A Challenge to Medicine
A Symposium
OUR NATIONAL HEALTH
BY HAVEN EMERSON
THESE are words to conjure with, for the health of a people stands at the side of liberty under the law and freedom in religious faith as a high objective for self-governing communities. The motives and methods of those who would replace professional by political control of medicine will bear critical scrutiny. A passionate desire for benevolence is often mated with fondness for power, where honesty of purpose is the excuse for impatience with opposition and contempt for practical difficulties. The honorable and enduring marriage of medicine and government has been too productive of social and individual benefits among us to be safely threatened by contemporary theorists and their administrative ambitions.
We are told that there are sick who are not served and that protection of health is not uniform in quality or universally available. To such obvious truths we assent, and as a measure of our belief and purpose we point to a half century and more of uninterrupted progress in both of these reasonable and primary demands upon the medical profession. Under all forms of government there has been for the past hundred years an overflowing treasury of internationally available knowledge of human biology and of the natural history of disease, its treatment and prevention. The results have been everywhere in the same direction, differing only in degree and time of occurrence. The suffering of the sick has been made more tolerable and of shorter duration, deaths have been prevented or postponed, and probability of survival has been improved at all ages. The rate and manner of such progress have varied with forms of government and with that major associated economic factor, the general standard of living of the wage earner. Where literacy and general education prevail, where earnings are high relative to the cost of living, and government does not exact an excessive share of income by taxes for its own activities and for past or threatening wars, there the individual, family, and social or political unit have invested with good judgment and a growing generosity in medical care. A useful index of this in our own country is the rising ratio of licensed physicians and of hospital beds to the number of the population, and increase in the per capita expenditures for public health.
This was characteristic of most of the political jurisdictions and population aggregates of the United States prior to 1929 and has, in the wealthier states and urban communities, prevailed up to the present time. Physicians of better education and in larger numbers have been more widely distributed, hospital capacity has been expanded in rural as well as in city areas and facilities improved to provide for diagnosis and treatment otherwise unobtainable, and sums devoted to the constructive and protective purposes of health have steadily mounted, as the people came to understand the values thus created. In all of this there has been a considerate and helpful partnership between philanthropy and government, between voluntary gifts of services and funds and their provision by tax monies under official auspices.
Under our tradition of free initiative in the selection and pursuit of self-support, whether in trade or profession, physicians have been drawn more to those areas where density of population, financial advantage, and pleasant conditions for the family were most promising than to impoverished, backward, and sparsely settled areas where neither brains nor devotion could win a reasonable medical livelihood.
Greater intricacy and refinement in medical techniques, and increasing interdependency of many specialties and the associated scientific skills in caring for the sick, have raised the cost of medical care, but not out of proportion to that of other satisfactions and necessities of modern life which people have learned to demand and pay for.
In a few of our states at large, and in an undetermined number of counties and smaller areas in a few other states, the average per capita income appears to be insufficient to permit that personal or collective investment necessary to provide for all the people medical services generally found in more favored states and communities, and there accepted as necessary.
The unexpectedness or unpredictability of illness is its most unpleasant and disturbing characteristic from a social and economic point of view, particularly in the case of serious or catastrophic emergencies of accident, infection, and senescence. It would seem that insurance principles would apply to secure for the people of small means medical care which the individual can afford if at all only at great sacrifice. Efforts should be continued to discover equitable methods to this end, but it must be admitted that no voluntary or compulsory collective system for meeting the cost of medical care in sickness has been put into operation abroad or in this country without development of abuses by the beneficiaries or sacrifice of medical progress among the physicians involved, or both. It has been claimed by some governments abroad, and conceded by their representative physicians and others, that some of the low-paid wage earners have received under compulsory sickness-insurance schemes more and better care than they had obtained before at their sole initiative and expense. It is well to bear in mind that in the opinion of competent sociologists and economists the dominant motive of all such insurance plans is relief of poverty and not the preservation of the public health.
