The Health of the Nation

I

THE innocent bystander can hardly be blamed for not knowing what the fight on ‘state medicine’ is all about. A battle of words has been noisily waged, even high-school children during the past year debating the subject as if it were a question still to be answered. Yet every doctor and every intelligent layman must admit upon reflection that we already have a sizable degree of state medicine, and that extensions of it are constantly being proposed and carried through without shocking the most rugged of the individualists. The press reports that the Republican State Committee of New York has petitioned the legislature for funds for three more cancer hospitals. It. has not been many years since cancer was regarded as a purely individual affliction, belonging in the bailiwick of the private practitioner. Now it develops that cancer is endowed with a public interest and that the state is concerned. And the Republican State Committee, whose history does not suggest a disturbing degree of radicalism, does not seem to turn a hair in recognizing the situation.

No, ‘state medicine’ is, on the lips of the alarmists, a conveniently inflammatory phrase, but state medicine is not the real issue. The issue is, to put it sharply, whether government shall more properly concern itself with the relief of one group of the population, the underprivileged, in illness, or whether it shall concern itself with better health for all groups of the population, the privileged and the underprivileged alike.

This is the dominant question in connection with the Federal legislation on health and security to be expected in the not distant future.

Up to the present, proposed national legislation has been rather in the first of these two directions — the social welfare or, colloquially, the ‘uplift’ approach, doing something for the needy, preoccupation with their ‘negative’ health rather than with ‘positive health ' for all groups of the population, a higher standard of physical and mental health for the individual citizen, greater industrial competence and more continuous employment, greater personal enjoyment of life.

It is no secret that when the Social Security Act was being drafted a few years ago a number of the advisers were of the opinion that ‘social security’ ought to include insurance not only against impoverished old age and unemployment, but also against the ‘hazards arising out of illness.’ It was proposed to include in the Social Security Act a compulsory health insurance programme. (‘Health insurance’ is the term used, but it is in a way a misnomer, for the real stress is on relief in illness.) In view of present constitutional limitations, the compulsory health insurance proposal was dependent upon legislation in the several states, involving, however, the principle of Federal grants-in-aid to the states that appropriated funds and passed the necessary legislation. The proposed health legislation, in short, brought sickness within the province of social security motivation — extending the power and funds of the Federal Government to give the underprivileged security in misfortune arising from old age, unemployment, or illness.

The compulsory sickness insurance part of the social security proposal was vigorously resisted by ‘organized medicine.’ There is no question that an organization group fought it narrowly, making no constructive counter proposal. They fought it not on the ground of difference in philosophy, in conception as to how government should meet the problem, but on the ground that government should not act at all. They fought, in other words, ‘state medicine.’ At the clarion call, ‘ Aux armes, médecins, formez vos bataillons,’ doctors in every hamlet ran forth with their muskets to line up against state medicine, government interference with their livelihood, the socialistic programmes of swivel-chair social economists.

The compulsory sickness insurance proposals were not included in the Social Security Act as passed; but the possibility of including them was not considered closed. The Social Security Board was given a mandate to study further the subject of the ‘economic risks arising out of illness.’ Moreover, as the old-age pension and unemployment insurance provisions of the Social Security Act have been put into operation, they have emphasized how often old-age pensioners are also ill and how great a factor illness is among the unemployed — and the unemployable. The emergence of these truths is considered to point the need for complementing the Social Security Act by extending coverage to ‘economic risks arising out of illness.’

There is, obviously, more to come. While well-known prophets do not seem to anticipate decisive action on any far-reaching health legislation at the present session of Congress, pressure for action still continues — and so does misunderstanding.

II

The American Foundation, whose dominant interest is to relate the result of accurate studies to confused present situations, felt that a large problem that concerns all of us has been falsely narrowed into a controversy, not between doctors, but between organized medicine, regarded by the other side as a guild of reactionaries defensively protecting a vested interest, and the social-welfare group, carrying the banner for the underprivileged. A difficult, complex, and delicate question has been distorted into a shallow debate: ‘Shall we or shall we not have state medicine?’ And from the whirlwind of superficial discussion the only harvest is a collection of cliches and slogans for and against state medicine.

