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often is very pleasing to its sponsers. Medical men working under such difficulties can scarcely avoid finding in medical practice exactly that which each social movement would seem to call for. At least they can make no pretense at conducting impersonal, unbiased, accurate examinations and treatments. When we remember how difficult it is, even in well-arranged hospitals, to keep on steady keel, we must not expect too much of those less fortunate. Our own records of short-circuiting bowel operations, suspensions, subtotal thyroidectomies, vaccine treatments, etc., should keep us humble.
Then finally should be mentioned various religious organizations which usually have a peculiar urge to enter the medical field. The medical activities of organizations have been generally unsuccessful and have reflected considerable loss of reputation, not to themselves, but to medicine. We should, however, study this problem carefully, since the logical evolution of modern medicine leads us, if we wish to live up to the best there is in medicine, definitely to the point of controlling the religious life of our patients, whether we enjoy that prospect or not. As it is now the medicine adapted to religious causes is “made to order" to suit the philosophy behind the religious movement to which it is made subordinate, and while it may "look good," yet it seldom is accurate or even honest.
The best reason why the well-equipped teaching hospitals only should serve as health centers can best be stated by saying that medical knowledge is a stream which, like a river, flows steadily on. It is not the same stream in any two successive years, since new truth is ever flowing up and each new truth shifts the relations between all the other elements of knowledge. It is difficult enough for the staff man of a teaching general hospital to keep his head above water in this rapidly flowing current; how very easy, therefore, must it be for medical men connected with various semimedical organizations to furnish medical service which is not up to date, which is lacking in proper balance, and which is faddy and generally ineffectual. We do not, by this figure of speech, suggest that medical knowledge is continuously proving itself wrong. Not at all. Nevertheless each truth is incomplete and the evaluation of each will depend on all the rest of knowledge. Like two automobile models which, if but one year different, seem similar, but if ten apart, quite different, and yet each was the best to date, so truth is in evolution. Each year the problems are those of emphasis and of selection between choices apparently desirable.
Second, our hospitals are best able to furnish efficient, well-balanced service, that is, to organize for the individual man efficient team play between specialists as well as between social organizations.
Medicine is still in the analytic stage; it has as yet developed more of these general philosophies which social and religious service demand and which they will create if we refuse them one. There is as yet little justification for standardized procedures or for routine practices, and social service centers will quickly formulate these if allowed. In medicine we are still dealing less with disease en
tities and more with individual cases, each a new research problem. No suit of clothes will fit two men equally well, and the better the tailor the more minute will the alterations be in order that the suit may be a perfect fit for one man. So it is in medicine: routine work is in itself a confession of inaccurate work. We must work out each problem as new, follow the evidence, and be willing to treat a headache by medicine, by glasses, by surgery, by physical therapy, by a new job, or by prayer if any one of these is what the accurate study of the case indicates. If therapy is so difficult, how much more difficult must be the application of medical science when applied to health?
If, therefore, medicine is to render to humanity its highest service, that is by furthering the good health of the community (and this is also its most difficult problem), its safest course is to apply to this cause its best forces, those of our general teaching hospitals. These best can serve as the controlling centers of all those medical activities which can convey to the public the best applications of scientific medicine.
PUBLIC HEALTH AND THE FEDERAL GOVERNMENT
AN IDEAL ARRANGEMENT FOR FEDERAL
Lee K. Frankel, New York, and James A. Tobey, Washington
Public health, like any other social science, can attain its highest development only by means of unified leadership. Since public health is unquestionably a function of government, it seems logical that this leadership should be exercised by government and so utilized that the whole public health movement would be welded into a homogeneous whole, thereby promoting and enhancing the vitality of the nation.
Public health is today in a flourishing condition, but in spite of much talk and many efforts at coordination, nothing of epoch-making importance has as yet been accomplished. To be sure, there are many exceptionally able individual leaders in the field of public health, who are working in harmonious relations. In the voluntary field, the National Health Council, now over six years old, has had a beneficial effect in promoting teamwork and cooperation among its fourteen members, all agencies interested in various phases of the national health field. The Council has not, however, attempted to assume any real leadership, and its accomplishments have been in the way of creating better understanding and comradeship among its member agencies with prevention of duplication, perhaps, but no central direction of united efforts against universal disease enemies. This matter of the national voluntary health agencies is mentioned in connection with the subject at hand because it is an integral part of the whole movement for the correlation of federal health activities. If there were today in existence a single powerful national public health association, with the combined
resources of the three largest existing independent national health societies, the influence which such a great organization could mobilize in support of a unified federal health service would do much to assure its success. Once such coordination was secured and a central leadership developed, there should be maintained the closest relationship between official and extra-governmental health agencies, the latter being the true supplements to the former, instead, as is now often the case, pointing the way and sometimes letting the government catch up as best it can.
In considering the actual methods requisite to achieve an ideal arrangement for the health activities of the national government, a basic proposition is that public health is a unit. It is, furthermore, generally a more important unit than any other single subject which may have health implications. Thus, the protection and promotion of the health of children, farmers, workers, mothers, city people, rural dwellers, immigrants, Indians, or any other class, group, or type of person is all part of the one big problem and cannot be separated entirely from it. Public health cannot be divided into age groups, or economic levels, or geographical or racial distinctions. It is the same problem in one of its ramifications, whether found in the home, school, factory, farm, or institution.
