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SOCIAL MEDICINE
458 The Qther, and more serious, handicap to the physician in any effort he may want to make towards the furtherance of " social trends " that overlap so closely SOCIAL MEDICINE with Medicine, is his want of time. This, as I say, is The Appeal of the Common Man probably a more severe handicap than mere lack of - special preparation in this field. For, after all, the doctor LORD HORDER’S ADDRESS IN NEW YORK is in the very midst of all that is happening to the various IN an address to the Institute onSocial Medicine of groups within the social fabric. He sees the people’s the New York Academy of Medicine on March 21, Lord needs and his natural inclination is towards helping ; if Horder spoke of the new field now opening for the it were not so he is unlikely to have chosen Medicine as statesman, the sociologist, and the doctor-a field that his vocation. But time is essential, and this he just hasn’t is common ground for all three. got. He hasn’t got it because he is generally grossly Although we have not been blind in the past to the overworked and his day is badly organised. And it is sociological aspects of Medicine, he said, we have as yet here, perhaps more than anywhere else, that the need done very little about it. I think the recognition of the for developing our health services is so urgent. omission has gone far in the United Kingdom towards When the statesman seeks to free the doctor from should be done trivialities and time wastage so that he may be able to deciding our statesmen that about it. Looking at our health services in a more pull his weight in the field of Social Medicine he deserves, objective way than the physician can possibly do they and must be given, all our sympathy and all our help. take note of this big gap that he himself is doing so little But there are many of us in Britain who think that this to fill. Then war, the accelerator, has taken a hand freedom should not be secured by nationalising Medicine, by stressing the importance of intelligence, agility, because we consider that such a policy would lose to endurance, strength," and by giving the term " positive Medicine two of its most virile characteristics, which are In short, " Social health " a more exact meaning. individual initiative and the spirit of adventure. the birth of a new outlook on Medicine ... signalises How, then, are we to free the doctor from his incessant human affairs, a new interpretation of human relations and hurry ? I think the Health Centre is the grind in a free society and a new scale of social values " (Crew). The Health Centre could do much to organise a answer. social science." But Virchow spoke of Medicine as a doctor’s work ; it could also save him from the sterilising Can his use of the word " science " be justified in-relation effects of isolation. ’Moreover it could itself be a place to Medicine ? I think it can and should.... But to make where the social aspects of Medicine of which I have been Medicine a complete science in the service of man we must speaking might be studied.... arrange that it infiltrates this important and now more
Special
Articles
something
great
"
...
"
clearly perceived sphere-as yet largely neglected-of social need. This sphere lies between that in which the diseases of the individual patient are presented and treated by the individual doctor and the sphere in which the preservation of the public health is achieved by the proved methods of the State health officer. This largely untilled field includes all the environmental factors which influence the citizen’s health and happiness-his conditions of work, his house and home life, his sense of security or insecurity, and his ignorance of the things that make for the salvation of his body and his mind. In short, as Professor Ryle has it, our next advance " (in concerned with causes " (as the Medicine) " will be last. was) " but with the ultimate, rather than with the intimate, causes of disease." "
...
OBSTACLES
As things are at present I do not feel at all hopeful that the physician is capable of dealing with his aspect of Medicine. I believe his incapacity to be due to two things -his lack of training for the particular job and his lack of time in which to do it. The student’s premedical education is lopsided. Almost from the moment the boy or girl has decided to become a doctor the confines of his or her interest tend to be more and more narrow. Medicine, which should have the widest contacts of any profession, almost ceases to be a " liberal " education, for its cultural outlook dwindles from this moment.... May I repeat something that I said about eight years ago ?‘? "... if it be advanced that the doctor’s training has not, up to now, fitted him for work of this sort, then the sooner it does so fit him the better. Inevitably the doctor’s work in the future will be more and more educational and less and less curative. More and more will he deal with the physiology and psychology of his patient, less and less with his pathology. He will spend his time keeping the fit fit rather than trying to make the unfit fit. And we must make it worth his while to do this work. This reorientation of his education, and of his work, is overdue, and it will remain overdue until reorientation occurs in the attitude of the health authorities towards him and towards his sphere of usefulness."