To the Foundation there seemed to be three other parties in interest: first, leaders in scientific medicine who on a broad question of national need certainly would not take a narrow guild point of view; secondly, the public, privileged and underprivileged alike; thirdly, the government.

Ultimately the government will be the umpire. The Administration will be in the best position to strike a balance between the intransigeance of a certain group of doctors on the one hand, and on the other the intransigeance of those so obsessed with the needs of the underprivileged that they conceive of the government rather as a continuous relief agency for certain economic groups than as the initiator and guardian of better standards for all groups — including the underprivileged, but without limiting the government’s functioning and its vision by their needs.

It seemed desirable to broaden the base of discussion, summon the other parties in interest, and break down the false alignment of medical science against social science. With the idea that a disinterested outside organization, assuming its capacity for integrity and for impartial procedure, might be able to perform a work of notable clarification, the American Foundation, as a first step, addressed to a selected list of leaders of scientific medicine in all parts of the country, who have been in practice or teaching for twenty years or more, the following questions: —

Has your experience led you to believe that an essential change in the organization of medical care throughout the country is needed?

If so, in what direction? If you do not consider that radical change is indicated, what, if any, evolutionary possibilities would you stress?

A similar letter was sent to a young group, as a control — graduates of the past five years recommended by deans of sixty-six ‘grade A’ medical schools. The theory was that these young men have been exposed to a vastly revised system of medical education, and have also come into their medical maturity in a period of great social changes. Their views as to the proper relation of government and medical practice have not been tested by experience — but by the same token they are not inhibited by it. Included also was a smaller group of men who have been in practice for approximately ten years. There was no questionnaire; the doctors’ analysis of the situation was not restricted.

In our judgment the three following conclusions may be fairly drawn from the results of the inquiry, consisting of approximately 5000 full and frank letters from doctors in every state: —

First, leading medical scientists of the country are almost unanimous in recognizing that modern scientific medical care is not available to a great majority of the population, and that the problem must now be met.

Secondly, while medical scientists agree with social scientists on the existence of the problem, they state the causes very differently.

The social scientist thinks the problem is largely reducible to terms of cost. The medical scientist thinks costs are too great, but that there are two other important reasons why good medical care is not available to most of the population: namely, the fact that much of the public continues to prefer patent medicines, quacks, and cultists, and — most important of the three causes — the fact that there is not, as yet, enough scientific medical care of first grade to ‘distribute,’ even if (as he does not agree) it were distributable.

Thirdly, the medical scientist opposes to the social scientist’s programme of compulsory insurance a programme that involves at least as much ‘state medicine’ as does compulsory insurance, but in very different ways. The medical scientist’s programme, an integration of an expanding degree of state medicine with private practice, rests upon two principles: evolutionary extension of the participation of government in public health services and medical care, and retention of the private practice of medicine. It ‘socializes’ certain medical services, but does not socialize the doctor. It may be called, synthetically, ‘limited state medicine with private practice.’ It will be described more fully hereafter. For the moment it will be enough to say that the programme in support of which scientific medical leaders from one angle or another seem most nearly to converge involves direct use of tax funds for the development of public health services, Federal, state, and local; partial tax support of hospitals in proportion to amount of care given to the indigent and near-indigent; extension of public laboratory facilities to make the scientific aids to diagnosis generally available at low units of cost and free to the indigent; admission that the medical needs of the indigent and the near-indigent are a fair charge on tax funds — as fair as their need for corned beef and doughnuts and a bed.

III

Let us consider the first of the three conclusions — the doctor’s estimate of the need. The social scientist has felt that the doctor’s realization of the extent of the social need has been deficient. It is quite true that some doctors are satisfied with the situation in their communities, but this is not the ‘ net’ of their testimony. The realized experience of years in these 5000 letters — from not only the Old South and the wide agricultural stretches of the West, but also cities with million-dollar hospitals — seems to us a more current, straighter, and vastly more moving record than voluminous surveys. ‘Facts,’ as one of our correspondents points out, ‘keep no better than fish.’ The practitioner’s daily life is a direct social experience. He constantly sees stark pictures not merely of tragic physical illness but also of sharp economic pressure, of social inequality at its most unequal. He is daily brought without ceremony into the heart of the individual and the family life. Not often in these days does he perform operations on the kitchen table and help mop up the kitchen afterward, but he still sees the picture of human need in more direct perspective than do most of the rest of us. Why not ask him what he thinks — from what he has seen?

