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Essays in War-Time: Further Studies in the Task of Social Hygiene
The main Recommendations made by the Commission, if we put aside the suggestions for obtaining a more exact statistical knowledge, may be placed under the heads of Treatment and Prevention. As regards the first, it is insisted that measures should be taken to render the best modern treatment, which should be free to all, readily available for the whole community, in such a way that those affected will have no hesitation in taking advantage of the facilities thus offered. The means of treatment should be organised by County Councils and Boroughs, under the Local Government Board, which should have power to make independent arrangements when the local authorities fail in their duties. Institutional treatment should be provided at all general hospitals, special arrangements made for the treatment of out-patients in the evenings, and no objection offered to patients seeking treatment outside their own neighbourhoods. The expenditure should be assisted by grants from Imperial Funds to the extent of 75 per cent. It may be added that, however heavy such expenditure may be, an economy can scarcely fail to be effected. The financial cost of venereal disease to-day is so vast as to be beyond calculation. It enters into every field of life. It is enough merely to consider the significant little fact that the cost of educating a deaf child is ten times as great as that of educating an ordinary child.
Under the head of Prevention we may place such a suggestion as that the existence of infective venereal disease should constitute legal incapacity for marriage, even when unknown, and be a sufficient cause for annulling the marriage at the discretion of the court. But by far the chief importance under this head is assigned by the Commission to education and instruction. We see here the vindication of those who for years have been teaching that the first essential in dealing with venereal disease is popular enlightenment. There must be more careful instruction—"through all types and grades of education"—on the sexual relations in regard to conduct, while further instruction should be provided in evening continuation schools, as well as factories and works, with the aid of properly constituted voluntary associations.
These are sound and practical recommendations which, as the Government has realised, can be put in action at once. A few years ago any attempt to control venereal disease was considered by many to be almost impious. Such disease was held to be the just visitation of God upon sin and to interfere would be wicked. We know better now. A large proportion of those who are most severely struck by venereal disease are new-born children and trustful wives, while a simple kiss or the use of towels and cups in common has constantly served to spread venereal disease in a family. Even when we turn to the commonest method of infection, we have still to remember that we are dealing largely with inexperienced youths, with loving and trustful girls, who have yielded to the deepest and most volcanic impulse of their natures, and have not yet learnt that that impulse is a thing to be held sacred for their own sakes and the sake of the race. In so far as there is sin, it is sin which must be shared by those who have failed to train and enlighten the young. A Pharisaic attitude is not only highly mischievous in its results, but is here altogether out of place. Much harm has been done in the past by the action of Benefit Societies in withholding recognition and treatment from venereal disease.
It is evident that this thought was at the back of the minds of those who framed these wise recommendations. We cannot expect to do away all at once with the feeling that venereal disease is "shameful." It may not even be desirable. But we can at least make clear that, in so far as there is any shame, it must be a question between the individual and his own conscience. From the point of view of science, syphilis and gonorrhoea are just diseases, like cancer and consumption, the only diseases with which they can be compared in the magnitude and extent of their results, and therefore it is best to speak of them by their scientific names, instead of trying to invent vague and awkward circumlocutions. From the point of view of society, any attitude of shame is unfortunate, because it is absolutely essential that these diseases should be met in the open and grappled with methodically and thoroughly. Otherwise, as the Commission recognises, the sufferer is apt to become the prey of ignorant quacks whose inefficient treatment is largely responsible for the development of the latest and worst afflictions these diseases produce when not effectually nipped in the bud. That they can be thus cut short—far more easily than consumption, to say nothing of cancer—is the fact which makes it possible to hope for a conquest over venereal disease. It is a conquest that would make the whole world more beautiful and deliver love from its ugliest shadow. But the victory cannot be won by science alone, not even in alliance with officialdom. It can only be won through the enlightened co-operation of the whole nation.
XII
THE NATIONALISATION OF HEALTH
It was inevitable that we should some day have to face the problem of medical reorganisation on a social basis. Along many lines social progress has led to the initiation of movements for the improvement of public health. But they are still incomplete and imperfectly co-ordinated. We have never realised that the great questions of health cannot safely be left to municipal tinkering and the patronage of Bumbledom. The result is chaos and a terrible waste, not only of what we call "hard cash," but also of sensitive flesh and blood. Health, there cannot be the slightest doubt, is a vastly more fundamental and important matter than education, to say nothing of such minor matters as the post office or the telephone system. Yet we have nationalised these before even giving a thought to the Nationalisation of Health.