‘
MEDICINE MUST BROADEN
There are some 54,000 practitioners engaged in medical care in my country. There are nearly three times that number in yours. What is called the " impactof these skilled armies upon the public mind is potentially tremendous. I have dealt with the doctor’s influence in society in another place, saying of him that I thought he was the most important citizen the nation possesses. This sounds egregious seeing that I am a doctor myself. But I believe the public takes the same view. The physician owes his power to three things-to his training, to his humanist outlook, and to his opportunity to effect a " close-up " with the individual patient. We must be insistent that the " close-up " should be preserved in any attempt to integrate our health services ; it is a privilege that should be jealously guarded in the interest of the citizen and of medical progress. But the scope of Medicine must broaden. There is today hardly a field of human endeavour that does not require the physician’s advice at some time or other. In the words of Sigerist, " no longer a magician, priest, craftsman or cleric, he must be more than a mere scientist. Scientist and social worker, prepared to cooperate in team-work and in close touch with the people he serves, a friend and a leader, he will direct all his efforts towards the prevention of disease and become a therapist when prevention has broken down-the social physician protecting the people and guiding them to a healthier and happier life." The " all-in " war that has so recently swept like a blizzard across our social fabric at home has shaken us rudely, physicians included, out of a number of our former complacencies. A few of us grouse because a lot of the things we have to do seem trivial, detached, or beneath our dignity. We can’t any more do only the things we like doing most, nor only the things we think we can do best. And I am not at all sure that we will ever have the same choice of doing things that we previously had, or that it is good that we should. And therefore I consider that to yield in this matter is an ignoble attitude. I would prefer to think that we orientate willingly and actively towards the general social scheme. The doctor’s
459
job has, by its nature and traditions, always been linked act effectively without expert help, and we must keep the citizen’s end up, since he learns to rely upon us for this. up closely with the special structure of the day ; only seem does the doctor to have recent times been But suppose the politician won’t be guided ?Suppose in quite
aloof from the rapidly changing pattern that has disclosed itself. the phrase " general social scheme " I do yet another plan ; I mean, pragmatically, things as they are at this moment in the unbroken stream When I not mean
use
of human welfare ; and of course I have in mind also the in the future. probable continueda trend of things I want to see " close-up "-or it would be more accurate to say a " closer-up "-between the physician and the social services. Is the physician-and when I say physician in this connexion I mean the family physician, than which I can give him no better or more significant title-is the physician going to continue only to cure or relieve disease, or is he going to make contact with this health business that we are finding to be such a vital national asset ?‘? This rigid distinction between the G.P. and the s.H.o. (State health officer), and, alas ! the antipathy so often seen between them, are surely due to a misconception on both sides as to what the medicine man’s function really is ; he was the " health man " to the tribe, and he should be still, and only, that, to the men and women of today. We all pay lip service to the great importance of preventive medicine. But again and again we say " that is the State health officer’s job," when really it is every doctor’s job. To do the G.P. justice; he does make many contributions to preventive medicine that are not recognised as such, but they should be recognised and it is the business of the State to recognise them. Inevitably, if the G.P. does not accept the challenge of this position, and is not helped by all of us to accept it, the s.H.o. service will expand whilst that of the G.P. contracts and there will then be intensified that rivalry between private and public medicine which we all of us surely deplore. I want to see the physician not only make use of the public-health services, but show some passionate conviction about them in his patient’s interest. Take school meals as one exampleif the physician is only doctrinaire on the matter, and not intensely practical, Mrs. Jones isn’t stimulated and the local education authority doesn’t
get busy.
-
THE BASIC NEEDS
Take the case of industry. Work is good ; work is health-giving. But it is the doctor’s duty to protect the worker against excess fatigue, against dullness, and against the various hazards of his job. In all these matters Medicine has accumulated a mass of facts, but they are very largely wasted because they are not implemented in terms of social service. If I embarked upon
the
subject of Nutrition, and the light which our rapidly growing knowledge in regard to it has thrown upon food, I could, of course, give equally striking examples of the need for the physician’s direction and execution. To say the truth, there is very little in the life of John Citizen, whether he be in a factory, an office, or a public-utility service, that does not give the physician scope for the practice of Social Medicine. Consider the basic needs of the citizen-I have long ago stated and re-stated them : 1. Sufficient of the proper food. 2. 3. 4.