One correspondent, who happens to be a member of the public health service of a Western state, presents the following picture: —

In this state approximately one third of the people die without consulting a doctor even in their fatal illness. The death certificate says ‘no medical attendant’ and cause of death is ‘unknown.’ In six of its thirtyone counties, less than one quarter of the mothers have medical care in childbirth. In seven of this state’s counties more than three quarters of the babies that die have had no medical care.

No one has ever tried to calculate what it would cost to provide adequate medical care for these thousands that receive no medical care at all. But there are a few considerations which suggest that the cost is far beyond this state’s ability to pay.

Many of our families live twenty miles or more from the nearest physician. Under the present system, the doctor charges one dollar per mile for country calls. It is possible that a socialized system could be devised which would reduce the cost of calls into the country, but under any system each call would mean many dollars. And to-day adequate care means several calls. Twenty years ago the doctor might call once and pronounce pneumonia, and that single visit might be considered adequate enough. But to-day the sputum must be ‘typed,’ the appropriate serum selected and administered. Perhaps the next day more serum will be required. Oxygen may be needed, and a skilled attendant to administer the oxygen. To provide such service at twenty miles from our base will cost, under any system, well into three figures. . . .

A conservative estimate from a health survey of this state made two years ago places the number of cases of active tuberculosis at not less than 15,000. At present there are no free beds for tuberculosis and very few of these patients can pay for sanatorium care. There is no provision for surgical treatment to save the patient’s life and stop the spread of infection. The same survey proves that there are in the state 20,000 people whose blood shows the presence of syphilis. Only one thousand are under the care of a physician.

The infant mortality in this state is the highest in the union. It was 126.1 per 1000 live births in 1935.

It is clear that the bill for adequate care will be a large one. What resources has this state to meet such a bill?

Health insurance can hardly be the answer in a state that has scarcely any industries. There is already an income tax and a two per cent sales tax. Taxes on property cannot be increased without a change in the state’s constitution; they have reached the maximum allowance of twenty mills in the dollar. If this state cannot afford to guarantee to its children life as well as liberty and the pursuit of happiness, what does the national government propose to do? How many states are there like this?

The first step, surely, is to define ‘adequate medical care,’ and the next step is to employ cost accountants to estimate its cost. Neither step has been taken at the present time.

A general practitioner in a South Dakota town leaves no doubt of ‘inadequacy’ in his state: —

Last year there was not enough raised on many farms to feed one horse or cow, and the price of feed was so high that one had to sign up to pay in the future a large price for this feed.

If we can have a reasonable crop with a reasonable price, we can get ahead considerably, but it seems that year after year we wait for that to happen, but it does not happen. . . .

There is hardly a person living in this county with rich soil who at the present time is able to go to a hospital for attendance.

A surgeon told me the other day people are brought to him just before they die.

The following letter pictures a county about thirty miles wide and forty miles long in a Southern state: —

The population is both white and colored; the natives are dependent upon the soil for a livelihood, the timber has been cut and sold; there is no industry to which to look for a steady payroll. The patients cannot budget, for the simple reason that they depend upon a pay crop; they have no say in setting the price; they must combat the elements, have no assurance of a given yield, cannot judge the future by the past. They have necessary expenses that must be paid first; if there is a surplus probably the doctor also will be paid, but more often the charge must be carried on his books. The physician has no way of figuring his income from year to year. . . .

It is all very nice for the medical fraternity to sit back and oppose state medicine, but for the rural sections I cannot see anything else, and the problem will have to be looked after by the Federal Government. The state, at least my own, and other neighboring states, are just as badly off: the conditions are the same as ours.

Insurance is not feasible, as the clientele could not pay the premiums. I can see only the one solution, for the Federal Government to take over the medical care of the rural sections at least.

