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The Health Program

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Much of the controversy concerning security against sickness has centered about schemes for compulsory health insurance, such as exists in Britain and many other countries. Those who advocate these plants point out that a large number of the population cannot afford to pay doctors’ and hospital bills. Organized medicine in the United States argues that there are plenty of doctors and hospitals available, that charges are moderated or eliminated entirely for the poor, and that it is desirable to maintain the relationship of individual responsibility between the patient and the physician. To this argument the reply is made that what is sought is not medical charity, but a means by which those in the middle and lower income groups who earn their way can be insured against the crushing burden of extraordinary expenses for illness.

The NRPB report scarcely touches this controversy. It makes no proposal for a health-insurance system; the nearest approach is a commendation for insurance against disability—which would presumably indemnify the sick or insured person for loss of income, but might co-exist with any conceivable system of medical service.

The reason for the omission may be that the government is not ready with a detailed plan in this hotly controversial field. Whatever the reason, the omission is in one respect fortunate, since it helps to transfer the center of interest to a far more important aspect of the health program. The big job is not so much to make sure that the sick are taken care of, necessary as that is, as to reduce the volume of sickness. Just as it is a defeatist social attitude to provide for compensation for the unemployed without striving to prevent unemployment, so it is defeatist to throw energies into care for the sick rather than to direct them into minimizing the need for that care.

According to an estimate the United States Public Health Service, 400,000,000 man-day are lost every year from all types of disability. In 1940, the loss in production alone was fifty times the loss from strikes. Similar figures could be piled up showing the economic cost of ill health—for example, the enormous toll of hospitalizations, or the poor physical and mental condition of a large proportion of men examined for the army. If one goes on to count the social and political cost, which ramifies into every phase of human life—including war, crime, and depression—the burden is literally incalculable.

It is the assumption of medical science that all illness, with the probably exception of old age and death, is theoretically preventable. Research workers are still engaged in the task of pushing back the frontiers of knowledge which makes prevention possible, and the territory conquered is already wide. Yet application of this knowledge lags far behind the discoveries of the scientists. We should think it a national scandal if the automobile or electrical industries were on-tenth as tardy in introducing the latest gadget as the nation is in adopting proved measures necessary to reduce deaths in childbirth or infectious diseases or malnutrition.

The first recommendation of the report is the obvious one of providing adequate public-health services. In June, 1942, there were more than 1,200 counties in the nation without the services of a full-time local or district health department. It is the health department which oversees sanitation, the isolation of contagious diseases and much of the other ordinary work of preventive medicine.

A good illustration of our antiquated attitude in this sector of life is that in 1940 the nation spent nearly $30 per capita of the population for the care of sickness, but only $1.35 per capita for the preventive work of health services.

Necessary improvements in sanitation alone will require $2,500,000,000 for construction work in the next decade. We are far behind an adequate program, in many parts of the country, for preventing communicable diseases, or for taking ordinary precautions in maternity and childhood. Expansion of the health program for mothers and children is an important recommendation of the report. Another is better proaction of factory and farm workers against occupational hazards.

The second item in the proposed health program deals with adequate nutrition. In spite of the enormous amount recently printed on this subject, few understand the prevalence, in the richest of all countries, of malnutrition, and fewer still its far reaching results, especially if suffered in infancy and childhood. Nutrition is partly a problem of having incomes sufficient to buy what we ought to eat. Even for those with sufficient knowledge and income, however, it is partly a problem of obtaining the required food values in the stuff that is turned out by the factory system and dished out in restaurants. It is probable that the poor farmer or peasant of centuries ago was in many cases better fed than the city-dweller of today, because he ate his own grains and vegetables without first removing half the nutriment from them. Finally—and this is a little recognized truth which the report does not mention—nutrition is an important emotional problem, since overeating and underrating, as well as irrational tastes and distastes for food which obstruct the natural tendency to crave what we need, are in nine cases out of ten traceable to personality disturbances acquired in childhood.

It will take public expenditure to spread the knowledge of what we ought to eat, in a form such that the ordinary citizen can choose a meal without the use of logarithmic tables. Provision of enough income to buy adequate food is a function of the whole security program. Incidentally, we are now experiencing a striking proof of the fact that for years many people have not had such an income. During depression, we thought we were growing a food surplus. Production of food in 1942 was 25 percent above the depression average. Lend-lease is taking but a small share of it. But we are short of almost everything except bread, for the simple reason that millions of men in the army are being fed, for the first time in their lives, as much of the good foods as the nutrition experts think they ought to have, while millions of industrial wage-workers can afford, for the first time in years, to buy good food in the markets. 

Knowledge and public regulation both will be necessary to improve the qualities of food available to the purchaser. (We have already made one great advance in that respect through the fortifying of bread.) Progress in dealing with the emotional difficulties, in this as in other fields, waits on the widespread application of psychiatry and mental hygiene.

In its section on the adequate medical care for all, the report emphasizes the provision of facilities rather than any new system of regulating or paying for them. However well provided certain areas are with hospitals and physicians, facilities for care of the sick are very unevenly distributed about the country. In 1940 the United States Public Health Service estimated that in rural areas at least 240 new hospitals are needed, with 15,500 beds. It is a well known fact that even in peacetime medical personnel is both scarce and of inferior quality in many more sparsely settled or poorer districts of the country. This condition cannot be expected to correct itself under medical individualism since doctors tend to congregate where the good hospitals and paying patients are.

What the NRPB Report has to offer on health is true and elementary, but it falls far short of a medical plan for the nation. The fact that we do not have such a plan is mainly the fault of the spirit that governs the American Medical Association. How far behind meeting its professional responsibility it falls may be learned from recent reports of the British Medical Association and the discussion in British medical journals.

In Britain, compulsory health insurance has been accepted for years, and nobody would think of abolishing it. But it is far from solving the problem; indeed, as practiced in Britain it has serious faults. Those in this country who are devoting their main efforts to arguing for it are just as far behind the times as those who argue against it.

Why must we start where Britain started some decades ago? Why can we not at least begin where Britain is? British authorities are now concerned, not merely with making access to medical care universal, but with vast improvements in preventive medicine, in the proper geographical distribution of medical facilities, in improving the quality of services offered by the general practitioner, both through continuous education and the organization of health centers. They are conceded with stimulating research and opening pathways between new knowledge and practice. They are concerned with the planning of the medical services as a single system, which will coordinate hospitals, public and private, public-health services, research and the individual medical man, around the effort to reduce the volume of sickness.

Such planning cannot be done by government economists or social workers. It is not a matter for actuaries and insurance systems. It is the function of experienced and creative medical men. As long as organized medicine in the United States continues to shirk its public duty while fighting a defensive battle against what it regards as lay encroachment upon its province, so long will both doctors and their potential patients suffer, and so long will the nation pay a gigantic bill for preventable illness.