At the present day medicine is mainly in the hands, as it was two thousand years ago, of the "private practitioner." His mental status has, indeed, changed. To-day he is submitted to a long and arduous training in magnificently equipped institutions; all the laboriously acquired processes and results of modern medicine and hygiene are brought within the student's reach. And when he leaves the hospital, often with the largest and noblest conception of the physician's place in life, what do we do with him? He becomes a "private practitioner," which means, as Duclaux, the late distinguished Director of the Pasteur Institute, put it, that we place him on the level of a retail grocer who must patiently stand behind his counter (without the privilege of advertising himself) until the public are pleased to come and buy advice or drugs which are usually applied for too late to be of much use, and may be thrown away at the buyer's good pleasure, without the possibility of any protest by the seller. It is little wonder that in many cases the doctor's work and aims suffer under such conditions; his nature is subdued to what it works in; he clings convulsively to his counter and its retail methods.
The fact is—and it is a fact that is slowly becoming apparent to all—that the private practice of medicine is out of date. It fails to answer the needs of our time. There are various reasons why this should be the case, but two are fundamental. In the first place, medicine has outgrown the capacity of any individual doctor; the only adequate private practitioner must have a sound general knowledge of medicine with an expert knowledge of a dozen specialties; that is to say, he must give place to a staff of doctors acting co-ordinately, for the present system, or lack of system, by which a patient wanders at random from private practitioner to specialist, from specialist to specialist ad infinitum, is altogether mischievous. Moreover, not only is it impossible for the private practitioner to possess the knowledge required to treat his patients adequately: he cannot possess the scientific mechanical equipment nowadays required alike for diagnosis and treatment, and every day becoming more elaborate, more expensive, more difficult to manipulate. It is installed in our great hospitals for the benefit of the poorest patient; it could, perhaps, be set up in a millionaire's palace, but it is hopelessly beyond the private practitioner, though without it his work must remain unsatisfactory and inadequate.58 In the second place, the whole direction of modern medicine is being changed and to an end away from private practice; our thoughts are not now mainly bent on the cure of disease but on its prevention. Medicine is becoming more and more transformed into hygiene, and in this transformation, though the tasks presented are larger and more systematic, they are also easier and more economical. These two fundamental tendencies of modern medicine—greater complexity of its methods and the predominantly preventive character of its aims—alone suffice to render the position of the private practitioner untenable. He cannot cope with the complexity of modern medicine; he has no authority to enforce its hygiene.
The medical system of the future must be a national system co-ordinating all the conditions of health. At the centre we should expect to find a Minister of Health, and every doctor of the State would give his whole time to his work and be paid by salary which in the case of the higher posts would be equal to that now fixed for the higher legal offices, for the chief doctor in the State ought to be at least as important an official as the Lord Chancellor. Hospitals and infirmaries would be alike nationalised, and, in place of the present antagonism between hospitals and the bulk of the medical profession, every doctor would be in touch with a hospital, thus having behind him a fully equipped and staffed institution for all purposes of diagnosis, consultation, treatment, and research, also serving for a centre of notification, registration, preventive and hygienic measures. In every district the citizen would have a certain amount of choice as regards the medical man to whom he may go for advice, but no one would be allowed to escape the medical supervision and registration of his district, for it is essential that the central Health Authority of every district should know the health conditions of all the inhabitants of the district. Only by some such organised and co-ordinated system as this can the primary conditions of Health, and preventive measures against disease, be genuinely socialised.
These views were put forward by the present writer twenty years ago in a little book on The Nationalisation of Health, which, though it met with wide approval, was probably regarded by most people as Utopian. Since then the times have moved, a new generation has sprung up, and ideas which, twenty years ago, were brooded over by isolated thinkers are now seen to be in the direct line of progress; they have become the property of parties and matters of active propaganda. Even before the introduction of State Insurance Professor Benjamin Moore, in his able book, The Dawn of the Health Age, anticipating the actual march of events, formulated a State Insurance Scheme which would lead on, as he pointed out, to a genuinely National Medical Service, and later, Dr. Macilwaine, in a little book entitled Medical Revolution, again advocated the same changes: the establishment of a Ministry of Health, a medical service on a preventive basis, and the reform of the hospitals which must constitute the nucleus of such a service. It may be said that for medical men no longer engaged in private practice it is easy to view the disappearance of private practice with serenity; but it must be added that it is precisely that disinterested serenity which makes possible also a clear insight into the problems and a wider view of the new horizons of medicine. Thus it is that to-day the dreamers of yesterday are justified.