An annual report sent through to us, covering the work of the county doctor in a Middle-Western state, reveals industry and accomplishment certainly, but hardly adequate medical care for the poor. He receives $1400 a year, but out of that he must buy the gas and oil for his car, amounting to $200 for last year (his calls cut of town totaled 2194 miles), and out of it he must also buy all drugs and supplies, costing $365 for last year. While measles, mumps, and rheumatism make the usual demands, surgery bulks large in the year’s record, which includes 542 teeth extractions, 55 obstetrical cases, 5 hysterectomies, 72 other abdominal operations.

Nor is most of the surgery minor: to run down the list, there are noted twenty-five tonsillectomies, eleven operations for piles, three eyes removed, one cancer of the lip, one cancer of the stomach, one gall bladder removed, one leg amputated, three cases of paracentesis of the ear, three of thoracentesis, one hernia, one prostatectomy, and all kinds of dislocations and fractures, including a fractured hip.

This county physician never ' refuses ’ a fence of any height. Whatever the operation, he does it. And what if he did not? Better in some cases, of course, but not in all. At the rate of 8⅓ cents for removing an eye, or a cancer, or a gall bladder, which sum is exactly what he averages for each operation, this county doctor is not ravening on the poor, but —

Are the indigent sick of the county getting ‘adequate’ medical care?

A general practitioner in a Kentucky town points out that even when a modern highway brings ‘adequate’ medical care almost to the door of some of the natives, they will still not build the last mile of road that would connect their cabin with the highway: —

They have lots of idle time, idle teams, and certainly plenty of rock to do it with, but they just don’t and they won’t. . ..

Not all of these people are desperately poor, as many social workers, calamity howlers, and ‘state medicine’ advocates would have one believe. Very few, if any, go hungry. Still fewer suffer from lack of proper clothing; and while they are quite willing to pay good prices for rattletrap automobiles, coon dogs, fox hounds, fiddles, banjos, French harps, and mean liquor, almost to the last man of them they are not willing to pay a doctor’s bill, if they can get out of it. , .

Insurance would not solve the problem of the last muddy mile of private lanes, from the highway to the home.

The above are not horrible examples from the social worker’s collection; they are from the doctors’ own daybooks.

IV

The Kentuckians who ‘just won’t’ build the last mile of road that would connect them with medical care illustrate the medical scientist’s protest to the social scientist that the cost of medical care is not the whole story. We have not as yet, he points out, a public that is asking for scientific medical care. Legislatures backed by uninformed public opinion repeatedly defeat legislation aiming at higher standards of medical and surgical practice. The public kills efforts to control advertising of quack remedies. Congress failed to pass the Copeland food and drug bill last June.

Not only does the negligent public commit the above sins of omission; even the intelligentsia, quite as numerously as the poor immigrants, patronize the quack. If modern scientific medical care were directly available to them, many would still choose patent medicines, quacks, cultists, and old women.

The medical scientist does not think — and this is the very centre of his position — that the task of providing medical care of high grade to the population can be discussed chiefly in terms of cost and availability. Medical care is neither a commodity nor a constant. It cannot be subject to the laws of commodity distribution. In medical science the field of the unknown is still vast, and the number of those fully competent to apply what is known is still very small. Even if it were possible to ‘distribute’ medical care, there is by no means a sufficient number of adequately trained men to supply it on a broad base. ‘The best is not yet good enough.’

‘Until the schools have met the challenge,’ as one undoubted leader of medical science points out, ‘regimentation by the state will only make matters worse. Under a democracy the competent and the incompetent are alike before the law. Socialization and bureaucracy will simply make a whited sepulchre for a dead profession.’ The problem of supplying medical care must be solved only in relation to that of developing medical care of high order, and of training and graduating and sending out to practice men who can supply it. Whatever the solution for present problems, the medical scientist maintains, it certainly cannot be making more mediocre medical care available to more people.

This ‘adequate medical care’ that falls so trippingly from the social scientist’s tongue cannot be standardized for distribution — at least not yet. For case A ‘adequate medical care’ consists in providing bread and milk; for case B it consists in providing an electrocardiograph to determine the presence or absence of a heart lesion.

