Kitabı oku: «Essays in War-Time: Further Studies in the Task of Social Hygiene», sayfa 7

XI
THE CONQUEST OF VENEREAL DISEASE

The final Report of the Royal Commission on Venereal Diseases has brought to an end an important and laborious investigation at what many may regard as an unfavourable moment. Perhaps, however, the moment is not so unfavourable as it seems. There is no period when venereal diseases flourish so exuberantly as in war time, and we shall have a sad harvest to gather here when the War is over.⁵⁴ Moreover, the War is teaching us to face the real facts of life more frankly and more courageously than ever before, and there is no field, scarcely even a battlefield, where a training in frankness and courage is so necessary as in this of Venereal Disease. It is difficult even to say that there is any larger field, for it has been found possible to doubt whether the great War of to-day, when all is summed up, will have produced more death, disease, and misery than is produced in the ordinary course of events, during a single generation, by venereal disease.

There are, as every man and woman ought to know, two main and quite distinct diseases (any other being unimportant) poetically termed "Venereal" because chiefly, though not by any means only, propagated in the intercourse over which the Roman goddess Venus once presided. These two diseases are syphilis and gonorrhoea. Both these diseases are very serious, often terrible, in their effects on the individual attacked, and both liable to be poisonous to the race. There has long been a popular notion that, while syphilis is indeed an awful disease, gonorrhoea may be accepted with a light heart. That, we now know, is a grave mistake. Gonorrhoea may seem trivial at the outset, but its results, especially for a woman and her children (when it allows her to have any), are anything but trivial; while its greater frequency, and the indifference with which it is regarded, still further increase its dangers.

About the serious nature of syphilis there is no doubt. It is a comparatively modern disease, not clearly known in Europe before the discovery of America at the end of the fifteenth century, and by some authorities⁵⁵ to-day supposed to have been imported from America. But it soon ravaged the whole of our world, and has continued to do so ever since. During recent years it has perhaps shown a slight tendency to decrease, though nothing to what could be achieved by systematic methods; but its evils are still sufficiently alarming. Exactly how common it is cannot be ascertained with certainty. At least 10 per cent., probably more, of the population in our large cities have been infected by syphilis, some before birth. In 1912 for an average strength of 120,000 men in the English Navy, nearly 300,000 days were lost as a result of venereal disease, while among 100,000 soldiers in the Home Army for the same year, an average of nearly 600 men were constantly sick from the same cause. We may estimate from this small example how vast must be the total loss of working power due to venereal disease. Moreover, in Sir William Osler's words, "of the killing diseases syphilis comes third or fourth." Its prevalence varies in different regions and different social classes. The mortality rate from syphilis for males above fifteen is highest for unskilled labour, then for the group intermediate between unskilled and skilled labour, then for the upper and middle class, followed by the group intermediate between this class and skilled labour, while skilled labour, textile workers, and miners follow, and agricultural labourers come out most favourably of all. These differences do not represent any ascending grade in virtue or sexual abstinence, but are dependent upon differences in social condition; thus syphilis is comparatively rare among agricultural labourers because they associate only with women they know and are not exposed to the temptation of strange women, while it is high among the upper class because they are shut out from sexual intimacy with women of their own class and so resort to prostitutes. On the whole, however, it will be seen, the poison of syphilis is fairly diffused among all classes. This poison may work through many years or even the whole of life, and its early manifestations are the least important. It may begin before birth: thus, one recent investigation shows that in 150 syphilitic families there were only 390 seemingly healthy children to 401 infant deaths, stillbirths, and miscarriages (as against 172 in 180 healthy families), the great majority of these failures being infant deaths and thus representing a large amount of wasted energy and expense.⁵⁶ Syphilis is, again, the most serious single cause of the most severe forms of brain disease and insanity, this often coming on many years after the infection, and when the early symptoms were but slight. Blindness and deafness from the beginning of life are in a large proportion of cases due to syphilis. There is, indeed, no organ of the body which is not liable to break down, often with fatal results, through syphilis, so that it has been well said that a doctor who knows syphilis thoroughly is familiar with every branch of his profession.

Gonorrhoea is a still commoner disease than syphilis; how common it is very difficult to say. It is also an older disease, for the ancient Egyptians knew it, and the Biblical King Esarhaddon of Assyria, as the records of his court show, once caught it. It seems to some people no more serious than a common cold, yet it is able to inflict much prolonged misery on its victims, while on the race its influence in the long run is even more deadly than that of syphilis, for gonorrhoea is the chief cause of sterility in women, that is to say, in from 30 to 50 per cent. of such cases, while of cases of sterility in men (which form a quarter to a third of the whole) gonorrhoea is the cause in from 70 to 90 per cent. The inflammation of the eyes of the new-born leading to blindness is also in 70 per cent. cases due to gonorrhoea in the mother, and this occurs in over six per 1,000 births.

Three years ago a Royal Commission was appointed to investigate the best methods of controlling venereal disease, as small-pox, typhus, and to a large extent typhoid, have already been controlled. The Commission was well composed, not merely of officials and doctors, but of experienced men and women in various fields, and the final Report is signed by all the members, any difference of opinion being confined to minor points (which it is unnecessary to touch on here) and to two members only. The recommendations are conceived in the most practical and broad-minded spirit. They are neither faddy nor goody-goody. Some indeed may wish that they had gone further. The Commission leave over for later consideration the question of notifying venereal disease as other infectious diseases are notified, and there is no recommendation for the provision of preventive methods against infection for use before intercourse, such as are officially favoured in Germany. But at both these points the Commissioners have been wise, for they are points to which sections of public opinion are still strongly hostile.⁵⁷ As they stand, the recommendations should carry conviction to all serious and reasonable persons. Already, indeed, the Government, without opposition, has expressed its willingness to undertake the financial burden which the Commission would impose on it.

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.