III. Public Hygiene in its Relations to Physicians

An important difference between man and animals is found in the extent to which he will sacrifice a present pleasure or convenience to secure a future good or to avoid a future evil. The savage will do this to only a very limited extent—little more, in fact, than the beaver or the squirrel—and the lesson is learned but slowly and by sad experience. This is especially the case as regards matters affecting health. When a man begins to take special precautions as to his diet or exercise, having in view rather his future health than his present comfort and tastes, he has in most cases already begun to suffer from the effects of his imprudence, and does not commence a hygienic course of life as a perfectly sound and healthy person. The same is true for a community. It will not usually submit to the burden of taxation necessary to secure drains and sewers or a proper registration of vital statistics, nor to the cost and inconvenience of the machinery necessary to limit the spread of contagious diseases, until the neglect of these things has resulted in such an amount of disease and death as to forcibly call attention to the matter. The result is, that the burden is far heavier than it would have been had the work been undertaken in proper season, and individuals may find it to their interest to leave the place and settle elsewhere rather than remain and meet their proportion of the expense.

When a state or municipality has so far advanced in civilization as to consider it desirable to take measures to protect the public health by preventing individuals from polluting the air or water liable to be used by their neighbors, etc., the services of the medical profession are always called upon. The foundation of public hygiene is information as to the occurrence of certain forms of disease, the cause of which can be referred with more or less precision to a certain limited locality. This information may be very imperfect, consisting of little more than rumor and opinions as to the existence of an undue amount of sickness or mortality in a certain place, or it may consist of precise reports setting forth the number of deaths from each cause, the proportion of each of these to the population by age, sex, occupation, etc., and of the whole to births—constituting what is commonly called the "vital statistics of a place"—and also of reports of the occurrence of certain preventable diseases; and between these two the information may be of various degrees of completeness, but, whatever there be, it is for the most part obtained either directly or indirectly from medical men. The reliability and completeness of the information thus obtained by the state determines to a great extent the direction and character of the work done in destroying or preventing the causes of disease, and it is also an important means of increasing our knowledge with regard to the nature of these causes.

The character of this information depends largely upon the character of the physicians who furnish it. In a large part of the country medicine is legally in the position of any common occupation; that is, the term "physician" is defined as applied to "any one who publicly announces himself to be a practitioner of this art, and undertakes to treat the sick either for or without reward." Under such circumstances there can be no guarantee that all who call themselves physicians are properly qualified or competent to furnish reliable information for registration purposes, and, as a matter of fact, a large number are not so qualified. It is for this reason that there is such a close connection between public health authorities, registration of vital statistics, and the registration of those physicians whose certificates as to causes of deaths, etc. will be accepted by the state; and hence the nature of the public health organization of a state and the personnel of its officials are matters of great importance to physicians. On the other hand, the efficiency of a public health service depends very largely upon the relations which it holds with, and the light in which it is regarded by, the medical profession. A health officer who is distrusted and disliked by the physicians of his district cannot effect much unless he can overcome this feeling, and his tenure of office must always be very insecure.

The official relations of the practitioner with the health authorities are usually confined to the subjects of registration of vital statistics and of checking the spread of contagious diseases. The most marked exception to this rule is furnished by the States of Alabama and North and South Carolina, in which the State Medical Society is the State Board of Health, having been given legislative powers and the right of selecting the health officers. The most complete organization of this kind is that of the State of Alabama, where by the act of 1875 the Medical Association of the State was constituted the State Board of Health, and the county medical societies in affiliation with the State Society were made county boards of health, to be under the general direction of the State Board. These county boards at first had advisory powers only, and were to be conducted without expense to the State or the county, except that the competent legal authorities of any county might invest the county board with such powers and duties for the promotion of the public health as might be mutually agreed on; but in such case the right to elect or appoint those employed in sanitary administration is reserved to the board of health, while all questions relating to salaries, appropriations, and expenditures shall be reserved to the legal authorities. It was further provided "that no board of health, or advisory or executive medical body of any name or kind for the exercise of public health functions, shall be established by authority of law in any county-town or city of this State except such as are contemplated by the provisions of this act, the object of this prohibition being to secure a uniform system of sanitary supervision throughout the State." By an act of 1881 the county board is directed to elect a health officer, who is to keep a register of the births, deaths, and cases of pestilential or infectious diseases occurring in the county, and furnish to physicians, free of charge, reliable vaccine—to obtain information as to the sanitary condition of his county, etc. etc. It will be seen that this plan of organization is an attempt to overcome the practical difficulties in the way of obtaining from physicians the information necessary for the registration of vital statistics and the work of preventing the spread of infectious diseases.