The medical scientist protests identifying the problem caused by lack of medical care with the more fundamental problem of lack of a living wage. He does not think that anything will be gained by a piecemeal attack on one result of our present economic situation. A man with influenza needs medicine, yes; but of what use is it to give him medicine, and even to keep him in the hospital for a day or two, and then turn him out into the slush again, with no underwear, holes in his shoes, no warm place in which to sit or sleep, and no food? Why, asks the medical scientist, ‘regiment’ the doctors — the only group with whom it is a tradition to give poor people what they need whether they can pay for it or not?

Many medical men feel that medicine has been ‘picked on’ as a particular field for experimentation that should have a more general aim. A professor of medicine in a grade A medical school, a member of the Association of American Physicians, puts it thus: —

Because of its social implications and sentimental appeal, medicine has been peculiarly the victim of promoters. Projects devised in biological ignorance have gained support almost in direct proportion to their fantasticality. There is no good evidence that scientific progress can be accelerated by such methods.

The medical scientist, in short, believes that government must do its planning and make its attack along a broader front.

V

It remains to show the more particularized objection the medical scientist has to compulsory health insurance, and to outline more fully what he proposes in its place — limited state medicine with private practice.

On insurance: the medical scientist of course admits the right of any part of the population to insure themselves as they see fit, as a personal and voluntary act. But since a large part of the population will not ‘choose’ to insure themselves, voluntary insurance can hardly constitute the general solution that is being sought. European systems that began as voluntary ended, it is observed, as compulsory.

The medical scientist thinks that government, instead of participating as contributor and organizer of a compulsory insurance system on the ‘risk’ and ‘average’ basis, had better assume directly the cost of services actually rendered in particular cases. This thesis that compulsory insurance ‘distributes the costs’ is, after all, regarded as a fallacy. Compulsory insurance merely substitutes, as a member of the Harvard medical faculty puts it, hidden taxes for direct taxes — a substitution that really ‘distributes’ nothing. The head of one of the departments at Johns Hopkins conveys the medical scientist’s repugnance to the idea that the insurance principle is applicable:

Insurance is a form of gamble, well organized and well intended, but fraught with much carelessness and reduction of the individual share in responsibility. The principle of ‘equality’ is fundamentally wrong and may give mathematical satisfaction but not a basic soundness.

Insurance, according to the type of medical scientist we have put to the fore in this discussion, is more concerned with ‘distributing’ the disadvantages of illness than it is in concentrating — in the individual — the possibilities of health. Even hospital insurance, however voluntary, and however applicable to the quasicommodity value of hospital services as opposed to the less tangible services of the physician, has the fundamental defect of all insurance: a tendency to focus attention not on the possibilities — and the imperative duty — of exercising preventive effort, but on ‘accommodations for more illness,’ which accommodations, some suggest, would be used (thus, perhaps, disturbing the law of averages upon which insurance rests). An assistant in medicine in a general hospital in New England, whose tone suggests a cynical knowledge of thrift in the original colonies, wrote: —

Any form of insurance providing for a possible two weeks’ hospitalization yearly per person would result in many provident New Englanders’ spending their two weeks’ vacation in the bed provided by taxation (and toward which their savings have been contributed) rather than in Florida.

Let the government do directly what it has to do for the indigent and the near-indigent. Compulsory insurance, observes the medical scientist, except with the government as the whole contributor, cannot be made to reach those that need it most. Why talk of ‘distributing’ the costs with reference to those that have no contribution to make to the cost? The medical scientist thinks of the hundreds and thousands he has cared for with no savings and no salary from which insurance could be paid; he thinks of the thousands of families with an income so small that anything out for insurance means that much out of underwear, food, or coal. With these in mind, it is not surprising that his attitude toward plans that rest upon ‘distributing the costs’ is sardonic.

Finally, the medical man believes that compulsory insurance — with its stress upon more care in illness (as opposed to stress upon positive health), with its mass therapy, its regimentation both of doctors on the panel and of patients (in spite of devices to save the principle of the personal relation) — subtly and continuously lowers the quality of medical care, the quality of the medical man, the quality of the patient’s conception of health.

VI

What does the medical scientist propose? And how — in sum — does his plan differ from the compulsory insurance proposal of the social scientist?