Starting with the proposition, then, that public health is a unit, it would logically seem to follow that all bureaus or activities of the national government which are carrying on health work should be brought together under central direction. As a matter of fact, more than one-third of the hundred or more major administrative units of the national government are concerned directly or indirectly with some phase of public health. There is no one bureau in the entire government which now deals solely with public health. Even that bureau which bears the name of Public Health Service devotes a large part of its energies to the administration of medical relief, which is curative and not preventive medicine or public health work in any sense of the word. Of all the bureaus and divisions concerned with public health there are, of course, only some eight which are concerned with the subject in a major way. With as many more the public health activity is important, but subordinate to the general scope of the bureau, as in the Bureau of Mines, where the promotion of the health and safety of miners is only one aspect of the entire mining problem with its many technical features.
Obviously, it would not be ideal to attempt to bring together thirty or forty bureaus or divisions merely because each had some sort of an interest in the public health. What can be done, however, is to assemble certain of the more important federal health agencies under the direction of a single executive, and from this central federal health agency detail experienced scientists to supervise or cooperate in the activities of other bureaus where it is essential that units other than public health services should take up health problems. This system is already provided for by law to a limited extent. For example, the chief surgeon of the United States Bureau of Mines of the Department of Commerce is
detailed from the commissioned corps of the Public Health Service of the Treasury Department.
This system of contract service whereby one government agency, which has the trained personnel and equipment, undertakes to operate in its own field on behalf of another bureau which is perhaps only interested casually in the specialty, as public health, also solves the problem or the objection which may arise, that there may be other units as important as health. Thus, the Indian is said to be a unit, and his entire social, economic, educational, and hygienic problems are so interrelated that they must all be administered by a single agency. The Indian Medical Service, comprising some two hundred physicians, has not been noted for its efficiency in the past. This service should be attached to a central federal health agency for purposes of selection, training, and scientific direction, and then detailed to the Commissioner of Indian Affairs for purposes of administrative direction. This procedure would be somewhat analogous to that already in effect by which the Public Health Service details officers to the commissioner of immigration in order to make the medical examinations of aliens. As a matter of fact, the Secretary of the Interior has recently requested the Surgeon General of the Public Health Service to assist in the reorganization of the Indian Medical Service.
When a central federal health agency is mentioned, the question at once arises as to whether the ideal would be a secretary of health in the cabinet. Fifteen years ago there was a determined agitation for a national bureau of health with such a secretary. While most of the great nations of the world, such as Great Britain, France, Germany, and others have established ministries of health, a department of health with a secretary in the president's cabinet is still only an ideal in the United States. Health yields in importance to no other branch of government, but its administration can be taken care of adequately without the necessity of having a place in the cabinet. Public health is a technical subject. Under the prevailing system of selecting cabinet officials it is at least questionable whether a sanitarian would be chosen for such a secretaryship, if there were one, and it is certain that there would be changes at fairly frequent intervals. All things considered, a new department is not necessary, and it might be further remarked as a very practical matter that Congress has shown much reluctance even to consider increasing the number of cabinet officers. Thus such a well-supported movement as that for a department of education has so far been unsuccessful.
While a secretary is not essential, an assistant secretary for public health would be desirable. It does not matter particularly in what department the federal central health agency is placed. At present, some kind of health work is done in all ten of the departments, as well as by a number of the independent establishments. The chief health bureau is the Public Health Service, which, for historical reasons only, is in the Treasury Department. Another important health agency, the Children's Bureau, is in the Department of Labor, while the
enforcement of the federal food and drugs act comes under the Bureau of Chemistry in the Department of Agriculture. Vital Statistics, the bookkeeping of public health, are collected and compiled in the Department of Commerce by the Bureau of the Census. School hygiene is in the Interior Department and nutritional research in the Department of Agriculture. The most significant problem is to assemble certain of the bureaus and activities; where they are to go is secondary.
To be specific, an ideal arrangement of federal health activities would consist of an assistant secretary for public health in any appropriate department and the nucleus for the central federal health arrangement would obviously be the Public Health Service. To it should be transferred the Division of Vital Statistics from the Department of Commerce; St. Elizabeth's Hospital, the government hospital for the insane, from the Department of the Interior; certain nutritional research now performed by the Bureau of Chemistry and the Bureau of Home Economics of the Department of Agriculture; and the medical division of the Office of Indian Affairs in the manner already outlined. The Children's Bureau should likewise come under the jurisdiction of the assistant secretary for health.
Scientific personnel should be detailed from this central public health agency to the Division of School Hygiene of the Bureau of Education (Interior Department); Bureau of Labor Statistics (Labor Department); and to the Bureau of Animal Industry, Bureau of Dairying, and the Extension Service (all in the Department of Agriculture); in addition to the details already authorized by law, which include the Bureau of Mines, Consular Service of the State Department, Bureau of Immigration, Coast Guard, Bureau of Chemistry, and the Alaska Division of the Bureau of Education, these details being made by the Public Health Service.
The problem of personnel would be an important one in an ideal arrangement. At present the Public Health Service has a corps of between two and three hundred commissioned medical officers and a much larger group of non-commissioned scientists, including physicians, sanitary engineers, dentists, chemists, and other sanitarians. There is no commissioned personnel in any of the other bureaus which should be brought together to form the central federal health agency. The status of the entire personnel should be equalized. The commissioned corps of the Public Health Service is not the best model, as it is a distinctly military system, though the bureau is essentially a civil one. Instead, the recent system adopted for the Foreign Service of the State Department, setting up grades and making promotions and advances a matter of merit and service, and establishing a career basis for the foreign department, would be an excellent model. The medical corps of the Public Health Service was founded in 1870, while the corps of the Foreign Service was created in 1923, and the latter is said to have taken many of its features from the former. Be that as it may, it also managed to omit some of the undersirable ones. Putting the entire person