While the great majority of physicians are willing to furnish the information as to the cause of death, etc. which is necessary for a useful registration, there are always some who either neglect or refuse to do so; and if the law be made compulsory, it provokes hostility unless compensation is furnished, while as regards the requiring physicians to furnish information as to the existence of contagious diseases, this always rouses opposition on the part of a certain number of medical men, even if payment for such notification is provided. And while this opposition is no doubt in many cases due to improper motives, such as personal hostility to the existing authorities, party politics, or a desire for notoriety, its strength nevertheless rests upon the fact that it is unjust for the state to compel the services of any man or class of men without furnishing compensation. The advocates of health and registration laws are thus placed between Scylla and Charybdis: if they propose compensation, which involves appropriations from the public treasury, the law cannot be passed; if there is no compensation allowed, complete results cannot be obtained.

The Alabama law makes compulsory the furnishing by physicians of information relating to births, deaths, and infectious diseases, and gives compensation—not in money, but by allowing the medical profession to have the sole management of the matter and to choose the health officers to whom they are to report; in other words, they are allowed to tax themselves. The result in Alabama is yet doubtful. If competent and faithful health officers and registrars can be obtained without paying them a fair compensation, it will be contrary to experience; and if these officers receive a salary, it will be strange if the positions do not become the reward of partisan political work.

It should be noted that the requiring a physician to report the births occurring in his practice stands on a very different basis from the requiring him to report the cause of death, since there is no special necessity for the former. It requires no expert knowledge to report a birth, and the duty should obviously devolve on the householder.

In those States in which by law only properly qualified medical men, as determined by examination, have the right to practice, to hold medical office, or to furnish medical certificates, the State certainly is entitled to require of all physicians thus registered and authoritatively recommended to the people as competent, that they shall furnish, free of charge, certificates of the cause of death in those cases where they are cognizant of such cause.

States and municipalities often demand much more than this; as, for instance, that the medical man shall fill out the whole certificate, including age, nativity, nativity of parents, etc., and that he shall furnish the information to the registrar. In some cases it is provided that any physician having attended a person during his last illness shall furnish the certificate: this would apply to cases where the physician may not have seen the case for weeks before death.

While it is most convenient to have the certificate of cause of death upon the same form which contains the data necessary to identify the individual, the certificate should be distinct from the latter, and the duty of making the return to the registrar should devolve on the householder or undertaker, and not on the physician. On the other hand, it is easy for the physician to be hypercritical in these matters: his certificate is to be considered rather as a statement of opinion than as a statement of facts within his personal knowledge, precisely as he would certify as to his own age and birthplace.

The compulsory notification of infectious diseases to the health authorities is a matter presenting much greater difficulties than that of certificates as to causes of death. The state has no right to require such notification from the physician without giving some quid pro quo, and it is not expedient to make it compulsory, even with payment, except from physicians employed by the state or municipality, to furnish gratuitous medical attendance to the poor. The state has the right to require such information from the parent or householder, and it has also the right to require the physician to notify the parent or householder as soon as he recognizes the existence of such infectious disease. It is extremely desirable that the health authorities of a city should receive promptly, and direct from physicians, notification of the occurrence of such diseases, and there will usually be no difficulty in obtaining this if the health officer has tact and discretion and the city is prepared to do its duty. This duty is not confined to registering the information or placarding the house, nor will it be properly performed by merely removing the sick person to a hospital and disinfecting the premises. If the case occur in a family which can secure its proper isolation, and the attending physician certifies that it is so isolated and makes himself responsible for its management (for which responsibility he should be paid by the patient or his friends), the health officer should not interfere nor do more than furnish a competent person to secure disinfection if required. The employment of a trained nurse known by the health authorities to be competent and reliable would do away with most of the difficulties connected with such cases in the upper and middle classes of society; and such nurses should be registered just as physicians and midwives are.