This truth, well recognized by the physicians of this country, accounts for some at least of the determined opposition of our medical profession to what is promoted under the misnomer of health insurance and is really a project for the spending of public funds as merely one way of redistributing wealth without regard to the quality or results of the medical service to be bought. The people of the United States and their physicians would be blind and churlish indeed if they did not take to heart the lessons of European experience, and gratefully acknowledge the warnings of the social ordering of medicine abroad which has been a major factor in Europe’s loss of scientific leadership in health and care of sickness.
An independent body of physicians determined to keep control of its standards of professional education and to continue in effect its guardianship of the interests of the sick, together with the voluntary or endowed hospital system which is the particular glory of individual and collective philanthropy in our generation, and most lately the development of prepayment plans to meet the hospital costs of illness, have been the chief elements in the success of American medicine in emphasizing quality of care rather than mass production, and in distinguishing between benevolent sentimentality and the blessings of the sanitary and medical sciences.
What, then, can be suggested to bring to all who need and wish to use them the resources of medical art and science, whether in sickness or for health, at a cost within personal or collective means? Are we to believe that there is a pressing national need, some urgent threat of neglected suffering created by failure of individual or administrative medicine? Is the time ripe for a considerable expansion in the amount of medical care for all the people and a shift of responsibility for it? Are the skills ready, and the means to implement them? Is it medical reorganization, or economic reorganization, or plain confidence that the people need to achieve their reasonable desires? Is federal legislation as proposed in the Capper bill (S.658) and in the Wagner bill (S. 1620) likely to bring about more improvement, in national health than can be expected otherwise? These and similar questions must be answered before physicians will accept administrative novelty as if it would necessarily bring a new superiority of medical care.
Dr. Sigerist has told you of his confidence that ‘our medical problem will be solved in a not distant future,’ of his belief ‘in the common sense of the people,’ of his ‘faith in the young medical generation.’ He admits that what he calls ‘health insurance,’ which in reality is compulsory insurance against the cost of sickness, is ‘not a panacea’ or ‘the ideal system,’ but he believes that ‘under the present social and economic conditions of the country’ it is the best possible solution if ‘ combined with an extension of public-health services.’
It seems to me reckless for the historian to attempt prophecy, or for a physician without wide experience in care of the sick or in public health to assume the rôle of medical economist or social expert, or for any recent arrival in our medical community, imbued as Dr. Sigerist is with the ideologies of other lands, to condemn the policies and actions of the profession of his adopted land, the realities of whose work are so remote from his own responsibilities.
The Assembly of the California Legislature is reported to have repudiated on June 15 its Governor’s favorite compulsory sickness-insurance bill by a 48-to-20 vote. The New York State Legislature adopted at its 1939 session the cautious plan of creating a commission to make further study of the facts before availing itself of its authority under the new state constitution to enact laws to provide for an insurance system for medical care. The Capper bill has met Congressional indifference, and lacks even the publicity of committee hearings to consider its federal requirements for compulsory sickness insurance for wage earners at the $60-a-week level or below.
Dr. Sigerist not only approves heartily of this bill as sound and constructive and ‘undoubtedly a great improvement on all European schemes,’ but declares that it ‘demonstrates that the overwhelming majority of the population, including the needy group, can be embraced by such a combination of compulsory and voluntary insurance.’ How a project of law still sleeping in committee can demonstrate anything but the hopes of its author and the ingenuity of legislative drafters is not apparent.
Senator Wagner has taken the lessons of European experience to heart, or perhaps he has had intimations of political inexpediency as well as of almost unanimous disapproval by physicians, dentists, and hospital administrators, and so has not provided openly and specifically for compulsory sickness insurance in the present form of his bill.
