Sir Arthur Newsholme

“ The first lesson, then, which has already been partially learnt, is that no member of a community can live to himself. We now believe in the solidarity of society; that the sores of one section of it means peril for all. And we are gradually learning to appreciate that this is true not only in respect of the acute infectious diseases, and of chronic infectious diseases, such as tuberculosis and syphilis, but of every disease and of every other factor in life which causes individual inefficiency, and which consequently inflicts additional burdens on the competent section of the community. ”

“ We scarcely realize how far we have gone in the socialization of medicine. It is impossible to go back, or to stand still. The services of the medical profession are needed, not only to provide the necessary service, but in helping to determine its conditions. One essential item will be the substitution for fees during sickness of an annual payment to private practitioners by each family for supervising its members in health, for inquiry into their industrial and domestic life, so far as it contains elements inimical to health, and for giving preventive more than curative advice. ”

“ In every American city visited by me I have been struck with the earnest desire of voluntary and official public health and social workers to profit by English experience, to adopt what is good, to secure the abolition of the short tenure of office of competent officers under the present political system, and to introduce civil service conditions for them. There is in many respects a close parallelism between the course of public health on both sides of the Atlantic; in some cities the English hygienist has much to learn in respect of advanced and original work ”

“ What is public health work? It is best defined by stating its object, which is to secure the maximum attainable health of every member of the community, so far as this can be secured by the authorities, local, state, or federal, concerned in any part of government, acting in coöperation with all voluntary agencies whose [Pg 44] work conduces to the same end. The connotation of public health becomes wider year by year. It embraces physiological as well as pathological life; being as much concerned with improving the standard of health of each person as with the prevention and cure of disease. ”

“ Thanks to the great discovery of Jenner and to the complete organization of measures for isolation of the sick, and for vaccination and surveillance of contacts, we can make the same claim for smallpox, whenever this mysterious disease begins its occasional world travels.
But we have to confess our continuing relative helplessness in preventing the spread of measles, and of acute catarrhs, among our endemic infections, and still more of influenza when—as recently—it makes its devastating swoop on the entire world, and secures a larger number of victims than the World War itself. ”

“ If communal provision has been recognized as a duty for police protection, for sanitation, for elementary education, should it not likewise be admitted for the more subtle and maleficent enemies of health which have been recognized, but which in no community have hitherto been completely combatted? ”

“ This may imply—and in England it does imply—the urgent need for reform and reconstruction of local as well of central public health administration; but to attempt to separate medical from public health provision is to repeat the blunders which, despite skilled advice to the contrary, have been made on two great historic occasions.
A complete service, adequate to the needs of the community, cannot be secured by a session’s legislation. It must grow as the result of steady advance. The motto in growth might well be, “First things first.” ”

“ On the point of equity, it must be admitted that any system of so-called insurance which, like that of the English Act, excludes a large proportion of the population who, while paying in taxes in aid of the insured, require but do not receive their benefits, is contrary to the principle that any expenditure of Government funds should enure to the whole community in need of the provision in question. ”

“ The public as well as the medical profession need to be educated, the latter in the carrying out of complete and prompt notification of cases of the disease, and in the use of all facilities provided for aiding diagnosis; the former in the risks of industrial and other dust infections, of indiscriminate expectoration, of alcoholism, of imperfect nutrition, of bad housing, and so on. We all need to learn the folly of imperfect measures against tuberculosis. Complete success can only be attained if we assume responsibility for the whole course of the life of the consumptive. ”

“ The real wealth of a nation does not consist in its money, in the volume of its trade, or in the extent of its dominion. These are only valuable insofar as they help to maintain a population—and not only a portion of it—of the right quality; men, women and children possessing bodily vigor, alert mind, firm character, courage and self-control. ”

“ Whose ignorance is it proposed to enlighten? Ignorance is common to all classes, and it is fundamentally important that systematic instruction in physiology and hygiene should be given in all our schools; and that especially every teacher should have adequate training in these subjects, and in the recognition of the common mental and physical defects of children. If [Pg 169] a course of instruction were given for all, approaching that which is given for public health nurses at Yale University, how much more hopeful would be the prospect of public health progress, both in New and Old England. ”

“ The recent epidemic of influenza has taught us several important lessons—First, we have been painfully reminded that we are completely ignorant of the causes of the pandemic waves of this terrible disease, which, at irregular intervals of years, traverse the world. We may surmise that the crowding and the mental and physical depression of war caused increased rapidity of spread and a greater fatality in the present outbreak; but influenza has spread and been only less fatal than in the present outbreak when there was no war, and we must admit our ignorance of the cause of this. ”

“ When we read of administrative scandals, it is desirable to have a sense of proportion, and to remember, as the reader of old records or even of Pepys’ diary will scarcely need to be reminded, that corruption was rampant in the past, and especially to remember that the best way to remove that most subtle and mischievous form of corruption which consists in giving and accepting appointments as political rewards, is by ourselves taking a part in local government, or by steadily upholding those who are doing so with integrity. ”