The great scheme of State Insurance was certainly an important step towards the socialisation of medicine. It came short, indeed, of the complete Nationalisation of Health as an affair of State. But that could not possibly be introduced at one move. Apart even from the difficulty of complete reorganisation, the two great vested interests of private medical practice on the one hand and Friendly Societies on the other would stand in the way. A complicated transitional period is necessary, during which those two interests are conciliated and gradually absorbed. It is this transitional period which State Insurance has inaugurated. To compare small things to great—as we may, for the same laws run all through Nature and Society—this scheme corresponds to the ancient Ptolomaean system of astronomy, with its painfully elaborate epicycles, which preceded and led on to the sublime simplicity of the Copernican system. We need not anticipate that the transitional stage of national insurance will endure as long as the ancient astronomy. Professor Moore estimated that it would lead to a completely national medical service in twenty-five years, and since the introduction of that method he has, too optimistically, reduced the period to ten years. We cannot reach simplicity at a bound; we must first attempt to systematise the recognised and established activities and adjust them harmoniously.
The organised refusal of the medical profession at the outset to carry on, under the conditions offered, the part assigned to it in the great National Insurance scheme opened out prospects not clearly realised by the organisers. No doubt its immediate aspects were unfortunate. It not only threatened to impede the working of a very complex machine, but it dismayed many who were not prepared to see doctors apparently taking up the position of the syndicalists, and arguing that a profession which is essential to the national welfare need not be carried out on national lines, but can be run exclusively by itself in its own interests. Such an attitude, however, usefully served to make clear how necessary it is becoming that the extension of medicine and hygiene in the national life should be accompanied by a corresponding extension in the national government. If we had had a Council of National Health, as well as of National Defence, or a Board of Health as well as a Board of Trade, a Minister of Health with a seat in the Cabinet, any scheme of Insurance would have been framed from the outset in close consultation with the profession which would have the duty of carrying it out. No subsequent friction would have been possible.
Had the Insurance scheme been so framed, it is perhaps doubtful whether it would have been so largely based on the old contract system. Club medical practice has long been in discredit, alike from the point of view of patient and doctor. It furnishes the least satisfactory form of medical relief for the patient, less adequate than that he could obtain either as a private patient or as a hospital patient. The doctor, on his side, though he may find it a very welcome addition to his income, regards Club practice as semi-charitable, and, moreover, a form of charity in which he is often imposed on; he seldom views his club patients with much satisfaction, and unless he is a self-sacrificing enthusiast, it is not to them that his best attention, his best time, his most expensive drugs, are devoted. To perpetuate and enlarge the club system of practice and to glorify it by affixing to it a national seal of approval, was, therefore, a somewhat risky experiment, not wisely to be attempted without careful consultation with those most concerned.
Another point might then also have become clear: the whole tendency of medicine is towards a recognition of the predominance of Hygiene. The modern aim is to prevent disease. The whole national system of medicine is being slowly though steadily built up in recognition of the great fact that the interests of Health come before the interests of Disease. It has been an unfortunate flaw in the magnificent scheme of Insurance that this vital fact was not allowed for, that the old-fashioned notion that treatment rather than prevention is the object of medicine was still perpetuated, and that nothing was done to co-ordinate the Insurance scheme with the existing Health Services.
It seems probable that in a Service of State medical officers the solution may ultimately be found. Such a solution would, indeed, immensely increase the value of the Insurance scheme, and, in the end, confer far greater benefits than at present on the millions of people who would come under its operation. For there can be no doubt the Club system is not only unscientific; it is also undemocratic. It perpetuates what was originally a semi-charitable and second-rate method of treatment of the poorer classes. A State medical officer, devoting his whole time and attention to his State patients, has no occasion to make invidious distinctions between public and private patients.
A further advantage of a State Medical Service is that it will facilitate the inevitable task of nationalising the hospitals, whether charitable or Poor-law. The Insurance Act, as it stands, opens no definite path in this direction. But nowadays, so vast and complicated has medicine become, even the most skilful doctor cannot adequately treat his patient unless he has a great hospital at his back, with a vast army of specialists and research-workers, and a manifold instrumental instalment.
A third, and even more fundamental, advantage of a State Medical Service is that it would help to bring Treatment into touch with Prevention. The private practitioner, as such, inside or outside the Insurance scheme, cannot conveniently go behind his patient's illness. But the State doctor would be entitled to ask: Why has this man broken down? The State's guardianship of the health of its citizens now begins at birth (is tending to be carried back before birth) and covers the school life. If a man falls ill, it is, nowadays, legitimate to inquire where the responsibility lies. It is all very well to patch up the diseased man with drugs or what not. But at best that is a makeshift method. The Consumptive Sanatoriums have aroused enthusiasm, and they also are all very well. But the Charity Organisation Society has shown that only about 50 per cent. of those who pass through such institutions become fit for work. It is not more treatment of disease that we want, it is less need for treatment. And a State Medical Service is the only method by which Medicine can be brought into close touch with Hygiene.
