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Chapter 6. Costs to community
84
CHAPTER 6 Costs to Community. It is now possible t o estimate approximately which of the following alternatives is the more expensive for the public : a combined scheme of physical and economic rehabilitation or sanatorium treatment and " " laisser faire." I f the idea of carrying through a complete programme of rehabilitation is given up, the social medical results remain incomplete, and expenses uncertain in amount, but certainly heavy, will have to be met. Somewhat more detailed information is to be found in a calculation made by the Manitoba Sanatorium, Hamilton, Canada, where about I,OOO-2,ooo dollars were spent in each case per year. (3,881.85 dollars for two years in one case 8,545"oo ,, four ,, another). According to the enquiries made by A. W. Sawyer and E. K. Richard, theloss on an average was about 3,ooo-4,ooo dollars in each case. The major part of the cost was due to working days lost (26~/o), sick benefit (0.4) , estimated time lost (33.40/0) and sanatorium and hospital treatment (16.2°/o). Newsholme estimates the loss to the community through each tuberculous person at £15o a year. A similar calculation has been made for the inmates of the tuberculosis settlement Herrnprotsch. The expenditure necessary for sanatorium or hospital treatment ranged between RM. 3,ooo and RM. 9,ooo per patient. Almost all these patients had since their first admission to a sanatorium, spent about three months of each year under institutional care. " O f the fiity-eight million dollars spent each year on sanatorium care, approximately twelve million dollars is spent on those who have had previous sanatorium care. The high rate of relapse with its attendant large expenditure indicates a weakness either in medical or social treatment or in both " (Burhoe 60). A detailed social analysis of the settlers employed at Papworth confirms the fact, that the tuberculous, in the course of his disease, repeatedly enters sanatoria and hospitals. The cost of such disconnected courses of treatment equals or exceeds that of full rehabilitation. It is possible to determine as we have shown above, the cost of an organisation which provides temporary or permanent sheltered employment, and which, when discharging patients, takes as their standard complete rehabilitation. When the organisation is efficient, the public assistance rates, which are based on a minimum standard of living, make possible the financing of a complete programme of rehabilitation, when work can be assured. I f it were possible and desirable to pay the equivalent of a full wage to the tuberculous worker instead of giving them work, one would not achieve on those lines the same social medical and social hygienic results as can be attained with smaller expenditure through the provision of work. From the standpoint of economics
85 alone, this programme may seem unsound. " To expect the community to make any extensive plans for the part-time or sheltered employment of the tuberculous, while there are armies of able-bodied unemployed is certainly optimistic on the part of those concerned with the rehabilitation of the handicapped. It is not going to happen, because it is economically unsound " (Burhoe 6x). Questions concerning social hygiene, must not be decided by industrial economics alone. Two entirely different problems are involved. Unemployment is a serious problem o f international economics. And, yet, even: to-day, increased rationalisation, efforts to raise the birth-rate, general treatment of disease, industrial hygiene, continued improvement of the working conditions f o r women and young people, are taking place in all countries, thus increasing the capacity for production without considering the consequent reaction on the labour market. If the considerations of the labour market were the decisive factor in rehabilitation, the tuberculous worker would be drawn into the whirlpool of industrial strain, when labour is needed, with no thought of social hygiene, and be the first to be eliminated when work is short. " The alteration in the economic position of the country has if anything shown that when industry is more prosperous many of the qualms of industrial concerns towards infection and substandard labour are subdued in their desire to obtain labour of almost any kind or description." (IV. Report of the Employment Committee 62). Health measures must however be taken independently of the fluctuation of the labour market, and a straight course of social medical work must be pursued. Obviously all health measures are handicapped in times of economic crisis. But during this period of crisis the tuberculous worker is eliminated from the economic process in accordance with the law of the survival of the fittest. Thus it is precisely such a period which offers the best prospects of excluding the tuberculous from industrial life and of utilising his enforced leisure for an intensive post-cure and of industrial convalescence. Social medicine must not fail tO seize the favourable moment at which the tuberculous, seeing here their only chance of existence, are ready to accept help and to c0-operate in each of the experiments for the improvement o f national health. If this opportunity is allowed to pass, improvement in the economic conditions may again encourage the tuberculous worker to conceal his disease, to the detriment of the national health and the national Exchequer. The scientific material for the foundation of a Rehabilitation legislation for the tuberculous is certainly very incomplete at present. "Rehabilitation has not kept pace with the preventive and curative faces of the sanatorium service... The problem, as a whole, is well worthy of further study. It is concerned with the cost of tuberculosis hospitalisation and with the responsibility of individual institutions in the postsanatorium care of patients. Likewise, it involves the community's responsibility towards patients who remain physically handicapped and unable to compete on even terms in industry and other occupations " (63). It is to be hoped that the experience gained in the sheltered industries will help to set up a complete system of industrial pathology, physiology, economy and thus prepare a rehabilitation legislation for the tuberculous workers. Until legislation stating the fight of the tuberculous to work has been introduced, and until it has been realized that the utilisation of his earning capacity does not relieve society of responsibility for him, the anti-tuberculosis system will remain imperfect and rehabilitation impossible.