What the medical scientist proposes is first of all the wisdom of depending, not upon a broad new procedure, but upon evolutionary development. The medical scientist’s ‘plan’ stresses preventive medicine — more planning for health, instead of more care in illness.

His programme is directed toward the health of the whole population rather than toward the illness of one part of the population. He feels that a national health policy, like a national defense policy or a national educational policy, must be framed with a view to the needs of all.

His programme includes the privileged and the underprivileged alike.

His programme recognizes that supplying medical care is only one part — a comparatively small part — of keeping people well, that ‘the medical problem is only a small part of the general economic problem of the too low living wage of about 80 per cent of Americans,’ and that the attack must be made upon the broader front.

His programme involves direct instead of indirect use of tax funds.

It invokes, as compulsory insurance does, the leadership of the Federal Government. It would interpret the ‘general welfare’ clause of the Constitution to mean that the Federal Government may and should assume responsibility for ultimately making accessible to every citizen the full benefits of medical science, not only to protect the population from epidemic and the social consequences of individual disease, but also to ensure to the individual citizen a new level of industrial competence, a new capacity for personal enjoyment.

VII

The first ‘item,’ then, in the medical scientist’s programme is emphasis on prevention by the marked expansion of public health services, Federal, state, and local.

The medical scientist knows that those of his colleagues who are still trying to build up the fence between curative medicine (reserved for doctors) and preventive medicine (public health officers will please keep over on their own side) are engaged in a hopeless task. Preventive medicine is now coming into the doctor’s office — where it has as true a place as it has in the office of the public health service. The doctors themselves grow weary of the negative conception of their task. A physician whose work includes both the research that makes preventive medicine possible and curative attempts to deal with desperate cases in a great city hospital recalls early days on a Southwestern cattle ranch to illustrate the scientist’s chagrin at concentrating on reparative labor rather than creatively ministering to the vitality of the race: —

In driving the huge herds overland, the best of the cowboys were stationed at the front of the herd, where the wild-eyed Texas steers were always on the point of ‘going places.’ Tenderfeet, like myself, followed after the ‘drag,’ the weak cows and forlorn ‘dogies’ needing constant prodding and encouragement to keep them in the herd.

Doctors are traditionally working on ‘ the drag,’ pulled along by public opinion as it relates to the social aspects of medicine, rather than shaping public opinion. Or they are kept in an idealistic sanctuary, thinking only the circumscribed thoughts Æsculapius and sentimental Americans w’ould have them think.

In one of our hospitals, a poliomyelitis victim with paralyzed muscles of respiration would have died at once but for the Drinker respirator. In it he has lived for more than a year — and has used up all that his family had saved and could borrow and some $10,000 of hospital funds. The child cannot live without this mechanical aid. How long is it our duty to keep the breath of life in him?

By a contraption which prevents bladder infections we keep paralyzed patients alive in our public wards for months or years instead of, as formerly, for weeks. Illustrations could be multiplied.

This writer would use the $10,000 of hospital funds for research designed to make control of disease more and more possible.

The conception of governmental responsibility moves steadily on. Nobody’s ‘views’ are going to stop it. Statutes against evolution have not greatly retarded it. For many years government limited its responsibility to the insane. Later tuberculosis was assumed. Now, year by year, one disease after another is discovered to have a claim upon public interest that brings it under state functioning — either because it threatens the health of society as a whole, or because it involves treatment too long and too expensive for the individual to compass. Massachusetts takes hold of cancer; New York takes hold of pneumonia. Arthritis, cardiac diseases, rheumatism, are now under consideration as diseases endowed with a public interest.

People begin to see that if the state does not deal at an early stage with the disease, and organize and pay for curative treatment, it will end by dealing later with the diseased as a public charge, paying for dependency what might have gone into a chance of cure. There is at this moment in operation a venereal disease programme stimulated by the United States Public Health Service, based upon recognition that institutions of all kinds are full of the end results of syphilis, and that venereal disease is indeed a social problem, with which other governments, notably Sweden, have been able to deal.

When the list of diseases with a ‘public interest’ is finally complete, how long will it be?