The present attitude of the medical profession sometimes strikes people as narrow, unpatriotic, and merely self-interested. But the Insurance Act has brought a powerful ferment of intellectual activity into the medical profession which in the end will work to finer issues. A significant sign of the times is the establishment of the State Medical Service Association, having for its aim the organisation of the medical profession as a State Service, the nationalisation of hospitals, and the unification of preventive and curative medicine. To many in the medical profession such schemes still seem "Utopian"; they are blind to a process which has been in ever increasing action for more than half a century and which they are themselves taking part in every day.
XIII
EUGENICS AND GENIUS
The cry is often heard to-day from those who watch with disapproval the efforts made to discourage the reckless procreation of the degenerate and the unfit: You are stamping out the germs of genius! It is widely held that genius is a kind of flower, unknown to the horticulturist, which only springs from diseased roots; make the plant healthily sound and your hope of blossoms is gone, you will see nothing but leaves. Or, according to the happier metaphor of Lombroso, the work of genius is an exquisite pearl, and pearls are the product of an obscure disease. To the medical mind, especially, it has sometimes been, naturally and properly no doubt, a source of satisfaction to imagine that the loveliest creations of human intellect may perhaps be employed to shed radiance on the shelves of the pathological museum. Thus we find eminent physicians warning us against any effort to decrease the vigour of pathological processes, and influential medical journals making solemn statements in the same sense. "Already," I read in a recent able and interesting editorial article in the British Medical Journal, "eugenists in their kind enthusiasm are threatening to stamp out the germs of possible genius."
Now it is quite easy to maintain that the health, happiness, and sanity of the whole community are more precious even than genius. It is so easy, indeed, that if the question of eugenics were submitted to the Referendum on this sole ground there can be little doubt what the result would be. There are not many people, even in the most highly educated communities, who value the possibility of a new poem, symphony, or mathematical law so highly that they would sacrifice their own health, happiness, and sanity to retain that possibility for their offspring. Of course we may declare that a majority which made such a decision must be composed of very low-minded uncultured people, altogether lacking in appreciation of pathology, and reflecting no credit on the eugenic cause they supported; but there can be little doubt that we should have to admit their existence.
We need not hasten, however, to place the question on this ground. It is first necessary to ascertain what reason there is to suppose that a regard for eugenic considerations in mating would tend to stamp out the germs of genius. Is there any reason at all? That is the question I am here concerned with.
The anti-eugenic argument on this point, whenever any argument is brought forward, consists in pointing to all sorts of men of genius and of talent who, it is alleged, were poor citizens, physical degenerates the prey of all manner of constitutional diseases, sometimes candidates for the lunatic asylum which they occasionally reached. The miscellaneous data which may thus be piled up are seldom critically sifted, and often very questionable, for it is difficult enough to obtain any positive biological knowledge concerning great men who died yesterday, and practically impossible in most cases to reach an unquestionable conclusion as regards those who died a century or more ago. Many of the most positive statements commonly made concerning the diseases even of modern genius are without any sure basis. The case of Nietzsche, who was seen by some of the chief specialists of the day, is still really quite obscure. So is that of Guy de Maupassant. Rousseau wrote the fullest and frankest account of his ailments, and the doctors made a post-mortem examination. Yet nearly all the medical experts—and they are many—who have investigated Rousseau's case reach different conclusions. It would be easy to multiply indefinitely the instances of great men of the past concerning whose condition of health or disease we are in hopeless perplexity.
This fact is, however, one that, as an argument, works both ways, and the important point is to make clear that it cannot concern us. No eugenic considerations can annihilate the man of genius when he is once born and bred. If eugenics is to stamp out the man of genius it must do so before he is born, by acting on his parents.
Nor is it possible to assume that if the man of genius, apart from his genius, is an unfit person to procreate the race, therefore his parents, not possessing any genius, were likewise unfit to propagate. It is easy to find persons of high ability who in other respects are unfit for the ends of life, ill-balanced in mental or physical development, neurasthenic, valetudinarian, the victims in varying degrees of all sorts of diseases. Yet their parents, without any high ability, were, to all appearance, robust, healthy, hard-working, commonplace people who would easily pass any ordinary eugenic tests. We know nothing as to the action of two seemingly ordinary persons on each other in constituting heredity, how hypertrophied intellectual aptitude comes about, what accidents, normal or pathological, may occur to the germ before birth, nor even how strenuous intellectual activity may affect the organism generally. We cannot argue that since these persons, apart from their genius, were not seemingly the best people to carry on the race, therefore a like judgment should be passed on their parents and the germs of genius thus be stamped out.