“ Hence my plea that the magnificent [Pg 143] potentialities of the Red Cross organization should not be allowed to fall into abeyance; that they should replace their relief work by preventive work; that, to use a well-known simile, they should erect a parapet at the top of a dangerous cliff as well as provide ambulances at its foot. In so doing they will, I am confident, not encroach on present successful work of existing bodies concerned with promoting child welfare, or with the prevention of tuberculosis or of venereal diseases, or with existing agencies for providing nurses for the poor. ”

“ It appears to me clear that over-population need not excite apprehension; that population in itself is the only means by which national wealth can materialise; and that our chief aim in securing national efficiency must be to train each unit of the population adequately for work, and to prevent the terrible loss of efficiency due to avoidable sickness.
And this brings me to the direct statement of the truism that health progress can only be secured by preventing preventible illness. ”

“ It is, I think, clear that the state will year by year take an increasing hand in medical matters. It is useless, even if it were desired, to attempt to oppose the inevitable and the eminently desirable trend towards vastly increased utilization by the state of medical science in the interests of humanity. It is for physicians to guide the course of events, and to insure that no plant is sown which will afterwards need to be uprooted; that no development is permitted which will hinder the fulfillment of our ideal. Personal hygiene forms a rapidly increasing part of public health work ”

“ It is commonly stated that, in the past, public health administration has concerned itself solely with mankind’s environment, failing to recognise the predominant importance of man himself as a transmitter of disease, and of his personal well-being and protection as the point to which energy should be directed. ”

“ For the linking of treatment provided largely out of public funds with insurance there is no justification, and it is contrary to the public interest; and it is unfortunate that monetary insurance has been provided in England for a section of the population under these unsatisfactory conditions, thus diverting expenditure from the public health services in which it was urgently needed, and in which its use would at once have been fruitful in increased health and happiness. ”

“ In the group of respiratory diseases I think we should include a number of diseases not commonly regarded as such, but in which, so far as can be judged, infection is received by inhalation; and I would, therefore, group together such miscellaneous diseases as poliomyelitis, cerebro-spinal fever, measles, bronchitis, pneumonia, and influenza. All agree in one particular, that attempted preventive measures against their spread are dubious in effect. ”

“ If there is a corrupt council, the remedy is not its supersession by an independent executive. Such an executive is the abrogation of popular government. “Good and efficient government is possible under almost any form of organization. More depends upon men than devices.... But ... if we believe that the functions of deliberation or determination of municipal policy and of administration [Pg 63] or the execution or carrying out of that policy should be kept distinct, we cannot avoid the conclusion that a city council is a necessary part of the municipal organization.” ”

“ Bishop Harman, an ophthalmic surgeon, and a member of the Council of the British Medical Association, says:
“In my out-patient clinic 60% of the patients are insured persons who attend for treatment that is essential to their industrial efficiency.... A scheme of medical benefit which does not provide for specialist service and for institutional treatment is no scheme, it is poorer in status than the Poor Law provision which does all these things.” ”

“ If we include the third of the total population who now receive in Great Britain the unsatisfactory medical benefit under the National (Health) Insurance Act, and remember the rapidly increasing scope of voluntary and official institutional treatment of disease, hesitation in accepting [Pg 116] the inevitable should be replaced by a determination to guide future developments and to render them efficient and economical. What is good for the public is good also for the members of the medical profession. ”

“ On page 438 of the sixth edition of his book Malthus says:
that the principal and most permanent cause of poverty has little or no direct relation to forms of government, or the unequal division of property; and that, as the rich do not in reality possess the power of finding employment and maintenance for the poor, the poor cannot in the nature of things, possess the right to demand them, are important truths flowing from the principle of population. ”

“ Other instances will occur to you, illustrating the importance of a broad outlook in the causation of disease or other forms of social misery. I will adduce one more. It is well known that infant mortality is much heavier among the poor than among the well-to-do. The rule does not hold universally in rural areas, but in towns it applies almost without exception. And it is assumed by a large school of social workers that enlightenment of the ignorance of the poor mother will effectively correct this evil. Such a lop-sided view ignores many of the elements of the problem of infant mortality. ”

“ These being the objects of public health, how far have we travelled toward securing the end in view? I do not propose to myself the pleasant task of showing to what extent the general death-rate has been lowered, infant and child mortality greatly reduced, the duration of life extended, how typhus and smallpox have been almost eradicated, typhoid fever made [Pg 46] a disappearing disease, and tuberculosis has become the cause of only half its former death rate. ”

“ The great public health requirements for the future are the conquest over acute respiratory infections, including not only affections of the lungs, but probably also measles and whooping cough, cerebro-spinal fever and poliomyelitis and their allies; and the prevention of cancer. So while thankful for the discoveries already made, and for the beneficent work already accomplished, we must hope that the rapid increase of Medical Research in England and here will in due time enable us to extend the application of preventive medicine to diseases so far uncontrollable. ”