When President Roosevelt issued Executive Order No. 7481, in October 1936, directing his Interdepartmental Committee to prepare a plan for better coördination of the health and welfare functions of the Federal Government, there seemed to be a prospect of critical study and constructive proposals which would correct the costly and confusing duplication of function and structure in our health agencies. Nothing of the kind has developed. Instead we have had a report from a technical committee, hardly more than a restatement of the findings of the unofficial Committee on the Costs of Medical Care of a decade ago. Following this came the stupendous product of the misnamed and still uncorroborated ‘National Health Survey,’which was a search for sickness, not a study of health. While the records are doubtless unbiased and the statistical analysis competent, the interpretations of the answers collected by the army of WPA investigators have created a volume of exaggeration as to the extent of medical inadequacy in the United States. From all parts of the country, evidence is being collected which casts serious doubt on the oft-repeated and, if true, shocking statement that more than a third of our population lack medical care and that a still larger number suller from economic disadvantage because of illness. And out of all this great expense and publicity comes not a word of explanation for the lack of medical care in each case so reported, because this question was not included in the survey schedule.
Then came the so-called National Health Conference in July 1938, where the decisions of the Interdepartmental Committee were delivered to a couple of hundred of mostly willing and responsive listeners. No conference and no discussion occurred, and the matter was closed as it began with a news release of predetermined conclusions.
Then, in February 1939, came the Wagner bill with its fantastic provision for more than 250 advisory councils, appointed by three administrative chiefs of bureaus, to consider, but not determine, the rules and conditions under which every state, whether wealthy or poor, healthy or sick, shall receive large federal subsidies for six several objects, including care of the sick, cash-indemnity insurance, hospital construction, and public-health services. To this extravagant proposal for enlarging the scope of federal spending at the sacrifice of the resources and self-determination of the states the medical profession is opposed, for reasons readily accessible in the Congressional Record and in the Journal of the American Medical Association.
To raise still further the exceptionally high level of our present national health, and to increase the availability of good care for the sick, physicians have urged the following: —
1. Centralization of all federal health and medical-care functions (except for Army and Navy) under the SurgeonGeneral of the United States Public Health Service and preferably with a Secretary of Health in the Cabinet.
2. Full-time trained public-health officers in charge of state and local health departments to serve all political subdivisions of sufficient size to justify the essential personnel.
3. State legislation which will authorize, in the interest of self-supporting wage earners and their families, plans for voluntary hospital prepayment and cash-indemnity insurance for sickness.
4. Assumption by local and state governments of financial responsibility for care of the indigent sick, so far as this is not voluntarily provided for by private philanthropy and the medical profession.
5. Retention and further coöperative development of the dual system of voluntary and tax-supported hospitals and dispensaries, with special attention to the needs of the rural population.
6. Continuance of the present functions of state and local government in the almost exclusive responsibility for institutional care of mental diseases, tuberculosis, and acute communicable diseases.
7. Provision as in the past several decades for federal grants-in-aid through the United States Public Health Service to states for prevention of disease, where it can be shown that state and local resources are insufficient to meet reasonable standards of public-health service.
Medicine’s answer to the challenge of the present federal administration for still better national health is to hold to the good ways we have learned to value, and to alter or expand these only as evidence brings conviction of the need, and as resources are available which will not handicap our successors by imposing upon them increasing burdensome indebtedness.
THE AMERICAN WAY
EVEN the superficially informed reader of Dr. Sigerist’s article ‘The Realities of Socialized Medicine’ must, whatever be his political or medical complexion, find fault with the use of the word ‘Realities.’ Certainly it is not a reality that all those who had the nation’s health at heart welcomed the so-called National Health Conference. Some recognized it for what it was — not a conference at all in the usual sense, but a meeting for the announcement of an already-prepared plan whose adoption, in the opinion of many, might well lead to national disaster. Surely the scientific side of Dr. Sigerist recognizes that the ‘documentary evidence’ concerning one third of our population’s being without medical service has been seriously questioned, and in any event means little. In a given year there are many (perhaps one third) who do not feel the need of a doctor and do not want one. Others are too ignorant or indolent to seek care. This does not mean that medical care is unobtainable. Of real importance is the excellent evidence that equally good medical service — and probably better — is just as available to all but a few thousands of our citizens, rich or poor, as could be most optimistically expected with any variety or shade of socialized medicine.