5.
Suitable shelter and clothing. A satisfactory job of work. Access to the fresh air and sun. Reasonable leisure and the amenities of life.
In every-one of these the doctor must stake out his claim, for in every one of them his is the knowledge that should guide and it is his enthusiasm that can stimulate to achievement. It is not as mere passengers that we physicians must take our part in these affairs. We must lead; we must guide the politicians since they cannot
it is as S)vift wrote in a letter to Pope : " AlthoughI have known many great Ministers ready enough to hear opinions," said Swift, " yet I have hardly seen one that would ever descend to take Advice ; and this pedantry ariseth from a maxim which they themselves do not believe at the same time they practice it, that there is something profound in politicks, which men of plain honest sense cannot arrive to." In that case the physician has no alternative but to appeal to public opinion, continuing to serve his patient in the manner which he believes to be in the patient’s best interest.... THE FUTURE
If, finally, any one of you should ask me, point-blank : " Do you see hope in the future of Medicine ? " I should reply : " Yes-I see more hope for ourselves as doctors and for the people who will come under our care, in the future of Medicine than perhaps in any other single thing in the new world towards which we are hacking our way. We at least have not-yet-forfeited the trust of people for whom we work ; we at least have not-yet-turned inwards in despair, bartering our spirit of adventure for a mere hope of security. We stand for sane knowledge, selflessness, and mercy in a world gone mad. We cannot let these people down who trust our profession, and it is in this firm resolve that we shall face the future of Medicine." A MEDICAL SERVICE FOR STUDENTS FROM OUR EDINBURGH CORRESPONDENT
FOR the past 17 years students at Edinburgh University have been entitled to free medical examination at entry and at other times as they wish ; they have also been encouraged to engage in physical education. Domiciliary treatment, though sometimes arranged unofficially, has hitherto not been organised by the university. Lately the service has been extended, and every new student is now advised to avail himself of the chance of free clinical examination and chest radiography. During the present academic year 752 (about 60 %) of the male students have taken advantage of the scheme ; and the proportion of women is about the same. Amongst the men pulmonary tuberculosis was disclosed in 8, all of whom had been unaware of it. Besides routine medical examinations, consultations are now held three days a week for students wanting advice ; and any student unfit to attend may obtain free domiciliary treatment. The medical service works in liaison with the department of students’ social service, the director of which makes a point of getting into touch with the parents of sick students. The service has been devised for the benefit of those whose homes are not in Edinburgh ; and local students are encouraged to seek the advice of their family doctor rather than call The Royal upon the university medical service. Infirmary has for many years provided a separate students’ ward, which is still used to the full. A dental service, organised through the Dental Hospital, is already in existence. Discussions which are now being held will, it is hoped, in the establishment of a university eventually result " sick bay " or " sick dormitory " in one of the university hostels : and a scheme for the full care of students with tuberculosis is also being considered. The physicians operating the medical service hope to obtain useful data on students’ health and on their physical and psychological reactions to environmental circumstances. " ... No-one can foresee the basic discoveries of tomorrow ; the predictable belongs to the level of applied research. At best we can merely select phenomena which we do not understand, confident that if we investigate them in a true scientific spirit, some useful knowledge will emerge."Dr. JAMES CRAIGIE, F.R.S., in his presidential address to the Society of American Bacteriologists. Bact. Rev. 1946, 10, i 3.
Special
Articles
something
great
"
...
"
clearly perceived sphere-as yet largely neglected-of social need. This sphere lies between that in which the diseases of the individual patient are presented and treated by the individual doctor and the sphere in which the preservation of the public health is achieved by the proved methods of the State health officer. This largely untilled field includes all the environmental factors which influence the citizen’s health and happiness-his conditions of work, his house and home life, his sense of security or insecurity, and his ignorance of the things that make for the salvation of his body and his mind. In short, as Professor Ryle has it, our next advance " (in concerned with causes " (as the Medicine) " will be last. was) " but with the ultimate, rather than with the intimate, causes of disease." "
...