VIII

The second proposal of the medical scientist’s programme is tax support for hospitals.

This proposal is based upon recognition of the fact that the hospital has become the centre of medical practice and of medical education, and that as such it cannot logically depend upon private philanthropy — already failing. The proposal is that tax funds should be allocated to private hospitals in direct relation to the amount of care they give to the indigent and the lowincome group — in the hospital or in the dispensary or in the home. On the basis that the indigent sick have a logical call upon tax funds, Federal grants-in-aid to the states are proposed to cover payment both to hospitals and to private practitioners for care of the indigent in hospitals, dispensaries, and in the patients’ homes. The cost would be met by local tax funds to the utmost possible degree, but with state aid generally, and with Federal aid under certain conditions and for certain types of communities.

The third proposal is extension of the facilities of tax-supported laboratories to make the scientific aids to diagnosis and treatment (urinalyses, blood counts, metabolism tests, X-ray, vaccines, and so forth) available to physicians generally, and thereby to their patients at low units of cost, and free to the indigent and near-indigent.

The fourth proposal is recognition of the principle that the medical care of the indigent and the near-indigent (or ‘medically indigent’) is a logical charge upon tax funds, local to the greatest possible degree, with state aid, and with Federal aid under certain conditions and for certain types of communities.

Most of the public has no conception of the astounding amount of free care doctors now give to the indigent — in hospitals, where every agency in the service except the doctor and possibly the pupil nurse is paid; in dispensaries, where young doctors devote most of their day to unpaid service; in the doctor’s office, and in patients’ homes to which the doctor sends no bill because he knows there is no money. Most of the world wants to end this highly illogical forced contribution of doctors’ service — in order, if for no other reason, that the costs of medical services to other groups may be put upon a more even base.

Federal grants-in-aid to the states, on the basis of care for the indigent, would permit a desirable national standardization of principles and procedures in medical care, always recognizing the necessity for local variations and adaptation to local conditions.

The fifth and last recommendation in this programme of limited state medicine and private practice is a Federal coordinating authority, a ministry of health for this country, a Department of Health with a medical Secretary of Health in the President’s Cabinet.

Medical men, however, do not like the Department of Welfare which the President’s message on reorganization several months ago proposed, and which would include the Social Security measures, Education, the Women’s Bureau in the Department of Labor, and so forth. It is not good ‘reorganization,’ the medical scientist submits, to bundle the above administrative unlikes together just because they all touch in some fashion upon the ‘welfare’ of the individual citizen. He does not think a heterogeneous new department of this kind would be a vast improvement over the present system. It would collect the now scattered health functions of the Federal Government, and to that extent would be an advance; but it would still make the critical error of assuming that the same national authorities can effectively administer vastly separate fields, which in fact require different kinds of expertness and experience, different planning, and utterly different procedures.

IX

This summary of the medical scientist’s ‘programme’ will be only inaccurate dogma unless we add that, in a way, the medical scientist disavows all ‘programmes,’ all charts, all fixed procedures — in short, the whole commodity conception. He is constantly apprehensive lest the ‘plan’ submerge the work. He favors no scheme for extending and distributing medical care that does not recognize the changing, vital, fluid nature of medical science, and that does not provide for avoiding fixation of mediocre standards. The heart of any plan will be national standards for medical education and research—and national funds for both.

To illustrate: he would not establish a single new ‘community hospital,’ except as it is clear that trained men can be made available to staff it. He would not ‘extend’ the facilities of tax-supported laboratories until it is clear that every laboratory thus ‘extended’ has the personnel and the facilities to meet adequately the added demand for highgrade work. He would check every scheme for ‘establishing,’ ‘founding,’ ‘extending,’ ‘distributing,’ by the degree to which it recognizes that the thing being dealt with is not a commodity, not a constant, but a force, fluid, vital, ever changing, effective only as it is permitted creative growth.

Will the government call the medical scientist into counsel as well as the social scientist? Under discerning leadership they can be brought into cooperation, for their views are rather different than opposed.

But before the national administration can bring about this cooperation it must itself be clear whether, in planning for health and security, its concern is chiefly with the illness of the underprivileged or with the health of the whole population.