Where the case cannot be thus isolated and properly cared for, it should be removed to a proper hospital. This presupposes that the city has such a hospital, and if it has not, and is not prepared for such cases, notification is useless. When the city places a house in quarantine so as to interfere with business, it should be for the shortest possible time consistent with securing thorough disinfection of the premises, and the city should bear not only the cost of such disinfection, but the cost of caring for the persons in the house in an isolated place until no further danger is to be apprehended for them. When the city undertakes to pay all expenses for isolation and disinfection of such cases, it has the right to require that all such cases shall be so treated, leaving it to private parties to meet the cost in case they prefer not to use the buildings and apparatus provided by the city for that purpose. And when the city does its duty in this respect, it will be found that physicians and the people will do theirs, with rare exceptions.

When a city becomes very unhealthy the usual policy is to conceal the fact as much as possible, and to attribute the mortality to some other than the real cause. The influence of the mercantile part of the community is in such a case strongly exerted on the daily press and on the health authorities to produce such representations of the condition of things as will tend to allay apprehensions on the part of their customers. The healthfulness of a place is usually estimated from its mortality reports, but the reliability of these is by no means always what it should be. Yellow fever is called typho-malarial or pernicious fever, typhoid is reported as diarrhoea or malarial fever, etc. etc., and great stress is laid upon what is called the sanitary condition of the place, which is declared to be excellent.

Unfortunately, this phrase, "sanitary condition," means different things at different times. When the mortality is low, sanitary condition means the healthfulness of a place; when it is high, it means the cleanliness of a place. To a certain extent physicians are responsible for the truth of the statistical returns, not so much in relation to the number as to the causes of deaths; but none save those who have practised in a city liable to epidemics can realize the enormous pressure which is brought to bear on medical men to induce them to aid in or wink at concealing the true state of the case. Of course, this ostrich-like policy is in the long run an exceedingly unwise one, but neither the average householder nor community can be expected at present to pursue any other, except under pressure.

There are many questions as to the best form of public health organization, and the powers and duties which should be conferred upon it, which can only be properly answered by taking into consideration the circumstances in each case. In a large city the health officers must have great powers if they are to be really efficient. They have to contend with ignorance, custom, and self-interest, and their action must in many cases be prompt and unrestricted if it is to be efficacious. They must sometimes be in conflict with wealthy and powerful corporations, whose interests are opposed to the reforms which they urge, and although their business is to protect the most important interest of the community at large—i.e. its health—against the interests of individuals, yet these last are much more immediately concerned, and are, naturally, so active that they are often, although few in number, able to defeat any attempt to interfere with their occupations.

It not unfrequently happens that a health board may have all the power necessary, so far as the laws are concerned, and yet may be able to accomplish little for want of funds to pay the inspectors and other officials whose services are necessary. For a city, a health officer usually does better work than a board of health: his responsibility is more direct, and he has stronger motives to do good work, than a board. Of course, a poor health officer is less efficient than a good board of health, but the general rule is as above stated. The problems of hygiene require special knowledge, and the man who is to deal with them requires special training. The folly of treating diseases by their names with popular or patent remedies is not greater than that of the attempt to make a healthy house or city by men who are not architects or engineers or physicians, or who have only the information possessed by the average architect or engineer or physician. And, of all professional or educated men, the physician especially should recognize his own ignorance. When he is asked what one should take for dyspepsia or pneumonia his answer is, "Take the advice of a physician;" and so when he is asked how the plumbing of a house should be arranged, how a hospital should be ventilated, how a city should be sewered, how a marsh should be dealt with or a water-supply provided, he should reply, "Get expert advice and supervision, and be prepared to pay the amount necessary to secure it." It is the special duty of the physician to exert his influence to secure properly constituted sanitary authorities for his own locality, his State, and for the nation, and to support these against the hostility which they must inevitably arouse if they are efficient. And he should do this, not blindly and as a partisan, but intelligently and with due consideration of all the important interests involved.

The body of educated physicians in a community forms the tribunal by which the work of sanitary officials is to be judged, and they cannot judge wisely unless they appreciate the difficulties with which health officials have to contend. If a city has an incompetent or dishonest board of health, the medical profession of that city are to a certain extent responsible for it; if a competent, energetic, and faithful sanitary officer is crippled and harassed or forced out of office because he is on the wrong side of politics, or because in the legitimate and proper exercise of his functions he has come in conflict with the interests of powerful and wealthy individuals or corporations, it is the duty of medical men to support him, and to do this actively and promptly. And I take great pleasure in being able to say, as the result of somewhat extended observation, that, as a rule, the physicians of this country do cheerfully and promptly co-operate with the sanitary authorities where such exist, and are the first to try to have them properly organized and given the necessary means and powers to do effective work.