OBSTACLES
As things are at present I do not feel at all hopeful that the physician is capable of dealing with his aspect of Medicine. I believe his incapacity to be due to two things -his lack of training for the particular job and his lack of time in which to do it. The student’s premedical education is lopsided. Almost from the moment the boy or girl has decided to become a doctor the confines of his or her interest tend to be more and more narrow. Medicine, which should have the widest contacts of any profession, almost ceases to be a " liberal " education, for its cultural outlook dwindles from this moment.... May I repeat something that I said about eight years ago ?‘? "... if it be advanced that the doctor’s training has not, up to now, fitted him for work of this sort, then the sooner it does so fit him the better. Inevitably the doctor’s work in the future will be more and more educational and less and less curative. More and more will he deal with the physiology and psychology of his patient, less and less with his pathology. He will spend his time keeping the fit fit rather than trying to make the unfit fit. And we must make it worth his while to do this work. This reorientation of his education, and of his work, is overdue, and it will remain overdue until reorientation occurs in the attitude of the health authorities towards him and towards his sphere of usefulness."
‘
MEDICINE MUST BROADEN
There are some 54,000 practitioners engaged in medical care in my country. There are nearly three times that number in yours. What is called the " impactof these skilled armies upon the public mind is potentially tremendous. I have dealt with the doctor’s influence in society in another place, saying of him that I thought he was the most important citizen the nation possesses. This sounds egregious seeing that I am a doctor myself. But I believe the public takes the same view. The physician owes his power to three things-to his training, to his humanist outlook, and to his opportunity to effect a " close-up " with the individual patient. We must be insistent that the " close-up " should be preserved in any attempt to integrate our health services ; it is a privilege that should be jealously guarded in the interest of the citizen and of medical progress. But the scope of Medicine must broaden. There is today hardly a field of human endeavour that does not require the physician’s advice at some time or other. In the words of Sigerist, " no longer a magician, priest, craftsman or cleric, he must be more than a mere scientist. Scientist and social worker, prepared to cooperate in team-work and in close touch with the people he serves, a friend and a leader, he will direct all his efforts towards the prevention of disease and become a therapist when prevention has broken down-the social physician protecting the people and guiding them to a healthier and happier life." The " all-in " war that has so recently swept like a blizzard across our social fabric at home has shaken us rudely, physicians included, out of a number of our former complacencies. A few of us grouse because a lot of the things we have to do seem trivial, detached, or beneath our dignity. We can’t any more do only the things we like doing most, nor only the things we think we can do best. And I am not at all sure that we will ever have the same choice of doing things that we previously had, or that it is good that we should. And therefore I consider that to yield in this matter is an ignoble attitude. I would prefer to think that we orientate willingly and actively towards the general social scheme. The doctor’s
459
job has, by its nature and traditions, always been linked act effectively without expert help, and we must keep the citizen’s end up, since he learns to rely upon us for this. up closely with the special structure of the day ; only seem does the doctor to have recent times been But suppose the politician won’t be guided ?Suppose in quite
aloof from the rapidly changing pattern that has disclosed itself. the phrase " general social scheme " I do yet another plan ; I mean, pragmatically, things as they are at this moment in the unbroken stream When I not mean
use
of human welfare ; and of course I have in mind also the in the future. probable continueda trend of things I want to see " close-up "-or it would be more accurate to say a " closer-up "-between the physician and the social services. Is the physician-and when I say physician in this connexion I mean the family physician, than which I can give him no better or more significant title-is the physician going to continue only to cure or relieve disease, or is he going to make contact with this health business that we are finding to be such a vital national asset ?‘? This rigid distinction between the G.P. and the s.H.o. (State health officer), and, alas ! the antipathy so often seen between them, are surely due to a misconception on both sides as to what the medicine man’s function really is ; he was the " health man " to the tribe, and he should be still, and only, that, to the men and women of today. We all pay lip service to the great importance of preventive medicine. But again and again we say " that is the State health officer’s job," when really it is every doctor’s job. To do the G.P. justice; he does make many contributions to preventive medicine that are not recognised as such, but they should be recognised and it is the business of the State to recognise them. Inevitably, if the G.P. does not accept the challenge of this position, and is not helped by all of us to accept it, the s.H.o. service will expand whilst that of the G.P. contracts and there will then be intensified that rivalry between private and public medicine which we all of us surely deplore. I want to see the physician not only make use of the public-health services, but show some passionate conviction about them in his patient’s interest. Take school meals as one exampleif the physician is only doctrinaire on the matter, and not intensely practical, Mrs. Jones isn’t stimulated and the local education authority doesn’t
get busy.