Not only does our present system make medical care accessible, but there are good indications that it is associated with better national health than is the case with other systems. Dr. Sigerist admits this point but attempts, with some justification, to explain it on the basis of higher living standards in the United States. He fails to emphasize, however, a much more salient fact: that is, the steady improvement in our health as opposed to the stationary or, frequently, retrograde condition of other peoples. As an actual fact, even preventive medicine tends to deteriorate with more than a minimum of control over the medical profession.
It should not be thought from the above paragraphs that our medical profession — the American Medical Association, if you please — is static, and unaware of or apathetic about defects in medical practice, as Dr. Sigerist and other critics intimate. Dr. Sigerist knows well that the A. M. A. not only fosters scientific advancement but also carefully studies the systems of other countries, and has approved numerous medical economic experiments of its component societies. Many workable changes have resulted. The insurance principle has been endorsed, but with what experience has shown to be reasonable reservations designed to safeguard the patient and the advancement of medical knowledge, and to avoid pernicious political control. I trust, and believe, the A. M.A. will never be stampeded into superficially ideal but obviously impractical schemes. Dr. Sigerist says that American doctors know little of European systems. On the contrary, I believe we have studied them rather thoroughly — hence the earnest resolve to work out something better. Incidentally, the estimate of larger medical incomes might or might not be a ‘reality’ with Dr. Sigerist’s socialized medicine. However, medical men recognize the promise as an inevitable part of each and every scheme — and, to be perfectly frank, believe they detect the smell of bait. Some, it should be realized, are even angered by the implication, real or imagined, that they can be bribed to forget their ideals.
Much more could be said (about costs, for instance) in refutation of Dr. Sigerist’s article as an exposition of the realities of socialized medicine. And, in this matter, realities arc essential. Certainly the majority of medical men believe that their own association can come nearer to the truth than any individual or other group. These physicians have not forgotten, in the recent wave of criticism and ‘smearing,’ that the A. M. A. now, as always, stands and works for the advancement of medicine and the welfare of mankind, and that it is still under the influence and leadership of the most intelligent, informed, and public-spirited doctors of America.
Finally — and this is said in all sincerity — may I question the propriety of the Atlantic’s seeming endorsement of Dr. Sigerist, who is primarily a historian and a rather recent arrival from Europe, as a qualified authority for the reassurance of Americans in regard to what, in its ultimate goal, means the introduction into this country of the Russian system of medical care?
ROGER S. SIDDALL
WITH the June issue the Atlantic makes the doctor once more remove the stethoscope from his ears and take notice. This time there is no smile on his face as he reads Dr. Sigerist’s article, ‘The Realities of Socialized Medicine.’ A
careless reader may not realize that Medicine is like the Atlantic. Both have two sides — a European side and an American one. Europe: totalitarian; control from above. America: personal initiative; control from within.
Despite many present-day tendencies, it is still our glorious national belief that this is a free democracy where activities are best conducted under a system of freedom of development and control. Why should Medicine be selected for governmental regimentation any more than, for example, the Church? Those who know the inner story of the strangulation of medical progress in Europe from governmental rigidity feel that American medical science and art are the hope of the profession to-day. Right now, by its own free efforts, American medicine leads the world. Even socially the picture painted by Dr. Sigerist is far too black. Less than 5 per cent of the people of the United States are more than thirty miles from a hospital. With automobiles and good roads, that is a fine distribution. The people, not the doctors, must be educated to use the facilities they have. Strange, but true; in the older communities where there are the greatest number of hospital beds per thousand of the population, these beds are utilized by patients for a much greater number of total days per year than are the fewer beds in the hospitals of communities that seem to have poor hospital facilities. The fewer the beds, the more they stand idle!
Dr. Sigerist was born in France and educated in Switzerland and Germany. Naturally he was ‘conditioned’ from very childhood to a Bismarckian concept of state medicine. The Chair of the History of Medicine at Johns Hopkins University now occupied by Dr. Sigerist was founded and first held by Dr. William H. Welch. How we should like to hear our ‘Popsy’ tell us now what he thought of socialized medicine!
JOSEPH T. SMITH