway workers’ clinic in Moscow is designed to serve the clinic needs of 100,000 railway workers and their families, — in all about one half million men, women, and children, — the workers being employed by four different railway systems which have station terminals and other facilities in Moscow. This clinic is subsidized by the social insurance fund and employs 143 full-time physicians, and 40 more attend to necessary calls in the homes of patients out of clinic hours. The average number of patients treated daily in the clinic is about 3500. Each physician must see a certain number of patients daily — for instance, each internist must see 35 patients, each pediatrician 28, each neurologist 30, each ophthalmologist 40, each dentist 18, each surgeon 45, and each ear, nose, and throat specialist 40. In addition to the physicians on the staff, there are 157 other full-time employees, including nurses, clerks, orderlies, janitors, and other attendants. There are 18 dental chairs occupied constantly, and the department of dentistry makes and distributes 30,000 sets of artificial teeth annually. There are also departments for making artificial limbs, body braces, spectacles, and crutches, and for issuing free medicines, bandages, and similar supplies. The physicians are paid a salary by the company out of the social insurance fund, which, of course, is a fund of the State. They devote their full time to the work, which requires about six hours daily actually at work in the clinic. The rest of his time the doctor has free to spend as he chooses. Large clinics, such as the railway workers’ clinic, publish medical journals of their own, and every month various phases of the work are described.

These are only a few examples of the methods that I saw first-hand last year in Europe — methods that are successfully solving the very problems that we are discussing with increasing fervor here. These countries, as I have stated, are solving their problems by one or another system of socialized medicine. Regardless of what system we apply to our own problems, our public is beginning to demand that in some way we produce similar effective results in the field of public health. The time is at hand when the medical profession must, of its own accord, shift the emphasis from private practice and curative medicine to preventive medicine and active public health. We shall have to carry adequate medical and hospital service to our rural communities; we shall have to stabilize our fees; we shall have to give, above all, service which convinces the public of its thoroughness and sincerity — otherwise an unwelcome radical system will be forced upon us. The physician of the future will be not only a minister to the sick, but also a teacher of health. Health service for all will be the rule, prevention the watchword.

1. The editor will be glad to answer questions regarding the illuminating statistics on which this article is based.↩