-
THE BASIC NEEDS
Take the case of industry. Work is good ; work is health-giving. But it is the doctor’s duty to protect the worker against excess fatigue, against dullness, and against the various hazards of his job. In all these matters Medicine has accumulated a mass of facts, but they are very largely wasted because they are not implemented in terms of social service. If I embarked upon
the
subject of Nutrition, and the light which our rapidly growing knowledge in regard to it has thrown upon food, I could, of course, give equally striking examples of the need for the physician’s direction and execution. To say the truth, there is very little in the life of John Citizen, whether he be in a factory, an office, or a public-utility service, that does not give the physician scope for the practice of Social Medicine. Consider the basic needs of the citizen-I have long ago stated and re-stated them : 1. Sufficient of the proper food. 2. 3. 4.
5.
Suitable shelter and clothing. A satisfactory job of work. Access to the fresh air and sun. Reasonable leisure and the amenities of life.
In every-one of these the doctor must stake out his claim, for in every one of them his is the knowledge that should guide and it is his enthusiasm that can stimulate to achievement. It is not as mere passengers that we physicians must take our part in these affairs. We must lead; we must guide the politicians since they cannot
it is as S)vift wrote in a letter to Pope : " AlthoughI have known many great Ministers ready enough to hear opinions," said Swift, " yet I have hardly seen one that would ever descend to take Advice ; and this pedantry ariseth from a maxim which they themselves do not believe at the same time they practice it, that there is something profound in politicks, which men of plain honest sense cannot arrive to." In that case the physician has no alternative but to appeal to public opinion, continuing to serve his patient in the manner which he believes to be in the patient’s best interest.... THE FUTURE
If, finally, any one of you should ask me, point-blank : " Do you see hope in the future of Medicine ? " I should reply : " Yes-I see more hope for ourselves as doctors and for the people who will come under our care, in the future of Medicine than perhaps in any other single thing in the new world towards which we are hacking our way. We at least have not-yet-forfeited the trust of people for whom we work ; we at least have not-yet-turned inwards in despair, bartering our spirit of adventure for a mere hope of security. We stand for sane knowledge, selflessness, and mercy in a world gone mad. We cannot let these people down who trust our profession, and it is in this firm resolve that we shall face the future of Medicine." A MEDICAL SERVICE FOR STUDENTS FROM OUR EDINBURGH CORRESPONDENT
FOR the past 17 years students at Edinburgh University have been entitled to free medical examination at entry and at other times as they wish ; they have also been encouraged to engage in physical education. Domiciliary treatment, though sometimes arranged unofficially, has hitherto not been organised by the university. Lately the service has been extended, and every new student is now advised to avail himself of the chance of free clinical examination and chest radiography. During the present academic year 752 (about 60 %) of the male students have taken advantage of the scheme ; and the proportion of women is about the same. Amongst the men pulmonary tuberculosis was disclosed in 8, all of whom had been unaware of it. Besides routine medical examinations, consultations are now held three days a week for students wanting advice ; and any student unfit to attend may obtain free domiciliary treatment. The medical service works in liaison with the department of students’ social service, the director of which makes a point of getting into touch with the parents of sick students. The service has been devised for the benefit of those whose homes are not in Edinburgh ; and local students are encouraged to seek the advice of their family doctor rather than call The Royal upon the university medical service. Infirmary has for many years provided a separate students’ ward, which is still used to the full. A dental service, organised through the Dental Hospital, is already in existence. Discussions which are now being held will, it is hoped, in the establishment of a university eventually result " sick bay " or " sick dormitory " in one of the university hostels : and a scheme for the full care of students with tuberculosis is also being considered. The physicians operating the medical service hope to obtain useful data on students’ health and on their physical and psychological reactions to environmental circumstances. " ... No-one can foresee the basic discoveries of tomorrow ; the predictable belongs to the level of applied research. At best we can merely select phenomena which we do not understand, confident that if we investigate them in a true scientific spirit, some useful knowledge will emerge."Dr. JAMES CRAIGIE, F.R.S., in his presidential address to the Society of American Bacteriologists. Bact. Rev. 1946, 10, i 3.