CHAPTER 6 Costs to Community. It is now possible t o estimate approximately which of the following alternatives is the more expensive for the public : a combined scheme of physical and economic rehabilitation or sanatorium treatment and " " laisser faire." I f the idea of carrying through a complete programme of rehabilitation is given up, the social medical results remain incomplete, and expenses uncertain in amount, but certainly heavy, will have to be met. Somewhat more detailed information is to be found in a calculation made by the Manitoba Sanatorium, Hamilton, Canada, where about I,OOO-2,ooo dollars were spent in each case per year. (3,881.85 dollars for two years in one case 8,545"oo ,, four ,, another). According to the enquiries made by A. W. Sawyer and E. K. Richard, theloss on an average was about 3,ooo-4,ooo dollars in each case. The major part of the cost was due to working days lost (26~/o), sick benefit (0.4) , estimated time lost (33.40/0) and sanatorium and hospital treatment (16.2°/o). Newsholme estimates the loss to the community through each tuberculous person at £15o a year. A similar calculation has been made for the inmates of the tuberculosis settlement Herrnprotsch. The expenditure necessary for sanatorium or hospital treatment ranged between RM. 3,ooo and RM. 9,ooo per patient. Almost all these patients had since their first admission to a sanatorium, spent about three months of each year under institutional care. " O f the fiity-eight million dollars spent each year on sanatorium care, approximately twelve million dollars is spent on those who have had previous sanatorium care. The high rate of relapse with its attendant large expenditure indicates a weakness either in medical or social treatment or in both " (Burhoe 60). A detailed social analysis of the settlers employed at Papworth confirms the fact, that the tuberculous, in the course of his disease, repeatedly enters sanatoria and hospitals. The cost of such disconnected courses of treatment equals or exceeds that of full rehabilitation. It is possible to determine as we have shown above, the cost of an organisation which provides temporary or permanent sheltered employment, and which, when discharging patients, takes as their standard complete rehabilitation. When the organisation is efficient, the public assistance rates, which are based on a minimum standard of living, make possible the financing of a complete programme of rehabilitation, when work can be assured. I f it were possible and desirable to pay the equivalent of a full wage to the tuberculous worker instead of giving them work, one would not achieve on those lines the same social medical and social hygienic results as can be attained with smaller expenditure through the provision of work. From the standpoint of economics
85 alone, this programme may seem unsound. " To expect the community to make any extensive plans for the part-time or sheltered employment of the tuberculous, while there are armies of able-bodied unemployed is certainly optimistic on the part of those concerned with the rehabilitation of the handicapped. It is not going to happen, because it is economically unsound " (Burhoe 6x). Questions concerning social hygiene, must not be decided by industrial economics alone. Two entirely different problems are involved. Unemployment is a serious problem o f international economics. And, yet, even: to-day, increased rationalisation, efforts to raise the birth-rate, general treatment of disease, industrial hygiene, continued improvement of the working conditions f o r women and young people, are taking place in all countries, thus increasing the capacity for production without considering the consequent reaction on the labour market. If the considerations of the labour market were the decisive factor in rehabilitation, the tuberculous worker would be drawn into the whirlpool of industrial strain, when labour is needed, with no thought of social hygiene, and be the first to be eliminated when work is short. " The alteration in the economic position of the country has if anything shown that when industry is more prosperous many of the qualms of industrial concerns towards infection and substandard labour are subdued in their desire to obtain labour of almost any kind or description." (IV. Report of the Employment Committee 62). Health measures must however be taken independently of the fluctuation of the labour market, and a straight course of social medical work must be pursued. Obviously all health measures are handicapped in times of economic crisis. But during this period of crisis the tuberculous worker is eliminated from the economic process in accordance with the law of the survival of the fittest. Thus it is precisely such a period which offers the best prospects of excluding the tuberculous from industrial life and of utilising his enforced leisure for an intensive post-cure and of industrial convalescence. Social medicine must not fail tO seize the favourable moment at which the tuberculous, seeing here their only chance of existence, are ready to accept help and to c0-operate in each of the experiments for the improvement o f national health. If this opportunity is allowed to pass, improvement in the economic conditions may again encourage the tuberculous worker to conceal his disease, to the detriment of the national health and the national Exchequer. The scientific material for the foundation of a Rehabilitation legislation for the tuberculous is certainly very incomplete at present. "Rehabilitation has not kept pace with the preventive and curative faces of the sanatorium service... The problem, as a whole, is well worthy of further study. It is concerned with the cost of tuberculosis hospitalisation and with the responsibility of individual institutions in the postsanatorium care of patients. Likewise, it involves the community's responsibility towards patients who remain physically handicapped and unable to compete on even terms in industry and other occupations " (63). It is to be hoped that the experience gained in the sheltered industries will help to set up a complete system of industrial pathology, physiology, economy and thus prepare a rehabilitation legislation for the tuberculous workers. Until legislation stating the fight of the tuberculous to work has been introduced, and until it has been realized that the utilisation of his earning capacity does not relieve society of responsibility for him, the anti-tuberculosis system will remain imperfect and rehabilitation impossible.